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Marano L, Verre L, Carbone L, Poto GE, Fusario D, Venezia DF, Calomino N, Kaźmierczak-Siedlecka K, Polom K, Marrelli D, Roviello F, Kok JHH, Vashist Y. Current Trends in Volume and Surgical Outcomes in Gastric Cancer. J Clin Med 2023; 12:jcm12072708. [PMID: 37048791 PMCID: PMC10094776 DOI: 10.3390/jcm12072708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/27/2023] [Accepted: 04/03/2023] [Indexed: 04/08/2023] Open
Abstract
Gastric cancer is ranked as the fifth most frequently diagnosed type of cancer. Complete resection with adequate lymphadenectomy represents the goal of treatment with curative intent. Quality assurance is a crucial factor in the evaluation of oncological surgical care, and centralization of healthcare in referral hospitals has been proposed in several countries. However, an international agreement about the setting of “high-volume hospitals” as well as “minimum volume standards” has not yet been clearly established. Despite the clear postoperative mortality benefits that have been described for gastric cancer surgery conducted by high-volume surgeons in high-volume hospitals, many authors have highlighted the limitations of a non-composite variable to define the ideal postoperative period. The textbook outcome represents a multidimensional measure assessing the quality of care for cancer patients. Transparent and easily available hospital data will increase patients’ awareness, providing suitable elements for a more informed hospital choice.
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Affiliation(s)
- Luigi Marano
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Luigi Verre
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Ludovico Carbone
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Gianmario Edoardo Poto
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Daniele Fusario
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | | | - Natale Calomino
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Karolina Kaźmierczak-Siedlecka
- Department of Medical Laboratory Diagnostics-Fahrenheit Biobank BBMRI.pl, Medical University of Gdansk, 80-308 Gdańsk, Poland
| | - Karol Polom
- Department of Surgical Oncology, Medical University of Gdansk, 80-308 Gdańsk, Poland
| | - Daniele Marrelli
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Franco Roviello
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Johnn Henry Herrera Kok
- Department of General and Digestive Surgery, Complejo Asistencial Universitario de León, 24071 León, Spain
| | - Yogesh Vashist
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh 11211, Saudi Arabia
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2
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Ning FL, Gu WJ, Zhao ZM, Du WY, Sun M, Cao SY, Zeng YJ, Abe M, Zhang CD. Association between hospital surgical case volume and postoperative mortality in patients undergoing gastrectomy for gastric cancer: a systematic review and meta-analysis. Int J Surg 2023; 109:936-945. [PMID: 36917144 PMCID: PMC10389614 DOI: 10.1097/js9.0000000000000269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/06/2023] [Indexed: 03/15/2023]
Abstract
BACKGROUND Postoperative mortality is an important indicator for evaluating surgical safety. Postoperative mortality is influenced by hospital volume; however, this association is not fully understood. This study aimed to investigate the volume-outcome association between the hospital surgical case volume for gastrectomies per year (hospital volume) and the risk of postoperative mortality in patients undergoing a gastrectomy for gastric cancer. METHODS Studies assessing the association between hospital volume and the postoperative mortality in patients who underwent gastrectomy for gastric cancer were searched for eligibility. Odds ratios were pooled for the highest versus lowest categories of hospital volume using a random-effects model. The volume-outcome association between hospital volume and the risk of postoperative mortality was analyzed. The study protocol was registered with Prospective Register of Systematic Reviews (PROSPERO). RESULTS Thirty studies including 586 993 participants were included. The risk of postgastrectomy mortality in patients with gastric cancer was 35% lower in hospitals with higher surgical case volumes than in their lower-volume counterparts (odds ratio: 0.65; 95% CI: 0.56-0.76; P <0.001). This relationship was consistent and robust in most subgroup analyses. Volume-outcome analysis found that the postgastrectomy mortality rate remained stable or was reduced after the hospital volume reached a plateau of 100 gastrectomy cases per year. CONCLUSIONS The current findings suggest that a higher-volume hospital can reduce the risk of postgastrectomy mortality in patients with gastric cancer, and that greater than or equal to 100 gastrectomies for gastric cancer per year may be defined as a high hospital surgical case volume.
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Affiliation(s)
- Fei-Long Ning
- Department of Gastrointestinal Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Wan-Jie Gu
- Departments of Intensive Care Unit
- Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou
| | - Zhe-Ming Zhao
- Department of Gastrointestinal Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang
| | - Wan-Ying Du
- Department of Gastrointestinal Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Min Sun
- Department of General Surgery, Taihe Hospital, Hubei University of Medicine, Shiyan
| | - Shi-Yi Cao
- School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yong-Ji Zeng
- Section of Gastroenterology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Masanobu Abe
- Division for Health Service Promotion, The University of Tokyo, Tokyo, Japan
| | - Chun-Dong Zhang
- Department of Gastrointestinal Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang
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3
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Concin N, Planchamp F, Abu-Rustum NR, Ataseven B, Cibula D, Fagotti A, Fotopoulou C, Knapp P, Marth C, Morice P, Querleu D, Sehouli J, Stepanyan A, Taskiran C, Vergote I, Wimberger P, Zapardiel I, Persson J. European Society of Gynaecological Oncology quality indicators for the surgical treatment of endometrial carcinoma. Int J Gynecol Cancer 2021; 31:1508-1529. [PMID: 34795020 DOI: 10.1136/ijgc-2021-003178] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Quality of surgical care as a crucial component of a comprehensive multi-disciplinary management improves outcomes in patients with endometrial carcinoma, notably helping to avoid suboptimal surgical treatment. Quality indicators (QIs) enable healthcare professionals to measure their clinical management with regard to ideal standards of care. OBJECTIVE In order to complete its set of QIs for the surgical management of gynecological cancers, the European Society of Gynaecological Oncology (ESGO) initiated the development of QIs for the surgical treatment of endometrial carcinoma. METHODS QIs were based on scientific evidence and/or expert consensus. The development process included a systematic literature search for the identification of potential QIs and documentation of the scientific evidence, two consensus meetings of a group of international experts, an internal validation process, and external review by a large international panel of clinicians and patient representatives. QIs were defined using a structured format comprising metrics specifications, and targets. A scoring system was then developed to ensure applicability and feasibility of a future ESGO accreditation process based on these QIs for endometrial carcinoma surgery and support any institutional or governmental quality assurance programs. RESULTS Twenty-nine structural, process and outcome indicators were defined. QIs 1-5 are general indicators related to center case load, training, experience of the surgeon, structured multi-disciplinarity of the team and active participation in clinical research. QIs 6 and 7 are related to the adequate pre-operative investigations. QIs 8-22 are related to peri-operative standards of care. QI 23 is related to molecular markers for endometrial carcinoma diagnosis and as determinants for treatment decisions. QI 24 addresses the compliance of management of patients after primary surgical treatment with the standards of care. QIs 25-29 highlight the need for a systematic assessment of surgical morbidity and oncologic outcome as well as standardized and comprehensive documentation of surgical and pathological elements. Each QI was associated with a score. An assessment form including a scoring system was built as basis for ESGO accreditation of centers for endometrial cancer surgery.
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Affiliation(s)
- Nicole Concin
- Department of Gynecology and Obstetrics; Innsbruck Medical Univeristy, Innsbruck, Austria .,Department of Gynecology and Gynecological Oncology, Evangelische Kliniken Essen-Mitte, Essen, Germany
| | | | - Nadeem R Abu-Rustum
- Department of Obstetrics and Gynecology, Memorial Sloann Kettering Cancer Center, New York, New York, USA
| | - Beyhan Ataseven
- Department of Gynecology and Gynecological Oncology, Evangelische Kliniken Essen-Mitte, Essen, Germany.,Department of Obstetrics and Gynaecology, University Hospital Munich (LMU), Munich, Germany
| | - David Cibula
- Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University, General University Hospital in Prague, Prague, Czech Republic
| | - Anna Fagotti
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Lazio, Italy
| | - Christina Fotopoulou
- Department of Gynaecologic Oncology, Imperial College London Faculty of Medicine, London, UK
| | - Pawel Knapp
- Department of Gynaecology and Gynaecologic Oncology, University Oncology Center of Bialystok, Medical University of Bialystok, Bialystok, Poland
| | - Christian Marth
- Department of Obstetrics and Gynecology, Innsbruck Medical University, Innsbruck, Austria
| | - Philippe Morice
- Department of Surgery, Institut Gustave Roussy, Villejuif, France
| | - Denis Querleu
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Lazio, Italy.,Department of Obstetrics and Gynecologic Oncology, University Hospitals Strasbourg, Strasbourg, Alsace, France
| | - Jalid Sehouli
- Department of Gynecology with Center for Oncological Surgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universitätzu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Artem Stepanyan
- Department of Gynecologic Oncology, Nairi Medical Center, Yerevan, Armenia
| | - Cagatay Taskiran
- Department of Obstetrics and Gynecology, Koç University School of Medicine, Ankara, Turkey.,Department of Gynecologic Oncology, VKV American Hospital, Istambul, Turkey
| | - Ignace Vergote
- Department of Gynecology and Obstetrics, Gynecologic Oncology, Leuven Cancer Institute, Catholic University Leuven, Leuven, Belgium
| | - Pauline Wimberger
- Department of Gynecology and Obstetrics, Technische Universität Dresden, Dresden, Germany.,National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - Ignacio Zapardiel
- Gynecologic Oncology Unit, La Paz University Hospital - IdiPAZ, Madrid, Spain
| | - Jan Persson
- Department of Obstetrics and Gynecology, Skåne University Hospital, Lund, Sweden.,Lund University, Faculty of Medicine, Clinical Sciences, Lund, Sweden
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4
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Iwatsuki M, Yamamoto H, Miyata H, Kakeji Y, Yoshida K, Konno H, Seto Y, Baba H. Association of surgeon and hospital volume with postoperative mortality after total gastrectomy for gastric cancer: data from 71,307 Japanese patients collected from a nationwide web-based data entry system. Gastric Cancer 2021; 24:526-534. [PMID: 33037492 DOI: 10.1007/s10120-020-01127-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 09/22/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite interest in surgeon and hospital volume effects on total gastrectomy (TG), clinical significance has not been confirmed in a large-scale population. This study aimed at clarifying the association of surgeon and hospital volume on postoperative mortality after TG for gastric cancer among Japanese patients in National Clinical Database (NCD). METHODS Between 2011 and 2015, we retrospectively extracted data on TG for gastric cancer from the NCD. The primary outcome was operative mortality. We divided surgeon volume as the number of TGs performed by a patient's surgeon in the previous year: S1 (0-2 cases), S2 (3-9), S3 (10-25), S4 (26-79) and hospital volume by the number of TGs performed in the previous year: H1 (0-11 cases), H2 (12-26), H3 (27-146). We calculated the 95% confidence interval (CI) for the mortality rate based on odds ratios (OR) estimated from a hierarchical logistic regression model. RESULTS We analyzed 71,307 patients at 2051 institutions. Low-volume surgeons and hospitals had significantly older and poorer-risk patients with various comorbidities. The operative mortality rate decreased with surgeon volume, 2.5% in S1 and 0.6% in S4. The operative mortality was 3.1% in H1, 1.7% in H2, and 1.2% in H3. After risk adjustment for surgeon, hospital volume and patient characteristics, hospital volume was significantly associated with operative morality (H3: OR = 0.53, 95% CI 0.43-0.63). CONCLUSIONS We demonstrate hospital volume has an impact on postoperative mortality after TG in a nationwide population study. These findings suggest centralization may improve outcomes after TG.
