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Vol. 21, No. 4, 2004
Issue release date: 2004

Impact of Volume and Specialization for Cancer Surgery

Weitz J. · Koch M. · Friess H. · Büchler M.W.
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Abstract

Background/Aims: The so-called volume/outcome relationship postulates that a higher caseload and specialization results in an improved outcome. The existence of such a relationship, however, is still debated in the literature. The objective of this review is to discuss the available data on this relationship in surgical oncology. Methods: A Medline analysis was performed using the following terms: volume, outcome, cancer, and surgery. The bibliography of each relevant article was screened for further studies. Results: For most malignancies a volume/outcome relationship was demonstrated in recent years. Components of this improved outcome are decreased perioperative morbidity and mortality, higher quality of life after surgery, improved economic outcome, and a better long-term prognosis for patients with cancer. The magnitude of this relationship, however, varies greatly among different malignancies. The exact reason for the volume/outcome relationship is still unknown. Conclusion: Concentrating high-risk procedures in high-volume hospitals might prevent thousands of perioperative deaths per year. This concept seems feasible for rare and high-risk diseases; however, it is unclear what threshold should be used for the definition of a high-volume provider. For common and low-risk diagnoses, it seems more realistic to educate the medical community in order to improve the outcome for the patients.



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References

  1. Luft HS, Bunker JP, Enthoven AC: Should operations be regionalized? The empirical relation between surgical volume and mortality. N Engl J Med 1979;301:1364–1369.
  2. Hillner BE, Smith TJ, Desch CE: Hospital an physician volume or specialization and outcomes in cancer treatment: Importance in quality of cancer care. J Clin Oncol 2000;18:2327–2340.
  3. Dudley RA, Johansen KL, Brand R, Rennie DJ, Milstein A: Selective referral to high-volume hospitals: Estimating potentially avoidable deaths. JAMA 2000;283:1159–1166.
  4. Begg CB, Cramer LD, Hoskins WJ, Brennan MF: Impact of hospital volume on operative mortality for major cancer surgery. JAMA 1998;280:1747–1751.
  5. Birkmeyer JD, Siewers AE, Finlayson EVA, Stukel TA, Lucas FL, Batista I, Welch G, Wennberg DE: Hospital volume and surgical mortality in the United States. N Engl J Med 2002;346:1128–1137.
  6. Harmon J, Tang D, Gordon T, Bowman H, Choti M, Kaufman H, Bender J, Duncan M, Magnuson T, Lillemoe K, Cameron J: Hospital volume can serve as a surrogate for surgeon volume for achieving excellent outcomes in colorectal resection. Ann Surg 1999;230:404–411.
  7. Choti MA, Bowman H, Pitt HA, Sosa JA, Sitzmann JV, Cameron JL, Gordon T: Should hepatic resections be performed at high-volume referral centers? J Gastrointest Surg 1998;2:11–20.
  8. Dimick JB, Pronovost PJ, Cowan JA, Lipsett PA: Postoperative complication rates after hepatic resection in Maryland hospitals. Arch Surg 2003;138:41–46.
  9. Bachmann MO, Alderson D, Edwards D, Wotton S, Bedford C, Peters TJ, Harvey IM: Cohort study in South and West England of the influence on specialization on the management and outcome of patients with esophageal and gastric cancers. Br J Surg 2002;89:914–922.
  10. Yao SL, Lu-Yao G: Population-based study of relationships between hospital volume of prostatectomies, patient outcomes, and length of hospital stay. J Natl Cancer Inst 1999;91:1950–1956.
  11. Karakiewicz PI, Bazinet M, Aprikian AG, Tanguay S, Elhilali MM: Thirty-day mortality rates and cumulative survival after radical retropubic prostatectomy. Urology 1998;52:1041–1046.
  12. Thorpe AC, Cleary R, Coles J, Vernon S, Reynolds J, Neals DE: Deaths and complications following prostatectomy in 1400 men in the northern region of England. Br J Urol 1994;74:559–565.
