'Where you're treated matters' in terms of cancer survival

A study of older patients with advanced head and neck cancers has found that where they were treated significantly influenced their survival. The study, led by researchers at Fred Hutchinson Cancer Research Center and published in the March 1 online edition of Cancer, found that patients who were treated at hospitals that saw a high number of head and neck cancers were 15 percent less likely to die of their disease as compared to patients who were treated at hospitals that saw a relatively low number of such cancers. The study also found that such patients were 12 percent less likely to die of their disease when treated at a National Cancer Institute -designated cancer center.

"Where you're treated matters," said corresponding author Eduardo Méndez, M.D., an assistant member of the Clinical Research Division at Fred Hutch.

Méndez and colleagues also hypothesized that patients with head and neck squamous cell carcinomas (HNSCCs) who were treated at high-volume hospitals would be more likely to receive therapy that complies with National Comprehensive Cancer Network guidelines due to the complexity of managing these cancers. Surprisingly, this was not the case, the researchers found.

According to an American Cancer Society estimate, 52,610 Americans were newly diagnosed with head and neck cancer in 2012. Many patients are diagnosed with locally advanced disease that has spread to the lymph nodes, which carries a much poorer prognosis compared to early stage disease. Patients with advanced disease require multidisciplinary management by a collaborative team comprised of multiple physician specialties and disciplines. NCCN guidelines, based on data from randomized controlled trials, recommend multimodality therapy (either surgery followed by adjuvant therapy or primary chemo-radiation) for almost all advanced cases.

The study found that despite the improved survival at high-volume hospitals, the proportion of patients who received multimodality therapy was similar – 78 percent and 79 percent – at low- and high-volume hospitals, respectively.

"NCCN guidelines are well publicized in the medical community and it was exciting to learn that clinicians at both high- and low-volume hospitals are implementing these guidelines into the complex clinical management of patients with head and neck cancer," said Méndez, who is an expert in the surgical treatment of head and neck cancer and an associate professor of otolaryngology-head and neck surgery at the University of Washington School of Medicine.

"Although this study does not necessarily mean that all patients with advanced HNSCC should be treated at high-volume hospitals or at NCI-designated cancer centers, it does suggest that features of these hospitals, such as a multidisciplinary team approach or other institutional factors, play a critical role in influencing survival without influencing whether patients receive NCCN-guideline therapy," the authors concluded.

The implementation of NCCN-guideline therapy can be challenging because there are toxicities associated with these treatments that require a high level of support and infrastructure, such as that found at comprehensive cancer centers, according to Méndez.

The Hutchinson Center/University of Washington Cancer Consortium is the Pacific Northwest's only NCI-designated comprehensive cancer center. Patient care is provided at Seattle Cancer Care Alliance, which, in partnership with Fred Hutch, UW and Seattle Children's, is a member of the NCCN.

The authors said that given the complex treatment and coordination required for patients with advanced HNSCC, suboptimal care and outcomes may be more likely in these patients compared to those who require less-complex care. In addition to their complexity, treatment modalities for advanced HNSCC have significant toxicities, which pose an additional barrier for fully implementing NCCN guideline therapy.

Prior studies in diseases other than HNSCC have shown that hospital volume and physician volume influence outcomes. However, this is the first study to examine whether hospital factors are associated with receiving multimodality therapy for patients with advanced HNSCC.

To conduct the study, researchers used the Surveillance, Epidemiology, and End Results-Medicare database to identify 1,195 patients age 66 and older who were diagnosed with advanced HNSCC between 2003 and 2007. Treatment modalities and survival were determined using Medicare data. Hospital volume was determined by the number of patients with HNSCC treated at each hospital.