Preparing for cancer surgery? Hospital choice is critical, experts say

More than 1,000 cancer patients in the central San Joaquin Valley need surgery every year, and their chances of survival hinge in part on which hospital they choose.

The right choice can reduce the risk of complications or even death. But health experts are concerned that patients may be unaware that the number of cancer surgeries performed should be included on any patient’s checklist.

There are a lot of factors to consider when choosing a hospital, including patient and doctor-hospital preference, the type and stage of a cancer, and patient-safety measures such as hospital infection control and readmission rates.

Research has shown that patients who choose hospitals that do few surgeries of particular types of cancer – bladder, brain, breast, colon, esophagus, liver, lung, pancreas, prostate, rectum or stomach – are more likely to have worse outcomes than those who choose hospitals that perform a large number.

Here is why: The evidence points to the importance of experienced operating room and post-surgical care teams working with highly-skilled surgeons to prevent complications.

More people will need this information in coming years. California health officials say one out of every two Californians born today will develop cancer at some point.

Valley surgeons say surgery volume in the Valley is increasing, but that cancer programs should not be judged on volume alone. They don’t want patients to be unduly alarmed by small numbers of surgeries, especially low-income patients for whom traveling three hours to a hospital where more surgeries are performed is not an option.

On the other hand, there is agreement that building cancer programs is important. Valley hospitals have recruited doctors for cancer surgeries – and plan to add more. Community Medical Centers and Saint Agnes Medical Center are investing millions to expand cancer care. And health experts say consolidating cancer surgeries could help the Valley achieve a higher surgery volume.

But some responsibility falls on cancer patients. In addition to asking how many times a surgeon has performed an operation, a cancer patient should ask how many surgeries are done at the hospital, said Maryann O’Sullivan, a health policy consultant and author of a November 2015 study, “Safety in Numbers: Cancer Surgeries in California Hospitals.”

“Cancer surgery is pretty serious stuff. You want to get it right and you want to avoid the complications. They can really make a difference to quality of life following surgery,” O’Sullivan said.

Despite what state officials say is solid evidence of the relationship between low volume and patient outcome, many Valley patients and other Californians are having cancer surgeries at low-volume hospitals, the Office of Statewide Health Planning and Development said in a report released in December.

The report for 2013, 2014 and the first nine months of 2015 shows that Valley hospitals performed as few as one or two of some of the 11 surgeries with outcomes linked to volume.

The state agency said it is not recommending that surgery volume be the only consideration that cancer patients use to choose a hospital, but it hopes patients will consider it and that the report makes it easier.

“In the past, patients unaware of the link between volume and outcome may have had their surgeries performed locally to avoid the inconvenience of travel,” the agency said. But with information about surgery volume, some may choose to go to high-volume hospitals. The many patients who are having surgeries at low-volume hospitals are “potentially increasing their risk of poor outcomes,” it said.

However, Valley surgeons dispute the report’s findings. For one thing, the state’s numbers for the Valley are outdated, they said.

Dr. Amir Fathi, a Fresno surgeon who operates at Community Regional Medical Center, said far more surgeries for pancreatic and liver cancer are being done now than the 20 pancreatic and 18 liver surgeries in 2014 reported by the state. “We do at least one per week of each, liver and pancreas.”

The Valley has come a long way in developing cancer programs, said Dr. Babak “Bobby” Eghbalieh, associate clinical professor at UCSF-Fresno and the cancer committee chairman at Community Medical Centers.

“Compared to a decade ago or 15 years ago, we have come so far in our care of cancer locally,” Eghbalieh said. “Most cancers can be, should be and will be treated in the Central Valley.”

Reasons for low volume

Surgery volume also doesn’t reflect the experience level of a surgeon or the skills of a hospital surgical team, surgeons and hospital officials said.

One surgeon may do surgeries at more than one hospital in Fresno, for example, and those surgeries combined can be a high volume for an individual doctor, said Paula Jordan, director of nursing services at Saint Agnes Medical Center.

Jordan said Saint Agnes is one of 54 hospitals in California that had 1 percent of the surgical volume for cancer surgeries reported by the state. Only six hospitals had 2 percent of the volume, and no hospital had more than 3 percent, she said. “Given the size of our population, Saint Agnes and other local hospitals compare quite favorably to similar-size California cities,” she said.

But there are reasons for the low surgery volumes, in some cases, surgeons said.

A cancer diagnosis such as esophageal is rare, and because of the Valley’s relatively smaller population only a few surgeries would be done every year. A sub-specialist might be needed for a surgery, but for a surgeon to devote a practice to a particular cancer requires having access to a certain number of patients. And there is the Fresno inferiority complex: Patients may be encouraged to go to out-of-town hospitals by referring physicians who are unaware that surgeries can safely be done here.

A low volume of surgeries doesn’t necessarily indicate a problem, either, they said. Take the case of prostate cancer: A lower number of prostate surgeries could speak to good support for well-trained urologists who know how to actively follow patients with low-grade tumors instead of operating on them.

