Quality Improvement for Surgical Resection of Pancreatic Head Adenocarcinoma Hospital and Surgeon Predictors of Higher Than Expected R1 Resection Using the National Cancer Database

• Published in: The American surgeon Vol. 87; no. 3; pp. 396 - 403
• Main Authors: Nuckles, Brandon W., Lam, Kenneth, Young, Katelyn A., Dove, James T., Shabahang, Mohsen M., Blansfield, Joseph A.
• Format: Journal Article
• Language: English
• Published: Los Angeles, CA SAGE Publications 01.03.2021
• Subjects: Adenocarcinoma - mortality; Adenocarcinoma - pathology; Adenocarcinoma - surgery; Adult; Aged; Aged, 80 and over; Databases, Factual; Female; Hospitals, High-Volume - standards; Hospitals, Low-Volume - standards; Humans; Male; Margins of Excision; Middle Aged; Nomograms; Pancreatic Neoplasms - mortality; Pancreatic Neoplasms - pathology; Pancreatic Neoplasms - surgery; Pancreaticoduodenectomy - standards; Quality Assurance, Health Care; Quality Improvement; Retrospective Studies; Survival Analysis; United States - epidemiology; United States; pancreatic adenocarcinoma; margin positivity; nomogram
• ISSN: 0003-1348; 1555-9823
• DOI: 10.1177/0003134820950281

Background The mainstay of treatment for pancreatic cancer is surgical resection; however, positive surgical margins remain commonplace. We identified hospitals with higher than predicted rates of positive margins and isolated factors that caused this discordance. Methods This is a retrospective review of patients with head of the pancreas adenocarcinoma in the National Cancer Database between 2004 and 2015. A nomogram was used to calculate the observed to expected positive margin rates (O/E) for facilities. If the O/E differed significantly (P < .05), it was considered an outlier. Results Among a total of 19 968 patients, 24.3% had positive margins. Among hospitals with lower than expected positive margin rates, 73.6% were academic or research programs, 17% were comprehensive community cancer programs, and none were community cancer programs (P = .0002). Within the group with higher than expected positive margin rates, 47% were comprehensive community cancer programs and 38.6% were academic or research programs (P = .0002). The mean hospital volume was higher in the low positive margin group (110.4 vs 48.8, P < .0001). Conclusions Facility type and hospital volume can predict improvement in the O/E ratio for margin positivity in pancreatic adenocarcinoma resection. Surgeons should consider referral to academic or research facilities with higher case volumes for improved surgical resection.