cornelis j.h. van de velde, md, phd,frcps(hon)facs(hon) professor of surgery
DESCRIPTION
How important is experience/volume in gastric cancer surgery?. Cornelis J.H. van de Velde, MD, PhD,FRCPS(hon)FACS(hon) Professor of Surgery President ECCO - the European Cancer Organization Past-President European Society of Surgical Oncology Leiden University Medical Center - PowerPoint PPT PresentationTRANSCRIPT
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Cornelis J.H. van de Velde, MD, PhD,FRCPS(hon)FACS(hon)Professor of SurgeryPresident ECCO - the European Cancer OrganizationPast-President European Society of Surgical OncologyLeiden University Medical CenterLeiden, The Netherlands
How important is experience/volume in gastric cancer surgery?
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Pean and Billroth
Surgery for gastric cancerSurgery for gastric cancer
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Importance of training and team effort
• Surgical oncology is top-class sport
• Training and (multidisciplinary) team effort essential
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Japanese vs Intergroup 0116 study
Japanese studyIntergroup 0116 study
red line: 60% survival, surgery only in Japanese trial
MacDonald, NEJM 2001, Sakuramoto, NEJM 2007MacDonald, NEJM 2001, Sakuramoto, NEJM 2007
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Dutch Gastric Cancer Trial
Hospital volumes
• 711 gastrectomies, 80 participating hospitals
• Average of 2.2 gastrectomies/hospital/year
(registered in study)
Quality Assurance
• Instruction in operating room by Japanese surgeon
• ‘Supervising surgeons’ present with every D2 gastrectomy
• Book and video
• Teaching meetings for surgeons
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Dutch Gastric Cancer Trial – 15-year follow-up
711 Patients with curative resection711 Patients with curative resection
Death of Gastric CancerD1: 48% D2: 37%P=0.01
Death of Other CausesHR=1.22P=NS
Songun, vd Velde et al, Lancet Oncology 2010
ConclusionConclusionD2 dissection should be D2 dissection should be
recommended as standard recommended as standard surgical approach in resectable surgical approach in resectable
gastric cancergastric cancer
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Conclusion on surgery
• D2 dissection should be recommended
• No splenectomy or pancreatectomy
• In experienced(High volume) centers
• PAND does not improve survival any further
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The effect of improvement of surgical quality over the introduction of The effect of improvement of surgical quality over the introduction of adjuvant therapyadjuvant therapy
After Dutch D1-D2 trial
During Dutch D1-D2 trial
Before Dutch D1-D2 trial
Perioperative chemotherapy
Surgery Alone
Krijnen et al., EJSO 2009Krijnen et al., EJSO 2009
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Trials vs nationwide improvements
• Trials → improve outcomes by
• Providing better treatment options
• Training surgeons
• Most patients treated outside trials
• → analyze outcomes on nationwide level
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2 Ways to improve surgical outcomes
Direct patients to the best places (“Centers of
Excellence”)
Improve care by everyone (“Quality improvement”)
Off-the-shelf process improvement
Outcomes-based quality improvement
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Survival in the Netherlands compared to Europe
EUROCARE-4
5-Year relative survival
Europe: 24.5%
Netherlands: 18.1%
Are we doing
something wrong?
Sant et al, Eur J Cancer 2009Sant et al, Eur J Cancer 2009
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Centralization in the Netherlands
Esophagectomy Gastrectomy
RED = High-volume surgery (>20/year)
• Esophagectomy: centralization effect
• Gastrectomy: decreasing number, no centralization
Dikken, vd Velde et al, EJC 2012Dikken, vd Velde et al, EJC 2012
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Outcomes esophagectomy vs gastrectomy
• 6-Month mortality:
• Gastrectomy → non-significant decrease
• Esophagectomy → significant decrease
• 3-Year survival:
• Gastrectomy → no improvement
• Esophagectomy → catch-up with gastric cancer
Dikken, vd Velde et al, EJC 2012Dikken, vd Velde et al, EJC 2012
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30-Day mortality in the Netherlands
Blue: esophagectomy ~ 4%
Green: gastrectomy ~ 8%
Higher mortality after gastrectomy for past 5 years
Dikken, vd Velde et al, EJC 2012Dikken, vd Velde et al, EJC 2012
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Conclusion
• Urgent need for improvement of gastric cancer care in the
Netherlands
• Centralization
• Auditing
• Use of multi-modality treatment
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Centralization: volume-outcome relation US
Birkmeyer et al, NEJM 2002Birkmeyer et al, NEJM 2002
“Patients can often improve their chances of survival
substantially, even at high volume hospitals, by selecting
surgeons who perform the operations frequently”
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Centralization: volume-outcome relation US
Finks et al, NEJM 2012Finks et al, NEJM 2012
• 10 years after initial US paper
• Decrease in postoperative mortality
• Esophagectomy: completely due to centralization
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Centralization in Denmark
Jensen et al, ejso2010Jensen et al, ejso2010
Study period 1999-2003 2003-2008
No. of departments 37 5
No. of operations 537 416
Anastomotic leakages (%) 6.1 5.0
Hospital mortality (%) 8.2 2.4
2003- Gastric cancer surgery restricted to 5 hospitals- Introduction national clinical guidelines- Introduction nationwide database
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Centralization in Denmark
Jensen et al, EJSO 2010Jensen et al, EJSO 2010
Cases with at leastCases with at least15 lymph nodes 15 lymph nodes removedremoved
2003: 19%2003: 19%
2008: 67%2008: 67%
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Literature on GastrectomiesNumber of patients in volume-outcome studies
• Smaller studies: often no volume-outcome effect
• Larger studies: volume-outcome effect
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Literature on Gastrectomies Definition of ‘high volume’ in positive studies
• Definition of ‘high volume’ in most studies ~20/year
• But studies with higher volumes
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Centralization: type of referral
Should centralization only be based on case
volume?
