Specialist surgery

“Some surgeons perform less than optimal surgery. Some are less competent technically than their colleagues; and some fail to supervise surgeons in training adequately.

… If by more meticulous attention to detail, the results of surgery could be improved, and our results suggest that this would not be difficult, the impact on survival might be greater than that of any of the adjuvant therapies currently under study.”

McArdle and Hole, BMJ 1991;302:1501-5

The surgeon as a prognostic factor in rectal cancer

Variability among 13 consultant surgeons (%)

Curative resection (R0)

40 – 76

Anastomotic leakage 0 – 25

Postoperative mortality

8 – 30

Local recurrence 0 – 21

Survival 20 – 63

Importance of training and team effort

• Surgical oncology is top-class sport

• Training and (multidisciplinary) team effort essential

Effect of surgical trainee program in Sweden

Stockholm I

(n = 686)

Stockholm II

(n = 481)

TME project

(n = 381)

p-value

Local recurrence 103 (15%) 66 (14%) 21 (6%) <0.0001

Cancer specific death

104 (15%) 77 (16%) 35 (9%) 0.002

Abdominoperineal resection

414 (60%) 266 (55%) 101 (27%) <0.0001

Martling et al. Lancet, 2000; 356: 93 - 96

Results of the Norwegian program

0

20

40

60

80

Local recurrence5-year survival

Percen

t

1986-81994-9

Percentage of CRM+ in MRC CRO7 trial

0

5

10

15

20

25

1998 1999 2000 2001 2002 2003 2004 2005

Year

P. Quirke et al. ASCO 2006

Trials have a large educational effect

The impact of hospital volume on outcome of rectal cancer surgery (1995-2003)

Swedish cancer registry 2006

0

1

2

3

4

5

6

7

8

9

10

250

249-200

199-150

149-120

119-100

99-85

84-70

69-55

54-40

39-25

<25

postoperative mortality %

annual no of op

Variability of outcome related to case volume

High-volume team Low-volume team p-value

Mean no. of operations / year >12 0-12

Curative surgery 245 (78) 277 (82)

Median (range) of follow-up (months)

41 (24-59) 43 (24-59)

Local recurrence 9 (4) 27 (10) 0.02

Distant metastasis 39 (16) 54 (19) 0.33

Rectal cancer death 26 (11) 51 (18) 0.007

Martling et al, Br J Surg 2002;89:1008-13

Centers of excellence are needed

Outcomes-based quality improvement

• Outcomes registry• Concurrent assessments of structure and process of care

– Registry-based, site visits• Analyses aimed at identifying best practices• Broad implementation of such practices• Outcomes tracking to confirm improvements

Current development of European audit of colorectal cancer treatment