Centralization to fewer surgeons results in better survival after esophageal cancer surgery

Patients who undergo surgery for oesophageal cancer have a much greater chance of long term survival if the operation is carried out by a surgeon who has performed this particular operation many times before. This according to a new, large-scale study conducted by researchers at Karolinska Institutet in Sweden, and published in the Journal of Clinical Oncology. In their article, the researchers conclude that oesophageal cancer surgery should be concentrated – or centralised – to fewer surgeons.

Surgery is the most widely established curative treatment for oesophageal cancer. However, it is a major operation and only a third of patients who undergo it survive for five or more years afterwards. The purpose of the present study was to ascertain the relation between hospital and surgeon volume and long-term survival in patients who underwent surgery for oesophageal cancer.

Earlier studies have shown that the surgeon's and the hospital's annual operation volume both affect short-term survival (1-3 months post-surgery), but there are few patients who die so soon afterwards. The few studies that have examined operation volume in relation to long-term survival have given conflicting results, while many lack information on other key prognostic factors, including tumour stage.

The study that is now published in the Journal of Clinical Oncology is the most comprehensive of its kind in the subject. It included all 1,335 patients operated on for oesophageal cancer in Sweden between 1987 and 2005 with follow-ups up to January 2011. Survival analysis was used to study the effect of annual hospital volume, annual surgeon volume and surgeon experience measured as cumulative surgeon volume as regards survival following oesophageal cancer surgery. The analyses were adjusted for all established prognostic factors.

The study's main finding is that patients operated on by surgeons with a high annual and total volume had 22 per cent lower long-term mortality than patients operated on by surgeons with a low annual and total operation volume. The hospital's annual volume, however, had no independent impact on long-term survival. From this, the researchers conclude that oesophageal cancer surgery should be concentrated to fewer surgeons, giving them the opportunity to maintain a high annual volume for this major, complicated procedure.