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  • br The study hypothesis of a stronger survival benefit

    2020-07-29


    The study AZD7687 of a stronger survival benefit of high-volume hospitals of more complex procedures and less so for other operations, was not supported by the findings. Instead long-term survival after colon cancer surgery was consistently improved by higher hospital volume. This might partly be explained by the superior statistical power in the colon cancer analyses, showing statistical significance for relatively weak associations. The finding regarding colon cancer surgery is in conflict with a recent sys-tematic review and meta-analysis of 11,978 patients, reporting no association between increased hospital volume and improved 5-year survival [36], but the meta-analysis included fewer than half of those in the present study. In this study, it was also possible to assess effect modification, which was not conducted in the meta-analysis, and interestingly the associations were more prominent in patients of older age, more comorbidity, and more advanced tumor stage. Centralization of such patients groups might be justified if a tailored centralization is warranted.
    Regarding esophageal cancer surgery, a recent systematic AZD7687 re-view and meta-analysis found that higher hospital volume was associated with improved 5-year survival [37]. The present study partly support those findings, because an improved survival was found in patients who had undergone esophagectomy in the 3rd quartile of hospital volume and in patients with more advanced tumor stage.
    Higher hospital volume of pancreatic cancer surgery was asso-ciated with improved long-term survival in a systematic review and meta-analysis [38]. These results are in line with some subgroup analyses in the present study, which revealed improved survival for higher volume hospitals in patients with more comorbidity and possibly also in patients with more advanced tumor stage.
    For rectal cancer surgery, a recent systematic review and meta-analysis did not find any association between higher hospital vol-ume and long-term survival [36], which is supported by the main analyses of the present study. However, the current study indicated an improved survival in subgroups of patients who underwent surgery at higher volume hospitals, which suggests a need for more studies with stratified analyses.
    The present study found no associations between higher hos-pital volume for surgery of cancer of the stomach, liver, bile ducts, or small bowel and 5-year mortality. For gastric cancer surgery, the negative findings are supported by some previous studies [12], but not by all [11]. Regarding liver cancer, the negative findings are contradicted by a previous study, but that study did not adjust for tumor stage [39]. The lack of association between higher hospital volume for bile duct cancer is in line with other studies [40]. Studies on small bowel cancer are scarce, and the present study had limited power and substantial missing data on tumor stage, thus more research is needed before a prognostic role of higher hospital vol-ume can be dismissed.
    Increased hospital volume of surgery can be achieved by centralizing procedures to fewer hospitals. However, some studies have indicated that surgeon volume for colorectal and esophageal cancer is more important than hospital volume [13,37,41]. It is possible that individual surgeons receive more training at smaller
    Please cite radioisotope article as: Gottlieb-Vedi E et al., Annual hospital volume of surgery for gastrointestinal cancer in relation to prognosis, European Journal of Surgical Oncology, https://doi.org/10.1016/j.ejso.2019.03.016
    6 E. Gottlieb-Vedi et al. / European Journal of Surgical Oncology xxx (xxxx) xxx
    Table 5
    Hospital volume (in quartiles) for gastrointestinal cancers in relation to disease-specific 5-year mortality in effect modification analyses.
    Prognostic factor
    Quartile I Quartile II Quartile III Quartile IV
    Hazard ratio (95% confidence interval)a
    Esophageal cancer
    Gastric cancer
    Liver cancer
    Pancreatic cancer
    Bile duct cancer
    Please cite this article as: Gottlieb-Vedi E et al., Annual hospital volume of surgery for gastrointestinal cancer in relation to prognosis, European Journal of Surgical Oncology, https://doi.org/10.1016/j.ejso.2019.03.016
    E. Gottlieb-Vedi et al. / European Journal of Surgical Oncology xxx (xxxx) xxx
    Prognostic factor
    Quartile I Quartile II Quartile III Quartile IV
    Hazard ratio (95% confidence interval)a
    Tumor stage 0-II
    III-IV
    Small bowel cancer
    Sex Male
    Female
    Charlson comorbidity score
    Calendar year of surgery <2009
    Tumor stage 0-II
    III-IV
    Colon cancer