The impact of ethnicity on the presentation and prognosis of patients with gastric adenocarcinoma. Results from the National Cancer Data Base.

BACKGROUND: Regional-based studies have indicated that ethnicity is associated with presentation and outcome in patients with gastric adenocarcinoma. To validate this observation in a large cohort, the authors of this report used the National Cancer Data Base (NCDB) to determine whether self-reported ethnicity influences presentation and survival in this patient population. METHODS: Patient demographics, tumor-related features, and treatment-related features were analyzed by ethnicity. Univariate analyses were performed using the chi-square test. Overall median and relative survival rates were examined by using the Kaplan-Meier method. Cox proportional-hazards models were used to identify the predictors of survival outcomes. RESULTS: Between 1995 and 2002, 81,095 cases of gastric adenocarcinoma were entered into the NCDB. There were 57,943 white patients (71.5%), 11,094 African-American patients (13.7%), 5665 Hispanic patients (7%), 4736 Asian/Pacific Islander (API) patients (5.8%), and 1657 patients of other ethnicities (2%). Significant differences were observed according to ethnicity among the variables that were compared (all P < .01). In patients with stage I and II disease, the 5-year relative survival rates for APIs (stage I, 77.2%; stage II, 48%) were more favorable than for whites (stage I, 58.7%; stage II, 32.8%), African Americans (stage I, 55.9%; stage II, 37.9%), and Hispanics (stage I, 60.8%; stage II, 39.3%). The overall median survival of APIs was more favorable than that of others (P < .01). Predictors of a better outcome were Asian race, female sex, younger age, earlier stage, lower grade, distal tumors, multimodality treatment, and care at a teaching hospital. CONCLUSIONS: Ethnicity was associated with differences in presentation and outcome of patients with gastric adenocarcinoma. APIs had a more favorable outcome than patients of other ethnicities. Further studies should target underlying biologic and socioeconomic factors to explain these differences.

Differences in the pattern of presentation and treatment of proximal and distal gastric cancer: results of the 2001 gastric patient care evaluation.

BACKGROUND: While the overall incidence of gastric cancer has declined in the United States of America, the incidence of proximal gastric cancers has increased. The purpose of this analysis was to highlight key differences between proximal and distal gastric cancer as they relate to presentation and treatment. METHODS: Data on 6,099 patients diagnosed with gastric adenocarcinoma were collected as a patient care evaluation under the auspices of the American College of Surgeons Commission on Cancer. The chi-square (chi (2)) test was used for comparisons of proportions across levels of categorical variables by site. RESULTS: The proximal cancer group included 1,924 patients (87% cardia, 13% fundus) and the distal cancer group included 1,311 patients (85% antrum, 15% pylorus). Proportionately, proximal cancer cases were male (P < 0.01), younger (P < 0.01), and White (P < 0.01); whereas, distal gastric cancer cases were Black (P < 0.01), Hispanic (P < 0.01), and Asian (P = 0.01). Surgery alone (without adjuvant chemotherapy or radiation) was utilized more frequently in distal disease (39.5%) compared to proximal disease (25.7%) (P < 0.01). Preoperative adjuvant therapy was utilized more frequently in proximal disease (41.7%) compared to distal disease (2.1%) (P < 0.01). CONCLUSIONS: The populations that developed proximal verses distal gastric cancer differed with respect to sex, age, and racial background. Cancer-directed treatments also differed based upon tumor location. Understanding these differences may someday enable us to identify important high-risk populations, prevention strategies, and ultimately best treatment strategies. Long-term survival differences will be explored when follow-up data become available.

Treatment trends and factors associated with survival in T1aN0 and T1bN0 breast cancer patients.

BACKGROUND: Breast conservation therapy (BCT) and adjuvant hormonal therapy for estrogen-receptor positive breast cancers have become standard of care. Our objectives were to evaluate trends in the surgical management and adjuvant therapy for early-stage breast cancer and to identify factors predicting survival. METHODS: Using the National Cancer Data Base (NCDB), patients with node-negative breast cancers less than 1 cm (T1aN0M0 and T1bN0M0) from 1993-2004 were identified. The time periods of 1993-1994, 1998-1999, and 2003-2004 were compared to analyze trends in surgical management and adjuvant therapy. Cox Proportional Hazards modeling was used to examine factors predicting survival. RESULTS: Overall, 123,212 cases of T1aN0M0 or T1bN0M0 breast cancer were identified. The use of breast conservation surgery increased from 61.3% in 1993/1994 to 78.3% in 2003/2004 with a concomitant decrease in the use of mastectomy. The use of radiation therapy also increased from 51.9% in 1993/1994 to 62.0% in 2003/2004. Adjuvant hormonal therapy administration rose sharply from 26.7% in 1993/1994 to 44.7% in 2003/2004. After adjusting for potential confounders, the difference in 5-year survival rates for T1a (94.3%) and T1b (93.1%) tumors was marginal (P = .04). Age, grade, size, and failure of BCS patients to receive radiation therapy and hormonal therapy were independent predictors of a higher likelihood of death. CONCLUSIONS: BCS utilization increased over time, but mastectomy rates may still be considered high given the small size of tumors in this cohort and the percent of patients eligible for BCT. The use of hormonal therapy increased significantly over the past decade. Further investigation into patient and physician factors affecting treatment choices is needed if BCT and hormonal therapy utilization is to increase.

