Volume 201 - Issue 8
Survival, mortality and morbidity outcomes after oesophagogastric cancer surgery in New South Wales, 2001–2008
Authors: Margaret Lee and Peter Gibbs
Med J Aust 2014; 201 (8): 447. || doi: 10.5694/mja14.00870
Published online: 20 October 2014
Published online: 20 October 2014
Does institutional volume matter?
To the Editor: Following a retrospective review of New South Wales data, Smith and colleagues concluded that the better long-term survival outcomes following surgery for oesophagogastric cancer at higher-volume centres support surgery only being done at these centres.1 However, much missing data creates uncertainty about this conclusion.
Survival outcomes directly relate to stage at diagnosis, so variable use of staging laparoscopy, endoscopic ultrasound and/or positron emission tomography, all of which can upstage a significant proportion of patients,2 and all more likely to be employed at higher-volume centres, could create considerable variation in recorded stage at diagnosis and in patient selection for surgery. Further, some patients considered surgical candidates at one hospital may be managed with definitive chemoradiation at another hospital.3 Most significantly, there are widely variable approaches to the use of adjuvant radiation and chemotherapy, including the timing and agents used,4 which have a significant impact on recurrence risk and survival. As 5-year survival is also confounded by deaths from other causes, this measure cannot be considered a reliable indicator of surgical quality. We note that more direct indicators — length of stay and 30-day mortality — did not differ for lower-volume versus higher-volume centres.
Attempting to compare hospital surgical outcomes where there are no data on the variable approaches to initial staging or multidisciplinary management is likely to end with an “apples versus oranges” comparison. While surgery at higher-volume centres may produce better outcomes, Smith et al do not have the data to conclusively show this.
Competing interests
No relevant disclosures.
References
- Smith RC, Creighton N, Lord RV, et al. Survival, mortality and morbidity outcomes after oesophagogastric cancer surgery in New South Wales, 2001–2008. Med J Aust 2014; 200: 408-413. 1
- Smyth E, Schöder H, Strong VE, et al. A prospective evaluation of the utility of 2-deoxy-2-[18F]fluoro-D-glucose positron emission topography and computed tomography in staging locally advanced gastric cancer. Cancer 2012; 118: 5481-5488. 2
- Hategan M, Cook N, Prewett S, et al. Trimodality therapy and definitive chemoradiotherapy for esophageal cancer: a single-center experience and review of the literature. Dis Esophagus 2014; May 27 [Epub ahead of print]. 3
- Kersten C, Cvancarova M, Mjåland S, Mjåland O. Does in-house availability of multidisciplinary teams increase survival in upper gastrointestinal-cancer? World J Gastrointest Oncol 2013; 5: 60-67. lefthere