“Numbers don’t tell you everything,” said Dr. David P. Winchester, medical director of the national cancer programs at the American College of Surgeons, based in Chicago.

Before his surgery for pancreatic cancer at Community Regional in November, Richard Evans, 60, of Lemoore, had the choice of going to the Mayo Clinic in Minnesota and a cancer center in Salt Lake City.

Evans, a research agronomist, said his primary care physician assured him that doctors in Fresno had the experience to do the surgery. But he asked Fathi how many patients he operated on in a year. He was reassured by the number – two or three a week.

He is happy with his decision to have the surgery at Community Regional, he said. It allowed him and his wife, Deone Evans, to be near their home. “If I had to do it over again, this is where I would come. I wouldn’t consider going anywhere else.”

A hospital is considered to be performing surgeries at a low volume if it does only one or two of a type a year, but the cutoff is less clear about how many surgeries are “enough.”

The “Safety in Numbers” cancer surgery study by the California Health Care Foundation said some minimums are being established. In 2015, three major hospital systems in the nation – Dartmouth-Hitchcock Medical Center in New Hampshire, Johns Hopkins Hospital and Health System in Maryland and the University of Michigan Health System – set yearly minimum annual standards for cancer surgeries at their hospitals: 20 surgeries of the esophagus and pancreas, 40 of the lung and 15 of the rectum.

By those standards, Community Regional met the minimum for surgery of the pancreas, and one Valley hospital – Fresno Heart & Surgical Hospital – met the minimum for lung surgeries. Saint Agnes, Community Regional, Clovis Community and Kaweah Delta Medical Center in Visalia came within a handful of the minimum for rectum surgeries.

No hospital in the Valley, however, came close to doing 20 surgeries of the esophagus. Clovis Community did the most with two, according to the state report. Only 354 surgeries for cancer of the esophagus were done statewide in 2014.

A low volume of surgeries was a factor in Dennis Pollock’s decision to have esophageal surgery at Stanford University Medical Center in 2011.

A retired Fresno Bee agriculture reporter, Pollock, 71, said: “I was not judging that Fresno is not up to this.” He equated his decision-making to that of a driver who needs to find a mechanic who specializes in a particular engine repair.

Pollock has been cancer-free for six years. “Looks like I may have made the right choice, for sure.”

Winchester of the American College of Surgeons said surgery numbers in Fresno appear to be adequate for most of the 11 surgeries that have had poor patient outcomes linked to low volumes. But the small number of bladder surgeries done in Fresno in 2014 could be worrisome.

Surgery for bladder cancer is high-risk, no matter where it is done, he said. “The complication rate is 50 percent. It is a very difficult disease to treat, and sometimes those complications are lethal.”

If he were living in Fresno and had this diagnosis, Winchester said: “I would talk to local people first, but I would be looking at regionalization.”

Consolidation recommended

Consolidating cancer surgery into regional centers is a course of action that O’Sullivan, the health policy consultant, advocates to increase surgery volume.

“It would really benefit the patients in your region if the hospitals could come together to decide which would be centers … for a particular kind of surgery,” she said.

Some consolidation is happening.

Community Medical Centers and Saint Agnes have multimillion-dollar cancer center projects in the works that could help more surgery patients remain in the Valley. Hospital officials have said they expect the centers will be busy. New cancer cases are projected to increase 45 percent nationwide by 2030.

And Kaiser consolidates care to increase volume and have doctors who specialize, said Barbara Crawford, vice president of quality and regulatory services for Kaiser Permanente Northern California. “In areas where we have specialized centers, the patients are offered the option to get their care there.”

But she said: “Travel can be problematic for some patients and families, and they choose to stay at their local medical center for that reason.”

Maria Tirado de Cuevas, 54, of Mendota, relied on a daughter to take her to Community Regional for a liver-cancer surgery last month. It would have been difficult for her daughter, who is working, to take the time off for doctor appointments at a hospital outside the Valley, she said through an interpreter. Her liver-cancer surgery was complex and included removal of her gallbladder and repair of a hernia. She is pleased with the outcome.

Tirado de Cuevas, who worked at an almond packing shed until illness forced her to stop, said that if her primary care doctor had not sent her to Fathi in Fresno for her surgery, “I would have asked him if he could find some help here.”

Otherwise, she said, “Maybe I would not have been able to (have) the surgery.”

Fathi, who came to Fresno last year and was recruited for his specialty in pancreas and liver surgery, said the emphasis in the Valley should be on building cancer centers of excellence.

“It’s our job to build these centers of excellence for people who live here who cannot afford to go outside the Valley,” he said. “It might sound like my personal gain to get them to stay, but it’s a huge burden to tell them to go to San Francisco when they cannot afford to have three proper meals a day.”

This story was originally published January 14, 2017 at 12:00 PM with the headline "Preparing for cancer surgery? Hospital choice is critical, experts say."