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Julian WT, Elshami M, Ammori JB, Hardacre JM, Ocuin LM. Comparison of Hospital Volume and Risk-Standardized Mortality Rate as a Proxy for Hospital Quality in Complex Oncologic Hepatopancreatobiliary Surgery. Ann Surg Oncol 2024; 31:4922-4930. [PMID: 38700800 PMCID: PMC11236847 DOI: 10.1245/s10434-024-15361-2] [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: 02/27/2024] [Accepted: 04/09/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND Centralization of hepatopancreatobiliary procedures to more experienced centers has been recommended but remains controversial. Hospital volume and risk-stratified mortality rates (RSMR) are metrics for interhospital comparison. We compared facility operative volume with facility RSMR as a proxy for hospital quality. PATIENTS AND METHODS Patients who underwent surgery for liver (LC), biliary tract (BTC), and pancreatic (PDAC) cancer were identified in the National Cancer Database (2004-2018). Hierarchical logistic regression was used to create facility-specific models for RSMR. Volume (high versus low) was determined by quintile. Performance (high versus low) was determined by RSMR tercile. Primary outcomes included median facility RSMR and RSMR distributions. Volume- and RSMR-based redistribution was simulated and compared for reductions in 90-day mortality. RESULTS A total of 106,217 patients treated at 1282 facilities were included; 17,695 had LC, 23,075 had BTC, and 65,447 had PDAC. High-volume centers (HVC) had lower RSMR compared with medium-volume centers and low-volume centers for LC, BTC, and PDAC (all p < 0.001). High-performance centers (HPC) had lower RSMR compared with medium-performance centers and low-performance centers for LC, BTC, and PDAC (all p < 0.001). Volume-based redistribution required 16.0 patients for LC, 11.2 for BTC, and 14.9 for PDAC reassigned to 15, 22, and 20 centers, respectively, per life saved within each US census region. RSMR-based redistribution required 4.7 patients for LC, 4.2 for BTC, and 4.9 for PDAC reassigned to 316, 403, and 418 centers, respectively, per life saved within each US census region. CONCLUSIONS HVC and HPC have the lowest overall and risk-standardized 90-day mortality after oncologic hepatopancreatobiliary procedures, but RSMR may outperform volume as a measure of hospital quality.
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Affiliation(s)
- William T Julian
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Mohamedraed Elshami
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - John B Ammori
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jeffrey M Hardacre
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Lee M Ocuin
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
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Bond MJG, Kuiper BI, Bolhuis K, Komurcu A, van Amerongen MJ, Chapelle T, Dejong CHC, Engelbrecht MRW, Gerhards MF, Grünhagen DJ, van Gulik T, Hermans JJ, de Jong KP, Klaase JM, Kok NFM, Leclercq WKG, Liem MSL, van Lienden KP, Molenaar IQ, Neumann UP, Patijn GA, Rijken AM, Ruers TM, Verhoef C, de Wilt JHW, Kazemier G, May AM, Punt CJA, Swijnenburg RJ. Intersurgeon Variability in Local Treatment Planning for Patients with Initially Unresectable Colorectal Cancer Liver Metastases: Analysis of the Liver Expert Panel of the Dutch Colorectal Cancer Group. Ann Surg Oncol 2023; 30:5376-5385. [PMID: 37118612 PMCID: PMC10409679 DOI: 10.1245/s10434-023-13510-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 03/06/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND Consensus on resectability criteria for colorectal cancer liver metastases (CRLM) is lacking, resulting in differences in therapeutic strategies. This study evaluated variability of resectability assessments and local treatment plans for patients with initially unresectable CRLM by the liver expert panel from the randomised phase III CAIRO5 study. METHODS The liver panel, comprising surgeons and radiologists, evaluated resectability by predefined criteria at baseline and 2-monthly thereafter. If surgeons judged CRLM as resectable, detailed local treatment plans were provided. The panel chair determined the conclusion of resectability status and local treatment advice, and forwarded it to local surgeons. RESULTS A total of 1149 panel evaluations of 496 patients were included. Intersurgeon disagreement was observed in 50% of evaluations and was lower at baseline than follow-up (36% vs. 60%, p < 0.001). Among surgeons in general, votes for resectable CRLM at baseline and follow-up ranged between 0-12% and 27-62%, and for permanently unresectable CRLM between 3-40% and 6-47%, respectively. Surgeons proposed different local treatment plans in 77% of patients. The most pronounced intersurgeon differences concerned the advice to proceed with hemihepatectomy versus parenchymal-preserving approaches. Eighty-four percent of patients judged by the panel as having resectable CRLM indeed received local treatment. Local surgeons followed the technical plan proposed by the panel in 40% of patients. CONCLUSION Considerable variability exists among expert liver surgeons in assessing resectability and local treatment planning of initially unresectable CRLM. This stresses the value of panel-based decisions, and the need for consensus guidelines on resectability criteria and technical approach to prevent unwarranted variability in clinical practice.
