SURGEON-RELATED FACTORS AND OUTCOME IN RECTAL-CANCER

Objective To determine whether surgical subspecialty training in color ectal surgery or frequency of rectal cancer resection by the surgeon a re independent prognostic factors for local recurrence (LR) and surviv al. Summary Background Data Variation in patient outcome in rectal can cer has been shown among centers and among individual surgeons. Howeve r, the prognostic importance of surgeon-related factors is largely unk nown. Methods All patients undergoing potentially curative low anterio r resection or abdominoperineal resection for primary adenocarcinoma o f the rectum between 1983 and 1990 at the five Edmonton general hospit als were reviewed in a historic-prospective study design. Preoperative , intraoperative, pathologic, adjuvant therapy, and outcome variables were obtained. Outcomes of interest included LR and disease-specific s urvival (DSS). To determine survival rates and to control both confoun ding and interaction, multivariate analysis was performed using CoX pr oportional hazards regression. Results The study included 683 patients involving 52 surgeons, with >5-year follow-up obtained on 663 (97%) p atients. There were five colorectal-trained surgeons who performed 109 (16%) of the operations. independent of surgeon training, 323 operati ons (47%) were done by surgeons performing < 21 rectal cancer resectio ns over the study period. Multivariate analysis showed that the risk o f LR was increased in patients of both noncolorectal trained surgeons (hazard ratio (HR) = 2.5, p = 0.001) and those of surgeons performing < 21 resections (HR = 1.8, p < 0.001). Stage (p < 0.001), use of adjuv ant therapy (p = 0.002), rectal perforation or tumor spill (p < 0.001) , and vascular/neural invasion (p = 0.002) also were significant progn ostic factors for LR. Similarly, decreased disease-specific survival w as found to be independently associated with noncolorectal-trained sur geons (HR = 1.5, p = 0.03) and surgeons performing <21 resections (HR = 1.4, p = 0.005). Stage (p < 0.001), grade (p = 0.02), age (p = 0.02) , rectal perforation or tumor spill (p < 0.001), and vascular or neura l invasion (p < 0.001) were other significant prognostic factors for D SS. Conclusion Outcome is improved with both colorectal surgical subsp ecialty training and a higher frequency of rectal cancer surgery. Ther efore, the surgical treatment of rectal cancer patients should rely ex clusively on surgeons with such training or surgeons with more experie nce.