Benefits of High-Volume Medical Oncology Care for Noncurable Pancreatic Adenocarcinoma: A Population-Based Analysis

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  • a Odette Cancer Centre, Sunnybrook Health Sciences Centre;
  • b University of Toronto;
  • c Sunnybrook Research Institute;
  • d Institute of Clinical Evaluative Sciences, Toronto, Ontario; and
  • e University of Manitoba, Winnipeg, Manitoba, Canada.
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Background: Although pancreatic adenocarcinoma (PA) surgery performed by high-volume (HV) providers yields better outcomes, volume–outcome relationships are unknown for medical oncologists. This study examined variation in practice and outcomes in noncurative management of PA based on medical oncology provider volume. Methods: This population-based cohort study linked administrative healthcare datasets and included nonresected PA from 2005 through 2016. The volume of PA consultations per medical oncology provider per year was divided into quintiles, with HV providers (≥16 patients/year) constituting the fifth quintile and low-volume (LV) providers the first to fourth quintiles. Outcomes were receipt of chemotherapy and overall survival (OS). The Brown-Forsythe-Levene (BFL) test for equality of variances was performed to assess outcome variability between provider-volume quintiles. Multivariate regression models were used to examine the association between management by HV provider and outcomes. Results: A total of 7,062 patients with noncurable PA consulted with medical oncology providers. Variability was seen in receipt of chemotherapy and median survival based on provider volume (BFL, P<.001 for both), with superior 1-year OS for HV providers (30.1%; 95% CI, 27.7%–32.4%) compared with LV providers (19.7%; 95% CI, 18.5%–20.6%) (P<.001). After adjustment for age at diagnosis, sex, comorbidity burden, rural residence, income, and diagnosis period, HV provider care was independently associated with higher odds of receiving chemotherapy (odds ratio, 1.19; 95% CI, 1.05–1.34) and with superior OS (hazard ratio, 0.79; 95% CI, 0.74–0.84). Conclusions: Significant variation was seen in noncurative management and outcomes of PA based on provider volume, with management by an HV provider being independently associated with superior OS and higher odds of receiving chemotherapy. This information is important to inform disease care pathways and care organization. Cancer care systems could consider increasing the number of HV providers to reduce variation and improve outcomes.

Submitted June 3, 2019; accepted for publication September 13, 2019.

Author contributions: Study concept and design: Hallet, Coburn. Data abstraction: Hallet, Davis, Beyfuss, Liu, Coburn. Data analysis and interpretation: All authors. Manuscript drafting, critical revision, and final approval: All authors.

Disclosures: Dr. Hallet has disclosed that she has received honoraria from Ipsen and Novartis Oncology. The remaining authors have disclosed that they have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.

Funding: This study was supported by the Institute of Clinical Evaluative Sciences (ICES), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). This study was supported by an operating grant from the Canadian Institutes of Health Research (CIHR; FRN #154131).

Disclaimer: The opinions, results, and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred. Parts of this material are based on data and information compiled and provided by the Canadian Institute for Health Information (CIHI). However, the analyses, conclusions, opinions, and statements expressed herein are those of the authors and not necessarily those of CIHI. Parts of this material are based on data and information provided by Cancer Care Ontario (CCO). The opinions, results, views, and conclusions reported in this paper are those of the authors and do not necessarily reflect those of CCO. No endorsement by CCO is intended or should be inferred.

Correspondence: Julie Hallet, MD, MSc, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, T2-063, Toronto, ON M4N 3M5, Canada. Email: julie.hallet@sunnybrook.ca
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