Trends in survival after treatment for breast cancer at high-volume centers: An update from the National Cancer Database (2007-2017).

The volume-outcome relationship for surgical procedures is well established in the U.S. healthcare system. Studies of adult ulcerative colitis (UC) demonstrate that high volume centers consistently produce better surgical outcomes with fewer complications than low volume centers. Recently, published guidelines from the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) recommend that pediatric UC surgeries be completed at high volume centers performing ≥10 pediatric colorectal surgeries annually. We aimed to evaluate the annual pediatric UC colectomy volume in hospitals across the U.S. and explore volume trends over time in high volume centers. We performed a cross-sectional analysis of pediatric (≤18 years) UC hospitalizations using the Kids’ Inpatient Database (KID), a nationally representative pediatric database that allows for valid nationwide estimates of pediatric inpatient hospitalization data. The KID includes approximately 7 million unique hospitalizations from up to 4,200 U.S. hospitals annually. We identified pediatric hospitalizations with a primary UC (International Classification of Diseases, Ninth Revision (ICD-9): 556.X) diagnosis and procedural code for total abdominal colectomy (TAC) (ICD-9: 45.8X) on a triennial basis between 1997 and 2012. We identified unique hospitals on an annual basis using a hospital ID-year combination. We defined high volume centers as performing ≥10 pediatric UC colectomies annually in accordance with ESPGHAN guidelines. A total of 517 unique hospital-year combinations accounted for 945 colectomies from 1997 to 2012. Weighted, this accounted for an estimated 1,610 pediatric UC colectomies (mean 268 colectomies per year). For hospitals performing 1 or more colectomies per year, the median annual hospital colectomy volume was 2 (IQR = 1,4). Less than 20% of colectomies were performed at high volume centers while 26.5% of colectomies occurred at centers performing ≤2 colectomies per year. High volume centers were more likely to be located in the Northeast and Midwest as compared to the South or West (p<0.01). No other patient or hospital characteristics were associated with having surgery at a high or low volume center (Table 1). Over the 15-year study period, there was a trend towards fewer colectomies being performed at high volume centers, though this trend appears to be reversing in more recent years (Figure 1). An alarmingly low proportion of colectomies in children with UC are performed at high volume centers. Hence the surgical care delivered to the vast majority of pediatric UC patients in the U.S. is not consistent with current guidelines. National efforts to re-direct care to high volume centers of excellence may lead to improved outcomes for pediatric UC patients. aLow Volume: < 10 colectomies annually; High volume: ≥ 10 colectomies annually. bRaw data is taken from the actual database. National Estimate reflects KID weighting of raw data to produce a national estimate. cData missing from 2012. Figure 1: Annual percentage estimates and standard errors of colectomies at high volume centers in the 1997-2012 KID database. Smoothing line demonstrates a decreasing proportion of colectomies in pediatric UC hospitalizations occurring at high volume centers over the 15-year study period with a modest increase in recent years.

P102 LOW PROPORTION OF TOTAL ABDOMINAL COLECTOMIES IN PEDIATRIC ULCERATIVE COLITIS OCCUR AT HIGH VOLUME CENTERS IN THE U.S.

Regionalization for thoracic surgery: Economic implications of regionalization in the United States