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Affiliation(s)
- Marinde J G Bond
- Department of Epidemiology, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Babette I Kuiper
- Department of Surgery, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Karen Bolhuis
- Department of Medical Oncology, Amsterdam UMC, Cancer Centre Amsterdam, Amsterdam, The Netherlands
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Aysun Komurcu
- The Netherlands Comprehensive Cancer Centre, Utrecht, The Netherlands
| | | | - Thiery Chapelle
- Department of Hepatobiliary, Transplantation, and Endocrine Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Cornelis H C Dejong
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- Universitätsklinikum Aachen, Aachen, Germany
| | - Marc R W Engelbrecht
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Amsterdam, The Netherlands
| | | | - Dirk J Grünhagen
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Thomas van Gulik
- Department of Surgery, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - John J Hermans
- Department of Radiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Koert P de Jong
- Department of Hepatobiliary Surgery and Liver Transplantation, University Medical Centre Groningen, Groningen, The Netherlands
| | - Joost M Klaase
- Department of Hepatobiliary Surgery and Liver Transplantation, University Medical Centre Groningen, Groningen, The Netherlands
| | - Niels F M Kok
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Mike S L Liem
- Department of Surgery, Medical Spectrum Twente, Enschede, The Netherlands
| | - Krijn P van Lienden
- Department of Radiology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Ulf P Neumann
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- Universitätsklinikum Aachen, Aachen, Germany
| | - Gijs A Patijn
- Department of Surgery, Isala Hospital, Zwolle, The Netherlands
| | - Arjen M Rijken
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | - Theo M Ruers
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Cornelis Verhoef
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Geert Kazemier
- Department of Surgery, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Anne M May
- Department of Epidemiology, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Cornelis J A Punt
- Department of Epidemiology, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Medical Oncology, Amsterdam UMC, Cancer Centre Amsterdam, Amsterdam, The Netherlands
| | - Rutger-Jan Swijnenburg
- Department of Surgery, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
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3
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Hellingman T, van Beneden MLH, den Bakker CM, Zonderhuis BM, Kazemier G. Perspectives of patients with colorectal cancer liver metastases on e-consultation in transmural care: a qualitative study : Is privacy really an issue? BMC Health Serv Res 2023; 23:541. [PMID: 37231462 DOI: 10.1186/s12913-023-09408-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 04/15/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Comprehensive cancer networks have been established to deliver high-quality care for patients with cancer. Logistic challenges are faced, when patients need to be referred for specialized treatments. Despite strengthened privacy legislations, digital platforms are increasingly used to consult specialists from dedicated liver centers or refer patients with colorectal cancer liver metastases (CRLM) for local treatment strategies. This qualitative study aimed to explore the perspectives of patients with CRLM regarding e-consultation of transmural specialists. METHODS A focus group study was conducted. Patients referred from regional hospitals to an academic liver center for treatment of CRLM were asked to participate. Focus group discussions were audio-recorded and transcribed verbatim. A thematic content analysis of data was conducted, comprising open, axial, and selective coding of the transcripts. The consolidated criteria for reporting qualitative research (COREQ) were used. RESULTS Two focus groups were held, involving 11 patients and 8 relatives. Three major themes were identified with regard to e-consultation in transmural care: 'data management', 'expertise', and 'information and coordination'. Confidence in the expertise of physicians appeared most important during the course of treatment, as patients experienced uncertainty after diagnosis of cancer. Despite the privacy risks, use of digital communication platforms to contact experts in the field were strongly endorsed to improve eligibility for potentially curative treatment. Moreover, e-consultation of specialists may reduce waiting times, due to effective coordination of care. CONCLUSION Initiatives to improve medical data transfer between care providers were encouraged to achieve effective coordination of oncological care. The potential hazard of privacy violation associated with digital data exchange is accepted by patients and their relatives, provided that use of digital data improves patient's own health care, research or education.
