Does Children's Oncology Group hospital membership improve survival for patients with neuroblastoma or Wilms tumor?

Pediatric Liver and Transplant Surgery: Results of an International Survey and Expert Consensus Recommendations

BACKGROUND

Pediatric liver surgery is a complex and challenging procedure and can be associated with major complications, including mortality. Best practices are not established. The aims of this study were to evaluate surgeons' individual and institutional practices in pediatric liver surgery and make recommendations applicable to the management of children who require liver surgery.

METHODS

A web-based survey was developed, focusing on the surgical management of children with liver conditions. It was distributed to 34 pediatric surgery faculty members of the Biliary Atresia and Related Disorders (BARD) consortium and 28 centers of the European Reference Network-Rare Liver. Using the Delphi method, a series of questions was then created to develop ideas about potential future developments in pediatric liver surgery.

RESULTS

The overall survey response rate was 70.6% (24/34), while the response rate for the Delphi questionnaire was 26.5% (9/34). In centers performing pediatric liver surgery, most pediatric subspecialties were present, although pediatric oncology was the least present (79.2%). Nearly all participants surveyed agreed that basic and advanced imaging modalities (including ERCP) should be available in those centers. Most pediatric liver surgeries were performed by pediatric surgeons (69.6%). A majority of participants agreed that centers treating pediatric liver tumors should include a pediatric transplant program (86%) able to perform technical variant grafts and living donor liver transplantation. Fifty-six percent of responders believe pediatric liver transplantation should be performed by specialized pediatric surgeons.

CONCLUSION

Pediatric liver surgery should be performed by specialized pediatric surgeons and should be centralized in regional centers of excellence where all pediatric subspecialists are present. Pediatric hepatobiliary and transplant training needs to be better promoted amongst pediatric surgery fellows to increase this subspecialized workforce.

Characteristics and outcome of children with renal tumors in the Netherlands: The first five-year's experience of national centralization

Around 6% of all childhood malignancies represent renal tumors, of which a majority includes Wilms tumor (WT). Although survival rates have improved over the last decades, specific patients are still at risk for adverse outcome. In the Netherlands, since 2015, pediatric oncology care for renal tumors has been centralized in the Princess Máxima Center for Pediatric Oncology. Here, we describe experiences of the first 5 years of centralized care and explore whether this influences the epidemiological landscape by comparing data with the Netherlands Cancer Registry (NCR). We identified all patients <19 years with a renal mass diagnosed between 01-01-2015 and 31-12-2019 in the Princess Máxima Center. Epidemiology, characteristics and management were analyzed. We identified 164 patients (including 1 patient who refused consent for registration), in our center with a suspicion of a renal tumor. The remaining 163 cases included WT (n = 118)/cystic partially differentiated nephroblastoma (n = 2)/nephrogenic rests only (n = 6) and non-WT (n = 37). In this period, the NCR included 138 children, 1 17-year-old patient was not referred to the Princess Máxima Center. Central radiology review (before starting treatment) was performed in 121/163 patients, and central pathology review in 148/152 patients that underwent surgery. Treatment stratification, according to SIOP/EpSSG protocols was pursued based on multidisciplinary consensus. Preoperative chemotherapy was administered in 133 patients, whereas 19 patients underwent upfront surgery. Surgery was performed in 152 patients, and from 133 biomaterial was stored. Centralization of care for children with renal tumors led to referral of all but 1 new renal tumor cases in the Netherlands, and leads to referral of very rare subtypes not registered in the NCR, that benefit from high quality diagnostics and multidisciplinary decision making. National centralization of care led to enhanced development of molecular diagnostics and other innovation-based treatments for the future.

