Volume-outcome analysis in rectal cancer: a plea for enquiry, evidence and evolution.


In the last three decades, since Luft suggested a link between hospital volume and patient outcome, little has changed. Despite great efforts to formally quantify the relationship between volume and cancer survival, much uncertainty remains. It is intuitive that increased experience (of the surgeon, the hospital or the ancillary staff) translates to better patient care but closer analysis of the literature uncovers widespread inconsistency in study design questioning validity of conclusions. Although centralisation of cancer services would seem beneficial, definitive evidence is only available regarding pancreatic and oesophageal disease and that pertaining to rectal cancer is heterogeneous and often flawed. A majority of evidence suggests better outcome for patients with rectal cancer managed in high volume centres. There are, however, many variables in data collection and interpretation rendering comparison between studies challenging. Definitions of the rectum range from distance from the anal verge (inherent disagreement e range 10e16 cm), to relationship to sacral promontory (subject to interpreter variation), and location of peritoneal reflection (cannot be interpreted endoscopically). Many authors fail to differentiate between sigmoid colon and rectum 3 and, those that do demonstrate wide variation. One of the largest studies, (more than 7000 patients) from the Californian Cancer Registry offered no description of tumour location. It concluded that patients undergoing surgery at high volume hospitals were less likely to have permanent colostomies and had better survival rates. The diagnosis of rectal cancer was, however, questionable as it was based only on a discharge letter, often written by the most junior team member with no reference to true anatomical location. Most US studies are published from a few high volume institutions with a select patient cohort and are based on retrospective analysis of large databases which, themselves are notoriously inaccurate. The European experience was recently explored by Ptok in a prospective trial of almost 7000 patients undergoing resection for rectal cancer. This is arguably the most complete data set available to date and great effort was made to overcome common biases. A clear definition of the rectum was provided, hospital volume was classified

DOI: 10.1016/j.ejso.2008.06.015


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@article{Hogan2009VolumeoutcomeAI, title={Volume-outcome analysis in rectal cancer: a plea for enquiry, evidence and evolution.}, author={Aisling Maria Hogan and Rory P. Kennelly and Desmond C. Winter}, journal={European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology}, year={2009}, volume={35 2}, pages={111-2} }