Background: US Hispanic patients tend to have lower incidence and mortality among many cancers, yet these aggregated data do not reflect cultural and ancestral diversity of Hispanic patients. For example, we previously reported that Dominican pancreatic cancer patients had improved survival compared to other Hispanic groups. We sought to characterize survival differences among disaggregated Hispanic ethnic groups with the deadliest cancers in the US. Methods: Breast, prostate, lung, liver, pancreas, colon, rectosigmoid, and rectal cancer cases among Non-Hispanic White (NHW), Mexican, Puerto Rican, Cuban, South/Central American, Dominican or “Hispanic Not Otherwise Specified” were extracted from the National Cancer Database (2010-2015). Analysis was restricted to patients with only one primary cancer diagnosis and the most prevalent histologies. Restricted mean survival times were determined. Survival across groups was compared using Cox proportional hazard models. Multivariable analysis included socioeconomic, pathologic, comorbidity, and treatment factors. Results: Across all cancers, Hispanic patients [54.7 months (95% CI: 54.0-55.4)] had significantly longer survival compared to NHW patients [50.5 months (95% CI: 50.5-51.0)], with Dominican patients having the longest survival [65.5 months (95% CI: 60.5-70.5)]. On univariable analysis, Dominican patients had lower risk of death across all cancers compared to NHW (HR 0.56, p&amp;lt;0.0001). When similarly analyzed by individual cancer type, Dominican patients had the lowest risk of death among each cancer except lung squamous cell carcinoma (SCC). On multivariable analysis, hazard of death was even lower for Dominican patients (HR 0.48, p&amp;lt;0.0001) compared to NHW patients across all cancer types. After adjusting for covariates, similar trends persisted for Dominican patients across all cancer types: breast (HR 0.46, p&amp;lt;0.0001), prostate (HR 0.42, p&amp;lt;0.0001), pancreatic adenocarcinoma (HR 0.49, p&amp;lt;0.0001), hepatocellular carcinoma (HR 0.54, p&amp;lt;0.0001), lung adenocarcinoma (HR 0.45, p&amp;lt;0.0001), lung SCC (HR 0.67, p=0.008), colon (HR 0.62, p=0.0004), rectosigmoid (HR 0.39, p=0.023), and rectal adenocarcinomas (HR 0.46, p=0.005). Lung SCC was the only cancer that Dominican patients trailed another group in lowest hazard of death (Cuban patients’ HR 0.64). Conclusion: Patients of Dominican descent experience improved survival compared to NHW and other Hispanic ethnic groups across nearly all common cancer types, regardless of socioeconomic factors, cancer stage and pathology, and treatment. Genomic diversity and cultural factors may influence differential survival among Hispanic groups. It is critical to accurately record data on disaggregated Hispanic ethnicity and to promote inclusion of a diverse patients in cancer research. This may in turn elucidate differences in carcinogenesis and treatment response. Citation Format: Andrea N. Riner, Kelly M. Herremans, Daniel Neal, Jose G. Trevino. Common themes for common cancers - trends in survival by disaggregated Hispanic ethnicity [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 35.

Shortening hospital length of stay after lobectomy for stage I non-small-cell lung cancer (NSCLC) remains a challenge, and the literature regarding factors associated with safe early discharge is limited. We sought to evaluate the safety of postoperative day (POD) 1 discharge after lobectomy and its correlation with institutional caseload using the National Cancer Database, jointly sponsored by the American College of Surgeons and the American Cancer Society. We identified patients with stage I NSCLC (tumour ≤4 cm, clinical N0, M0) in the National Cancer Database who underwent lobectomy from 2010 to 2015. Hospital surgical volume was assigned based on total surgical volume for lung cancer. The cohort was divided into 2 groups: POD 1 discharge [length of stay (LOS) ≤ 1] and the standard discharge (LOS > 1). Outcome variables were compared in propensity matched cohorts, and the multivariable regression model was created to assess factors associated with LOS ≤ 1 and the occurrence of adverse events (unplanned readmissions, 30- and 90-day deaths). A total of 52830 patients underwent lobectomy for stage I NSCLC across 1231 treating facilities; 3879 (7.3%) patients were discharged on day 1 (LOS ≤ 1), whereas 48951 (92.7%) were discharged after day 1 (LOS > 1). Factors associated with LOS ≤ 1 included male sex, higher socioeconomic status, right middle lobectomy, minimally invasive surgery and high-volume centres. The risk of adverse events was higher for LOS ≤ 1 in low [odds ratio (OR): 1.913, 95% confidence interval (CI) 1.448-2.527; P < 0.001] and median quartiles (OR: 2.258; 95% CI 1.881-2.711; P < 0.001), but equivalent in high-volume centres (OR: 0.871, 95% CI 0.556-1.364; P = 0.54). The safety and efficacy of early discharge on POD 1 following lobectomy are associated with lung cancer surgical volume. Implementation of 'enhanced recovery' protocols is likely related to safe early discharges from high-volume centres.

