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July 21, 2008

Effect of Hospital Type and Volume on Lymph Node Evaluation for Gastric and Pancreatic Cancer

Author Affiliations

Author Affiliations: Cancer Programs, American College of Surgeons (Drs Bilimoria, Winchester, and Ko and Mr Stewart) Chicago, Illinois; and Departments of Surgery, Feinberg School of Medicine, Northwestern University (Drs Bilimoria, Wayne, and Bentrem), and Evanston Northwestern Healthcare (Drs Talamonti and Winchester), Chicago, Illinois, and University of California, Los Angeles; and Veterans Affairs Greater Los Angeles Healthcare System (Drs Tomlinson and Ko).

Arch Surg. 2008;143(7):671-678. doi:10.1001/archsurg.143.7.671

Hypothesis  For gastric and pancreatic cancer, regional lymph node evaluation is important to accurately stage disease in a patient and may be associated with improved survival. We hypothesized that National Comprehensive Cancer Network (NCCN), National Cancer Institute (NCI)–designated institutions, and high-volume hospitals examine more lymph nodes for gastric and pancreatic malignant neoplasms than do low-volume centers and community hospitals.

Design  Volume-outcome study.

Setting  Academic research.

Patients  Using the National Cancer Data Base (January 1, 2003, to December 31, 2004), patients were identified who underwent resection for gastric (n = 3088) and pancreatic (n = 1130 [pancreaticoduodenectomy only]) cancer.

Main Outcome Measures  Multivariable logistic regression analysis was used to assess the effect of hospital type and volume on nodal evaluation (≥15 nodes).

Results  Only 23.2% of patients with gastric cancer and 16.4% of patients with pancreatic cancer in the United States underwent evaluation of at least 15 lymph nodes. Patients undergoing surgery had more lymph nodes examined at NCCN-NCI hospitals than at community hospitals (median, 12 vs 6 for gastric cancer and 9 vs 6 for pancreatic cancer; P < .001). Patients at highest-volume hospitals had more lymph nodes examined than patients at low-volume hospitals (median, 10 vs 6 for gastric cancer and 8 vs 6 for pancreatic cancer; P < .001). On multivariable analysis, patients undergoing surgery at NCCN-NCI and high-volume hospitals were more likely to have at least 15 lymph nodes evaluated compared with patients undergoing surgery at community hospitals and low-volume centers (P < .001 and P =.02, respectively).

Conclusions  Nodal examination is important for staging, adjuvant therapy decision making, and clinical trial stratification. Moreover, differences in nodal evaluation may contribute to improved long-term outcomes at NCCN-NCI centers and high-volume hospitals for patients with gastric and pancreatic cancer.