Centralization of pancreatic cancer treatment within an integrated healthcare system improves overall survival

Published:September 30, 2021DOI:


      • Centralization of pancreatic cancer surgery has been shown to improve outcomes.
      • We centralized surgeries, oncology, gastroenterology, and interventional radiology.
      • Median length of survival improved by 3 months.
      • 25% more patients had >16 lymph nodes removed.
      • 30% of patients received neoadjuvant therapy, from 10% pre-centralization.



      Higher-volume centers for pancreatic cancer surgeries have been shown to have improved outcomes such as length of stay. We examined how centralization of pancreatic cancer care within a regional integrated healthcare system improves overall survival.


      We conducted a retrospective study of 1621 patients treated for pancreatic cancer from February 2010 to December 2018. Care was consolidated into 4 Centers of Excellence (COE) in surgery, medical oncology, and other specialties. Descriptive statistics, bivariate analysis, Chi-square tests, and Kaplan–Meier analysis were performed.


      Neoadjuvant chemotherapy use rose from 10% to 31% (p < .001). The median overall survival (OS) improved by 3 months after centralization (p < .001), but this did not reach significance on multivariate analysis.


      Our results suggest that in a large integrated healthcare system, centralization improves overall survival and neoadjuvant therapy utilization for pancreatic cancer patients.


