Elderly Patients Strongly Benefit from Centralization of Pancreatic Cancer Surgery: A Population-Based Study

Series from expert centers suggest that pancreas cancer surgery is safe for elderly patients but nationwide data, taking hospital volume into account, are lacking. From the Netherlands Cancer Registry, all 3420 patients who underwent pancreatoduodenectomy (PD) for primary pancreatic or periampullary carcinoma in 2005-2013 were selected. Associations between age (< 75, a parts per thousand yen75 years), hospital volume (tertiles), and postoperative mortality (30, 90 day) were evaluated by chi (2) tests and logistic regression analyses. Overall survival was investigated by means of Kaplan-Meier and Cox proportional hazard regression analyses. The proportion of elderly patients (a parts per thousand yen75 years) undergoing PD increased from 15 % in 2005-2007 to 20 % in 2011-2013 (p = 0.009). In low (< 15 per year), medium (15-28 per year), and high (> 28 per year) hospital volume tertiles, the proportion of elderly patients was 16, 20, and 17 %, respectively (p = 0.10). With increasing hospital volume, 30-day postoperative mortality was 6.0-4.5-2.9 % (p = 0.002) and 90-day mortality 9.3-8.0-5.3 % (p = 0.001), respectively. Within each volume tertile, adjusted 30- and 90-day mortality of elderly patients was 1.6-2.5 times higher compared to outcomes of younger patients. Adjusted 30-day mortality in elderly patients was higher in low-volume hospitals (odds ratio = 2.87, 95 % confidence interval 1.15-7.17) compared to high-volume hospitals. Similarly, elderly patients had a worse overall survival in low-volume hospitals (hazard ratio = 1.28, 95 % confidence interval 1.01-1.63). Postoperative mortality of elderly patients in high-volume hospitals was similar to mortality of younger patients in low- and medium-volume hospitals. Elderly patients benefit from centralization by undergoing PD in high-volume hospitals, both with respect to postoperative mortality and survival. It would seem reasonable to place elderly patients into a high-risk category; they should only undergo surgery in the highest-tertile-volume hospitals.