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Affiliation(s)
- Masaaki Iwatsuki
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Hiroyuki Yamamoto
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan
| | - Hiroaki Miyata
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan
| | - Yoshihiro Kakeji
- Database Committee, The Japanese Society of Gastroenterological Surgery, Tokyo, Japan
| | - Kazuhiro Yoshida
- Department of Surgical Oncology, Gifu University School of Medicine, Gifu, Japan
| | - Hiroyuki Konno
- Hamamatsu University School of Medicine Hamamatsu, Hamamatsu, Japan
| | - Yasuyuki Seto
- The Japanese Society of Gastroenterological Surgery, Tokyo, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.
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Narendra A, Baade PD, Aitken JF, Fawcett J, Leggett B, Leggett C, Tian K, Sklavos T, Smithers BM. Hospital characteristics associated with better 'quality of surgery' and survival following oesophagogastric cancer surgery in Queensland: a population-level study. ANZ J Surg 2020; 91:323-328. [PMID: 33155394 DOI: 10.1111/ans.16397] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/13/2020] [Accepted: 09/28/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The impact of hospital characteristics on the quality of surgery and survival following oesophagogastric cancer surgery has not been well established in Australia. We assessed the interaction between hospital volume, service capability and surgical outcomes, with the hypothesis that both the quality of surgery and survival are better following treatment in high-volume, high service capability hospitals. METHODS All patients undergoing oesophagectomy and gastrectomy for cancer in Queensland, between 2001 and 2015, were included. Demographic, pathology and outcome data were collected. Hospitals were categorized into high (HV) (≥5 gastrectomies; ≥6 oesophagectomies) and low volume (LV). Hospital service capability was defined as high (HS) and low (LS), and then linked to hospital volume: HVHS, LVHS and LVLS. Higher quality surgery was defined using six perioperative parameters. Univariable comparisons of quality of surgery between hospital groups used chi-squared tests. The 5-year overall survival was compared using log-rank tests and Cox proportional hazard models. RESULTS For both gastrectomy and oesophagectomy, higher quality surgery occurred more frequently in HVHS hospitals (gastrectomy: HVHS = 44.2%, LVHS = 23.1%, LVLS = 29.1% (P < 0.01); oesophagectomy: HVHS = 34.5%, LVHS = 24.4%, LVLS = 21.7% (P = 0.01)). Following oesophagectomy, the 3- and 5-year overall survival was better following treatment in HVHS (P < 0.01). There was no difference between the groups following gastrectomy. CONCLUSION In Queensland, the quality of surgery was higher in HVHS hospitals performing gastrectomy and oesophagectomy; however, the impact on cancer survival was only seen following oesophagectomy.
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Affiliation(s)
- Aaditya Narendra
- The University of Queensland, Princess Alexandra Hospital, Cancer Alliance Queensland, Burke Street Centre, Brisbane, Queensland, Australia
| | - Peter D Baade
- Cancer Council Queensland, Brisbane, Queensland, Australia
| | - Joanne F Aitken
- The University of Queensland, The University of Southern Queensland, Cancer Council Queensland, Brisbane, Queensland, Australia
| | - Jonathan Fawcett
- Hepato-Pancreatico-Biliary Unit, Princess Alexandra Hospital, The University of Queensland, Brisbane, Queensland, Australia
| | - Brandon Leggett
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Callum Leggett
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Kevin Tian
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | | | - B Mark Smithers
- Upper-GI, Soft Tissue and Melanoma Unit, Princess Alexandra Hospital, Cancer Alliance Queensland, The University of Queensland, Brisbane, Queensland, Australia
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6
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Effect of Hospital Volume With Respect to Performing Gastric Cancer Resection on Recurrence and Survival: Results From the CRITICS Trial. Ann Surg 2020; 270:1096-1102. [PMID: 29995679 DOI: 10.1097/sla.0000000000002940] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE We examined the association between surgical hospital volume and both overall survival (OS) and disease-free survival (DFS) using data obtained from the international CRITICS (ChemoRadiotherapy after Induction chemotherapy In Cancer of the Stomach) trial. SUMMARY BACKGROUND DATA In the CRITICS trial, patients with resectable gastric cancer were randomized to receive preoperative chemotherapy followed by adequate gastrectomy and either chemotherapy or chemoradiotherapy. METHODS Patients in the CRITICS trial who underwent a gastrectomy with curative intent in a Dutch hospital were included in the analysis. The annual number of gastric cancer surgeries performed at the participating hospitals was obtained from the Netherlands Cancer Registry; the hospitals were then classified as low-volume (1-20 surgeries/year) or high-volume (≥21 surgeries/year) and matched with the CRITICS trial data. Univariate and multivariate analyses were then performed to evaluate the hazard ratio (HR) between hospital volume and both OS and DFS. RESULTS From 2007 through 2015, 788 patients were included in the CRITICS trial. Among these 788 patients, 494 were eligible for our study; the median follow-up was 5.0 years. Five-year OS was 59.2% and 46.1% in the high-volume and low-volume hospitals, respectively. Multivariate analysis revealed that undergoing surgery in a high-volume hospital was associated with higher OS [HR = 0.69, 95% confidence interval (CI) = 0.50-0.94, P = 0.020] and DFS (HR = 0.73, 95% CI: 0.54-0.99, P = 0.040). CONCLUSIONS In the CRITICS trial, hospitals with a high annual volume of gastric cancer surgery were associated with higher overall and DFS. These findings emphasize the value of centralizing gastric cancer surgeries in the Western world.
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7
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Proyectos de estandarización del tratamiento del cáncer de la unión esofagogástrica: centralización, registros y formación. Cir Esp 2019; 97:470-476. [DOI: 10.1016/j.ciresp.2019.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 03/18/2019] [Indexed: 01/26/2023]
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8
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Wang BY, Hung WH, Wu SC, Chen HC, Huang CL, Lin CH, Chen HS. Comparison Between Esophagectomy and Definitive Chemoradiotherapy in Patients With Esophageal Cancer. Ann Thorac Surg 2019; 107:1060-1067. [DOI: 10.1016/j.athoracsur.2018.11.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 11/05/2018] [Accepted: 11/17/2018] [Indexed: 11/29/2022]
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9
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Nimptsch U, Haist T, Gockel I, Mansky T, Lorenz D. Complex gastric surgery in Germany—is centralization beneficial? Observational study using national hospital discharge data. Langenbecks Arch Surg 2018; 404:93-101. [DOI: 10.1007/s00423-018-1742-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 12/10/2018] [Indexed: 01/21/2023]
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10
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van Putten M, Nelen SD, Lemmens VEPP, Stoot JHMB, Hartgrink HH, Gisbertz SS, Spillenaar Bilgen EJ, Heisterkamp J, Verhoeven RHA, Nieuwenhuijzen GAP. Overall survival before and after centralization of gastric cancer surgery in the Netherlands. Br J Surg 2018; 105:1807-1815. [PMID: 30132789 DOI: 10.1002/bjs.10931] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 06/06/2018] [Accepted: 06/12/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Centralization of surgery has been shown to improve outcomes for oesophageal and pancreatic cancer, and has been implemented for gastric cancer since 2012 in the Netherlands. This study evaluated the impact of centralizing gastric cancer surgery on outcomes for all patients with gastric cancer. METHODS Patients diagnosed with non-cardia gastric adenocarcinoma in the intervals 2009-2011 and 2013-2015 were selected from the Netherlands Cancer Registry. Clinicopathological data, treatment characteristics and mortality were assessed for the periods before (2009-2011) and after (2013-2015) centralization. Cox regression analyses were used to assess differences in overall survival between these intervals. RESULTS A total of 7204 patients were included. Resection rates increased slightly from 37·6 per cent before to 39·6 per cent after centralization (P = 0·023). Before centralization, 50·1 per cent of surgically treated patients underwent gastrectomy in hospitals that performed fewer than ten procedures annually, compared with 9·2 per cent after centralization. Patients who had gastrectomy in the second interval were younger and more often underwent total gastrectomy (29·3 per cent before versus 41·2 per cent after centralization). Thirty-day postoperative mortality rates dropped from 6·5 to 4·1 per cent (P = 0·004), and 90-day mortality rates decreased from 10·6 to 7·2 per cent (P = 0·002). Two-year overall survival rates increased from 55·4 to 58·5 per cent among patients who had gastrectomy (P = 0·031) and from 27·1 to 29·6 per cent for all patients (P = 0·003). Improvements remained after adjustment for case mix; however, adjustment for hospital volume attenuated this association for surgically treated patients. CONCLUSION Centralization of gastric cancer surgery was associated with reduced postoperative mortality and improved survival.
