Is treatment in certified cancer centers related to better survival in patients with pancreatic cancer? Evidence from a large German cohort study

Martin Roessler, Jochen Schmitt, Christoph Bobeth, Michael Gerken, Kees Kleihues-van Tol, Christoph Reissfelder, Bettina M Rau, Marius Distler, Pompiliu Piso, Christian Günster, Monika Klinkhammer-Schalke, Olaf Schoffer, Veronika Bierbaum, Martin Roessler, Jochen Schmitt, Christoph Bobeth, Michael Gerken, Kees Kleihues-van Tol, Christoph Reissfelder, Bettina M Rau, Marius Distler, Pompiliu Piso, Christian Günster, Monika Klinkhammer-Schalke, Olaf Schoffer, Veronika Bierbaum

Abstract

Background: Treatment of cancer patients in certified cancer centers, that meet specific quality standards in term of structures and procedures of medical care, is a national treatment goal in Germany. However, convincing evidence that treatment in certified cancer centers is associated with better outcomes in patients with pancreatic cancer is still missing.

Methods: We used patient-specific information (demographic characteristics, diagnoses, treatments) from German statutory health insurance data covering the period 2009-2017 and hospital characteristics from the German Standardized Quality Reports. We investigated differences in survival between patients treated in hospitals with and without pancreatic cancer center certification by the German Cancer Society (GCS) using the Kaplan-Meier estimator and Cox regression with shared frailty.

Results: The final sample included 45,318 patients with pancreatic cancer treated in 1,051 hospitals (96 GCS-certified, 955 not GCS-certified). 5,426 (12.0%) of the patients were treated in GCS-certified pancreatic cancer centers. Patients treated in certified and non-certified hospitals had similar distributions of age, sex, and comorbidities. Median survival was 8.0 months in GCS-certified pancreatic cancer centers and 4.4 months in non-certified hospitals. Cox regression adjusting for multiple patient and hospital characteristics yielded a significantly lower hazard of long-term, all-cause mortality in patients treated in GCS-certified pancreatic centers (Hazard ratio = 0.89; 95%-CI = 0.85-0.93). This result remained robust in multiple sensitivity analyses, including stratified estimations for subgroups of patients and hospitals.

Conclusion: This robust observational evidence suggests that patients with pancreatic cancer benefit from treatment in a certified cancer center in terms of survival. Therefore, the certification of hospitals appears to be a powerful strategy to improve patient outcomes in pancreatic cancer care.

Trial registration: ClinicalTrials.gov ( NCT04334239 ).

Keywords: Certified cancer center; Cohort study; Cox regression; Pancreatic cancer; Survival.

Conflict of interest statement

MR, JS, CB, OS, and VB work at a university hospital with certified cancer centers. In addition, they received funding from the Innovation Committee of the Federal Joint Committee during the conduct of the study. Unrelated to this study, JS received institutional funding for investigator-initiated research from Sanofi, Pfizer, Novartis, ALK, and acted as a payed consultant for Sanofi, Novartis, ALK and Lilly. OS is a member of the certification commission “Skin Cancer Centers” of the German Cancer Society. The other authors declare that they have no conflict of interest.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Inclusion and exclusion of patients
Fig. 2
Fig. 2
Share of patients treated in GCS-certified pancreatic cancer centers over time
Fig. 3
Fig. 3
Survival by center status with 95%-confidence intervals

