Cancer surgery survival better at busy hospitals: two strategies--selective referral and quality improvement--might address the disparities.(Clinical Rounds)

SAN DIEGO -- A new study has found that foregut cancer patients are significantly more likely to live 5 years after surgery if their operations are performed in hospitals doing a large number of procedures annually, Dr. John D. Birkmeyer said at a symposium sponsored by the Society of Surgical Oncology.

To determine the association between hospital volume of surgical procedures and long-term surgical mortality, Dr. Birkmeyer and his coinvestigators analyzed 10 years of information (1992-2002) in a linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database.

The researchers divided hospitals into high-, medium-, and low-volume terciles based on the number of procedures performed each year. They adjusted data for patient age, acuity, comorbidities, income, stage, and adjuvant therapy to ensure they were not making unfair comparisons.

The most dramatic differences in the data were produced by esophageal resections, Dr. Birkmeyer reported. Five-year survival was twice as high for high-volume hospitals as for low-volume centers: 34% vs. 17%.

For gastric surgery, the survival curves were similar but showed a smaller difference at five years: 32% vs. 26%.

For pancreatic cancer, high-volume hospitals started out with a large advantage in postoperative survival that lasted for about 2 years. Although the difference was still significant at 5 years, it was narrower: 16% vs. 11%. "Quality in this particular cancer may help you run, but it won't help you hide," Dr. Birkmeyer said at the meeting, where he presented results for three of six cancers in the new study.

"For foregut cancer, hospital volume has a huge effect in terms of hospital mortality--bigger than on almost any other operation," he said. "High-volume hospitals have better outcomes largely because they have higher-volume surgeons," he added.