How Surgeon Skill and Volume Impact Rectal Cancer Surgery Outcomes

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• Surgeon as the Most Important Prognostic Factor
• Stockholm TME Training Clinical Trial
• High-Volume vs. Low-Volume Surgeons
• Combining Education and Surgical Volume
• Implications for Choosing a Surgeon
• Role of a Medical Second Opinion

Surgeon as the Most Important Prognostic Factor

The technical skill and experience of the cancer surgeon are the most significant prognostic factors in rectal cancer treatment, even more so than molecular markers or TNM staging. Dr. Torbjorn Holm, MD, a leading colorectal surgeon, emphasizes that a surgeon's ability to perform a precise operation directly dictates a patient's overall survival and local recurrence rates. This principle underscores that the choice of surgeon is a critical decision in the cancer journey.

Dr. Anton Titov, MD, the interviewer, notes that this finding is consistent with surgical quality studies across other cancer specialties. The surgeon's competence determines the success of the entire multimodal treatment plan for rectal cancer.

Stockholm TME Training Clinical Trial

Dr. Torbjorn Holm, MD, co-authored a pivotal clinical trial in Stockholm that began in 1994. The study was initiated with Professor Bill Heald from England, a pioneer in teaching the total mesorectal excision (TME) technique. This method involves removing the rectum along with its surrounding envelope of tissue (the mesorectum) in one intact piece, which is crucial for minimizing cancer recurrence.

The trial assessed all rectal cancer patients operated on between 1995 and 1997. Surgeons were divided into groups based on their participation in these specialized TME training courses. The robust Swedish rectal cancer registry provided the data necessary to directly link surgical education to patient outcomes.

High-Volume vs. Low-Volume Surgeons

The clinical trial defined a "high-volume" rectal cancer surgeon as one performing more than 15 operations per year. The results were striking. Surgeons who were both high-volume and had attended TME training achieved significantly better results. They had superior local control and survival rates for their patients.

The worst outcomes were seen in patients operated on by low-volume surgeons who had not received the specialized TME education. This group performed fewer than 15 surgeries annually and lacked the formal training, leading to higher recurrence rates. Among the five high-volume surgeons in Stockholm, a few who operated most frequently had the absolute best results.

Combining Education and Surgical Volume

Dr. Torbjorn Holm, MD, stresses that surgical experience alone is not a substitute for proper education in the best techniques. A surgeon can perform many operations, but if they are not using the optimal, evidence-based method like TME, patient outcomes will not be ideal. The reverse is also true; a surgeon educated in TME must perform the procedure frequently to maintain and refine their skill.

The key to the best rectal cancer surgery outcomes is the combination of specialized training and a high volume of practice. This dual requirement ensures that a surgeon is not only knowledgeable but also technically proficient and adaptable to each patient's unique anatomy.

Implications for Choosing a Surgeon

For a patient seeking the best rectal cancer treatment, this research provides a clear framework. It is essential to find a surgeon who is specifically trained in advanced techniques like total mesorectal excision and who operates on rectal cancer frequently. Patients should feel empowered to ask a potential surgeon about their specific training in rectal cancer surgery and their annual case volume.

Dr. Anton Titov, MD, highlights that a surgeon must also be flexible enough to personalize the surgical approach to the individual patient's condition. Competence and the ability to tailor the operation are hallmarks of an expert rectal cancer surgeon.

Role of a Medical Second Opinion

Seeking a medical second opinion is a highly recommended step in confirming a rectal cancer diagnosis and treatment plan. A second opinion can verify that surgery is indeed necessary and that the proposed surgical approach is the current standard of care. It also provides an opportunity to evaluate the chosen surgeon's qualifications, training, and experience against the benchmarks established by clinical trials.

This process ensures a patient can be confident they are choosing the best rectal cancer treatment center and the most qualified cancer surgeon for their care, ultimately optimizing their chances for a successful outcome.

Full Transcript

Dr. Anton Titov, MD: Surgeon is the most important prognostic factor in cancer treatment. Leading Swedish rectal cancer surgeon discusses rectal cancer surgical treatment. Surgeons must know how to do the correct type of operation. Surgical experience is not a substitute for education and knowledge of the best method of treatment.

