Centralization of Esophagectomy: How Far Should We Go?

Background

This study was designed to define a statistically sound and clinically meaningful cutoff point for annual hospital volume for esophagectomy. Higher hospital volumes are associated with improved outcomes after esophagectomy. However, reported optimal volumes in literature vary, and minimal volume standards in different countries show considerable variation. So far, there has been no research on the noncategorical, nonlinear, volume-outcome relationship in esophagectomy.

Methods

Data were derived from the Netherlands Cancer Registry. Restricted cubic splines were used to investigate the nonlinear effects of annual hospital volume on 6 month and 2 year mortality rates. Outcomes were adjusted for year of diagnosis, case-mix, and (neo)adjuvant treatment.

Results

Between 1989 and 2009, 10,025 patients underwent esophagectomy for cancer in the Netherlands. Annual hospital volumes varied between 1 and 83 year, increasing over time. Increasing annual hospital volume showed a continuous, nonlinear decrease in hazard ratio (HR) for mortality along the curve. Increasing hospital volume from 20 year (baseline, HR = 1.00) to 40 and 60 year was associated with decreasing 6 month mortality, with a HR of 0.73 (95 % confidence interval (0.65–0.83) and 0.67 (0.58–0.77) respectively. Beyond 60 year, no further decrease was detected. Higher hospital volume also was associated with decreasing 2 year mortality until 50 esophagectomies year with a HR of 0.86 (0.79–0.93).

Conclusions

Centralization of esophagectomy to a minimum of 20 resections/year has been effectively introduced in the Netherlands. Increasing annual hospital volume was associated with a nonlinear decrease in mortality up to 40–60 esophagectomies/year, after which a plateau was reached. This finding may guide quality improvement efforts worldwide.     

How Should We Treat Patients with Locally Advanced Prostate Cancer?

Men with locally advanced prostate cancer are generally offered active treatment (radiotherapy or hormone therapy alone or in combination) with the aim of extending progression-free and overall survival. There is now good evidence from recent studies to suggest that patients who are treated with radiotherapy benefit from the addition of neoadjuvant or adjuvant hormone therapy. However, the extent of the contribution of radiotherapy in patients receiving hormone therapy is unclear, as the trials evaluating this combination approach did not include a hormone therapy only arm. Two ongoing trials, an International Intergroup study involving the National Cancer Institute of Canada (NCIC), the Medical Research Council (MRC), and the National Cancer Institute (NCI) in the United States, and a Scandinavian Prostate Cancer Group (SPCG) trial, are addressing this issue. Results should be available in the latter part of the decade. The optimum nature and schedule of hormone therapy are also unresolved. When hormone therapy is used to treat locally advanced disease, either as adjuvant therapy or immediate monotherapy, patients have traditionally undergone medical (e.g. goserelin [‘Zoladex’¹]) or surgical castration. However, bicalutamide (‘Casodex’¹) 150 mg monotherapy may offer important benefits over castration with respect to quality of life, particularly the maintenance of physical capacity and sexual interest, as well as preservation of bone mineral density and muscle mass, while achieving a similar survival outcome. Nonetheless, the benefits of bicalutamide 150 mg monotherapy must be balanced against the risk of developing gynecomastia and/or breast pain. Patients presenting with locally advanced prostate cancer should be given a clear explanation on all available treatment options and allowed to make an informed choice.     

Should We Deny Surgery for Malignant Hepato-Pancreatico-Biliary Tumors to Elderly Patients?

Malignant hepato-pancreatico-biliary (HPB) tumors have their highest incidence within the sixth to eighth decades of life. The aging of the world population has resulted in a dramatic increase in the number of elderly patients considered for resection of malignant HPB tumors. Because elderly patients are more likely to have more co-morbidities, cognitive impairment, and decreased life expectancy, the benefit and appropriateness of these procedures must be scrutinized for geriatric patients. Therefore, many surgeons have compared the perioperative and long-term outcome of hepatic and pancreatic resections for elderly and younger patients. In most series the elderly population was defined by an age of 70 years or older. The results demonstrate that hepatic resection for hepatocellular carcinoma and colorectal liver metastases can be safely performed in well-selected elderly patients with long-term outcome comparable to younger patients. Similar findings are also reported for pancreatic resection in elderly patients with either ampullary or pancreatic cancer. Although the survival benefit of pancreatico-duodenectomy is limited in all age groups, the absence of competitive therapy justifies this procedure as the sole curative option in younger as well as older patients. Data on resection of gallbladder cancer and hilar bile duct cancer in the elderly are sparse, but there is evidence from large series on resection of these types of tumors that advanced age per se is not a risk factor for reduced outcome. Therefore, surgical options should not be denied to elderly patients with a malignant HPB tumor, and the evaluation should include surgeons expert in HPB surgery.     

How Can We Improve the Quality of Life of Dialysis Patients?

As medical advances are made in the care of persons with chronic illnesses including those with end‐stage renal disease (ESRD), patients are not only experiencing increasing life expectancy but also bearing the burden of illness and treatment for a longer duration of time. With this in mind, it is increasingly important for health care providers to pay close attention to their individual patient's perceptions of their health, fitness, life satisfaction, and well‐being. This assessment of Health‐Related Quality of Life (HRQOL) also includes an evaluation of the patient's level of satisfaction with treatment, outcome, and health status, also taking into account their perspective on future prospects. In addition to improving patient–provider communication by helping in the identification and prioritization of problems, it is important to note that high HRQOL has been shown to be associated with better medical outcomes, including reduction in hospitalizations and death. In this review, we outline several validated tools that are used to quantitatively measure HRQOL in the ESRD population and incorporate these instruments in a review of specific, evidence‐based measures by which we can measurably improve health‐related quality of life in dialysis patients.     

How Should We Investigate Breast Implant Rupture?

We aimed to examine a cohort of patients presenting with breast implant complications to establish the sensitivity and specificity of clinical examination, Ultrasound Scanning (US) and Magnetic Resonance Imaging (MRI) in the diagnosis of implant rupture, and to examine the correlation between US and MRI. We performed a 26-month retrospective review. Patients underwent US and MRI to exclude rupture. Results of US and MRI were compared prospectively for concordance, then retrospectively to clinical findings and surgical diagnosis. Thirty-four patients with 60 implants were reviewed. The sensitivities of clinical diagnosis, US, and MRI for rupture was 42%, 50%, and 83%, respectively, while the specificities were 50%, 90%, and 90%. The concordance between US and MRI was 87%. MRI is the investigation of choice for implant rupture. US is a valuable alternative with good concordance with MRI. When US is positive for implant rupture an MRI is not necessary to confirm the diagnosis. Knowledge of the sensitivity and specificity as well as the concordance between the two investigations is useful to ensure the appropriate use of available resources.