Is the Distance Worth It? Patients With Rectal Cancer Traveling to High-Volume Centers Experience Improved Outcomes

219 Background: Interest is growing in value in health care, defined as better outcomes at lower costs. A primary driver of cost in radiation oncology is the use of IMRT. We examined the patterns and correlates of use of IMRT across Michigan using publicly available data. Methods: As a certificate of need state, Michigan requires every radiation oncology facility to report yearly the number of external beam and IMRT treatments delivered. Data for 2005-2008 were obtained through a Freedom of Information Act request of the Michigan Department of Community Health, while 2009-2010 data were available at its website. Percentage of external beam treatments delivered using IMRT (IMRT%) was examined across centers over time and repeated-measures longitudinal linear regression was used to identify factors associated with use. Results: During 2005-2010, 48 to 65 centers reported data. Median IMRT% (range) rose steadily during the study period: 2005 16% (0-64); 2006 21% (0-57); 2007 27% (0-79); 2008 37% (7-85); 2009 41% (0-87) 2010 45% (7-100). There was also significant between-center variation (see table). Regression modeling demonstrated that IMRT% was associated with year (+6.7% per year, p<0.0001), facility type (+7.1% freestanding versus hospital, p<0.11), facility annual volume (+5.0% high volume: 7,000+ versus low: <7,000, p=0.01) and the interaction between year and volume (low volume +2.4% per year versus high volume p<0.02). The significant interaction between year and volume suggests that the greatest IMRT% growth was in low volume centers (6.7% per year versus 4.3% per year for high volume). Conclusions: IMRT utilization has grown steadily across Michigan between 2005 and 2010. There is significant variation in its use that appears to be related in part to facility characteristics. The newly established Michigan Radiation Oncology Quality Collaborative (MROQC) is beginning to explore the use of IMRT in patients with breast and lung cancer statewide to identify those groups of patients where improved outcomes may justify its higher cost. [Table: see text]

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Predictors of rectal cancer resection at high-volume hospitals among Medicare patients.

Journal of Clinical Oncology ◽

10.1200/jco.2018.36.4_suppl.808 ◽

2018 ◽

Vol 36 (4_suppl) ◽

pp. 808-808

Author(s):

Mary E. Charlton ◽

Catherine Chioreso ◽

Irena Gribovskaja-Rupp ◽

Chi Lin ◽

Marcia M Ward ◽

...

Keyword(s):

Rectal Cancer ◽

Rectal Adenocarcinoma ◽

High Volume ◽

Neoadjuvant Chemoradiation ◽

Sphincter Preservation ◽

Cancer Center ◽

Medicare Beneficiaries ◽

Co Morbidity ◽

High Volume Hospital ◽

Low Volume

808 Background: Hospitals that perform high volumes of rectal cancer resections achieve superior rates of sphincter preservation and survival compared to those that do not, but many rectal cancer resections are still performed in low-volume centers. We aimed to determine the patient, provider and pathway characteristics associated with receipt of surgery from high-volume hospitals. Methods: Patient and provider characteristics were extracted from the SEER-Medicare database for Medicare beneficiaries (age 66+) with stage II/III rectal adenocarcinoma diagnosed 2007-2011 who received rectal cancer-directed surgery. Hospitals were divided into quartiles by volume of rectal cancer resections, and were also classified by NCI cancer center designation. Results: 2056 patients were included, and 57% received surgery in a high-volume hospital or NCI-designated center. Those residing in census tracts classified as rural and having higher median incomes, lower poverty, and higher levels of education more frequently received surgery in high-volume hospitals; there were no differences by age, gender, stage, or co-morbidity status. 55% of patients received surgery at the same facility where they received the colonoscopy that identified their cancer. In multivariate analyses, the strongest predictor of receiving one’s surgery in a high-volume hospital was receipt of colonoscopy at a high-volume facility (OR = 3.75, 95% CI: 2.93-4.79). Those treated in high-volume hospitals more often had guideline-recommended staging (TRUS/MRI) and treatment (neoadjuvant chemoradiation). Conclusions: Rectal cancer patients tended to stay at the facility where their cancer was diagnosed; and did not typically seek out high-volume providers if their colonoscopy was performed in a low-volume facility. This suggests that colonoscopists may have substantial influence over where patients receive surgery. Given that rurality, income and education appear to more strongly predict receipt of surgery at a high-volume hospital compared to clinical characteristics, further research is needed to understand considerations driving patient decisions and referring providers’ recommendations for care.