References

    1. Ferlay J, Colombet M, Soerjomataram I, Mathers C, Parkin D, Piñeros M, et al. Estimating the global cancer incidence and mortality in 2018: GLOBOCAN sources and methods. Int J Cancer. 2019;144(8):1941–1953. doi: 10.1002/ijc.31937.
    1. Wild C, Weiderpass E, Stewart B. World cancer report: Cancer research for cancer prevention. Lyon, France: International Agency for Research on Cancer; 2020.
    1. GEKID. ZfKD at RKI . Krebs in Deutschland für 2015/2016. Berlin: Robert Koch-Institut; 2020.
    1. Strobel O, Neoptolemos J, Jäger D, Büchler MW. Optimizing the outcomes of pancreatic cancer surgery. Nat Rev Clin Oncol. 2019;16(1):11–26. doi: 10.1038/s41571-018-0112-1.
    1. Oba A, Ho F, Bao QR, Al-Musawi MH, Schulick RD, Chiaro MD. Neoadjuvant treatment in pancreatic cancer. Front Oncol. 2020;10:245. doi: 10.3389/fonc.2020.00245.
    1. McGuigan A, Kelly P, Turkington RC, Jones C, Coleman HG, McCain RS. Pancreatic cancer: A review of clinical diagnosis, epidemiology, treatment and outcomes. World J Gastroenterol. 2018;24(43):4846–4861. doi: 10.3748/wjg.v24.i43.4846.
    1. Hui D, De La Rosa A, Chen J, Dibaj S, Delgado Guay M, Heung Y, et al. State of palliative care services at US cancer centers: An updated national survey. Cancer [Internet]. 2020;126(9):2013–23. Available from: 10.1002/cncr.32738
    1. Griesshammer E, Adam H, Sibert NT, Wesselmann S. Implementing quality metrics in European Cancer Centers (ECCs) World J Urol. 2021;39(1):49–56. doi: 10.1007/s00345-020-03165-4.
    1. Wind A, Rajan A, van Harten WH. Quality assessments for cancer centers in the European Union. BMC Health Serv Res. 2016;16(1):1–8. doi: 10.1186/s12913-016-1738-2.
    1. Bundesministerium für Gesundheit. Nationaler Krebsplan [Internet]. 2021. Available from:
    1. Mehta R, Ejaz A, Hyer JM, Tsilimigras DI, White S, Merath K, et al. The impact of Dedicated Cancer Centers on outcomes among medicare beneficiaries undergoing liver and pancreatic cancer surgery. Ann Surg Oncol. 2019;26(12):4083–4090. doi: 10.1245/s10434-019-07677-1.
    1. Trautmann F, Reißfelder C, Pecqueux M, Weitz J, Schmitt J. Evidence-based quality standards improve prognosis in colon cancer care. Eur J Surg Oncol [Internet]. 2018;44(9):1324–30. Available from:
    1. Birkmeyer NJ, Goodney PP, Stukel TA, Hillner BE, Birkmeyer JD. Do cancer centers designated by the National Cancer Institute have better surgical outcomes? Cancer. 2005;103(3):435–441. doi: 10.1002/cncr.20785.
    1. Brucker SY, Schumacher C, Sohn C, Rezai M, Bamberg M, Wallwiener D. Benchmarking the quality of breast cancer care in a nationwide voluntary system: The first five-year results (2003–2007) from germany as a proof of concept. BMC Cancer. 2008;8(1):1–3. doi: 10.1186/1471-2407-8-358.
    1. Butea-Bocu MC, Müller G, Pucheril D, Kroeger E, Otto U. Is there a clinical benefit from prostate cancer center certification? An evaluation of functional and oncologic outcomes from 22,649 radical prostatectomy patients. World J Urol. 2021;39(1):5–10. doi: 10.1007/s00345-020-03411-9.
    1. Völkel V, Draeger T, Gerken M, Fuerst A, Klinkhammer-Schalke M. Long-term survival of patients with colon and rectum carcinomas: Is there a difference between cancer centers and non-certified hospitals? Gesundheitswesen. 2018;81(10):801–807.
    1. Kranz J, Grundmann RT, Steffens JA. Does structural and process quality of certified prostate cancer centers result in better medical care? Urologe. 2021;60:59–66. doi: 10.1007/s00120-020-01321-7.
    1. Richter M, Sonnow L, Mehdizadeh-Shrifi A, Richter A, Koch R, Zipprich A. German oncology certification system for colorectal cancer – relative survival rates of a single certified centre vs. National and international registry data. Innov Surg Sci [Internet]. 2021;000010151520210002. Available from: 10.1515/iss-2021-0002
