PAST
Volume-outcome relationships in technically demanding surgical oncology procedures have been well reported in the United States (US), most extensively in pancreatic and esophageal cancers. Those reports encouraged patients to seek care at high-volume centers, leading to trends of centralization and improved outcomes. However, centralization policies, either financially driven or mandatory, have never been enacted in the US and continue to be controversial.1 In this retrospective cohort study using the Texas Inpatient Database, we investigated changes over 15 years in the volume distribution of gastrectomies in Texas. Despite improvement, patient morbidity and mortality remained higher at low- and intermediate-volume centers than at high-volume centers, demonstrating that volume-outcome relationships still exist for gastrectomy. Patient and hospital differences impact this, but the volume relationship is still clear despite a slow but ongoing trend of centralization of gastrectomy for gastric cancer patients in Texas. The paper also described the challenges of centralization of gastrectomy and standardized delivery of high-quality cancer care in the US.
PRESENT
Proactive nationwide centralization of high-risk oncological resections in The Netherlands has occurred, and remarkable improvement in treatment outcomes has been reported;2,3 however, similar mandated centralization may not be realistic with the geographic, transportation, and payor systems in the US. Payors can play a significant role in this, as they already do in so many other aspects of healthcare, from treatment options to what is performed in network. Continued consideration and discussions of not whether but how regionalization of complex surgical procedures should be conducted are needed in this country. Moreover, further effort must be taken to improve patients’ access to high-quality cancer care. A previous study of national data reported that patients with non-White race and low socioeconomic status had limited access to high-quality gastric cancer care, defined as the use of preoperative chemotherapy.4 Our current study demonstrated similar results, showing limited access among certain patient populations (characterized by age, race, comorbidities, and socioeconomic status).
FUTURE
Another approach to improve treatment outcomes of gastric cancer in the US is standardization (equalization) of gastric cancer care. One US study showed the use of preoperative chemotherapy has increased sharply over the past two decades. This was more common in academic centers, but still less than 50% of patients received preoperative therapy in non-academic centers.4 Further efforts to improve adherence to guidelines’ among US surgeons would improve outcomes of gastric cancer treatment. Furthermore, the quality of surgery for gastric cancer is not well standardized in the US. National Comprehensive Cancer Network (NCCN) guidelines still reference original, and outdated, Japanese guidelines from the 1980s to define the extent of D1 and D2 lymph node dissections.5 One more concern is the application of robotic surgery for gastrectomy without quality control. A nationwide effort is needed to promote communication among US gastric surgeons to help standardize gastric cancer treatment and surgical procedures.
Footnotes
DISCLOSURES Naruhiko Ikoma and Paul Mansfield have no conflicts of interest to disclose.
REFERENCES
- 1.Ikoma N, Kim B, Elting LS, Shih YT, Badgwell BD, Mansfield P. Trends in volume-outcome relationship in gastrectomies in Texas. Ann Surg Oncol. 2019; 26:2694–2702. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.de Wilde RF, Besselink MG, van der Tweel I, et al. Impact of nationwide centralization of pancreaticoduodenectomy on hospital mortality. Br J Surg. 2012;99(3):404–410. [DOI] [PubMed] [Google Scholar]
- 3.Dikken JL, Dassen AE, Lemmens VE, et al. Effect of hospital volume on postoperative mortality and survival after oesophageal and gastric cancer surgery in the Netherlands between 1989 and 2009. Eur J Cancer. 2012;48(7):1004–1013. [DOI] [PubMed] [Google Scholar]
- 4.Ikoma N, Cormier JN, Feig B, et al. Racial disparities in preoperative chemotherapy use in gastric cancer patients in the United States: Analysis of the National Cancer Data Base, 2006–2014. Cancer. 2018;124(5):998–1007. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Ajani JA, D’Amico TA, Almhanna K, Bentrem DJ, Chao J, Das P et al. Gastric Cancer, Version 1.2019. NCCN Clinical Practice Guidelines in Oncology. National Comprehensive Cancer Network. Available at: https://www.nccn.org/professionals/physician_gls/PDF/gastric.pdf. Accessed 14 May 2019. [DOI] [PubMed] [Google Scholar]