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Impact of Hospital Procedure Volume on Surgical Operation and Long-Term Outcomes in High-Risk Curatively Resected Rectal Cancer: Findings From the Intergroup 0114 Study

From the Department of Medical Oncology, Dana-Farber Cancer Institute; Division of General Medicine, Department of Medicine, Brigham and Women's Hospital; Department of Health Care Policy and Channing Laboratory, Harvard Medical School; Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA; Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill; Cancer and Leukemia Group B Statistical Center, Durham, NC; Departments of Epidemiology and Biostatistics, Department of Medicine, Health Outcomes Research Group, Memorial Sloan-Kettering Cancer Center; St. Vincent's Clinical Cancer Center, New York, NY; Allegheny Cancer Center, Allegheny General Hospital, Pittsburgh, PA; and Division of Hematology-Oncology, Northwestern University, Chicago, IL.

Address reprint requests to Jeffrey A. Meyerhardt, MD, Dana-Farber Cancer Institute, 44 Binney St, Boston, MA 02115; e-mail: jmeyerhardt{at}partners.org.

PURPOSE: Prior studies have demonstrated superior outcomes after a curative surgical resection of rectal cancer at hospitals where the volume of such surgeries is high. However, because these studies often lack detailed information on tumor and treatment characteristics as well as cancer recurrence, the true nature of this relation remains uncertain.

PATIENTS AND METHODS: We studied a nested cohort of 1,330 patients with stage II and stage III rectal cancer participating in a multicenter, adjuvant chemoradiotherapy trial. We analyzed differences in rates of sphincter-preserving operations, overall survival, and cancer recurrence by hospital surgical volume.

RESULTS: We observed a significant difference in the rates of abdominoperineal resections across tertiles of hospital procedure volume (46.3% for patients resected at low-volume, 41.3% at medium-volume, and 31.8% at high-volume hospitals; P < .0001), even after adjustment for tumor distance from the anal verge. However, this higher rate of sphincter-sparing operations at high-volume centers was not accompanied by any increase in recurrence rates. Hospital surgical volume did not predict overall, disease-free, recurrence-free, or local recurrence-free survival. However, among patients who did not complete the planned adjuvant chemoradiotherapy (270 patients), those who underwent surgery at low-volume hospitals had a significant increase in cancer recurrence (adjusted hazard ratio, 1.94; 95% CI, 1.01 to 3.72; P = .04 for the trend) and a nonsignificant trend toward increased overall mortality (P = .08) and local recurrence (P = .10). In contrast, no significant volume-outcome relation was noted among patients who did complete postoperative therapy.

CONCLUSION: Using prospectively recorded data, we found that hospital surgical volume had no significant effect on rectal cancer recurrence or survival when patients completed standard adjuvant therapy. Sphincter-preserving surgery was more commonly performed at high-volume centers.

The research for CALGB 9081 was supported, in part, by grants from the National Cancer Institute (CA31946) to the Cancer and Leukemia Group B (Richard L. Schilsky, MD, Chairman). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Cancer Institute. This study supported by NCI grant to J.A.M. (1K07CA97992-01A1) and an American Society of Clinical Oncology Career Development Award to J.A.M.

Authors' disclosures of potential conflicts of interest are found at the end of this article.

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