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Treatment of Gastric Adenocarcinoma May Differ Among Hospital Types in the United States, a Report from the National Cancer Data Base

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Journal of Gastrointestinal Surgery Aims and scope

Abstract

The concept that complex surgical procedures should be performed at high-volume centers to improve surgical morbidity and mortality is becoming widely accepted. We wanted to determine if there were differences in the treatment of patients with gastric cancer between community cancer centers and teaching hospitals in the United States. Data from the 2001 Gastric Cancer Patient Care Evaluation Study of the National Cancer Data Base comprising 6,047 patients with gastric adenocarcinoma treated at 691 hospitals were assessed. The mean number of patients treated was larger at teaching hospitals (14/year) when compared to community centers (5–9/year) (p < 0.05). The utilization of laparoscopy and endoscopic ultrasonography were significantly more common at teaching centers (p < 0.01). Pathologic assessment of greater than 15 nodes was documented in 31% of specimen at community hospitals and 38% at teaching hospitals (p < 0.01). Adjusted for cancer stage, chemotherapy and radiation therapy were utilized with equal frequency at all types of treatment centers. The 30-day postoperative mortality was lowest at teaching hospitals (5.5%) and highest at community hospitals (9.9%) (p < 0.01). These data support previous publications demonstrating that patients with diseases requiring specialized treatment have lower operative mortality when treated at high-volume centers.

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Abbreviations

AJCC:

American Joint Committee on Cancer

CoC:

Commission on Cancer

CHCP:

Community Hospital Cancer Program

COMP:

Community Hospital Comprehensive Cancer Program

NCDB:

National Cancer Data Base

PCE:

Patient Care Evaluation

THCP:

Teaching Hospital Cancer Program

US:

United States

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Author information

Authors and Affiliations

  1. Department of Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA

    Kaye M. Reid-Lombardo & John H. Donohue

  2. American College of Surgeons, Commission on Cancer, 633 North St. Clair, Chicago, IL, 60611, USA

    Greer Gay & Lina Patel-Parekh

  3. Department of Gastrointestinal Medical Oncology, The University of Texas, M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, P.O. Box 426, Houston, TX, 77030, USA

    Jaffer A. Ajani

Authors
  1. Kaye M. Reid-Lombardo
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  2. Greer Gay
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  3. Lina Patel-Parekh
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  4. Jaffer A. Ajani
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  5. John H. Donohue
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Gastric Patient Care Evaluation Group from the Commission on Cancer

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Correspondence to Kaye M. Reid-Lombardo.

Additional information

DISCUSSION

Richard H. Bell, Jr. M. D. (Chicago Ill): Thank you, Dr. Reid-Lombardo. That was a nice presentation. This report deals with the thorny issue of where complex GI procedures are best done and by whom, and this is not an academic discussion, because in your data you suggest that there are about 500 preventable operative deaths per year in the United States for gastric cancer patients. The difficult question for me in all of this is identifying what is about large tertiary hospitals that results in better operative outcomes for complex GI cases. I think if we are going to argue for centralization, we need to understand the rationale for doing that. It is obviously a contentious issue.

So in this respect, I was disappointed a little bit with the way you examined your results, becaused you claimed that surgical volume predicts good outcomes, but this was really not a study of volume. You divided your hospitals based on structure and not on volume. You divided the hospitals based on their classification by the American College of Surgeons. And although you didn’t show it, there was data in the manuscript that showed there were actually significant volume overlaps between the three categories. It was certainly not a clean distinction by volume. Some of the less complex hospitals in your study did as many operations as the tertiary medical centers, although their average number was smaller. So I thought this study would have been more illuminating if, in addition to what you look at, you had looked at volume as an independent variable in addition to structure. You actually have an unusual study here in that you can look at both structure and volume. It may be that the structure of tertiary hospitals the better equipment, the higher performing ICUs, the resident coverage, all of these things are the primary driver of better outcomes.

From an educational point of view, this has implications in the sense that it would not do any good to do a better job of training community general surgeons to be more proficient in gastrectomy if the community hospitals is fundamentally a less capable environment for this type of operation. You have the data to lok at both structure and volume, and I wish you had done that perhaps in the future manuscript you will. Thank you.

Kaye Reid-Lombardo, M. D. (Rochester, Minn) Thank you, Dr. Bell. I definitely agree with you that it is less about volume, especially with gastric cancer, because, you are right, even at teaching hospitals the volumes are not that high. I think it has more to do with the infrastructure at each institution, as is being reported by many authors as well. I think factors such as ICU availability or the radiologic availability at each institution have more of an impact than the surgeon in and of him or herself. So I think this study will allow us to further examine things like infrastructure and see what the differences are and to make better recommendations based on that examination.

Michael A. Choti, M. D. (Baltimore, Md) Dr. Reid-Lombardo, I enjoyed your presentation and thank you for the opportunity to have reviewed the manuscript in advance. This is just another example of how the National Cancer Database can be a useful tool for analyzing a variety of cancer mangement question. This database is robust and different from SEER or other databases. I encourage others to utilize this resource.

I have two questions. The first, you report a surprisingly low number of palliative gastrectomies, yet you define this as margin positive resection and not based on symptomatic indications. While it is uncommon to have both proximal and distal positive margins, even in palliative resections, it is more common to have noncurative or R2 gastrectomy. In such cases the margins may be negative but residual disease is left behind as nodes or peritoneal implants. Were you able to see the difference between the margin positive and R2 resection?

The second question relates to the number of lymph nodes evaluated in this series. As you know, guidelines recommend histologic evaluation of at least 15 nodes. It was interesting how few gastrectomies in fact achieve greater 15 nodes. This number is significantly less than even colorectal cancer, where much attention has recently been given. Do you think in this case it is the pathologist diligence as much as the extent of lymphadenectomy that is the problem? Or are we setting the bar to high with the recommendation of 15 or more nodes? Thank you.

Dr. Reid-Lombardo: Thank you for questions. To answer your first question, it aws difficult to analyze R2, and so that is why we difficult to analyze R2, and so that is why we evaluated based on margin status. I would have expected a higher palliative rate as well. We could not analyze that from the database. I think to improve on the lymph node sampling , the pathologist and surgeon must work hand in hand. The pathologist should analyze the resected specimen at the time that the surgeon is still in the operating room and provide feedback. If there are less than 15 nodes, then more node sampling should be done by the surgeon. Now, I know the western studies have not shown improved survival among patients with D1 and D2 rescted nodes, but sampling more nodes would almost seem to me to assure that we are doing a more extended lymphadenectomy. One way that we can achieve that goal is to have better discussion, and not only discussion, but the pathology report should clearly indicate how many nodes have been examined and how many are positive or negative. Thank you.

The members of the Gastric Patient Care Evaluation Group from the Commission on Cancer are as follows:

Carol Conner Ph.D., M.D.; Thomas Habermann, M.D.; Scott A. Hundahl, M.D.; Martin S. Karpeh, Jr., M.D.; M. Margaret Kemeny, M.D.; Paul J. Kurtin, M.D.; Gregory Y. Lauwers, M.D.; Paul F. Mansfield, M.D.; Peter W. T. Pisters, M.D.; Andrew K. Stewart, M.A.; Zuo Feng Zhang, M.D.

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Reid-Lombardo, K.M., Gay, G., Patel-Parekh, L. et al. Treatment of Gastric Adenocarcinoma May Differ Among Hospital Types in the United States, a Report from the National Cancer Data Base. J Gastrointest Surg 11, 410–420 (2007). https://doi.org/10.1007/s11605-006-0040-8

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  • DOI: https://doi.org/10.1007/s11605-006-0040-8

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