VARIATIONS IN TREATMENT OF RECTAL-CANCER - THE INFLUENCE OF HOSPITAL TYPE AND CASELOAD

PURPOSE: Surgical options for the treatment of rectal cancer may invol ve sphincter-sparing procedures (SSP) or abdominoperineal resection (A PR). We sought to examine variations in the surgical treatment of rect al cancer for a large, well-defined patient population and specificall y to determine if differences exist in management and survival based o n hospital type and surgical caseload. METHODS: The Cancer Surveillanc e Program database for Los Angeles County was used to retrospectively retrieve data on all patients who underwent SSP or APR for rectal aden ocarcinoma between 1988 and 1992. RESULTS: A total of 2,006 patients w ith adenocarcinoma of the rectum underwent SSP or APR during the study period. Overall, 55 percent underwent SSP, and the remaining 45 perce nt underwent APR. Use of SSP remained relatively constant for each yea r of the five-year period. Substantial variability was seen in the use of SSP at various hospital types. For localized disease, this varied from as low as 52 percent at teaching hospitals to as high as 78 perce nt at hospitals approved by the American College of Surgeons (P = 0.06 7). To examine the role of caseload experience, hospitals were divided into those completing an average of five or fewer rectal cancer cases per year vs. those completing an average of more than five cases per year. For localized disease, hospitals with higher caseloads performed SSP in significantly more cases, 69 vs. 63 percent (P = 0.049). Survi val was seen to be significantly improved for patients operated on at hospitals with higher caseloads, in cases of both localized and region al diseases (P < 0.001). CONCLUSION: Surgical choices in the treatment of rectal cancer may vary widely, even in a well-defined geographic r egion. Although the reasons for this variability are multifactorial, h ospital environment and surgical caseload experience seem to have a si gnificant role in the choice of surgical procedure and on survival.