The Volume-Outcome Relationship in Cancer Surgery: A Hard Sell

Since the first volume-outcome relationships in the medical care were reported by Luft in 1979,1 there has been a persistent and sometimes emotional debate about whether certain sorts of complex, elective care should be restricted to high-volume medical centers. Over the past 2 decades, numerous studies have shown that higher hospital volume is associated with lower postoperative mortality and morbidity rates after a great number of different surgical procedures.2–12 These include both high-risk operations and less complex procedures. There are also reports on improved survival after cancer surgery done in high-volume specialty centers as compared with low- and medium-volume units.13–16 Still, the referral pattern has remained practically unchanged in most countries, and few if any signs of regionalization of complex procedures have been seen. In The Netherlands, 40% to 46% of pancreaticoduodenectomies continue to be done in low-volume units,7 and such operations are practiced in 50% of Swedish hospitals, most of which do less than three operations annually.17 Although relations between volume and outcome have long been recognized efforts to concentrate, selective procedures in high-volume hospitals are only now beginning to gain momentum. What explains the hesitation?