Impact of facility volume on the outcomes of minimally invasive radical hysterectomy for early-stage cervical cancer

Abstract

<h3>Objectives:</h3> Investigate the average facility volume of minimally invasive radical hysterectomy (MIRH) and the impact of facility volume on the outcomes of patients with apparent early-stage cervical carcinoma. <h3>Methods:</h3> The National Cancer Database was accessed and patients with a cervical malignancy who underwent MIRH between 2010 and 2016 were identified. Annual facility volume was calculated, and high-volume centers were defined as those who performed at least 6 procedures per year. Impact of facility volume on inpatient stay, readmission rate and overall survival (OS) was evaluated for patients with apparent early-stage disease and no history of another tumor with available survival data. OS was compared with the log-rank test while a multivariate Cox model was constructed to control for confounders. <h3>Results:</h3> A total of 5806 patients with cervical cancer underwent MIRH between 2010-2016 in 669 facilities. Median facility volume was 1.5 cases per year; only 19 facilities performed at least 6 MIRH per year. A total of 3529 patients with apparent early-stage disease who underwent MIRH were selected; 16.7% were managed at a high-volume center. Patient age, race, and presence of co-morbidities and tumor extension was comparable between high and low-volume centers. Rate of robotic-assisted surgery was 22.7% and 20.9% for patients undergoing surgery at high and low-volume centers, p=0.33. Conversion to open surgery (2% vs 2.9%, p=0.24), and 30-day readmission (5.4% vs 4%, p=0.12) rates were comparable between high and low-volume centers. Patients at high-volume centers were more likely to be discharged within 1 day (65.6% vs 60.5%, p=0.022). There was no difference in the OS between patients who had MIRH at a high or low- volume centers, p=0.14; 3-year OS rates were 92.5% and 94.2% respectively. After controlling for confounders, patients who had MIRH at a high-volume center did not have better survival (HR: 1.32, 95% CI: 0.96, 1.33). <h3>Conclusions:</h3> Given the rarity of cervical cancer, MIRH was a highly de-centralized procedure with the vast majority of centers not achieving a large annual surgical volume. However, we could not observe a direct impact of hospital volume on outcomes for patients with apparent early stage disease.