  13. Hu JC, Gold KF, Pashos CL, Mehta SS, Litwin MS: Role of surgeon volume in radical prostatectomy outcomes. J Clin Oncol 2003;21:401–405.
  14. Luft HS, Hunt SS, Maerki SC: The volume-outcome relationship: Practice-makes-perfect or selective-referral patterns? Health Serv Res 1987;22:157–182.
  15. McArdle CS, Hole D: Impact of variability among surgeons on postoperative morbidity and mortality and ultimate survival. BMJ 1991;302:1501–1505.
  16. Riley G, Lubitz J: Outcomes of surgery among the Medicare aged. Health Care Financ Rev 1985;7:37–47.
  17. Hannan EL, O’Donell JF, Kilburn H, Bernard HR, Yazici A: Investigation of the relationship between volume and mortality for surgical procedures performed in New York State hospitals. JAMA 1989;262:503–510.
  18. Hughes RG, Hunt SS, Luft HS: Effects of surgeon volume and hospital volume on quality of care in hospitals. Med Care 1987;25:489–503.
  19. Kelly JV, Hellinger FJ: Physician and hospital factors associated with mortality of surgical patients. Med Care 1986;24:785–800.
  20. Maerki SC, Luft HS, Hunt SS: Selecting categories of patients for regionalization. Med Care 1986;24:148–158.
  21. Rosen L, Stasik JJ, Reed JF: Variations in colon and rectal surgical mortality: Comparison of specialties with a state-legislated database. Dis Colon Rectum 1996;39:129–135.
  22. Schrag D, Cramer LD, Bach PB, Cohen AM, Warren JL, Begg CB: Influence of hospital procedure volume on outcomes following surgery for colon cancer. JAMA 2000;284:3028–3035.
  23. Callahan MA, Christos PJ, Gold HT, Mushlin AI, Daley J: Influence of surgical subspecialty training on in-hospital mortality for gastrectomy and colectomy patients. Ann Surg 2003;238:629–639.
  24. Schrag D, Panageas KS, Riedel E, Bach PB, Guillem JG, Begg CB: Surgeon volume compared to hospital volume as a predictor of outcome following primary colon cancer resection. J Surg Oncol 2003;83:68–78.
  25. Dimick JB, Cowan JA, Upchurch GR, Colletti LM: Hospital volume and surgical outcomes for elderly patients with colorectal cancer in the United States. J Surg Res 2003;114:50–56.
  26. Sosa JA, Bowman HM, Tielsch J, Powe NR, Gordon T, Udelsman R: The importance of surgeon experience for clinical and economic outcomes from thyroidectomy. Ann Surg 1998;228:320–330.
  27. Romano PS, Mark DH: Patient and hospital characteristics related to in-hospital mortality after lung cancer resection. Chest 1992;101:1332–1337.
  28. Silvestri GA, Handy J, Lackland D, Corvey E, Reed CE: Specialists achieve better outcomes than generalists for lung cancer surgery. Chest 1998;114:675–680.
  29. Marusch F, Koch A, Schmidt U, Pross M, Gastinger I, Lippert H: Hospital caseload and the results achieved in patients with rectal cancer. Br J Surg 2001;88:1397–1402.
  30. Hodgson DC, Zhang W, Zaslavsky AM, Fuchs CS, Wright WE, Ayanian JZ: Relation of hospital volume to colostomy rates and survival for patients with rectal cancer. J Natl Cancer Inst 2003;95:708–716.
  31. Simunovic M, To T, Baxter N, Balshem A, Ross E, Cohen Z, McLeod R, Engstrom P, Sigurdson E: Hospital procedure volume and teaching status do not influence treatment and outcome measures of rectal cancer surgery in a large general population. J Gastrointest Surg 2000;4:324–330.
  32. Parry JM, Collins S, Mathers J, Scott NA, Woodman C: Influence of volume of work on the outcome of treatment for patients with colorectal cancer. Br J Surg 1999;86:475–481.