    1. Schrodi S, Tillack A, Niedostatek A, Werner C, Schubert-Fritschle G, Engel J. No survival benefit for patients with treatment in certified breast centers-a population-based evaluation of german cancer registry data. The Breast Journal. 2015;21(5,5):490–500. doi: 10.1111/tbj.12444.
    1. Beckmann MW, Brucker C, Hanf V, Rauh C, Bani MR, Knob S, et al. Quality assured health care in certified breast centers and improvement of the prognosis of breast cancer patients. Onkologie. 2011;34(7, 7):362–7. doi: 10.1159/000329601.
    1. Heil J, Gondos A, Rauch G, Marmé F, Rom J, Golatta M, et al. Outcome analysis of patients with primary breast cancer initially treated at a certified academic breast unit. Breast. 2012;21(3, 3):303–8. doi: 10.1016/j.breast.2012.01.009.
    1. Brenner H, Gefeller O, Hakulinen T. Period analysis for “up-to-date” cancer survival data: Theory, empirical evaluation, computational realisation and applications. Eur J Cancer. 2004;40(3):326–335. doi: 10.1016/j.ejca.2003.10.013.
    1. Kowalski C, Graeven U, von Kalle C, Lang H, Beckmann MW, Blohmer J-U, et al. Shifting cancer care towards multidisciplinarity: The cancer center certification program of the German Cancer Society. BMC Cancer. 2017;17(1):1–9. doi: 10.1186/s12885-017-3824-1.
    1. OnkoZert. OnkoMap [Internet]. 2021. Available from:
    1. Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998;36(1):8–27. doi: 10.1097/00005650-199801000-00004.
    1. van Walraven C, McAlister FA. Competing risk bias was common in kaplan-meier risk estimates published in prominent medical journals. J Clin Epidemiol [Internet]. 2016;69:170–173.e8. Available from:
    1. Templeton AJ, Amir E, Tannock IF. Informative censoring - a neglected cause of bias in oncology trials. Nat Rev Clin Oncol. 2020;17(6):327–328. doi: 10.1038/s41571-020-0368-0.
    1. O’Quigley J. Survival analysis: Proportional and non-proportional hazards regression [Internet]. London: Springer; 2021. Available from:
    1. Balan TA, Putter H. A tutorial on frailty models. Stat Methods Med Res [Internet]. 2020;29(11):3424–54. Available from: 10.1177/0962280220921889
    1. De Angelis R, Sant M, Coleman MP, Francisci S, Baili P, Pierannunzio D, et al. Cancer survival in europe 1999–2007 by country and age: Results of EUROCARE-5 - a population-based study. Lancet Oncol [Internet]. 2014;15(1):23–34. Available from:
    1. Alsfasser G, Leicht H, Günster C, Rau BM, Schillinger G, Klar E. Volume–outcome relationship in pancreatic surgery. Br J Surg [Internet]. 2015;103(1):136–43. Available from: 10.1002/bjs.9958
    1. Ohlmeier C, Langner I, Hillebrand K, Schmedt N, Mikolajczyk R, Riedel O, et al. Mortality in the german pharmacoepidemiological research database (GePaRD) compared to national data in germany: Results from a validation study. BMC Public Health. 2015;15(1):1–7. doi: 10.1186/s12889-015-1943-7.
    1. Suissa S. Immortal time bias in pharmacoepidemiology. Am J Epidemiol. 2008;167(4):492–499. doi: 10.1093/aje/kwm324.
    1. Conroy T, Hammel P, Hebbar M, Ben Abdelghani M, Wei AC, Raoul J-L, et al. FOLFIRINOX or gemcitabine as adjuvant therapy for pancreatic cancer. N Engl J Med. 2018;379(25):2395–2406. doi: 10.1056/NEJMoa1809775.
    1. Springfeld C, Jäger D, Büchler MW, Strobel O, Hackert T, Palmer DH, et al. Chemotherapy for pancreatic cancer. Q Med Rev. 2019;48(3):e159–e174.
    1. Roessel S van, Veldhuisen E van, Klompmaker S, Janssen QP, Abu Hilal M, Alseidi A, et al. Evaluation of Adjuvant Chemotherapy in Patients With Resected Pancreatic Cancer After Neoadjuvant FOLFIRINOX Treatment. JAMA Oncol [Internet]. 2020;6(11):1733–40. Available from: 10.1001/jamaoncol.2020.3537

Source: PubMed

Szponzorok és közreműködők

Egészségi állapot

Kábítószer-beavatkozások

3
Iratkozz fel