Disparities in referral to high-volume pancreatic cancer treatment centers impact survival
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Referrals from low-volume to high-volume centers appeared associated with longer OS among patients with pancreatic ductal adenocarcinoma, according to study results published in JAMA Surgery.
Researchers also found that socioeconomic and geographic disparities in referrals result in shorter OS for patients of disadvantaged backgrounds.
Rationale and methodology
Referral of patients with pancreatic ductal adenocarcinoma to high-volume centers is a critical component of care, especially for those with resectable disease, according to study background. However, it remained unclear how patterns of referral affect survival outcomes.
Thomas L. Sutton, MD, resident in the department of surgery at Oregon Health & Science University, and colleagues sought to better understand the role of treatment site and selection bias as a driver of disparities in outcomes among 8,026 patients (mean age, 71 years; 52% men) diagnosed in Oregon with locoregional (n = 3,419) or metastatic (n = 4,607) pancreatic ductal adenocarcinoma between 1997 and 2018.
Researchers also examined and characterized socioeconomic factors associated with referral from low- to high-volume centers.
OS and treatment patterns evaluated through Kaplan-Meier analysis and logistic regression served as main outcomes.
Median follow-up was 4.3 months from diagnosis.
Findings
First-course care received at a combination of low- and high-volume centers appeared associated with improvements in median OS among those with locoregional (16.6 months; 95% CI, 15.3-17.9) and metastatic disease (6.1 months; 95% CI, 4.9-7.3) compared with care at a high-volume center only (locoregional, 11.5 months; 95% CI, 10.7-12.3; metastatic, 3.9 months; 95% CI, 3.5-4.3) or a low-volume center only (locoregional, 8.2 months; 95% CI, 7.7-8.7; metastatic, 2.1 months; 95% CI, 1.9-2.3).
When researchers stratified patients according to center of diagnosis vs. treating center, they observed smaller improvements in median OS among patients treated at high-volume centers with locoregional disease (10.4 months vs. 9.9 months; P = .03) and with metastatic disease (3.6 months vs. 2.7 months; P < .001).
Most patients (94%) diagnosed at a high-volume center received treatment at a high-volume center, compared with only 18% of patients diagnosed at low-volume centers.
Factors associated with higher odds of subsequent treatment at a high-volume center among patients diagnosed at a low-volume center included later year of diagnosis and higher estimated income, whereas older age, metastatic disease and farther geographic distance from a high-volume center appeared independently associated with lower odds.
Limitations of the study included the retrospective design, potential for misrepresentation of disease burden, and use of patient ZIP code to approximate distance and socioeconomic status.
Implications
“Patients referred from low-volume to high-volume centers experienced superior outcomes, but socioeconomic, demographic and geographic disparities exist in referral and treatment favoring individuals who are younger and affluent and those located near high-volume centers,” Sutton and colleagues wrote. “High-volume centers should ensure that their patient population reflects that of their catchment area for pancreatic adenocarcinoma.”
This study appropriately recognizes disparities that exist for underserved patients with pancreatic cancer, according to an accompanying editorial by Michael A. Mederos, MD, and O. Joe Hines, MD, both in the department of surgery at University of California, Los Angeles.
“The conclusion that diagnosis and/or treatment at [high-volume centers] is associated with improved overall survival may be overstated given study limitations,” they wrote. “Clear advantages exist for patients who have access to [high-volume centers] over those who do not have the ability or resources to do so. The current economic and health care models in the United States exacerbate these differences and are mostly responsible for the touted improved outcomes at [high-volume centers].”
References:
- Mederos MA, et al. JAMA Surg. 2022;doi:10.1001/jamasurg.2022.6720.
- Sutton TL, et al. JAMA Surg. 2022;doi:10.1001/jamasurg.2022.6709.
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