Adenocarcinoma of the gastro-esophageal junction: Is centralization policy always a good idea?

Abstract

This study aims to review the available literature on the volume-outcome relationship in esophageal cancer. Given the controversies surrounding the treatment of gastro-esophageal junction (GEJ) cancer this review focusses on these specific tumors. Literature shows that staging of esophageal cancer should be performed by dedicated, specialized radiologists and endoscopists. This certainly applies to GEJ tumors since slight staging differences have major treatment impact. Since early neoplastic signs are subtle, state-of-the-art endoscopes and sufficient endoscopist and pathologist expertise are necessary for the treatment of Barret's dysplasia or early cancer. In addition, given the possible complications of endoscopic resections, an expert center having surgical and endoscopic experience of treating complications is advisable. Most literature focusses on the relationship between hospital resection volume and surgical postoperative mortality and long-term survival. Several large meta-analyses show clear survival benefit and lower postoperative mortality rates in high-volume hospitals. The included literature was however heterogeneous with definitions of high-volume hospitals ranging from 2.33 to as much as 87 annual esophagectomies. Hospital volume seems to positively affect total esophageal cancer related costs. Literature also suggests centralization is necessary up to a certain threshold but not infinitely; a plateau might be reached in the volume-outcome relationship at an annual hospital volume of 50 or 60. However, more evidence is necessary to determine optimal cut-off values. Several studies suggest that much of the hospital volume benefit is explained by higher surgeon volume in high-volume hospitals, but the extent remains a matter of debate. Also, in the palliative setting a survival benefit of being treated in high-volume centers has been shown. The results of this review underline the importance of centralization of all aspects of the multimodal treatment of gastro-esophageal cancer. Especially for GEJ carcinomas highly specialized medical personnel is necessary. However, given the heterogeneity of the volume-outcome literature, clear international volume thresholds are difficult to establish.