Examining the Effect of Travel Distance to Pediatric Cancer Centers and Rurality on Survival and Treatment Experiences: A Systematic Review

Accessing pediatric cancer treatment remains problematic for rural families or those living at increased distances from specialized centers. Rural adult cancer patients or those living far removed from treatment may present with later stage disease, receive different treatments than their closer counterparts, and experience worsened survival. While the financial and psychosocial strain of increased travel is well documented, effects of travel distance on similar outcomes for pediatric cancer patients remain ill-defined. We conducted a systematic review to synthesize literature examining the effect of travel distance and/or rurality (as a proxy for distance) on pediatric cancer treatment experiences and survival outcomes. Included studies examined travel distance to specialized centers or rural status for patients above 21 years of age. Studies were excluded if they focused on financial or quality of life outcomes. We analyzed 24 studies covering myriad malignancies and outcomes, including location of care, clinical trial participation, and likelihood of receiving specialized treatments such as stem cell transplants or proton beam therapy. Most were retrospective, and 9 were conducted outside the United States. While some studies suggest rural patients may experience worsened survival and those traveling furthest may experience shorter hospitalization times/rates, the available evidence does not uniformly assert negative effects of increased distance.

Prognostic Factors for Wilms Tumor Recurrence: A Review of the Literature

Simple Summary

A Wilms tumor is a childhood kidney tumor. In high-income countries, 90% of patients with this tumor survive. However, the tumor recurs in 15% of patients. It is important to identify the patients at risk of recurrence in order to adjust treatment in such a way that recurrence may potentially be prevented. However, we are currently unable to determine precisely which patients are at risk of recurrence. Therefore, we present an overview of factors that influence the risk of recurrence, also known as prognostic factors. These factors range from patient-, tumor- and treatment-related characteristics to geographic and socioeconomic factors. In addition to these factors, biological markers, such as genetic alterations, should be studied more intensively as these markers may be able to better identify patients at risk of tumor recurrence.

Abstract

In high-income countries, the overall survival of children with Wilms tumors (WT) is ~90%. However, overall, 15% of patients experience tumor recurrence. The adverse prognostic factors currently used for risk stratification (advanced stage, high risk histology, and combined loss of heterozygosity at 1p and 16q in chemotherapy-naïve WTs) are present in only one third of these cases, and the significance of these factors is prone to change with advancing knowledge and improved treatment regimens. Therefore, we present a comprehensive, updated overview of the published prognostic variables for WT recurrence, ranging from patient-, tumor- and treatment-related characteristics to geographic and socioeconomic factors. Improved first-line treatment regimens based on clinicopathological characteristics and advancing knowledge on copy number variations unveil the importance of further investigating the significance of biological markers for WT recurrence in international collaborations.

[DKG certification of paediatric cancer centres - a wide field …]

Die Gesellschaft für Pädiatrische Onkologie und Hämatologie (GPOH) und die Deutsche Krebsgesellschaft (DKG) haben Kriterien für die DKG-Zertifizierung der Kinderonkologie erarbeitet, nach denen 2017 in Deutschland erstmals pädiatrisch-onkologische Abteilungen zertifiziert wurden. Das Ziel der DKG-Zertifizierung ist „die Vereinheitlichung und die transparente Darstellung der Versorgungsqualität für pädiatrische Patientinnen und Patienten mit hämato-onkologischen Erkrankungen“, wie 2018 in einer Veröffentlichung von Mensah et al. dargestellt. Die Auswahl der Zertifizierungskriterien hat innerhalb der GPOH zu einer intensiven Diskussion darüber geführt, inwieweit die Kriterien für sich genommen einer wissenschaftlichen Überprüfbarkeit standhalten und damit valide Parameter für die Bestimmung der Versorgungsqualität in der Kinderonkologie in Deutschland darstellen.

Wir haben untersucht, ob aus der Arbeit von Mensah et al. valide Folgerungen für das deutsche Gesundheitssystem ableitbar sind. Dabei zeigt sich, dass die momentan definierten DKG-Zertifizierungskriterien für die Kinderonkologie in Deutschland in kritischen Bereichen einer fundierten wissenschaftlichen Grundlage entbehren.

Diese Arbeit stellt Fallzahlen als Maß für Qualität in der Kinderonkologie infrage und regt die Entwicklung alternativer Kriterien für die Überprüfbarkeit von Qualität in der deutschen Kinderonkologie an.