  33. Dimick JB, Cattaneo SM, Lipsett PA, Pronovost PJ, Heitmiller RF: Hospital volume is related to clinical and economic outcomes of esophageal resection in Maryland. Ann Thorac Surg 2001;72:334–339.
  34. Sosa JA, Bowman HM, Gordon T, Bass E, Yeo CJ, Lillemoe KD, Pitt HA, Tielsch JM, Cameron JL: Importance of hospital volume in the overall management of pancreatic cancer. Ann Surg 1998;228:429–438.
  35. Gordon T, Burleyson G, Tielsch J, Cameron J: The effects of regionalization on cost and outcome for one general high-risk surgical procedure. Ann Surg 1995;221:43–49.
  36. Hermanek P, Wiebelt H, Riedl S, Staimmer D, Hermanek P: Langzeitergebnisse der chirurgischen Therapie des Coloncarcinoms. Chirurg 1994;65:287–297.
  37. Hermanek P, Wiebelt H, Staimmer D, Riedl S: Prognostic factors of rectum carcinoma: Experience of the German multicentre study SGCRC. Tumori 1995;81(suppl):60–64.

    External Resources

  38. Portner GA, Soskolne CL, Yakimets WW, Newman SC: Surgeon-related factors and outcome in rectal cancer. Ann Surg 1998;227:157–167.
  39. Holm T, Johansson H, Cedermark B, Ekelund G, Rutqvist LE: Influence of hospital and surgeon-related factors on outcome of rectal cancer with or without preoperative radiotherapy. Br J Surg 1997;84:657–663.
  40. Sainsbury R, Haward B, Rider L, Johnston C, Round C: Influence of clinician workload and patterns of treatment on survival form breast cancer. Lancet 1995;345:1265–1270.
  41. Bonett A, Roder D, Esterman A: Case-survival rates for infiltrating ductal carcinomas by category of hospital at diagnosis in South Australia. Med J Aust 1991;154:695–697.
  42. Roohan PJ, Bickell NA, Baptiste MS, Therriault GD, Ferrara EP, Siu AL: Hospital volume differences and five-year survival from breast cancer. Am J Publ Hlth 1998;88:454–457.
  43. Nguyen HN, Averette HE, Hoskins W, Penalver M, Servin BU, Steren A: National survey of ovarian carcinoma. V. The impact of physician’s specialty on patients’ survival. Cancer 1993;72:3663–3670.
  44. Kehoe S, Powell J, Wilson S, Woodman C: The influence of the operating surgeon’s specialisation on patient survival in ovarian carcinoma. Br J Surg 1994;70:1014–1017.
  45. Woodman C, Baghdady A, Collins S, Clyma JA: What changes in the organisation of cancer services will improve the outcome for women with ovarian cancer? Br J Obstet Gynaecol 1997;104:135–139.
  46. Junor EJ, Hole DJ, Gillis CR: Management of ovarian cancer: Referral to a multidisciplinary team matters. Br J Cancer 1994;70:363–370.
  47. Munoz KA, Harlan LC, Trimble EL: Patterns of care for women with ovarian cancer in the United States. J Clin Oncol 1997;15:3408–3415.
  48. Birkmeyer JD, Warshaw AL, Finlayson SR, Grove MR, Tosteson AN: Relationship between hospital volume and late survival after pancreaticoduodenectomy. Surgery 1999;126:178–183.
  49. Finlayson EVA, Birkmeyer JD: Effect of hospital volume on life expectancy after selected cancer operations in older adults: A decision analysis. J Am Coll Surg 2003;196:410–417.
  50. Martling L, Cedermark B, Johansson H, Rutquist LE, Holm T: The surgeon as a prognostic factor after the introduction of total mesorectal excision in the treatment of rectal cancer. Br J Surg 2002;89:1008–1013.
  51. Schrag D, Panageas KS, Riedel E, Cramer LD, Guillem JG, Bach PB, Begg CB: Hospital and surgeon procedure volume as predictors of outcome following rectal cancer resection. Ann Surg 2002;236:583–592.
  52. Skinner KA, Helsper JT, Deapen D, Ye W, Sposto R: Breast cancer: Do specialists make a difference? Ann Surg Oncol 2003;10:606–615.