Treatment of gastric adenocarcinoma may differ among hospital types in the United States, a report from theNational Cancer Data Base.

The concept that complex surgical procedures should be performed at high-volume centers to improve surgical morbidity and mortality is becoming widely accepted. We wanted to determine if there were differences in the treatment of patients with gastric cancer between community cancer centers and teaching hospitals in the United States. Data from the 2001 Gastric Cancer Patient Care Evaluation Study of the National Cancer Data Base comprising 6,047 patients with gastric adenocarcinoma treated at 691 hospitals were assessed. The mean number of patients treated was larger at teaching hospitals (14/year) when compared to community centers (5-9/year) (p<0.05). The utilization of laparoscopy and endoscopic ultrasonography were significantly more common at teaching centers (p<0.01). Pathologic assessment of greater than 15 nodes was documented in 31% of specimen at community hospitals and 38% at teaching hospitals (p<0.01). Adjusted for cancer stage, chemotherapy and radiation therapy were utilized with equal frequency at all types of treatment centers. The 30-day postoperative mortality was lowest at teaching hospitals (5.5%) and highest at community hospitals (9.9%) (p<0.01). These data support previous publications demonstrating that patients with diseases requiring specialized treatment have lower operative mortality when treated at high-volume centers.

Characteristics and treatment of metaplastic breast cancer: analysis of 892 cases from the National Cancer Data Base.

BACKGROUND: Metaplastic breast cancer (MBC) is characterized by various combinations of adenocarcinoma, mesenchymal, and other epithelial components. It was officially recognized as a distinct pathologic diagnosis in 2000. With few published reports, we hypothesized that MBC may have markedly different characteristics at presentation than typical infiltrating ductal carcinoma (IDC) and may be managed differently. METHODS: Data from patients with MBC and IDC reported to the National Cancer Database from January 2001 through December 2003 were reviewed for year of diagnosis, patient age, race/ethnicity, tumor size, nodal status, American Joint Committee on Cancer (AJCC) stage, tumor grade, hormone receptor status, and initial treatment, and were analyzed statistically by the Pearson chi(2) test. RESULTS: A total of 892 patients with MBC and 255,164 patients with IDC were identified. The group with MBC was older (mean age, 61.1 vs. 59.7 years; P = .001), had a significantly increased proportion of African American (14.1%, 126 of 892, vs. 10.2%, 25,900 of 255,164; odds ratio [OR], 1.455, P = .001) and Hispanic patients (5.5%, 49 of 892 vs. 3.9%, 9,947 of 255,164; OR, 1.817, P = .001), had fewer T1 tumors (29.5% vs. 65.2%), more N0 tumors (78.1% vs. 65.7%, OR, .5, P = .001), more poorly or undifferentiated tumors (67.8% vs. 38.8%), and fewer estrogen receptor-positive tumors (11.3% vs. 74.1%, OR, 22.4, P = .001) than the IDC group. Patients with MBC were treated with breast-conserving surgery less frequently than patients with IDC (38.5% vs. 55.8%, OR, 2.0, P = .001) because of the larger tumor size. Chemotherapy was used more often for patients with MBC (53.4% vs. 42.1%, OR, 1.6, P = .001) because of more advanced AJCC stage. CONCLUSIONS: MBC is a rare tumor with different characteristics than IDC: it presents with larger tumor size, less nodal involvement, higher tumor grade, and hormone receptor negativity. Patients with MBC are treated more aggressively than IDC (more often with mastectomy and chemotherapy) because of a higher stage at presentation, but are being treated by the same principles as IDC. Follow-up will determine the long-term results of the current treatment.

Treatment trends in early-stage invasive lobular carcinoma: a report from the National Cancer Data Base.

OBJECTIVE: To examine treatment trends in invasive lobular carcinoma (ILC) over the last 15 years and, in particular, to compare rates of recurrence and disease-free survival associated with breast conservation therapy compared with mastectomy. SUMMARY BACKGROUND DATA: The biologic characteristics of ILC make it difficult to estimate the extent of the disease by either clinical examination or mammography, and can also make it difficult to detect axillary lymph node metastases. Because of this, there has been a bias toward treating ILC with aggressive therapy. METHODS: Patients with ILC were selected from the National Cancer Data Base (1989-2001) using an extensive set of inclusion and exclusion criteria. A total of 21,596 patients were selected, including 8108 who received breast conservation therapy and 13,488 who received mastectomy. Analysis included demographic characteristics, trends in usage of sentinel lymph node biopsy, rates of local and distant recurrence, and 5-year disease-free survival rates. RESULTS: The use of breast conversation therapy increased almost threefold during the study period. From 1998 to 2001, the use of sentinel node biopsy increased more than twofold in the breast conservation group (an average of 23% in 1998 versus 57% in 2001), compared with limited usage in the mastectomy group (an average of 10% in 1998 versus 23% in 2001). Local recurrence rates were very low and disease-free survival rates were correspondingly high in both treatment groups for all diagnosis years and across all pathologic tumor size/lymph node status designations. CONCLUSIONS: Less invasive treatment options are becoming widely used for invasive lobular carcinoma, yielding outcomes equivalent to those seen with more aggressive treatment.