The European study on centralisation of childhood cancer treatment

BACKGROUND

It is generally agreed to centralise treatment of childhood cancers (CCs). We analysed (1) the degree of centralisation of CCs in European countries and 2) the relations between centralisation and survival.

PATIENTS AND METHODS

The analysis comprised 4415 CCs, diagnosed between 2000 and 2007 and followed up to the end of 2013, from Belgium, Bulgaria, Finland, Ireland, the Netherlands and Slovenia. All these countries had national population-based cancer registries and were able to provide information on diagnosis, treatment, treatment hospitals, and survival. Each case was then classified according to whether the patient was treated in a high- or a low-volume hospital among those providing CC treatment. A Cox proportional hazard model was used to calculate the relation between volume category and five-year survival, adjusting by age, sex and diagnostic group.

RESULTS

The number of hospitals providing treatment for CCs ranged from six (Slovenia) to slightly more than 40 (the Netherlands and Belgium). We identified a single higher volume hospital in Ireland and in Slovenia, treating 80% and 97% of cases, respectively, and three to five major hospitals in the other countries, treating between 65% and 93% of cases. Outcome was significantly better when primary treatment was given in high-volume hospitals compared to low-volume hospitals for central nervous system tumours (relative risk [RR] = 0.71), haematologic tumours (RR = 0.74) and for all CC combined (RR = 0.83).

CONCLUSION

Treatment centralisation is associated with survival benefits and should be further strengthened in these countries. New plans for centralisation should include ongoing evaluation.

Decreased Early Mortality in Young Adult Patients With Acute Lymphoblastic Leukemia Treated at Specialized Cancer Centers in California

PURPOSE

Studies suggest that patients with acute lymphoblastic leukemia (ALL) have superior survival when treated at specialized cancer centers (SCCs). However, the association of early mortality (< 60 days) with location of initial care, sociodemographic factors, and complications has not been evaluated in pediatric and young adult (YA) patients with ALL.

METHODS

Using the California Cancer Registry linked to hospitalization data, we identified pediatric and YA patients with ALL who received inpatient leukemia treatment between 1991 and 2014. Patients were classified as receiving all or part/none of their care at an SCC (Children's Oncology Group- or National Cancer Institute-designated cancer center). Propensity scores were created for treatment at an SCC in each age group. Multivariable, inverse probability-weighted Cox proportional hazards regression models identified factors associated with early mortality. Results are presented as hazard ratios (HRs) and 95% CIs.

RESULTS

Among 6,531 newly diagnosed pediatric (≤ 18 years) and YA (19 to 39 years of age) patients with ALL, 1.6% of children and 5.4% of YAs died within 60 days of diagnosis. Most children received all of their care at an SCC (n = 4,752; 85.7%) compared with 35.5% of YAs (n = 1,779). Early mortality rates were lower in pediatric patients and those receiving all care at an SCC (pediatric: all, 1.5%, v part/none, 2.4%; P = .049; YAs: all, 3.2%, v part/none, 6.6%; P = .001). However, in adjusted models, receiving all care at an SCC was associated with significantly lower early mortality in YAs (HR, 0.51; 95% CI, 0.32 to 0.81), but not in pediatric patients (HR, 0.77; 95% CI, 0.47 to 1.25).

CONCLUSION

YAs with ALL experience significant reductions in early mortality after treatment at SCCs.

Adolescent and young adult oncology patients: Disparities in access to specialized cancer centers

BACKGROUND

Adolescents and young adults (AYAs) ages 15 to 39 years with cancer continue to experience disparate survival outcomes compared with their younger and older counterparts. This may be caused in part by differential access to specialized cancer centers (SCCs), because treatment at SCCs has been associated with improved overall survival. The authors examined social and clinical factors associated with AYA use of SCCs (defined as Children's Oncology Group-designated or National Cancer Institute-designated centers).