Volume-based vs. Outcome-based referral
Gruen et al, CA Cancer J Clin 2009Gruen et al, CA Cancer J Clin 2009
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Outcome-based centralization in West-Netherlands
Surgical audit for Esophagectomies
-11 low volume hospitals
-10 years of retrospective data (1990-1999)
-INTERVENTION in 2000
-Concentration of procedures in 3 hospitals with the best performance
Wouters et al, J Surg Oncol 2009Wouters et al, J Surg Oncol 2009
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Improvement after outcome-based centralization
1990-1994 1995-1999 2000-2005 N (%) N (%) N (%) P value
Margins R0 R1 R2 unknown
107 (69.5) 34 (22.1) 10 (6.5) 3 (1.9)
140 (74.9)
21 (11.2) 25 (13.4) 1 (0.5)
201 (75.8) 44 (16.6) 13 (4.9) 7 (2.6)
0.003
Surg. Complications no yes unknown
83 (53.9) 66 (42.9) 5 (3.2)
108 (57.8) 77 (41.2) 2 (1.1)
148 (55.8) 111 (41.9) 6 (2.3)
0.70
Hospital stay (days)
<0.001
median 20 21 17 (p25 – p75) (9-92) (9-125) (8-273) In hospital mortality
22 (14.3)
23 (12.3)
11 (4.2)
<0.001
Total no. of patients
154
187
265
J Surg Oncol 2009J Surg Oncol 2009
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Effects on survival
Significant improvement in survival after esophagectomy
J Surg Oncol 2009J Surg Oncol 2009
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Comparison with rest of the Netherlands
0
5
10
15
20
1990-1994 1995-1999 2000-2004
nation-wideIKW-region
hospital mortality
W W
W
J Surg Oncol 2009J Surg Oncol 2009
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Conclusion
Outcome-based referral provides a method for
centralization
by selecting
hospitals with the best outcomes
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Auditing
• Definition
• “providers of care are monitored and their performance is benchmarked against their peers”
• Surgical Hawthorne effect
• Gastric cancer audits currently performed in several European Countries
• United Kingdom
• Denmark
• Sweden
• Netherlands
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Effect of auditing
Knowledge transfer
Feedback
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Great Britain
National OesophagoGastric Cancer Audit
www.augis.orgwww.augis.org
- Patient characteristics
- Preoperative staging
- Treatment modalities
- Surgery
- Multi-modality
- Outcomes
- Complications/mortality
- Survival
- Quality of Life
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Analyzing risk-adjusted outcomes on hospital level
www.augis.orgwww.augis.org
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Netherlands
• Started as of 2011:minimal 40 procedures in 2012
• Covering all esophagectomies and gastrectomies in the
Netherlands
• Collaboration with Colorectal Audit, Breast Audit
www.clinicalaudit.nlwww.clinicalaudit.nl
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International comparison
• Compare national audits and cancer registries
• Esophageal and gastric resections 2004-2009• Netherlands: N = 5,791
• Sweden: N = 653 (part of Sweden)
• Denmark: N = 1,420
• England: N = 12,000
• Goals• Compare differences between countries
• Analyse possible volume-outcome relation
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Differences in 30-day mortality between countries
Esophagectomies Gastrectomies
Significant differences between countries
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Differences in annual hospital volumes
• Large differences in annual hospital volumes
• Denmark: centralization of esophagectomies and gastrectomies
Esophagectomies Gastrectomies
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Effect of hospital volume on 30-day mortality
Esophagectomies Gastrectomies
Lower 30-day mortality with increasing hospital volume
• Esophagectomies: up to >40/jaar
• Gastrectomies: up to >20/jaar
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Conclusions
• Participating countries:
• Considerable variation in hospital volumes and 30-day
mortality
• Significant relation between volume and 30-day mortality
• But not the only explanation for differences between countries
• Limitations of this pilot study:
• Differences between used datasets
• Comorbidity, TNM stage, multimodality therapy
• Need for a uniform European Upper GI Cancer Registry
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Possible purposes Data required
Compare outcomes after surgery Type of surgery, case-mix (comorbidity), complications, short-term mortality
Compare resection rates All patients with a diagnosis of oesophagogastric cancer, type of surgery
Compare patterns of care Type of surgery, chemotherapy, radiotherapy, etc.
Compare long term outcomes Follow-up data, TNM stage
European Upper GI Registry(ESSO initiative ,chair : W Allum)
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Quality Assurance Project: an ESSO initiative
One European Cancer Audit
Quality Variation
Identify and spread Best Practice Research Outcome monitoring (feedback) Guidelines Development
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Feedback by auditing
•Casemix adjusted
•Tools to improve
•Identify best practice
•Only feedback to participating registration
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European Audit on Cancer Treatment European Audit on Cancer Treatment OutcomeOutcome
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Levels of evidence
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Conclusion
•Nationwide improvements require
nationwide interventions
•Centralization
•Auditing
‘The best care, for every cancer patient’