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Affiliation(s)
- M van Putten
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Eindhoven, The Netherlands
| | - S D Nelen
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - V E P P Lemmens
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Eindhoven, The Netherlands.,Department of Public Health, Erasmus MC - University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - J H M B Stoot
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - H H Hartgrink
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - S S Gisbertz
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | | | - J Heisterkamp
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - R H A Verhoeven
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Eindhoven, The Netherlands
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11
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Choi H, Yang SY, Cho HS, Kim W, Park EC, Han KT. Mortality differences by surgical volume among patients with stomach cancer: a threshold for a favorable volume-outcome relationship. World J Surg Oncol 2017; 15:134. [PMID: 28716145 PMCID: PMC5513131 DOI: 10.1186/s12957-017-1203-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Accepted: 07/08/2017] [Indexed: 01/20/2023] Open
Abstract
Background Many studies have assessed the volume-outcome relationship in cancer patients, but most focused on better outcomes in higher volume groups rather than identifying a specific threshold that could assist in clinical decision-making for achieving the best outcomes. The current study suggests an optimal volume for achieving good outcome, as an extension of previous studies on the volume-outcome relationship in stomach cancer patients. Methods We used National Health Insurance Service (NHIS) Sampling Cohort data during 2004–2013, comprising healthcare claims for 2550 patients with newly diagnosed stomach cancer. We conducted survival analyses adopting the Cox proportional hazard model to investigate the association of three threshold values for surgical volume of stomach cancer patients for cancer-specific mortality using the Youden index. Results Overall, 17.10% of patients died due to cancer during the study period. The risk of mortality among patients who received surgical treatment gradually decreased with increasing surgical volume at the hospital, while the risk of mortality increased again in “high” surgical volume hospitals, resulting in a j-shaped curve (mid-low = hazard ratio (HR) 0.773, 95% confidence interval (CI) 0.608–0.983; mid-high = HR 0.541, 95% CI 0.372–0.788; high = HR 0.659, 95% CI 0.473–0.917; ref = low). These associations were especially significant in regions with unsubstantial surgical volumes and less severe cases. Conclusion The optimal surgical volume threshold was about 727.3 surgical cases for stomach cancer per hospital over the 1-year study period in South Korea. However, such positive effects decreased after exceeding a certain volume of surgeries.
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Affiliation(s)
- Hyeok Choi
- Premedical Courses, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seong-Yoon Yang
- Premedical Courses, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hee-Seung Cho
- Premedical Courses, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Woorim Kim
- Department of Public Health, Graduate School, Yonsei University, Seoul, Republic of Korea.,Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea
| | - Eun-Cheol Park
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea.,Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyu-Tae Han
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea. .,Research and Analysis Team, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea.
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12
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Nelen SD, Heuthorst L, Verhoeven RHA, Polat F, Kruyt PM, Reijnders K, Ferenschild FTJ, Bonenkamp JJ, Rutter JE, de Wilt JHW, Spillenaar Bilgen EJ. Impact of Centralizing Gastric Cancer Surgery on Treatment, Morbidity, and Mortality. J Gastrointest Surg 2017; 21:2000-2008. [PMID: 28815471 PMCID: PMC5698358 DOI: 10.1007/s11605-017-3531-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 07/31/2017] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Centralization of gastric cancer surgery is thought to improve outcome and has been imposed in the Netherlands since 2012. This study analyzes the effect of centralization in terms of treatment outcome and survival in the Eastern part of the Netherlands. METHODS All gastric cancer patients without distant metastases who underwent a gastrectomy in six hospitals in the Eastern part of the Netherlands between 2008 and 2011 (pre-centralization) and 2013-2016 (post-centralization) were selected from the Netherlands Cancer Registry. Patient and tumor characteristics and treatment outcomes (duration of surgery, blood loss, resection margin, lymphadenectomy, chemotherapy, postoperative complications and hospital stay, and overall and disease-free survival) were analyzed and compared between pre- and post-centralization. RESULTS One hundred forty-four patients were included pre-centralization and 106 patients post-centralization. Patient and tumor characteristics were almost similar in the two periods. After centralization, more patients were treated with perioperative chemotherapy (25 vs. 42% p < 0.01). The proportion of patients treated with an adequate lymphadenectomy (21 vs. 93% p < 0.01) and laparoscopic surgery (6 vs. 40% p < 0.01) increased significantly (p < 0.01). The amount of cardiac complications (16 vs. 7.5% p < 0.05) decreased; however, complications needing a re-intervention were comparable (42 vs. 40% p = 0.79). Median hospital stay decreased from 10 to 8 days (p < 0.01). A 30-day mortality did not differ significantly (4.2 vs. 1.9%). A 1-year overall (78 vs. 80% p = 0.17) and disease-free survival (73 vs. 74% p = 0.66) remained stable. DISCUSSION Centralizing gastric cancer treatment in the Eastern part of the Netherlands resulted in improved lymph node harvesting and a successful introduction of laparoscopic gastrectomies. Centralization has not translated into improved mortality, and other variables may also have led to these improved outcomes. Further research using a nationwide population-based study will be needed to confirm these data.
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Affiliation(s)
- S. D. Nelen
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein 10, Route 618, P.O. 9101, 6500 HB Nijmegen, the Netherlands
| | - L. Heuthorst
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein 10, Route 618, P.O. 9101, 6500 HB Nijmegen, the Netherlands
| | - R. H. A. Verhoeven
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
| | - F. Polat
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Ph. M. Kruyt
- Department of Surgery, Gelderse Vallei Hospital, Ede, the Netherlands
| | - K. Reijnders
- Department of Surgery, Slingeland Hospital, Doetinchem, the Netherlands
| | - F. T. J. Ferenschild
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein 10, Route 618, P.O. 9101, 6500 HB Nijmegen, the Netherlands ,Department of Surgery, Maasziekenhuis Pantein, Boxmeer, the Netherlands
| | - J. J. Bonenkamp
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein 10, Route 618, P.O. 9101, 6500 HB Nijmegen, the Netherlands
| | - J. E. Rutter
- Department of Surgery, Rijnstate Hospital, Arnhem, the Netherlands
| | - J. H. W. de Wilt
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein 10, Route 618, P.O. 9101, 6500 HB Nijmegen, the Netherlands
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Is Centralization Needed for Esophageal and Gastric Cancer Patients With Low Operative Risk? Ann Surg 2016; 264:823-830. [DOI: 10.1097/sla.0000000000001768] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Altini M, Carretta E, Morgagni P, Carradori T, Ciotti E, Prati E, Garcea D, Amadori D, Falcini F, Nanni O, Nanni O. Is a clear benefit in survival enough to modify patient access to the surgery service? A retrospective analysis in a cohort of gastric cancer patients. Gastric Cancer 2015; 18:159-66. [PMID: 24477419 DOI: 10.1007/s10120-014-0346-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Accepted: 01/13/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Surgery has become an important tool for cancer treatment, requiring many available resources and a good organization of the surgery service. The aim of this study was to provide robust data for policymakers on the impact of hospital volume on survival, taking into account different sources of information. METHODS We performed a retrospective study in a cohort of patients with gastric cancer submitted to partial or total gastrectomy. Data for the analysis were retrieved from regional administrative databases, the regional death registry, and histological reports. The main outcome measures were operative mortality and long-term survival. The associations between hospital volume and risk of mortality were calculated using a Cox multiple regression analysis. RESULTS The estimated relationship between operative mortality and volume was not statistically significant. Conversely, high-volume hospitals had an increased likelihood of long-term survival compared to low-volume institutions: hazard ratio 0.79 (95% confidence interval, 0.66-0.94, p = 0.01). The percentage variation between crude and adjusted HRs using only administrative data or administrative and histological data was very small. However, the combined use of administrative and clinical data provided a more accurate model for estimating risk-adjusted mortality. CONCLUSIONS A positive association between hospital volume and survival was evident for long-term outcome after adjusting for patient and tumor confounding. Moreover, the patient's choice of hospital was not guided by specific care pathways or screening programs, and prognosis was not poorer for patients in high-volume hospitals. These findings suggest that there is leeway for improving access to surgery for gastric cancer patients.
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Affiliation(s)
- Mattia Altini
- Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Via Piero Maroncelli 40, 47014, Meldola, FC, Italy,
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Hsu PK, Chen HS, Wu SC, Wang BY, Liu CY, Shih CH, Liu CC. Impact of hospital volume on long-term survival after resection for oesophageal cancer: a population-based study in Taiwan†. Eur J Cardiothorac Surg 2014; 46:e127-35; discussion e135. [PMID: 25281656 DOI: 10.1093/ejcts/ezu377] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES Previous studies have shown that patients who undergo oesophageal cancer surgery in high-volume hospitals have lower postoperative mortality rates. However, the impact of hospital volume on long-term survival is controversial. METHODS We identified 2151 patients who were diagnosed with oesophageal cancer between 2008 and 2011 from a national population-based cancer registry in Taiwan. High-volume hospitals were defined as those performing more than 86 oesophagectomies during that period (22 cases/year). Patients were stratified by whether they received preoperative chemoradiation. Cox regression analyses were used to determine the survival impact of hospital volume. RESULTS The 3-year overall survival rates after oesophagectomies were 44.9% in high-volume hospitals, compared with 40.2% in low-volume hospitals (P = 0.002). For patients who received preoperative chemoradiation (n = 850), the 1- and 3-year overall survival rates were 74.7 and 36.8%, respectively, in high-volume hospitals, compared with 73.5 and 42.6%, respectively, in low-volume hospitals (P = 0.333). For patients who did not receive preoperative chemoradiation (n = 1301), the 1- and 3-year overall survival rates were 78.1 and 50.0%, respectively, in high-volume hospitals, compared with 67.9 and 38.8%, respectively, in low-volume hospitals (P < 0.001). Multivariate analysis showed that hospital volume, resection margin, cT, pT and pN stages are significant independent prognostic factors. CONCLUSIONS Overall survival rate of patients who undergo oesophagectomies without preoperative chemoradiation at high-volume hospitals is significantly higher than at low-volume hospitals. However, there was no significant correlation between hospital volume and long-term outcome in patients who received preoperative chemoradiation.