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Treatment at high-volume facilities and academic centers in relation to overall survival in patients with locally advanced pancreatic cancer: A National Cancer Database analysis

Journal of Clinical Oncology ◽

10.1200/jco.2018.36.4_suppl.392 ◽

2018 ◽

Vol 36 (4_suppl) ◽

pp. 392-392

Author(s):

John David ◽

Sungjin Kim ◽

Erik Anderson ◽

Arman Torossian ◽

Simon Lo ◽

...

Keyword(s):

Pancreatic Cancer ◽

Overall Survival ◽

Surgical Resection ◽

Locally Advanced ◽

Advanced Pancreatic Cancer ◽

High Volume ◽

Locally Advanced Pancreatic Cancer ◽

Median Income ◽

National Cancer Database ◽

Improved Outcomes

392 Background: Numerous studies have shown that treatment at a high volume facility (HVF) for patients (pts) with pancreatic cancer is associated with improved outcomes, particularly with pancreatectomy. In fact, a recent study showed that pts undergoing a pancreatectomy at an academic center (AC) is independently associated with improved outcomes. However, the role of chemotherapy (CT) and radiation (RT) in the treatment of locally advanced pancreatic cancer (LAPC) at HVF and AC, to our knowledge, has not been studied. Herein, we investigate the benefit of treatment at HVF and AC compared to low volume facilities (LVF) and non-academic centers (NAC) with CT or chemoradiation (CRT) in pts with LAPC. Methods: The National Cancer Database (NCDB) was utilized to identify LAPC patients treated at all facility types. All patients were treated with CT or CRT. Univariate (UVA) and multivariate (MVA) Cox regression were performed to identify the impact of HVF and AC on overall survival (OS) when compared to LVF and NAC, respectively. HVF was defined as the top 5% of facilities by number of pts treated. Results: From 2004 – 2014, a total of 10139 pts were identified. The median age was 66 years (range 22-90) with median follow up of 48.8 months (46-52.1 months); 49.9% were male and 50.1% female. All pts had clinical stage 3/T4 disease irrespective of nodal metastases. Of these, 4779 pts were treated at an AC and 5260 were treated at a NAC and 588 were treated at HVF and 9551 were treated at LVF. On UVA, age, high median income, high education level, comorbidities, and recent year of diagnosis were associated with improved OS. ACs were associated with improved OS when compared to non-AC (HR 0.92 95% CI 0.88 – 0.96, p = 0.004), as were HVF when compared to LVH (HR 0.84 95% CI 0.76 – 0.92, p < 0.001). Odds ratio for undergoing surgical resection at HVF and AC was 1.68 and 1.37 (p < 0.001), respectively, when compared to LVF and NAC. Conclusions: The treatment of LAPC patients with CT or CRT at an AC led to significantly improved rate of surgical resection and OS. In the absence of prospective data, these results support the referral of pts with LAPC to HVF and/or AC for evaluation and treatment.

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Nonoperative management (NOM) in rectal cancer: Physician perspectives on offering NOM as standard of care.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.4_suppl.79 ◽

2020 ◽

Vol 38 (4_suppl) ◽

pp. 79-79

Author(s):

Andrea Marie Covelli ◽

Fayez A. Quereshy ◽

Erin Diane Kennedy ◽

Sami A. Chadi ◽

Frances Catriona Wright

Keyword(s):

