Hospital type- and volume-outcome relationships in esophageal cancer patients receiving non-surgical treatments

doi:10.3748/wjg.v21.i4.1234

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World Journal of Gastroenterology

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

Retrospective Study

World J Gastroenterol. Jan 28, 2015; 21(4): 1234-1242
Published online Jan 28, 2015. doi: 10.3748/wjg.v21.i4.1234

Table 1 Patient characteristics according to hospital type n (%)

Variables	Total	Medical center or not
Variables	Total	Yes	No	P value
Patient number	6106	4180	1926
Hospital number	62	19	43
Sex				0.963
Male	5768 (94.5)	3949 (94.5)	1819 (94.4)
Female	338 (5.5)	231 (5.5)	107 (5.6)
Age (yr)				< 0.001
< 40	189 (3.1)	133 (3.2)	56 (2.9)
40-49	1413 (23.1)	908 (21.7)	505 (26.2)
50-59	2272 (37.1)	1577 (37.7)	695 (36.1)
60-69	1278 (20.9)	915 (21.9)	363 (18.9)
70-79	658 (10.8)	433 (10.4)	225 (11.7)
≥ 80	296 (4.9)	214 (5.1)	82 (4.3)
Tumor length (cm)				0.006
mean ± SD	5.3 ± 3.1	5.4 ± 3.0	5.1 ± 3.2
cT stage				0.009
1	531 (8.7)	340 (8.1)	191 (9.9)
2	838 (13.7)	544 (13.0)	294 (15.3)
3	2994 (49.0)	2086 (49.9)	908 (47.1)
4	1339 (21.9)	901 (21.6)	438 (22.7)
Unknown	404 (6.6)	309 (7.4)	95 (4.9)
cN stage				< 0.001
0	1385 (22.7)	862 (20.6)	523 (27.2)
1/2/3	4488 (73.5)	3141 (75.1)	1347 (69.9)
Unknown	233 (3.8)	177 (4.2)	56 (2.9)
cM stage				0.424
0	4261 (69.8)	2931 (70.1)	1330 (69.1)
1	1731 (28.4)	1167 (27.9)	564 (29.3)
Unknown	114 (1.9)	82 (2.0)	32 (1.7)
Tumor location				< 0.001
Upper third	1445 (23.7)	936 (22.4)	509 (26.4)
Middle third	2152 (35.2)	1390 (33.3)	762 (39.6)
Lower third	1134 (186)	758 (18.1)	376 (19.5)
Unknown	1375 (22.5)	1096 (26.2)	279 (14.5)
Tumor differentiation				< 0.001
Well	150 (2.5)	108 (2.6)	42 (2.2)
Moderate	2759 (45.2)	1781 (42.6)	978 (50.8)
Poorly	1309 (21.4)	916 (21.9)	393 (20.4)
Unknown	1888 (30.9)	1375 (32.9)	513 (26.6)
Treatment modality				0.009
Surgery with neoadjuvant chemoradiation	850 (13.9)	610 (14.6)	240 (12.5)
Surgery without neoadjuvant chemoradiation	1301 (21.3)	914 (21.9)	387 (20.1)
No surgery	3955 (64.8)	2656 (63.5)	1299 (67.5)
Hospital volume				< 0.001
Q1-Q2	3137	1504 (36.0)	1633 (84.8)
Q3-Q4	2969	2676 (64.0)	293 (15.2)
Hospital volume				< 0.001
Q1-Q3	4717	2791 (66.8)	1926 (100.0)
Q4	1389	1389 (33.2)	-

Table 2 Patient characteristics according to hospital volume n (%)

