Caseload and Outcome after Brachytherapy

Abstract

Improved patient outcomes have been correlated with high caseload hospitals for a multitude of conditions, including cancer. Using avariety of end points this is true for the treatment of brain tumours, breast cancer and particularly colorectal cancer. The most definitive evidence comes from a Cochrane meta-analysis of the treatment of colorectal cancer between high-volume/specialist hospitals and surgeons and low-volume/specialist hospitals and surgeons. Overall 5 year survival was significantly improved for patients with colorectal cancer treated in high-volume hospitals (hazard ratio ¼ 0.90, 95% confidence interval 0.5e0.96). The volume outcome relationship was somewhat stronger for the individual surgeon than the hospital as the hazard ratio for high-volume versus low-volume surgeons was hazard ratio ¼ 0.88, 95% confidence interval 0.83e0.93 [1]. Data previously published in the west of Scotland had shown that survival was significantly better in both colorectal cancer [2] and breast cancer [3] when patients were treated by high caseload surgeons. Surgeons with a high throughput may have better individual skills and as a consequence carry out a more thorough and technically demanding operation. A study from Finland has shown that surgeons with a high caseload dissect more lymph nodes from the axilla than surgeons with a low caseload (mean number of lymph nodes 11.2 versus 9.4; P ¼� 0.001) [4]. High caseload surgeons were also more likely to carry out breast conservation rather than mastectomy (P � 0.001) and higher caseloads were related to better survival (P ¼ 0.031) [5]. A high caseload may be a surrogate for more subtle factors other than just individual surgical skill. A study that examined the 7 year survival of patients with breast cancer in Quebec [6] showed a survival advantage for women treated in centres seeing more than 100 new cases of breast cancer per year. Survival was better among those treated in high case volume hospitals, but the significance of caseload disappeared when other factors that were associated with improved survival, such as teaching status, research activity and onsite radiotherapy, were taken into account. There is far less in the literature about caseload volume and outcome after radiotherapy. External beam radiotherapy treatment for nasopharynx cancer is a technically demanding exercise. Therefore it is unsurprising that a group in Taiwan found that patients had a better 10 year survival when treated by physicians who treated more than 35 cases a year compared with those who treated less than 35 cases (75% versus 61%; P � 0.01) [7]. We could find no publications correlating caseload and outcome from