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Affiliation(s)
- Po-Kuei Hsu
- Division of Chest Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hui-Shan Chen
- Institute of Health and Welfare Policy, National Yang-Ming University, Taipei, Taiwan
| | - Shiao-Chi Wu
- Institute of Health and Welfare Policy, National Yang-Ming University, Taipei, Taiwan
| | - Bing-Yen Wang
- Division of Thoracic Surgery, Department of Surgery, Changhua Christian Hospital, Taichung, Taiwan
| | - Chao-Yu Liu
- Division of Thoracic Surgery, Department of Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Chih-Hsun Shih
- Division of Thoracic Surgery, Department of Surgery, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - Chia-Chuan Liu
- Division of Thoracic Surgery, Department of Surgery, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan
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Nagem R, Bicalho LGMF, Lourenço LG. Surgical treatment of gastric cancer in a community hospital in Brazil: who are we treating and how? J Gastrointest Cancer 2014; 44:410-6. [PMID: 23812916 DOI: 10.1007/s12029-013-9516-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE Surgical treatment of gastric cancer has risks, and the current trend in developed countries is to centralize cases in high-volume centers. Many countries, however, particularly the developing ones, have to rely in low-volume centers for the most part of gastric cancer operations. We aimed to verify the characteristics of the patients and tumors as well as the in-hospital outcomes in a community hospital in Brazil treating gastric cancer. METHODS This is a retrospective study on patients undergoing surgical treatment of gastric adenocarcinoma at a community hospital in Brazil. The authors reviewed demographic, clinical, pathological, and perioperative data. RESULTS A total of 28 patients were operated on during the study period. Mean age was 69.5 years, 53.6% were male, 67.9% had anemia, 78.5% had ASA score ≥ 3, 89.3% were at nutritional risk, intestinal/diffuse ratio was 1.6, 68.5% had tumor ≥ 6 cm, involvement of lower/middle third of the stomach occurred in 96.4%, 73.7% had serosal invasion, 79% had stage III disease, median number of dissected nodes was 23, median operative time was 255 min, 21.4% had urgent procedures, 67.8% had curative surgery, 50% had distal gastrectomy, 43.5% had a Billroth I, median length of stay was 17 days, 53.6% had some admission to the intensive care unit, 21.4% required relaparotomy, 25% had wound infection/dehiscence, and mortality was 66.7/18.2% (urgent/non-urgent surgery). CONCLUSION We treat elderly malnourished patients with multiple comorbidities and advanced cancer. Improvement is required in lymph node dissection, non-surgical therapies, and critical care.
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Affiliation(s)
- Rachid Nagem
- Department of Surgery, Unacon-Betim, Av. Edmeia Lazarotti, 3800, Betim, Brazil,
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Yoshida N, Baba Y, Watanabe M, Ida S, Ishimoto T, Karashima R, Iwagami S, Imamura Y, Sakamoto Y, Miyamoto Y, Baba H. Original scoring system for predicting postoperative morbidity after esophagectomy for esophageal cancer. Surg Today 2014; 45:346-54. [PMID: 24997754 DOI: 10.1007/s00595-014-0958-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Accepted: 05/21/2014] [Indexed: 12/30/2022]
Abstract
PURPOSE Postoperative morbidity remains common after esophagectomy. There are currently few tools that can be used to estimate the incidence of complications. This study aimed to create a novel scoring system for predicting postoperative morbidity. METHODS A total of 365 patients who underwent elective esophagectomy with two- or three-field lymphadenectomy for esophageal cancer were retrospectively analyzed. Patients were divided into development (n = 250) and validation datasets (n = 115). A scoring system was established by specifying the expected morbidity incidence values for all independent predictors in the development dataset, after which, the reproducibility was confirmed in the validation dataset. RESULTS The incidence of any morbidity was 44.7 %. Male sex, severe emaciation (body mass index <18), a lower performance status (grade 1 or 2), operation ≥540 min and massive bleeding (blood loss/body weight ≥20) were independent predictors of postoperative morbidity. The total of all predictive scores was calculated. The incidence of any morbidity and of severe morbidity (Clavien-Dindo classification ≥IIIb) significantly correlated with the score after dividing the scores into three groups (≤8, 10 and 11 and ≥13). This finding was also confirmed in the validation dataset. CONCLUSION The current scoring system is considered to be useful for predicting postoperative morbidity after esophagectomy.
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Affiliation(s)
- Naoya Yoshida
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuoku, Kumamoto, 860-8556, Japan
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Young JA, Shimi SM, Kerr L, McPhillips G, Thompson AM. Reduction in gastric cancer surgical mortality over 10 years: An adverse events analysis. Ann Med Surg (Lond) 2014; 3:26-30. [PMID: 25568781 PMCID: PMC4268482 DOI: 10.1016/j.amsu.2014.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Revised: 02/25/2014] [Accepted: 03/03/2014] [Indexed: 12/15/2022] Open
Abstract
Background The reduction in gastric cancer mortality is due to a reduction in incidence and of surgical mortality. This study was to examine adverse events in patients with gastric cancer dying under surgical care. Methods Adverse events in surgical care were prospectively audited in patients who died of gastric cancer in Scottish hospitals. A cohort retrospective study examining deaths and contributing adverse events was compared for the periods 1996–2000 and 2001–2005. Results Between 1996 and 2005, 1083 patients with gastric cancer died on surgical wards in Scottish hospitals. The annual number of deaths under surgical care fell significantly from an average of 128 deaths per annum in years 1996–2000 to 88 deaths per annum in 2001–2005 (p < 0.001). This occurred in parallel with the decline in gastric cancer incidence over the same period. There was an increase in the proportion of gastric cancer resections carried out in 7 major hospitals in Scotland in the second period of the study (p < 0.001). The mean number of deaths in the group of patients, who had gastric cancer resection and palliative surgery, were significantly lower in the second period of the study In addition, when all patients were considered as a group, the mean number of anaesthetic, critical care, medical management and technical surgery adverse events were significantly lower in the second study period. Conclusion There has been a reduction in deaths and adverse events for patients with gastric cancer under surgical care and this has been associated with surgical subspecialisation in oesophago-gastric cancer surgery.
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Affiliation(s)
- J A Young
- Department of Surgery and Molecular Oncology, Ninewells Hospital and Medical School, Dundee DD1 9SY, United Kingdom
| | - S M Shimi
- Department of Surgery and Molecular Oncology, Ninewells Hospital and Medical School, Dundee DD1 9SY, United Kingdom
| | - L Kerr
- Scottish Audit of Surgical Mortality, Cirrus Building, Marchburn Drive, Paisley PA3 2SJ, United Kingdom
| | - G McPhillips
- Scottish Audit of Surgical Mortality, Cirrus Building, Marchburn Drive, Paisley PA3 2SJ, United Kingdom
| | - A M Thompson
- Department of Surgery and Molecular Oncology, Ninewells Hospital and Medical School, Dundee DD1 9SY, United Kingdom ; Scottish Audit of Surgical Mortality, Cirrus Building, Marchburn Drive, Paisley PA3 2SJ, United Kingdom
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Liu Y, Chen J, Shao N, Feng Y, Wang Y, Zhang L. Clinical value of hematologic test in predicting tumor response to neoadjuvant chemotherapy with esophageal squamous cell carcinoma. World J Surg Oncol 2014; 12:43. [PMID: 24568553 PMCID: PMC3938076 DOI: 10.1186/1477-7819-12-43] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 02/12/2014] [Indexed: 01/02/2023] Open
Abstract
Background To investigate the relationship between hematologic test results and the predictive effect of regression of esophageal cancer after neoadjuvant chemotherapy (NACT), we analyzed pre-NACT hematologic data and their relationship to tumor regression. Methods Thirty-eight consecutive patients with locally advanced squamous cell esophageal carcinoma who had undergone two cycles of paclitaxel/carboplatin NACT were enrolled. On the day prior to the first cycle of chemotherapy, hematologic tests, including routine blood test and biochemical examinations, were recorded. All patients were confirmed to have no history of hepatitis. Surgical resection was performed when clinical restaging showed effective regression. Histopathological examination was routinely performed to evaluate the postoperative effects of chemotherapy. Results After two cycles of NACT, tumor imaging evaluation showed that 27 of the 38 patients had CR and PR, including 25 patients who underwent radical esophagectomies. Six patients had stable disease and five patients had progressive disease. According to the hematologic test results before NACT, patients with higher white blood cell counts, lymphocyte percentages, mononuclear cell counts, neutrophilic granulocyte counts, and eosinophilic granulocyte counts and lower alanine aminotransferase (ALT) level had a significantly greater opportunity for an effective response. Conclusion Basal host immunologic function and hepatic function are associated with tumor response to NACT in patients with esophageal cancer. These parameters may have a certain predictive efficacy on NACT for esophageal squamous cell carcinoma.
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Affiliation(s)
| | - Jinfeng Chen
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, People's Republic of China.
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Arrington AK, Nelson R, Patel SS, Luu C, Ko M, Garcia-Aguilar J, Kim J. Timing of chemotherapy and survival in patients with resectable gastric adenocarcinoma. World J Gastrointest Surg 2013; 5:321-328. [PMID: 24392183 PMCID: PMC3879416 DOI: 10.4240/wjgs.v5.i12.321] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 11/19/2013] [Accepted: 12/13/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the timing of chemotherapy in gastric cancer by comparing survival outcomes in treatment groups.
METHODS: Patients with surgically resected gastric adenocarcinoma from 1988 to 2006 were identified from the Los Angeles County Cancer Surveillance Program. To evaluate the population most likely to receive and/or benefit from adjunct chemotherapy, inclusion criteria consisted of Stage II or III gastric cancer patients > 18 years of age who underwent curative-intent surgical resection. Patients were categorized into three groups according to the receipt of chemotherapy: (1) no chemotherapy; (2) preoperative chemotherapy; or (3) postoperative chemotherapy. Clinical and pathologic characteristics were compared across the different treatment arms.
RESULTS: Of 1518 patients with surgically resected gastric cancer, 327 (21.5%) received perioperative chemotherapy. The majority of these 327 patients were male (68%) with a mean age of 61.5 years; and they were significantly younger than non-chemotherapy patients (mean age, 70.7; P < 0.001). Most patients had tumors frequently located in the distal stomach (34.5%). Preoperative chemotherapy was administered to 11.3% of patients (n = 37) and postoperative therapy to 88.7% of patients (n = 290). An overall survival benefit according to timing of chemotherapy was not observed on univariate or multivariate analysis. Similar results were observed with stage-specific survival analyses (5-year overall survival: Stage II, 25% vs 30%, respectively; Stage III, 14% vs 11%, respectively). Therefore, our results do not identify a survival advantage for specific timing of chemotherapy in locally advanced gastric cancer.
CONCLUSION: This study supports the implementation of a randomized trial comparing the timing of perioperative therapy in patients with locally advanced gastric cancer.
