title: High provider volume is associated with lower rate of secondary therapies after definitive radiotherapy for localized prostate cancer.
abstract: OBJECTIVE
  The relationship between provider volume and cancer control has not been studied in the setting of definitive radiotherapy. We examined the effect of annual and cumulative provider volume on the rate of use of secondary therapies after definitive external-beam radiotherapy (EBRT) for localized prostate cancer.
  
  
  METHODS
  The cohort consisted of 3907 patients treated with definitive radiotherapy without neoadjuvant or adjuvant hormonal therapy (delivered within 12 mo of EBRT) between 1989 and 2000. Overall median follow-up was 6.2 yr versus 3.8 yr in event-free patients. All were treated by 72 radiation oncologists, with an average annual provider volume of 14 cases (median: 10.4; range: 1-39) and an average cumulative volume of 138 (median: 105; mean: 138). Secondary treatment was defined as hormonal therapy after definitive EBRT. Age and comorbidities represented covariates in Cox regression analyses.
  
  
  RESULTS
  Of all patients, 731 (18.7%) received secondary therapy. The median failure-free survival was not reached (mean: 11.2 yr). At 5 and 10 yr, secondary therapy-free survival rates were 79.5% and 61.3%, respectively. Annual (p=0.007) and cumulative (p=0.003) provider volumes were independent predictors of failure-free survival. After adjustment for covariates, cubic splines demonstrated lower rates of secondary therapy for annual provider volume > 10 cases and for cumulative provider volume > 200 cases.
  
  
  CONCLUSIONS
  Our data suggest that to minimize the rates of secondary therapy, EBRT should ideally be delivered by high-volume providers with an annual or cumulative volume in excess of, respectively, 10 or 200 cases.
authors.affiliation: Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, QC, Canada.
authors.forename: Claudio
authors.initials: C
authors.lastname: Jeldres
authors.forename: Nazareno
authors.initials: N
authors.lastname: Suardi
authors.forename: Fred
authors.initials: F
authors.lastname: Saad
authors.forename: Francesco
authors.initials: F
authors.lastname: Montorsi
authors.forename: Shahrokh F
authors.initials: SF
authors.lastname: Shariat
authors.forename: Paul
authors.initials: P
authors.lastname: Perrotte
authors.forename: Naeem
authors.initials: N
authors.lastname: Bhojani
authors.forename: Jochen
authors.initials: J
authors.lastname: Walz
authors.forename: Georg C
authors.initials: GC
authors.lastname: Hutterer
authors.forename: Markus
authors.initials: M
authors.lastname: Graefen
authors.forename: Luc
authors.initials: L
authors.lastname: Valiquette
authors.forename: Pierre I
authors.initials: PI
authors.lastname: Karakiewicz
mesh_terms: D000368:Aged; D015331:Cohort Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D011471:Prostatic Neoplasms / Q000473:pathology / Q000532:radiotherapy* / Q000628:therapy; D011792:Quebec / Q000453:epidemiology; D011878:Radiotherapy / Q000706:statistics & numerical data*