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Affiliation(s)
- T Hellingman
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, de Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
| | - M L H van Beneden
- Department of Strategy and Innovation, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, de Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - C M den Bakker
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, de Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
- Department of Surgery, Spaarne Gasthuis, Boerhaavelaan 22, 2035 RC, Haarlem, The Netherlands
| | - B M Zonderhuis
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, de Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - G Kazemier
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, de Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
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Tepelenis K, Pappas-Gogos G, Ntellas P, Tsimogiannis K, Dadouli K, Mauri D, Glantzounis GK. The Role of Preoperative Chemotherapy in the Management of Synchronous Resectable Colorectal Liver Metastases: A Meta-Analysis. Curr Oncol 2023; 30:4499-4511. [PMID: 37232798 DOI: 10.3390/curroncol30050340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/16/2023] [Accepted: 04/17/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND The indications of preoperative chemotherapy, for initially resectable synchronous colorectal liver metastases, remain controversial. This meta-analysis aimed to assess the efficacy and safety of preoperative chemotherapy in such patients. METHODS Six retrospective studies were included in the meta-analysis with 1036 patients. Some 554 patients were allocated to the preoperative group, and 482 others were allocated to the surgery group. RESULTS Major hepatectomy was more common in the preoperative group than in the surgery group (43.1% vs. 28.8%, p < 0.001). Furthermore, the percentage of patients with more than three liver metastases was higher in the preoperative group compared to the surgery group (12.6% vs. 5.4%, p < 0.002). Preoperative chemotherapy showed no statistically significant impact on overall survival. Combined disease free/relapse survival analysis of patients with high disease burden (liver metastases > 3, maximum diameter > 5 cm, clinical risk score ≥ 3) demonstrated that there is a 12% lower risk of recurrence in favor of preoperative chemotherapy. Combined analysis showed a statistically significant (77% higher probability) of postoperative morbidity in patients who received preoperative chemotherapy (p = 0.002). CONCLUSIONS Preoperative chemotherapy should be suggested in patients with high disease burden. The number of cycles of preoperative chemotherapy should be low (3-4) to avoid increased postoperative morbidity. However more prospective studies are needed to clarify the exact role of preoperative chemotherapy in patients with synchronous resectable colorectal liver metastases.
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Affiliation(s)
- Kostas Tepelenis
- Hepatobiliary and Pancreatic Surgery (HPB) Unit, Department of Surgery, University Hospital of Ioannina and Faculty of Medicine, School of Health Sciences, University of Ioannina, 451 10 Ioannina, Greece
| | - Georgios Pappas-Gogos
- Hepatobiliary and Pancreatic Surgery (HPB) Unit, Department of Surgery, University Hospital of Ioannina and Faculty of Medicine, School of Health Sciences, University of Ioannina, 451 10 Ioannina, Greece
- Second Department of Surgery, General University Hospital of Alexandroupolis and Medical School, Democritus University of Thrace, 691 00 Alexandroupoli, Greece
| | - Panagiotis Ntellas
- Department of Oncology, University Hospital of Ioannina and Faculty of Medicine, School of Health Sciences, University of Ioannina, 451 10 Ioannina, Greece
| | - Konstantinos Tsimogiannis
- Hepatobiliary and Pancreatic Surgery (HPB) Unit, Department of Surgery, University Hospital of Ioannina and Faculty of Medicine, School of Health Sciences, University of Ioannina, 451 10 Ioannina, Greece
| | - Katerina Dadouli
- Laboratory of Hygiene and Epidemiology, Faculty of Medicine, University of Thessaly, 382 21 Larisa, Greece
| | - Davide Mauri
- Department of Oncology, University Hospital of Ioannina and Faculty of Medicine, School of Health Sciences, University of Ioannina, 451 10 Ioannina, Greece
| | - Georgios K Glantzounis
- Hepatobiliary and Pancreatic Surgery (HPB) Unit, Department of Surgery, University Hospital of Ioannina and Faculty of Medicine, School of Health Sciences, University of Ioannina, 451 10 Ioannina, Greece