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Chan D, Reid T, White C, Willicombe A, Blackshaw G, Clark G, Havard T, Escofet X, Crosby T, Roberts S, Lewis W. Influence of a Regional Centralised Upper Gastrointestinal Cancer Service Model on Patient Safety, Quality of Care and Survival. Clin Oncol (R Coll Radiol) 2013; 25:719-25. [DOI: 10.1016/j.clon.2013.08.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Revised: 06/10/2013] [Accepted: 06/20/2013] [Indexed: 01/28/2023]
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Dixon M, Mahar A, Paszat L, McLeod R, Law C, Swallow C, Helyer L, Seeveratnam R, Cardoso R, Bekaii-Saab T, Chau I, Church N, Coit D, Crane CH, Earle C, Mansfield P, Marcon N, Miner T, Noh SH, Porter G, Posner MC, Prachand V, Sano T, Van de Velde CJH, Wong S, Coburn N. What provider volumes and characteristics are appropriate for gastric cancer resection? Results of an international RAND/UCLA expert panel. Surgery 2013; 154:1100-9. [PMID: 24075275 DOI: 10.1016/j.surg.2013.05.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Accepted: 05/10/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND A relationship between higher volume providers and improved outcomes has been suggested by some studies and has been used to construct guidelines for many diseases. For gastric cancer (GC), however, optimal volume cutoffs are not clear. METHODS A multidisciplinary expert panel of 16 physicians from 6 countries scored 120 scenarios regarding provider characteristics for gastric resections for GC. Appropriateness of scenarios was scored from 1 (highly inappropriate) to 9 (highly appropriate). Median appropriateness scores from 1 to 3 were considered inappropriate, 4 to 6 uncertain, and 7 to 9 appropriate. Agreement was reached when 12 of 16 panelists scored the statement similarly. Appropriate scenarios agreed on were scored subsequently for necessity. RESULTS Surgeon and hospital practice volume scenarios were evaluated. The panel felt it was inappropriate for surgeons doing ≤2 GC cases per year to perform a multivisceral resection (MVR), D2 lymphadenectomy (D2-LND), or laparoscopic total gastrectomy, and ≤6 GC cases per year for an MVR involving a pancreatoduodenectomy (MVR-PD), or endoscopic mucosal resections (EMR). It was considered appropriate for surgeons doing ≥11 GC cases per year to perform open gastrectomy or D2-LND, and ≥20 GC cases per year for any MVR, laparoscopic gastrectomy, or EMR. For hospitals, it was considered inappropriate for hospitals managing ≤4 GC cases per year to perform D2-LND or laparoscopic total gastrectomy, and ≤10 GC cases per year, for MVR-PD or EMR. Hospital volumes ≥21 cases per year was considered appropriate for any GC procedure. It was inappropriate for an MVR to be performed in a hospital without interventional radiology services and for a MVR-PD in a hospital with no level I intensive care unit. CONCLUSION Appropriate and inappropriate provider volumes for a variety of gastric procedures have been defined by an international expert panel.
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Affiliation(s)
- Matthew Dixon
- Sunnybrook Research Institute, Toronto, Ontario, Canada; Department of Surgery, Maimonides Medical Center, Brooklyn, NY
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Coupland VH, Lagergren J, Lüchtenborg M, Jack RH, Allum W, Holmberg L, Hanna GB, Pearce N, Møller H. Hospital volume, proportion resected and mortality from oesophageal and gastric cancer: a population-based study in England, 2004-2008. Gut 2013; 62:961-6. [PMID: 23086798 DOI: 10.1136/gutjnl-2012-303008] [Citation(s) in RCA: 125] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE This study assessed the associations between hospital volume, resection rate and survival of oesophageal and gastric cancer patients in England. DESIGN 62,811 patients diagnosed with oesophageal or gastric cancer between 2004 and 2008 were identified from a national population-based cancer registration and Hospital Episode Statistics-linked dataset. Cox regression analyses were used to assess all-cause mortality according to hospital volume and resection rate, adjusting for case-mix variables (sex, age, socioeconomic deprivation, comorbidity and type of cancer). HRs and 95% CIs, according to hospital volume, were evaluated for three predefined periods following surgery: <30, 30-365, and >365 days. Analysis of mortality in relation to resection rate was performed among all patients and among the 13 189 (21%) resected patients. RESULTS Increasing hospital volume was associated with lower mortality (p trend=0.0001; HR 0.87, 95% CI 0.79 to 0.95 for hospitals resecting 80+ and compared with <20 patients a year). In relative terms, the association between increasing hospital volume and lower mortality was particularly strong in the first 30 days following surgery (p trend<0.0001; HR 0.52, (0.39 to 0.70)), but a clinically relevant association remained beyond 1 year (p trend=0.0011; HR 0.82, (0.72 to 0.95)). Increasing resection rates were associated with lower mortality among all patients (p trend<0.0001; HR 0.86, (0.84 to 0.89) for the highest, compared with the lowest resection quintile). CONCLUSIONS With evidence of lower short-term and longer-term mortality for patients resected in high-volume hospitals, this study supports further centralisation of oesophageal and gastric cancer surgical services in England.
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Affiliation(s)
- Victoria H Coupland
- King's College London, Thames Cancer Registry, 42, Weston Street, London SE1 3QD, UK.
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Bringeland E, Wasmuth H, Johnsen G, Johnsen T, Juel I, Mjønes P, Uggen P, Ystgaard B, Grønbech J. Outcomes among patients treated for gastric adenocarcinoma during the last decade. J Surg Oncol 2013; 107:752-757. [DOI: 10.1002/jso.23320] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Risk factors for pulmonary complications after esophagectomy for esophageal cancer. Surg Today 2013; 44:526-32. [DOI: 10.1007/s00595-013-0577-6] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Accepted: 01/21/2013] [Indexed: 11/26/2022]
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Yoshida N, Watanabe M, Baba Y, Iwagami S, Ishimoto T, Iwatsuki M, Sakamoto Y, Miyamoto Y, Ozaki N, Baba H. Estimation of physiologic ability and surgical stress (E-PASS) can assess short-term outcome after esophagectomy for esophageal cancer. Esophagus 2013. [DOI: 10.1007/s10388-013-0369-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
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Jiang L, Yang KH, Guan QL, Zhao P, Chen Y, Tian JH. Survival and recurrence free benefits with different lymphadenectomy for resectable gastric cancer: a meta-analysis. J Surg Oncol 2013; 107:807-14. [PMID: 23512524 DOI: 10.1002/jso.23325] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Accepted: 01/16/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND The objective of the present meta-analysis was to estimate the magnitude of survival and recurrence free benefits from different lymphadenectomy in patients with resectable gastric cancer. METHODS A comprehensive search was performed for original studies published from their inception to 2012. Two reviewers independently assessed search results, methodological quality, and data extraction of included studies. Results regarding the overall survival (OS) and recurrence free survival (RFS) in the meta-analysis were expressed as hazard ratios (HR) with 95% confidence intervals (CI). RESULTS Twelve randomized control trials (RCTs) were eligible for final meta-analysis. There was not significant difference in OS between D1 and D2 lymphadenectomy (HR = 0.92, 95% CI: 0.77-1.10, P = 0.36), but subgroup analysis of patients without splenectomy and/or pancreatectomy has a trend for OS much more benefiting D2 compared to D1 patients. A significant RFS improvement was found in favor of D2 lymphadenectomy, sensitivity analysis also gives similar fixed effect estimates (HR = 0.68, 95% CI: 0.58-0.81, P = 0.84). There were no significant differences in OS and RFS between D2 group and D3 group (1 trial). CONCLUSIONS The present meta-analysis indicates that D2 lymphadenectomy with spleen and pancreas preservation offers the most survival benefit for patients with gastric cancer when done safety.
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Affiliation(s)
- Lei Jiang
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
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Young J, Shimi S, Waugh L, McPhillips G, Thompson A. Improved short term surgical outcomes in Scotland for oesophageal cancer. Eur J Surg Oncol 2013; 39:131-5. [DOI: 10.1016/j.ejso.2012.10.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Revised: 08/23/2012] [Accepted: 10/04/2012] [Indexed: 11/25/2022] Open
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Dikken JL, van Sandick JW, Allum WH, Johansson J, Jensen LS, Putter H, Coupland VH, Wouters MWJM, Lemmens VEP, van de Velde CJH, van der Geest LGM, Larsson HJ, Cats A, Verheij M. Differences in outcomes of oesophageal and gastric cancer surgery across Europe. Br J Surg 2012. [PMID: 23180474 DOI: 10.1002/bjs.8966] [Citation(s) in RCA: 124] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND In several European countries, centralization of oesophagogastric cancer surgery has been realized and clinical audits initiated. The present study was designed to evaluate differences in resection rates, outcomes and annual hospital volumes between these countries, and to analyse the relationship between hospital volume and outcomes. METHODS National data were obtained from cancer registries or clinical audits in the Netherlands, Sweden, Denmark and England. Differences in outcomes were analysed between countries and between hospital volume categories, adjusting for available case-mix factors. RESULTS Between 2004 and 2009, 10 854 oesophagectomies and 9010 gastrectomies were registered. Resection rates in England were 18·2 and 21·6 per cent for oesophageal and gastric cancer respectively, compared with 28·5-29·9 and 41·4-41·9 per cent in the Netherlands and Denmark (P < 0·001). The adjusted 30-day mortality rate after oesophagectomy was lowest in Sweden (1·9 per cent). After gastrectomy, the adjusted 30-day mortality rate was significantly higher in the Netherlands (6·9 per cent) than in Sweden (3·5 per cent; P = 0·017) and Denmark (4·3 per cent; P = 0·029). Increasing hospital volume was associated with a lower 30-day mortality rate after oesophagectomy (odds ratio 0·55 (95 per cent confidence interval 0·42 to 0·72) for at least 41 versus 1-10 procedures per year) and gastrectomy (odds ratio 0·64 (0·41 to 0·99) for at least 21 versus 1-10 procedures per year). CONCLUSION Hospitals performing larger numbers of oesophagogastric cancer resections had a lower 30-day mortality rate. Differences in outcomes between several European countries could not be explained by differences in hospital volumes. To understand these differences in outcomes and resection rates, with reliable case-mix adjustments, a uniform European upper gastrointestinal cancer audit with recording of standardized data is warranted.