Rectal Cancer ◽

Neoadjuvant Chemoradiotherapy ◽

Oncologic Outcome ◽

Standard Of Care ◽

High Volume ◽

Operative Management ◽

Oncologic Outcomes ◽

Snowball Sampling ◽

Structured Interviews ◽

And Gender

79 Background: 20% of rectal cancer patients will have a complete clinical response (cCR) following neoadjuvant chemoradiotherapy. Non-operative management (NOM) with close surveillance can spare patients proctectomy and avoid the sequelae of surgery. Patients are interested in and advocate for NOM, whereas oncologists appear to be reluctant to offer this option. We wished to identify the perceptions and barriers that oncologists face when considering NOM. Methods: This qualitative study explored oncologists’ experiences treating rectal cancer and identified their perceptions and values around NOM. Purposive and snowball sampling identified medical, radiation and surgical oncologists’ who treat a high volume of rectal cancer across Canada. Oncologists varied in length/location of practice and gender. Data were collected via semi-structured interviews. Constant comparative analysis identified key concepts. Results: Data saturation was achieved after 40 interviews: 20 surgeons, 12 radiation and 8 medical oncologists. The dominant theme was “NOM is not ready for prime time’. Most oncologists felt that there is insufficient long-term data around NOM and single center studies appear ‘too good to be true’. Physicians voiced concerns about worsening oncologic outcomes in the setting of regrowth, the challenges in determining a cCR and apprehension around patient compliance to surveillance. Some oncologists felt that NOM is limited to a very select population and voiced reluctance in offering it to younger patients or patients with more advanced disease. There was little consideration to improved functional outcomes with NOM. Overall the majority of participants felt that NOM is ‘ trading the benefit of saving the rectum for the uncertainty of an inferior oncologic outcome’. Conclusions: Oncologists felt that NOM should not be offered as a standard of care option following a cCR. Most felt that there is insufficient data supporting NOM and are concerned around worse oncologic outcomes. Patient views of NOM are critically needed to assess if patients value the same outcomes. Additional research is needed to address barriers should patients wish to consider NOM as a treatment option in the setting of a cCR.

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The effect of rectal washout on local recurrence following rectal cancer surgery

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2017.0202 ◽

2018 ◽

Vol 100 (2) ◽

pp. 146-151 ◽

Cited By ~ 1

Author(s):

SR Moosvi ◽

K Manley ◽

J Hernon

Keyword(s):

Rectal Cancer ◽

Local Recurrence ◽

Anterior Resection ◽

High Volume ◽

Conclusive Evidence ◽

Rectal Cancer Surgery ◽

Single Institution ◽

Recurrence Rates ◽

Rectal Washout ◽

Significant Difference

Introduction Local recurrence after surgery for rectal cancer is associated with significant morbidity and debilitating symptoms. Intraoperative rectal washout has been linked to a reduction in local recurrence but there is no conclusive evidence. The aim of this study was to evaluate whether performing rectal washout had any effect on the incidence of local recurrence in patients undergoing anterior resection for rectal cancer in the context of the current surgical management. Methods A total of 395 consecutive patients who underwent anterior resection with or without rectal washout for rectal cancer between January 2003 and July 2009 at a high volume single institution were analysed retrospectively. A standardised process for performing washout was used and all patients had standardised surgery in the form of total mesorectal excision. Neoadjuvant and adjuvant therapy was used on a selected basis. Patients were followed up for five years and local recurrence rates were compared in the two groups. Results Of the 395 patients, 297 had rectal washout and 98 did not. Both groups were well matched with regard to various important clinical, operative and histopathological characteristics. Overall, the local recurrence rate was 5.3%. There was no significant difference in the incidence of local recurrence between the washout group (5.7%) and the no washout group (4.1%). Conclusions Among our cohort of patients, there was no statistical difference in the incidence of local recurrence after anterior resection with or without rectal washout. This suggests that other factors are more significant in the development of local recurrence.

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High-Volume Surgeons Have Improved Outcomes after Robotic Transthoracic Esophagectomy in the Community Setting

Journal of the American College of Surgeons ◽

10.1016/j.jamcollsurg.2021.07.487 ◽

2021 ◽

Vol 233 (5) ◽

pp. S236

Author(s):

Jamie Glasser ◽

Cassandra Schuster ◽

Kenneth Meredith ◽

Jamie Huston

Keyword(s):

Community Setting ◽

High Volume ◽

Transthoracic Esophagectomy ◽

Improved Outcomes

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The Impact of Regionalization of Pancreaticoduodenectomy for Pancreatic Cancer in North Carolina since 2004

The American Surgeon ◽

10.1177/000313481408000619 ◽

2014 ◽

Vol 80 (6) ◽

pp. 561-566 ◽

Cited By ~ 12

Author(s):

Ryan Z. Swan ◽

David J. Niemeyer ◽

Ramanathan M. Seshadri ◽

Kyle J. Thompson ◽

Amanda Walters ◽

...

