Treatment at low‐volume hospitals is associated with reduced short‐term and long‐term outcomes for patients with retroperitoneal sarcoma

Abstract

Background Retroperitoneal sarcomas (RPS) are rare tumors for which complete surgical resection remains the mainstay of treatment. We sought to determine the impact of hospital case volume on RPS outcomes. Methods We identified 6950 patients with primary RPS who underwent surgical resection from the National Cancer Data Base (1998–2011). Treating hospitals were classified by annual case volume; low volume hospitals (LVHs) and high volume hospitals (HVHs) were defined as ≤10 and >10 cases/year, respectively. Overall survival (OS) was compared using Kaplan-Meier curves. Cox proportional hazard models were created to compare risks. Results Of 1131 reporting hospitals, most (n=1127, 99.6%) were LVHs treating the majority of patients (n=6270; 90.2%). Patients treated at LVHs were more likely to have lower grade and smaller tumors, receive radiation therapy, and undergo incomplete gross (R2) resection. Patients treated at HVHs had lower 30-day readmission rates (1.8% vs 3.4%, p<0.001), 30-day (1.9% vs 3.1%, p=0.004) and 90-day mortality (3.2% vs 5.7%, p=0.007); longer median OS (76.2 vs 64.2 months, p<0.001) and higher 5-year OS (58% vs 52%, p<0.001). After controlling for age, gender, insurance status, tumor size, tumor grade, resection margin status, and radiation administration, treatment at a HVH was independently associated with a reduced risk of death (HR 0.77, 95% CI 0.65–0.91, p=0.003). Conclusion Primary RPS are rare tumors for which few surgeons and institutions have significant experience and expertise in their multidisciplinary management and surgical resection. Although additional studies are needed, patient outcomes may be impacted by treating facility case volume and experience.

Recurrence patterns after resection of retroperitoneal sarcomas: An eight‐institution study from the US Sarcoma Collaborative

“…Our cohort of multiple academic institutions represents a more broad perspective into the management of those complex cases compared to a single center study. Furthermore, outcomes described in this study are likely not transferrable to low volume centers as was shown by recent studies investigating this question …”

A sommelier to guide wine selection and a specialist to manage the sarcoma patient: Barriers to referral and definition of a sarcoma specialist

“…However, retroperitoneal sarcomas (RPS) are among the largest tumors in the human body and in addition to their large size, their proximity to critical organs and major vessels makes surgery very challenging. As expected, multiple studies to date have demonstrated that outcomes for RPS patients are clearly better when they are managed by specialists vs nonspecialists 3–5 …”

“…In conclusion, just as sommeliers have an important, very specific role in the dining experience for a restaurant patron, sarcoma specialists are critical for the patient with this rare and challenging cancer. Institutional thresholds for high case volume (eg, for RPS, >10 per year) have been proposed and deserve further study 3,4 ; but in reality, many sarcoma specialists as defined above would far exceed these numbers. Referral to a sarcoma specialist has the additional benefit of centralizing research efforts and facilitating enrollment into therapeutic clinical trials.…”

A call to action: Why sarcoma surgery needs to be centralized

“…Experienced centers simply have better outcomes. In the current study by Keung et al, of the 1131 hospitals reporting data concerning 6950 patients treated over a 13‐year period and included in the study, only 4 hospitals (0.4%) met the criteria for an HVH, treating 680 patients (9.8%) . These 4 institutions all were academic research centers.…”

“…Nevertheless, data included in the data sets may be accurate even if not fully representative. Thus, a carefully crafted analysis tailored to the strength of the data, as the article by Keung et al is, still can be valid. However, using such data sets to track volume trends overall may not be.…”