Benefits of specialisation in the management of pancreatic cancer: results of a Scottish population-based study

Abstract

Pancreatic cancer is associated with a very poor prognosis; however, in selected patients, resection may improve survival. Several recent reports have demonstrated that concentration of treatment activity for patients with pancreatic cancer has resulted in improved outcomes. The aim of this study was to ascertain if there was any evidence of benefit for specialised care of patients with pancreatic cancer in Scotland. Records of patients diagnosed with pancreatic cancer during the period 1993 -1997 were identified. Three indicators of co-morbidity were calculated for each patient. Operative procedures were classified as resection, other surgery or biliary stent. Prior to analysis, consultants were assigned as specialist pancreatic surgeons, clinicians with an interest in pancreatic disease or nonspecialists. Data were analysed with regard to 30-day mortality and survival outcome. The final study population included 2794 patients. The 30-day mortality following resection was 8%, and hospital or consultant volume did not affect postoperative mortality. The 30-day mortality rate following palliative surgical operations was 20%, and consultants with higher case loads or with a specialist pancreatic practice had significantly fewer postoperative deaths (P ¼ 0.014 and 0.002, respectively). For patients undergoing potentially curative or palliative surgery, the adjusted hazard of death was higher in patients with advanced years, increased co-morbidity, metastatic disease, and was lower for those managed by a specialist (RHR 0.63, 95% CI 0.50 -0.78) or by a clinician with an interest in pancreatic disease (RHR 0.63,. The risk of death 3 years after diagnosis of pancreatic cancer is higher among patients undergoing surgical intervention by nonspecialists. Specialisation and concentration of cancer care has major implications for the delivery of health services.

Impact of centralization of pancreatoduodenectomy on reported radical resections rates in a nationwide pathology database

“…The achievement of an R0 resection margin is one of the most important prognostic factors in the treatment of pancreatic head tumours, thus the current results suggest that patients treated in high‐volume hospitals may have a better long‐term survival in patients with pancreatic head tumours than those treated in low‐volume hospitals. This is confirmed by two recent studies that showed that centralization improves the 2‐ and 3‐year survival after surgery for pancreatic head tumours.…”

“…2 A number of studies have outlined the relationship between hospital volume, post-operative mortality, and survival for patients undergoing surgery for pancreatic and peri-ampullary neoplasms. [3][4][5][6][7][8][9][10][11][12] It has been postulated that both short-and long-term improvements in the outcome of a pancreatic resection are mainly as a result of improvements in the quality of HPB surgery and peri-operative care. 7 In patients with pancreatic ductal adenocarcinoma (PDAC), the ratio of nodal involvement and, to a somewhat lesser extent, the negative resection margin (R0) are the most important prognostic factors for long-term survival.…”

The role of cancer registries in cancer control

“…77 Although these are indirect indicators of quality of care, they have been shown to be important in determining outcome. [78][79][80] Simple measures such as delay in diagnosis, or delay in receiving appropriate treatment, provide information on equity and access, as well as potentially infl uencing outcome. 81 Auditing the nature of the diagnostic and therapeutic procedures actually performed provides a more direct indication of the quality of care; if the focus is effectiveness of care, then the choice of indicators should be known to have an effect on its outcome.…”

Survival in patients with primary liver cancer, gallbladder and extrahepatic biliary tract cancer and pancreatic cancer in Europe 1999–2007: Results of EUROCARE-5

“…There have also been improvements in both adjuvant and palliative chemotherapy. Radiotherapy [4][5][6] and centralized surgery have also been proposed [7,8]. The repercussion of these changes at the population level is not known.…”