Cancer Surgery, Especially by Experienced Surgeons, Saving More Lives

Reports from several governmental and nongovernmental organizations show that overall cancer death rates have declined.

Vivian Ho

While there are several factors that can account for this trend—increased diagnosis of cancer at earlier stages, for example—a new medical research study shows that cancer surgery also has become safer over time. Furthermore, there is a significant association between the number of operations performed by hospitals and by doctors and the decreased numbers of cancer deaths.

“Operative mortality rates for six specific cancers declined between the time periods 1988 to 1991 and 1997 to 2000 in the three states we studied,” says Vivian Ho, an associate professor of economics at Rice and a fellow in health economics at Rice’s James A. Baker III Institute for Public Policy. “In the same time periods, the number of hospital and doctor operations for those cancers increased, and the association between more operations and lower cancer death rates in hospitals was quite significant.”

The statistics reflect the total volume of surgeries performed at a particular hospital or the total number of operations performed by a particular doctor regardless of hospital location. While prior research found that hospitals and surgeons performing more operations tended to have fewer cancer patient deaths, no study has examined the association between provider volume and trends in cancer surgery mortality over time. In an article titled “Trends in Hospital and Surgeon Volume and Operative Mortality for Cancer Surgery” in the Annals of Surgical Oncology, Ho and co-authors Martin J. Heslin, Huifeng Yun, and Lee Howard from the University of Alabama report on the first comprehensive study to analyze data on six different types of cancer operations with an extensive sample of surgeons and hospitals in Florida, New Jersey, and New York.

The researchers measured population-based trends in deaths from operations for colorectal cancer, specifically colon cancer and cancer of the rectum; pulmonary lobectomies; pneumonectomies; esophagectomies; and pancreaticoduodenectomies, or the Whipple procedure, over a 13-year period.

The smallest decline in patient mortality occurred in pulmonary lobectomy patients, specifically a decline of .8 percent from 4.1 percent between 1988 and 1991 to 3.3 percent from 1997 to 2000. Esophagectomy patients, whose rate of death declined from 14.5 percent to 10.5 percent over the sample period, experienced the largest decrease.

Between the time periods 1988 to 1991 and 1997 to 2000, the volume of hospital and doctor operations increased for five of the six types of cancers, with the mean percentage increase equal to 24.3 percent for hospitals and 24.2 percent for surgeons. Further statistical analyses suggest that these increases in provider volume can explain the entire decline in operative mortality for pulmonary lobectomy and a substantial part of the mortality decline in four of the six other surgeries.

In light of their findings, Ho and her research colleagues urge the expansion of centralization efforts such as the Leapfrog Group, a coalition of large employers and other healthcare purchasers that encourages patients and employees to seek out high-volume providers. They also believe that enforcement by states of Certificate of Need regulations, such as those for open-heart surgery and transplantation, might encourage even lower cancer mortality rates by limiting the number of hospitals that perform only a few cancer operations.

First introduced by the federal government in the 1970s and still in force in some states today, Certificate of Need regulations permit hospitals and other healthcare providers to build costly new facilities or offer certain new or expanded services only if they can demonstrate a proven need for them. The program is designed to prevent unnecessary duplication of services by selecting the best proposal among competing applicants who wish to provide a particular healthcare service.

—B. J. Almond