Effect of surgical volume and hospital type on outcome in non-small cell lung cancer surgery: A Finnish population-based study

doi:10.1016/j.lungcan.2007.07.020

Lung Cancer

Volume 59, Issue 1, January 2008, Pages 119-125

https://doi.org/10.1016/j.lungcan.2007.07.020 Get rights and content

Summary

Objective

Hospital mortality and long-term survival in major cancer surgery seems to be affected by hospital related factors. We evaluated the effect of university versus non-university hospital type, and surgical volume (0–4, 5–10, 11–20, and >20 average of cases/year) on the immediate and long-term survival of surgical non-small cell lung cancer (NSCLC) patients.

Patients and methods

Between 1988 and 2002, the number of NSCLC resections with curative intent in Finland was 5339. Follow-up until the end of 2003 from national registries was available on 91% (4878 of 5339) of patients.

Results

Multivariate analysis showed that hospital mortality was unaffected by hospital type or volume, but delay of >4 months from diagnosis to surgery did have an adverse effect. Surgery at university hospitals was associated with significantly better cancer-related and overall survival, as also was surgery at very low-volume but mainly private hospitals (0–4 cases/year).

Conclusions

Undergoing surgery for non-small cell lung cancer at a university hospital may offer an advantage for long-term survival, but large hospital volume in itself did not.

Summary

Multivariate analysis on the effect of hospital type and surgical volume on immediate and long-term survival of 4878 lung cancer surgery patients, 1988–2002, showed that surgery at university hospitals was associated with significantly better cancer-related and overall survival, but hospital mortality did not differ. Large hospital volume did not independently predict a better outcome.

Introduction

The results of surgery for esophageal, pancreatic, and hepatobiliary cancer appear to depend on the surgeon, hospital type, and volume [1], [2], [3], [4], [5], [6], [7]. Some authors have found no such association regarding lung cancer surgery [7], [8], [9], especially when all participating centers had uniform protocols for treatment and staging [9]. Lung cancer surgery is hazardous and incapacitating. Hospital mortality is still 3% for lobectomy and 5–10% for pneumonectomy [10]. Over 12% of the survivors die within 6 months, and functional health status in comparison to the preoperative status remains significantly impaired [11].

The surgeon should do the minimum lung resection that offers a chance for cure, maintain a balance between operative risk and chance of cure, and accurately stage the patients in order to provide treatment results comparable with other centers [12]. This objective might not be achieved without a dedicated multidisciplinary lung cancer team that has access to extensive facilities.

We carried out this study to learn whether the hospital mortality and long-term survival of lung cancer patients depends on the surgical volume and hospital type.

Section snippets

Patients

From 1988 to 2002, 5339 patients in Finland underwent thoracotomy or thoracoscopy with curative intent for non-small cell lung cancer. Of these, 328 patients underwent multiple procedures during the study period, usually a definitive resection after an initial open biopsy or a completion procedure due to a non-radical resection margin. Each patient was accounted for only once, and follow-up began after the first definitive lung resection. Registry data was available until the end of 2003 on

Results

Surgery was carried out in 26 hospitals. During the study period, eight hospitals had an average of zero to four cases per year, nine hospitals had 5–10, five hospitals had 11–20, and four had over 20. The average yearly number of patients that underwent surgery with curative intent for NSCLC totaled 325.

Of 4878 patients, 2291 (47%) had localized disease at surgery. The procedure was reported as curative in 2743 (57%). The hospital mortality was 3.4% (95/2821) for lobectomies and bilobectomies

Discussion

We observed no significant differences in hospital mortality between type of hospital or dependence on surgical volumes. No differences in frequency appeared in the type of operative procedure, so a pre-selection of low-risk resections into the non-university and other than highest volume hospitals is an unlikely explanation. The exceptions were the smallest volume hospitals: mainly private clinics where experienced surgeons treated highly selected patients. In the literature, 30-day mortality

Conflict of interest statement

None of the authors have conflicts of interest to declare regarding this study.

Acknowledgements

We would like to thank Anna M. Koivisto, M.Sc, for performing the statistical analyses, and Yvonne Sundström for expert secretarial help. This study was supported by a grant from the Helsinki University Hospital Research Fund.

