1 Department of Radiation Oncology, Penn State Cancer Institute, and
| 2 Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania;
| 3 Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida;
| 4 Department of Surgery, and
| 5 Department of Biochemistry and Molecular Biology, Penn State College of Medicine, Hershey, Pennsylvania; and Department of Surgical Oncology, Baptist MD Anderson Cancer Center, Jacksonville, Florida.
Background: Increased facility surgical treatment volume is sometimes associated with improved survival in patients with cancer; however, published studies evaluating volume are heterogeneous and disparate in their patient inclusion and definition of volume. The purpose of this work was to evaluate uniformly the impact of surgical facility volume on survival in patients with cancer. Methods: The National Cancer Database was searched for patients diagnosed in 2004 through 2013 with the 12 cancers most commonly treated surgically. Facilities were stratified by 4 categories using the overall population (low, intermediate, high, and very high), each including 25% of patients, and then stratified by each individual disease site. Five-year postsurgery survival was estimated using both the Kaplan-Meier method and corresponding log-rank tests for group comparisons. Cox proportional hazard models were used to evaluate the effects of facility volume on 5-year postsurgery survival further, adjusted for multiple covariates. Results: A total of 3,923,618 patients who underwent surgery were included from 1,139 facilities. Of these, 40.4% had breast cancer, 12.8% prostate cancer, and 10.0% colon cancer. Most patients were female (65.0%), White (86.4%), and privately insured (51.6%) with stage 0–III disease (64.8%). For all cancers, the risk of death for patients undergoing surgery at very high-volume facilities was 88% of that for those treated at low-volume facilities. Hazard ratios (HRs) were greatest (very high vs low volume) for cancer of the prostate (HR, 0.66; 95% CI, 0.63–0.69), pancreas (HR, 0.75; 95% CI, 0.71–0.78), and esophagus (HR, 0.78; 95% CI, 0.73–0.83), and for melanoma (HR, 0.81; 95% CI, 0.78–0.84); differences were smallest for uterine and non–small cell lung cancers. Overall survival differences were greatest for cancers of the brain, pancreas, and esophagus. Conclusions: Patients treated surgically at higher-volume facilities consistently had improved overall survival compared with those treated at low-volume centers, although the magnitude of difference was cancer-specific.
Submitted December 12, 2019; accepted for publication August 19, 2020. Published online February 9, 2021.
Author contributions:Study concept and design: All authors. Data acquisition, analysis, and interpretation: Shen, Walter, Wang, Zaorsky. Statistical analysis: Shen, Wang. Study supervision: Zaorsky. Manuscript preparation: Stoltzfus, Zaorsky. Critical revision of the manuscript for important intellectual content: All authors.
Disclosures: Dr. Trifiletti has disclosed that he receives grant/research support from Novocure. Dr. Zaorsky has disclosed that he receives support from the NIH (LRP 1 L30 CA231572-0), and the American Cancer Society–Tri State CEOs Against Cancer Clinician Scientist Development (CSDG-20-013-01-CCE). 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.
BekelisK, MarthNJ, WongK, . Primary stroke center hospitalization for elderly patients with stroke: implications for case fatality and travel times. JAMA Intern Med 2016;176:1361–1368.10.1001/jamainternmed.2016.391927455403)| false
VermaV, AhernCA, BerlindCG, . Facility volume and postoperative outcomes for malignant pleural mesothelioma: A National Cancer Data Base analysis. Lung Cancer 2018;120:7–13.10.1016/j.lungcan.2018.03.01929748018)| false
BajajA, MartinB, BhasinR,
. The impact of academic facility type and case volume on survival in patients undergoing curative radiation therapy for muscle-invasive bladder cancer. Int J Radiat Oncol Biol Phys2018;100:851–857.
BajajA, MartinB, BhasinR, . The impact of academic facility type and case volume on survival in patients undergoing curative radiation therapy for muscle-invasive bladder cancer. Int J Radiat Oncol Biol Phys 2018;100:851–857.10.1016/j.ijrobp.2017.11.04029485062)| false
BilimoriaKY, StewartAK, WinchesterDP, . The National Cancer Data Base: a powerful initiative to improve cancer care in the United States. Ann Surg Oncol 2008;15:683–690.10.1245/s10434-007-9747-318183467)| false
ZaorskyNG, ZhangY, WalterV, . Clinical trial accrual at initial course of therapy for cancer and its impact on survival. J Natl Compr Canc Netw 2019;17:1309–1316.3169398610.6004/jnccn.2019.7321)| false
CheungMC, HamiltonK, ShermanR,
. Impact of teaching facility status and high-volume centers on outcomes for lung cancer resection: an examination of 13,469 surgical patients. Ann Surg Oncol2009;16:3–13.
CheungMC, HamiltonK, ShermanR, . Impact of teaching facility status and high-volume centers on outcomes for lung cancer resection: an examination of 13,469 surgical patients. Ann Surg Oncol 2009;16:3–13.1860037910.1245/s10434-008-0025-9)| false
LüchtenborgM, RiazSP, CouplandVH, . High procedure volume is strongly associated with improved survival after lung cancer surgery. J Clin Oncol 2013;31:3141–3146.2389796210.1200/JCO.2013.49.0219)| false
SchragD, PanageasKS, RiedelE, . Surgeon volume compared to hospital volume as a predictor of outcome following primary colon cancer resection. J Surg Oncol 2003;83:68–78, discussion 78–79.1277219810.1002/jso.10244)| false
GutierrezJC, PerezEA, MoffatFL, . Should soft tissue sarcomas be treated at high-volume centers? An analysis of 4205 patients. Ann Surg 2007;245:952–958.10.1097/01.sla.0000250438.04393.a817522521)| false
HaqueW, VermaV, ButlerEB,
. Trimodality therapy for esophageal cancer at high volume facilities is associated with improved postoperative outcomes and overall survival. Dis Esophagus2019;32:doy067.
HaqueW, VermaV, ButlerEB, . Trimodality therapy for esophageal cancer at high volume facilities is associated with improved postoperative outcomes and overall survival. Dis Esophagus 2019;32:doy067.3005283510.1093/dote/doy067)| false
ChenAY, FedewaS, PavluckA, . Improved survival is associated with treatment at high-volume teaching facilities for patients with advanced stage laryngeal cancer. Cancer 2010;116:4744–4752.2058976110.1002/cncr.25364)| false
KoshyM, MalikR, MahmoodU,
. Stereotactic body radiotherapy and treatment at a high volume facility is associated with improved survival in patients with inoperable stage I non-small cell lung cancer. Radiother Oncol2015;114:148–154.
KoshyM, MalikR, MahmoodU, . Stereotactic body radiotherapy and treatment at a high volume facility is associated with improved survival in patients with inoperable stage I non-small cell lung cancer. Radiother Oncol 2015;114:148–154.10.1016/j.radonc.2014.12.004)| false
BristowRE, PalisBE, ChiDS,
. The National Cancer Database report on advanced-stage epithelial ovarian cancer: impact of hospital surgical case volume on overall survival and surgical treatment paradigm. Gynecol Oncol2010;118:262–267.
BristowRE, PalisBE, ChiDS, . The National Cancer Database report on advanced-stage epithelial ovarian cancer: impact of hospital surgical case volume on overall survival and surgical treatment paradigm. Gynecol Oncol 2010;118:262–267.10.1016/j.ygyno.2010.05.02520573392)| false
LuoR, GiordanoSH, FreemanJL, . Referral to medical oncology: a crucial step in the treatment of older patients with stage III colon cancer. Oncologist 2006;11:1025–1033.10.1634/theoncologist.11-9-102517030645)| false