If you needed major surgery to treat cancer, how would you decide where to have it?
The decision involves lots of factors, but studies conclude you should not go to a hospital that rarely performs the surgery because it could compromise your results, including your chance of survival.
To help cancer patients who need surgery, the Pennsylvania Health Care Cost Containment Council (PHC4) recently released its first-ever online list of hospital surgical volumes for 11 types of cancer: bladder, brain, breast, colon, esophagus, liver, lung, pancreas, prostate, rectum, and stomach. The volumes were compiled from hospital billing data for 2017.
"Reporting volume for these cancer surgeries is important because there is strong evidence that links hospital surgical volume and patient outcomes," said Joe Martin, executive director of PHC4, an independent state-funded organization. "It's another tool for cancer patients and their families to use when considering treatment options."
Some types of cancer, including gynecological and skin, are not included in the report because there is insufficient evidence that surgical volume makes a difference.
The PHC4 tool is modeled on the California Healthcare Foundation's 2015 report, Safety in Numbers: Cancer Surgeries in California Hospitals. The report acknowledged that questions remain about what is the lowest acceptable number of procedures a hospital should perform, but defined "low volume" as doing only one or two surgeries a year for a particular cancer.
Almost 75 percent of California hospitals — 249 out of 341 — performed a low volume of certain cancer surgeries. Low volumes correlated with higher surgery-related death rates, more post-operative complications, longer hospital stays, and for certain cancers, a higher chance of recurrence.
Why would cancer patients put faith in hospitals that lack strong surgical track records? Patients may be unaware that highly experienced medical teams are important for complicated procedures, or they may not want to travel long distances to a high-volume hospital.
The California report, which interviewed hospital leaders, also found that low-volume hospitals may not refer patients to bigger centers, sometimes because of the financial loss, but also because losing business means surgeons may not be able "to maintain their skills and interest in serving rural communities."
To overcome such barriers, some places have set volume minimums for certain cancer surgeries. New York state has a minimum for Medicaid reimbursement for breast cancer surgeries. The University of Michigan Health System and Johns Hopkins Hospital in Baltimore require annual minimums for esophagus, lung, pancreas and rectal cancer operations.
The PHC4 report found the percentage of Keystone State hospitals with low volumes in 2017 — meaning they did only one or two surgeries — varied depending on the cancer. Breast cancer had the most surgeries statewide, with 11,856 procedures at 140 hospitals and outpatient centers; only 6.4 percent of these facilities had low volumes. At the other extreme, of the 54 hospitals that did 208 stomach cancer surgeries, 57 percent had low volumes.
For the six cancer types with the lowest statewide surgery totals — bladder, esophagus, liver, pancreas, rectum and stomach — more than a third of hospitals performed only one or two surgeries in 2017.
Martin noted that a hospital could have a mix of volumes, depending on the types of cancer, "so it's important to look at the full picture when considering options."
A mixed pattern is seen even in many hospitals in the densely populated five-county Southeastern Pennsylvania region. For example, Pennsylvania Hospital, which is part of the Penn Medicine system, did many prostate, colon and breast surgeries, but only one or two bladder and esophagus procedures. Pancreatic cancer surgery volume was low at many centers, including Temple University Hospital, Bryn Mawr Hospital, Grand View Hospital, and Delaware County Memorial Hospital.