Unfortunately, you just got diagnosed with lung cancer. You and your family are desperately trying to figure out where to go and which doctor to see. All too often, these decisions are made based upon insurance requirements or long standing relationships between physicians, but without a lot of patient input. But what if I told you that you could decrease your complications and improve your chances of survival if you drive a little farther, past your local hospital, to a specialized center that treats a higher volume of lung cancer patients? What would it take for you, the patient, to go the extra distance? Should doctors talk about this aspect of cancer care or is that somehow taboo in the U.S. health system?

These questions came to my mind during the annual meeting of the Society of Thoracic Surgeons (STS) in San Diego, California. At the meeting, one of the featured papers presented was: “Thoracic Surgery Regionalization Within an Integrated Health Care System Improves Outcomes From Major Pulmonary Resections for Lung Cancer,” presented by Sora Ely, MD, of the UCSF East Bay Surgery Program in Oakland (see press release here). In 2014, the Kaiser Permanente Northern California (KPNC) network regionalized their lung cancer surgery, going from 16 hospitals down to five designated Centers of Excellence. Their results comparing early patient outcomes after lung cancer surgery in the pre- and post-regionalization time periods were astounding. Patients were more likely to receive minimally invasive surgery (86 percent vs. 57 percent), spent less time in the ICU (-1.7 days) and in the hospital (-3.3 days), and had less total (26 percent vs. 39 percent) and major (10 percent vs. 14 percent) complications after regionalization, all statistically significant. It would therefore seem to be a no-brainer that regionalization is great for patients! But is it? Or is this simply just more food for thought in a long-running discussion on the “volume-outcome” effect in complex surgery?

The rationale for regionalization of complex care has been discussed extensively since seminal publications by Loft (1979) and Birkmeyer (2002). Many other studies have added specifically to the lung cancer surgery literature, generally suggesting a decrease in death within 30 days of surgery (the ultimate short-term outcome!) of between 1–4 percent, favoring high-volume over low-volume centers. But many of these studies are fraught with methodological problems and often do not account for patient or tumor risk factors when making comparisons. More carefully performed studies, including one from our own group, showed no difference in short term complications or death that could be attributed directly to a “volume-outcome” effect. But are we asking the right question? Are short-term outcomes all there is to regionalization and volume effects? They are certainly important. Complications affect patients’ ability to tolerate further treatment, their mental well-being, and their quality of life. Remarkably however, patients are pretty resistant to the idea of traveling to specialty hospitals based upon the chance of decreased short-term complications, even for cancer care. In a recent study using survey data (Resio 2018), investigators found that in order to get even half of patients to travel to a specialty center, that center had to have a 10 percent or greater decrease in the rate of complications and a 5 percent or greater decrease in death from the operation. Remarkably, 12 percent of patients were resistant to the idea of changing hospitals for almost any numeric improvement in short term outcomes! It seems apparent that low percentage changes of rare adverse events may therefore not be particularly tangible to patients. More likely, they are asking themselves not what is going to happen in the hospital, but rather “Is this cancer going to kill me?” Although much of the focus on quality improvement has centered on in-hospital and short-term outcomes, cancer cures and survival rates are arguably a much better quality metric. Many lung cancer surgeons can do a quick wedge resection for a cancer with minimal complications and look great on short-term quality reports and rating scales. But what happens when that patient actually needed a bigger operation with more lung and more lymph nodes removed? That operation statistically will have more complications. But should the surgeon be penalized or described as a poor performer? Obviously not.

Unfortunately, there are remarkably fewer studies examining whether cancer treatment at a specialty or high-volume center improves patients’ chances of actually surviving their cancer. Dr. Ely and colleagues did not address this question in their study presented at the STS. An older study from the SEER database suggested that patients who undergo resection at the highest-volume hospitals had an 11 percent increase in five-year survival. That study was based upon historical data from 1985–1996, well before many advances in staging, surgical care, and postoperative care that are common place at high-volume, regional hospitals. Additionally, advances in molecular classification and targeted treatment of lung cancer have changed treatment paradigms across even more advanced cancer stages. This may also give patients a survival boost at experienced centers.

So the question remains: how far would you drive to increase your chances of surviving cancer? It is a tough number to pin down. And it is tough to consider asking that question without taking potential patient barriers such as time away from work, costs of and ability to travel, insurance restrictions, and other socioeconomic factors into account. Any plan for true regionalization would have to be mindful of the actual distance patients have to travel to get to specialty centers. We don’t want to decrease access to care for patients with limited ability to travel. That said, perhaps it is time to look closely at stage- and patient-matched survival outcomes between different centers, at least among those within unified health care systems like KPNC. In similar systems without insurance barriers, more efforts should be made to centralize care and to develop uniform multidisciplinary staging and treatment plans and enhanced recovery after surgery pathways. Maybe less is more when it comes to hospitals treating lung cancer. Regionalization of complex surgery to high-volume hospitals has already been implemented in Canada with some favorable results. Shouldn’t we at least consider similar policies?

Brendon M. Stiles, MD is an Associate Professor of Cardiothoracic Surgery at Weill Cornell Medicine, New York-Presbyterian Hospital.