Evidence has long supported a volume-outcome relationship for surgical resection of pancreatic cancer, yet surgery alone is not enough to prolong survival in patients with localized disease. James L. Abbruzzese, MD, of Duke University and Duke Cancer Institute, Durham, North Carolina, discussed his thoughts on the volume-outcome relationship in a general session on pancreatic cancer patterns of care and impact on outcomes held during the 2016 Gastrointestinal Cancers Symposium.1
Dr. Abbruzzese also commented on a separate presentation by Mandelson et al,2 which evaluated the impact of adjuvant therapy at a high-volume center on overall survival (see above).2 His main point was that the better results seen at high-volume and academic centers might be attributed more to “process” than to “volume.”
What Is Driving the Difference?
“High-volume or academic centers may be a proxy for structural and process differences that include staffing; advanced surgical technology; use of guidelines and treatment algorithms; more accurate staging; and multidisciplinary management, which includes disease-specific tumor boards,” Dr. Abbruzzese suggested.
He views many specialties as important for the optimal management of pancreatic cancer, and they are more common in high-volume and academic centers. In addition to the more obvious disciplines, he cited diagnostic imaging, interventional radiology, nutrition, pain management, palliative care, endocrinology, and more. The initial assessment alone, pointed out Dr. Abbruzzese, involves several imaging modalities with sequences optimized to assess tumor/vascular relationships, the liver parenchyma, and the peritoneum/omentum.
Composition of the Health-Care Team
Multidisciplinary assessment is needed to exclude definitive evidence of metastatic disease and evaluate the critical tumor/vascular relationship. Accurate initial staging is critical to determining the institutional management strategy for clearly resectable, borderline resectable, unresectable/locally advanced, and metastatic disease.
Finally, supportive and palliative care is also a complex process that includes nutritional support, pain management, antiemesis interventions, and treatments for the many toxic effects of therapy. “These services must collaborate to ensure effective care,” Dr. Abbruzzese said.
In sum, high-volume and academic centers have enough patients to develop technical expertise, to accumulate the experience needed to anticipate problems and intervene rapidly, and to staff a multidisciplinary team that facilitates multifaceted management of pancreatic cancer, he said.
“I think the differences are likely to reside in the composition of the health-care team, rather than whether the care is rendered in a high-volume center or in the community,” Dr. Abbruzzese maintained. “Adequate patient volumes lead to deep expertise and are important for highly technical aspects of care.”■
Disclosure: Dr. Abbruzzese has consulted for Acerta Pharma, Celgene, Daiichi Sankyo, EMD Serono, Halozyme Therapeutics, and Merck Sharp & Dohme. He has received honoraria from Celgene and Halozyme Therapeutics.
References
1. Abbruzzese JL: Role of academic centers in the management of pancreatic cancer. 2016 Gastrointestinal Cancers Symposium. Presented January 22, 2016.
2. Mandelson MT, Picozzi VJ: Resected pancreatic cancer: Impact of adjuvant therapy at a high-volume center on overall survival. 2016 Gastrointestinal Cancers Symposium. Abstract 191. Presented January 22, 2016.
