The Volume-Outcome Relationship in Cancer Surgery - Do Rural Patients have a Choice? — ASN Events

The Volume-Outcome Relationship in Cancer Surgery - Do Rural Patients have a Choice? (#93)

Mark Smithers 1 , Dannie Zarate 2 , Hazel Harden 2 , Shoni Colquist 2 , Euan Walpole 3
  1. Princess Alexandra Hospital, Woolloongabba, QLD, Australia
  2. Queensland Cancer Control Analysis Team, Queensland Health, Brisbane, Queensland, Australia
  3. PAH and QEII Hospital Network, Queensland Health, Brisbane, Qld, Australia


Evidence of higher operative mortality for complex cancer surgeries performed in low volume hospitals have led to the consolidation of these procedures in high volume centres in many health service networks around the world. In this study, we analysed the volume-outcome relationship in three complex cancer surgeries in Queensland and estimated the proportion of patients treated by low volume hospitals according to their remoteness of residence.


We analysed the 30-day postoperative mortality rate of all Queensland residents who underwent Whipple surgery for pancreatic cancer (n=664), lobectomy, partial resection, or pneumonectomy for non-small cell lung cancer (n=2,570), and gastrectomy for gastrointestinal cancers (n=1,017) diagnosed between 2001 and 2010. The median annual hospital volume in each procedure group was used to divide hospitals into low and high volume categories, while patients were classified into metropolitan, regional, and rural groups based on residence at diagnosis. Risk adjustments were made using proportional hazards regression controlling for demographic and clinical characteristics.


The 30-day postoperative mortality rates were 2.7% for Whipple surgery, 1.8% for NSCLC resection, and 4.0% for gastrectomy. Relative to high volume hospitals, the risk of postoperative death in low volume hospitals was 4.8 times higher (95% confidence interval [CI]: 1.5-15.0) for Whipple surgery, 2.5 times higher (CI: 1.6-4.1) for NSCLC resection, and 1.7 times higher (CI: 0.9-2.9) for gastrectomy. Across the three procedure groups, 75% of rural patients underwent surgery in low volume hospitals, compared to 55% and 45% for metropolitan and regional patients respectively.


Complex cancer surgery outcomes are poorer in low volume hospitals. Referral to high volume hospitals is likely to impact the majority of rural cancer patients who are treated in low volume centres.