The following highlights summarize the principle findings of the NCDB, which are presented in more detail in other reports, some of which have been published and others of which are in press or submitted awaiting review. Collectively, these findings present a broad pattern of NCDB assessment of cancer patterns of care. In addition to the resulting journal publications, 1,600 NCDB participating hospitals receive a customized summary of similar patterns of care and outcome at their facility compared with national norms, which is then used for quality assurance purposes.

PurposeIn pancreatic surgery, a relation between surgical volume and postoperative mortality and overall survival (OS) has been recognized, with high-volume centers reporting significantly better survival rates. We aimed to explore the influence of hospital volume on administration of palliative chemotherapy and OS in the Netherlands.MethodsPatients diagnosed between 2007 and 2011 with metastatic pancreatic cancer were identified in the Netherlands Cancer Registry. Three types of high-volume centers were defined: high-volume (1) incidence center, based on the number of patients diagnosed with metastatic pancreatic cancer, (2) treatment center based on number of patients with metastatic pancreatic cancer who started treatment with palliative chemotherapy and (3) surgical center based on the number of resections with curative intent for pancreatic cancer. Independent predictors of administration of palliative chemotherapy were evaluated by means of logistic regression analysis. The multivariable Cox proportional hazard model was used to assess the impact of being diagnosed or treated in high-volume centers on survival.ResultsA total of 5385 patients presented with metastatic pancreatic cancer of which 24 % received palliative chemotherapy. Being treated with chemotherapy in a high-volume chemotherapy treatment center was associated with improved survival (HR 0.76, 95 % CI 0.67–0.87). Also, in all patients with metastatic pancreatic cancer, being diagnosed in a high-volume surgical center was associated with improved survival (HR 0.74, 95 % CI 0.66–0.83).ConclusionsHospital volume of palliative chemotherapy for metastatic pancreatic cancer was associated with improved survival, demonstrating that a volume–outcome relationship, as described for pancreatic surgery, may also exist for pancreatic medical oncology.Electronic supplementary materialThe online version of this article (doi:10.1007/s00432-016-2140-5) contains supplementary material, which is available to authorized users.

457 Background: The impact of hospital volume on the outcomes of cancer surgery has been well established. The present studies investigates how race/ethnicity influences the utilization of high-volume centers for hepatobiliary and pancreatic surgery. Methods: Patients that underwent surgery for hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (ICC), extrahepatic cholangiocarcinoma (ECC), ampullary adenocarcinoma (AC), or pancreatic ductal adenocarcinoma (PDAC) between 2006 and 2015 were identified from the National Cancer Data Base. Hospitals were divided into low- and high-volume centers based on the medium number of cancer surgeries per year. Multivariable logistic regression analyses predicting receipt of care at a low-volume center based on age, sex, race/ethnicity, comorbidities, insurance, income, travel distance, geographic location, urban/metro location, and tumor stage were performed. All analyses were performed separately by tumor type. Results: 8,962 patients with HCC, 2,119 with ICC, 3,973 with ECC, 5,125 with AC, and 25,231 with PDAC were identified. Non-Hispanic black patients were more likely to undergo resection for AC (vs. non-Hispanic white: AOR, 1.326; p = 0.0125) or PDAC (vs. non-Hispanic white: AOR, 1.187; p = 0.0002) at a low volume centers. Hispanic patients more often underwent surgery for ECC (vs. non-Hispanic white: AOR, 1.731; p &lt; 0.0001) or PDAC (vs. non-Hispanic white: 2.030; p &lt; 0.0001) cancer at a low-volume center. Patients of Asian descent were significantly less often treated for HCC at a low volume center (vs. non-Hispanic white: AOR, 0.644; p &lt; 0.0001) compared to non-Hispanic whites. Non-Hispanic black, Hispanic, or Asian race/ethnicity did not impact the likelihood of receiving care at a low volume center for any other tumor types. Conclusions: The results of this study suggest that race/ethnicity influences the likelihood of receiving care at a high-volume cancer center, even after controlling for other barriers to access to care, including insurance status, income and travel distance.

