A. L. Lazarides, B. E. Brigman, W. C. Eward, Department of Orthopedics Surgery, Duke Medical Center, Durham, NC J. A. Somarelli, Department of Medicine, Duke Cancer Institute, Durham, NC D. L. Kerr, R. T. Kreulen, Duke University School of Medicine, Durham, NC D. P. Nussbaum, D. G. Blazer, Department of General Surgery, Duke Medical Center, Durham, NC.
Clin Orthop Relat Res. 2019 Apr;477(4):718-727. doi: 10.1097/01.blo.0000533623.60399.1b.
For many cancer types, survival is improved when patients receive management at treatment centers that encounter high numbers of patients annually. This correlation may be more important with less common malignancies such as sarcoma. Existing evidence, however, is limited and inconclusive as to whether facility volume may be associated with survival in soft tissue sarcoma.
QUESTIONS/PURPOSES: The purpose of this study was to examine the association between facility volume and overall survival in patients with soft tissue sarcoma of the extremities. In investigating this aim, we sought to (1) examine differences in the treatment characteristics of high- and low-volume facilities; (2) estimate the 5-year survival by facility volume; and (3) examine the association between facility volume and of traveling a further distance to a high-volume center and overall survival when controlling for confounding factors.
The largest sarcoma patient registry to date is contained within the National Cancer Database (NCDB) and captures > 70% of new cancer diagnoses annually. We retrospectively analyzed 25,406 patients with soft tissue sarcoma of the extremities in the NCDB from 1998 through 2012. Patients were stratified based on per-year facility sarcoma volume and we used univariate comparisons and multivariate proportional hazards analyses to correlate survival measures with facility volume and various other patient-, tumor-, and treatment-related factors. First, we evaluated long-term survival for all variables using the Kaplan-Meier method with statistical comparisons based on the log-rank test. Multiple patient, tumor, and treatment characteristics were compared between the two facility-volume groups and then included them in the multivariate proportional hazards model. Of the 25,406 patients analyzed, 3310 were treated at high-volume centers (≥ 20 patients annually) and 22,096 were treated at low-volume centers. Patient demographics were generally not different between both patient cohorts, although patients treated at high-volume centers were more likely to have larger and higher grade tumors (64% versus 56% size ≥ 5 cm, 28% versus 14% undifferentiated grade, p < 0.001).
When controlling for patient, tumor, and treatment characteristics in a multivariate proportional hazards analysis, patients treated at high-volume facilities had an overall lower risk of mortality than those treated at low-volume centers (hazard ratio, 0.81 [0.75-0.88], p < 0.001). Patients treated at high-volume centers were also less likely to have positive margins (odds ratio [OR], 0.59 [0.52-0.68], p < 0.001) and in patients who received radiation, those treated at high-volume centers were more likely to have radiation before surgery (40.5% versus 21.7%, p < 0.001); there was no difference in the type of surgery performed (resection versus amputation) (OR, 1.01 [0.84-1.23], p = 0.883).
With the largest patient cohort to date, this database review suggests that certain patients with soft tissue sarcoma of the extremities, particularly those with large high-grade tumors, may benefit from treatment at high-volume centers. Further investigation is necessary to help improve the referral of appropriate patients to high-volume sarcoma centers and to increase the treatment capacity of and access to such centers.
Level III, therapeutic study.
对于许多癌症类型，患者在接受每年治疗大量患者的治疗中心的管理时，生存率会提高。对于肉瘤等罕见恶性肿瘤，这种相关性可能更为重要。然而，现有证据在设施数量是否与软组织肉瘤的生存率相关方面是有限且不确定的。
问题/目的：本研究旨在检查设施数量与四肢软组织肉瘤患者总生存率之间的关联。在研究这个目的时，我们试图（1）检查高容量和低容量设施之间的治疗特征差异；（2）估计设施数量的 5 年生存率；（3）当控制混杂因素时，检查设施数量与到高容量中心的更远距离旅行之间的关系以及与总生存率的关系。
迄今为止最大的肉瘤患者登记处包含在国家癌症数据库（NCDB）中，每年捕获> 70％的新癌症诊断。我们回顾性分析了 1998 年至 2012 年 NCDB 中 25406 例四肢软组织肉瘤患者。根据每年设施肉瘤量对患者进行分层，我们使用单变量比较和多变量比例风险分析将生存措施与设施量和各种其他患者、肿瘤和治疗相关因素相关联。首先，我们使用 Kaplan-Meier 方法评估所有变量的长期生存情况，并根据对数秩检验进行统计学比较。比较了两组设施量之间的多个患者、肿瘤和治疗特征，然后将其纳入多变量比例风险模型。在分析的 25406 例患者中，有 3310 例在高容量中心（每年≥ 20 例）治疗，22096 例在低容量中心治疗。患者的人口统计学特征通常在两组患者之间没有差异，尽管在高容量中心治疗的患者更有可能有更大和更高分级的肿瘤（64％与 56％的肿瘤大小≥ 5cm，28％与 14％的未分化分级，p<0.001）。
在多变量比例风险分析中，当控制患者、肿瘤和治疗特征时，在高容量设施治疗的患者总死亡率低于在低容量中心治疗的患者（风险比，0.81[0.75-0.88]，p<0.001）。在高容量中心治疗的患者也更不可能有阳性切缘（优势比[OR]，0.59[0.52-0.68]，p<0.001），在接受放疗的患者中，在高容量中心治疗的患者更有可能在手术前接受放疗（40.5％与 21.7％，p<0.001）；手术类型（切除与截肢）没有差异（OR，1.01[0.84-1.23]，p=0.883）。
在迄今为止最大的患者队列中，这项数据库回顾性研究表明，某些四肢软组织肉瘤患者，特别是那些有大的高级别肿瘤的患者，可能受益于高容量中心的治疗。需要进一步研究以帮助改善将适当患者转诊到高容量肉瘤中心的工作，并提高此类中心的治疗能力和可及性。
三级，治疗性研究。