Variables	Hospital volume			Hospital volume
Variables	Q1-Q2	Q3-Q4	P value	Q1-Q3	Q4	P value
No. of annual cases	≤ 225	> 225		≤ 377	> 377
No. of patients	3137	2969		4717	1389
No. of hospitals	54	8		59	3
Sex			0.295			0.295
Male	2954 (94.2)	2814 (94.8)		4465 (94.7)	1303 (93.8)
Female	183 (5.8)	155 (5.2)		252 (5.3)	86 (6.2)
Age (yr)			0.182			0.56
< 40	88 (2.8)	101 (3.4)		142 (3.0)	47 (3.3)
40-49	715 (22.8)	698 (23.5)		1108 (23.3)	305 (22.0)
50-59	1194 (36.9)	1078 (36.3)		1762 (37.1)	510 (36.7)
60-69	629 (20.1)	649 (21.9)		976 (20.6)	302 (21.8)
70-79	352 (11.3)	306 (10.3)		496 (10.5)	162 (11.7)
≥ 80	159 (5.1)	137 (4.6)		233 (4.9)	63 (4.5)
Tumor length (cm)			0.845			< 0.001
mean ± SD	5.3 ± 3.2	5.3 ± 2.9		5.2 ± 3.0	5.7 ± 3.0
cT stage			0.005			< 0.001
1	245 (7.8)	286 (9.6)		412 (8.7)	119 (8.6)
2	466 (14.9)	372 (12.5)		711 (15.1)	127 (9.1)
3	1531 (48.8)	1463 (49.3)		2167 (45.9)	827 (59.5)
4	710 (22.6)	629 (21.2)		1073 (22.8)	266 (19.2)
Unknown	185 (5.9)	219 (7.4)		354 (7.5)	50 (3.6)
cN stage			< 0.001			< 0.001
0	820 (26.1)	565 (19.0)		1183 (25.1)	202 (14.5)
1/2/3	2210 (70.5)	2278 (76.7)		3340 (70.8)	1148 (82.7)
Unknown	107 (3.4)	126 (4.2)		194 (4.1)	39 (4.1)
cM stage			0.002			0.014
0	2177 (69.4)	2084 (70.2)		3257 (69.1)	1004 (72.3)
1	919 (29.3)	812 (27.4)		1362 (28.9)	369 (26.6)
Unknown	41 (1.3)	73 (2.5)		98 (2.1)	16 (1.2)
Tumor location			< 0.001			< 0.001
Upper third	801 (25.5)	644 (21.7)		1192 (25.3)	253 (18.2)
Middle third	1223 (39.0)	929 (31.3)		1785 (37.8)	367 (26.4)
Lower third	600 (19.1)	534 (18.0)		894 (19.0)	240 (17.3)
Unknown	513 (16.4)	862 (29.0)		846 (17.9)	529 (38.1)
Tumor differentiation			< 0.001			< 0.001
Well	76 (2.4)	74 (2.5)		128 (2.7)	22 (1.6)
Moderate	1611 (51.4)	1148 (38.7)		2256 (47.8)	503 (36.2)
Poorly	677 (21.6)	632 (21.3)		892 (18.9)	417 (30.0)
Unknown	773 (24.6)	1115 (37.6)		1441 (30.6)	447 (32.2)
Treatment modality			< 0.001			< 0.001
Surgery with neoadjuvant chemoradiation	381 (12.1)	469 (15.8)		524 (11.1)	326 (23.5)
Surgery without neoadjuvant chemoradiation	643 (20.4)	658 (22.2)		1056 (22.4)	245 (17.6)
No surgery	2113 (67.4)	1842 (62.0)		3137 (66.5)	818 (58.9)
Hospital type			< 0.001			< 0.001
Medical center	1504 (47.9)	2676 (90.1)		2791 (59.2)	1389 (100.0)
Not center	1633 (52.1)	293 (9.9)		1926 (40.8)	0

Table 3 Patient characteristics according to hospital type and hospital volume in non-surgical treatment patients (n = 3955) n (%)

Variables	Medical center			Hospital volume			Hospital volume
Variables	Yes	No	P value	Q1-2	Q3-4	P value	Q1-3	Q4	P value
Sex			NS			NS			NS
Male	2523 (95.0)	1220 (94.0)		1917 (94.2)	1826 (95.1)		2845 (94.8)	898 (94.2)
Female	133 (5.0)	79 (6.0)		118 (5.8)	94 (4.9)		157 (5.2)	55 (5.8)
Age (yr)			< 0.05^a			NS			NS
< 40	84 (3.2)	29 (2.2)		50 (2.5)	63 (3.3)		83 (2.8)	30 (3.1)
40-49	536 (20.2)	315 (24.2)		425 (20.1)	426 (22.2)		636 (21.2)	215 (22.6)
50-59	957 (36.0)	433 (33.3)		723 (35.5)	667 (34.7)		1052 (35.0)	338 (35.5)
60-69	587 (22.1)	255 (19.6)		417 (20.5)	425 (22.1)		645 (21.5)	197 (20.7)
70-79	304 (11.4)	187 (14.4)		270 (13.3)	221 (11.5)		371 (12.4)	120 (12.6)
≥ 80	188 (7.1)	80 (6.2)		150 (7.4)	118 (6.1)		215 (7.2)	53 (5.6)
Tumor location			NS			< 0.01^d			NS
Upper third	759 (28.6)	430 (33.1)		680 (33.4)	509 (26.5)		642 (21.4)	174 (18.3)
Middle third	841 (31.7)	501 (38.6)		773 (38.0)	569 (29.6)		1079 (35.9)	263 (27.6)
Lower third	336 (12.7)	169 (13.0)		222 (10.9)	283 (14.7)		694 (23.1)	184 (19.3)
Unknown	720 (27.1)	199 (15.3)		360 (17.7)	559 (29.1)		587 (19.6)	332 (34.8)
Tumor differentiation			NS			< 0.05^c			< 0.01^d
Well	50 (1.9)	27 (2.1)		43 (2.1)	34 (1.8)		66 (2.2)	11 (1.1)
Moderate	985 (37.1)	577 (44.4)		910 (44.7)	652 (34.0)		1176 (39.1)	386 (40.5)
Poorly	547 (20.1)	264 (20.3)		428 (21.0)	383 (19.9)		534 (17.8)	277 (29.1)
Unknown	1074 (40.4)	431 (33.2)		654 (32.1)	851 (44.3)		1226 (40.8)	279 (29.3)
Clinical stage			< 0.01^b			< 0.01^d			< 0.05^c
0/I	70 (2.7)	67 (5.2)		77 (3.6)	60 (3.3)		111 (3.9)	26 (2.5)
II	272 (10.2)	200 (15.4)		298 (14.1)	174 (9.5)		375 (12.9)	97 (9.3)
III	1184 (44.6)	509 (39.2)		865 (40.9)	828 (45.0)		1233 (42.4)	460 (43.9)
IV	1071 (40.3)	507 (39.0)		841 (39.8)	737 (40.0)		1138 (39.1)	440 (42.0)
Unknown	59 (2.2)	16 (1.2)		32 (1.5)	43 (2.3)		51 (1.8)	24 (2.3)
Treatment modality			< 0.05^a			< 0.01^d			< 0.01^d
Chemotherapy	234 (8.8)	99 (7.6)		175 (8.3)	158 (8.6)		228 (7.8)	105 (10.0)
Radiotherapy	259 (9.8)	183 (14.1)		282 (13.4)	160 (8.7)		362 (12.5)	80 (7.6)
Chemoradiation	2040 (76.8)	980 (75.4)		1572 (74.4)	1448 (78.6)		2206 (75.9)	814 (77.8)
Unknown	123 (4.6)	37 (2.9)		84 (4.0)	76 (4.1)		112 (3.9)	48 (4.6)
Stage-specific 3-yr survival
Stage I	33.44%	48.35%		41.81%	43.03%		42.23%	45.86%
Stage II	21.1%	21.12%		22.53%	18.74%		22.60%	15.76%
Stage III	11.84%	14.11%		12.61%	12.32%		12.61%	12.03%
Stage IV	6.6%	5.05%		6.2%	6.03%		6.04%	6.36%