The aim of this study was to investigate the volume-outcome relationship in kidney transplantation by examining graft and patient outcomes using standardized risk adjustment (observed-to-expected outcomes). A secondary objective was to examine the geographic proximity of low, medium, and high-volume kidney transplant centers in the United States. The significant survival benefit of kidney transplantation in the context of a severe shortage of donor organs mandates strategies to optimize outcomes. Unlike for other solid organ transplants, the relationship between surgical volume and kidney transplant outcomes has not been clearly established. The Scientific Registry of Transplant Recipients was used to examine national outcomes for adults undergoing deceased donor kidney transplantation from January 1, 1999 to December 31, 2013 (15-year study period). Observed-to-expected rates of graft loss and patient death were compared for low, medium, and high-volume centers. The geographic proximity of low-volume centers to higher volume centers was determined to assess the impact of regionalization on patient travel burden. A total of 206,179 procedures were analyzed. Compared with low-volume centers, high-volume centers had significantly lower observed-to-expected rates of 1-month graft loss (0.93 vs 1.18, P<0.001), 1-year graft loss (0.97 vs 1.12, P<0.001), 1-month patient death (0.90 vs 1.29, P=0.005), and 1-year patient death (0.95 vs 1.15, P=0.001). Low-volume centers were frequently in close proximity to higher volume centers, with a median distance of 7 miles (interquartile range: 2 to 75). A robust volume-outcome relationship was observed for deceased donor kidney transplantation, and low-volume centers are frequently in close proximity to higher volume centers. Increased regionalization could improve outcomes, but should be considered carefully in light of the potential negative impact on transplant volume and access to care.

e18556 Background: Considerable efforts to improve disparities in breast cancer outcomes for underserved women have occurred over the past 3 decades. This study was conducted to evaluate trends in survival, by race-ethnicity, for women diagnosed with breast cancer in Florida over a 26-year period to assess potential improvement in racial-ethnic disparities. Methods: This was a retrospective cohort study of women diagnosed with invasive breast cancer in Florida between 1990-2015. Data were obtained from the Florida Cancer Data System. Women in the study were categorized according to race (white/black) and Hispanic ethnicity (yes/no) as non-Hispanic white (NHW), non-Hispanic black (NHB), Hispanic white (HW), and Hispanic black (HB). Cumulative incidence estimates of 5- and 10-year breast cancer death with 95% confidence intervals (CI) were obtained by race-ethnicity, according to diagnosis year. Subdistribution hazard models were used to obtain subdistribution hazard ratios (sHR) for the relative rate of breast cancer death accounting for competing causes. Results: Compared to NHW women, minority women were more likely to be younger, be uninsured or have Medicaid as health insurance, live in high poverty neighborhoods, have more advanced disease at diagnosis, have high grade tumors, have hormone receptor negative tumors, and receive chemotherapy as treatment. Minority women were less likely to receive surgery. Over the course of the study, breast cancer mortality decreased for all racial-ethnic groups, and racial-ethnic minorities had greater absolute and relative improvement in breast cancer survival for nearly all metrics compared to non-Hispanic white (NHW) women. However, for the most recent time period (2010-2015), black women still experienced significant survival disparities with non-Hispanic black (NHB) women having twice the rate of 5-year (sHR = 2.04: 95% CI; 1.91-2.19) and 10-year (sHR = 2.02: 95% CI; 1.89-2.16) breast cancer death. Conclusions: Despite efforts to improve disparities in breast cancer outcomes for underserved women in Florida, additional targeted approaches are needed to reduce the poorer survival in black (especially NHB) women. Our next step is to conduct a mediation analysis of the most important factors driving racial/ethnic disparities in breast cancer outcomes for women in Florida.

