Cancer centers and high-volume hospitals may examine more lymph nodes in cancer patients

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Patients with gastric or pancreatic cancer appear to have more lymph nodes examined for the spread of their disease if they are treated at hospitals performing more cancer surgeries or those designated as comprehensive cancer centers, according to a report in the July issue of Archives of Surgery, one of the JAMA/Archives journals.

Lymph node metastases (indicating the spread of cancer) have been shown to predict patients’ prognosis after cancer tissue is removed from the stomach or pancreas, according to background information in the article. If too few lymph nodes are examined for malignant cells, a patient’s cancer may be incorrectly classified, altering prognosis, treatment decisions and eligibility for clinical trials. “Although the precise number varies, current guidelines recommend resection and pathologic evaluation of at least 15 regional lymph nodes for gastric and pancreatic cancer,” the authors write.

Karl Y. Bilimoria, M.D., M.S., of the American College of Surgeons and Feinberg School of Medicine, Northwestern University, Chicago, and colleagues used records from the National Cancer Data Base (NCDB) to identify patients who had surgery for gastric or pancreatic cancer that was diagnosed in 2003 or 2004.

Hospitals at which patients had surgery were classified based on case volume and also based on access to cancer-related services and specialists.

Of 3,088 patients with gastric cancer, 11.6 percent had surgery at a hospital designated as a National Cancer Institute (NCI) comprehensive cancer center or as part of the National Comprehensive Cancer Network (NCCN-NCI hospitals), 34 percent at other academic hospitals (affiliated with a medical school but not designated as NCCN-NCI facilities) and 54.4 percent at community hospitals. Nineteen percent of 1,130 pancreatic cancer patients had surgery at NCCN-NCI hospitals, 43.3 percent at other academic hospitals and 37.7 percent at community hospitals.

“Patients undergoing surgery had more lymph nodes examined at NCCN-NCI hospitals than at community hospitals (median [midpoint], 12 vs. six for gastric cancer and nine vs. six for pancreatic cancer),” the authors write. “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).” Overall, 23.2 percent of patients with gastric cancer and 16.4 percent of patients with pancreatic cancer had at least 15 lymph nodes evaluated. Patients at high-volume or NCCN-NCI hospitals were more likely to have at least 15 lymph nodes evaluated than patients undergoing surgery at community or low-volume hospitals.

“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,” the authors write. “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.”

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(Arch Surg. 2008;143[7]:671-678. Available pre-embargo to the media at jamamedia.org.)

Editor’s Note: This study was supported in part by the American College of Surgeons Clinical Scholars in Residence program and by a grant from the Goldberg Family Charitable Trust. The NCDB is supported by the American College of Surgeons, the Commission on Cancer and the American Cancer Society. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Contact: Marla Paul
312-503-8928
JAMA and Archives Journals

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