The standard of care for many patients with esophageal cancer, particularly those with early-stage or locally advanced disease, is esophagectomy. Ongoing efforts have encouraged centralization of these procedures to high-volume centers, despite increased travel burden for some patients. In a large retrospective cohort study of the National Cancer Database in the United States (N = 17,970), Sara Sakowitz, MS, MPH, and colleagues examined the association between travel distance to high-volume centers and survival.
Traveling to undergo esophagectomy at high-volume centers was found to be linked with superior 1-year and 5-year overall survival compared with receiving care locally at low-volume centers. These findings persisted after comprehensive multivariable risk adjustment, consideration of hospital clustering, and among patients who experienced fragmented care due to travel distance. Survival benefits were most significant for patients with locoregionally advanced disease. Mortality risk was 30% lower at 1 year and 20% lower at 5 years for those who traveled to high-volume centers. The authors suggest that high-volume centers may have established multidisciplinary care pathways, greater experience perioperatively managing advanced tumor burdens, and access to advanced therapies or clinical trials, which may contribute to improved outcomes. Traveling to receive care at high-volume centers was associated with increased lymph node harvest and greater likelihood of complete resection with negative margins. Other factors associated with greater mortality include increasing age, greater comorbidity, Medicaid insurance, and stage III disease.
High level
The association between high-volume centers and survival has implications toward national policy and practice, as well as the broader centralization of complex oncologic care, and warrants further discussion. To continue the momentum of this initiative, future studies should seek to ascertain barriers to care and develop novel targeted treatment pathways to ensure equitable access to high-volume centers and high-quality care for patients with esophageal adenocarcinoma. More research is also needed to determine whether increased travel distance may contribute to postoperative care fragmentation and readmission to centers closer to the patient’s residence. High-volume centers may find discharge planning to be more complex, given the need to coordinate transportation, and should continue to expand their armamentarium of telehealth resources and other approaches to enhance continuity of care. With socioeconomic and demographic factors presenting barriers for some patients, clinicians and hospitals must seek to build and expand referral networks across communities, counties, and states, to ensure that all patients have access to optimal esophagectomy and perioperative care.
Ground level
The link between high-volume centers and survival in this study supports regionalization of care for patients with esophageal adenocarcinoma, particularly those who require more complex or multimodal management of their disease. Centralization of surgical management for esophageal cancer to high-volume centers may be linked with improved outcomes and should be considered, especially for patients with locoregionally advanced disease. Clinicians must consider the socioeconomic barriers, social determinants of health, and access to psychosocial support and advocate to help patients overcome barriers to receiving optimal surgical care.