Impact of surgeon volume on outcomes of rectal cancer surgery: A systematic review and meta-analysis

doi:10.1016/j.surge.2010.07.003

The Surgeon

Volume 8, Issue 6, December 2010, Pages 341-352

https://doi.org/10.1016/j.surge.2010.07.003 Get rights and content

Abstract

Aim

To clarify the relationship between surgeon caseload and patient outcomes for patients undergoing rectal cancer surgery in order to inform debate about organisation of services.

Methods

We searched Medline and Embase for articles published up to March 2010, and included studies examining surgeon caseload and outcomes in rectal cancer patients treated after 1990. Outcomes considered were 30-day mortality, overall survival, anastomotic leak, local recurrence, permanent stoma and abdominoperineal excision rates. We assessed the risk of bias in included studies and performed random effects meta-analyses based on both unadjusted and casemix adjusted data.

Results

Eleven included studies enrolled 18,301 rectal cancer patients undergoing resective surgery. Unadjusted meta-analysis showed a statistically significant benefit in favour of high volume surgeons for 30-day postoperative mortality (OR = 0.57, 95% CI: 0.43–0.77; based on three studies, 4809 patients) and overall survival (HR = 0.76, 95% CI 0.63–0.90; based on two studies, 1376 patients), although the former relationship was attenuated and non-significant when based on two studies (9685 patients) that adjusted for casemix (OR = 0.79, 95% CI: 0.59–1.06). Pooling of three studies (2202 patients) showed no significant relationship between surgeon volume and anastomotic leak rate. Permanent stoma formation was less likely for high volume surgeons (adjusted OR = 0.75, 95% CI: 0.64 to 0.88; based on two studies, 9685 patients) and APER rates were lower for high volume surgeons (unadjusted OR = 0.58, 95% CI: 0.45 to 0.76); based on six studies, 3921 participants.

Conclusions

This review gives evidence that higher surgeon volume is associated with better overall survival, lower permanent stoma and APER rates.

Introduction

Colorectal cancer is the most common gastrointestinal cancer in the Western world, and the second most common cause of cancer related mortality.¹ Approximately one third of these cancers are located within the rectum.² In recent years, much interest has been given to the relationship between surgeon caseload and patient outcomes after surgery for cancer,3, 4, 5 including colorectal cancer.6, 7, 8, 9, 10, 11 Some evidence suggests that the surgeon is an important prognostic factor in colorectal cancer surgery: in particular, a higher surgeon caseload7, 8, 10, 11 and specialisation12, 13 have been associated with better outcomes. For rectal cancer surgery, there have been conflicting reports on this volume-outcome relationship.14, 15, 16, 17 The management of rectal cancer differs substantially from that of colon cancer, particularly in the use of more accurate staging investigations, administration of neo-adjuvant chemo-radiotherapy and surgical procedures that often involve specialized skills not required for colon cancer surgery. Furthermore, rectal cancer surgery has seen considerable changes in recent years, including the general acceptance of total mesorectal excision (TME) as a technique to reduce local recurrence and a drive towards more sphincter-preserving procedures with no oncological compromise.¹⁸ With such emphasis on surgical skill and techniques, it is important to identify potential risk factors for adverse outcomes, including the level of surgical specialisation and caseload. Surgeon caseload is an objective, quantitative measurement and likely to reflect the qualitative descriptor of “specialisation”, although these may not be completely interchangeable.

Although the volume-outcome relationship in rectal cancer has been previously assessed using meta-analysis,15, 16, 17 these reviews included studies on patients treated from the mid-1980’s when the management of rectal cancer patients was substantially different from current treatment. The aim of this review is to evaluate the effect of surgeon volume on the outcome from modern rectal cancer surgery, selecting only studies which reported on rectal cancer patients treated after 1990, and to give a quantitative estimate of such volume effect using meta-analysis.

Section snippets

Inclusion criteria

We considered all studies reporting surgeon caseload and outcomes for colorectal and rectal cancer surgery in patients undergoing treatment after 1990, including rectosigmoid tumours. We included studies that reported at least one of the following outcome measures: 30-day or postoperative mortality, overall survival, anastomotic leak rate, local recurrence rates, permanent stoma and abdominoperineal excision of the rectum (APER) rates. We excluded studies on colorectal cancer for which it was

Description of included studies

The search strategy identified a total of 1000 potentially relevant studies of which 980 were excluded on the basis of title or abstract as they did not fulfil the inclusion criteria for this review. We obtained full papers for 20 studies, of which a further eleven studies were excluded as they did not meet the inclusion criteria. We found two studies6, 25 not identified by the initial search strategy in the references of the included literature, totalling 11 studies for the review. However, we

30-day or postoperative mortality

Unadjusted meta-analysis of three studies,8, 26, 29 including a total of 4809 patients, showed that patients treated by HV surgeons had a significantly lower risk of postoperative death than those treated by LV surgeons (OR = 0.57, 95% CI: 0.43–0.77, Fig. 4a).

