As immunotherapies and other drug therapies proliferate, complicating care, several Canadian oncologists have recently posed a question: should patients be steered to get systemic treatment at high-volume centers?
For surgery, studies have consistently found a correlation between the number of complex operations a facility performs and better outcomes, including lower mortality rates, the physicians wrote in a recent editorial in the Journal of Oncology Practice (JOP).1 One 1998 landmark study they cited found that a patient’s likelihood of dying from an esophagectomy ranged from 3.4% at high-volume hospitals to 17.3% at low-volume hospitals.2
While there hasn’t been a similar level of volume-to-outcome scrutiny surrounding the receipt of systemic therapy for cancer, this type of research needs to kick into high gear moving forward, said Michael Raphael, MD, the editorial’s lead author and a medical oncologist at Sunnybrook Health Sciences Centre in Toronto, Ontario, in an interview with Cancer Therapy Advisor.
“The treatment of patients has become much more complex and thankfully, that’s associated with longer and better outcomes,” Dr Raphael said. “But it makes it much more difficult for the practicing oncologist to make sure that they’re providing optimal care for each patient.” Should oncologists, he asked, still be treating every type of malignancy in 2019?
Dr Raphael described some of the potential downsides of sending individuals to high-volume treatment locations, including whether patients would be willing or able to travel for drug treatment, which, unlike surgery, could feasibly require multiple sessions over the course of many months. Also, steering patients to high-volume centers for systemic treatment could worsen existing health disparities, he said, “further marginalizing those patients who can’t afford to travel.”
One-third of patients can be easily motivated to travel at least an hour further for a cancer operation once they learn about the safety and quality advantages of doing so, according to a study published in 2018 in JAMA Network Open. But 12% of the 1016 individuals surveyed were highly resistant to travel, and they were more likely to be nonwhite, lower-income patients, according to the study’s findings.3
But Daniel Boffa, MD, who was one of the authors of the JAMA Network Open study, believes that any treatment advantages that high-volume centers might have over their community counterparts could be more easily bridged for drug therapy than complex surgery, and this could be achieved without forcing patients to travel. Through consultation with a specialty center, the community facility could both get guidance on the optimal regimen and support if worrisome complications or side effects develop, said Dr Boffa, who is also professor of thoracic surgery at Yale School of Medicine in New Haven, Connecticut. “If you have a chemotherapy complication, you don’t necessarily need the same support [onsite] than if you have an esophagectomy complication,” he said.
The entire field of research “has shown that regionalization is the nuclear option,” Dr Boffa observed. “You’re much better off optimizing care for patients closer to home,” he added. He cited numerous advantages of this approach, including better treatment compliance by the patient, easier evaluation if side effects emerge, and enhanced ability to monitor patient quality of life.