SURGEON INFLUENCED VARIABLES IN THE OUTCOME
OF RECTAL CANCER SURGERY
Steven D. Wexner M.D., FACS, FRCS, FRCS(Ed)
Chairman, Department of Colorectal Surgery
Cleveland Clinic Florida, Weston, FL
Professor of Surgery, Ohio State University Health Sciences Center at the Cleveland Clinic
Foundation
Clinical Professor, Department of Surgery, University of South Florida College of
Medicine
Susan M. Cera, MD
Clinical Associate
Cleveland Clinic Florida
Objectives:
1. Understand the large differences in the local and overall recurrence rates after
potentially curative rectal cancer surgery that relate directly to the specialty and
volume of the surgeon who performs the operation
Introduction
Rectal carcinoma remains a major public health problem in the United States and in other
developed countries. The National Cancer Institute estimated 42,000 new cases of rectal
cancer in the United States in the year 2003 (1). Since its description, the total mesorectal
excision (TME) technique has gained wide acceptance and has been proven to be an
important factor in improving both local disease control and survival. However, it has been
well demonstrated that other factors such as surgeon’s experience, training and volume are
directly related to the outcome, recurrence and survival rates of patients operated on for
rectal cancer.
Surgeon specialization
Using a state legislated database, Rosen showed that the mortality rate for patients with
moderately severe health problems at admission was lower if a colorectal surgeon rather than
a general surgeon had operated (2). The mortality rate for patients of all severity levels was
1.4% for colorectal surgeons and 7.3% for institutional general surgeons. When the patients
with a severity level of 2 or 3 were considered, the mortality for colorectal surgeon was
0.82% and 5.7%, respectively, compared to 3.8% and 16.4%, respectively, for institutional
general surgeons. The length of hospitalization was similarly increased for institutional
general surgeons, 16.1 days at level 2 and 21.2 days at level 3 cases compared to 12.3 days
and 17 days for colorectal surgeons, respectively. Recently, Callahan et al (3) examined the
relationship of surgeon subspecialty training and interests to in-hospital mortality while
controlling for both hospital and surgeon volume. For colectomies, the authors found that
risk-adjusted mortality was substantially lower when performed by subspecialty interested
and trained surgeons than by nonsubspecialty-trained surgeons (2.4% versus 4.8%, adjusted
odds ratio [OR] = 0.45; 95% confidence interval [CI] = 0.34, 0.60; P < 0.0001), even after
accounting for hospital and surgeon volume and patient characteristics. Dorrance et al (4)
published their results of 378 patients who underwent curative surgery for colorectal cancer
by surgeons with different specialty interests. At a median follow up of 45 months, the only
factors associated with a significantly reduced local recurrence rate were the length of the
resected specimen and colorectal specialization. The authors concluded that surgeons with
demonstrable interest in colorectal cancer achieved lower both local and overall recurrence
rates compared with vascular, transplant, or general surgeons; many other data from around
the world have confirmed these findings. Read et al (5) published their data on determining
the effect of surgeon variability on disease-free survival and local control in patients with
adenocarcinoma of the rectum. Three hundred eighty-four consecutive patients treated by
colorectal surgeons were compared to 133 treated by non-colorectal surgeons; all patients
received preoperative radiotherapy. Overall actuarial disease-free survival and local control
rates were 77% and 93%, respectively, for colorectal surgeons versus 68% and 84%,
respectively, for non-colorectal surgeons (p<0.005 for both). The authors concluded that
good outcome for patients with rectal adenocarcinoma who underwent neoadjuvant external
beam radiotherapy and proctectomy is associated with subspecialty training in colon and
rectal surgery. More recently, Platell et al (6) compared the risk adjusted survival between
rectal cancer patients managed in general units versus a colorectal unit from 1996 to 2001.
These results were compared to a historical control group who did not receive
chemoradiation therapy, treated between 1989 and 1994. Patients in the colorectal group who
had either Stage I or Stage III cancers were noted to have significantly higher survivals rates
when compared to the other two groups.
Surgeon volume
In addition to specialization, rectal cancer recurrence and survival rates have tremendous
variability among surgeons, strongly linked to surgical volume. Phillips (7) showed that
among 20 surgeons who entered more than 30 patients in the Large Bowel Cancer Project,
only 3 surgeons had less than a 5% recurrence rate, while 7 had a greater than 15%
recurrence rate. This finding led them to conclude that the surgeon was an independent
prognostic factor “that needs to be considered pari passu with Dukes’ staging”. Hermanek et
al (8) analyzed a subgroup of 600 patients who had undergone curative rectal resection from
the German Study Group Colorectal Carcinoma (SGCRC). They showed that patients whose
surgeons had less than 15 cases enrolled in the trial were at increased risk for local recurrence.
Furthermore, even among the higher volume surgeons, one surgeon had an odds ratio of 4.81
for local recurrence compared to the 1.71 seen in the others. They concluded that the minimal
volume of rectal surgery that offers optimal recurrence rates was 1 to 2 resections per month.
Matling et al (9) presented their results of 652 patients operated for rectal cancer. Their
outcome was compared to patients operated on by teams that included high volume surgeons
(more than 12 operations per year), teams that included low volume surgeons (12 operations
or fewer per year), and demonstrated that better results were obtained in patients treated by
high volume surgeons. McArdle (10) also demonstrated the surgeon’s variability with
mortality rates after curative resection ranging from 0 to 20% and local recurrence rates from
0 to 21% depending on the surgeon. The 10-year survival after curative resection ranged
from 20 to 63%. It is interesting to contrast these convincing data supporting high volume
specialization with the report from 4 surgeons who classified themselves as non-specialists in
colorectal surgery (11). They reported a 2% postoperative mortality rate following elective
surgery and 13% mortality rate following emergency surgery. Their 5 years survival rate for
curative resection was 67%, which compares favorably with the literature. However, based
on the current analysis, since the range of major colorectal procedures performed by these
surgeons ranged from 29 to 83, these surgeons are higher volume surgeons.
Conclusion
There are large differences in the local and overall recurrence rates after potentially
curative rectal cancer surgery that relate directly to the specialty and volume of the surgeon
who performs the operation.
References
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