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        • Sung H.
        • Ferlay J.
        • Siegel R.L.
        • et al.
        Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.
        CA A Cancer J Clin. 2021; 71: 209-249
        • American Cancer Society. Facts & Figures 2021. American Cancer Society. Atlanta, Ga
        Lifetime Risk (Percent) of Being Diagnosed with Cancer by Site and Race/Ethnicity: Both Sexes, 18 SEER Areas, 2013-2015 (Table 1.15).
        • Lemmens V.E.
        • Bosscha K.
        • van der Schelling G.
        • Brenninkmeijer S.
        • Coebergh J.W.
        • de Hingh I.H.
        Improving outcome for patients with pancreatic cancer through centralization.
        Br J Surg. 2011; 98: 1455-1462
        • de Wilde R.F.
        • Besselink M.G.
        • van der Tweel I.
        • de Hingh I.H.
        • van Eijck C.H.
        • et al Dejong CH.
        Dutch Pancreatic Cancer Group. Impact of nationwide centralization of pancreaticoduodenectomy on hospital mortality.
        Br J Surg. 2012; 99: 404-410
        • Fong Y.
        • Gonen M.
        • Rubin D.
        • et al.
        Long-term survival is superior after resection for cancer in high volume centers.
        Ann Surg. 2005; 242: 540-544
        • Sheetz K.H.
        • Dimick J.B.
        • Nathan H.
        Centralization of high-risk cancer surgery within existing hospital systems.
        J Clin Oncol. 2019 Dec 1; 37: 3234-3242
        • Polonski A.
        • Izbicki J.R.
        • Uzunoglu F.G.
        Centralization of pancreatic surgery in europe.
        J Gastrointest Surg. 2019 Oct; 23: 2081-2092
        • Gooiker G.A.
        • Lemmens V.E.
        • Besselink M.G.
        • et al.
        Impact of centralization of pancreatic cancer surgery on resection rates and survival.
        Br J Surg. 2014 Jul; 101: 1000-1005
        • Ryan C.E.
        • Wood T.W.
        • Ross S.B.
        • Smart A.E.
        • Sukharamwala P.B.
        • Rosemurgy A.S.
        Pancreaticoduodenectomy in Florida: do 20-year trends document the salutary benefits of centralization of care?.
        HPB. 2015 Sep; 17: 832-838
        • Krautz C.
        • Gall C.
        • Gefeller O.
        • et al.
        In-hospital mortality and failure to rescue following hepatobiliary surgery in Germany - a nationwide analysis.
        BMC Surg. 2020 Jul 29; 20: 171
        • Joseph B.
        • Morton J.M.
        • Hernandez-Boussard T.
        • Rubinfeld I.
        • Faraj C.
        • Velanovich V.
        Relationship between hospital volume, system clinical resources, and mortality in pancreatic resection.
        J Am Coll Surg. 2009 Apr; 208: 520-527
        • Birkmeyer J.D.
        • StukelTA
        • Siewers A.E.
        • et al.
        Surgeon volume and operative mortality in the United States.
        N Engl J Med. 2003; 349: 2117-2127
        • Ashfaq A.
        • Pockaj B.A.
        • Gray R.J.
        • et al.
        Nodal counts and lymph node ratio impacts survival after distal pancreactomy for pancreatic adenocarcinoma.
        J Gastrointest Surg. 2012; 16: 920-926
        • Hellan M.
        • Sun C.L.
        • Artinyan A.
        • et al.
        The impact of lymph node number on survival in patients with lymph node-negative panreatic cancer.
        Pancreas. 2008; 37: 19-34
        • Mirkin K.A.
        • Hollenbeak C.S.
        • Wong J.
        Greater lymph node retrieval and lymph node ratio impacts survival in resected pancreatic cancer.
        J Surg Res. 2017 Dec; 220: 12-24
        • Warschkow R.
        • Tsai C.
        • Köhn N.
        • et al.
        Role of lymphadenectomy, adjuvant chemotherapy, and treatment at high-volume centers in patients with resected pancreatic cancer-a distinct view on lymph node yield.
        Langenbeck's Arch Surg. 2020 Feb; 405: 43-54
        • Farnell M.B.
        • Pearson R.K.
        • Sarr M.G.
        • et al.
        A prospective randomized trial comparing standard pancreaticoduodenctomy with pancreaticoduodenectomy with extended lymphadenectomy in resectable pancreatic head adenocarcinoma.
        Surgery. 2005; 138 (618-2)
        • Pedrazzoli S.
        • DiCarlo V.
        • Dionigi R.
        • et al.
        Standard versus extended lymphadenectomy associated with pancreaticoduodenectomy in the surgical treatment of adenocarinoma of head of the pancreas: a multicenter, prospective, randomized study. Lymphadenectomy study group.
        Ann Surg. 1998; 228: 508-517
        • Jang J.Y.
        • Han Y.
        • Lee H.
        • et al.
        Oncological benefits of neoadjuvant chemoradiation with gemcitabine versus upfront surgery in patients with borderline resectable pancreatic cancer: a prospective, randomized, open-label, multicenter phase 2/3 trial.
        Ann Surg. 2018 Aug; 268: 215-222
        • Dhir M.
        • Malhotra G.K.
        • Sohal D.P.S.
        • et al.
        Neoadjuvant treatment of pancreatic adenocarcinoma: a systematic review and meta-analysis of 5520 patients.
        World J Surg Oncol. 2017 Oct 10; 15: 183
        • Versteijne E.
        • Suker M.
        • Groothuis K.
        • et al.
        Dutch pancreatic cancer group. Preoperative chemoradiotherapy versus immediate surgery for resectable and borderline resectable pancreatic cancer: results of the Dutch randomized phase III PREOPANC trial.
        J Clin Oncol. 2020 Jun 1; 38: 1763-1773
        • Maeda S.
        • Moore A.M.
        • Yohanathan L.
        • et al.
        Impact of resection margin status on survival in pancreatic cancer patients after neoadjuvant treatment and pancreatoduodenectomy.
        Surgery. 2020 May; 167: 803-811
        • Tummers W.S.
        • Groen J.V.
        • Sibinga Mulder B.G.
        • et al.
        Impact of resection margin status on recurrence and survival in pancreatic cancer surgery.
        Br J Surg. 2019 Jul; 106: 1055-1065
        • Vonlanthen R.
        • Lodge P.
        • Barkun J.S.
        • et al.
        Toward a consensus on centralization in surgery.
        Ann Surg. 2018 Nov; 268: 712-724