title: Trends in the management of esophageal carcinoma based on provider volume: treatment practices of 618 esophageal surgeons.
abstract: Controversy exists regarding optimal treatment practices for esophageal cancer. Esophagectomy has received focus as one of the index procedures for both hospital and surgical quality despite a relative paucity of controlled trials to define best practices. A survey was created to determine the degree of heterogeneity in the treatment of esophageal cancer among a diverse group of surgeons and to use high-volume (HV) (>/=15 cases/year) and low-volume (LV) (<15 cases/year) designations to discern specific differences in the management of esophageal cancer from the surgeon's perspective. Based on society rosters, surgeons (n = 4000) in the USA and 15 countries were contacted via mail and queried regarding their treatment practices for esophageal cancer using a 50-item survey instrument addressing demographics, utilization of neoadjuvant chemoradiotherapy, and choice of surgical approach for esophageal resection and palliation. There were 618 esophageal surgeons among respondents (n = 1447), of which 77 (12.5%) were considered HV. The majority of HV surgeons (87%) practiced in an academic setting and had cardiothoracic training, while most LV surgeons were general surgeons in private practice (52.3%). Both HV and LV surgeons favored the hand-sewn cervical anastomosis and the stomach conduit. Minimally invasive esophagectomy is performed more frequently by HV surgeons when compared with LV surgeons (P = 0.045). Most HV surgeons use neoadjuvant therapy for patients with nodal involvement, while LV surgeons are more likely to leave the decision to the oncologist. With a few notable exceptions, substantial heterogeneity exists among surgeons' management strategies for esophageal cancer, particularly when grouped and analyzed by case volume. These results highlight the need for controlled trials to determine best practices in the treatment of this complex patient population.
authors.affiliation: Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA.
authors.forename: C K
authors.initials: CK
authors.lastname: Enestvedt
authors.forename: K A
authors.initials: KA
authors.lastname: Perry
authors.forename: C
authors.initials: C
authors.lastname: Kim
authors.forename: P W
authors.initials: PW
authors.lastname: McConnell
authors.forename: B S
authors.initials: BS
authors.lastname: Diggs
authors.forename: A
authors.initials: A
authors.lastname: Vernon
authors.forename: R W
authors.initials: RW
authors.lastname: O'Rourke
authors.forename: J D
authors.initials: JD
authors.lastname: Luketich
authors.forename: J G
authors.initials: JG
authors.lastname: Hunter
authors.forename: B A
authors.initials: BA
authors.lastname: Jobe
mesh_terms: D000046:Academic Medical Centers / Q000706:statistics & numerical data; D000714:Anastomosis, Surgical / Q000379:methods / Q000706:statistics & numerical data; D002277:Carcinoma / Q000601:surgery*; D017024:Chemotherapy, Adjuvant / Q000706:statistics & numerical data; D003952:Diagnostic Imaging / Q000706:statistics & numerical data; D004938:Esophageal Neoplasms / Q000601:surgery*; D016629:Esophagectomy / Q000379:methods; D005260:Female; D013502:General Surgery / Q000706:statistics & numerical data; D006801:Humans; D008197:Lymph Node Excision; D008207:Lymphatic Metastasis; D008297:Male; D008495:Medical Oncology / Q000706:statistics & numerical data; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D020360:Neoadjuvant Therapy / Q000706:statistics & numerical data; D009367:Neoplasm Staging; D010166:Palliative Care / Q000706:statistics & numerical data; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011331:Private Practice / Q000706:statistics & numerical data; D018714:Radiotherapy, Adjuvant / Q000706:statistics & numerical data; D013043:Specialties, Surgical / Q000706:statistics & numerical data*; D015607:Stents / Q000706:statistics & numerical data; D017792:Surgical Stapling / Q000706:statistics & numerical data; D013536:Suture Techniques / Q000706:statistics & numerical data; D013903:Thoracic Surgery / Q000706:statistics & numerical data; D016526:Workload / Q000706:statistics & numerical data