Improving long-Term outcomes for patients with extra-Abdominal soft tissue sarcoma regionalization to high-volume centers, improved compliance with guidelines or both?

Introduction. Optimization of outcomes of extra-Abdominal STS is not clearly understood. We sought to determine whether hospital surgical volume and adherence to NCCN guidelines, or both, are associated with outcomes in the treatment of extra-Abdominal soft tissue sarcoma (STS). Methods. The National Cancer Database (NCDB) was queried for patients undergoing surgery for extra-Abdominal STS diagnosed from 2003 to 2007. Mean annual hospital volume for STS surgery was divided into volume terciles (1T ≤3, 2T 4-10, and 3T ≥11 cases/year). Adherence to NCCN guidelines was determined. Primary outcome was overall survival. Results. Our study population consisted of 13,684 patients with a median age of 56 years. 3T hospitals were more likely to adhere to NCCN guidelines for stage III patients (63% versus 47%; p≤0.001) than 1T hospitals. On multivariable analysis, adherence to NCCN guidelines was associated with improved survival (HR = 0.79, CI 0.73-0.87; p<0.001), but hospital volume was not (3T versus 1T: HR = 0.92, CI 0.82-1.02; p=0.12). Five-year overall survival was comparable for compliant groups at 1T, 2T, and 3T hospitals (72%, 72.4%, and 72.6%, resp.). 3T hospitals were not associated with a lower risk of 30-day mortality (OR 0.70, 95% CI 0.44-1.11) compared to 1T hospitals but did have a higher R0 resection rate (OR 1.43, 95% CI 1.32-1.54). Conclusions. Adherence to NCCN guidelines, irrespective of hospital volume, is associated with improved overall survival for patients with extra-Abdominal STS. High-volume hospitals more often adhere to guidelines, but low-volume hospitals that follow national guidelines may achieve comparable outcomes.