Attrition after Neoadjuvant Chemotherapy in Foregut Cancer: Experience at a Tertiary Center in the Deep South.

Background: Neoadjuvant chemotherapy (NAC) is increasingly used in the management of foregut cancers to downstage tumors, treat micrometastases, and improve oncological outcomes. However, many patients fail to undergo surgical resection after NAC. This study aims to identify the underlying causes of non-tumor biology-related attrition and thus evaluate the potentially modifiable factors contributing to pre-surgical attrition.

Methods: A retrospective review was conducted of patients with non-metastatic gastric or pancreatic adenocarcinoma treated between 2018-2022 at a tertiary and safety net hospital in the Southeastern U.S. Multivariable logistic regression and a root cause analysis (RCA) were performed to examine the association of sociodemographic factors with attrition and delineate underlying root causes.

Results: Of 169 patients who received NAC, 47% (n = 80) experienced potentially modifiable attrition that was unrelated to disease progression. A diagnosis of pancreatic cancer (p = 0.001), age ≥ 75 (p = 0.04), and ≥ 3 ED visits after diagnosis (p=0.03) were independently associated with attrition on multivariable analysis. Four causes of non-tumor biology-related attrition were identified on RCA: physical deconditioning due to chemotherapy toxicity, malignancy or procedural complications, loss to follow-up resulting from missed appointments, healthcare delivery factors including delayed or absent referral to specialists, and patient refusal of treatment. Attrition was associated with significantly worse survival in both pancreatic and gastric cancer.

Discussion: Nearly 50% of patients receiving NAC for pancreatic and gastric cancer failed to undergo surgery due to potentially modifiable causes. Addressing the underlying barriers through the implementation of structured prehabilitation programs, symptom management clinics, and cancer care navigators may reduce non-tumor biology-related attrition and improve outcomes.