Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2025 Oct;32(10):7740-7750.
doi: 10.1245/s10434-025-17795-8. Epub 2025 Jul 17.

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

Michelle Holland #  1   2 , Jaspinder Sanghera #  1   2 , Ioannis Liapis  1   2 , Rida Ahmad  3 , Krisha Amin  3 , Ahmed Abdalla  4 , Martin J Heslin  1 , Smita Bhatia  2 , Annabelle L Fonseca  5   6
Affiliations

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

Michelle Holland et al. Ann Surg Oncol. 2025 Oct.

Abstract

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.

Keywords: Attrition; Deconditioning; Gastric cancer; Neoadjuvant chemotherapy; Pancreatic cancer.

PubMed Disclaimer

Conflict of interest statement

Disclosure: Work is supported by the Surgical Oncology Research Training Program Grant T32CA229102.

Figures

Fig. 1
Fig. 1
Attrition flow chart
Fig. 2
Fig. 2
Survival probability by cancer type and attrition status
Fig. 3
Fig. 3
Root cause analysis
See this image and copyright information in PMC

References

    1. Siegel RL, Giaquinto AN, Jemal A. Cancer statistics. CA Cancer J Clin [Internet]. 2024;74(1):12–49. - PubMed
    1. Fonseca AL, Ahmad R, Amin K, Tripathi M, Abdalla A, Hearld L, et al. Understanding barriers to guideline-concordant treatment in foregut cancer: from data to solutions. Ann Surg Oncol [Internet]. 2024;31(9):6007. - PMC - PubMed
    1. Lee YS, Lee JC, Yang SY, Kim J, Hwang JH. Neoadjuvant therapy versus upfront surgery in resectable pancreatic cancer according to intention-to-treat and per-protocol analysis: a systematic review and meta-analysis. Sci Rep. 2019;9(1):1–8. - PMC - PubMed
    1. Lisa Hang N, McMillian N, MaryElizabeth Stein M, Ajani JA, D TA, Chair V, et al. NCCN Guidelines Version 4.2024 Gastric Cancer Continue NCCN Guidelines Panel Disclosures [Internet]. 2024. https://www.nccn.org/home/member-
    1. Lurie RH, Cardin DB, Gabriela Chiorean E, Hutchinson Cancer Center Jared Christensen FA, Chung V, Czito B, et al. NCCN Guidelines Version 3.2024 Pancreatic Adenocarcinoma Continue NCCN Guidelines Version 3.2024 Pancreatic Adenocarcinoma [Internet]. 2024. https://www.nccn.org/home/member-

LinkOut - more resources