Researchers have found differences in hospitals giving care to patients with gastric or pancreatic cancer. The report, published in the July issue of Archives of Surgery, found that if patients are treated at hospitals that conduct relatively more cancer surgeries or at hospitals deemed comprehensive care centers, the patients have more lymph nodes examined by physicians who are investigating the spread and prognosis of their disease.
Cancer often originates in gastric system and metastasizes (spreads) to other parts of the body, including the lymph nodes. After cancer tissue is taken out of the stomach or pancreas, the metastatic progress in the lymph nodes has been used to predict a patients’ prognosis. If a physician analyze too few of these lymph nodes and come to an incorrect conclusion about the state of malignancy, an incorrect cancer classification may result. This ultimately changes the prognosis, the treatment method, and a patient’s eligibility for clinical trials. The authors note that, “Although the precise number varies, current guidelines recommend resection and pathologic evaluation of at least 15 regional lymph nodes for gastric and pancreatic cancer.”
To further study the practice of evaluating lymph nodes, Karl Y. Bilimoria, M.D., M.S. (American College of Surgeons and Feinberg School of Medicine, Northwestern University, Chicago) and colleagues analyzed records from the National Cancer Data Base (NCDB). The researchers identified patients who had a gastric or pancreatic cancer diagnosis in 2003 or 2004 and then had surgery. The investigators also classified the hospitals where the surgeries occurred, organizing them by case volume and by the level of cancer-related services and specialists.
There were 3,088 patients with gastric cancer. Of these:
- 11.6% had surgery at a National Cancer Institute (NCI) or National Comprehensive Cancer Network (NCCN-NCI) hospital
- 34% had surgery at a hospital affiliated with a medical schools but not NCCN-NCI
- 54.4% had surgery at community hospitals
There were 1,130 patients with pancreatic cancer. Of these:
- 19% had surgery at NCCN-NCI hospitals
- 43.3% had surgery at a hospital affiliated with a medical schools but not NCCN-NCI
- 37.7% had surgery at community hospitals
The researchers found that patients who had surgery at NCCN-NCI hospitals had more lymph nodes examined than patients who had surgery at community hospitals. Specifically, gastric cancer patients had an average of 12 lymph nodes examined at NCCN-NCI hospitals compared to 6 at community hospitals, and pancreatic cancer patients had 9 compared to 6, respectively. In addition, “Patients at highest-volume hospitals had more lymph nodes examined than patients at low-volume hospitals (median, 10 vs. six for gastric cancer and eight vs. six for pancreatic cancer).” Though 15 lymph node evaluations are recommended, only 23.3% of gastric cancer patients and 16.4% of pancreatic patients received such treatment. Compared to patients at community or low-volume hospitals, those at high-volume or NCCN-NCI hospitals were more likely to have 15 or more nodes evaluated.
“Nodal status is a powerful predictor of outcome, and every reasonable attempt should be made to assess the optimal number of lymph nodes to accurately stage disease in patients with gastric and pancreatic cancer,” conclude the researchers. “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.”
Effect of Hospital Type and Volume on Lymph Node Evaluation for Gastric and Pancreatic Cancer
Karl Y. Bilimoria, MD, MS; Mark S. Talamonti, MD; Jeffrey D. Wayne, MD; James S. Tomlinson, MD; Andrew K. Stewart, MA; David P. Winchester, MD; Clifford Y. Ko, MD, MS, MSHS; David J. Bentrem, MD
Archives of Surgery (2008). 143[7]: pp. 671 – 678.
Written by: Peter M Crosta