O. K. Jawitz1, M. Turner1, M. Adam1, C. Mantyh1, J. Migaly1 1Duke University Medical Center,Department Of Surgery,Durham, NC, USA
Introduction:
Cancer resections performed at high-volume colorectal surgery centers are associated with improved post-operative outcomes including fewer complications such as anastomotic leak and increased survival. It is not known if patients who do not live in proximity to high-volume centers benefit from choosing to travel to these institutions as opposed to receiving their care at local, low-volume centers.
Methods:
The 2006-2014 National Cancer Database (NCDB) was queried for patients with pathologic stage I-III colon adenocarcinoma who underwent cancer treatment at a single center. Travel distances to treatment centers were calculated. Matching the first and fourth quartiles of travel distance with first and fourth quartiles of institution surgical volume established short distance/low-volume (local) and long distance/high-volume (travel) cohorts. The primary outcome of interest was overall survival compared between the local and travel cohorts. Secondary outcomes included incidence of positive resection margins, adequate lymph node harvesting, length of stay, readmission rates, 30-day and 90-day mortality, and use of adjuvant chemotherapy.
Results:
A total of 33,339 patients met inclusion criteria, including 18,163 patients that traveled ≤2.6 miles to centers that performed ≤ 34 resections per year (local) and 15,176 patients that traveled ≥ 21.8 miles to centers that performed ≥ 83 resections annually (travel). In unadjusted analysis, patients in the travel cohort had lower rates of positive resection margins (3.3% vs. 5.0%, p<0.001), more frequently had adequate lymph node harvests (88.9% vs. 79.2%, p<0.001), and had lower 30-day (2.4% vs. 4.0%, p<0.001) and 90-day mortality (4.0% vs. 6.6%, p<0.001). On multivariable logistic regression analysis adjusting for patient demographic, tumor, and facility characteristics, traveling longer distances to high-volume centers remained an independent predictor of improved overall survival (hazard ratio 0.84, p<0.001) and secondary outcomes of adequate lymph node harvesting (OR 0.48, p<0.001), negative resection margins (OR 0.65, p<0.001), lower readmission rates (OR 0.84, p<0.001), 30-day mortality (OR 0.75, p<0.001), and 90-day mortality (OR 0.74, p<0.001).
Conclusion:
For patients with stage I-III colon cancer who do not live in proximity to high-volume colorectal surgery centers, traveling to these institutions as opposed to receiving treatment at local low-volume centers conveys a postoperative survival advantage. Additionally, rates of adequate oncologic resections and readmission are superior to those who seek care locally. Patients with stage I-III colon cancer should be encouraged to undergo surgical resection at high-volume centers, even if this involves traveling outside of their local region.