NEW YORK, NY – Hospital experience is one of many important factors patients must consider when deciding where to have their surgery. New evidence published in this week’s issue of the Journal of the American Medical Association (JAMA) offers information that could aid patients in making that challenging decision.
Investigators at Memorial Sloan-Kettering Cancer Center found a relatively small survival benefit – two percent – among patients who undergo commonly performed colon cancer operations at high-volume hospitals compared to facilities that perform a smaller number of these moderate-risk procedures. This contrasts with previous research that indicates patients are up to 15 percent more likely to survive complicated, high-risk cancer surgeries when they are performed at high-volume hospitals.
The current study shows a 3.5 percent postoperative mortality rate for patients treated at hospitals that performed the most colon cancer surgeries compared to 5.5 percent for those treated at the lower volume hospitals. The association between a high volume of operations and better survival persisted after taking into account the patients’ age at diagnosis, sex, race, cancer stage, and other variables.
Researchers retrospectively examined information from the Surveillance, Epidemiology and End Results (SEER) Medicare-linked database on almost 28,000 patients aged 65 years and older who had surgery for colon cancer diagnosed between 1991 and 1996. They evaluated whether patients lived or died within 30 days after surgery and recorded their overall long-term survival by hospital procedure volume.
"The small survival differences we observed should reassure patients who are trying to decide where to have surgery, especially if they have easy access to a hospital that does a large volume of colon cancer surgery," said Deborah Schrag, MD, medical oncologist at Memorial Sloan-Kettering, and lead author of the study. "However, patients should weigh this modest benefit against the advantages of having surgery performed at a familiar hospital in their own community."
"It is also important to point out that shopping around for a hospital is not an option when colon cancer surgery needs to be done on an emergency basis," adds Dr. Schrag. While prior studies have looked at volume and outcome for colon cancer surgery, the current results are compelling because they rely on a large, nationally representative sample of Medicare beneficiaries. Although the research does not include patients under age 65, people over 65 are the most likely to get colon cancer.
Researchers also considered why the association between volume and postoperative survival exists. Specifically, they questioned whether patients with more advanced disease spread to the lymph nodes were more likely to have chemotherapy administered after resection at the high-volume hospitals. However, the findings indicate that rates of chemotherapy use were similar at hospitals regardless of surgical case volume.
Study investigators did not measure the volume of procedures performed by the individual surgeon. "Our findings offer averages for patients to consider, but it may be that going to a very experienced surgeon at a low-volume hospital is just as good as going to a high-volume hospital," said Dr. Schrag.
The authors conclude that more research is needed to determine the underlying mechanisms – such as intraoperative and postoperative care, and access to a multi-disciplinary team of health care professionals – that may explain the relationship between hospital volume and clinical outcomes, and how those factors interact with the skill of the surgeon.
Memorial Sloan-Kettering Cancer Center is the world’s oldest and largest institution devoted to prevention, patient care, research and education in cancer. Our scientists and clinicians generate innovative approaches to better understand, diagnose and treat cancer. Our specialists are leaders in biomedical research and in translating the latest research to advance the standard of cancer care worldwide.
Journal
JAMA