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78 Volume Outcome KCE reports 113 RELATION BETWEEN SURGEON VOLUME AND 2-YEAR MORTALITY RATE Because of lack of an international cut off for surgeon volume in the literature, we used the volume threshold for oesophagectomies (≥ 6/year) which was identified in the previous section (see page 57). When this volume threshold is applied, low volume surgeons (1-5/year) have 58.1% 2-year mortality rate while high volume (≥ 6/year) surgeons have a 43.3% mortality rate (Table 5.30). Survival curve are presented in Figure 5.15. Table 5.30: Pancreatic cancer surgery: 2-year mortality per surgeon based on international volume thresholds Cut off Surgeon volume category Cut off for oesophagectomy because of lack of cut off for pancreatectomy Number surgeons Number cases 2-year mortality Nbr deaths % 6/year 1-5/year 100 167 97 58.1 ≥ 6 /year 9 120 52 43.3 Figure 5.15 Pancreatic cancer surgery: survival curve by surgeon volume (threshold 6/year)
KCE Reports 113 Volume Outcome 79 Table 5.31 shows the results from logistic regression (with GEE adjustment for clustering of patients within centres). Patients operated by surgeons performing less than 6 interventions per year have a 50% higher odds of mortality than patients operated by surgeons performing at least 6 interventions per year, taking into account patient and tumour characteristics: odds ratio and 95% CI 1.51 (1.06, 2.16). Table 5.31: Pancreatic cancer surgery: Correlation-corrected logistic regression (GEE) estimates of determinants of 2-year mortality Model without adjustment for case mix Factor OR 95%CI Surgeon Volume 1-5/year 1.80 1.06 3.07 ≥ 6 /year 1.00 1.00 1.00 Model with adjustment for patient characteristics (MCD data) Surgeon Volume 1-5/year 1.54 1.02 2.34 ≥ 6 /year 1.00 1.00 1.00 Sex male vs female 1.30 0.83 2.05 Age increase of 1 yr 1.03 1.00 1.06 Principal Duodenum vs Pancreas 1.19 0.38 3.75 Diagnosis Extrahepatic bile ducts or Ampulla of Vater versus Pancreas 0.42 0.22 0.79 Charlson score increase of 1 1.07 0.79 1.46 Model with adjustment for patient and tumour characteristics (MCD and BCR data) Surgeon Volume 1-5/year 1.51 1.06 2.16 ≥ 6 /year 1.00 1.00 1.00 Sex male vs female 1.46 0.90 2.36 Age increase of 1 yr 1.04 1.00 1.08 Principal Duodenum vs Pancreas 1.09 0.34 3.43 Diagnosis Extrahepatic bile ducts or Ampulla of Vater versus Pancreas 0.42 0.19 0.94 Charlson score increase of 1 1.07 0.78 1.46 Stage unknown 1.20 0.52 2.74 IV 2.06 0.60 7.08 III 4.55 1.42 14.62 II 2.35 1.12 4.94 0-I 1.00 1.00 1.00 5.3.7 Discussion 5.3.7.1 External validation of the definition of the procedure According to the Belgian Cancer Registry, there were 1 080 new cases of pancreas cancer in Belgium in 2004. See Table 5.1 (page 45). In the 2004 Minimal Clinical Data (MCD), we identified 1 526 patients with the principal diagnosis of malignant neoplasm of pancreas (see Table 5.19, page 66). The higher number of patients in the MCD is explainable by the fact that these hospital stays are not restricted to patients whose cancer started in 2004. The study by Topal et al. supplies us with reference material. 156 Topal and colleagues obtained minimal clinical data (MCD) on all pancreaticoduodenectomies (PDs) performed in Belgium between 2000 and 2004. A total of 1 842 PDs were registered based on ICD-9-CM procedure code 527 and/or NIHDI billing code 242023. When we compare these selection criteria with ours (see Table 5.18), we notice that Topal et al. focused on only one operative technique, i.e. the pancreaticoduodenectomy (the Whipple procedure), which is the surgical procedure to remove the head of the pancreas. On the other hand, however, they did not select on principal diagnosis and therefore included patients with peripancreatic cancer or even with a disorder that is not cancer related such as chronic pancreatitis. Considering these differences in patient selection, it seems justifiable that Topal’s absolute number of patients (1 842 over five years) is slightly higher than ours (320 in one year, see Table 5.19).
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