Esophageal Cancer Surgery: Spontaneous Centralization in the US Contributed to Reduce Mortality Without Causing Health Disparities

Background: Improvement in mortality has been shown for esophagectomies performed at high-volume centers. Objective: This study aimed to determine if centralization of esophageal cancer surgery occurred in the US, and to establish its impact on postoperative mortality. In addition, we aimed to analyze the relationship between regionalization of cancer care and health disparities. Methods: A retrospective population-based analysis was performed using the National Inpatient Sample for the period 2000–2014. Adult patients (≥ 18 years of age) diagnosed with esophageal cancer and who underwent esophagectomy were included. Yearly hospital volume was categorized as low (< 5 procedures), intermediate (5–20 procedures), and high (> 20 procedures). Multivariable analyses on the potential effect of hospital volume on patient outcomes were performed, and the yearly rate of esophagectomies was estimated using Poisson regression. Results: A total of 5235 patients were included. Esophagectomy at low- [odds ratio (OR) 2.17] and intermediate-volume (OR 1.62) hospitals, compared with high-volume hospitals, was associated with a significant increase in mortality. The percentage of esophagectomies performed at high-volume centers significantly increased during the study period (29.2–68.5%; p < 0.0001). The trend towards high-volume hospitals was different among the different US regions: South (7.7–54.3%), West (15.0–67.6%), Midwest (37.3–67.7%), and Northeast (55.8–86.8%) [p < 0.0001]. Overall, the mortality rate of esophagectomy dropped from 10.0 to 3.5% (p = 0.006), with non-White race, public insurance, and low household income patients also showing a significant reduction in mortality. Conclusions: A spontaneous centralization for esophageal cancer surgery occurred in the US. This process was associated with a decrease in the mortality rate, without contributing to health disparities. © 2018, Society of Surgical Oncology.