During the last two decades, minimally invasive surgery has gained wide acceptance for colorectal cancer treatment. However, the spread of laparoscopy for colorectal cancer surgery was slow, in fact very slow in contrast to gallbladder surgery. Why? Doubts about long-term oncologic outcomes. Are those doubts already overwhelmed? Is laparoscopy being use in preference to open surgery?
Everything changed after the publication of COST (Clinical Outcomes of Surgical Therapy) trial group results in 2004 and 2007, and COLOR (Colon Cancer Laparoscopic or Open Resection) II trial. These studies concluded for similar short-term and long-term oncologic outcomes between open and laparoscopic surgery in colon cancer. Additionally, there were the traditionally known advantages of laparoscopy (faster recovery, less pain, early first oral intake, early bowel movements, lower rate of incisional hernias). Following these studies an increase in colon cancer laparoscopy was seen in most centers. Rectal cancer is another story (keep reading) …
Similar short-term and long-term oncologic outcomes between open and laparoscopic surgery in colon cancer.
A publication from Dr Heather Yeo et al in J Natl Cancer Inst from 2015, analyzed data of 8 NCCN (National Comprehensive Cancer Network) centers. The objective was to analyze the incidence of minimally invasive surgery in colorectal cancer treatment in those credited centers, with experienced surgeons, and understand the differences found. Between 2005 and 2010 the overall rate of laparoscopic colon resection was 36%, while open surgery was 64%. Did you think results would be different? Well, I did. But there was an increase use of laparoscopy during those years. In 2006, 35% of patients with colon cancer stage I-III were operated by laparoscopy, while in 2010 51% of stage I-III colon cancer patients were submitted to minimally invasive resection. Older patients, male patients and patients with less comorbidities were more likely to be submitted to minimally invasive surgery. Stage IV colon cancer has different numbers, with rates between 10% - 20% for minimally invasive surgery during those years. Interesting and impressive is the difference between NCCN centers. In 2010 center 1 was operating 79% of patients by laparoscopy, while center 2 was using laparoscopy only in 23% of cases. Additionally, patients treated in center 1 were more likely to be operated by laparoscopy than in center 8. Interesting to see is that absolute numbers were not important, since center 8 operated 741 patients while center 1 operated 131 cases, but percentage of laparoscopy was statistically higher in center 1. So, why do we insist in define refence centers only by numbers?
There is a difference between NCCN centres on the use of laparoscopy.
Dr Heather Yeo et al state that if non-NCCN centers had been included, the rate of laparoscopy use among USA would be higher. They justify this statement with more complex cases treated in NCCN centers not possible to be treated by minimally invasive surgery. This may be true but also may be a factor that works against the need for the so called "experienced surgeons" of reference centers. If NCCN center surgeons are created as reference because they are better and with more experience, it would be expected for them to operate those complex cases better and with minimally invasive surgery, cases the non-reference centers could not operate due to the “lack” of experience of their surgeons. Wouldn’t it be more accurate to define reference centers by results? I believe a reference center is naturally born, because both doctors and patients recognize the better outcomes reached by a surgeon and center, even in complicated cases.
For rectal cancer data are a little bit different. Those studies (COST and COLOR II) did not analyze the oncologic outcomes between minimally invasive surgery and open surgery for rectal cancer. In fact, some following studies failed to unequivocally conclude for the similarity of results of laparoscopic vs open surgery for rectal cancer. Because of that, there are still doubts about the use of laparoscopy in rectal cancer. In 2019, NCCN guidelines state there are studies showing similar oncologic results, but others concluded that laparoscopy is associated with higher rates of circumferential margin positivity and incomplete TME. These doubts justify the small rate of 37% of patients with rectal cancer stage I-III treated by laparoscopy in NCCN centers. NCCN guidelines state there is no indication for minimally invasive surgery for locally advanced rectal cancer or imaging showing high-risk margin, and for acute bowel obstruction. Additionally, NCCN guidelines advise that a surgeon must have experience. What is an experienced surgeon? How many cases must he perform? Which outcomes must he achieve? Is the definition of experienced surgeon equal for all surgeons? Once again, I believe outcomes analysis is the answer.
There are still doubts about the use of laparoscopy in rectal cancer. NCCN guidelines advise that a surgeon must have experience. What is an experienced surgeon?
Reference Centers may be created because the best treatment conditions (Radiotherapy, Oncology, Gastroenterology able to perform techniques, Radiology with intervention, Pathology) together with Surgery are easily available and able to respond on time, but results must be the main factor. To be able to treat all cases on time is becoming a problem in several centers worldwide. Since centralization, some centers are unable to respond on time and treatments are being delayed. The increased number of patients was not followed by more doctors, because of that doctors are having a huge amount of cases and are getting tired. Additionally, patients are getting further and further away from cancer treating hospitals. When returning to their homes, patients having complications resort to smaller local hospitals where doctors do not treat colorectal cancer. So, why should they treat the complications? In fact, will they be capable of? Following other author opinion, I believe creating conditions in smaller hospitals to properly treat most cancer patients (with Oncology, Radiotherapy, Radiology …) is crucial to allow patients to get treatment on time and relieve doctors in reference centers from the huge workload. The so-called Reference Centers should be essential for complex cases and difficult complications, because those doctors should be better and achieve better outcomes. At least they should…
Results must be the cornerstone to create a Reference Center, not numbers.
In resume, outcomes must be the crucial factor for a surgeon and center to be a reference in such a pathology. Creating a Reference Center by law based on absolute numbers makes no sense, is wrong and will be harmful to patients and doctors in the medium and long term. The actual idea of prohibiting some doctors from operating some pathologies with the objective to concentrate each and every case in the same group is pathetic and non-sense. If you are good you will be asked to operate and treat more patients. If you are good your results will be better. If you are good your colleagues will send you patients. If you are good, patients will ask for you. If you are good you will be a naturally born reference. If you are good there is no need to be afraid… Healthy competition is good.
Do not try to be the best by eliminating the best in others. Be the best by overwhelming the best in others. Learn the best from your fellows to become the best.
References:
Dr. Carlos Eduardo Costa Almeida
General Surgeon