Is oncologic surgery in a low-volume district general hospital justified? A critical 24-year audit

BACKGROUND: An ongoing discussion focusses on centralization of oncologic surgery and effects of surgical and institutional volumes on outcome – questioning if oncologic surgery in low-volume district general hospitals is justified. METHODS: Data of 543 patients undergoing surgery for various cancer entities from 03/1978 until 12/2001 were entered in a prospectively maintained database. Endpoints were 30-day mortality (30 DM), the rate of locoregional recurrence (LR), overall survival (OAS), cause-specific survival (CSS) of entity- and UICC stage-groups and disease-free survival (DFS). Data were benchmarked. RESULTS: After censoring patients undergoing minimal-risk surgery, 30 DM comprised 11% for all patients – 8.1% for patients after elective surgery and 8% after R0 resection. 30 DM caused by surgical complications was 0.7%, 0.8% and 0.3%, respectively, 30 DM caused by medical causes 10.3% (cardiac in 5.1%, pulmonary in 2.0% and other causes in 3.2%), 7.2% and 7.6%, respectively. LR, OAS, CSS and DFS rates were appropriate or excellent. CONCLUSIONS: Surgical proficiency can be maintained in a low-volume hospital. Outcome was compromised by a comparably high 30 DM dominated by medical complications, emphasizing the importance of risk assessment and interdisciplinary institutional support. A policy of selective referral is prudent. Frequent oncologic entities associated with acceptable comorbidity can be safely managed in district general hospitals, which in turn qualifies for membership in cooperating virtual regional centers.