Jang et al present a well-done study concluding that surgeon subspecialty is an important factor in improving survival for patients with gastric cancer. The authors conclude that high-volume gastric surgeons (those performing ≥50 gastric cancer operations per year) provide better outcomes for patients.
The topic of surgical subspecialization has been widely debated in the field of surgical oncology. Studies have established that operations such as pancreaticoduodenectomy, when performed at high-volume centers, improve patient outcomes.1 For gastric cancer, this is more difficult to study given the relatively lower incidence of this disease in the United States than in Eastern countries. In the United States, a high-volume gastric cancer center is defined as one performing 14 or more gastric cancer operations per year.2 Only 2 or 3 centers in the United States are performing more than 50 gastric cancer operations per year, including my own center. Therefore, this study has significant strength in numbers; however, the reason for better outcomes could be better defined. It is logical that a surgeon with extensive experience in a particular procedure that is performed in high volume is likely to achieve a more efficient and precise resection, especially with regard to a complete lymphadenectomy, needed for appropriate staging to define adjuvant treatment. However, additional factors may be involved, including the value of a tertiary care facility, where the ability to “rescue” a patient who sustains a complication is better. The authors do not give specific data on complications in the 2 groups compared, and it would have been helpful to identify whether the more experienced surgeons had fewer complications or were better able to recognize complications that occurred. The weaknesses of this article are acknowledged by the authors, including the impact of the long period of the study given the many advances in surgical technique, neoadjuvant and adjuvant treatment patterns, and changes in the epidemiology of gastric cancer (more proximal lesions). However, given the complexity of addressing this topic, this is a well-done study that raises awareness of the impact of volume and subspecialization for gastric cancer.