# Hospital variation in treatment for synchronous metastatic esophageal and gastric cancer: A nationwide population‐based study in the Netherlands

## TL;DR

This study found significant differences in cancer treatment and survival outcomes for patients diagnosed at different hospitals in the Netherlands.

## Contribution

The study reveals substantial variation in systemic treatment and survival outcomes for metastatic esophageal and gastric cancer across hospitals.

## Key findings

- Hospital of diagnosis was significantly associated with the probability of receiving systemic treatment.
- Patients diagnosed at hospitals with lower systemic treatment probabilities had worse overall survival.
- Variation in treatment ranged from 19.8% to 69.6% for esophageal cancer and 15.8% to 81.3% for gastric cancer.

## Abstract

Care for metastatic esophageal (EC) or gastric cancer (GC) includes a large variety of treatment modalities. Data on treatment variation across centers are unknown. This study investigated treatment variation across hospitals and its effect on overall survival (OS) in the Netherlands by conducting a nationwide retrospective cohort study with population‐based data from the Netherlands Cancer Registry. Patients diagnosed with synchronous metastatic EC/GC between 2015 and 2022 were included. Multilevel logistic regression assessed treatment patterns according to hospital of diagnosis. OS was analyzed using Cox regression analysis after categorizing hospitals into tertiles based on their adjusted odds (low/medium/high) for systemic treatment (chemotherapy, targeted therapy, and immunotherapy). Among 8406 EC and 3871 GC patients, the proportion receiving systemic treatment varied substantially: 19.8%–69.6% for EC and 15.8%–81.3% for GC across hospitals. Hospital of diagnosis was significantly associated with the adjusted probability of receiving systemic treatment (p < .0001). Ten out of 78 EC (12.8%) and 7 out of 73 (9.6%) GC hospitals had significantly lower systemic treatment probabilities. EC patients with OS ≥4 months diagnosed at hospitals with lower probabilities had significantly worse OS compared to high‐probability hospitals (hazard ratios [HR] 0.87 [0.79–0.95] p = .002). GC patients from low‐probability hospitals had significantly worse OS than from medium‐ (HR 0.86 [0.76–0.96], p = .011) or high‐probability hospitals (HR 0.73 [0.64–0.82], p < .0001). In conclusion, this study showed substantial hospital variation in treatment for metastatic EC and GC. Hospital of diagnosis was not only associated with the probability of receiving systemic treatment but also OS. This reflects the challenge of ensuring equal healthcare access.

A range of treatment options exist for metastatic esophageal (EC) and gastric cancer (GC). Which modalities or combination thereof are optimal for these malignancies, however, remains uncertain. Here, the authors examined differences in systemic treatment for metastatic EC and GC across hospitals in the Netherlands. Analyses reveal substantial variations in treatment for both diseases. Notably, while hospital of diagnosis was significantly associated with probability of receiving systemic treatment, no associations were found for diagnosis in specialized surgical or high‐volume centers. Hospital of diagnosis was further linked to overall survival. The findings underscore the importance of improving equitable access to care.