Photo by Robert Hood / Fred Hutch News Service
Even in cancer care, it’s location, location, location.
Patients treated at one of a handful of specialized cancer centers collectively had a 9 percent higher survival rate over five years when compared to cancer patients treated at community hospitals, a recent study showed.
While the study’s authors plan more analysis to better grasp the disparity, they posed several theories to explain the stronger outcomes among 11 “freestanding” cancer hospitals they measured. Those 11 centers included Seattle Cancer Care Alliance, the treatment arm of Fred Hutchinson Cancer Research Center.
"Now that the data seem clear, the next steps will be to try and dig deeper to address" why outcomes were measured higher at the 11 centers, said Dr. Fred Appelbaum, president of SCCA and deputy director of Fred Hutch.
The study, conducted by Memorial Sloan Kettering Cancer Center and recently published online in JAMA Oncology, found survival-outcome gaps exist among four types of hospitals that treat people for cancer:
- At 11 freestanding cancer hospitals that are exempt from the Medicare prospective payment system, (PPS), the five-year survival rate was 53 percent. [PPS is a hospital-reimbursement system in which Medicare payments are made based on a predetermined and fixed amount. SCCA does accept Medicare, and a large number of SCCA patients are on Medicare.]
- At 32 National Cancer Institute-designated cancer centers that are not PPS exempt, the five-year survival rate was 49 percent.
- At 252 other academic teaching hospitals, the survival rate for that same span was 46 percent.
- At 4,873 "remaining hospitals," including community hospitals, the five-year survival rate was 44 percent.
To compare patient outcomes among those four groups, researchers analyzed two parallel data sets. They dissected fee-for-service Medicare claims that cover all aspects of inpatient and outpatient cancer care but don’t contain any information on patients’ cancer stages. Their second source was the Surveillance, Epidemiology, and End Results Medicare database that does include statistics on cancer stage.
In total, the study looked at nearly 750,000 patients who had cancers of the lung, prostate, breast or colon, among other types. The patients started cancer treatment or management of recurrent disease in 2006. The analysis of those patients ended in 2011.
The 11 PPS-exempt cancer centers also included Dana-Farber Cancer Institute in Boston and MD Anderson Cancer Center in Houston.
Fred Hutch file
Appelbaum, who was not involved in the study, said he has some theories for the measured differences in survival rates among the hospital groups.
“In general, each of the PPS-exempt centers see many more cancer patients than are seen at other [medical] facilities. There are innumerable examples in medicine where outcomes improve with volume," he said. "In part, because of the larger volumes, the PPS-exempt centers usually create teams of physicians that are dedicated to a single type of cancer – for example, we have seven or eight medical oncologists who see nothing but breast cancer; I restrict my practice to acute leukemia.
“… Now, try and imagine a busy clinician at a community hospital who in one day may see several cases of lung, colon, and breast cancer, and may see an uncommon form of leukemia once or twice a year. How can such a person possibly keep up in all of the diseases?”
What’s more, for doctors at cancer centers, “the mission is cancer,” said Dr. David Pfister, lead author and chief of head and neck oncology at Memorial Sloan Kettering Cancer Center – one of the 11 cancer-specialty facilities where outcomes were assessed against more than 5,000 other U.S. hospitals.
But within that focused mission, there is an array of cancer-specialty groups that fuel expertise among physicians, Pfister said.
“For example, all I see are cancers from the neck up and below the brain, for the most part,” Pfister said. “I have an enormous amount of experience that is incrementally higher than what you’re going to get in a community practice where you might see the particularly rare tumors every once in a while. [Here], they become almost a regular occurrence. It allows you to know the literature, to get a sense of clinical behavior. … Clearly, you’re in a position to do clinical investigation into it.”
Appelbaum cited three more general distinctions that tend to separate specialized cancer centers, like SCCA, from hospitals in the other three groups:
- Doctors at large cancer hospitals have access to the newest laboratory and imaging facilities, which are overseen in-house by individuals specializing in cancer. At most community hospitals, specimens are sent away to commercial laboratories.
- At large cancer centers, interdisciplinary teams work together to create pathways that all adhere to and offer the best outcomes. At SCCA, for example, the lung cancer group includes surgeons, medical oncologists, radiation oncologists, pathologists and radiologists. At community hospitals, each practitioner treats patients in his or her own way.
- At large cancer centers, there’s access to the newest therapies while they are still being studied – and before they become available to the general public.
The Sloan Kettering researchers also found that patients treated at the 11 PPS-exempt hospitals had “a 10 percent lower chance of dying in the first year” than did patients treated at the more than 4,800 facilities that included community hospitals – 18 percent versus 28 percent.
That gap alone “is substantial and represents potentially preventable deaths of cancer patients,” Dr. Peter Bach, director of Sloan Kettering’s Center for Health Policy & Outcomes, said in a released statement. He was a senior author of the study.
“… A next step would be to figure out the mechanics underpinning it. Is it due to readmissions or mortality rates after surgery? Are people having severe side effects keeping them from finishing the chemotherapy that benefits them? We need to break down the data and figure out where the gaps in care are, and none of it is simple,” Bach said.
Can the 11 PPS-exempt hospitals share any lessons with other medical centers so that, theoretically, all cancer patients can access the same level of care?
“I suspect some of these approaches can begin to be applied in the community setting, but I don't think all of them can,” Appelbaum said. “We have level-1 trauma centers for a reason. If a patient is terribly injured, you want them getting care at the right place at the right time. I don't think cancer is any less complicated or important.”
Despite the measured outcome gaps among the four hospital groups, lead author Pfister said he does not interpret the findings to mean all cancer patients should flock “to some center of excellence.”
“Cancer is an emotionally difficult thing where having a supportive family is important,” Pfister said. “When they have the option to travel, they really prefer to get treated close to home."
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Bill Briggs is a former Fred Hutch News Service staff writer. Follow him at @writerdude. Previously, he was a contributing writer for NBCNews.com and TODAY.com, covering breaking news, health and the military. Prior, he was a staff writer for The Denver Post, part of the newspaper's team that earned the Pulitzer Prize for coverage of the Columbine High School massacre. He has authored two books, including "The Third Miracle: an Ordinary Man, a medical Mystery, and a Trial of Faith."
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