OBJECTIVE Treatment of cerebrovascular malformations has grown in complexity with the development of multimodal approaches, including microsurgery, endovascular treatments, and radiosurgery. In spite of this changing standard of care, the provision of care continues across a variety of settings. The authors sought to determine the risk of adverse outcome after treatment of patients with vascular malformations in the US. Patient, surgeon, and hospital characteristics, including volume, were tested as potential outcome predictors. METHODS The authors examined data collected between 2000 and 2009 in the Nationwide Inpatient Sample (NIS) database, assessing safety, quality, and cost-effectiveness. They performed multivariate analyses of trends in microsurgical, radiosurgical, and endovascular treatment by hospital and surgeon volume, using death, routine discharge percentage, length of stay (LOS), complications, and hospital charges as end points. They further computed the value of care, which was defined as the ratio of the functional outcome (routine discharge percentage) to cost of care to the payer (hospital charges). RESULTS The authors identified 8227 patients with vascular malformations who were treated at US hospitals. Hospitals and surgeons were classified by yearly case volume. Compared with low-volume hospitals (2 or fewer cases/year), high-volume hospitals (16 or more cases/year) had shorter LOS (3 vs 2 days, p = 0.005), higher total charges ($37,374 vs $19,986, p = 0.003), more frequent discharge to home (p < 0.001), and lower mortality rates (0.7% vs 1.16%, p = 0.010). High-volume surgeons (7 or more cases/year) likewise had superior outcomes compared with low-volume surgeons (1 or fewer cases/year), with shorter LOS (2 vs 3 days, p = 0.03), more frequent discharge to home (p < 0.001), and lower mortality rates (0.7% vs 1.10%, p = 0.005). Underlying these outcomes, the rates of intervention for surgery, angiography, embolization, and radiosurgery were likewise significantly different in high- versus low-volume practices. Based on these results the authors modeled how outcomes might change if care were consolidated at designated centers of excellence (COEs), and found that on an annual basis, care at high-volume hospital COEs would result in 18.5 fewer deaths, 1252.1 fewer hospital days, 182.7 more discharges home without additional services, 48.5 fewer medical complications, and 117.4 fewer perioperative complications. Surgeon-level rates for high-volume COEs demonstrated an even larger benefit over current standards, with 27.4 fewer deaths, 10,713.7 fewer hospital days, a $51.6-million reduction in charges, 370.9 additional routine discharges, and reduced complications in all categories (27.8 fewer surgical, 198.0 fewer medical, and 32.1 fewer perioperative) compared with care at non-COEs. CONCLUSIONS For patients with vascular malformations who were treated in the US between 2000 and 2009, treatment performed at high-volume centers was associated with significantly lower morbidity and, for high-volume surgeons, with lower mortality rates. These data suggest that treatment by high-volume institutions and surgeons will yield superior outcomes and superior value. The authors therefore advocate the creation of care paradigms that triage patients to high-volume institutions and surgeons, which can serve as cerebrovascular COEs.

