Facility volume and postoperative outcomes for malignant pleural mesothelioma: A National Cancer Data Base analysis

Our plain-English summary of Facility volume and postoperative outcomes for malignant pleural mesothelioma: A National Cancer Data Base analysis, by V. Verma, C.A. Ahern, C.G. Berlind, et al (Lung Cancer, 2018).

The study

• Authors: V. Verma, C.A. Ahern, C.G. Berlind, W.D. Lindsay, S. Grover, M.J. Culligan, J.S. Friedberg, C.B. Simone
• Journal: Lung Cancer
• Published: 2018;120:7-13
• Cited by: 19 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Purpose: This study of a large, contemporary national database evaluated postoperative outcomes and overall survival (OS) for malignant pleural mesothelioma (MPM) by facility volume.

Methods: The National Cancer Database was queried for newly-diagnosed non-metastatic MPM undergoing definitive surgery (extrapleural pneumonectomy (EPP) or pleurectomy/decortication (P/D)). Patients were dichotomized into those receiving therapy at a high-volume facility (HVF), defined a priori at the 90th percentile of case volume, with all others categorized as lower-volume facilities (LVFs). Statistics included multivariable logistic regression, Kaplan-Meier analysis, propensity-matching, and multivariable Cox proportional hazards modeling. Sensitivity analysis varied the dichotomized HVF-LVF cutoff and evaluated effects on postoperative outcomes and OS.

Results: Of 1307 patients, 621 (48%) were treated at LVFs and 686 (52%) at HVFs. HVFs were more often in the Middle/South Atlantic regions, and less likely in New England, South, and Midwest. Notably, 75% of procedures at HVFs were P/Ds, versus 84% at LVFs (p < 0.001). Patients treated at HVFs experienced shorter length of postoperative hospitalization (p = 0.035), lower 30-day readmission rates (4.6% vs. 6.1%, p = 0.021), and lower 90-day mortality rates (10.0% vs. 14.6%, p = 0.029). Median OS for respective groups were 18 versus 15 months (p = 0.010), which were not significant following propensity-matching (p = 0.540). On multivariable analysis, facility volume did not independently predict for OS. Sensitivity analyses confirmed the postoperative outcomes and OS findings.

Conclusions: This is the largest investigation to date assessing facility volume and outcomes following surgery for MPM. Although no independent effects on OS were observed, postoperative outcomes were more favorable at HVFs. These findings have implications for postoperative management, patient counseling, referring providers, and cost-effectiveness.

Copyright © 2018 Elsevier B.V. All rights reserved.

In plain English

This was a retrospective analysis of the U.S. National Cancer Data Base for 2004–2012. It covered 1307 patients at 476 facilities with newly diagnosed malignant pleural mesothelioma without distant spread. All had one of two major operations: extrapleural pneumonectomy or pleurectomy/decortication. Facilities at or above the 90th percentile of case volume were called high-volume. Of the patients, 686 were treated at high-volume facilities and 621 at lower-volume ones. Asbestos exposure was not studied. Patients at high-volume facilities had lower 30-day readmission (4.6% vs. 6.1%) and lower 90-day mortality (10.0% vs. 14.6%). Their hospital stays were statistically shorter, although the median was 6 days in both groups. Thirty-day mortality was similar (4.7% vs. 4.6%). Median overall survival was 18 versus 15 months, but the difference was not statistically significant after propensity matching. Facility volume did not independently predict survival. The authors concluded that postoperative outcomes were more favorable at high-volume facilities, with no independent effect on survival. They noted that retrospective studies cannot fully control for bias, and that the database does not list specific complications.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective analysis of a national cancer registry database (National Cancer Data Base), using logistic regression, Kaplan-Meier analysis, propensity matching and Cox modeling
• Who was studied: 1307 patients with newly diagnosed, non-metastatic malignant pleural mesothelioma who had extrapleural pneumonectomy or pleurectomy/decortication, treated at 476 facilities in the United States, from the NCDB file covering 2004–2012
• Exposure: Asbestos exposure was not studied. The comparison was treatment at a high-volume facility (at or above the 90th percentile of patients treated per facility) versus a lower-volume facility
• Main results:
  • 686 patients (52%) were treated at high-volume facilities and 621 (48%) at lower-volume facilities
  • Pleurectomy/decortication made up 84% of procedures at lower-volume facilities versus 75% at high-volume facilities (p less than 0.001)
  • Median postoperative hospital stay was 6 days in both groups, but it was statistically lower at high-volume facilities (p = 0.035)
  • The 30-day readmission rate was 4.6% at high-volume facilities versus 6.1% at lower-volume facilities (p = 0.021)
  • There was no difference in 30-day mortality: 4.7% at high-volume versus 4.6% at lower-volume facilities (p = 0.656)
  • The 90-day mortality rate was 10.0% at high-volume facilities versus 14.6% at lower-volume facilities (p = 0.029)
  • In the overall population, median overall survival was 18 months (95% CI 17–19) at high-volume facilities versus 15 months (95% CI 13–17) at lower-volume facilities (p = 0.010)
  • After propensity matching, median overall survival was 17 versus 15 months, a difference that was not statistically significant (p = 0.540)
  • On multivariable analysis, facility volume did not independently predict overall survival
  • In sensitivity analysis, the 30-day readmission and 90-day mortality findings held at all tested volume cutoffs. Length of stay was statistically significant at cutoffs from the 87th percentile upward
• The authors' conclusion: The authors concluded that facility volume had no independent effect on overall survival, but postoperative outcomes were more favorable at high-volume facilities. They described the data as needing corroboration by other studies
• Limitations the authors state:
  • As a retrospective study, it cannot completely control for biases in who received a particular treatment
  • Facilities treated very few patients: an average of 2.7 patients each over the whole period
  • Facility volume relates to the population of the area and is not necessarily an accurate stand-in for surgeon experience or skill
  • Only Commission on Cancer-accredited facilities contribute data, so the findings may not represent the whole U.S. population
  • The database does not list specific postoperative complications
  • Missing values for histology and surgical margins make interpretation difficult
  • The database does not track variables such as pulmonary function tests, salvage and intraoperative therapies, or clinical trial enrollment, all of which could affect survival

Topics

The National Library of Medicine indexes this study under subjects our site covers: Lung cancer, Mesothelioma.

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Overall Survival, Extrapleural Pneumonectomy (EPP), Pleurectomy/Decortication (P/D).

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• Impact of Hospital Volume on Outcomes of Elective Pneumonectomy in the United States — J. Hadaya, V. Dobaria, et al. (2020)
• National Cancer Database Report on Pneumonectomy Versus Lung-Sparing Surgery for Malignant Pleural Mesothelioma — V. Verma, C.A. Ahern, et al. (2017)
• Role of postoperative radiotherapy in the management of malignant pleural mesothelioma : A propensity score matching of the SEER database — O. Abdel-Rahman (2017)

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