METHODS

A retrospective, population-based analysis was performed on all hospital admissions of AYA oncology patients in California during 1991 through 2014 (n = 127,250) using the Office of Statewide Health Planning and Development database. Multivariable logistic regression analyses examined the contribution of social and clinical factors on always receiving care from an SCC (vs sometimes or never). Results are presented as adjusted odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Over the past 20 years, the percentage of patients always receiving inpatient care at an SCC increased over time (from 27% in 1991 to 43% in 2014). In multivariable regression analyses, AYA patients were less likely to always receive care from an SCC if they had public insurance (OR, 0.64; 95% CI, 0.62-0.66), were uninsured (OR, 0.51; 95% CI, 0.46-0.56), were Hispanic (OR, 0.88; 95% CI, 0.85-0.91), lived > 5 miles from an SCC, or had a diagnosis other than leukemia and central nervous system tumors.

CONCLUSIONS

Receiving care at an SCC was influenced by insurance, race/ethnicity, geography, and tumor type. Identifying the barriers associated with decreased SCC use is an important first step toward improving outcomes in AYA oncology patients. Cancer 2017;123:2516-23. © 2017 American Cancer Society.

Pediatric Oncology Discharges With Febrile Neutropenia: Variation in Location of Care

We examined the use of Pediatric Cancer Specialty Centers (PCSCs) over time and the length of stay (LOS) in pediatric oncology patients with a diagnosis of febrile neutropenia. PCSCs were defined as Children's Oncology Group and California Children's Services designated centers. We performed a retrospective analysis on all discharges of pediatric (0 to 18) oncology patients with febrile neutropenia in California (1983 to 2011) using the private Office of Statewide Health Planning and Development database. We examined influence of age, sex, race/ethnicity, payer, income, distance, tumor type, and complications on utilization of PCSCs and LOS (SAS 9.2). Analysis of 24,559 pediatric oncology febrile neutropenia discharges showed hospitalizations in PCSCs increasing from 48% in 1983 to 94% in 2011. The adjusted regression analysis showed decreased PCSC utilization for ages 15 to 18, Hispanic patients, and those living >40 miles away. The median PCSC LOS was 9 days compared with 7 days at a non-PCSC (P<0.0001). Discharge from a PCSC was associated with a LOS >8 days after controlling for complications. Inpatient PCSC care for febrile neutropenia in California has increased since 1983. Receiving care at a PCSC is influenced by age, tumor type, ethnicity, geography, and complications.

Patterns of Performance of Oncologic Surgery by North American Pediatric Urologists: A Report from the Pediatric Urologic Oncology Working Group of the Society for Pediatric Urology

PURPOSE

Objective data on patterns of oncology practice among pediatric urologists are lacking. We reviewed surgical case logs submitted to the American Board of Urology by those self-reporting as pediatric urologists. We hypothesized that logs would reveal a low oncology volume (fewer than 5 cases) and identify orchiectomy as the most common oncology cases, and that less than 25% of logs would show nephrectomy for renal tumor.

MATERIALS AND METHODS

Case logs submitted for American Board of Urology certification, recertification or pediatric subspecialty certification were reviewed and standardized to represent 12-month practice. Data were collected on pediatric oncologic surgeries as noted by procedure codes linked with oncologic diagnosis codes for patients up to age 30 years.

RESULTS

We identified 281 case logs meeting study criteria. A total of 364 oncology cases were logged and 131 logs (46.6%) listed at least 1 oncology case, while 150 (53.4%) contained no oncology cases. The 75th, 90th and 95th percentiles of oncology volume were represented by reporting 2, 3 and 4 cases, respectively. A total of 13 logs (4.6%) accounted for more than a third of all oncology cases (35.9%). The most frequent oncology case logged was orchiectomy, which was documented in 83 logs (29.5%). On Poisson regression surgeon variables associated with higher oncology volume included male gender (IRR 2.8, 95% CI 2.1-3.9), 2010 log year (IRR 2.4, 95% CI 1.3-4.4), 2015 log year (IRR 3.7, 95% CI 2.1-6.4) and nonpediatric subspecialty certification log (IRR 1.6, 95% CI 1.2-2.3).

CONCLUSIONS

Few pediatric urologists perform a high volume of oncologic surgeries based on surgical case logs submitted to the American Board of Urology. A small cohort of pediatric urologists logged the majority of such cases.

