Influence of delays to nonemergent colon cancer surgery on operative mortality, disease-specific survival and overall survival.

BACKGROUND: There has been minimal research on the influence of delays for cancer treatments on patient outcomes. We measured the influence of delays to nonemergent colon cancer surgery on operative mortality, disease-specific survival and overall survival. METHODS: We used the linked Surveillance, Epidemiology and End Results (SEER)-Medicare databases (1993-1996) to identify patients who underwent nonemergent colon cancer surgery. We assessed 2 time intervals: surgeon consult to hospital admission for surgery and first diagnostic test for colon cancer to hospital admission. Follow-up data were available to the end of 2003. We selected the time intervals to create patient groups with clinical relevance and they did not extend past 120 days. RESULTS: We identified 7989 patients who underwent nonemergent colon cancer surgery. Median delays from surgeon consult to admission and from first diagnostic test to admission were 7 and 17 days, respectively. The odds of operative mortality were similar if the consult-to-admission interval was 22 days or more versus 1-7 days (odds ratio [OR] 1.0, 95% confidence interval [CI] 0.6-1.8, p = 0.91) or if the test-to-admission interval was 43 days or more versus 1-14 days (OR 0.8, 95% CI 0.4-1.5, p = 0.51), respectively. For these same respective interval comparisons, disease-specific survival was not influenced by the consult-to-admission wait (hazard ratio [HR] 1.0, 95% CI 0.9-1.2, p = 0.91) or the test-to-admission wait (HR 1.0, 95% CI 0.8-1.1, p = 0.63). The risk of death was slightly greater if the consult-to-admission interval was 22 or more days versus 1-7 days (HR 1.1, 95% CI 1.0-1.2, p = 0.013) and if the test-to-admission interval was 43 days or more versus 1-14 days (HR 1.2, 95% CI 1.1-1.3, p = 0.003). CONCLUSION: It is unlikely that delays to nonemergent colon cancer surgery longer than 3 weeks from initial surgical consult or longer than 6 weeks from first diagnostic test negatively impact operative mortality, disease-specific survival or overall survival.

Survival after liver resection for metastatic colorectal carcinoma in a large population.

BACKGROUND: Previous reports of liver resection for metastatic colorectal cancer (CRC) are typically from single centers and cannot account for selection or referral bias. We measured longterm survival after liver resection for metastatic CRC in the province of Ontario, Canada (population 12 million). STUDY DESIGN: The Ontario Cancer Registry is an administrative database that links all hospital records, pathology reports, and vital statistics for patients with a diagnosis of cancer. We used the Registry to identify and obtain information on all patients who underwent liver resection for metastatic CRC in calendar years 1996 to 2004. Pathology reports of the original CRC resection and subsequent liver resections were individually reviewed. RESULTS: Eight hundred forty-one resections were performed at 43 centers across Ontario during the 9-year period, including wedge resection (n = 303; 36%); lobectomy (n = 466; 55%); and trisectionectomy (n = 72; 9%). Ninety-one percent and 54% of resections were performed at teaching and high-volume centers (> 80 resections), respectively. Most liver resections were performed more than 120 days after original CRC operation (672 of 841; 80%). Perioperative mortality was 3%. Unadjusted 1-, 3-, and 5-year survival after liver resection was 88%, 59%, and 43%, respectively. Survival was improved when resection was performed for fewer than 2 tumor nodules, at high-volume centers, or in the years 2001 to 2004. CONCLUSIONS: Results in this population-based series are consistent with those of single-hospital series assessing longterm survival after liver resection for metastatic CRC. These findings support continued efforts to aggressively identify and resect CRC liver metastases.

Influence of hospital characteristics on operative death and survival of patients after major cancer surgery in Ontario.

BACKGROUND: There is a lack of information from Canadian hospitals on the role of hospital characteristics such as procedure volume and teaching status on the survival of patients who undergo major cancer resection. Therefore, we chose to study these relationships using data from patients treated in Ontario hospitals. METHODS: We used the Ontario Cancer Registry from calendar years 1990-2000 to obtain data on patients who underwent surgery for breast, colon, lung or esophageal cancer or who underwent major liver surgery related to a cancer diagnosis between 1990 and 1995 in order to assess the influence of volume of procedures and teaching status of hospitals on in-hospital death rate and long-term survival. For each disease site and before observing patient outcomes data, volume cut-off points were selected to create volume groups with similar numbers of patients. Teaching hospitals were those directly affiliated with a medical school. Logistic regression and proportional hazards models were used to consider the clustering of data at the hospital level and to assess operative death and long-term survival. We also used 4 measures to gauge the degree of procedure regionalization across the province including (1) the number of hospitals performing a procedure; (2) the percentage of patients treated in teaching hospitals; (3) the percentage of rural patients treated in higher volume procedure hospitals; and (4) median distances travelled by patients to receive care. RESULTS: The number of patients in our cohorts who underwent resection of the breast, colon, lung, esophagus or liver was 14 346, 8398, 2698, 629 and 362, respectively. Surgery in a high-volume versus a low-volume hospital did not have a statistically significant influence on the odds of operative death for patients who underwent colon, liver, lung or esophageal cancer resection. The risk of long-term death was increased in low-volume versus high-volume hospitals for patients who underwent resection of the breast (hazard ratio [HR] 1.2, 95% confidence interval [95% CI] 1.0-1.4, p < 0.05), lung (HR 1.3, 95% CI 1.1-1.6, p < 0.01) and liver (HR 1.7, 95% CI 1.0-2.7, p = 0.04). There were no significant differences in the odds of operative (in-hospital) death or risk of long-term death among patients treated in teaching compared with nonteaching hospitals. There was more regionalization of liver, lung and esophageal operations versus breast and colon operations. CONCLUSIONS: Increased hospital procedure volume correlated with improved longterm survival for patients in Ontario who underwent some, but not all, cancer resections, whereas hospital teaching status had no significant impact on patient outcomes. Across the province, further regionalization of care may help improve the quality of some cancer procedures.

Lymph node counts, rates of positive lymph nodes, and patient survival for colon cancer surgery in Ontario, Canada: a population-based study.

BACKGROUND AND OBJECTIVES: This study assessed lymph node counts, lymph node status (positive or negative), and survival among patients undergoing colon cancer surgery in Ontario, Canada. METHODS: We obtained data from the Ontario Cancer Registry on 960 patients who underwent a major colon cancer resection in years 1991-1993. Patients and hospitals were ranked by lymph node count to correlate lymph node counts and lymph node status. For node-negative patients we assessed the influence of patient, hospital, and tumor factors on lymph node counts and survival. RESULTS: The rate of node-positive patients was similar among the lymph node count groups. For example, the odds ratio of a patient being node positive if the lymph node count was 10-36 versus 1-3 was 1.0 (CI 0.6-1.6, P = 0.42). Among node-negative patients, survival was improved for patients with a high (10-36) versus low (1-3) lymph node count (HR 0.6, CI 0.4-1.0, P = 0.03). No patient, hospital, or tumor factors predicted both a higher lymph node count and improved survival. CONCLUSIONS: In this population-based study of patients undergoing colon cancer surgery, higher lymph node counts did not correlate with increased rates of node-positive status.