Two studies adjusted for casemix,8, 11 one of which¹¹ was not included in the unadjusted analysis. In a total of 9685 patients, the risk of postoperative death was lower for patients treated by HV surgeons than for those treated by LV

Discussion

This review was performed out of a perceived need to clarify the controversial issue regarding the role of surgeon caseload in the treatment of rectal cancer.³²

Conflict of interest statement

We declare no personal, financial or political interest which could influence the findings in the submitted material.

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Evidence that centralisation of rectal cancer surgery may improve long-term oncological outcomes has been presented in two meta-analyses. The first, an analysis of 18,301 patients by Archampong et al., demonstrated a significant association between high volume surgeons and overall survival [15]. More recently, a meta-analysis by Chioreso et al. demonstrated an association between higher hospital volume and improved overall survival but no association between surgeon volume and survival [16].
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Data were collected from the National Cancer Registry of Ireland to include all patients with Stage I-III rectal cancer undergoing rectal cancer surgery with curative intent between 2003 and 2012. Five-year overall survival and cancer-specific survival was compared between patients in the pre-centralisation (2003–2007) and post-centralisation period (2008–2012) and between patients receiving surgery in designated cancer centres and non-cancer centres.
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Survival following resection of rectal cancer was significantly improved following implementation of a national cancer strategy incorporating centralisation of rectal cancer surgery.
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The impact of surgeon volume on outcomes has been observed in many different surgical specialties including: breast oncologic surgery, bariatric surgery, gynecological oncology operations, and colorectal operations [3–7]. Several studies have demonstrated an association between high surgeon volume and decreased complication rates, cancer recurrence risk, and decreased overall oncological mortality when managed by subspecialty areas [3–5,7]. In addition to other surgical specialties, this surgeon volume-outcome effect has also been observed for thyroid surgical outcomes in pediatric patients where increased surgeon volume has been associated with lower complication rates, decreased length of hospital stay, lower cost, and lower mortality rates [8–11].
The study aim was to systematically review literature evaluating surgeon volume-outcome relationships for thyroid and parathyroid operations in order to inform surgical quality improvement initiatives. Current literature suggests surgeons who perform a high volume of thyroid and/or parathyroid operations have better outcomes than low volume surgeons, though specific volume definition are not standardized.
Eligible studies were selected through a literature search focused on the effect of surgeon volume on thyroid and parathyroid surgery patient outcomes. The literature search was conducted in accordance with the PRISMA guidelines. Publication dates extended from January 1998 to February 2021, and were limited to articles published in English.
A total of 33 studies were included: 25 studies evaluating thyroid surgery outcomes, 4 studies evaluating parathyroid surgery outcomes, and 4 studies evaluating both thyroid and parathyroid (mixed) surgery outcomes. Higher volume thyroid and parathyroid surgeons were found to be associated with fewer surgical and medical complications, shorter length of hospital stay, and reduced total cost when compared to lower volume surgeons. This volume-outcome relationship was also found to specifically affect the complication and recurrence rates for thyroid cancer patients undergoing surgery, especially for individuals with advanced stage disease.
The heterogeneity in cut-offs used for characterizing surgeons as high versus low volume, and also in subsequent patient outcome measures, limited direct study comparisons. The trend of improved patient outcomes with higher surgeon volume for both thyroid and parathyroid surgeries was consistently present in all studies reviewed.
Surgery for rectal cancer: Differences in resection rates among hospitals in the Netherlands
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Numerous quality improvement initiatives for rectal cancer surgery have focused on textbook outcome parameters. In these studies, resection rate and patients who did not undergo surgery are not included, but these parameters might help to evaluate the surgical care for rectal cancer. The aim of this study is to assess the variation of non-metastatic rectal cancer resection rates among hospitals and its effect on patient outcomes.
All patients diagnosed with non-metastatic rectal cancer between 2013 and 2018 were selected from the Netherlands Cancer Registry. Hospitals were categorized in quartiles according to resection rates. A multivariable logistic analysis was performed to determine variation in resection rate between these quartiles using a logistic regression analysis to correct for confounders. The association between resection rates and survival was analyzed using Kaplan-Meier method and Cox-regression analysis.
A total of 22,530 patients were included in the analysis. Resection rates varied from 68 to 89% between hospitals. After multivariable analysis, resection rate remained significantly different among the quartiles when correcting for several factors (odds ratio (95%Confidence-interval) 1.71 (1.56–1.88), 2.42 (2.19–2.67), and 4.04 (3.61–4.53) for increasing resection rate quartiles, in reference to the lowest quartile). A higher resection rate was associated with better overall survival, in multivariable analysis this survival benefit could no longer be identified.
There is a substantial variation in resection rates for rectal cancer among hospitals in the Netherlands with an impact on overall survival. This may be a relevant issue when analyzing the overall quality of rectal cancer care.
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Prior studies have demonstrated wide variation in the quality of cancer surgery among hospitals, with superior outcomes often found at larger hospitals and those recognized for their high-quality cancer care, including survival and adherence to guideline-recommended care.1–16 These volume-outcome relationships have been of particular interest in cancer care, including common cancers such as breast,7–10 colorectal,1,5,14–16 and prostate cancers.11–13 Despite this evidence, a substantial proportion of cancer patients are treated in smaller hospitals that do not have accredited cancer programs.
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Individuals diagnosed with breast, prostate and colorectal cancer in 2015 completed online surveys in 2017–2018. Participants were categorized as “directed” to a surgeon (relied on referral) or “active” (sought additional information), and hospitals were categorized by NCI-designation, CoC accreditation, and academic affiliation.
Of 299 participants, 42% were active. Individuals with breast cancer were more active (aOR = 2.46,95%CI:1.32–4.59). Active participants had nonsignificantly higher odds of surgery at NCI-designated facilities (aOR = 2.04,95%CI:0.95–4.38), or academic centers (aOR = 1.51,95%CI:0.86–2.64).
While most participants were directed to their cancer surgeon, active participants tended to select NCI-designated/academic hospitals. Although centralization of cancer care would require altering referral patterns, decision-support resources may help patients make informed choices.
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Current literature suggests surgeons who perform large volumes of rectal cancer resections achieve superior outcomes, but only about half of rectal cancer resections are performed by high-volume surgeons in comprehensive hospitals. Little is known about the considerations of patients with rectal cancer when deciding where to receive surgery.
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Evidence suggests that high-volume facilities achieve better rectal cancer outcomes.
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Two thousand three hundred subjects (average age = 75) met the criteria. Greater proportions of those treated at NCI-designated facilities received transrectal ultrasound (TRUS) or magnetic resonance imaging (MRI)-pelvis (62.1 vs. 29.9 %), neoadjuvant chemotherapy (63.9 vs. 41.8 %), and neoadjuvant radiation (70.8 vs. 46.3 %), all p < 0.0001. On multivariate analysis, odds ratios (95 % confidence intervals) for receiving TRUS or MRI, neoadjuvant chemotherapy, or neoadjuvant radiation among beneficiaries treated at NCI-designated facilities were 3.51 (2.60–4.73), 2.32 (1.71–3.16), and 2.66 (1.93–3.67), respectively. Results by residency and medical school affiliation were similar in direction to NCI designation.
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Impact of surgeon volume on outcomes of rectal cancer surgery: A systematic review and meta-analysis

