Colon cancer surgery performed by highly skilled surgeons improves long-term survival for patients

CHICAGO: Colon cancer patients achieve better five-year survival rates when the surgeons who treat them are rated as highly skilled, according to findings from what authors say is the first study to link a surgeon’s technical skills with improved long-term clinical outcomes. The study is published online in JAMA Oncology and virtually presented as part of the American College of Surgeons Commission on Cancer’s Annual Research Paper Competition.

“In the last few years, studies have shown that patients of more highly skilled surgeons have fewer immediate postoperative complications. This study moves to the next level and shows that patients of more highly skilled surgeons not only have fewer complications in the short term, they survive longer,” said Brian C. Brajcich, MD, a clinical scholar with the American College of Surgeons (ACS), research fellow at Northwestern University School of Medicine, and lead study author.

The study was conducted by the Illinois Surgical Quality Improvement Collaborative (ISQIC), a group of 56 hospitals that perform 80 percent of the complex surgical operations across the state. The ISQIC is a collaborative partner with the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP^®).

“A previous study done by our group found that lapses in surgical technique can result in a complication within a few days of surgery.¹ This study is striking because no one has looked directly at the relationship between surgical skill and improved survival at the five-year mark, and, yes, surgeons with better skill achieve considerably better survival rates for their patients,” said Karl Y. Bilimoria, MD, MS, FACS, Director of the Surgical Outcomes and Quality Improvement Center (SOQIC) at Northwestern Medicine, Chicago, and an ACS Faculty Scholar.

Excluding skin cancers, colorectal cancer is the third most common type of cancer diagnosed in both men and women in the United States. The American Cancer Society estimates nearly 105,000 cases of colon cancer and 43,000 cases of rectal cancer will be newly diagnosed in 2020.² Surgery is a mainstay of treatment. The type of surgery depends on the extent and location of the cancer and the goal of treatment. During a laparoscopic colectomy, for example, the surgeon removes the cancerous area of the colon, a small segment of normal colon on either side, and nearby lymph nodes.³

Study investigators recruited surgeons from the ISQIC in 2016 to participate in a video-based technical skills assessment program. Each surgeon was videotaped while performing a minimally invasive right hemicolectomy (partial surgical removal of the colon). Videos were reviewed by 12 or more surgeons, including two colorectal surgeons experienced in evaluating surgical video tapes. Each reviewer assigned a skill score to the video he or she reviewed. Skill scores were derived from the American Society of Colon and Rectal Surgeons Video Assessment Tool,⁴ which assesses factors such as gentleness of tissue manipulation, efficient and methodical performance of the procedure, and extent of surgical excision. Skill levels for the surgeons in the study reflected the mean skill score from all reviewers.

The study included 609 patients who underwent laparoscopic colectomy by one of the participating surgeons between 2012 and 2017. Five surgeons who achieved the highest technical skill scores also had the highest volume of procedures in the study, as well as the highest average annual number of surgical cases; the totals were more than two times higher than the number of procedures performed by other surgeons. Overall, five-year survival for these surgeons was 79 percent. Five-year survival rates were 55 percent for medium-skilled surgeons and 60 percent for low-skilled surgeons.

“This study demonstrates that surgical technical skill is an important driver of long-term outcomes in cancer surgery. When talking about ways to improve outcomes for patients, we surgeons should not only think about quality measures but ways to improve surgeons’ skills through some form of surgical coaching,” Dr. Brajcich said.

Patients also may take proactive steps. “Patients can ask their surgeon how many of these procedures they regularly perform. Volume of cases is a reflection of expertise. Patients also can ask their surgeon what he or she does to stay up to date and improve skills. These questions can help patients make informed decisions about where to seek care,” Dr. Bilimoria said.

The Northwestern Medicine health system is bringing surgeons together in the Technical Excellence Collaborative to review one another’s work, find opportunities for improvement in technique, and follow patients to track their outcomes, Dr. Bilimoria said.

“High surgical volumes have been shown to result in lower morbidity and improved outcomes for many types of surgery and this study shows that technical skill also results in improved survival for patients with colon cancer,” said Kelly K. Hunt, MD, FACS, who is not affiliated with the study, and is professor and chair, department of breast surgical oncology, The University of Texas MD Anderson Cancer Center, Houston.

“The ACS Cancer Research Program has also shown that adherence to the critical elements of an operation [operative standards] also results in improved outcomes and quality of life for cancer patients. Therefore, the Cancer Surgery Standards Program [CSSP] was formed to develop synoptic operative reporting templates, electronic documentation tools, and educational content around these operative standards. Ultimately, the program seeks to facilitate adoption and utilization of synoptic operative reporting tools for improved outcomes in all major cancer operations,” concluded Dr. Hunt, who serves as CSSP Vice-Chair.

Other study authors include Jonah J. Stulberg, MD, PhD, MPH; Bryan E. Palis, MA; Jeanette W. Chung, PhD; Reiping Huang, PhD; and Heidi Nelson, MD, FACS.

“FACS” designates that a surgeon is a Fellow of the American College of Surgeons.

This work is supported by the Agency for Healthcare Research and Quality (5RO1H5024516), a grant from the Health Care Services Corporation, Northwestern Institute for Collaborative Effectiveness Research in Oncology, and a grant from the National Cancer Institute (T32CA247801).

Citation: Association Between Surgical Technical Skill and Long-term Survival for Colon Cancer JAMA Oncology. Published online October 30, 2020. DOI:10.1001/jamaoncol.2020.5462

1. Curtis NJ et al. Association of surgical skill assessment with clinical outcomes in cancer surgery. JAMA Surg. 2020:155(7) 590-598.
2. American Cancer Society. Key statistics for colorectal cancer: how common is colorectal cancer? Available at: https://www.cancer.org/cancer/colon-rectal-cancer/about/key-statistics.html. Accessed October 27, 2020.
3. American Cancer Society. Surgery for Colon Cancer. Available at: https://www.cancer.org/cancer/colon-rectal-cancer/treating/colon-surgery.html. Accessed October 27, 2020.
4. Champagne BJ et al. The American Society of Colon and Rectal Surgeons assessment tool for performance of laparoscopic colectomy. Dis Colon Rectum. 2017;60(7);737-744.

About the American College of Surgeons

The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has approximately 90,000 members and is the largest organization of surgeons in the world. "FACS" designates that a surgeon is a Fellow of the American College of Surgeons.

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