  53. Mikeljevic JS, Haward RA, Johnston C, Sainsbury R, Forman D: Surgeon workload and survival from breast cancer. Br J Cancer 2003;89:487–491.
  54. Davis S, Dahlberg S, Myers MH, Chen A, Steinhorn SC: Hodgkin’s disease in the United States: a comparison of patient characteristics and survival in the Centralized Cancer Patient Data System and the Surveillance, Epidemiology and End Results Program. J Natl Cancer Inst 1987;78:471–478.
  55. Feuer EJ, Frey CM, Brawley OW, Nayfield SG, Cunningham JB, Geller NL, Bosl GJ, Kramer BS: After a treatment breakthrough: A comparison of trial and population-based data for advanced testicular cancer. J Clin Oncol 1994;12:368–377.
  56. Harding MJ, Paul J, Gillis CR, Kaye SB: Management of malignant teratoma: Does referral to a specialist unit matter? Lancet 1993;341:999–1002.
  57. Collette L, Sylvester RJ, Stenning SP, Fossa SD, Mead GM, de Witt R, de Mulder PH, Neymark N, Lallemand E, Kaye SB: Impact of the treating institution on survival of patients with poor-prognosis metastatic nonseminoma: European Organization for Research and Treatment of Cancer Genito-Urinary Tract Cancer Collaborative Group and the Medical Research Council Testicular Cancer Working Party. J Natl Cancer Inst 1999;91:839–846.
  58. Aass N, Klepp O, Cavallin-Stahl E, Dahl O, Wicklund H, Unsgaard B, Baldetorp L, Ahlstrom S, Fossa SD: Prognostic factors in unselected patients with nonseminomatous metastatic testicular cancer: A multicenter experience. J Clin Oncol 1991;9:818–826.
  59. Horowitz MM, Przepiorka D, Champlin RE, Gale RP, Gratwohl A, Herzig RH, Prentice HG, Rimm AA, Ringden O, Bortin MM: Should HLA-identical sibling bone marrow transplants for leukemia be restricted to large centers? Blood 1992;79:2771–2774.
  60. Sowden AJ, Deeks JJ, Sheldon TA: Volume and outcome in coronary artery bypass graft surgery: True association or artefact? BMJ 1995;311:151–155.
  61. Hannan EL: The relation between volume and outcome in health care. N Engl J Med 1999;340:1677–1679.
  62. Johnson PM, Malatjalian D, Porter GA: Adequacy of nodal harvest in colorectal cancer: A consecutive cohort study. J Gastrointest Surg 2002;6:883–890.
  63. Mella J, Biffin A, Radcliffe AG: Population-based audit of colorectal cancer management in two UK health regions: Colorectal Cancer Working Group, Royal College of Surgeons of England Clinical Epidemiology and Audit Group. Br J Surg 1997;84:1731–1736.
  64. Kingston RD, Walsch S, Jeacock J: Curative resection: the major determinant of survival in patient with large bowel cancer. J R Coll Surg Edinb 1991;36:298–302.
  65. Kee F, Wilson RH, Harper C: Influence of hospital clinician workload on survival from colorectal cancer. BMJ 1999;318:1381–1385.
  66. Khuri SF, Daley J, Henderson J: Relation of surgical volume to outcome in eight common operations: Results from the VA National Surgical Quality Improvement Program. Ann Surg 1999;230:414–429.
  67. Dowdall JF, Maguire D, McAnena OJ: Experience of surgery for rectal cancer with total mesorectal excision in a general practice. Br J Surg 2002;89:1014–1019.
  68. Laine C, Sox HC: Does practice really make perfect? Ann Intern Med 2003;139:696–698.
  69. Meyerhardt JA, Catalano PJ, Schrag D, Ayanian JZ, Haller DG, Mayer RJ, Macdonald JS, Benson AB, Fuchs CS: Association of hospital volume and outcomes in patients with colon cancer at high risk for recurrence. Ann Intern Med 2003;139:649–657.
