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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