To the Editor I read with interest the study by Diaz and Pawlik1 analyzing optimal location centralization of hospitals performing pancreatic resection in California (estimated 40 million inhabitants). The move from more than 100 hospitals to some 9 hospitals would create very high-volume hospitals for pancreatic resection (median >100 resections per year). Investigating data from the same region, others have suggested that centralization would jeopardize access for vulnerable groups (elderly individuals; racial minority groups; and some payer systems) and potentially increase health care disparities.2 Further, the analysis of available resection assumes the optimal number of resections have been reached, but this can only be investigated by evaluation of the resection rates in the population (eg, pancreatectomies per 100 000 inhabitants3,4) or, even more precise, the actual age-adjusted resection rates for pancreatic cancer per se. Are the 1056 resections in year 2016 sufficient for a population of almost 40 million? Have all (potential) resectable cases been given an opportunity to be considered for surgery or seen by an expert multidisciplinary team? With increasing use of neoadjuvant strategies, one must consider the provision of care for borderline and locally advanced cancers because these tumors may be considered irresectable in some but not all centers.5 Notably, patients who are never considered for surgery owing to system barriers have a 100% mortality (for pancreatic cancer), even if resectable. Creating care pathways, ensuring network levels of expertise, and providing access to proper hubs for supraselected situations may avoid sending the patients on an unexpected journey.
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Søreide K. Regionalization of Pancreatectomy for Pancreatic Cancer. JAMA Surg. Published online May 27, 2020. doi:10.1001/jamasurg.2020.0850
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