References (25)

O. Birim et al.
Prognostic factors in non-small cell lung cancer surgery
Eur J Surg Oncol
(2006)
E.V. Finlayson et al.
Effects of hospital volume on life expectancy after selected cancer operations in older adults: a decision analysis
J Am Coll Surg
(2003)
R.J. Ginsberg
Lung cancer surgery: acceptable morbidity and mortality, expected results and quality control
Surg Oncol
(2002)
J.R. Handy et al.
What happens to patients undergoing lung cancer surgery? Outcomes and quality of life before and after surgery
Chest
(2002)
A.N. Graham et al.
Systematic nodal dissection in the intrathoracic staging of patients with non-small cell lung cancer
J Thorac Cardiovasc Surg
(1999)
J.M. Chatkin et al.
Is there a gender difference in non-small cell lung cancer survival?
Gend Med
(2004)
C.M. Tammemagi et al.
Smoking and lung cancer survival: the role of comorbidity and treatment
Chest
(2004)
G.A. Silvestri et al.
Specialists achieve better outcomes than generalists for lung cancer surgery
Chest
(1998)
C.B. Begg et al.
Impact of hospital volume on operative mortality for major cancer surgery
JAMA
(1998)
J.D. Birkmeyer et al.
Hospital volume and surgical mortality in the United States
N Engl J Med
(2002)

E.V. Finlayson et al.

Hospital volume and operative mortality in cancer surgery: a national study

Arch Surg

(2003)

B.E. Hillner et al.

Hospital and physician volume or specialization and outcomes in cancer treatment: importance in quality of cancer care

J Clin Oncol

(2000)

Cited by (22)

