MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC.
Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC.
JCO Oncol Pract. 2020 Sep;16(9):e991-e1003. doi: 10.1200/JOP.19.00460. Epub 2020 Apr 8.
Surgical resection remains the cornerstone of retroperitoneal soft tissue sarcoma (RPS) treatment. Patient- and sarcoma-related factors are well known to influence survival outcomes. The effect of hospital-related factors on long-term survival, however, are not well understood. We sought to assess the relative contribution of hospital-level factors to mortality after surgical treatment of RPS.
The 2004-2015 National Cancer Database was used to identify 10,113 patients who underwent surgical treatment of RPS. Patient-, sarcoma-, hospital-, and treatment-level factors were compared by increasing survival times. Stepwise multivariable Cox regression was performed that controlled for covariates to measure the relative contributions of these factors on overall survival (OS). Effect modification analyses ascertained how hospital type modulates the volume relationship with respect to RPS mortality.
Factors predictive of worsening OS were older age, nonprivate insurance, low income, presence of comorbidities, tumor histology, high grade or stage, and R2 resection (for all, < .05). Increasing hospital surgical volume predicted decreasing risk of death across all survival times. However, analysis by hospital type demonstrated that compared with academic centers, the risk of death at community centers increased significantly as surgical volume increased (hazard ratio, 1.26; 95% CI, 1.03 to 1.53).
Hospital factors affect mortality after surgical treatment of RPS. Specifically, hospital type alters the surgical volume-outcome relationship for RPS mortality such that community centers perform worse with increasing volumes. Recommendations that higher surgical volume improves outcomes cannot be applied universally and must be re-examined in other complex surgical cancers.
手术切除仍然是腹膜后软组织肉瘤（RPS）治疗的基石。患者和肉瘤相关因素已被证明会影响生存结果。然而，医院相关因素对长期生存的影响尚不清楚。我们旨在评估医院水平因素对 RPS 手术后生存的相对贡献。
使用 2004-2015 年国家癌症数据库，确定了 10113 例接受 RPS 手术治疗的患者。通过增加生存时间比较患者、肉瘤、医院和治疗水平因素。进行逐步多变量 Cox 回归，控制协变量，以衡量这些因素对总生存（OS）的相对贡献。效应修饰分析确定了医院类型如何调节与 RPS 死亡率相关的体积关系。
与 OS 恶化相关的因素包括年龄较大、非私人保险、低收入、合并症、肿瘤组织学、高分级或分期以及 R2 切除（均<0.05）。随着手术量的增加，医院手术量的增加预测了所有生存时间的死亡风险降低。然而，按医院类型进行的分析表明，与学术中心相比，随着手术量的增加，社区中心的死亡风险显著增加（危险比，1.26；95%置信区间，1.03 至 1.53）。
医院因素影响 RPS 手术后的死亡率。具体来说，医院类型改变了 RPS 死亡率的手术量-结果关系，即社区中心的手术量增加，效果较差。更高的手术量可改善结果的建议不能普遍适用，必须在其他复杂的癌症手术中重新审查。