Abstract

Aim

Methods

Results

Conclusions

Introduction

Section snippets

Inclusion criteria

Description of included studies

30-day or postoperative mortality

Discussion

Conflict of interest statement

Clin Gastroenterol Hepatol

Controlled Clin Trial

Eur J Surg Oncol

Eur J Surg Oncol

GLOBOCAN 2002. Cancer incidence, mortality and prevalence worldwide IARC CancerBase No. 5, version 2.0

Cancer statistics, 2009

CA Cancer J Clin

Is volume related to outcome in healthcare? A systematic review and methodologic critique of the literature

Ann Intern Med

Should Operations be regionalized?

N Engl J Med

Impact of hospital volume on operative mortality for major cancer surgery

JAMA

Consultant surgeons and pathologists of the lothian and borders health boards. Lothian and borders large bowel cancer project: immediate outcome after surgery

Br J Surg

Hospital volume can serve as a surrogate for surgeon volume for achieving excellent outcomes in colorectal resection

Ann Surg

Impact of surgeon volume and specialization on short-term outcomes in colorectal cancer surgery

Br J Surg

Surgeon and hospital volume and the management of colorectal cancer patients in Australia

ANZ J Surg

Influence of volume of work on the outcome of treatment for patients with colorectal cancer

Br J Surg

Relation of surgeon and hospital volume to processes and outcomes of colorectal cancer surgery

Ann Surg

Reduction of postoperative morbidity and mortality in patients with rectal cancer following the introduction of a colorectal unit

Br J Surg

Evidence of the effect of ‘specialization’ on the management, surgical outcome and survival from colorectal cancer in Wessex

Br J Surg

Influence of caseload and surgical speciality on outcome following surgery for colorectal cancer: a review of evidence. Part 1: short-term outcome

Colorectal Dis

Influence of caseload and surgical speciality on outcome following surgery for colorectal cancer: a review of evidence. Part 2: long-term outcome

Colorectal Dis

The effect of provider case volume on cancer mortality: systematic review and meta-analysis

CA Cancer J Clin

A national perspective on the decline of abdominoperineal resection for rectal cancer

Ann Surg

Effect of surgeon and hospital factors on the outcome from the surgical management of colorectal cancer, in School of Medical Sciences