The aim of this study was to determine whether hospital volume was associated with mortality in breast cancer, and what thresholds of case volume impacted survival. Prior literature has demonstrated improved survival with treatment at high volume centers among less common cancers requiring technically complex surgery. All adults (18 to 90 years) with stages 0-III unilateral breast cancer diagnosed from 2004 to 2012 were identified from the American College of Surgeons National Cancer Data Base (NCDB). A multivariable Cox proportional hazards model with restricted cubic splines was used to examine the association of annual hospital volume and overall survival, after adjusting for measured covariates. Intergroup comparisons of patient and treatment characteristics were conducted with X and analysis of variance (ANOVA). The log-rank test was used to test survival differences between groups. A multivariable Cox proportional hazards model was used to estimate hazard ratios (HRs) associated with each volume group. One million sixty-four thousand two hundred and fifty-one patients met inclusion criteria. The median age of the sample was 60 (interquartile range 50 to 70). Hospitals were categorized into 3 groups using restricted cubic spline analysis: low-volume (<148 cases/year), moderate-volume (148 to 298 cases/year), and high-volume (>298 cases/year). Treatment at high volume centers was associated with an 11% reduction in overall mortality for all patients (HR 0.89); those with stage 0-I, ER+/PR+ or ER+/PR- breast cancers derived the greatest benefit. Treatment at high volume centers is associated with improved survival for breast cancer patients regardless of stage. High case volume could serve as a proxy for the institutional infrastructure required to deliver complex multidisciplinary breast cancer treatment.

How high is a high-volume pancreatic surgery centre?

For many cancer types, survival is improved when patients receive management at treatment centers that encounter high numbers of patients annually. This correlation may be more important with less common malignancies such as sarcoma. Existing evidence, however, is limited and inconclusive as to whether facility volume may be associated with survival in soft tissue sarcoma. The purpose of this study was to examine the association between facility volume and overall survival in patients with soft tissue sarcoma of the extremities. In investigating this aim, we sought to (1) examine differences in the treatment characteristics of high- and low-volume facilities; (2) estimate the 5-year survival by facility volume; and (3) examine the association between facility volume and of traveling a further distance to a high-volume center and overall survival when controlling for confounding factors. The largest sarcoma patient registry to date is contained within the National Cancer Database (NCDB) and captures > 70% of new cancer diagnoses annually. We retrospectively analyzed 25,406 patients with soft tissue sarcoma of the extremities in the NCDB from 1998 through 2012. Patients were stratified based on per-year facility sarcoma volume and we used univariate comparisons and multivariate proportional hazards analyses to correlate survival measures with facility volume and various other patient-, tumor-, and treatment-related factors. First, we evaluated long-term survival for all variables using the Kaplan-Meier method with statistical comparisons based on the log-rank test. Multiple patient, tumor, and treatment characteristics were compared between the two facility-volume groups and then included them in the multivariate proportional hazards model. Of the 25,406 patients analyzed, 3310 were treated at high-volume centers (≥ 20 patients annually) and 22,096 were treated at low-volume centers. Patient demographics were generally not different between both patient cohorts, although patients treated at high-volume centers were more likely to have larger and higher grade tumors (64% versus 56% size ≥ 5 cm, 28% versus 14% undifferentiated grade, p < 0.001). When controlling for patient, tumor, and treatment characteristics in a multivariate proportional hazards analysis, patients treated at high-volume facilities had an overall lower risk of mortality than those treated at low-volume centers (hazard ratio, 0.81 [0.75-0.88], p < 0.001). Patients treated at high-volume centers were also less likely to have positive margins (odds ratio [OR], 0.59 [0.52-0.68], p < 0.001) and in patients who received radiation, those treated at high-volume centers were more likely to have radiation before surgery (40.5% versus 21.7%, p < 0.001); there was no difference in the type of surgery performed (resection versus amputation) (OR, 1.01 [0.84-1.23], p = 0.883). With the largest patient cohort to date, this database review suggests that certain patients with soft tissue sarcoma of the extremities, particularly those with large high-grade tumors, may benefit from treatment at high-volume centers. Further investigation is necessary to help improve the referral of appropriate patients to high-volume sarcoma centers and to increase the treatment capacity of and access to such centers. Level III, therapeutic study.

Breast cancer, menopause, and long-term survivorship: critical issues for the 21st century