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Affiliation(s)
- J L Dikken
- Departments of Surgery, Leiden University Medical Center, Leiden, The Netherlands
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Dikken JL, Stiekema J, van de Velde CJH, Verheij M, Cats A, Wouters MWJM, van Sandick JW. Quality of care indicators for the surgical treatment of gastric cancer: a systematic review. Ann Surg Oncol 2012; 20:381-98. [PMID: 23054104 DOI: 10.1245/s10434-012-2574-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Indexed: 02/03/2023]
Abstract
BACKGROUND Quality assurance is increasingly acknowledged as a crucial factor for the (surgical) treatment of gastric cancer. The purpose of the current study was to define a minimum set of evidence-based quality of care indicators for the surgical treatment of locally advanced gastric cancer. METHODS A systematic review of the literature published between January 1990 and May 2011 was performed, using search terms on gastric cancer, treatment, and quality of care. Studies were selected based on predefined selection criteria. Potential quality of care indicators were assessed based on their level of evidence and were grouped into structure, process, and outcome indicators. RESULTS A total of 173 articles were included in the current study. For structural measures, evidence was found for the inverse relationship between hospital volume and postoperative mortality as well as overall survival. Regarding process measures, the most common indicators concerned surgical technique, perioperative care, and multimodality treatment. The only outcome indicator with supporting evidence was a microscopically radical resection. CONCLUSIONS Although specific literature on quality of care indicators for the surgical treatment of locally advanced gastric cancer is limited, several quality of care indicators could be identified. These indicators can be used in clinical audits and other quality assurance programs.
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Affiliation(s)
- Johan L Dikken
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
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Ho VKY, Damhuis RAM, Hartgrink HH. Adherence to national guidelines for gastric cancer in the Netherlands: a retrospective population-based audit. Int J Cancer 2012; 132:1156-61. [PMID: 22777695 DOI: 10.1002/ijc.27718] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Revised: 05/30/2012] [Accepted: 06/11/2012] [Indexed: 11/09/2022]
Abstract
In May 2009, a new clinical practice guideline for gastric cancer was released in the Netherlands. To determine the impact of this guideline, we evaluated trends in patterns of care, thereby focusing on the use of perioperative chemotherapy, the adequacy of lymphadenectomy and the proportion of non-curative resections. For our evaluation, we retrospectively collected information from the Netherlands Cancer Registry on 2,511 patients diagnosed with primary adenocarcinoma of the stomach during the period July 2008-June 2010, excluding tumors of the cardia. After comparing clinical management for patients diagnosed from July 2008 to June 2009 with that for patients diagnosed from July 2009 to June 2010, we conclude that our indicators for guideline adherence did not show major change, except for the proportion of patients that received an adequate lymphadenectomy (examination of ≥10 lymph nodes), which increased from 49% to 58% (p = 0.005), this increase being more pronounced for high-volume hospitals (p = 0.006). Preoperative chemotherapy was given in 45% of patients and 25% of resections was non-curative. For the total study population, the resection rate was 41% and 30-day mortality was 5.7%. However, this measure may underestimate the real operative risk for gastric cancer patients given supplementary information on postdischarge death and prolonged hospital stay.
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Affiliation(s)
- Vincent K Y Ho
- Department of Registry and Research, Comprehensive Cancer Centre the Netherlands (IKNL), Utrecht, The Netherlands.
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Abstract
OBJECTIVE This review summarizes reporting of complications of esophageal cancer surgery. BACKGROUND Accurate assessment of morbidity and mortality after surgery for cancer is essential to compare centers, allow data synthesis, and inform clinical decision-making. A lack of defined standards may distort clinically relevant treatment effects. METHODS Systematic literature searches identified articles published between 2005 and 2009 reporting morbidity and mortality after esophagectomy for cancer. Data were analyzed for frequency of complication reporting and to check whether outcomes were defined and classified for severity and whether a validated system for grading complications was used. Information about reporting outcomes adjusting for baseline risk factors was collated, and a descriptive summary of the results of included outcomes was undertaken. RESULTS Of 3458 abstracts, 224 full papers were reviewed and 122 were included (17 randomized trials and 105 observational studies), reporting outcomes of 57,299 esophagectomies. No single complication was reported in all papers, and 60 (60.6%) did not define any of the measured complications. Anastomotic leak was the most commonly reported morbidity, assessed in 80 (80.1%) articles, defined in 28 (28.3%), but 22 different descriptions were used. Five papers (5.1%) categorized morbidity with a validated grading system. One hundred fifteen papers reported postoperative mortality rates, 25 defining the term using 10 different definitions. In-hospital mortality was the most commonly used term for postoperative death, with 6 different interpretations of this phrase. Eighteen papers adjusted outcomes for baseline risk factors and 60 presented baseline measures of comorbidity. CONCLUSIONS Outcome reporting after esophageal cancer surgery is heterogeneous and inconsistent, and it lacks methodological rigor. A consensus approach to reporting clinical outcomes should be considered, and at the minimum it is recommended that a "core outcome set" is defined and used in all studies reporting outcomes of esophageal cancer surgery. This will allow meaningful cross study comparisons and analyses to evaluate surgery.
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Rutegård M, Charonis K, Lu Y, Lagergren P, Lagergren J, Rouvelas I. Population-based esophageal cancer survival after resection without neoadjuvant therapy: an update. Surgery 2012; 152:903-10. [PMID: 22657730 DOI: 10.1016/j.surg.2012.03.025] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Accepted: 03/22/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND There are few population-based studies addressing the survival after resection for esophageal cancer. This study represents an update of a nationwide Swedish cohort initiated in 1987. METHODS Based on data from the Swedish Patient Register, Swedish Cancer Register, and histopathologic records, 1,008 patients who had undergone esophageal resection as the only treatment for esophageal cancer were identified between January 1, 1987 and December 31, 2005. These were followed until death or emigration through linkage to the Swedish Total Population Register until January 1, 2009. Tumor stage, location, and histology were assessed from histopathologic reports, and comorbidities were assessed from the Patient Register. Cox proportional hazards regression models were used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs) regarding survival. The results were adjusted for age, sex, comorbidity, tumor stage, location, histology, surgical radicality, and hospital volume. RESULTS The proportion of patients surviving for 5 years increased from 19.7% in 1987-1991 to 30.7% in 1997-2000, but remained at 30.5% between 2001 and 2005. No difference in overall adjusted survival was found between the periods of 2001-2005 and 1997-2000 (adjusted HR, 0.89; 95% CI, 0.70-1.13). Thirty-day mortality decreased from 4.9% in 1997-2000 to 2.0% in 2001-2005, rendering an adjusted HR of 0.26 (95% CI, 0.08-0.87). CONCLUSION After adjusting for relevant prognostic factors, long-term population-based survival after resection for esophageal cancer was unchanged between 2001 and 2005 compared to 1997-2000, while the corresponding 30-day mortality improved.
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Affiliation(s)
- Martin Rutegård
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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Mahar AL, McLeod RS, Kiss A, Paszat L, Coburn NG. A Systematic Review of the Effect of Institution and Surgeon Factors on Surgical Outcomes for Gastric Cancer. J Am Coll Surg 2012; 214:860-8.e12. [DOI: 10.1016/j.jamcollsurg.2011.12.050] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 12/14/2011] [Accepted: 12/21/2011] [Indexed: 02/06/2023]
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Rutegård M, Lagergren P, Rouvelas I, Mason R, Lagergren J. Surgical complications and long-term survival after esophagectomy for cancer in a nationwide Swedish cohort study. Eur J Surg Oncol 2012; 38:555-61. [PMID: 22483704 DOI: 10.1016/j.ejso.2012.02.177] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Revised: 02/08/2012] [Accepted: 02/23/2012] [Indexed: 01/08/2023] Open
Abstract
AIMS Acute surgical complications after esophageal resection for cancer may decrease the long-term survival. Previous results on this topic are conflicting and no population-based studies are available. METHODS A prospective, nationwide Swedish study was conducted in 2001-2010. Eligible patients comprised those afflicted by esophageal or cardia cancer and underwent surgical resection in Sweden in 2001-2005. Details concerning patient and tumor characteristics, surgical procedures, and postoperative surgical complications were collected prospectively. Follow-up for mortality, starting from 90 days after the surgery, was done until May 2010. Cox proportional-hazards regression was performed to estimate hazard ratios (HRs) and 95% confidence intervals (CIs), adjusted for age, tumor stage, sex, histology, comorbidity, surgical approach and surgical radicality. RESULTS Among 567 included patients who survived at least 90 days postoperatively, 130 (22.9%) sustained a predefined surgical complication within 30 days of surgery. The adjusted HR of mortality was increased in patients who sustained surgical complications, compared to patients without such complications (HR 1.29, 95% CI 1.02-1.63). CONCLUSIONS The occurrence of surgical complications might be an independent predictor for poorer long-term survival in patients resected for esophageal cancer, even in patients who survived the postoperative period.
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Affiliation(s)
- M Rutegård
- Upper Gastrointestinal Research, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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Dikken JL, Cats A, Verheij M, van de Velde CJ. Randomized trials and quality assurance in gastric cancer surgery. J Surg Oncol 2012; 107:298-305. [DOI: 10.1002/jso.23080] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Accepted: 02/09/2012] [Indexed: 01/07/2023]
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Dikken JL, Dassen AE, Lemmens VEP, Putter H, Krijnen P, van der Geest L, Bosscha K, Verheij M, van de Velde CJH, Wouters MWJM. Effect of hospital volume on postoperative mortality and survival after oesophageal and gastric cancer surgery in the Netherlands between 1989 and 2009. Eur J Cancer 2012; 48:1004-13. [PMID: 22456179 DOI: 10.1016/j.ejca.2012.02.064] [Citation(s) in RCA: 122] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Revised: 01/02/2012] [Accepted: 02/19/2012] [Indexed: 12/22/2022]
Abstract
BACKGROUND High hospital volume is associated with better outcomes after oesophagectomy and gastrectomy. In the Netherlands, a minimal volume standard of 10 oesophagectomies per year was introduced in 2006. For gastrectomy, no minimal volume standard was set. Aims of this study were to describe changes in hospital volumes, mortality and survival and to explore if high hospital volume is associated with better outcomes after oesophagectomy and gastrectomy in the Netherlands. METHODS From 1989 to 2009, 24,246 patients underwent oesophagectomy (N = 10,025) or gastrectomy (N = 14,221) in the Netherlands. Annual hospital volumes were defined as very low (1-5), low (6-10), medium (11-20), and high (≥ 21). Volume-outcome analyses were performed using Cox regression, adjusting for year of diagnosis, case-mix and the use of multi-modality treatment. RESULTS From 1989 to 2009, the percentage of patients treated in high-volume hospitals increased for oesophagectomy (from 7% to 64%), but decreased for gastrectomy (from 8% to 5%). Six-month mortality (from 15% to 7%) and 3-year survival (from 41% to 52%) improved after oesophagectomy, and to a lesser extent after gastrectomy (6-month mortality: 15%-10%, three-year survival: 55-58%). High hospital volume was associated with lower 6-month mortality (hazard ratio (HR) 0.48, P<0.001) and longer 3-year survival (HR 0.77, P<0.001) after oesophagectomy, but not after gastrectomy. CONCLUSIONS Oesophagectomy was effectively centralised in the Netherlands, improving mortality and survival. Gastrectomies were mainly performed in low volumes, and outcomes after gastrectomy improved to a lesser extent, indicating an urgent need for improvement in quality of surgery and perioperative care for gastric cancer in the Netherlands.
