Hospital volume (i.e., the number of operations performed at a hospital) has been associated with outcomes after surgery for cancers of the pancreas, esophagus, prostate, breast, lung, and colon. However, the association between hospital volume and outcomes after rectal cancer surgery has been less clear.
David C. Hodgson, M.D., of the Princess Margaret Hospital and the University of Toronto in Canada, John Z. Ayanian, M.D., of the Harvard Medical School in Boston, and their colleagues compared outcome measures among 7,257 patients who underwent surgery for rectal cancer.
Hodgson and his colleagues found that patients treated at low-volume hospitals (those performing fewer than 7 rectal cancer operations per year) had a higher postoperative mortality rate (4.8% versus 1.6%) and lower 2-year survival rate (76.6% versus 83.7%) than patients treated at high-volume hospitals (those performing more than 20 operations per year).
Moreover, patients treated at low-volume hospitals had a 7% increase in absolute risk of permanent colostomy (a procedure to permanently reroute the passage of waste materials from the body) compared with those treated at high-volume hospitals. Studies have reported substantial impairment in patients' quality of life after colostomy.
The authors point out that some of these differences may be the result of surgeon characteristics, such as experience, training, or attitudes about colostomy. They suggest that future studies compare the relative impact of volume with other characteristics of hospitals and surgeons.
"Identifying processes of care that contribute to these differences may improve patients' outcomes," the authors write. "The quality of preoperative imaging, anesthesia support, surgical technique, nursing care, surgical pathology reporting, perioperative medical consultations, and access to appropriate ambulatory care and adjuvant therapy may all contribute to the outcomes of patients with rectal cancer."
In an accompanying editorial, Thomas J. Smith, M.D., of the Massey Cancer Center of the Virginia Commonwealth University Health System in Richmond, and his colleagues say that the new findings are consistent with the "wide and deep" body of knowledge that shows a strong relationship between volume and quality, and that the data are compelling enough to demand changes in how cancer care is delivered.
They provide some possible solutions, such as asking surgeons to report data on their outcomes and concentrating cancer care in high-volume hospitals. "It should be noted that such improvements … may not save costs--just lives," they write. "That is a good start."
Contact: Vince Rice, Princess Margaret Hospital, 416-946-4501 ext. 5771; fax: 416-946-4585, vince.rice@uhn.on.ca.
John Lacey, Harvard Medical School, 617-432-0441; fax: 617-432-0446, john_lacey@hms.harvard.edu.
Editorial: Pam Disalvo Lepley, Virginia Commonwealth University, 804-828-6057; fax: 804-827-0176, pdlepley@vcu.edu
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;95:708–16.
Editorial: Smith TJ, Hillner BE, Bear HD. Taking action on the volume–quality relationship: How long can we hide our heads in the colostomy bag? J Natl Cancer Inst 2003;95:695–7.
Note: The Journal of the National Cancer Institute is published by Oxford University Press and is not affiliated with the National Cancer Institute. Attribution to the Journal of the National Cancer Institute is requested in all news coverage.
Journal
JNCI Journal of the National Cancer Institute