Research Article: Should Informed Consent for Cancer Treatment Include a Discussion about Hospital Outcome Disparities?

Date Published: October 21, 2008

Publisher: Public Library of Science

Author(s): Nadine Housri, Robert J Weil, David I Shalowitz, Leonidas G Koniaris

Abstract: Background to the DebateSeveral studies have found disparities in the outcome of medical procedures across different hospitals—better outcomes have been associated with higher procedure volume. An Institute of Medicine workshop found such a “volume–outcome relationship” for two types of cancer surgery: resection of the pancreas and esophagus ( This debate examines whether physicians have an ethical obligation to inform patients of hospital outcome disparities for these cancers.

Partial Text: Thirty years ago, Luft and colleagues published the mortality rates for 12 surgical procedures of varying complexity in 1,498 hospitals, finding the mortality of open-heart surgery, vascular surgery, transurethral prostatectomy, and coronary bypass to be inversely related to hospital volume [1]. Since then, further studies have found an association between improved outcome and high hospital procedure volume [2–19] or teaching hospital status [20–23]. Such reports have led to calls for regionalization of care [12,24,25], and have served as the impetus leading consumer groups and policy makers to use hospital volume as a quality indicator and, in some cases, to direct patients to high-volume centers for select procedures [26,27] .

In their thoughtful and provocative viewpoint, Nadine Housri and Leonidas Koniaris propose that hospital outcome studies should be a necessary and obligatory component of the informed consent process ahead of offering surgery for cancer. Reviewing a number of the salient papers published over the past 30 years, they re-emphasize that, for some cancers, hospitals with higher volumes and/or teaching-training facilities have statistically lower rates of postoperative mortality and increased rates of survival (both indicators of surgical quality). In the field of oncological surgery, this association is true only of resections for esophageal and pancreatic cancer.

To what extent do volume–outcomes data matter in patients’ decision-making? The National Cancer Policy Board of the Institute of Medicine concluded that “volume per se does not result in good outcomes in health care but is instead a proxy measure for other factors [potentially including] physician skill, experienced interdisciplinary teams, or well-organized care processes” [39]. The volume–outcome relationship is therefore less likely to be valuable to patients selecting a cancer treatment site than the actual outcomes data from potential treating institutions. Put another way, outcomes data from multiple institutions are likely to be important to a patient’s selection of a treatment center, but the causes of differences in outcomes, whether case volume, teaching status, or otherwise, are far less likely to matter.