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Meyer YM, Olthof PB, Grünhagen DJ, Swijnenburg RJ, Elferink MAG, Verhoef C. Interregional practice variations in the use of local therapy for synchronous colorectal liver metastases in the Netherlands. HPB (Oxford) 2022; 24:1651-1658. [PMID: 35501243 DOI: 10.1016/j.hpb.2022.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 03/15/2022] [Accepted: 04/12/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the Dutch regional practice variation in treatment of synchronous colorectal liver metastases (CRLM) over time and assess their impact on patients survival. METHODS Two cohorts of patients with synchronous CRLM were selected from the Netherlands Cancer Registry (NCR). All patients diagnosed between 2014 and 2018 were selected to analyze interregional practice variations in local therapy (LT) with multivariable logistic regression. Overall survival (OS) was assessed for patients diagnosed from 2008 to 2013 using Kaplan Meier method and Cox regression analyses. RESULTS The proportion of patients who underwent LT increased from 15.5% to 21.9%. Interregional use of LT varied from 19.1% to 25.0%. Multivariable logistic regression showed significant differences between regions in the use of LT (p = 0.001) in 2014-2018. There was no association between OS and region of diagnosis for patients who underwent LT after correction for confounders.The use of LT for CRLM increased from 15.5% in 2008-2013 to 21.9% in 2014-2018. Three-year OS increased from 16% to 19% respectively. CONCLUSION Interregional practice variations have decreased. The remaining differences are not associated with OS. The use of local therapy and 3-year overall survival have increased over time. Local practice should be monitored to prevent undesirable variation in outcomes.
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Affiliation(s)
- Yannick M Meyer
- Erasmus MC Cancer Institute, Department of Surgical Oncology and Gastrointestinal Surgery, Rotterdam, the Netherlands
| | - Pim B Olthof
- Erasmus MC Cancer Institute, Department of Surgical Oncology and Gastrointestinal Surgery, Rotterdam, the Netherlands
| | - Dirk J Grünhagen
- Erasmus MC Cancer Institute, Department of Surgical Oncology and Gastrointestinal Surgery, Rotterdam, the Netherlands
| | | | - Marloes A G Elferink
- Department of Research & Development, Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands
| | - Cornelis Verhoef
- Erasmus MC Cancer Institute, Department of Surgical Oncology and Gastrointestinal Surgery, Rotterdam, the Netherlands.
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Ljunggren M, Weibull CE, Rosander E, Palmer G, Glimelius B, Martling A, Nordenvall C. Hospital factors and metastatic surgery in colorectal cancer patients, a population-based cohort study. BMC Cancer 2022; 22:907. [PMID: 35986249 PMCID: PMC9392345 DOI: 10.1186/s12885-022-10005-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 08/16/2022] [Indexed: 11/15/2022] Open
Abstract
Background Only a limited proportion of patients with metastatic colorectal cancer (mCRC) receives metastatic surgery (including local ablative therapy). The aim was to investigate whether hospital volume and hospital level were associated with the chance of metastatic surgery. Methods This national cohort retrieved from the CRCBaSe linkage included all Swedish adult patients diagnosed with synchronous mCRC in 2009–2016. The association between annual hospital volume of incident mCRC patients and the chance of metastatic surgery, and survival, were assessed using logistic regression and Cox regression models, respectively. Hospital level (university/non-university) was evaluated as a secondary exposure in a similar manner. Both uni- and multivariable (adjusted for sex, age, Charlson comorbidity index, year of diagnosis, cancer characteristics and socioeconomic factors) models were fitted. Results A total of 1,674 (17%) out of 9,968 mCRC patients had metastatic surgery. High hospital volume was not associated with increased odds of metastatic surgery after including hospital level in the model, whereas hospital level was (odds ratio (OR) (95% confidence interval (CI)): 1.94 (1.68–2.24)). All-cause mortality was lower in university versus non-university hospitals (hazard ratio (95% CI): 0.83 (0.78–0.88)). Conclusions Patients with mCRC initially cared for by a university hospital experienced a greater chance to receive metastatic surgery and had superior overall survival. High hospital volume in itself was not associated with a greater chance to receive metastatic surgery nor a greater survival probability. Additional efforts should be imposed to provide more equal care for mCRC patients across Swedish hospitals. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-10005-8.
