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Survival, mortality and morbidity outcomes after oesophagogastric cancer surgery in New South Wales, 2001–2008

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To the Editor: Following a retrospective review of New South Wales data, Smith and colleagues concluded that the better long-term survival outcomes following surgery for oesophagogastric cancer at higher-volume centres support surgery only being done at these centres.1 However, much missing data creates uncertainty about this conclusion.

Survival outcomes directly relate to stage at diagnosis, so variable use of staging laparoscopy, endoscopic ultrasound and/or positron emission tomography, all of which can upstage a significant proportion of patients,2 and all more likely to be employed at higher-volume centres, could create considerable variation in recorded stage at diagnosis and in patient selection for surgery. Further, some patients considered surgical candidates at one hospital may be managed with definitive chemoradiation at another hospital.3 Most significantly, there are widely variable approaches to the use of adjuvant radiation and chemotherapy, including the timing and agents used,4 which have a significant impact on recurrence risk and survival. As 5-year survival is also confounded by deaths from other causes, this measure cannot be considered a reliable indicator of surgical quality. We note that more direct indicators — length of stay and 30-day mortality —…