Division of Oncology, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, California.
Division of Hematology and Oncology, University of California Davis Comprehensive Cancer Center, Sacramento, California.
Cancer. 2019 Nov 1;125(21):3853-3863. doi: 10.1002/cncr.32290. Epub 2019 Aug 9.
Several studies have investigated the relationship between experience measured by caseload and oncological outcomes, economics, and access to care for prostate cancer care. Oncological outcomes have been limited to biochemical failure after radical prostatectomy. Questions remain regarding the more definitive measures of outcomes and their relationship with caseload.
The National Cancer Database was used to investigate the outcomes of radical prostatectomy in the United States. With overall survival (OS) as the primary outcome, the relationship between the facility annual caseload (FAC) for all prostate cancer encounters and the facility annual surgical caseload (FASC) for those requiring radical prostatectomy was examined with a Cox proportional hazards model. Four volume groups were defined by caseload: <50th percentile (volume group 1 [VG1]), 50th to 74th percentiles (volume group 2 [VG2]), 75th to 89th percentiles (volume group 3 [VG3]), and ≥90th percentile (volume group 4 [VG4]). By FAC/FASC, 11%/8%, 17%/18%, 25%/26%, and 47%/49% of patients were treated in VG1 through VG4, respectively.
Between 2004 and 2014, 488,389 patients underwent radical prostatectomy. At a median follow-up of 60.75 months, the median OS was not reached. There was a significant OS benefit as the caseload increased. For FAC, the adjusted OS difference between VG1 and VG4 at 90th percentile survivorship reached 13.2 months (hazard ratio [HR], 1.30; 95% CI, 1.23-1.36; P < .0001). For FASC, this was 11.3 months (HR, 1.25; 95% CI, 1.192-1.321; P < .0001).
There is a statistically significant OS advantage from performing radical prostatectomy at a facility with a high annual caseload. Caseload measured by all prostate cancer encounters is a better predictor of favorable outcomes than the number of surgeries performed at a facility.
An in-depth analysis of 488,389 cases of radical prostatectomy performed in more than 1000 facilities over a 10-year period showed better survival when surgery was performed in facilities with more experience and greater caseload. A survival difference of up to 13 months was observed when comparing patients treated at less experienced versus more experienced centers. Experience across all stages of prostate cancer was a stronger predictor of survival outcome than just the number of surgeries performed.
已有多项研究调查了病例量所反映的经验与前列腺癌治疗的肿瘤学结局、经济学和可及性之间的关系。肿瘤学结局仅限于根治性前列腺切除术的生化失败。对于更明确的结局衡量标准及其与病例量的关系，仍存在一些疑问。
本研究使用国家癌症数据库调查了美国的根治性前列腺切除术结局。以总生存（OS）为主要结局，使用 Cox 比例风险模型，研究了所有前列腺癌就诊的医疗机构年度病例量（FAC）与需要根治性前列腺切除术的医疗机构年度手术病例量（FASC）之间的关系。根据病例量，将容量组定义为 4 个：<50 百分位（容量组 1 [VG1]）、50 至 74 百分位（容量组 2 [VG2]）、75 至 89 百分位（容量组 3 [VG3]）和≥90 百分位（容量组 4 [VG4]）。按 FAC/FASC 分类，11%/8%、17%/18%、25%/26%和 47%/49%的患者分别在 VG1 到 VG4 中接受治疗。
在 2004 年至 2014 年间，共有 488389 例患者接受了根治性前列腺切除术。中位随访 60.75 个月时，中位 OS 未达到。随着病例量的增加，OS 显著获益。对于 FAC，VG1 和 VG4 在 90 百分位生存率时，调整后的 OS 差异达到 13.2 个月（风险比 [HR]，1.30；95%置信区间 [CI]，1.23-1.36；P<.0001）。对于 FASC，这一数值为 11.3 个月（HR，1.25；95%CI，1.192-1.321；P<.0001）。
在高年度病例量的医疗机构进行根治性前列腺切除术具有统计学意义上的 OS 优势。通过所有前列腺癌就诊病例量来衡量的病例量，比在医疗机构进行的手术数量更能预测有利的结局。
对 10 年间在 1000 多家医疗机构进行的 488389 例根治性前列腺切除术的深入分析表明，在经验丰富、病例量较大的医疗机构进行手术时，患者的生存率更高。在比较经验较少和较多的中心治疗的患者时，观察到高达 13 个月的生存差异。在前列腺癌所有阶段的经验，比手术量更能预测生存结局。