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Meyer Y, Olthof PB, Grünhagen DJ, de Hingh I, de Wilt JHW, Verhoef C, Elferink MAG. Treatment of metachronous colorectal cancer metastases in the Netherlands: A population-based study. Eur J Surg Oncol 2021; 48:1104-1109. [PMID: 34895970 DOI: 10.1016/j.ejso.2021.12.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/25/2021] [Accepted: 12/02/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND This study aimed to describe the treatment of metachronous colorectal cancer metastases in a recent population-based cohort. METHOD Patients with stage I-III colorectal cancer (CRC), diagnosed between January 1st and June 30th, 2015 who were surgically treated with curative intent were selected from the Netherlands Cancer Registry. Follow-up was at least 3 years after diagnosis of the primary tumour. Treatment of metachronous metastases was categorized into local treatment, systemic treatment, and best supportive care. Overall survival was estimated using Kaplan-Meier method. RESULTS Out of 5412 patients, 782 (14%) developed metachronous metastases, of whom 393 (50%) underwent local treatment (LT) with or without systemic therapy, 30% of patients underwent only systemic therapy (ST) and 19% only best supportive care (BSC). The most common metastatic site was the liver (51%) followed by lungs (33%) and peritoneum (22%). LT rates were 69%, 66%, and 44% for liver-only, lung-only and, peritoneal-only metastases respectively. Patients receiving LT and ST were significantly younger than patients receiving LT alone, while patients receiving BSC were significantly older than the other groups (p < 0.001). Patients with liver-only or lung-only metastases had a 3-year OS of 50.2% (43.3-56.7 95% CI) and 61.5% (50.7-70.6 95% CI) respectively. Patients with peritoneal-only disease had a lower 3-year OS, 18.1% (10.1-28.0 95% CI). CONCLUSION Patients with metastases confined to the liver and lung have the highest rates of local treatment for metachronous metastatic colorectal cancer. The number of patients who underwent local treatment is higher than reported in previous Dutch and international studies.
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Affiliation(s)
- Y Meyer
- Erasmus MC Cancer Institute, Department of Surgical Oncology and Gastrointestinal Surgery, Rotterdam, the Netherlands
| | - P B Olthof
- Erasmus MC Cancer Institute, Department of Surgical Oncology and Gastrointestinal Surgery, Rotterdam, the Netherlands
| | - D J Grünhagen
- Erasmus MC Cancer Institute, Department of Surgical Oncology and Gastrointestinal Surgery, Rotterdam, the Netherlands
| | - I de Hingh
- Department of Surgery, Catharina Ziekenhuis Eindhoven, the Netherlands
| | - J H W de Wilt
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - C Verhoef
- Erasmus MC Cancer Institute, Department of Surgical Oncology and Gastrointestinal Surgery, Rotterdam, the Netherlands
| | - M A G Elferink
- Department of Research & Development, Netherlands Comprehensive Cancer Organisation, Utrecht, the Netherlands.
