Cancer care in the pediatric surgical patient: A paradigm to abolish volume-outcome disparities in surgery

DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
Surgery (Impact Factor: 3.11). 02/2009; 145(1):76-85. DOI: 10.1016/j.surg.2008.08.011
Source: PubMed

ABSTRACT The objective of this study was to define the prognostic significance of hospital surgical volume on outcomes for pediatric neuroblastoma and Wilms tumor.
The Florida Cancer Data System was examined for all pediatric patients treated between 1981 and 2004.
Of the 869 patients with neuroblastoma identified, 463 were treated at 5 high-volume centers (HVC) and 406 were treated at 61 low-volume centers (LVC). There were no differences in sex, age at diagnosis, race, ethnicity, or stage of disease between the 2 groups. The 5- and 10-year survival rates were identical between treatment groups (70.6% and 67.7% at HVC vs 69.3% and 65.2% at LVC, P = .243). Multivariate analysis identified age at diagnosis and tumor stage as independent prognostic factors. Of the 790 patients with Wilms tumor identified, 395 were treated at 5 HVC and 395 were treated at 50 LVC. There were no differences in sex, age of diagnosis, or stage of disease between the 2 groups. The 5- and 10-year survival rates were identical between treatment groups (91.3% and 89.9% at HVC vs 89.7% and 88.5% at LVC, P = .698). Multivariate analysis identified ethnicity, tumor stage, and use of chemotherapy as independent prognostic factors.
Survival rates for patients with neuroblastoma and Wilms tumor are unrelated to the hospital surgical volume or patient race. This result stands in stark contrast to a variety of adult malignancies. Models used for pediatric patient care for cancer may provide insight into ways to improve the treatment of adult patients in need of complex cancer care.

  • [Show abstract] [Hide abstract]
    ABSTRACT: Purpose: The purpose of this study was to identify health disparities in children with non-CNS solid tumor malignancies and examine their impact on disease presentation and outcome. Methods: We examined the records of all children (age <= 18 years) diagnosed with a non-CNS solid tumor malignancy and enrolled in the Texas Cancer Registry between 1995 and 2009 (n = 4603). The primary outcomemeasures were disease stage and overall survival (OS). Covariates included gender, age, race/ethnicity, year of diagnosis, socioeconomic status (SES), and driving distance to the nearest pediatric cancer treatment facility. Statistical analyses included life table methods, logistic, and Cox regression. Statistical significance was defined as p < 0.05. Results: Children with advanced-stage disease were more likely to be male, <10 years old, and Hispanic or non-Hispanic Blacks (all p < 0.05). Distance to treatment and SES did not impact stage of disease at presentation. However, Hispanic and non-Hispanic Blacks and patients in the lowest SES quartile had the worst 1-and 5year survival (all p < 0.05). The adjusted OS differed by age, race, and stage, but not SES or distance to the nearest treatment facility. Conclusions: Race/ethnicity plays an important role in survival for children with non-CNS solid tumor malignancies. Future work should better define these differences to establish mechanisms to decrease their impact. Published by Elsevier Inc.
    Journal of Pediatric Surgery 10/2014; 50(1). DOI:10.1016/j.jpedsurg.2014.10.037 · 1.31 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: IMPORTANCE Analyses of volume-outcome relationships in adult surgery have found that hospital and physician characteristics affect patient outcomes, such as length of stay, hospital charges, complications, and mortality. Similar investigations in children's surgical specialties are fewer in number, and their conclusions are less clear. OBJECTIVE To review the evidence regarding surgeon or hospital experience and their influence on outcomes in children's surgery. EVIDENCE REVIEW A MEDLINE and EMBASE search was conducted for English-language studies published from January 1, 1980, through April 13, 2012. Titles and abstracts were screened in a standardized manner by 2 reviewers. Studies selected for inclusion had to use a measure of hospital or surgeon experience as a predictor variable and had to report postoperative outcomes as dependent response variables. Included studies were reviewed with regard to methodologic quality, and study results were extracted. FINDINGS Sixty-three studies were reviewed. Significant heterogeneity was detected in exposure definitions, outcome measures, and risk adjustment, with the greatest heterogeneity seen in appendectomy studies. Various exposure levels were examined: hospital level in 48 (68%) studies, surgeon level in 11 (17%), and both in 9 (14%). Nineteen percent of studies did not adjust for confounding, and 57% did not adjust for sample clustering. The most consistent methods and reproducible results were seen in the pediatric cardiac surgical literature. Forty-nine studies (78%) showed positive correlation between experience and most primary outcomes, but differences in outcomes and exposure definitions made comparisons between studies difficult. In general, hospital-level factors tended to correlate with outcomes for high-complexity procedures, whereas surgeon-level factors tended to correlate with outcomes for more common procedures. CONCLUSIONS AND RELEVANCE Data on experience-related outcomes in children's surgery are limited in number and vary widely in methodologic quality. Future studies should seek both to standardize definitions, making results more applicable, and to differentiate procedures affected by surgeon experience from those more affected by hospital resources and system-level variables.
    03/2013; 167(5):1-8. DOI:10.1001/jamapediatrics.2013.25
  • Surgery 09/2009; 146(3):527–528. DOI:10.1016/j.surg.2009.04.032 · 3.11 Impact Factor