Low Mortality Rates Found After CRC Surgery by Recently Trained Physicians

A study published in The Annals of The Royal College of Surgeons of England¹ found that training programs implemented in 1998 and afterward were associated with lower adjusted 90-day postoperative colorectal cancer mortality rates (AMRs) in patients in England treated by physicians trained after this point. Doctors trained before 1998 had higher AMRs.

Colorectal cancer (CRC) is the third most common cancer in the world, and the second leading cause of cancer death.² The primary method of treating CRC is resection surgery to remove the tumor and other lymph nodes. However, surgery has changed in England over the past 30 years. The Calman principles of surgery introduced in 1997 aimed to standardize training across all specialties, reducing the training duration from 12 years to about 7, which raised some concerns. The Modernising Medical Careers (MMC) training was introduced in 2005 and reduced the number of working hours per week needed. This study aimed to assess whether these changes in training affected the AMR for elective surgery for CRC in England.

The Association of Coloproctology of Great Britain and Ireland provided data for the retrospective cohort study via the Clinical Outcome Publication of 2016. Patients were included if they were aged 18 years and older, had been diagnosed with CRC between 2010 and 2015, were from England, and had elective major resection. Colorectal consultants were excluded if they had insufficient data, were a consultant for less than 1 year, or were unlicensed.

The consultants were separated into 2 cohorts: pre–Calman-trained (pre-CTr), who were trained before 1998, and post–Calman-trained (post-CTr), who were trained after 1998. The latter group was further split into 2 groups: those trained under the Calman Training Principles between 1998 and 2007 (CTr) and those who studied under the MMC curriculum from 2008 on (MMC). AMR was the primary outcome measure.

There were 551 consultants and 51,562 procedures included in the study. There were 467 consultants trained post CTr and 87.3% of the consultants were men. A lower number of resections was found in consultants in the post-CTr cohort (median [IQR], 89 [61-118]) compared with the pre-CTr cohort (104 [79-138]) during the 5-year period in which the data were collected.

All consultants in this study had a median (IQR) AMR of 2.2% (2.8%). A significantly lower AMR was found in consultants who trained post CTr (median [IQR] AMR, 2.1% [2.9]) compared with consultants trained pre-CTr (2.7% [2.0]). No other significant differences were found between the cohorts.

There were some limitations to this study. The study used AMR alone rather than including factors such as type of surgical access and chemoradiotherapy, which could affect the outcomes. AMR is also not reliant on 1 surgeon but rather the whole team of people who are performing the surgery. Elective surgery has a lower risk of mortality, and mortality rates are only one reflection of a surgeon’s work, which means that it is not always the best at identifying performance. Experience may also negate the influence of training.

The researchers concluded that patients who had a resection between 2010 and 2015 had a lower AMR when the surgeon had been trained post CTr compared with consultants trained beforehand. Future studies should focus on the influence of laparoscopic surgery and other similar factors on decreased AMR.

References

1. Taib AG, Patel Z, Kler A, Maxwell-Armstrong CA. Have changes in colorectal surgery training impacted on mortality in cancer patients? a retrospective cohort study of 51,562 procedures. Ann R Coll Surg Engl. Published online September 3, 2024. doi:10.1308/rcsann.2024.0059
2. Colorectal cancer: key facts. World Health Organization. July 11, 2023. Accessed September 3, 2024. https://www.who.int/news-room/fact-sheets/detail/colorectal-cancer