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Combined Volume of Complex Cancer Operations Protects Long-Term Survival in a Low-Volume Setting
Susanna de Geus, Marianna Papageorge, Alison Woods, Gordana Rasic, Sing Chau Ng, David McAneny, Jennifer F. Tseng, Teviah E. Sachs
Surgery, Boston Medical Center, Boston, Massachusetts, United States

Objective: Centralization for complex cancer surgery may not always be feasible due to socioeconomic disparities, geographic constraints, or patient preference. The present study investigates how the combined volume of complex cancer operations impacts long-term survival at hospitals that are low-volume for a specific high-risk cancer operation.

Design: retrospective cohort study

Setting: low-volume hospital

Patients: Patients who underwent surgery for pancreatic adenocarcinoma, gastric adenocarcinoma, hepatocellular carcinoma, esophageal adenocarcinoma, non-small cell lung cancer, or colorectal adenocarcinoma were identified from the National Cancer Data Base (2004-2018). For every operation, three separate cohorts were created: low-volume hospitals (LVH) for both the individual cancer operation and the total number of those complex operations, mixed-volume hospital (MVH) with low-volume for the individual cancer operation but high-volume for total number of complex operations, and high-volume hospitals (HVH) for each specific operation. Survival analyses included the Kaplan-Meijer method, hierarchical generalized linear models and accelerated failure time models with Weibull distribuion were used, adjusted for patient-level covariates.

Main outcomes measure: 5-year survival

Results: In total, 22,579 pancreatic adenocarcinoma, 7,203 gastric adenocarcinoma, 2,327 hepatocellular carcinoma, 11,486 esophageal adenocarcinoma, 9,482 non-small cell lung cancer, and 21,464 rectal adenocarcinoma were identified. LVH was significantly (all p<0.01) predictive for decreased 5-year survival compared to HVH across all malignancies: pancreatic adenocarcinoma (16.5% vs. 20.6%), gastric adenocarcinoma (32.4% vs. 44.1%), hepatocellular carcinoma (40.0% vs. 48.1%), esophageal carcinoma (37.9% vs. 49.7%), non-small cell lung cancer (37.1% vs. 37.5%), or rectal adenocarcinoma (61.1% vs. 68.6%). Patients who underwent surgery at MVH and HVH demonstrated similar 5-year survival for pancreatic adenocarcinoma (17.9% vs. 20.6%; p=0.1011), hepatocellular carcinoma (40.2% vs. 48.1%; p=0.1056), esophageal adenocarcinoma (48.0% vs. 49.7%; p=0.5779), and rectal adenocarcinoma (68.5% vs. 68.6%; p=0.5734). Patients who underwent surgery for gastric adenocarcinoma at MVH had decreased 5-year survival compared to patients at HVH (40.2% vs. 44.1%; p<0.000), whereas patients who underwent surgery for non-small cell lung cancer at MVH demonstrated increased 5-year survival compared to patients at HVH (42.6% vs. 37.5%; p=0.0281).

Conclusions: The results of this study suggest that hospitals that perform sufficient complex cancer surgeries, but are low volume a specific high risk cancer operation, demonstrate similar survival to centers that are high volume for the operation. These hospital provide a model for the centralization of complex cancer surgery outcomes to improve quality and access to care for patients who cannot, or choose not to, receive their care at high-volume centers.

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