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Processes of Care and the Impact of Surgical Volumes on Cancer-specific Survival: A Population-based Study in Bladder Cancer

Urology. 2014 Nov;84(5):1049-57.

Urology. 2014 Nov;84(5):1049-57.

Abstract

OBJECTIVE:

To describe the relationships between procedure volume and late survival after cystectomy for muscle-invasive bladder cancer (MIBC) and explore variables explaining any effect.

MATERIALS AND METHODS:

Electronic records of treatment and surgical pathology reports were linked to a population-based registry to identify patients who underwent cystectomy during 1994-2008 in Ontario, Canada. Explanatory variables included adjuvant chemotherapy, lymph node dissection (LND), and margin status. A Cox proportional hazards regression model was used to explore associations between volume and cancer-specific survival (CSS) as well as overall survival.

RESULTS:

The cohort included 2802 MIBC patients treated with cystectomy. High-volume hospitals were more likely to have used adjuvant chemotherapy (25% vs 18%; P <.001), more likely to have performed an LND (83% vs 53%; P <.001), and associated with a lower 90-day mortality (6% vs 10%; P = .032). Low-volume hospitals had a lower 5-year CSS rate of 32% (28%-36%) compared with those of high-volume centers at 38% (33%-42%). Individual surgeon volume was similarly associated with both early- and long-term outcomes. In multivariate analysis, both surgeon and hospital volumes were associated with CSS and overall survival. The surgeon volume effect on long-term outcomes was modestly modified by indicators of the quality of the LND, with little effect of the other explanatory variables.

CONCLUSION:

Higher provider volume is associated with higher CSS in patients with MIBC in the general population. The volume effect was modestly mediated by the quality of LND.

Copyright © 2014 Elsevier Inc. All rights reserved.

Comment from Maria Ribal: In a large single-centre series, early complications for radical cystectomy (within 3 months of surgery) were seen in 58% of patients. In general, lower morbidity and (perioperative) mortality have been observed by surgeons and in hospitals with a higher caseload and therefore more experience. In this paper Siemens et al. analysed the outcomes of radical cystectomy using a population-based registry in Ontario, Canada. High volume hospitals achieved a lower 90-day mortality and in multivariate analysis both surgeon and hospitals volume were related to better cancer specific and overall survival.

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