Patterns of relapse in patients with localized gastric adenocarcinoma who had surgery with or without adjunctive therapy: costs and effectiveness of surveillance

// Elena Elimova 1, 8 , Rebecca S. Slack 2 , Hsiang-Chun Chen 2 , Venkatram Planjery 1 , Hironori Shiozaki 1 , Yusuke Shimodaira 1 , Nick Charalampakis 1 , Quan Lin 1 , Kazuto Harada 1 , Roopma Wadhwa 1 , Jeannelyn S. Estrella 3 , Dilsa Mizrak Kaya 1 , Tara Sagebiel 4 , Jeffrey H. Lee 5 , Brian Weston 5 , Manoop Bhutani 5 , Mariela Blum Murphy 1 , Aurelio Matamoros 4 , Bruce Minsky 6 , Prajnan Das 6 , Paul F. Mansfield 7 , Brian D. Badgwell 7 and Jaffer A. Ajani 1 1 Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA 2 Department of Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA 3 Department of Pathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA 4 Department of Diagnostic Imaging, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA 5 Department of Gastroenterology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA 6 Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA 7 Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA 8 Department of Medical Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada Correspondence to: Jaffer A. Ajani, email: jajani@mdanderson.org Keywords: localized gastric adenocarcinoma, cancer surveillance, cost-effectiveness analysis, imaging studies, esophagogastroduodenoscopy Received: December 02, 2016 Accepted: June 02, 2017 Published: July 13, 2017 ABSTRACT Purpose: After therapy of localized gastric adenocarcinoma (GAC) patients, the costs of surveillance, relapse patterns, and possibility of salvage are unknown. Materials and Methods: We identified 246 patients, who after having a negative peritoneal staging, received therapy (any therapy which included surgery) and were surveyed (every 3–6 months in the first 3 years, then yearly; ~10 CTs and ~7 endoscopies per patient). We used the 2016 Medicare dollars reimbursed as the “costs” for surveillance. Results: Common features were: Caucasians (57%), men (60%), poorly differentiated histology (76%), preoperative chemotherapy (74%), preoperative chemoradiation (59%), and had surgery (100%). At a median follow-up of 3.7 years (range, 0.1 to 18.3), the median overall survival (OS) was 9.2 years (95% CI, 6.0 to 11.2). Tumor grade ( p = 0.02), p/yp stage ( p < 0.001), % residual GAC ( p = 0.05), the R status ( p = 0.01), total gastrectomy ( p = 0.001), and relapse type ( p = 0.02) were associated with OS. Relapse occurred in 79 (32%) patients (only 8% were local-regional) and 90% occurred within 36 months of surgery. P/yp stage ( p < 0.001) and total gastrectomy ( p = 0.01) were independent prognosticators for OS in the multivariate analysis. Only 1 relapsed patient had successful salvage therapy. The estimated reimbursement for imaging studies and endoscopies was $1,761,221.91 (marked underestimation of actual costs). Conclusions: The median OS of localized GAC patients was excellent with infrequent local-regional relapses. Rigorous surveillance had a low yield and high “costs”. Our data suggest that less frequent surveillance intervals and limiting expensive investigations to symptomatic patients may be warranted.