Managed Clinical Network for esophageal cancer enables reduction of variation between hospitals trends in treatment strategies, lead time, and 2-year survival.

INTRODUCTION: Despite evidence-based guidelines, variation in esophageal cancer care exists in daily practice. Many oncology networks deployed regional agreements to standardize the patient care pathway and reduce unwarranted clinical variation. The aim of this study was to explore the trends in variation of esophageal cancer care between participating hospitals of the Managed Clinical Network (MCN) in the Netherlands. MATERIALS AND METHODS: Patients with esophageal cancer diagnosed from 2012 to 2016 were selected from the Netherlands Cancer Registry. Variation on treatment strategies, lead time to start of treatment, and 2-year survival, were calculated and compared between five clusters of hospitals within the network. RESULTS: A total of 1763 patients, diagnosed in 17 hospitals, were included. 71% of all patients received treatment with a curative intent, which ranged from 69% to 77% between the clusters of hospitals in 2015-2016. Although variation in treatment modalities between the clusters was observed in 2012-2014, no significant variation existed in 2015-2016, except for patients receiving no treatment at all. The 2-year overall survival of patients receiving treatment with a curative intent did not vary significantly between the clusters of hospitals (range: 56%-63%). Nevertheless, the median lead time before patients started treatment with a curative intent varied between clusters of hospitals in 2015-2016 (range: 34-47 days; p < 0.001). CONCLUSION: Limited variation in esophageal cancer treatment between clusters of hospitals in the MCN existed. This study shows that oncology networks can promote standardization of cancer care and reduce variation between hospitals through insight into variation.

[Submucosal presentation of Whipple's disease: a variant that is easily missed]. / Submucosale presentatie van de ziekte van Whipple: een variant die gemakkelijk wordt gemist.

Whipple's disease is a multisystem, and often chronic, disease caused by infection with the bacterium Tropheryma whipplei, and mainly occurs in middle-aged Caucasian men. In most cases, histological detection of large numbers of bacteria-laden macrophages in the mucosa of the small intestine confirms the diagnosis. Less commonly, these macrophages may be sparse and predominantly located beneath the mucosa. In these submucosally presenting cases, endoscopic and classic histological clues are absent and, therefore, the diagnosis can be missed. As a result, further periodic acid-Schiff (PAS) staining and PCR analysis are of great importance in arriving at the correct diagnosis.