Patients having aggressive surgery for pleural mesothelioma at high-volume facilities experience fewer complications, shorter hospital stays and lower 30-day readmission rates than those treated at low-volume centers.
Overall survival rates were higher and 90-day mortality rates were lower at the high-volume facilities, according to a study published in the June issue of Lung Cancer.
The new study, based on data from the National Cancer Database (NCDB), is the largest to compare facility volume with post-surgery outcome for pleural mesothelioma.
“In general, going to a high-volume center for oncology care makes sense, but particularly for a rare cancer such as mesothelioma,” Dr. Charles Simone, radiation oncologist at University of Maryland Medical Center and study co-author, told Asbestos.com. “Coupled with being one of the largest oncology surgeries there is, it makes expertise critically important.”
Simone is the director at the Maryland Proton Treatment Center and part of the multidisciplinary mesothelioma tumor board at the University of Maryland Medical Center.
He was joined by researchers from Penn Medicine in Philadelphia and the Allegheny General Hospital in Pittsburgh.
“Our hypothesis [going into the study] was there would be less perioperative mortality in high-volume centers because there is more surgical expertise,” Simone said. “And that’s exactly what we found.”
Fewer Complications at High-Volume Facilities
The study compared complications of pleural mesothelioma patients treated at high-volume facilities (HVF) with those treated at low-volume facilities (LVF).
HVF vs. LVF
|30-Day Readmission Rates||4.6 percent||6.1 percent|
|90-Day Mortality Rate||10 percent||14.6 percent|
|Median Overall Survival||18 months||15 months|
|Source: “Facility volume and postoperative outcomes for malignant pleural mesothelioma: A National Cancer Data Base analysis,” published in the journal Lung Cancer in June 2018.|
The study involved 1,307 cases of pleural mesothelioma from 2004 to 2013 with 48 percent coming from a low-volume facility.
A high-volume facility was defined as being in the top 10 percent in the number of mesothelioma surgical cases handled. All others were in the low-volume category.
Inclusion criteria were patients with newly diagnosed disease who underwent either an extrapleural pneumonectomy (EPP) or a pleurectomy and decortication (P/D), the two most aggressive surgeries for the asbestos-related cancer.
Surgery for mesothelioma is challenging and typically comes with some level of post-operative complications.
According to an earlier randomized trial, 69 percent of patients experience post-operative complications with EPP.
P/D accounted for 84 percent of surgeries at the low-volume facilities and 75 percent at the high-volume centers.
“The high-volume facilities were more apt to do the (EPP) — which is known to have a higher toxicity rate and a potentially worse survival rate — but survival was better in those high-volume centers because there is more expertise,” Simone said. “That tells me the difference [in facility types] is even more extreme than it appears on paper.”
Patient Selection for Surgery Still Key
The HVF were mostly (84 percent) academic, while 72 percent of the LVF were community based.
Patient selection and adjuvant therapy may have factored into the HVF having a more optimistic rating than the LVF.
Only 8 percent of patients at the HVF had the toughest-to-treat sarcomatoid histology, while 13 percent at the LVF had that mesothelioma cell type.
The percentage of patients receiving chemotherapy and radiation was higher (71 percent and 23 percent, respectively) at the HVF than at the LVF (56 percent and 14 percent, respectively).
Regardless of facility, higher overall survival was associated with patients receiving chemotherapy and increasing radiation dosage.
“If these surgeries were easy to do, it probably wouldn’t make much difference,” Simone said. “For this tumor type, and for this surgery, expertise makes a difference.”