Rectal cancer services – is it time for specialization within units?

Abstract

Colorectal surgery has emerged as a subspeciality of general surgery. Within colorectal surgery there have been further subspecializations – pelvic floor, intestinal failure, inflammatory bowel disease and advanced pelvic malignancy, to name but a few. The objective of subspecialization is to ensure that patients have access to the widest range of treatment options, enabling shared decision-making and enhancing outcomes. The management of rectal cancer is becoming ever more complex. Multidisciplinary teams must be conversant with an increasing range of treatment options. Should a patient undergo organ-preserving chemoradiotherapy? Should they have transanal endoscopic operation/transanal endoscopic microsurgery (TEO/TEMS) or be considered for a major resection? If a major resection, then are the best results obtained with open, laparoscopic or robotic surgery? Rectal cancer surgery with performance of a high-quality total mesorectal excision is one of the most technically challenging procedures we do. The evidence is clear that if it can be performed to a high standard then local recurrence rates will be lower, thus surgeons are a prognostic factor [1, 2]. We also know that more and more colorectal surgeons are performing fewer and fewer rectal cancer excisions. The Association of Coloproctology of Great Britain and Ireland (ACPGBI) and Getting it Right First Time/National Consultant Information Programme (GIRFT/NCIP) support National Institute of Health and Care Excellence (NICE) guidance NG151 regarding annual minimum volumes for major rectal excision at both surgeon and institutional level. NICE recommends a minimum case load of five major rectal excisions per year at surgeon level and 10 at institutional level [3]. It should be noted that that these are minimum thresholds, and we would recommend that both Trusts providing rectal cancer surgery and surgeons operating on patients with rectal cancer should aim for higher annual case volumes in order to deliver excellence and innovation and provide a more resilient service. Subspecialization in colorectal surgery in the United Kingdom has dramatically improved outcomes from bowel cancer over the last few decades [4, 5] and survival rates are dramatically better than they were in the 1980s. Despite this, survival rates for colorectal cancer remain poorer in the UK than in other Western countries [4]. Over a similar timeframe, there has been a significant increase in the numbers of colorectal surgeons in the UK, stimulated by a need to improve on-call frequency and to deal with ever rising numbers of referrals for suspected colorectal cancer. This has led to a reduction in the case volumes of individual surgeons. Major surgery for rectal cancer is technically demanding and is a high-stakes business. The surgeon is constrained by the boundaries of the bony pelvis with limited working space and little margin for error. This can have significant ramifications for patients, including local recurrence of cancer, major bleeding, anastomotic leak and genitourinary dysfunction. Data from the National Bowel Cancer Audit (NBOCA) [5], the GIRFT Programme [6] and the Model Health System have shown that there is significant variation in the performance of rectal cancer surgery. Such a high degree of variation between units suggests that some of this variation is unwarranted, i.e. variation that cannot be explained by patient factors such as comorbidity or tumour factors such as site or stage. Research evidence from across the world, corroborated with national audit data from the NBOCA, has demonstrated an operative case volume effect at both surgeon and hospital level. These data have historically been complicated to aggregate and interpret as there are no universally agreed definitions of high- versus low-volume hospitals or surgeons. Meta-analysis has shown that 30-day mortality and permanent stoma rates are both lower when surgery is performed by high-volume surgeons [7]. A review of the