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Association between surgical case volume and survival in T1 bladder cancer: A need for centralization of care?

ABSTRACT: Introduction Prior research demonstrated an association between surgeon case volume and survival in muscle-invasive bladder cancer (BC). This relationship, however, has not been investigated in the setting of high-risk, non-muscle-invasive BC (NMIBC). Hence, we investigated whether a higher surgeon case volume of T1 BC translates into improved survival outcomes. Methods Province-wide pathology reports (January 2002 to December 2015) were linked with health administrative data to identify patients diagnosed with T1 BC. For each patient, we determined the T1 case volume of the involved surgeon by benchmarking (percentile) her/him against his/her colleagues during a lookback period of one year. The volume-outcome (overall survival) relationship was then investigated by Cox proportional hazards regression (unadjusted and adjusted for a wide range of assumed confounders) that incorporated volume in three different ways (?80th percentile vs. below, ? median vs. below, continuous [quintiles]). Effect sizes were presented as hazard ratios (95% confidence interval). Results We identified 7426 patients who were diagnosed with T1 BC and followed for a median of 4.8 years. A third of all patients (n=1895, 25.5%) received surgery by a high-volume surgeon (80th percentile and higher). Higher T1 case volume was associated with improved survival both in unadjusted (80th percentile: 0.93 [0.86–0.99]; median: 0.93 [0.87–0.99]; continuous: 0.97 [0.94–0.99]) and adjusted analysis (80th percentile: 0.94 [0.88–1.01]; median: 0.93 [0.87–0.99]; continuous: 0.97 [0.95–0.99]) regardless of the method by which volume was analyzed. Conclusions This population-based cohort study demonstrated a volume-outcome relationship in T1 BC and raises questions regarding the centralization of care in high-risk NMIBC.

SUBMITTER: Wettstein M

PROVIDER: S-EPMC7492039 | biostudies-literature | 2020 Sep

REPOSITORIES: biostudies-literature

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Project description:ObjectiveTo examine the association between surgical volume and survival of women with early-stage cervical cancer who underwent radical hysterectomy.MethodsThis is a nationwide multicenter retrospective study examining consecutive women with clinical stage IB1-IIB cervical cancer who underwent radical hysterectomy and pelvic lymphadenectomy from 2004 to 2008 (N=5,964). The surgical volume per site over the 5-year period was defined as low-volume (fewer than 32 surgeries, 46 [39.7%] institutions, n=649 [10.9%]), mid-volume (32-104 surgeries, 60 [51.7%] institutions, n=3,662 [61.4%]), and high-volume (105 surgeries or more, 10 [8.6%] institutions, n=1,653 [27.7%]). Surgical volume-specific survival was examined with multivariable analysis and propensity score matching.ResultsThe median number of surgeries per site was 44 (interquartile range, 17-65). The 5-year disease-free survival rates among stage IB1-IIB disease were 77.2%, 79.9%, and 84.5% for low-, mid-, and high-volume groups, respectively. On multivariable analysis, women in high-volume centers had a decreased risk of recurrence (adjusted hazard ratio [HR] 0.69, 95% CI 0.58-0.82, P<.001) and all-cause mortality (adjusted HR 0.73, 95% CI 0.59-0.90, P=.003) compared with those in mid-volume centers. Specifically, women in high-volume centers had a decreased risk of local recurrence (adjusted HR 0.62, 95% CI 0.49-0.78, P<.001) but not distant recurrence (adjusted HR 0.85, 95% CI 0.67-1.06, P=.142) compared with those in mid-volume centers. Among 1,700 women with clinical stage IB1 disease treated with surgery alone, surgery at high-volume centers was associated with a decreased risk of recurrence (adjusted HR 0.45, 95% CI 0.25-0.79, P=.006) and all-cause mortality (adjusted HR 0.29, 95% CI 0.11-0.76, P=.013) compared with surgery at mid-volume centers on multivariable analysis. After propensity score matching, surgery at high-volume centers remained an independent prognostic factor for decreased recurrence (adjusted HR 0.69, 95% CI 0.57-0.84, P<.001) and all-cause mortality (adjusted HR 0.75, 95% CI 0.59-0.95, P=.016) compared with surgery at mid- and low-volume centers on multivariable analysis.ConclusionHospital volume for radical hysterectomy may be a prognostic factor for early-stage cervical cancer. Surgery at high-volume centers is associated with decreased local recurrence risk and improved survival.

Project description:It is not know if hospital-level extracorporeal cardiopulmonary resuscitation (ECPR) case volume, or postcannulation clinical management associate with survival outcomes.ObjectivesTo describe variation in postresuscitation management practices, and annual hospital-level case volume, for patients who receive ECPR and to determine associations between these management practices and hospital survival.DesignObservational cohort study using case-mix adjusted survival analysis.Setting and participantsAdult patients greater than or equal to 18 years old who received ECPR from the Extracorporeal Life Support Organization Registry from 2008 to 2019.Main outcomes and measuresGeneralized estimating equation logistic regression was used to determine factors associated with hospital survival, accounting for clustering by center. Factors analyzed included specific clinical management interventions after starting extracorporeal membrane oxygenation (ECMO) including coronary angiography, mechanical unloading of the left ventricle on ECMO (with additional placement of a peripheral ventricular assist device, intra-aortic balloon pump, or surgical vent), placement of an arterial perfusion catheter distal to the arterial return cannula (to mitigate leg ischemia); potentially modifiable on-ECMO hemodynamics (arterial pulsatility, mean arterial pressure, ECMO flow); plus hospital-level annual case volume for adult ECPR.ResultsCase-mix adjusted patient-level management practices varied widely across individual hospitals. We analyzed 7,488 adults (29% survival); median age 55 (interquartile range, 44-64), 68% of whom were male. Adjusted hospital survival on ECMO was associated with mechanical unloading of the left ventricle (odds ratio [OR], 1.3; 95% CI, 1.08-1.55; p = 0.005), performance of coronary angiography (OR, 1.34; 95% CI, 1.11- 1.61; p = 0.002), and placement of an arterial perfusion catheter distal to the return cannula (OR, 1.39; 95% CI, 1.05-1.84; p = 0.022). Survival varied by 44% across hospitals after case-mix adjustment and was higher at centers that perform more than 12 ECPR cases/yr (OR, 1.23; 95% CI, 1.04-1.45; p = 0.015) versus medium- and low-volume centers.Conclusions and relevanceModifiable ECMO management strategies and annual case volume vary across hospitals, appear to be associated with survival and should be the focus of future research to test if these hypothesis-generating associations are causal in nature.

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Association between surgical case volume and survival in T1 bladder cancer: A need for centralization of care?

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