^aP < 0.05, patients in medical center vs non-medical center hospital;

^bP < 0.01, patients in medical center vs non-medical center hospital;

^cP < 0.05, patients in low volume hospitals vs high volume hospitals;

^dP < 0.01, patients in low volume hospitals vs high volume hospitals. NS: Not significant.

Table 4 Cox regression analysis of the relationship between prognostic factors and outcome in patients without esophagectomy

Variables	Univariate analysis			Multivariate analysis
	Univariate analysis			Model 1			Model 2			Model 3
	HR	95%CI	P value	HR	95%CI	P value	HR	95%CI	P value	HR	95%CI	P value
Age (yr)
< 55	1	-		1	-
≥ 55	0.94	0.88-1.01	0.091	0.96	0.90-1.03	0.288	0.96	0.90-1.03	0.297	0.96	0.90-1.04	0.322
Sex
Male	1	-		1	-
Female	0.86	0.73-1.00	0.053	0.9	0.76-1.06	0.19	0.9	0.76-1.05	0.185	0.89	0.76-1.05	0.176
cT stage
T1/2	1	-		1	-
T3/4	1.77	1.61-1.96	< 0.001	1.55	1.40-1.73	< 0.001	1.56	1.40-1.73	< 0.001	1.55	1.39-1.73	< 0.001
cN stage
N negative	1	-		1	-
N positive	1.64	1.48-1.81	< 0.001	1.22	1.09-1.37	0.001	1.22	1.09-1.37	0.001	1.21	1.08-1.36	0.001
cM stage
0	1	-		1	-
1	1.67	1.56-1.80	< 0.001	1.52	1.41-1.64	< 0.001	1.52	1.41-1.64	< 0.001	1.52	1.41-1.64	< 0.001
Hospital type
Medical center	1	-		1	-
Not center	0.92	0.86-0.99	0.028	0.97	0.90-1.05	0.447
Hospital volume
Q3-4	1	-		1	-
Q1-2	0.97	0.90-1.03	0.315				0.99	0.92-1.06	0.694
Hospital volume
Q4	1	-
Q1-3	0.87	0.80-0.94	0.001							0.91	0.83-0.99	0.028

Model 1: Impact of hospital type adjusted for age, sex and clinical tumor-node-metastasis (TNM) stages; Model 2: Impact of hospital volume (Q3-4 vs Q1-2) adjusted for age, sex and clinical TNM stages; Model 3: Impact of hospital volume (Q4 vs Q1-3) adjusted for age, sex and clinical TNM stages.

Citation: Hsu PK, Chen HS, Wang BY, Wu SC, Liu CY, Shih CH, Liu CC. Hospital type- and volume-outcome relationships in esophageal cancer patients receiving non-surgical treatments. World J Gastroenterol 2015; 21(4): 1234-1242
URL: https://www.wjgnet.com/1007-9327/full/v21/i4/1234.htm
DOI: https://dx.doi.org/10.3748/wjg.v21.i4.1234