Treatment outcomes in pediatric melanoma-Are there benefits to specialized care?

PURPOSE

The purpose of this study was to evaluate the impact of hospital specialization on survival in pediatric melanoma.

METHODS

We reviewed all patients under 18years old with cutaneous melanoma evaluated at MD Anderson Cancer Center, a National Cancer Institute (NCI)-designated center, from 2000 to 2014. We compared overall survival (OS) and disease-free survival (DFS) between patients who underwent all treatments at MDACC (Group A, n=146) and those who underwent initial surgical treatment at a non-NCI center (Group B, n=58). Kaplan-Meier survival curves were compared using the log-rank test.

RESULTS

Group A patients had significantly better OS and DFS (both p<0.001). Five-year OS was 97% (95% CI 92%-99%) in Group A versus 88% (95% CI 74%-94%) in Group B. Group survival differences were most notable in Stage 3 and 4 patients. Group A patients presenting with stage III or IV disease had a 5-year OS rate of 91.2% (95% CI 75.1%-97.1%) compared to 80.8% (95% CI 59.8%-91.5%) in Group B. The DFS rate was 94.4% (95% CI 88.5%-97.3%) in Group A versus 77.2% (95% CI 62.5%-86.7%) in Group B.

CONCLUSION

Surgical treatment at a comprehensive cancer center may improve outcomes for pediatric melanoma especially for patients presenting with later stage disease.

LEVEL OF EVIDENCE

Case-control study: Level III.

Clinical Trials Infrastructure as a Quality Improvement Intervention in Low- and Middle-Income Countries

Mounting evidence suggests that participation in clinical trials confers neither advantage nor disadvantage on those enrolled. Narrow focus on the question of a "trial effect," however, distracts from a broader mechanism by which patients may benefit from ongoing clinical research. We hypothesize that the existence of clinical trials infrastructure-the organizational culture, systems, and expertise that develop as a product of sustained participation in cooperative clinical trials research-may function as a quality improvement lever, improving the quality of care and outcomes of all patients within an institution or region independent of their individual participation in trials. We further contend that this "infrastructure effect" can yield particular benefits for patients in low- and middle-income countries (LMICs). The hypothesis of an infrastructure effect as a quality improvement intervention, if correct, justifies enhanced research capacity in LMIC as a pillar of health system development.

Volume-Outcome Relationships in Pediatric Acute Lymphoblastic Leukemia: Association Between Hospital Pediatric and Pediatric Oncology Volume With Mortality and Intensive Care Resources During Initial Therapy

BACKGROUND

There are few contemporary studies of volume-outcome relationships in pediatric oncology. Children with acute lymphoblastic leukemia (ALL) are treated at a wide variety of hospitals. We investigated if inpatient hospital volume influences outcomes. The objective of this study was to evaluate the relationship between inpatient pediatric and pediatric oncology volume and mortality and intensive care resources (ICU care). We hypothesized an inverse relationship between volume and these outcomes.

PATIENTS AND METHODS

This was a retrospective cohort study. Patients 0 to 18 years of age in the Pediatric Health Information System or Perspective Premier Database from 2009 to 2011 with ALL were included. Exposures were considered as the average inpatient pediatric and pediatric oncology volume. The primary outcome was inpatient mortality; secondary outcome was need for ICU care.

RESULTS

The included population comprised 3350 patients from 75 hospitals. The inpatient mortality rate was 0.86% (95% confidence interval, 0.58%-1.2%). In the unadjusted analysis, mortality increased as pediatric oncology volume increased from low (0%) to high volume (1.3%) (P = .009). The small number of deaths precluded multivariable analysis of this outcome. Pediatric and pediatric oncology volume was not associated with ICU care when we controlled for potential confounders.

CONCLUSION

Induction mortality was low. We did not observe an inverse relationship between volume and mortality or ICU care. This suggests that in a modern treatment era, treatment at a low-volume center might not be associated with increased mortality or ICU care in the first portion of therapy. This relationship should be evaluated in other oncology populations with higher mortality rates and with longer-term outcomes.

