Hospital procedure volume and prognosis with respect to testicular cancer patients: a population‐based study in Osaka, Japan

Abstract

Since the introduction of cisplatin-containing chemotherapy in the late 1970s, the standard chemotherapy protocol of cisplatin, etoposide and bleomycin has markedly improved the prognosis of testicular germ-cell cancer (TGCC).(1) Furthermore, subsequently developed salvage chemotherapy regimens, salvage surgery, highly stereotactic radiation therapy and progress in diagnostic modalities have further improved survival even with advanced-stage cancer and/or distant metastasis.(2-4) TGCC is known worldwide as a curable malignancy and with the medical progress described above, we would have expected to see equivalent prognostic improvements in Osaka, Japan. However, the 5-year prognoses of patients in Osaka diagnosed with testicular cancer (TC) were worse than those from the Surveillance Epidemiology and End Results (SEER) program, (5) possibly because of insufficient diffusion of the standard chemotherapy to smaller hospitals. (6) Following this previous report from the years 1975-1992, we have further updated the observation period of survival, analyzed the association between hospital procedure volume and survival and evaluated the centralization of patients' hospital referral using the Osaka Cancer Registry (OCR) database. Materials and MethodsData sources. Subjects with TC (ICD10, C62) were retrieved from the OCR database. The subjects included for survival analysis were reported cases diagnosed during 1993-1999, as the latest 5-year follow-up data in the OCR were cases diagnosed by 1999. Subjects with second primary testicular tumors were excluded from survival analysis as in the EUROCARE study. Categorization for hospital procedure volume and patients' hospital referral period. To evaluate the survival difference between hospitals, hospitals were categorized into three groups (A, B and C) according to patient procedure volume, in other words the number of patients treated. The three groups contained almost the same numbers of patients. To evaluate the hospital referral trend, the 12 years of 1990-2001, including the survival study period of 1993-1999, was divided into three consecutive 4-year periods.Relative survival. The Kaplan-Meier method was used for calculating survival and the 95% confidence interval. The starting point of survival time was defined as the date of the first diagnosis and the end-point was death from any cause. The closing date was defined as 5 years after the starting point. Cases lost to followup were censored at the latest date when they were confirmed as being alive. The expected survival was estimated by the Ederer II method, (8) using the survival probability in the general population similar to the subjects with respect to sex, age and calendar year. A survival probability table prepared by the National Cancer Center, (9) was used. Relative survival was calculated as the ratio of observed to expected survival.Hazard ratio. Prognostic factors of TGCC were analyzed using the Cox proportional hazards model. Independent variables were the hospital groups, clinical stage (distant/local...

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