Researchers have found differences in hospitals giving care to patients
with gastric or pancreatic cancer. The report, published in the July
issue of Archives of Surgery, found that if
patients are treated at hospitals that conduct relatively more cancer
surgeries or at hospitals deemed comprehensive care centers, the
patients have more lymph nodes examined by physicians who are
investigating the spread and prognosis of their disease.
Cancer often originates in gastric system and metastasizes (spreads) to
other parts of the body, including the lymph nodes. After cancer tissue
is taken out of the stomach or pancreas, the metastatic progress in the
lymph nodes has been used to predict a patients' prognosis. If a
physician analyze too few of these lymph nodes and come to an incorrect
conclusion about the state of malignancy, an incorrect cancer
classification may result. This ultimately changes the prognosis, the
treatment method, and a patient's eligibility for clinical trials. The
authors note that, "Although the precise number varies,
current guidelines recommend resection and pathologic evaluation of at
least 15 regional lymph nodes for gastric and pancreatic cancer."
To further study the practice of evaluating lymph nodes, Karl Y.
Bilimoria, M.D., M.S. (American College of Surgeons and Feinberg School
of Medicine, Northwestern University, Chicago) and colleagues analyzed
records from the National Cancer Data Base (NCDB). The researchers
identified patients who had a gastric or pancreatic cancer diagnosis in
2003 or 2004 and then had surgery. The investigators also classified
the hospitals where the surgeries occurred, organizing them by case
volume and by the level of cancer-related services and specialists.
There were 3,088 patients with gastric cancer. Of these:
11.6% had surgery at a National Cancer Institute
(NCI) or National Comprehensive Cancer Network (NCCN-NCI) hospital
34% had surgery at a hospital affiliated with a medical
schools but not NCCN-NCI
54.4% had surgery at community hospitals
There were 1,130 patients with pancreatic cancer. Of these:
19% had surgery at NCCN-NCI hospitals
43.3% had surgery at a hospital affiliated with a
medical schools but not NCCN-NCI
37.7% had surgery at community hospitals
The researchers found that patients who had surgery at NCCN-NCI
hospitals had more lymph nodes examined than patients who had surgery
at community hospitals. Specifically, gastric cancer patients had an
average of 12 lymph nodes examined at NCCN-NCI hospitals compared to 6
at community hospitals, and pancreatic cancer patients had 9 compared
to 6, respectively. In addition, "Patients at highest-volume hospitals
had more lymph nodes examined than patients at low-volume hospitals
(median, 10 vs. six for gastric cancer and eight vs. six for pancreatic
cancer)." Though 15 lymph node evaluations are recommended, only 23.3%
of gastric cancer patients and 16.4% of pancreatic patients received
such treatment. Compared to patients at community or low-volume
hospitals, those at high-volume or NCCN-NCI hospitals were more likely
to have 15 or more nodes evaluated.
"Nodal status is a powerful predictor of outcome, and every reasonable
attempt should be made to assess the optimal number of lymph nodes to
accurately stage disease in patients with gastric and pancreatic
cancer," conclude the researchers. "Moreover, differences in nodal
evaluation may contribute to improved long-term outcomes at NCCN-NCI
centers and high-volume hospitals for patients with gastric and
pancreatic cancer."
Effect of Hospital Type and Volume on Lymph Node Evaluation
for Gastric and Pancreatic Cancer
Karl Y. Bilimoria, MD, MS; Mark S. Talamonti, MD; Jeffrey D. Wayne, MD;
James S. Tomlinson, MD; Andrew K. Stewart, MA; David P. Winchester, MD;
Clifford Y. Ko, MD, MS, MSHS; David J. Bentrem, MD
Archives of Surgery (2008).
143[7]: pp. 671
- 678.
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Written by: Peter M Crosta