The Impact of Institutional Volume of Endoscopic Resection on Early-Stage Gastric Cancer Outcomes.

BACKGROUND

Endoscopic resection (ER) is increasingly utilized for early gastric cancer (EGC) due to its minimally invasive profile and comparable survival to gastrectomy (GR). However, concerns regarding oncologic efficacy and institutional volume impact persist. This study evaluates how ER volume quartiles impact outcomes and guideline adherence in EGC management.

METHODS

A retrospective analysis of the NCDB from 2010 to 2021 for patients with cT1aN0M0 gastric adenocarcinoma was performed comparing ER and GR. Primary outcomes were oncologic outcomes, rates of guideline adherence, and survival stratified by institutional ER volume tertiles (high, mid, low). Multivariable logistic, linear regression, and Cox proportional hazards models were used.

RESULTS

A total of 1461 patients were analyzed; 937 (61.4%) undergoing ER and 524 (35.7%) GR. 57.5% of ER occurred in the latter half of the study time period, and increasing proportional ER utilization in EGC was observed over time. When stratified by ER volume tertiles, margin positivity (14.6% high volume vs. 13.7% mid vs. 15.5% low, p = 0.85), LVI rates (6.3% high vs. 9.5% mid vs. 9.7% low, p = 0.32), guideline discordant care (22.6% high vs. 22.3% mid vs. 24.3% low, p = 0.82), and survival (vs. low volume: high HR 1.04, p = 0.87; mid HR 1.27, p = 0.39) did not differ by institutional ER volume. High-volume centers preferentially used ER (OR 1.76, p < 0.01) compared to low and mid-volume centers. Guideline-discordant ER correlated with earlier years (OR 0.69, p = 0.03) but not institutional volume (vs. low volume: high OR 0.94, p = 0.76; mid OR 0.90, p = 0.61).

CONCLUSION

ER for EGC is rapidly expanding across US institutions at all volume levels. ER achieves comparable oncological outcomes and survival independent of ER volume when guideline-concordant criteria are met, suggesting centralization may be unnecessary for EGC. The guideline discordant care rate of ~24% across all institutions highlights the need for adherence to ER criteria for EGC.