Keyword(s):

North Carolina ◽

Significant Risk ◽

High Volume ◽

Major Morbidity ◽

The North ◽

Time Period ◽

Improved Outcomes ◽

Before And After ◽

Low Volume ◽

The Impact

Pancreaticoduodenectomy (PD) carries a significant risk. High-volume centers (HVCs) provide improved outcomes and regionalization is advocated. Rapid regionalization could, however, have detrimental effects. North Carolina has multiple HVCs, including an additional HVC added in late 2006. We investigated regionalization of PD and its effects before, and after, the establishment of this fourth HVC. The North Carolina Hospital Discharge Database was queried for all PDs performed during 2004 to 2006 and 2007 to 2009. Hospitals were categorized by PD volume as: low (one to nine/year), medium (10 to 19/year), and high (20/year or more). Mortality and major morbidity was assessed by comparing volume groups across time periods. Number of PDs for cancer increased 91 per cent (129 to 246 cases) at HVCs, whereas decreasing at low-volume (62 to 58 cases) and medium-volume (80 to 46 cases) centers. Percentage of PD for cancer performed at HVCs increased significantly (47.6 to 70.3%) while decreasing for low- and medium-volume centers ( P < 0.001). Mortality was significantly less at HVCs (2.8%) compared with low-volume centers (10.3%) for 2007 to 2009. Odds ratio for mortality was significantly lower at HVCs during 2004 to 2006 (0.31) and 2007 to 2009 (0.34). Mortality for PD performed for cancer decreased from 6.6 to 4.6 per cent ( P = 0.31). Major morbidity was not significantly different between groups within either time period; however, there was a significant increase in major morbidity at low-volume centers ( P = 0.018). Regionalization of PD for cancer is occurring in North Carolina. Mortality was significantly lower at HVCs, and rapid regionalization has not detracted from the superior outcomes at HVCs.

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Pathologic complete response rates after neoadjuvant treatment in rectal cancer: An analysis of the NCDB.

Journal of Clinical Oncology ◽

10.1200/jco.2016.34.4_suppl.713 ◽

2016 ◽

Vol 34 (4_suppl) ◽

pp. 713-713 ◽

Cited By ~ 1

Author(s):

Patrick D. Lorimer ◽

Russell C. Kirks ◽

Danielle Boselli ◽

Anthony Joseph Crimaldi ◽

Joshua S. Hill ◽

...

Keyword(s):

Rectal Cancer ◽

Neoadjuvant Therapy ◽

Mixed Models ◽

Generalized Linear Mixed Models ◽

Linear Mixed Models ◽

Pathologic Complete Response ◽

High Volume ◽

Complete Response ◽

Lower Grade ◽

T Classification

713 Background: Pathologic complete response (pCR) of rectal cancer following neoadjuvant therapy is associated with decreased local recurrence and increased overall survival. The present study utilizes a large national dataset to identify predictors of pCR in rectal cancer. Methods: The NCDB was queried for patients with non-metastatic rectal cancer (2004-2011) who underwent neoadjuvant therapy (regional radiation dose 4500 cGy, boost dose 540 cGy) followed by surgical resection. Generalized linear mixed models were used to analyze the probability of pCR by hospital volume with adjustments for demographic, socioeconomic, staging, and tumor characteristics. Hospitals were separated into groups based on the number of resections performed per year <2, 2-5, and 5+. To account for clustering of cases at individual hospitals, a random effect was used at the hospital level and covariates were included as fixed effects. Results: 7,859 patients met inclusion criteria from 951 participating hospitals. Generalized linear mixed models demonstrated that the odds of achieving pCR was independently associated with more recent diagnosis, female gender, private insurance, smaller tumor size, lower grade, lower clinical T-classification, increasing interval between the end of radiation and surgery, and treatment at higher volume institutions (Table). Conclusions: The incidence of pCR was associated with favorable tumor factors (size, grade, T classification), demographics (insurance status) as well as treatment factors (time between radiation and surgery and institutional volume). With the data available, it is not clear what is driving the higher rates of pCR at high volume institutions. Research specifically targeted at understanding processes which are associated with pCR in high volume institutions is needed so that similar results can be achieved across the spectrum of facilities caring for patients in this population. [Table: see text]

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