Centralisation of cancer services vindicatedBMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c3336 (Published 22 June 2010) Cite this as: BMJ 2010;340:c3336
All rapid responses
The 30-day mortalities for low, medium and high volume hospitals
reported by Cathcart et al were 3.0%, 2.7% and 2.4% respectively, p=0.22.
The 90-day mortalities were 7.6%, 6.2% and 5.7% respectively, p=0.007 (1).
Thus the trend to better outcomes seen at 30 days in the high volume
hospitals was confirmed at 90 days, there being a 250%, 250% and 240%
increase in mortalities in all three types of hospital from 30 to 90 days.
Why the continued attrition of patients after 30 days?
Busy anesthesiologists tend to think their job has been done when
their patients wake up or, if admitted to an intensive care unit, when
they have been discharged from the unit. Busy surgeons tend to think their
job is done when their patients have been discharged from hospital and
especially after their first clinic visit when they are considered well
enough to withstand adjuvant chemotherapy if that is planned. Surgical
clinics can become overloaded very quickly if patients are not discharged
and surgeons do not expect their patients to die after discharge unless
they have developed complications and had a prolonged stay in an ICU, but
with the pressure on ICU beds few are admitted in an US tertiary referral
center even after some of the largest of cancer operations. Furthermore
whilst surgeons do no generate much revenue from seeing patients in clinic
oncologists depend upon them for their incomes and it is very difficult to
escpae having to refer cancer patients to an oncologist for litigenous
The 250% increase in mortality from 30 to 90 days in all three groups
of hospitals is alarming. Possible causes include the persistent effects
of a systemic energy deficit present before surgery as perhaps in the case
of patients who were being treated for depression before surgery and
those who have fractured a hip in a fall. Another possibility is the
purging of adenine nucleotide pools promoted by the vogue of transfusing
large volumes of crystalloids as considered in a paper in the British
Journal of Aneasthesia and its accompanying eletters (2). Blood
transfusions too could be a contributing factor. But collectively it is
difficult to believe that these are responsible for the 4.6%, 3.5%, and
3.3% absolute increase in mortality between 30 and 90 days after
cystectomy constituting the 250% increases. What of the increases being
due to adjuvant chemotherapy which in one study
was administered in 4 courses at 28-day intervals and consisted of 100
mg./M.2 cisplatin, 60 mg./M.2 doxorubicin and 600 mg./M.2 cyclophosphamide
(3). Nasty stuff.
1. Paul J Cathcart, Jan van der Meulen, Mark Emberton, and John
Kelly. Centralisation of cancer services vindicated
BMJ 2010; 340: c3336.
2. D. R. McIlroy, D. V. Pilcher, and G. I. Snell. Does anaesthetic
management affect early outcomes after lung transplant? An exploratory
analysis. Br. J. Anaesth. 2009; 102: 506-514.
3. Skinner DG, Daniels JR, Russell CA, Lieskovsky G, Boyd SD, Nichols
P, Kern W, Sakamoto J, Krailo M, Groshen S. The role of adjuvant
chemotherapy following cystectomy for invasive bladder cancer: a
prospective comparative trial. J Urol. 1991 Mar;145(3):459-64; discussion
Competing interests: No competing interests