Variation in receipt of therapy and survival with provider volume for medical oncology in non-curative esophago-gastric cancer: a population-based analysis

Abstract

Background While surgical care by high-volume providers for esophago-gastric cancer (EGC) yields better outcomes, volume-outcome relationships are unknown for systemic therapy. We examined receipt of therapy and outcomes in the non-curative management of EGC based on medical oncology provider volume. Methods We conducted a population based retrospective cohort study of non-curative EGC over 2005-2017 by linking administrative healthcare datasets. The volume of new EGC consultations per medical oncology provider per year was calculated and divided into quintiles. High-volume (HV) medical oncologists were defined as the 4-5th quintiles. Outcomes were receipt of chemotherapy and overall survival (OS). Multivariate logistic and Cox-proportional hazards regressions examined the association between management by HV medical oncologist, receipt of systemic therapy, and OS. Results 7011 EGC patients with non-curative management consulted with medical oncology. 1-year OS was superior for HV medical oncologists (> 11 patients/year), with 28.4% (95% CI 26.7-30.2%) compared to 25.1% (95% CI 23.8-26.3%) for low volume (p < 0.001). After adjusting for age, sex, comorbidity burden, rurality, income quintile, and diagnosis year, HV medical oncologist was independently associated with higher odds of receiving chemotherapy (OR 1.13, 95% CI 1.01-1.26), and independently associated with superior OS (HR 0.89, 95% CI 0.84-0.93). Conclusions Medical oncology provider volume was associated with variation in non-curative management and outcomes of EGC. Care by an HV medical oncologist was independently associated with higher odds of receiving chemotherapy and superior OS, after adjusting for case mix. This information is important to inform disease care pathways and care organization; an increase in the number of HV medical oncologists may reduce variation and improve outcomes.

Material deprivation and access to cancer care in a universal health care system

“…We defined advanced GI cancers as noncuratively treated cancers according to published guidelines 17‐20 . Detailed inclusion definitions for each cancer can be found in Table 1, and coding definitions can be found in Supporting Table 1.…”

“…Therefore, we defined patients with advanced colorectal cancer as those patients diagnosed with stage IV disease who did not undergo resection of the colon or rectum in addition to resection of metastases in the liver or lungs or ablation. Advanced gastric, pancreatic, and esophageal cancers were defined on the basis of noncurative treatment definitions 19,23 . Patients undergoing resection of the primary tumor were excluded 19,23 .…”

“…Advanced gastric, pancreatic, and esophageal cancers were defined on the basis of noncurative treatment definitions 19,23 . Patients undergoing resection of the primary tumor were excluded 19,23 . Patients receiving nonpalliative radiation were excluded for esophageal cancers because this constitutes potential curative‐intent or neoadjuvant treatment 19,23 .…”

“…Patients undergoing resection of the primary tumor were excluded 19,23 . Patients receiving nonpalliative radiation were excluded for esophageal cancers because this constitutes potential curative‐intent or neoadjuvant treatment 19,23 . There is no protocol for curative radiation for gastric cancer; however, neoadjuvant radiotherapy may be used to reduce the tumor size before surgery.…”

Economic impacts of care by high-volume providers for non-curative esophagogastric cancer: a population-based analysis

“…Whether clinical volume also plays a role in the delivery of medical cancer care is less clear and the need for such information has been highlighted [4]. Recent data indicated improved survival for solid malignancies with care by high-volume medical oncologists [5][6][7].…”