Better Survival in Patients with Esophageal Cancer After Surgical Treatment in University Hospitals: A Plea for Performance by Surgical Oncologists

Abstract

Background: In primary esophageal cancer, studies have frequently focused on surgical patients in an effort to link outcome to hospital-or surgeon-related experience, with operative mortality used as the main outcome measure. Many studies have found an inverse relationship between operative mortality and hospital volume and surgical expertise. This study aims to assess the influence of surgeon-related expertise and hospital volume on the relative survival of operated esophageal cancer patients.Methods: From January 1994 to January 2002, a total of 1149 consecutive patients with primary esophageal cancer were diagnosed in the region of the Comprehensive Cancer Center North-Netherlands. As a proxy for surgeon-related expertise, hospitals in this region were categorized into three types: university, teaching nonuniversity, and nonteaching hospitals. The influence of hospital type on the relative survival of operated patients was studied by a multivariate Poisson regression model.Results: Of the 1149 patients, 18.5% underwent surgery. There was no evidence of selective referral for surgery between the three hospital types with regard to age, tumor stage, and location. For operated patients, the 5-year relative survival was 49.2% for the university hospital versus 32.6% and 27.3% for teaching nonuniversity and nonteaching hospitals, respectively (P = .0039). When adjusted for age, tumor stage, hospital volume and referral frequency, the relative excess risk of death for the university hospital was considerably lower at .57 (95% confidence interval, .29-1.12) compared with nonteaching hospitals and .43 (95% confidence interval, .24-.76) compared with teaching nonuniversity hospitals (P = .0126).Conclusions: In our region, patients with esophageal cancer who underwent esophagectomy in the university hospital had a markedly better relative survival compared with those who underwent surgery at teaching nonuniversity and nonteaching hospitals, emphasizing the need for referral of esophageal surgery to centers with a greater experience.

Effect of hospital characteristics on outcome of patients with gastric cancer: A population based study in North-East Netherlands

“…Better outcome was also found in specialised centres [15][16][17][18]. Verhoef et al described significantly better outcome in oesophageal cancer surgery in the university hospital compared with other, non-university teaching and non teaching, hospitals in our region [19].…”

“…As in our case, the university hospital is a low volume hospital for gastric cancer, it becomes evident that other factors than the caseload prevail. The better outcome for oesophageal cancer surgery that Verhoef et al described in our region might therefore not be attributed to the university hospital on basis of the highest volume but other hospital related qualities [19]. This might also be the case for the benefit described by Bachmann et al, based on the difficulty to distinguish this volume aspect from other hospital related qualities [22].…”

Quality-of-care indicators for oesophageal cancer surgery: A review

“…There is considerable evidence that the transhiatal approach leads to a reduced postoperative morbidity rate [26][27][28][29] . Presumed that the transthoracic approach with an extended lymphadenectomy is technically more challenging, one could propose that the performance of transthoracic oesophagectomies in patients with a tumour located in the distal oesophagus should be regarded as a quality indicator.…”

The quality of cancer care initiative in the Netherlands

“…Most articles reported on surgical procedures, studies investigating other aspects of the care process for cancer patients where found sporadically. Besides, outcome was generally limited to postoperative morbidity and mortality, though some recent studies also report on use of breast conserving therapies, recurrence rates, survival, quality of life and patient satisfaction (16)(17)(18). Differences in quality of diagnostic procedures and pathology examinations between providers are certainly underexposed, in literature only a few articles addressing this subject were found (19)(20)(21)(22)(23)(24)(25).…”