Wilms tumor: Successes and challenges in management outside of cooperative clinical trials

OBJECTIVE/BACKGROUND

Management of Wilms tumor (WT) in children depends on a multidisciplinary approach to treatment, and outcomes have significantly improved as reported by cooperative group clinical trials. Here, we review the clinical outcomes of patients with WT and identify challenges and barriers encountered in multidisciplinary management outside of cooperative clinical trials.

METHODS

We retrospectively reviewed the clinical records of 35 children with WT treated between April 2002 and June 2013 at the Children's Cancer Institute in Lebanon.

RESULTS

Upfront resection was performed in 23 cases. Biopsies were performed for Stage V tumors (n=4), those with unresectable tumors or inferior vena caval thrombus (n=5), and patients who had partial surgery performed elsewhere prior to presentation (n=2). One patient died due to toxicity prior to surgery. The tumor was Stage I in eight patients, Stage II in five patients, Stages III and IV in nine patients each, and bilateral (Stage V) in four patients. Adherence to The National Wilms Tumor Study-5 recommendations was adequate. At the time of analysis, 30 patients were free of disease and four patients had relapse-all having metastatic disease initially.

CONCLUSION

The National Wilms Tumor Study-5 therapy resulted in favorable outcomes in children with nonmetastatic Wilms tumor in the setting of a multidisciplinary approach to therapy and resolution of financial barriers to medical care. Upstaging due to prior intervention and lung radiation therapy to all those with computed tomography-detected lung nodules may both have resulted in overtreatment of a subset of patients. Finally, the relatively high incidence of bilateral tumors suggests the need for further genetic and molecular studies in this patient population.

Subspecialization within pediatric surgical groups in North America

PURPOSE

The purpose of this study was to assess the current status of subspecialization in North American pediatric surgical practices and to evaluate factors associated with subspecialization.

METHODS

A survey was sent to each pediatric surgical practice in the United States and Canada. For each of 44 operation types, ranging in complexity and volume, the respondents chose one of the following responses: 1. everyone does the operation; 2. group policy--only some surgeons do the operation; 3. group policy--anyone can do it but mentorship required; 4. only some do it due to referral patterns; 5. no one in the group does it. Association of various factors with degree of subspecialization was analyzed using nonparametric statistics with p<0.05 considered significant.

RESULTS

Response rate was 70%. There was significant variability in subspecialization among groups. Factors found to be significantly associated with increased subspecialization included free-standing children's hospitals, pediatric surgery training programs, higher number of surgeons, higher case volume, and greater volume of tertiary/quaternary cases.

CONCLUSIONS

There is wide variation in the degree of subspecialization among North American pediatric surgery practices. These data will help to inform ongoing debate around strategies that may be useful in optimizing pediatric surgical care and patient outcomes in the future.

Health disparities are important determinants of outcome for children with solid tumor malignancies

PURPOSE

The purpose of this study was to identify health disparities in children with non-CNS solid tumor malignancies and examine their impact on disease presentation and outcome.

METHODS

We examined the records of all children (age≤18years) diagnosed with a non-CNS solid tumor malignancy and enrolled in the Texas Cancer Registry between 1995 and 2009 (n=4603). The primary outcome measures were disease stage and overall survival (OS). Covariates included gender, age, race/ethnicity, year of diagnosis, socioeconomic status (SES), and driving distance to the nearest pediatric cancer treatment facility. Statistical analyses included life table methods, logistic, and Cox regression. Statistical significance was defined as p<0.05.

RESULTS

Children with advanced-stage disease were more likely to be male, <10years old, and Hispanic or non-Hispanic Blacks (all p<0.05). Distance to treatment and SES did not impact stage of disease at presentation. However, Hispanic and non-Hispanic Blacks and patients in the lowest SES quartile had the worst 1- and 5-year survival (all p<0.05). The adjusted OS differed by age, race, and stage, but not SES or distance to the nearest treatment facility.