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Affiliation(s)
- Johan L Dikken
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333ZA Leiden, The Netherlands
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Kelly P, Paulin F, Lamont D, Baker L, Clearly S, Exon D, Thompson A. Pre-treatment plasma proteomic markers associated with survival in oesophageal cancer. Br J Cancer 2012; 106:955-61. [PMID: 22294182 PMCID: PMC3305965 DOI: 10.1038/bjc.2012.15] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background: The incidence of oesophageal adenocarcinoma is increasing worldwide but survival remains poor. Neoadjuvant chemotherapy can improve survival, but prognostic and predictive biomarkers are required. This study built upon preclinical approaches to identify prognostic plasma proteomic markers in oesophageal cancer. Methods: Plasma samples collected before and during the treatment of oesophageal cancer and non-cancer controls were analysed by surface-enhanced laser desorption/ionisation time-of-flight (SELDI-TOF) mass spectroscopy (MS). Protein peaks were identified by MS in tryptic digests of purified fractions. Associations between peak intensities obtained in the spectra and clinical endpoints (survival, disease-free survival) were tested by univariate (Fisher's exact test) and multivariate analysis (binary logistic regression). Results: Plasma protein peaks were identified that differed significantly (P<0.05, ANOVA) between the oesophageal cancer and control groups at baseline. Three peaks, confirmed as apolipoprotein A-I, serum amyloid A and transthyretin, in baseline (pre-treatment) samples were associated by univariate and multivariate analysis with disease-free survival and overall survival. Conclusion: Plasma proteins can be detected prior to treatment for oesophageal cancer that are associated with outcome and merit testing as prognostic and predictive markers of response to guide chemotherapy in oesophageal cancer.
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Affiliation(s)
- P Kelly
- Dundee Cancer Centre, University of Dundee, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK.
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de Manzoni G, Di Leo A. Esophageal Cancer Surgery: The Importance of Hospital Volume. Updates Surg 2012. [DOI: 10.1007/978-88-470-2330-7_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Suttie SA, Nanthakumaran S, Mofidi R, Rapson T, Gilbert FJ, Thompson AM, Park KGM. The impact of operative approach for oesophageal cancer on outcome: the transhiatal approach may influence circumferential margin involvement. Eur J Surg Oncol 2011; 38:157-65. [PMID: 22154884 DOI: 10.1016/j.ejso.2011.11.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Revised: 09/13/2011] [Accepted: 11/15/2011] [Indexed: 10/14/2022] Open
Abstract
AIM Surgery for oesophageal cancer remains the only means of cure for invasive tumours. It is claimed that the surgical approach for these cancers impacts on morbidity and may influence the ability to achieve tumour clearance and therefore survival, however there is no conclusive evidence to support one approach over another. This study aims to determine the impact of operative approach on tumour margin involvement and survival. METHODS Data were extracted from the Scottish Audit of Gastric and Oesophageal Cancer (SAGOC), a prospective population-based audit of all oesophageal and gastric cancers in Scotland between 1997 and 1999 with a minimum of five-year follow up. Analysis focused on the three commonest approaches (Ivor Lewis n = 140, transhiatal n = 68, left thoraco-laparotomy n = 142) for oesophageal cancer. RESULTS Operative approach had no significant impact on post-operative morbidity, mortality, overall margin involvement and survival. Transhiatal approach resulted in significantly more circumferential margin involvement (p = 0.019), and the presence of circumferential margin involvement significantly reduced five-year survival (median survival 13 months) compared to no margin involvement (median survival 25 months, p = 0.001). CONCLUSION Surgical approach for oesophageal cancer had no significant effect on morbidity, post-operative mortality and five-year survival. Non-selective use of the transhiatal approach is associated with a significantly greater circumferential margin involvement, with positive circumferential margin impacting adversely on 5-year survival.
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Affiliation(s)
- S A Suttie
- Department of Surgery and Molecular Oncology, University of Dundee, Ninewells Hospital and Medical School, Dundee DD1 9SY, Scotland, United Kingdom.
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Wouters MWJM, Gooiker GA, van Sandick JW, Tollenaar RAEM. The volume-outcome relation in the surgical treatment of esophageal cancer: a systematic review and meta-analysis. Cancer 2011; 118:1754-63. [PMID: 22009562 DOI: 10.1002/cncr.26383] [Citation(s) in RCA: 123] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Revised: 04/06/2011] [Accepted: 04/26/2011] [Indexed: 01/16/2023]
Abstract
This study was undertaken to conduct a systematic review and meta-analysis of the literature on the relation between procedural volume and outcome of esophagectomies. A systematic search was carried out to identify articles investigating effects of hospital or surgeon volume on short-term and long-term outcomes published between 1995 and 2010. Articles were scrutinized for methodological quality, and after inclusion of only high-quality studies, a meta-analysis assuming a random effects model was done to estimate the effect of higher volume on patient outcome. Heterogeneity in study results was evaluated with an I(2) -test and risk of publication bias with an Egger regression intercept. Forty-three studies were found. Sixteen studies met the strict inclusion criteria for the meta-analysis on hospital volume and postoperative mortality and 4 studies on hospital volume and survival. The pooled estimated effect size was significant for high-volume providers in the analysis of postoperative mortality (odds ratio [OR], 2.30; 95% confidence interval [CI], 1.89-2.80) and in the survival analysis (OR, 1.17; 95% CI, 1.05-1.30). The meta-analysis of surgical volume and outcome showed no significant results. Studies in which the results were adjusted not only for patient characteristics but also for tumor characteristics and urgency of the operation showed a stronger correlation between hospital volume and mortality. Also, studies performed on data from the United States showed higher effect sizes. The evidence for hospital volume as an important determinant of outcome in esophageal cancer surgery is strong. Concentration of procedures in high-volume hospitals with a dedicated setting for the treatment of esophageal cancer might lead to an overall improvement in patient outcome.
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Affiliation(s)
- Michel W J M Wouters
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands.
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Anderson O, Ni Z, Møller H, Coupland VH, Davies EA, Allum WH, Hanna GB. Hospital volume and survival in oesophagectomy and gastrectomy for cancer. Eur J Cancer 2011; 47:2408-14. [PMID: 21835609 DOI: 10.1016/j.ejca.2011.07.001] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2011] [Revised: 05/16/2011] [Accepted: 07/07/2011] [Indexed: 01/13/2023]
Abstract
BACKGROUND High volume upper gastrointestinal cancer hospitals demonstrate improved postoperative mortality rates, but the impact on survival is unclear. This population-based cohort study explores the effect of hospital volume on survival following upper gastrointestinal cancer surgery. PATIENTS AND METHODS This study used a population-based cohort of 3866 patients who underwent surgery for oesophageal or gastric cancer between 1998 and 2008 with follow-up until December 2008. RESULTS Hospital volume ranged from 1 to 68 cases/year. Overall, 5-year survival was 27%. Increasing age and advanced stage of disease were independently correlated with shorter survival. High hospital volume was significantly and independently correlated with improved 30-day mortality postoperatively (P<0.001), but not with survival beyond 30 days. CONCLUSION The correlation between hospital volume and improved 30-day mortality following oesophageal and gastric cancer surgery supports the centralisation of upper gastrointestinal cancer surgery services. The low survival in both high and low volume hospitals beyond 30 days highlights the need for increasing earlier diagnosis and optimising approaches to radical treatment.
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Affiliation(s)
- Oliver Anderson
- Imperial College London, Department of Surgery and Cancer, St. Mary's Hospital, London, UK
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Rutegård M, Lagergren P, Rouvelas I, Lagergren J. Intrathoracic anastomotic leakage and mortality after esophageal cancer resection: a population-based study. Ann Surg Oncol 2011; 19:99-103. [PMID: 21769467 DOI: 10.1245/s10434-011-1926-6] [Citation(s) in RCA: 131] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Indexed: 12/14/2022]
Abstract
BACKGROUND Results are conflicting and no population-based studies are available regarding the postoperative mortality after intrathoracic anastomotic leakage. The current study addressed the unselected and independent fatality rate of intrathoracic esophageal anastomotic leaks after resection for cancer. METHODS A prospective, nationwide study was conducted in Sweden in April 2001 through December 2005. Details concerning patient and tumor characteristics, surgical procedures, postoperative anastomotic leakage, and mortality were collected prospectively. Logistic regression was performed to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs), adjusted for age, tumor stage, comorbidity, and hospital volume. RESULTS Among 559 resected patients with an intrathoracic anastomosis, 44 patients (7.9%) sustained an anastomotic leak within 30 days of surgery. Of these, 8 patients (18.2%) died within 90 days of surgery, compared with 32 of the 515 patients without leakage (6.2%) (P = .003). The adjusted OR of postoperative death following intrathoracic anastomotic leakage was increased 3-fold compared with those without such a complication (OR 3.0, 95% CI 1.2-7.2). CONCLUSION Intrathoracic anastomotic leakage after esophageal resection for cancer remains a major risk factor for short-term postoperative death in an unselected, population-based setting.
