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Originally published as JCO Early Release 10.1200/JCO.2009.23.0052 on August 31 2009 © 2009 American Society of Clinical Oncology.
Centralization of Cancer Surgery: What Does It Mean for Surgical Training?Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, and Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, MA Since volume-outcome relationships were first described, editorials have been written and debates have ensued regarding whether that information will actually impact practice1,2: What are the policy implications? Will practice patterns change? Are patients willing to travel for "better care"? In this issue of Journal of Clinical Oncology, Stitzenberg et al3 take a step in addressing each of these concerns with empirical evidence. In particular, they describe the impact of the centralization of complex cancer surgery on travel burden in the New York, New Jersey, and Pennsylvania tristate area. The first and most important observation Stitzenberg et al3 make is that practice patterns changed from 1996 to 2006. For pancreatic and esophageal surgery, the likelihood that a patient will have surgery at a high-volume hospital has increased four and five times, respectively. However, for colon and rectal procedures, the likelihood of surgery at a high-volume hospital was basically unchanged. This finding is not surprising—the relationship between volume and both operative and long-term mortality is more compelling for esophageal and pancreatic resection than for colorectal surgery.4–6 For colorectal procedures, surgical mortality is lower in general, and the relationship between volume and mortality is of a smaller magnitude.5–8 Furthermore, selective referral has been promoted by both an Institute of Medicine systematic review and the Leapfrog Group for pancreatic and esophageal resections, but not for colorectal surgery.9,10 The analysis by Stitzenberg et al3 also demonstrated a significant decline in in-hospital mortality rates for esophageal (8.2% to 3.1%) and pancreatic cancer (7.3% to 3.8%) over the study period. Mortality also declined significantly for colorectal surgery, although the magnitude of the change was less. Although this suggests that other secular trends, such as improvements in perioperative management and patient selection, may in part be responsible, it does support the concept that centralization of complex surgery may contribute to improved surgical outcomes. One would expect that such centralization would be most feasible in the densely populated Northeastern tristate area examined in this study. It is therefore unclear how well these data reflect the experience in more rural regions of the country where travel distance would undoubtedly be longer. Stitzenberg et al3 provide reassuring evidence that centralization of high-risk surgeries did not exacerbate racial or socioeconomic disparities in mortality or site of care, more research is necessary before concluding that centralization does not increase disparities, especially in regions of the country with longer travel distances. Notwithstanding these limitations, the observation that patients are having their pancreatic and esophageal cancer operations at higher-volume centers while mortality for these high-risk procedures has declined contemporaneously suggests that the centralization strategy has gained traction. Evidence is strongest for the most complex procedures, such as esophagectomy and pancreatectomy, but has extended to include liver resection and operations for rectal cancer and soft tissue sarcoma, and the list continues to grow. There is even some argument that this principle might be applied to all cancer surgery. However, the implications of such a paradigm shift are far reaching, difficult to fully anticipate and extend across multiple issues related to the organization and delivery of surgical care. Its potential impact on the training of surgeons is one example of consequences that are difficult to anticipate. Traditionally, the majority of cancer surgery has been performed by general surgeons, some of whom developed subspecialty interests, but whose training encompassed the entire spectrum of surgical disease, including benign and malignant disease and emergency and trauma care. Because of a myriad of factors, including but not limited to marked advances in technology, the increasing complexity of patients, and an increased understanding of pathophysiology, the fund of knowledge and experience necessary for such broadly based practice has increased exponentially. Coupled with recent work hour restrictions, it has become increasingly difficult for graduating general surgery residents to be as prepared to independently practice the traditional scope of general surgery as were their predecessors. This is at least one factor in the growing trend for graduating surgical residents in the United States to seek additional fellowship training; recent figures suggest that more than 70% enter such subspecialty training after completion of 5 years of general surgery residency. To meet this increasing demand, there has been an explosion of fellowship programs within the United States. Some, such as