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To the Editor: In their study on the influence of hospital volume and surgical volume on 30-day mortality after major operative procedures in patients with cancer, Dr Begg and colleagues¹ attempt to address a complex and difficult task with an elegant approach. However, this study cannot address 1 important association of quality outcome.

While a high-volume center is more likely to achieve better outcome, excellent outcome is still feasible in low-volume centers under certain circumstances. For instance, Begg et al list zero mortality after pancreatectomy in 5 hospitals with only 5 patients each during the study interval of 10 years. At the City of Hope National Medical Center, a "low-volume" institution according to a definition offered by Lieberman et al,² 54 patients have undergone partial or total pancreatectomy between 1988 and 1998, including 50 for a diagnosis of cancer. Nine surgeons performed a median of 6 such procedures during this . . . [Full Text of this Article]