A cancer surgeon must be able to adjust his surgical technique and match the scope of operation to the patient’s condition. Is your cancer surgeon competent and flexible enough to personalize the surgical operation for you?

Surgery for rectal cancer. Who is the best cancer surgeon? Is surgery the best treatment for rectal cancer? Rectal cancer surgery options. Advanced rectal cancer surgery. Medical second opinion confirms that the rectal cancer diagnosis is correct and complete. Medical second opinion also confirms that rectal cancer surgery is required.

Best treatment for rectal cancer. Medical second opinion helps to choose the best treatment for rectal cancer. Get a medical second opinion on rectal cancer and be confident that your treatment is the best. Best rectal cancer treatment center and cancer surgeon.

Video interview with a leading expert in rectal cancer treatment surgery and minimally invasive rectal cancer treatment. Colorectal cancer leading cancer surgeon. You authored a very detailed clinical trial: "Cancer surgeon as the prognostic factor in rectal cancer treatment."

In cancer treatment, the skill of the cancer surgeon is the most important factor for the best prognosis. There are many clinical trials that determine how molecular markers and TNM staging impact cancer treatment and prognosis. But the leading cancer surgeon's quality and skill is the most important prognostic factor in overall survival in cancer.

Could you please comment on your studies of surgery’s quality? What determines the experience of the cancer surgeon in colorectal cancer treatment?

Dr. Torbjorn Holm, MD: The importance of the skill and quality of the cancer surgeon has been studied extensively. We did a clinical trial in Stockholm. We assessed colorectal cancer surgeons who participated in educational projects.

In 1994, we started a project with colorectal cancer surgeon Professor Bill Heald from England. He was teaching colorectal surgeons in Stockholm on how to do a good total mesorectal excision in rectal cancer patients. We had colorectal cancer surgeons who participated in those courses. We also had colorectal cancer surgeons who did not participate in total mesorectal excision surgery training courses.

We have a very good rectal cancer registry in Sweden. From the rectal cancer registry, we could see which rectal cancer surgeons operated on which rectal cancer patients. This was when Dr. Heald was teaching total mesorectal excision rectal cancer surgery in Stockholm.

So we assessed all patients that had been operated on for rectal cancer between 1995 and 1997. We could see that rectal cancer patients were operated on by colorectal surgeons who participated in the courses. We also saw that patients were operated on by high-volume rectal cancer surgeons.

We defined "high-volume" as rectal cancer surgeons doing more than 15 operations per year. So there were two groups: rectal cancer surgeons who participated in courses on total mesorectal excision training and rectal cancer surgeons who did not participate. There were also high-volume rectal cancer surgeons and low-volume rectal cancer surgeons who did fewer than 15 rectal cancer surgeries per year.

Fifty percent of all rectal cancer patients had been operated on by high-volume surgeons. These rectal cancer surgeons attended total mesorectal excision training courses.

High-volume rectal cancer surgeons who attended TME training had significantly better results than surgeons who had been to the courses but who did less than 15 rectal cancer surgeries per year. The worst results of surgical treatment of rectal cancer were by those colorectal surgeons who did not attend the total mesorectal excision training course and had low-volume surgical practice for rectal cancer.

Dr. Anton Titov, MD: These rectal cancer surgery quality results correlate with surgery quality clinical trials in other specialties. Your clinical trial also showed that two or three rectal cancer surgeons had the highest number of rectal cancer surgery cases. They had the best results among all rectal cancer surgeons in the registry.

Dr. Torbjorn Holm, MD: Yes, exactly. We were five rectal cancer surgeons in Stockholm doing more than 15 operations per year. We had significantly better rectal cancer surgery results than surgeons doing fewer operations. We also had better results than surgeons who did not attend special training on TME rectal cancer surgery.

So it's very important, as I said before. You have to have the correct education. You have to have the numbers. You must do many surgical operations of the type that's required. You have to combine both.

Sometimes you don't have the correct education and do a lot of surgeries. It does not matter. You need both education and the skill. You must do a large number of surgical operations to obtain the best results in rectal cancer surgical treatment.

Dr. Anton Titov, MD: Surgery for rectal cancer. What skills must a cancer surgeon have? How to choose the best cancer surgeon for rectal cancer treatment? Video interview with leading Swedish cancer surgeon.