Nationwide effect of high procedure volume in lung cancer surgery on in-house mortality in Germany
2020, Lung Cancer
Citation Excerpt :
We could show a significant inverse relationship of occurrence of severe complications and FTR with hospital volume, which supports this factor as an important variable for the observed volume mortality relationship. Retrospective studies for the most part carried out in countries others than the United States did not find an association between hospital volume and outcome after lung cancer resection [8–11]. In contrast several studies identified hospital volume to be a significant independent variable of death [7,19–23].
The literature reports that hospital caseload volume is associated with survival for lung cancer resection. The aim of this study is to explore this association in a nationwide setting according to individual hospital caseload volume of every inpatient case in Germany.
This retrospective analysis of nationwide hospital discharge data in Germany between 2014 and 2017 comprises 121,837 patients of whom 36,051 (29.6 %) underwent surgical anatomic resection. Hospital volumes were defined according to the number of patient resections for lung cancer in each hospital, and patients were categorized into 5 quintiles based on hospital caseload volume. A logistic regression model accounting for death according to sex, age, comorbidity, and resection volume was calculated, and effect modification was evaluated using the Mantel–Haenszel method.
In-house mortality ranged from 2.1 % in very high-volume centers to 4.0 % in very low-volume hospitals (p < 0.01). In multivariable logistic regression analysis, lower in-house mortality in very high-volume centers performing > 140 anatomic lung resections per year was observed compared with very low-volume centers performing < 27 resections (OR, 0.58; CI, 0.46 to 0.72; p < 0.01). This relationship also held for failure to rescue rates (12.9 vs 16.7 %, p = 0.01), although a greater number of extended resections were performed (23.1 vs. 14.8 %, p < 0.01).
Hospitals with high volumes of lung cancer resections performed surgery with a higher ratio of complex procedures and achieved reduced in-house mortality, fewer complications, and lower failure to rescue rates.
Patient and Facility Demographics Related Outcomes in Early-Stage Non-Small Cell Lung Cancer Treated with Radiofrequency Ablation: A National Cancer Database Analysis
2018, Journal of Vascular and Interventional Radiology
To determine facility and patient demographics associated with survival in early-stage non-small cell lung cancer (NSCLC) treated with radiofrequency (RF) ablation.
The National Cancer Database was queried for cases of stage 1a NSCLC treated with RF ablation without chemotherapy or radiotherapy from 2004 to 2014. High-volume centers (HVCs) were defined as the top 95^th percentile of facilities by number of procedures performed. Overall survival (OS) was estimated with the Kaplan-Meier method, and comparisons between survival curves were performed with the log-rank test. Propensity score-matched cohort analysis was performed. P values less than .05 were considered statistically significant.
In the final cohort, 967 cases were included. Estimated median survival and follow-up were 33.1 and 62.5 months, respectively. Of 305 facilities, 15 were determined to be HVCs, treating 13 or more patients from 2004 to 2014. A total of 335 cases (34.6%) were treated at HVCs. On multivariate Cox regression analysis, treatment at an HVC was independently associated with improved OS (hazard ratio [HR] = 0.766; P = .006). After propensity score adjustment, 1-, 3-, and 5-year OS was 89.8%, 51.2%, and 27.7%, respectively, for patients treated at HVCs, compared to 85.2%, 41.5%, and 19.6%, respectively, for patients treated at non-HVCs (P = .015). Increasing age (HR = 1.012; P = .013) and higher T-classification (HR = 1.392; P < .001) were independently associated with worse OS.
Patients with early-stage NSCLC treated with RF ablation at HVCs experienced a significant increase in OS, suggesting regionalization of lung cancer management as a means of improving outcomes.
Lung Cancer Screening and Its Impact on Surgical Volume
2017, Surgical Clinics of North America
Citation Excerpt :
Patients operated on at high-volume centers have lower postoperative complication rates and lower 30-day mortality. Outcomes seem to be better in large teaching hospitals51,52 and the surgeon’s subspecialty—thoracic or cardiothoracic surgery versus general surgery—also influences in-hospital mortality.53,54 Despite a clear need for thoracic surgeons, the workforce is projected to decrease.
Surgery in high-volume hospitals not commission on cancer accreditation leads to increased cancer-specific survival for early-stage lung cancer
2015, American Journal of Surgery
Quality of oncologic outcomes is of paramount importance in the care of patients with non–small cell lung cancer (NSCLC). We sought to evaluate the relationship of hospital volume for lobectomy on cancer-specific survival in NSCLC patients treated in California, as well as the influence of Commission on Cancer (CoC) accreditation.
The California Cancer Registry was queried from 2004 to 2011 for cases of Stage I NSCLC and 8,345 patients were identified. Statistical analysis was used to determine prognostic factors for cancer-specific survival.
A total of 7,587 patients were treated surgically. CoC accreditation was not significant for cancer-specific survival, but treatment in high-volume centers was associated with longer survival when compared with low- and medium-volume centers (hazard ratio 1.77, 1.474 to 2.141 and hazard ratio 1.23, 1.058 to 1.438).
These data suggest that surgical treatment in high-volume hospitals is associated with longer cancer-specific survival for early-stage NSCLC, but that CoC accreditation is not.
Does surgeon experience affect outcomes in pathologic stage i lung cancer?
2015, Journal of Thoracic and Cardiovascular Surgery
The study objective was to evaluate the influence of surgeon experience on outcomes in early-stage non–small cell lung cancer.
