Adjuvant Care at High-Volume Centers Shows Improved Survival in Pancreatic Cancer

James L. Abbruzzese, MD

Patients with pancreatic cancer who were treated at high-volume centers had a 16-month improvement in overall survival versus those who were treated at community medical centers, according to findings from a study presented at the 2016 Gastrointestinal Cancers Symposium.

In the retrospective study, researchers examined 139 patients with pancreatic cancer treated at high-volume centers and 106 patients treated in a community medical center. Patients at the high-volume center had a median survival of 44 months, with a 39% 5-year survival rate, whereas patients treated in a community medical center had a median survival of 28 months, with a 25% 5-year survival rate.

Improvements in survival experienced by patients with pancreatic cancer treated with adjuvant chemotherapy at high-volume centers compared with community practices could be related to the ability to provide multidisciplinary care, James L. Abbruzzese, MD, said during the meeting.

“If we accept the results of the respective study, then there are two possible explanations. Volume is obviously one, but I am going to try to suggest that there are other factors that are at least as important or even more important,” said Abbruzzese, professor of Medicine, associate director of Clinical Research and Training, Duke University.

OncLive,

OncLive: Why do high-volume centers have better outcomes for patients with pancreatic cancer?

In an interview with Abbruzzese discusses the underlying disparity between high-volume centers and community medical centers.Abbruzzese: The session was geared around some data that was presented at the meeting suggesting that patients who received adjuvant chemotherapy after pancreatic resection had better outcomes if they received their chemotherapy through a high-volume center versus out in the community. It was a retrospective study, which I think controlled for all the factors that they could control for, but the fact that it is retrospective means that it's difficult to ascribe all of the differences that were seen to the fact that patients were treated at a high-volume center.

The bottom line of the abstract was that patients had better outcomes if they were treated at the high-volume center. The question then is, "Why would that be the case?" It's known that with respect to surgery, the higher the volume of surgery that a surgeon performs, the better overall outcomes there generally is. That has been demonstrated in numerous studies. What's not really understood is whether other elements of care, like chemotherapy, are better delivered in a high-volume center as well. If that's the case, then why is that so?

I represented, on a panel discussion, the viewpoint of the larger academic center, and I think the reason for the positive outcome for the abstract that was presented probably has to do more with the processes and extensive number of physicians with different specialties that can be brought to these centers for patients with pancreatic cancer. This is compared to just volume alone for the positive outcome.

What an academic center provides for patients is that they have ready access to individuals with expertise in surgery, radiation oncologists, medical oncologists, nutritionists, gastroenterologists, and so on. All of the elements that are required to take optimal care of the patients are centered in one place. It makes it very convenient for patients.

It also means that the people who are typically working closely together, working in multidisciplinary groups and doing research together, are together. I think these are the process issues that relate to the better outcomes seen at the larger centers.

I don't think there were any strong arguments against that feeling either, but there are other competing issues for patients. Cost is one major issue, as is the need to travel, especially for older patients or for individuals that for logistical and cost reasons cannot travel to a major center for multidisciplinary care.

The challenge we discussed, especially toward the end of the presentation, is if there are any other approaches that would be able to bring the specialty care out to the patients in a way that achieves the good outcomes seen, but without having the patient actually, physically travel to a high-volume center.

What are some of the challenges for the high-volume, multidisciplinary centers?

The biggest one, and this also came up toward the end of the session, is the economics around that. How does an academic center maintain its economic viability in an increasingly cost-aware, value-aware system?

For community centers that don't have all these options to offer patients, what can they do to provide better care for patients with pancreatic cancer?

Currently, academic centers work because of the reimbursement received for the care of the patients. There is a sufficient amount of reimbursement for the care to be able to provide access to all the ancillary people and support that the patients need. Going forward, as Medicare and other payers look at models for reimbursement for the cost of care, I think that is going to put a lot of academic and high-volume centers to be able to maintain the personnel required to provide the best overall care. That's a big stressor that I think is coming in the future.It's a big challenge. We talked about if there are ways that community-based practices can use Internet-based technologies, like video teleconferences and other ways of just getting advice and input from multiple specialists for their patients with pancreatic cancer. It's a real challenge and I don't think we can really develop a one-size-fits-all sort of approach to this. In most cases, it's probably going to require developing close collaborations with individual centers that are willing to provide these community centers with resources over the Internet and other strategies to try and help them out.