Minimally invasive surgery for most GI cancers infrequent at most hospitals

Last Updated: 2017-05-26

By Joan Stephenson

NEW YORK (Reuters Health) - Although there may be some important benefits for patients who undergo minimally invasive surgery (MIS) for gastrointestinal cancer, the majority of U.S. hospitals do not use MIS to treat such patients, new research suggests.

In addition to finding considerable variation of MIS use for gastrointestinal cancer resection across U.S. hospitals, the study showed that hospitals with higher rates of MIS use “appear to guide patients through the postoperative period more efficiently, and patients treated at these hospitals are able to start their postoperative cancer treatments, such as chemotherapy, sooner,” first author Meredith C. Mason, of Baylor College of Medicine in Houston, told Reuters Health by email.

Although a number of studies indicate that MIS offers such benefits as lower rates of complications and shorter hospitalizations and recovery times, research also suggests that adoption of this approach to treat GI cancers over the last decade has been slow, she noted.

To investigate the extent to which MIS is being used to treat GI cancers, the researchers analyzed data from the National Cancer Data Base, a prospectively based registry with information from more than 1,500 Commission on Cancer-accredited facilities.

The retrospective cohort study involved more than 137,000 patients who had undergone surgical resection of esophageal, gastric, pancreatic, hepatobiliary, colon, or rectal cancer in 2010 to 2013. The researchers calculated disease-specific, hospital-level, adjusted MIS utilization rates to evaluate MIS use and its relationship to perioperative outcomes.

Use of MIS for all GI cancers included in the study increased significantly from 2010 to 2013, ranging from a 42% increase for colon cancer to a 68% increase for rectal cancer, the researchers report in Annals of Surgery, online May 11.

Despite this trend, most hospitals remain “low utilizers” of the approach for most types of GI malignancies, using it in no more than 30% of cases. The exceptions were MIS use for colon and rectal cancers, for which a minority of hospitals (30% and 44%, respectively) were low utilizers of MIS.

An analysis of perioperative outcomes across hospital MIS utilization quartiles found that the median number of lymph nodes examined was significantly greater and median hospital length of stay was significantly shorter with increasing hospital use of MIS (p<0.001 for all cancer types for both outcomes).

Higher rates of MIS use also were associated with a faster transition after surgery to receiving adjuvant chemotherapy for some cancer types. Postoperative complications are frequently the reason patients are unable to make this transition, the researchers note.

Median time to adjuvant treatment significantly decreased across quartiles for gastric and colon cancers (52 days vs. 48 days for gastric cancer, p=0.025; 46 vs. 43 days for colon, p<0.001). For gastric cancer patients, each 10% increase in MIS utilization across deciles was associated with 3.3 fewer days to receiving adjuvant chemotherapy.

Care at facilities with higher MIS rates was associated with a significantly lower risk of death for colon cancer and rectal cancer, but not for other GI cancers.

The findings show “the extent of the variation across U.S. hospitals in terms of minimally invasive surgery use for gastrointestinal cancer resection and that this variation seems to translate into important differences in postoperative outcomes and the efficiency of cancer care,” Dr. Mason said.

It’s possible, she noted, that hospitals with higher MIS use also have additional resources that allow them to be more efficient in the care they deliver.

“If this is the case, it would be critical to understand what these resources are and how they could potentially be modeled at other hospitals in order to help them improve the quality of cancer care for their patients,” she said.

In finding differences in the uptake of MIS between hospitals and outcomes, “these associations should not be viewed as evidence of causation,” Dr. Nancy Baxter, an American Society of Clinical Oncology expert in GI cancers and head of the division of general surgery at St. Michael’s Hospital in Toronto, told Reuters Health by email.

Hospitals that have a high rate of MIS may differ from those with a low rate in many other ways, such as volume of surgery, experience with the cancer and access to other resources like ICUs, explained Dr. Baxter, who was not involved in the current study.

Because of this, “it is difficult to attribute any outcome differences only to the rate of use of minimally invasive surgery,” she said.

“Interestingly, for outcomes like length of stay and time to adjuvant therapy, although significant differences were found, the actual number of days that differed was very small,” she added.

The study had no commercial funding, and the authors reported no conflicts of interest.

SOURCE: http://bit.ly/2rT6IuP

Ann Surg 2017.