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8
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Nationwide oncological networks for resection of colorectal liver metastases in the Netherlands: Differences and postoperative outcomes. Eur J Surg Oncol 2021; 48:435-448. [PMID: 34801321 DOI: 10.1016/j.ejso.2021.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 08/29/2021] [Accepted: 09/02/2021] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Widespread differences in patient demographics and disease burden between hospitals for resection of colorectal liver metastases (CRLM) have been described. In the Netherlands, networks consisting of at least one tertiary referral centre and several regional hospitals have been established to optimize treatment and outcomes. The aim of this study was to assess variation in case-mix, and outcomes between these networks. METHODS This was a population-based study including all patients who underwent CRLM resection in the Netherlands between 2014 and 2019. Variation in case-mix and outcomes between seven networks covering the whole country was evaluated. Differences in case-mix, expected 30-day major morbidity (Clavien-Dindo ≥3a) and 30-day mortality between networks were assessed. RESULTS In total 5383 patients were included. Thirty-day major morbidity was 5.7% and 30-day mortality was 1.5%. Significant differences between networks were observed for Charlson Comorbidity Index, ASA 3+, previous liver resection, liver disease, preoperative MRI, preoperative chemotherapy, ≥3 CRLM, diameter of largest CRLM ≥55 mm, major resection, combined resection and ablation, rectal primary tumour, bilobar and extrahepatic disease. Uncorrected 30-day major morbidity ranged between 3.3% and 13.1% for hospitals, 30-day mortality ranged between 0.0% and 4.5%. Uncorrected 30-day major morbidity ranged between 4.4% and 6.0% for networks, 30-day mortality ranged between 0.0% and 2.5%. No negative outliers were observed after case-mix correction. CONCLUSION Variation in case-mix and outcomes are considerably smaller on a network level as compared to a hospital level. Therefore, auditing is more meaningful at a network level and collaboration of hospitals within networks should be pursued.
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Hellingman T, de Swart ME, Joosten JJA, Meijerink MR, de Vries JJJ, de Waard JWD, van Zweeden AA, Zonderhuis BM, Kazemier G. The value of a dedicated multidisciplinary expert panel to assess treatment strategy in patients suffering from colorectal cancer liver metastases. Surg Oncol 2020; 35:412-417. [PMID: 33035790 DOI: 10.1016/j.suronc.2020.09.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 08/18/2020] [Accepted: 09/27/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND For patients with colorectal cancer liver metastases (CRLM), local treatment is the only treatment with curative intent. The majority of patients with CRLM are however evaluated in multidisciplinary teams of colorectal cancer specialists often lacking expertise in local treatment of liver tumors. The aim of this study was therefore to assess the value of a dedicated multidisciplinary panel consisting of hepatobiliary surgeons and interventional radiologists for patients suffering from liver-only CRLM. METHODS Patients diagnosed with liver-only CRLM in 2016 were identified in a tertiary referral hospital, and two of the referring hospitals in the Netherlands. Diagnostic imaging was independently reviewed by a panel of four hepatobiliary surgeons and two interventional radiologists to re-evaluate treatment strategy retrospectively. If two or more panelists assessed all lesions eligible for resection and/or ablation, patients were deemed eligible for local treatment with curative intent. Interrater reliability between hepatobiliary surgeons was assessed through intraclass correlation coefficient (ICC) and weighted Cohen's kappa. RESULTS Diagnostic imaging of 61 patients with liver-only metastases were reviewed. Local treatment strategies appeared feasible in 40/61 (65.6%) patients. Five out of 25 patients (20.0%) initially assigned to systemic therapy were deemed eligible for upfront local treatment with curative intent (p = 0.015). In this subgroup, interrater reliability between hepatobiliary surgeons was substantial (ICC: 0.704, 95% CI: 0.536-0.838, n = 25). CONCLUSION Assessment of treatment strategy by a dedicated multidisciplinary panel including liver experts may result in an increased number of patients eligible for potentially curative treatment and reduce undertreatment of patients suffering from liver-only CRLM.
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Affiliation(s)
- T Hellingman
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Surgery, Cancer Center Amsterdam, De Boelelaan, 1117, Amsterdam, the Netherlands.