  70. Halm E, Lee C, Chassin MR: Is volume related to outcome in health care? A systematic review and methodologic critique of the literature. Ann Intern Med 2002;137:511–520.
  71. Panageas KS, Schrag D, Riedel E, Bach PB, Begg CB: The effect of clustering of outcomes on the association of procedure volume and surgical outcomes. Ann Intern Med 2003;139:658–665.
  72. Wade TP, Halabay IA, Stapleton DR, Virgo KS, Johnson FE: Population-based analysis of treatment of pancreatic cancer and Whipple resection: Department of Defense hospitals, 1984–1994. Surgery 1996;120:680–685.
  73. Gordon T, Bowman H, Tielsch J, Bass E, Burleyson G, Cameron JL: Statewide regionalization of pancreaticoduodenectomy and its effect on in-house mortality. Ann Surg 1998;228:71–78.
  74. Birkmeyer JD, Finlayson EVA, Birkmeyer CM: Volume standards for high-risk surgical procedures: Potential benefits of the leapfrog initiative. Surgery 2001;130:415–422.
  75. Birkmeyer JD, Skinner JS, Wennberg DE: Will volume-based referral strategies reduce costs or just save lives? Health Affairs 2002;21:234–241.
  76. Birkmeyer JD, Siewers AE, Marth NJ, Goodmann DC: Regionalization of high-risk surgery and implications for patient travel times. JAMA 2003;290:2703–2708.
  77. Christian CK, Gustafson ML, Betensky RA, Daley J, Zinner MJ: The leapfrog volume criteria may fall short in identifying high-quality surgical centers. Ann Surg 2003;238:447–457.
  78. Martling L, Holm T, Rutquist LE, Moran BJ, Heald RJ, Cedermark B: Effect of a surgical training programme on outcome of rectal cancer in the county of Stockholm. Lancet 2000;356:93–96.
  79. Dimick JB, Cowan JA, Ailawadi G, Wainess RM, Upchurch GR: National variation in operative mortality rates for esophageal resection and the need for quality improvement. Arch Surg 2003;138:1305–1309.
  80. Patti MG, Corvera CU, Glasgow RE, Way LW: A hospital’s annual rate of esophagectomy influences the operative mortality rate. J Gastrointest Surg 1998;2:186–192.
  81. Dimick JB, Pronovost PJ, Cowan JA, Lipsett PA: Surgical volume and quality of care for esophageal resection: Do high volume hospitals have fewer complications? Ann Thorac Surg 2003;75:337–341.
  82. Dimick JB, Pronovost PJ, Cowan JA, Lipsett PA, Stanley JC, Upchurch GR: Variations in postoperative complication rates after high-risk surgery in the United States. Surgery 2003;134:534–541.
  83. Birkmeyer JD, Finlayson SR, Tosteson AN, Sharp SM, Warshaw AL, Fisher ES: Effect of hospital volume on in-hospital mortality with pancreaticoduodenectomy. Surgery 1999;125:250–256.
  84. Ho V, Heslin MJ: Effect of hospital volume and experience on in-hospital mortality for pancreaticoduodenectomy. Ann Surg 2003;237:509–514.
  85. Janes RH, Niederhuber JE, Chmiel JS, Winchester DP, Ocwieja K, Karnell JH, Clive RE, Menck HR: National patterns of care for pancreatic cancer: Results of a survey by the commission on cancer. Ann Surg 1996;223:261–272.
  86. Lieberman MD, Kilburn H, Lindsey M: Relation of perioperative deaths to hospital volume among patients undergoing pancreatic resection for malignancy. Ann Surg 1995;222:638–645.
  87. Neoptolemos JP, Russel RC, Bramhall S, Theis B: Low mortality following resection for pancreatic and periampullary tumours in 1,026 patients. Br J Surg 1997;84:1370–1376.
  88. Simunovic M, To T, Theriault M, Langer B: Relation between hospital surgical volume and outcome for pancreatic resection for neoplasm in a publicly funded health care system. CMAJ 1999;160:643–648.


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