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Surgical Technical Skill and Long-Term Survival After Surgery for Colon Cancer


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In a study reported as a research letter in JAMA Oncology, Brajcich et al found that higher-rated surgical technical skill was associated with significantly improved long-term survival in patients undergoing surgery for colon cancer. 

Study Details

In the study, surgeons were recruited from the Illinois Surgical Quality Improvement Collaborative in 2016 for a video-based technical skills assessment program. Each surgeon submitted one representative video of a laparoscopic right hemicolectomy that they had performed. Each video was reviewed by at least 12 surgeons, including 2 colorectal surgeons with video evaluation experience, and skill scores were assigned using the American Society of Colon & Rectal Surgeons Video Assessment Tool. The skill score for each surgeon was the mean score from all raters. Association with overall survival was analyzed using skill score tertiles and as a continuous variable.  

Key Findings

Overall, 15 participating surgeons—including 9 colorectal surgeons and 6 general surgeons—from 11 hospitals performed laparoscopic colectomy on 609 patients. In total, 100 surgeries were performed by surgeons in the low-skill tertile, 145 by surgeons in the middle-skill tertile, and 364 by surgeons in the high-skill tertile. 

Overall survival at 5 years according to skill tertile was 79% for high skill, 55% for medium skill, and 60% for low skill (overall P = .01).

In analysis adjusting for patient characteristics, survival was significantly improved among those who had undergone surgery by surgeons in the high-skill vs low-skill tertile (hazard ratio [HR] = 0.31, 95% confidence interval [CI] = 0.18–0.54, P < .001). In analysis as a continuous variable, each 0.1-point skill score increment was associated with a significantly greater likelihood of survival (HR = 0.90 per increment, 95% CI = 0.84–0.97, P = .01).

KEY POINTS

  • Overall survival at 5 years according to skill tertile was 79% for high skill, 55% for medium skill, and 60% for low skill.
  • A stage-stratified analysis indicated that the association between skill tertile and survival was strongest among patients with stage II disease.
  • The mean number of lymph nodes examined was 23.9 for the high-skill, 21.2 for the middle-skill, and 20.3 for the low-skill tertiles, but no significant difference among tertiles was observed on adjusted analysis.

In analysis excluding deaths occurring within 90 days of surgery, hazard ratios vs the low-skill tertile were 0.56 (95% CI = 0.29–1.06) for the middle-skill tertile and 0.35 (95% CI = 0.22–0.58) for the high-skill tertile.

A stage-stratified analysis indicated that the association between skill tertile and survival was strongest among patients with stage II disease, with hazard ratios of 0.14 (95% CI = 0.07–0.30, P < .001) for high vs low skill and 0.12 (95% CI = 0.04–0.39, P < .001) for middle vs low skill. The hazard ratio per 0.1 increment in score was 0.85 (95% CI = 0.78–0.94, P < .001).

In analysis of 307 open procedures, survival was improved for the high-skill (HR = 0.41, 95% CI = 0.18–0.90, P = .03) and middle-skill (HR = 0.41, 95% CI = 0.23–0.72, P = .002) vs the low skill tertiles. A significant improvement per each 0.1-point skill score increment was not observed (HR = 0.91, 95% CI = 0.80–1.05, P = .20).

The mean number of lymph nodes examined was 23.9 for the high-skill, 21.2 for the middle-skill, and 20.3 for the low-skill tertiles, but no significant difference among tertiles was observed on adjusted analysis.

The investigators stated, “This study demonstrates an association between surgical technical skill and long-term survival following cancer surgery. This association persists when excluding early postoperative deaths, suggesting that these findings are not solely attributable to mortality from surgical complications…Skill may affect survival through oncologic resection quality (eg, lymph node harvesting) or may reflect surgeon characteristics, such as operative volume or guideline adherence. Additionally, fewer complications might reduce long-term morbidity affecting nutrition and physical function.”

Karl Y. Bilimoria, MD, MS, of the American College of Surgeons, Chicago, and the Robert H. Lurie Comprehensive Cancer Center, Northwestern University, is the corresponding author for the JAMA Oncology article.

Disclosure: The study was supported by the Agency for Healthcare Research and Quality, Health Care Services Corporation, the Northwestern Institute for Comparative Effectiveness Research in Oncology, and the National Cancer Institute. For full disclosures of the study authors, visit jamanetwork.com.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
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