11.01 Outcomes after CRS-HIPEC by Facility: Do Higher Volumes Matter?

K. N. Partain1, E. Gabriel1, K. Attwood2, C. Powers3, M. Kim3, S. P. Bagaria1, S. N. Hochwald3  1Mayo Clinic – Florida,Department Of Surgery, Section Of Surgical Oncology,Jacksonville, FL, USA 2Roswell Park Cancer Institute,Department Of Biostatistics,Buffalo, NY, USA 3Roswell Park Cancer Institute,Department Of Surgical Oncology,Buffalo, NY, USA

Introduction:  Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) offers favorable outcomes for select patients with appendiceal and colorectal cancer (CRC). Studies have suggested that this procedure should be performed at high-volume centers, which can limit access to treatment. The purpose of this study was to determine the association between treatment volume and outcomes for CRS-HIPEC.

Methods: This was a retrospective analysis using the National Cancer Data Base, 2004-2013. CRS-HIPEC treatment centers were stratified by low-volume (<10 cases/decade), middle-volume (11-20), and high-volume (>20). Patients who received any systemic chemotherapy were excluded. The primary, long-term outcome was overall survival (OS). Secondary, short-term outcomes included the number of lymph nodes examined in the surgical specimen, post-operative hospital length of stay (LOS), unplanned readmission rate, and 30- and 90-day mortality. 

Results: A total of 749 cases were identified: 303 at low-volume, 138 at middle-volume, and 308 at high-volume centers. Carcinomatosis of appendiceal origin was present in 84.5% of cases, with the remainder of CRC origin. Table 1 summarizes the baseline demographic and clinical characteristics among the three types of centers. Overall, the cases treated among different centers were similar with respect to age, race, insurance status, and comorbid status (as reported by the Charlson-Deyo comorbidity score). The average distance traveled was highly variable (low: 54.5 miles, middle: 238.3 miles, high: 364.1 miles; p<0.001). There was no difference in the average number of lymph nodes examined (low: 13.7, middle: 14.0, high: 12.4; p=0.33), readmission rates (low: 8.7%, middle: 8.9%, high 6.7%; p=0.87), 30-day morality (low: 0.9%, middle: 0.8%, high:1.8%; p=0.59), or 90-day mortality (low: 4.1%, middle: 3.4%, high:4.7%; p=0.83). There was a difference in the average hospital LOS (low: 13.9 days, middle: 17.3 days, high: 19.2 days; p=0.008). The median follow-up for OS was 48.3 months (range 0.5 – 101.8 months). There was no significant association between case volume and median OS (low: 45.8 months, middle: 58.4 months, high: 59.4 months; p=0.43).

Conclusion: Contrary to the push for centralization of CRS-HIPEC, this data suggests that CRS-HIPEC can be completed at lower volume performing centers to achieve similar short- and long-term outcomes compared to higher performing centers. Development of CRS-HIPEC programs in geographic areas of need may be beneficial for patients located far from centralized facilities.