CONCLUSIONS

Race/ethnicity plays an important role in survival for children with non-CNS solid tumor malignancies. Future work should better define these differences to establish mechanisms to decrease their impact.

Utility of an Australasian registry for children undergoing radiation treatment

INTRODUCTION

The aim of this study was to evaluate the utility of an Australasian registry ('the Registry') for children undergoing radiation treatment (RT).

METHODS

Children under the age of 16 years who received a course of radiation between January 1997 and December 2010 and were enrolled on the Registry form the subjects of this study.

RESULTS

A total of 2232 courses of RT were delivered, predominantly with radical intent (87%). Registrations fluctuated over time, but around one-half of children diagnosed with cancer undergo a course of RT. The most prevalent age range at time of RT was 10-15 years, and the most common diagnoses were central nervous system tumours (34%) and acute lymphoblastic leukaemia (20%).

CONCLUSIONS

The Registry provides a reflection of the patterns of care of children undergoing RT in Australia and a mechanism for determining the resources necessary to manage children by RT (human, facilities and emerging technologies, such as proton therapy). It lacks the detail to provide information on radiotherapy quality and disease outcomes which should be the subject of separate audit studies. The utility of the Registry has been hampered by its voluntary nature and varying needs for consent. Completion of registry forms is a logical requirement for inclusion in the definition of a subspecialist in paediatric radiation oncology.

Hospital variation in sphincter preservation for elderly rectal cancer patients

BACKGROUND

The primary goal of an operation for rectal cancer is to cure cancer and, where possible, preserve continence. A wide range of sphincter preservation rates have been reported. This study evaluated hospital variation in the use of low anterior resection (LAR), local excision (LE), and abdominoperineal resection (APR) in the treatment of elderly rectal cancer patients.

METHODS

Using Surveillance, Epidemiology, and End Results-Medicare linked data, we identified 4959 patients older than 65 y with stage I-III rectal cancer diagnosed from 2000-2005 who underwent operative intervention at one of 370 hospitals. We evaluated the distribution of hospital-specific procedure rates and used generalized mixed models with random hospital effects to examine the influence of patient characteristics and hospital on operation type, using APR as a reference.

RESULTS

The median hospital performed APR on 33% of elderly patients with rectal cancer. Hospital was a stronger predictor of LAR receipt than any patient characteristic, explaining 32% of procedure choice, but not a strong predictor of LE, explaining only 3.8%. Receipt of LE was primarily related to tumor size and tumor stage, which combined explained 31% of procedure variation.

CONCLUSIONS

Receipt of LE is primarily determined by patient characteristics. In contrast, the hospital where surgery is performed significantly influences whether a patient undergoes an LAR or APR. Understanding the factors that cause this institutional variation is crucial to ensuring equitable availability of sphincter preservation.

The volume effect in paediatric oncology: a systematic review

BACKGROUND

For several adult cancer types, there is evidence that treatment in high volume hospitals, high case volume providers, or in specialised hospitals leads to a better outcome. The aim of this study is to give an overview of the existing evidence regarding the volume effect in paediatric oncology related to the quality of care or survival.

MATERIALS AND METHODS

An extensive search was carried out for studies on the effect of provider case volume on the quality of care or survival in childhood cancer. Information about study characteristics, comparisons, results, and quality assessment were abstracted.

RESULTS

In total, 14 studies were included in this systematic review. Studies with a low risk of bias provide evidence that treatment of children with brain tumours, acute lymphoblastic leukaemia, osteosarcoma, Ewing's sarcoma, or children receiving treatment with allogenic bone marrow transplantation in higher volume hospitals, specialised hospitals, or by high case volume providers, is related with a better outcome.

CONCLUSIONS

This systematic review provides support for the statement that higher volume hospitals, higher case volume providers, and specialised hospitals are related to the better outcome in paediatric oncology. No studies reported a negative effect of a higher volume.