| | - M E de Swart
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Surgery, Cancer Center Amsterdam, De Boelelaan, 1117, Amsterdam, the Netherlands
| | - J J A Joosten
- Dijklander Hospital, Department of Surgery, Maelsonstraat 3, Hoorn, the Netherlands
| | - M R Meijerink
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Radiology and Nuclear Medicine, Cancer Center Amsterdam, De Boelelaan, 1117, Amsterdam, the Netherlands
| | - J J J de Vries
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Radiology and Nuclear Medicine, Cancer Center Amsterdam, De Boelelaan, 1117, Amsterdam, the Netherlands
| | - J W D de Waard
- Dijklander Hospital, Department of Surgery, Maelsonstraat 3, Hoorn, the Netherlands
| | - A A van Zweeden
- Amstelland Hospital, Department of Internal Medicine, Laan van de Helende Meesters 8, Amstelveen, the Netherlands
| | - B M Zonderhuis
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Surgery, Cancer Center Amsterdam, De Boelelaan, 1117, Amsterdam, the Netherlands
| | - G Kazemier
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Surgery, Cancer Center Amsterdam, De Boelelaan, 1117, Amsterdam, the Netherlands
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Hellingman T, Swart MED, Meijerink MR, Schreurs WH, Zonderhuis BM, Kazemier G. Optimization of transmural care by implementation of an online expert panel to assess treatment strategy in patients suffering from colorectal cancer liver metastases: A prospective analysis. J Telemed Telecare 2020; 28:559-567. [PMID: 33019855 DOI: 10.1177/1357633x20957136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Centralization of oncological care results in a growing demand for specialized consultations and referrals. Improved telemedicine solutions are needed to facilitate access to specialist care and select patients eligible for referral. The purpose of this quality improvement initiative was to optimize transmural care for patients suffering from colorectal cancer liver metastases through implementation of an online expert panel. METHODS A digital communication platform was developed to share medical data, including high-quality diagnostic imaging of patients suffering from colorectal cancer liver metastases. Feasibility of local treatment strategies was assessed by a panel of liver specialists to select patients for referral. After implementation, an observational cohort study was conducted to evaluate quality improvement in transmural care using revised Standards for Quality Improvement Reporting Excellence guidelines. RESULTS From September 2016-September 2018, eight hospitals were connected to the platform, covering a population of 3 m. In total, 123 cases were assessed, of which 54 (43.9%) were prevented from needless physical referral. Assessment of treatment strategy by an online expert panel significantly reduced the average lead time during multidisciplinary team meetings from 3.73 min to 2.12 min per patient (p < 0.01). CONCLUSIONS Implementation of an online expert panel is an innovative, accessible and user-friendly way to provide cancer-specific expertise to regional hospitals. E-consultation of such panels may result in more efficient multidisciplinary team meetings and prevent fragile patients from needless referral. Sustainability of these panels however is subject to structural financial compensation, so a cost-effectiveness analysis is warranted.
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Affiliation(s)
- Tessa Hellingman
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - Merijn E de Swart
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - Martijn R Meijerink
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | | | - Barbara M Zonderhuis
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - Geert Kazemier
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
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11
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Raoof M, Jutric Z, Haye S, Ituarte PHG, Zhao B, Singh G, Melstrom L, Warner SG, Clary B, Fong Y. Systematic failure to operate on colorectal cancer liver metastases in California. Cancer Med 2020; 9:6256-6267. [PMID: 32687265 PMCID: PMC7476837 DOI: 10.1002/cam4.3316] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/18/2020] [Accepted: 07/03/2020] [Indexed: 12/30/2022] Open
Abstract
Background Despite evidence that liver resection improves survival in patients with colorectal cancer liver metastases (CRCLM) and may be potentially curative, there are no population‐level data examining utilization and predictors of liver resection in the United States. Methods This is a population‐based cross‐sectional study. We abstracted data on patients with synchronous CRCLM using California Cancer Registry from 2000 to 2012 and linked the records to the Office of Statewide Health Planning Inpatient Database. Quantum Geographic Information System (QGIS) was used to map liver resection rates to California counties. Patient‐ and hospital‐level predictors were determined using mixed‐effects logistic regression. Results Of the 24 828 patients diagnosed with stage‐IV colorectal cancer, 16 382 (70%) had synchronous CRCLM. Overall liver resection rate for synchronous CRCLM was 10% (county resection rates ranging from 0% to 33%) with no improvement over time. There was no correlation between county incidence of synchronous CRCLM and rate of resection (R2 = .0005). On multivariable analysis, sociodemographic and treatment‐initiating‐facility characteristics were independently associated with receipt of liver resection after controlling for patient disease‐ and comorbidity‐related factors. For instance, odds of liver resection decreased in patients with black race (OR 0.75 vs white) and Medicaid insurance (OR 0.62 vs private/PPO); but increased with initial treatment at NCI hospital (OR 1.69 vs Non‐NCI hospital), or a high volume (10 + cases/year) (OR 1.40 vs low volume) liver surgery hospital. Conclusion In this population‐based study, only 10% of patients with liver metastases underwent liver resection. Furthermore, the study identifies wide variations and significant population‐level disparities in the utilization of liver resection for CRCLM in California.
