Enzinger Peter C, Benedetti Jacqueline K, Meyerhardt Jeffrey A, McCoy Sheryl, Hundahl Scott A, Macdonald John S, Fuchs Charles S
Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02115, USA.
Ann Surg. 2007 Mar;245(3):426-34. doi: 10.1097/01.sla.0000245469.35088.42.
Some, but not all, studies using registry data have suggested a small but significant long-term survival advantage following a curative surgical resection of gastric cancer at hospitals where the volume of such surgeries is high. However, because such data may be significantly influenced by the impact of postoperative mortality, and may be imbalanced for factors important to survival, the true nature of this relationship remains uncertain.
We conducted a nested volume-outcome study in a sample of 448 surgical survivors with stage IB through IV (M0) gastric and gastroesophageal junction adenocarcinoma, previously randomized to adjuvant chemoradiation after surgery or surgery alone, to measure the effect of hospital surgical volume, as assessed by Medicare claims data, on overall survival and gastric cancer recurrence.
In this selected sample of postoperative survivors, hospital surgical volume was not predictive of overall survival (P = 0.46) or disease-free survival (P = 0.43) at a median follow-up of 8.9 years. However, patients who underwent either a D1 or D2 dissection at a high- or moderate-volume center experienced an adjusted hazard ratio of 0.80 (95% CI, 0.53-1.20) for overall survival and 0.78 (95% CI, 0.53-1.14) for disease-free survival compared with those patients resected at a low-volume hospital; these results were not statistically significant. When a D0 resection was performed, hospital procedure volume showed no impact on survival.
Excluding the impact of perioperative mortality by utilizing prospectively recorded data from a large postoperative adjuvant trial, hospital procedure volume had no overall effect on long-term gastric cancer survival. The potential benefit of moderate- to high-volume centers for patients who underwent a D1 or D2 dissection requires confirmation in larger studies.
一些（但并非全部）使用登记数据的研究表明，在胃癌手术量高的医院进行根治性手术切除后，患者具有虽小但显著的长期生存优势。然而，由于此类数据可能受到术后死亡率的显著影响，且在对生存至关重要的因素方面可能存在不均衡性，这种关系的真实性质仍不确定。
我们对448例IB期至IV期（M0）胃癌和胃食管交界腺癌手术幸存者进行了一项嵌套式手术量 - 结局研究，这些患者之前被随机分配接受术后辅助放化疗或单纯手术，以通过医疗保险理赔数据评估医院手术量对总生存和胃癌复发的影响。
在这个选定的术后幸存者样本中，中位随访8.9年时，医院手术量不能预测总生存（P = 0.46）或无病生存（P = 0.43）。然而，与在低手术量医院接受手术的患者相比，在高手术量或中等手术量中心接受D1或D2清扫的患者，其总生存的调整后风险比为0.80（95%CI，0.53 - 1.20），无病生存的调整后风险比为0.78（95%CI，0.53 - 1.14）；这些结果无统计学意义。当进行D0切除时，医院手术量对生存无影响。
通过利用大型术后辅助试验的前瞻性记录数据排除围手术期死亡率的影响后，医院手术量对胃癌长期生存无总体影响。对于接受D1或D2清扫的患者，中等至高手术量中心的潜在益处需要在更大规模的研究中得到证实。
