High-Volume Rectal Cancer Centers Save Lives

Viewpoints from Steven Wexner, MD

Patients may make decisions as to where to obtain healthcare based upon geographic convenience or anticipated outcomes.

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Ideally, these two variables might overlap, allowing the patient the convenience of treatment at a center near to their home at which optimal outcomes can be anticipated. However, not all patients with rectal cancer are fortunate enough to live near high-volume rectal cancer centers.

The variability and outcomes in rectal cancer care have been well established and repeatedly documented. The improvements in both short-term surrogate histopathologic and in long-term rates of recurrence and survival have been repeatedly proven throughout European and United Kingdom rectal cancer centers of excellence. (Wexner et. al., Berho et. al.)

After six years of work, the American College of Surgeons (ACS) Commission on Cancer (NAPRC) National Accreditation Program for Rectal Cancer (NAPRC) has launched. (Monson et. al., Wexner et. al., Wexner et. al.)

Although case volumes are not stipulated as an accreditation standard, high-volume rectal cancer hospitals might inherently be more interested in being accredited than might low-volume hospitals.

In an effort to determine whether or not higher-volume centers offer improved outcomes, a group led by senior author, Fergal Fleming, MBBCh, a member of the team who helped launch the NAPRC, evaluated 18,605 patients within the National Cancer Database (NCDB), a hospital-based registry sponsored by the ACS CoC and the American Cancer Society.

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They specifically assessed patients with stage II or III rectal cancer treated between 2006 and 2012. They used quartiles of < 4.6 to 10.6, 10.7 to 26.2, and > 26.2 linear distance miles between the patient’s residential zip code and the treating hospital address.

They classified rectal cancer volumes as the average number of proctectomies per institution during the seven-year period as either < 8, 8 to 15, 16 to 26, and > 26; combined quartiles were then defined.

Two thousand sixty-seven patients were in the long-distance, high- volume group and 1,367 in the short-distance, low-volume group.

When controlled for patient factor stage and hospital factors, the patients in the short-distance, low-volume group had a lower probability of ≥ 12 lymph nodes and appropriate receipt of neoadjuvant chemoradiation. Furthermore, these patients had a higher 30-day and 90-day mortality.

Conversely, patients who traveled a long distance to a high-volume center had better lymph node yield, higher compliance with neoadjuvant chemo radiation guidelines, lower 30- to 90-day mortality rates and improved five-year survival.

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The timing of this important article is impeccable as it highlights the importance of high-volume rectal cancer care in optimizing patient outcomes. Moreover, it helps show patients that traveling longer distances is very worthwhile, despite any geographic inconvenience.