Cooperative group trials in pediatric oncology: the surgeon's role

The early history of the pediatric cooperative group trials is reviewed, and the surgeons who played a critical role in their formation are discussed. The vital information provided from the tumor specimens submitted as part of the protocols is presented, as well as how this information advanced our management of infants and children treated on current protocols of the Children's Oncology Group. Finally, a survey of the surgeons currently active in the clinical trials defined the "critical lessons" learned from the sequence of protocols by the cooperative groups which have advanced our surgical treatment of patients today.

Subspecialization may improve an esophageal atresia service but has not addressed declining trainee experience

BACKGROUND

Subspecialization defined pediatric surgery using Alder Hey innovations in neonatal surgical units (Rickham) and anesthesia (Jackson-Rees). In neonatal surgery, United Kingdom subspecialization for cloacal extrophy and biliary atresia acknowledges their dependence on multidisciplinary management and the desirability of caseload for training. We phased in regional subspecialization for esophageal atresia (EA) repair and replacement surgery while trainee numbers increased nationally to reduce hours. We examined EA outcomes and training during subspecialization.

METHODS

We analyzed EA cases (1999-2009) treated at Alder Hey Children's Hospital in two 5-year cohorts, the first early phase of incomplete subspecialization and the later near-total or "comprehensive" subspecialization phase. These periods approximated those before and after trainee numbers rose sharply to reduce working hours.

RESULTS

Of 119 cases, 60 in the early cohort shared similar characteristics with the 59 in the later cohort. Near-complete subspecialization was achieved in the second 5 years with 97% of cases performed under a surgeon with an EA specialty interest; in the earlier cohort, 25% of surgeries were undertaken by surgeons without EA subspecialty interest. With near-complete subspecialization, pediatric intensive care unit stay fell from 5 (4-11) to 4 (2-7) days (median (IQR); P = .005), and approaches such as the Bianchi axillary repair and Bax single-stage jejunal interposition were introduced; hospital stay went from 25 (12-63) to 17 (13-28) days (P = .27), and deaths, from 6 to 3 children (P = .49). Mortality was 7.6% (9/119) compared with 14% (19/134) in our previous institutional series (χ(2) = 2.8, P = .09), and neonatal mortality fell from 6% to 0 (P = .008). Near doubling of trainee numbers accompanied an approximately 3-fold fall in repairs per trainee over the study.

CONCLUSION

Near-complete subspecialization for EA coincided with reduced pediatric intensive care unit stay, successful introduction of cosmetic axillary approaches, and extension of our replacement service to offer all interposition types. It has not reversed the steep decline in trainee experience of EA that has been associated with the greater numbers of trainees that have been employed to reduce working hours.

Oncologic outcomes of partial versus radical nephrectomy for unilateral Wilms tumor

BACKGROUND

Radical nephrectomy (RN) is the recommended surgical management as part of multi-modality therapy for unilateral Wilms tumor (UWT). Based on recent data demonstrating that renal preserving surgery decreases the likelihood of chronic renal disease and associated co-morbidities, we analyzed oncologic outcomes of patients after partial nephrectomy (PN) for UWT.

METHODS

We identified all published cases of PN for UWT. Cases of elective PN for UWT were analyzed for tumor stage, presence, timing and location of disease recurrence, and overall survival (OS). Eighty-two patients had adequate data for analysis. For comparison, these endpoints were collected on consecutive children undergoing RN for UWT from 1985 to 2010 at our institution.

RESULTS

Of the 82 PN patients, tumor stage was: I-64, II-10, III-6, IV-2. Of the 121 RN patients, the staging was: I-24, II-45, III-29, IV-23. In the PN group, at a median of 48 months (3-372), the recurrence-free survival (RFS), local RFS and OS were 89.1%, 92.7%, and 95.1%, respectively. In the RN group, at a median of 69 months (0-214), the RFS, local RFS, and OS were 83.1%, 95.0%, and 95.0%, respectively. After controlling for stage, there were no statistically significant differences in the above oncologic outcomes between the groups.

CONCLUSION

Based on reported data, the oncologic outcomes of PN for UWT in selected patients do not appear to differ from those of RN. PN for appropriately selected patients with UWT should be studied in prospective, co-operative group trials.