colorectal or cardiothoracic surgery, are approved by the Accreditation Council for Medical Education. Others, however, such as surgical oncology and hepatobiliary, are certified by specialty societies. For surgical oncology, a certificate is issued by the Society of Surgical Oncology (SSO) at the completion of one of the 19 SSO-approved fellowships. Other fellowships exist, but they are not SSO approved. Moreover, recent American Board of Surgery recertification data would suggest that less than 10% of cancer surgery in the United States is currently done by fellowship-trained surgical oncologists (T. Biester, personal communication, April 2009). There are currently 250 accredited general surgery residencies in the United States producing approximately 1,000 general surgeons each year.11 The Residency Review Committee for Surgery provides minimum volume thresholds for graduating general surgery residents and compiles a report of the average experience.11 Of the 750 cases required for graduation, 72 must be in the alimentary tract, including both esophageal and colorectal procedures, and three must be pancreatic procedures. The average graduating US general surgery resident performs nine esophageal cases during their residency. The majority of these are antireflux procedures, with only two resections or bypasses (range, 0 to 12). The average resident performs 10 operations on the pancreas, more than triple the minimum requirement of three; however, this includes a wide range of procedures in terms of indications as well as complexity. The average US general surgery resident graduate logs four pancreaticoduodenectomies or Whipple procedures (range, 0 to 31). The resident that reported 31 such procedures is probably quite prepared to perform this procedure, but what about the resident that performed none? In contrast with the modest experience with esophageal and pancreatic surgery, the average general surgery resident performs 120 procedures involving the large intestine (range, 80 to 160), approximately 50% of which are colectomies. As a result, most general surgery residents feel comfortable performing this procedure without additional training—another possible explanation for the lack of centralization for colorectal procedures observed by Stitzenberg et al.3 The American Board of Surgery has recently recognized this trend, developing a General Surgery Residency Patient Care Outline that prioritizes procedures and diseases. Esophagectomy, pancreatectomy, and operations for rectal cancer are classified as Complex Operations, "...not consistently performed by general surgeons in training and not typically performed in general surgery practice. Generic experience in complex procedures in residency is required, but competence in individual procedures is not specified. Some residency programs may provide sufficient experience for competence in some specific procedures."12 The implications of this policy for case volume minimums have not yet been fully explored. Given the current 7 to 9 years of surgical residency and subsequent fellowship, the increased desire for subspecialty training by residents themselves, and the increasing evidence that complex surgery is being centralized, earlier specialization or tracking into subspecialties seems to make a lot of sense.13 For example, in the traditional residency, residents who will specialize in thoracic or vascular surgery, and therefore will never perform a Whipple procedure in practice, are as likely to scrub on these procedures as those who will specialize in pancreatic surgery. Given the relative rarity of such procedures, they could be considered a valuable educational resource to be carefully allocated and preferentially assigned to those surgeons in training who are dedicated to a career in this field. Likewise, complex cardiac or vascular procedures could be preferentially assigned to residents dedicated to these fields. Rather than having each general surgery resident perform four Whipple procedures during their chief residency (final year of general surgery training), it might be more strategic to identify the minority of residents intending to actually perform this procedure as part of their practice and concentrate the experience for this group of residents. As appealing as early and increased specialization appears at first glance, it is not without its drawbacks. The discipline of surgery cannot reliably be parceled into neat, independent boxes. The lines are blurred, and there is significant risk that procedures will fall through the cracks. Although we have few metrics that would permit us to balance higher quality with access, this has to be part of the discussion. Perhaps of greatest concern is the impact of such change on general surgery; this is particularly relevant in discussions of centralization and further specialization of cancer surgery. General surgeons still perform the majority of cancer surgery in this country, with colon and breast cancer surgery among the most frequent operations they perform. Even if we tripled the number of surgical oncology training programs tomorrow, concentration of all cancer surgery in the hands of subspecialists would likely create enormous access