title: Assessment of advanced gastric cancer management in the United States.
abstract: BACKGROUND
  Increasing attention is being placed on utilization of treatment for advanced malignancies. Though some suggest it is futile, recent reports have advocated noncurative surgery for advanced gastric cancer. Our objectives were to (1) assess treatment trends, (2) identify predictors of surgery, and (3) evaluate the effect of treatment on outcomes.
  
  
  METHODS
  Patients with stage IV gastric adenocarcinoma were identified from the National Cancer Data Base (1998-2007). Patients who underwent emergent surgery were excluded. Models were developed to identify factors associated with treatment receipt and to compare adjusted overall survival by treatment group.
  
  
  RESULTS
  Twenty-four percent (n = 22,430) of patients presented with stage IV gastric adenocarcinoma; 1.5 % (n = 414) underwent emergent surgery. Of the remaining 21,039 patients, 62.4 % underwent treatment (87.0 % chemotherapy with or without radiotherapy (C ± RT), 5.6 % surgery, 7.2 % combined surgery and C ± RT). Over the decade, surgery rates increased by 43 %, and C ± RT use increased by 16 % while receipt of no treatment decreased by 26 % (all p < 0.001). Patients who were younger, white, and insured, as well as those with distal tumors were more likely to undergo surgery. Reasons for receiving no treatment were multifactorial but were most strongly associated with advanced age and being uninsured. Median survival was longest for patients selected to undergo surgery and C ± RT (13.5 months) versus C ± RT alone (6.1 months), surgery alone (4.8 months), or no treatment (1.7 months, all p < 0.001).
  
  
  CONCLUSIONS
  Utilization of nonemergent surgical treatment and C ± RT for metastatic gastric adenocarcinoma has increased considerably over time, especially in certain patient populations; however, the true utility and cost of these treatments remain unknown.
authors.affiliation: Department of Surgery and Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
authors.forename: Karen L
authors.initials: KL
authors.lastname: Sherman
authors.forename: Ryan P
authors.initials: RP
authors.lastname: Merkow
authors.forename: Anuj M
authors.initials: AM
authors.lastname: Shah
authors.forename: C Edward
authors.initials: CE
authors.lastname: Wang
authors.forename: Karl Y
authors.initials: KY
authors.lastname: Bilimoria
authors.forename: David J
authors.initials: DJ
authors.lastname: Bentrem
mesh_terms: D000230:Adenocarcinoma / Q000556:secondary / Q000628:therapy*; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000970:Antineoplastic Agents / Q000627:therapeutic use*; D016009:Chi-Square Distribution; D003131:Combined Modality Therapy / Q000706:statistics & numerical data / Q000639:trends; D013505:Digestive System Surgical Procedures / Q000706:statistics & numerical data* / Q000639:trends; D004358:Drug Therapy / Q000706:statistics & numerical data / Q000639:trends; D005260:Female; D006801:Humans; D007348:Insurance, Health; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009362:Neoplasm Metastasis; D016016:Proportional Hazards Models; D013274:Stomach Neoplasms / Q000473:pathology / Q000628:therapy*; D014481:United States; D044465:White People
chemical_list: D000970:Antineoplastic Agents