A Paucity of Data
If drug treatment were regionalized, one potential advantage might be that the entire clinical team would become more accustomed to the regimens, including the nurses who help manage the potential side effects of treatment, and the pharmacists who assist with dose adjustments, Dr Raphael said.
“Potentially, that could be associated with better patient outcomes,” Dr Raphael said. “That remains unknown based on the current literature.”
To date, there are relatively few studies looking at a care center’s volume in relation to patient outcomes following systemic drug treatment, Dr Raphael and his colleagues wrote in the JOP editorial. In an initial literature review, Dr Raphael and his coauthors identified a dozen studies looking at the volume-outcome relationship with systemic therapy, the bulk of which involved melanoma, pancreatic cancer, or testicular malignancies. But they also were critical of those studies, identifying methodological limitations such as a reliance on retrospective data and poor adjustment for patient case mix.1
The paucity of research could be in part due to the difficulties in comparing drug treatment outcomes with results from surgical procedures, Dr Raphael said. While an operation is a single event with a designated surgeon and a short-term goal, such as achieving 30-day mortality — drug treatment can last for months and can involve several specialists and follow-up tests.
For the less-common disease of testicular cancer, though, a group of physicians has already made the case — via a 2017 commentary in the Journal of Clinical Oncology — that patients should either be treated in high-volume centers or have access to the expertise typically found at these large health systems.4 One analysis they cite, published in 2014, showed that nearly one-fourth of the primary retroperitoneal lymph node dissections done in the US during a 10-year stretch were performed by just 3 urologists. Among the small percentage of urologists who perform this specific surgery in the US, the median annual case load was a single procedure, according to the analysis published in the journal Urology.5
Selection and administration of the therapies involved may require particular provider expertise, said Craig Nichols, MD, a medical oncologist who specializes in testicular cancer and was also one of the authors of the 2017 JCO commentary.
“It’s an uncommon disease and very few people have sufficient experience to handle complex cases,” said Dr Nichols, who also is an executive officer at the Southwest Oncology Group (SWOG) Cancer Research Network. “It’s a disease where we have good data sets that [show that] high-volume centers have not only better outcomes, but less expensive outcomes — pretty much across the board — but particularly in complex surgeries.”