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Affiliation(s)
- Martin Rutegård
- Upper Gastrointestinal Research, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden,
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Gillies RS, Simpkin A, Sgromo B, Marshall REK, Maynard ND. Left thoracoabdominal esophagectomy: results from a single specialist center. Dis Esophagus 2011; 24:138-44. [PMID: 20819097 DOI: 10.1111/j.1442-2050.2010.01107.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The left thoracoabdominal approach to esophagectomy is not widely performed, despite offering excellent exposure to tumors of the esophagogastric junction. Criticisms of the approach have focused on historically high rates of mortality, complications, and positive resection margins. Our aim was to determine whether left thoracoabdominal esophagectomy could combine a radical oncological resection with acceptably low mortality and morbidity. A retrospective cohort study of all left thoracoabdominal esophagectomies was performed at a single specialist center over an 11-year period. Primary outcomes were in-hospital mortality, complications, resection margin involvement, and lymph node yield; secondary outcomes were 1-year and 5-year survival. Two hundred eleven esophagectomies were performed. In-hospital mortality was 5.7% (12/211). One hundred one subjects (47.9%) had an uncomplicated recovery; 110 subjects (52.1%) developed at least one complication. There were 15 clinically significant anastomotic leaks (7.1%). Twenty-four subjects (11.4%) required emergency reoperation, the most common indication being anastomotic leakage. Complete tumor excision (R0 resection) was achieved in 151 of 211 cases (71.6%); median lymph node yield was 24. One-year and 5-year survival rates were 70% (147/211) and 21% (24/116), respectively. Left thoracoabdominal esophagectomy can combine a radical oncological resection with acceptably low mortality and morbidity.
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Affiliation(s)
- R S Gillies
- Department of Esophagogastric Surgery, Oxford Cancer and Hematology Centre, Churchill Hospital, Oxford, UK.
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Collins GS, Jibawi A, McCulloch P. Control chart methods for monitoring surgical performance: a case study from gastro-oesophageal surgery. Eur J Surg Oncol 2010; 37:473-80. [PMID: 21195577 DOI: 10.1016/j.ejso.2010.10.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2010] [Revised: 09/17/2010] [Accepted: 10/26/2010] [Indexed: 12/16/2022] Open
Abstract
Graphical methods are becoming increasingly used to monitor adverse outcomes from surgical interventions. However, uptake of such methods has largely been in the area of cardiothoracic surgery or in transplants with relatively little impact made in surgical oncology. A number of the more commonly used graphical methods including the Cumulative Mortality plot, Variable Life-Adjusted Display, Cumulative Sum (CUSUM) and funnel plots will be described. Accounting for heterogeneity in case-mix will be discussed and how ignoring case-mix can have considerable consequences. All methods will be illustrated using data from the Scottish Audit of Gastro-Oesophageal Cancer services (SAGOCS) data set.
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Affiliation(s)
- G S Collins
- Centre for Statistics in Medicine, University of Oxford, Wolfson College Annexe, Linton Road, Oxford, United Kingdom.
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Chang KH, McAnena OJ, Smith MJ, Salman RR, Khan MF, Lowe D. Surgery for oesophageal cancer at Galway University Hospital 1993-2008. Ir J Med Sci 2010; 179:521-7. [PMID: 20848322 DOI: 10.1007/s11845-010-0573-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Accepted: 09/03/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND Surgical volume and outcome remain controversial in the management of oesophageal cancer. AIMS To assess the outcome of oesophagectomy for cancer at Galway University Hospital (GUH). METHODS Between 1994 and 2008, patients who underwent oesophagectomy were analysed. RESULTS During the study period, 126 oesophagectomies were performed for cancer. The average surgeon volume was 9 cases per year. The 30-day and overall in-hospital mortality rates were 6.3 and 7.9%, respectively. Restructuring of our critical care services has led to a reduction in 30-day mortality from 8.2 to 5.1%. The use of neoadjuvant chemoradiotherapy has increased from 17 to 35% during the study period. In patients who underwent resection, the 3 and 5-year overall survival rates were 45 and 29%, respectively. CONCLUSIONS Operative morbidity and mortality at GUH are comparable with worldwide outcomes. Improved resources and national restructuring of cancer services have significantly improved the quality of care and outcomes of patients.
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Affiliation(s)
- K H Chang
- Department of Surgery, Galway University Hospital, National University of Ireland, Galway, Republic of Ireland.
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Borowski DW, Bradburn DM, Mills SJ, Bharathan B, Wilson RG, Ratcliffe AA, Kelly SB. Volume-outcome analysis of colorectal cancer-related outcomes. Br J Surg 2010; 97:1416-30. [PMID: 20632311 DOI: 10.1002/bjs.7111] [Citation(s) in RCA: 132] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Significant associations between caseload and surgical outcomes highlight the conflict between local cancer care and the need for centralization. This study examined the effect of hospital volume on short-term outcomes and survival, adjusting for the effect of surgeon caseload. METHODS Between 1998 and 2002, 8219 patients with colorectal cancer were identified in a regional population-based audit. Outcomes were assessed using univariable and multivariable analysis to allow case mix adjustment. Surgeons were categorized as low (26 or fewer operations annually), medium (27-40) or high (more than 40) volume. Hospitals were categorized as low (86 or fewer), medium (87-109) or high (more than 109) volume. RESULTS Some 7411 (90.2 per cent) of 8219 patients underwent surgery with an anastomotic leak rate of 2.9 per cent (162 of 5581), perioperative mortality rate of 8.0 per cent (591 of 7411) and 5-year survival rate of 46.8 per cent. Medium- and high-volume surgeons were associated with significantly better operative mortality (odds ratio (OR) 0.74, P = 0.010 and OR 0.66, P = 0.002 respectively) and survival (hazard ratio (HR) 0.88, P = 0.003 and HR 0.93, P = 0.090 respectively) than low-volume surgeons. Rectal cancer survival was significantly better in high-volume versus low-volume hospitals (HR 0.85, P = 0.036), with no difference between medium- and low-volume hospitals (HR 0.96, P = 0.505). CONCLUSION This study has confirmed the relevance of minimum volume standards for individual surgeons. Organization of services in high-volume units may improve survival in patients with rectal cancer.
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Affiliation(s)
- D W Borowski
- Department of Surgery, North Tyneside General Hospital, North Shields, UK
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Rouvelas I, Lagergren J. The impact of volume on outcomes after oesophageal cancer surgery. ANZ J Surg 2010; 80:634-41. [DOI: 10.1111/j.1445-2197.2010.05406.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Hølmebakk T, Frykholm G, Viste A. Introducing national guidelines on perioperative chemotherapy for gastric cancer in Norway: a retrospective audit. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2010; 36:610-6. [PMID: 20627647 DOI: 10.1016/j.ejso.2010.05.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Accepted: 05/04/2010] [Indexed: 12/19/2022]
Abstract
BACKGROUND In 2006, perioperative chemotherapy with epirubicin, cisplatin/oxaliplatin, and capecitabine was recommended in the National Guidelines for patients with resectable gastric cancer in Norway. We conducted a national audit related to clinical aspects, local organisation and the implementation of this multimodal treatment. PATIENTS AND METHODS All Norwegian departments of oncology were asked to submit aggregated data on gastric cancer patients who had started perioperative chemotherapy for cure; departments of surgery were asked to report on patients undergoing resection after preoperative chemotherapy. Data were retrospectively collected. RESULTS All 20 departments of oncology and 20 of 21 departments of surgery responded. Of 336 patients operated on for gastric cancer and reported by surgeons, 144 (43%) received preoperative chemotherapy. 169 patients were reported by departments of oncology. 152 (90%) completed the preoperative cycles; 92 (54%) started the postoperative cycles; and 68 (40%) completed all cycles. Toxicity grade >or= 3, overall and haematological, increased during postoperative compared to preoperative cycles, 50 vs. 34% (P = 0.012) and 35 vs. 20% (P = 0.012), respectively. Surgical morbidity and mortality were 26 and <2%, respectively. R0 resection was achieved in 86% of surgically treated patients. Five per cent had a complete pathological response (ypT0) and 48% were node negative (ypN0). Within the first year, the National Guidelines were implemented in 19 of 25 hospitals (76%). CONCLUSIONS In this population-based series, the tolerability of perioperative chemotherapy reported in the MAGIC trial was reproduced. Toxicity grade >or= 3 was considerable and significantly increased related to postoperative cycles. The National Guidelines were rapidly adopted.
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Affiliation(s)
- T Hølmebakk
- Department of Surgical Gastroenterology, Oslo University Hospital, Aker, 0514 Oslo, Norway.
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Detection of oesophageal cancer biomarkers by plasma proteomic profiling of human cell line xenografts in response to chemotherapy. Br J Cancer 2010; 103:232-8. [PMID: 20551956 PMCID: PMC2906736 DOI: 10.1038/sj.bjc.6605741] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Background: The incidence of oesophageal adenocarcinoma is increasing worldwide but survival remains poor. Neoadjuvant chemotherapy may improve survival, but targeting treatment to patients who respond to chemotherapy could be improved by the availability of markers of response. This study sought proteomic markers of therapeutic response using an adenocarcinoma xenograft model. Methods: Epirubicin, cisplatin or 5-fluorouracil was administered to severe combined immune-deficient mice bearing OE19 oesophageal adenocarcinoma xenografts. Murine plasma samples from treated and untreated xenografts were analysed by surface-enhanced laser desorption/ionisation time-of-flight mass spectroscopy, and panels of peaks were found using class prediction models that distinguished treatment groups. Proteins in these peaks were identified by mass spectroscopy in tryptic digests of purified fractions. Five paired samples from oesophageal cancer patients before and after chemotherapy were analysed using the same methodology. Results: Plasma protein peaks were identified that differed significantly (P<0.05, ANOVA) between the treated xenograft and control groups. Marker panels predicted treated vs untreated xenografts with sensitivities of 100%, specificities of 86–100% and test efficiencies of 89–100%. Three of the proteins identified in these panels, apolipoprotein A-I, serum amyloid A and transthyretin were confirmed in the clinical samples. Conclusion: Plasma protein markers can be detected in response to chemotherapy in oesophageal adenocarcinoma xenografts and in clinical samples, and have the potential to monitor response and guide chemotherapy in oesophageal adenocarcinoma.
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