Volume-Outcome Relationship in Oncological Surgery: data and models for the future in a volume edited by Prof. Montorsi, Rector of Humanitas University

Professor Marco Montorsi, Rector of Humanitas University and Director of the General and Digestive Surgery Unit at the Humanitas Clinical Institute, is the author of the monograph ‘Volume-Outcome Relationship in Oncological Surgery’ published by Springer. This is part of a series of works annually published by the Italian Society of Surgery (SIC), of which Professor Montorsi was president. The book brings together the contributions of some leading Italian and international experts and offers a complete overview of the relation between volume of surgical operations and their outcomes in oncological surgery. The work focuses on Italian hospitals and is based on national and regional data.

The relation between the volume of surgical operations and their outcome in different fields of oncological surgery (tumors of the upper and lower gastrointestinal tract, hepatobiliopancreatic system, breast, sarcomas) has been the subject of several debates around the world. The work by Prof. Montorsi presents the latest results of some studies conducted in Europe and the United States and suggests possible solutions.

“This topic is the subject of much discussion, as results are not fully defined yet. It all stems from some initial observations made in the United States in the 1970s. These observations pointed out that surgical interventions carried out in hospitals experiencing a higher volume of activity – and therefore being more experienced – had better results in terms of reducing operative mortality”, explains Prof. Montorsi. “Many studies have been conducted and many conferences have been held in the last fifty years. This has resulted in many speculations, but some problems still remain unsolved”

The topic is not only relevant for clinics but also for the national health policy. “A key point of the debate is: what happens if we concentrate complex and major oncological surgery in a few clinical centres? Studies suggest that the outcomes and the quality of services are generally improved and that the healthcare expenditure is optimized, but at the same time some other issues arise, such as how to manage the patient’s life and much more”, Prof. Montorsi notes.

The book holds the contributions of the more experienced surgeons in all the different fields considered. “Each expert has been entrusted with a chapter. Two sections of the book deal with the situation in the USA where, also due to the pressure of the insurance market, there is much talk about concentrating certain medical operations in  few, high level, clinical centres. Another chapter is dedicated to the European situation. Europe is still far from a shared solution and countries are following different paths: only few of them have laws that are pushing in this direction”.

Some clear indications emerge from the study: “Italian data confirm the high quality of our surgery. The general consensus by specialists is that some highly complex medical interventions should be concentrated in fewer centres with a higher volume of activity”. Despite the general consensus, some issues remain as yet unsolved: “How to organize this highly concentrated structure? In which areas of the country and according to what criteria?”.

A key question concerns the role of national authorities. “Is the concentration of surgical activity in high level and highly experienced centres the only way forward for everyone? The answer could be no, if we think of some successful initiatives such as mobile surgical teams”, stresses the Rector of Humanitas University.

However, a spontaneous concentration process is already underway, at least according to data provided by the PNE, the National Outcomes Program of AGENAS (National Agency for Regional Health Services), which monitors the outcomes and results of interventions in all regions. From, 2014 to 2018, the percentage of patients who turned to a highly specialized centre has increased from 30 to 40 percent for pancreas and esophagus surgery. According to Montorsi “There is an ongoing trend concentrating highly complex surgery in highly specialized hospitals , and that comes from the patients themselves, who today are much more informed”.

Another key fact emerges from the book: we are not starting from scratch. “We already have an effective  concentration model  : the Breast Units, which are established by law. Today, any type of intervention in this field is authorized only in certain specific centres. Those who do not comply with the regulations may incur in some economic sanctions such as reduced reimbursement of services”, adds Prof. Montorsi. “This is the model to start from. Another important issue is based on the national oncological network, as defined by an agreement between the State and the Regions last year. The agreement document clearly indicates the volume-outcome relationship as one of the indicators to be taken into consideration”.

All of this has an impact on the training of future doctors. “A key point is medical training. If surgery is concentrated in a few excellence centres, then Specialization schools will be able to offer high level training opportunities. This way, specialists having completed a first round of training could be offered a period of further excellence training – like fellowship –  in these high level centres” continues Prof. Montorsi. Scientific Societies should also apply to lead the process of accreditation of professionals, something which is already happening in other countries.

The editor of the book believes that now is the time to address this issue at a national level. “Covid has exacerbated the problem, making the organization of hospitals and patient mobility even more difficult. Time is now: tackling the problem would benefit the entire health care system”.