problems. Referral of all cancer surgery would likewise have strikingly negative economic consequences for general surgical practices and for smaller hospitals that frequently depend on the general surgeon's case volume for economic viability.14 Even recognizing that most general surgeons are not going to do the most complex elective surgeries in practice, experience during training with pancreatectomy and esophagectomy continues to be of value. For example, during the Whipple operation, the resident has the opportunity to perform an open cholecystectomy, an operation that is vanishingly infrequent with the advent of minimally invasive approaches, but a necessary part of the general surgeon's armamentarium in cases that cannot be performed laparoscopically. They likewise perform a biliary anastomosis and manage the duodenum and pancreas, providing transferrable skills that may inform their operative approach to biliary and pancreatic trauma or perforated duodenal ulcer, conditions that the practicing general surgeon still needs to be able to handle and which are infrequently encountered in most residencies. Technological advancements such as increased use of simulation and intraoperative video may offer future solutions to these limitations. For example, the ability to simulate a common bile duct or pancreatic injury could provide the necessary experience to deal with these situations. Similarly, if a general surgeon in a remote area found himself in a situation they were ill-equipped to deal with, they could videoconference with a colleague who could help to safely handle the situation. However, until such advances are ready for prime time, we are in a difficult situation without a clear-cut answer. Stitzenberg et al3 offer thought-provoking evidence that the complex cancer operations proposed by the Institute of Medicine report and Leapfrog Group for triage to high-volume centers are indeed increasingly being performed at high-volume hospitals in the United States. This observation may help to inform the evolution of the current system of surgical training. The implications of these changes for future generations of surgeons must be carefully considered, because they could have unintended negative consequences. Pilot studies and careful follow-up are warranted to make sure that reform of surgical education is accomplished in a thoughtful, sustainable manner. Increased centralization of complex cancer care seems here to stay, and it is critical that we develop the best system possible to train the surgeons to provide that care. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author(s) indicated no potential conflicts of interest. AUTHOR CONTRIBUTIONS Conception and design: Caprice C. Greenberg, Deborah Schrag Administrative support: Deborah Schrag Manuscript writing: Caprice C. Greenberg, Stanley W. Ashley, Deborah Schrag Final approval of manuscript: Caprice C. Greenberg, Stanley W. Ashley, Deborah Schrag REFERENCES
1. Epstein AM: Volume and outcome: It is time to move ahead. N Engl J Med 346:1161–1164, 2002. 2. Smith TJ, Hillner BE, Bear HD: Taking action on the volume-quality relationship: How long can we hide our heads in the colostomy bag? J Natl Cancer Inst 95:695–697, 2003. 3. Stitzenberg KB, Sigurdson ER, Egleston BL, et al: Centralization of cancer surgery: Implications for patient access to optimal care. J Clin Oncol 27:4671–4678, 2009. 4. Begg CB, Cramer LD, Hoskins WJ, et al: Impact of hospital volume on operative mortality for major cancer surgery. JAMA 280:1747–1751, 1998. 5. Birkmeyer JD, Siewers AE, Finlayson EV, et al: Hospital volume and surgical mortality in the United States. N Engl J Med 346:1128–1137, 2002. 6. Birkmeyer JD, Stukel TA, Siewers AE, et al: Surgeon volume and operative mortality in the United States. N Engl J Med 349:2117–2127, 2003. 7. Schrag D, Cramer LD, Bach PB, et al: Influence of hospital procedure volume on outcomes following surgery for colon cancer. JAMA 284:3028–3035, 2000. 8. Schrag D, Panageas KS, Riedel E, et al: Hospital and surgeon procedure volume as predictors of outcome following rectal cancer resection. Ann Surg 236:583–592, 2002.[CrossRef][Medline] 9. The Leapfrog Group. Evidence-Based Hospital Referral: The Leapfrog Group FactSheet. http://www.leapfroggroup.org/media/file/Leapfrog-Evidence-Based_Hospital_Referral_Fact_Sheet.pdf. 10. Halm EA, Lee C, Chassin MR: Is volume related to outcome in health care? A systematic review and methodologic critique of the literature. Ann Intern Med 137:511–520, 2002. 11. Accreditation Council for Graduate Medical Education. http://www.acgme.org/acWebsite/navPages/nav_440.asp. 12. The American Board of Surgery. SCORE Patient Care Curriculum Outline Released. http://home.absurgery.org/default.jsp?news_score408&ref=pub. 13. Debas HT, Bass BL, Brennan MF, et al: American Surgical Association Blue Ribbon Committee Report on Surgical Education: 2004. Ann Surg 241:1–8, 2005.[CrossRef][Medline] 14. Fischer JE: The impending disappearance of the general surgeon. JAMA 298:2191–2193, 2007.
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Copyright © 2009 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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