title: Multimodality Treatment of T4 Gastric Cancer in the United States: Utilization Trends and Impact on Survival.
abstract: BACKGROUND
  National guidelines advocate use of multimodality therapy (MMT) for treatment of T4 gastric cancer (T4GC). Prior studies demonstrate poor compliance with these guidelines. We sought to assess treatment trends and association between different treatment approaches and overall survival (OS) in a large cohort of U.S.
  
  
  METHODS
  Patients diagnosed with clinical T4 gastric adenocarcinoma were selected from the National Cancer Data Base (1998-2011). Temporal trends, risk factors associated with failure to receive treatment, and effect of treatments on OS were assessed.
  
  
  RESULTS
  Of 4369 patients with T4GC, only 15 % (n = 652) received MMT. Treatment with MMT increased over time, and was utilized in 25 % of patients after 2006. Older age, African American race, nonprivate insurance, proximal tumor location, and clinical node-negative disease were associated with failure to receive surgery; older age, female sex, poorly differentiated tumor grade, clinical node-negative disease, and prolonged postoperative length of stay were associated with failure to complete MMT in patients who underwent surgical resection. Median OS was longest in patients receiving MMT (19.2 months), and was similarly poor in patients undergoing surgical resection (9.0 months) or nonsurgical therapy (8.3 months; p < 0.001). Median OS was longer in patients receiving neoadjuvant therapy compared to patients receiving adjuvant therapy (27.8 vs. 16.6 months; p = 0.004).
  
  
  CONCLUSIONS
  Treatment with neoadjuvant MMT is increasing and is associated with prolonged survival. Surgery alone and chemotherapy with or without radiotherapy without resection are associated with similarly poor outcomes. Appropriate treatment sequencing may facilitate delivery of MMT and improve outcomes in patients with T4GC.
authors.affiliation: Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Lea
authors.initials: L
authors.lastname: Lowenfeld
authors.affiliation: Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Jashodeep
authors.initials: J
authors.lastname: Datta
authors.affiliation: Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Russell S
authors.initials: RS
authors.lastname: Lewis
authors.affiliation: Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Matthew T
authors.initials: MT
authors.lastname: McMillan
authors.affiliation: Division of Hematology/Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Ronac
authors.initials: R
authors.lastname: Mamtani
authors.affiliation: Division of Hematology/Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Nevena
authors.initials: N
authors.lastname: Damjanov
authors.affiliation: Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Vinay
authors.initials: V
authors.lastname: Chandrasekhara
authors.affiliation: Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Giorgos C
authors.initials: GC
authors.lastname: Karakousis
authors.affiliation: Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Drebin
authors.affiliation: Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Douglas L
authors.initials: DL
authors.lastname: Fraker
authors.affiliation: Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. robert.roses@uphs.upenn.edu.
authors.forename: Robert E
authors.initials: RE
authors.lastname: Roses
mesh_terms: D000230:Adenocarcinoma / Q000401:mortality* / Q000473:pathology / Q000628:therapy; D000368:Aged; D017024:Chemotherapy, Adjuvant; D015331:Cohort Studies; D003131:Combined Modality Therapy / Q000401:mortality* / Q000706:statistics & numerical data*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D009367:Neoplasm Staging; D011379:Prognosis; D018714:Radiotherapy, Adjuvant; D013274:Stomach Neoplasms / Q000401:mortality* / Q000473:pathology / Q000628:therapy; D015996:Survival Rate; D014481:United States