In an institutional database, patients undergoing operations for pathologic stage I non–small cell lung cancer were categorized by surgeon experience: within 5 years of completion of training, the low experience group; with 5 to 15 years of experience, the moderate experience group; and with more than 15 years, the high experience group.
From 2000 to 2012, 800 operations (638 lobectomies, 162 sublobar resection) were performed with the following distribution: low experience 178 (22.2%), moderate experience 224 (28.0%), and high experience 398 (49.8%). Patients in the groups were similar in age and comorbidities. The use of video-assisted thoracoscopic surgery was higher in the moderate experience group (low experience: 62/178 [34.8%], moderate experience: 151/224 [67.4%], and high experience: 133/398 [33.4%], P < .001), as was the mean number of mediastinal (N2) lymph node stations sampled (low experience: 2.8 ± 1.6, moderate experience: 3.5 ± 1.7, high experience: 2.3 ± 1.4, P < .001). The risk of perioperative morbidity was similar across all groups (low experience: 54/178 [30.3%], moderate experience: 51/224 [22.8%], and high experience: 115/398 [28.9%], P = .163). Five-year overall survival in the moderate experience group was 76.9% compared with 67.5% in the low experience group (P < .001) and 71.4% in the high experience group (P = .006). In a Cox proportional hazard model, increasing age, male gender, prior cancer, and R1 resection were associated with an elevated risk of mortality, whereas being operated on by surgeons with moderate experience and having a greater number of mediastinal (N2) lymph node stations sampled were protective.
The experience of the surgeon does not affect perioperative outcomes after resection for pathologic stage I non–small cell lung cancer. At least moderate experience after fellowship is associated with improved long-term survival.
Treatment of stage I and II non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American college of chest physicians evidence-based clinical practice guidelines
2013, Chest
The treatment of stage I and II non-small cell lung cancer (NSCLC) in patients with good or low surgical risk is primarily surgical resection. However, this area is undergoing many changes. With a greater prevalence of CT imaging, many lung cancers are being found that are small or constitute primarily ground-glass opacities. Treatment such as sublobar resection and nonsurgical approaches such as stereotactic body radiotherapy (SBRT) are being explored. With the advent of minimally invasive resections, the criteria to classify a patient as too ill to undergo an anatomic lung resection are being redefined.
The writing panel selected topics for review based on clinical relevance to treatment of early-stage lung cancer and the amount and quality of data available for analysis and relative controversy on best approaches in stage I and II NSCLC: general surgical care vs specialist care; sublobar vs lobar surgical approaches to stage I lung cancer; video-assisted thoracic surgery vs open resection; mediastinal lymph node sampling vs lymphadenectomy at the time of surgical resection; the use of radiation therapy, with a focus on SBRT, for primary treatment of early-stage NSCLC in high-risk or medically inoperable patients as well as adjuvant radiation therapy in the sublobar and lobar resection settings; adjuvant chemotherapy for early-stage NSCLC; and the impact of ethnicity, geography, and socioeconomic status on lung cancer survival. Recommendations by the writing committee were based on an evidence-based review of the literature and in accordance with the approach described by the Guidelines Oversight Committee of the American College of Chest Physicians.
Surgical resection remains the primary and preferred approach to the treatment of stage I and II NSCLC. Lobectomy or greater resection remains the preferred approach to T1b and larger tumors. The use of sublobar resection for T1a tumors and the application of adjuvant radiation therapy in this group are being actively studied in large clinical trials. Every patient should have systematic mediastinal lymph node sampling at the time of curative intent surgical resection, and mediastinal lymphadenectomy can be performed without increased morbidity. Perioperative morbidity and mortality are reduced and long-term survival is improved when surgical resection is performed by a board-certified thoracic surgeon. The use of adjuvant chemotherapy for stage II NSCLC is recommended and has shown benefit. The use of adjuvant radiation or chemotherapy for stage I NSCLC is of unproven benefit. Primary radiation therapy remains the primary curative intent approach for patients who refuse surgical resection or are determined by a multidisciplinary team to be inoperable. There is growing evidence that SBRT provides greater local control than standard radiation therapy for high-risk and medically inoperable patients with NSCLC. The role of ablative therapies in the treatment of high-risk patients with stage I NSCLC is evolving. Radiofrequency ablation, the most studied of the ablative modalities, has been used effectively in medically inoperable patients with small (< 3 cm) peripheral NSCLC that are clinical stage I.

View all citing articles on Scopus

View full text

Effect of surgical volume and hospital type on outcome in non-small cell lung cancer surgery: A Finnish population-based study

Summary

Objective

Patients and methods

Results

Conclusions

Summary

Introduction

Section snippets

Patients

Results

Discussion

Conflict of interest statement

Acknowledgements

Eur J Surg Oncol

J Am Coll Surg

Surg Oncol

Chest

J Thorac Cardiovasc Surg

Gend Med

Chest

Chest

Impact of hospital volume on operative mortality for major cancer surgery

JAMA

Hospital volume and surgical mortality in the United States

N Engl J Med

Hospital volume and operative mortality in cancer surgery: a national study

Arch Surg

Hospital and physician volume or specialization and outcomes in cancer treatment: importance in quality of cancer care

J Clin Oncol