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Affiliation(s)
- Mustafa Raoof
- Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Zeljka Jutric
- Department of Surgery, University of California Irvine, Irvine, CA, USA
| | - Sidra Haye
- Department of Economics, University of California Irvine, Irvine, CA, USA
| | - Philip H G Ituarte
- Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Beiqun Zhao
- Department of Surgery, University of San Diego, San Diego, CA, USA
| | - Gagandeep Singh
- Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Laleh Melstrom
- Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Susanne G Warner
- Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Bryan Clary
- Department of Surgery, University of San Diego, San Diego, CA, USA
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
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12
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Walraven J, Desar I, Hoeven van der J, Aben K, Hillegersberg van R, Rasch C, Lemmens V, Verhoeven R. Analysis of 105.000 patients with cancer: have they been discussed in oncologic multidisciplinary team meetings? A nationwide population-based study in the Netherlands. Eur J Cancer 2019; 121:85-93. [DOI: 10.1016/j.ejca.2019.08.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 08/14/2019] [Accepted: 08/14/2019] [Indexed: 12/24/2022]
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13
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van Amerongen MJ, Jenniskens SFM, van den Boezem PB, Fütterer JJ, de Wilt JHW. Radiofrequency ablation compared to surgical resection for curative treatment of patients with colorectal liver metastases - a meta-analysis. HPB (Oxford) 2017; 19:749-756. [PMID: 28687147 DOI: 10.1016/j.hpb.2017.05.011] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 05/21/2017] [Accepted: 05/24/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Hepatic resection and ablative treatments, such as RFA are available treatment options for liver tumors. Advantages and disadvantages of these treatment options in patients with colorectal liver metastases need further evaluation. The purpose of this study was to systematically evaluate the role of radiofrequency ablation (RFA) compared to surgery in the curative treatment of patients with colorectal liver metastases (CRLM). METHODS A systematic search was performed from MEDLINE, EMBASE and the Cochrane Library for studies directly comparing RFA with resection for CRLM, after which variables were evaluated. RESULTS RFA had significantly lower complication rates (OR = 0.44, 95% CI = 0.26-0.75, P = 0.002) compared to resection. However, RFA showed a higher rate of any recurrence (OR = 1.66, 95% CI = 1.15-2.40, P = 0.007), local recurrence (OR = 9.56, 95% CI = 6.85-13.35, P = 0.001), intrahepatic recurrence (OR = 1.96, 95% CI = 1.34-2.87, P = 0.001) and extrahepatic recurrence (OR = 1.21, 95% CI = 0.90-1.63, P = 0.22). Also, 5-year disease-free survival (OR = 2.20, 95% CI = 1.28-3.79, P = 0.005) and overall survival (OR = 2.35, 95% CI = 1.49-3.69, P = 0.001) were significantly lower in patients treated with RFA. CONCLUSIONS RFA showed a significantly lower rate of complications, but also a lower survival and a higher rate of recurrence as compared to surgical resection. All the included studies were subject to possible patient selection bias and therefore randomized clinical trials are needed to accurately evaluate these treatment modalities.
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Affiliation(s)
- Martinus J van Amerongen
- Department of Radiology and Nuclear Medicine, Radboud University Nijmegen Medical Center, The Netherlands.
| | - Sjoerd F M Jenniskens
- Department of Radiology and Nuclear Medicine, Radboud University Nijmegen Medical Center, The Netherlands
| | | | - Jurgen J Fütterer
- Department of Radiology and Nuclear Medicine, Radboud University Nijmegen Medical Center, The Netherlands; MIRA Institute for Biomedical Engineering and Technical Medicine, University of Twente, The Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Nijmegen Medical Center, The Netherlands
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