The Canadian Centre for Applied Research in Cancer Control

Evaluation of the systemic cancer therapy volume-outcome association: a population-based study to inform the optimal provincial organization and delivery of systemic cancer therapy

Lead Researcher(s):  Michael J. Raphael

Lead Institution: Sunnybrook Research Institute

Co-Investigators:Peter Austin, Christopher Booth, Katherine Enright, Craig Earle, Natalie Coburn, Julie Hallet, Antoine Eskander, Joseph Del Paggio

ARCC Program Area(s): Health Systems, Services, and Policy

Funding Term: 2021-2022

Project Summary:

There is strong evidence in the surgical oncology literature to support an association between higher hospital and surgeon case volumes and better patient outcomes.1-10  Based on this “volume-outcome” relationship, regionalization policies have been implemented in many jurisdictions, where care is redirected to specific hospitals and surgeons to ensure high case volumes. 11-14  It is not known whether the volume-outcome relationship extends to the non-operative management of cancer.15 This information is critical to determine whether regionalization policies for non-operative cancer care are justified.

The overarching objective of this research proposal is to inform the optimal provincial coordination of systemic cancer therapy delivery in Canada. To support this objective, we will evaluate if there is an association between volume of systemic cancer therapy provision and outcomes. We will evaluate survival, quality metric adherence, and economic outcomes. We will establish volume-thresholds that can be tracked as quality indicators or used by decision makers to inform policy. Finally, we will evaluate the association between physician specialization and outcomes. This will help determine whether the complexity of contemporary cancer care requires reforms or adjustments to current scopes of practice.

The funding requested from Canadian Center for Applied Research in Cancer Control will be used to perform a proof-of-concept study using ‘real-world evidence’ from the Ontario population-level databases housed at ICES. This proof-of-concept study will demonstrate the feasibility of our methods to evaluate the volume-outcome association among patients receiving systemic therapy for advanced gastric cancer. The hope is that we can leverage the findings from this proof-of-concept study using a single-cancer site (gastric cancer) in a single province (Ontario) to support a larger application for funding from a Canadian Institute of Health Research grant for a multi-cancer site, pan-Canadian research project.

We will use the Ontario Cancer Registry to identify all patients with advanced gastric cancer treated with systemic therapy in Ontario, Canada. We will deterministically-link these patients to multiple administrative healthcare databases housed at ICES. We will fit a series of multi-level (patient, provider, hospital) regression models to estimate the association between volume of systemic therapy provision and outcomes. We will use these models to parse out the contribution of each level to the differences in outcomes seen. Restricted cubic splines will be used to determine volume thresholds.

The insights from this research project will provide the evidence base for innovative new models of organizational cancer policy that will improve the quality of care and outcomes for patients living with cancer in Canada.


  1. Birkmeyer JD, Stukel TA, Siewers AE, et al: Surgeon volume and operative mortality in the United States. New England Journal of Medicine 349:2117-2127, 2003
  2. Halm EA, Lee C, Chassin MR: Is volume related to outcome in health care? A systematic review and methodologic critique of the literature. Annals of internal medicine 137:511-520, 2002
  3. Ross JS, Normand S-LT, Wang Y, et al: Hospital volume and 30-day mortality for three common medical conditions. New England Journal of Medicine 362:1110-1118, 2010
  4. Hannan EL, O’Donnell JF, Kilburn H, et al: Investigation of the relationship between volume and mortality for surgical procedures performed in New York State hospitals. Jama 262:503-510, 1989
  5. Hannan EL, Radzyner M, Rubin D, et al: The influence of hospital and surgeon volume on in-hospital mortality for colectomy, gastrectomy, and lung lobectomy in patients with cancer. 131:6-15, 2002
  6. Begg CB, Cramer LD, Hoskins WJ, et al: Impact of hospital volume on operative mortality for major cancer surgery. Jama 280:1747-1751, 1998
  7. Nathens AB, Jurkovich GJ, Maier RV, et al: Relationship between trauma center volume and outcomes. Jama 285:1164-1171, 2001
  8. Siemens DR, Mackillop WJ, Peng Y, et al: Processes of care and the impact of surgical volumes on cancer-specific survival: a population-based study in bladder cancer. Urology 84:1049-57, 2014
  9. Lüchtenborg M, Riaz SP, Coupland VH, et al: High procedure volume is strongly associated with improved survival after lung cancer surgery. Journal of Clinical Oncology 31:3141-3146, 2013
  10. Huo YR, Phan K, Morris DL, et al: Systematic review and a meta-analysis of hospital and surgeon volume/outcome relationships in colorectal cancer surgery. Journal of Gastrointestinal Oncology 8:534-546, 2017
  11. Sundaresan S, McLeod R, Irish J, et al: Early results after regionalization of thoracic surgical practice in a single-payer system. The Annals of thoracic surgery 95:472-479, 2013
  12. Bendzsak AM, Baxter NN, Darling GE, et al: Regionalization and Outcomes of Lung Cancer Surgery in Ontario, Canada. Journal of Clinical Oncology 35:2772-2780, 2017
  13. Hamilton SM, Johnston WC, Voaklander DC: Outcomes after the regionalization of major surgical procedures in the Alberta Capital Health Region (Edmonton). Canadian Journal of Surgery 44:51, 2001
  14. Simunovic M, Urbach D, Major D, et al: Assessing the volume-outcome hypothesis and region-level quality improvement interventions: pancreas cancer surgery in two Canadian Provinces. Annals of Surgical Oncology 17:2537-2544, 2010
  15. Raphael MJ, Siemens DR, Booth CM: Would Regionalization of Systemic Cancer Therapy Improve the Quality of Cancer Care? J Oncol Pract 15:349-356, 2019
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