Long distances in Northern Norway. Implications for the patients and who should operate him?

Kirurgi, kreft og kvinnehelseklinikken

Long distances in Northern Norway. Implications for the patients and who should operate him?

Rolv-Ole LindsetmoMD, PhD, MPH

Head Department of Gastroenterological SurgeryUniversity Hospital of North Norway,

Tromsø


Long distances?


Universitetssykehuset Nord-Norge HF

Nordlandssykehuset HF

Helgelandssykehuset HF

Helse Finnmark HF

32531

27311

29400

25311

17811

13023

64

Total:

11


Long distances?Travel time/distances from community to

operating hospital, 2005-2008, 707 patients operated for colon cancer

minutes kmMean 119 141,7

Long distances should not be of anyconcern in elective surgery


Practical approach to work-up and follow-up when patients have to travel long distances:

• All hospitals have CT and endoscopy service. “Local work-up - centralized treatment”

• Pathology service/lab in two hospitals

• Telemedical connections between all hospitals

• Follow-up at GP or nearest hospital according to national guidelines.


Who should do the follow-up?

Knut M Augestad, Barthold Vonen, Ranveig Aspevik,

Torunn Nestvold, Unni Ringberg, Roar Johnsen, Jan

Norum and Rolv-Ole Lindsetmo

Should the surgeon or the general practitioner (GP) follow

up patients after surgery for colon cancer? A randomized

controlled trial protocol focusing on quality of life, cost-

effectiveness and serious clinical events

BMC Health Serv Res. 2008; 8: 137


Hospital volume of ca coli operations in hospitals in Northern Norway

Ca coli operations 2008 2009 2010 (until 01.08)

Hammerfest 18 11 9 Kirkenes 8 5 6 UNN, Tromsø 49 35 65 (whole year) UNN, Harstad 23 21 ? UNN, Narvik 9 10 ? Bodø 32 34 19 Vesterålen 10 14 11 Lofoten 9 2 2 Mo i Rana 25 18 20 Sandnessjøen 12 18 7 Mosjøen 0 0 0


Hospital volumeCa coli operations in hospitals in

Northern Norway 2007-2009


Who should operate the patient?

• From the Norwegian Guidelines 2010:

• Surgical treatment of cancer in the large bowel and in the rectum should be performed by specialists in gastrointestinal surgery.

• Institutions with single specialists or ”hired in/short term specialists” based solutions should avoid elective treatment of colorectal cancer

• Institutions giving treatment to patients with colorectal cancer should establish MDT for discussing investigation and treatment plans


Hospitals performing ca coli operations in Northern Norway in 2011

2008 2009 2010 til 01.08.Hammerfest 18 11 9 Kirkenes 8 5 6 Unn Tromsø 49 35 65 (whole year)UNN, Harstad 23 21 ? UNN, Narvik 9 10 ? Bodø 32 34 19 Vesterålen 10 14 11 Lofoten 9 2 2 Mo i Rana 25 18 20 Sandnessjøen 12 18 7 Mosjøen 0 0 0

Kirkenes 8 5 6

UNN, Narvik 9 10 ?

Vesterålen 10 14 11

Lofoten 9 2 2

Mosjøen 0 0 0


What about the results?• Comparative data available in 2012

• Adherence to guidelines?

• Standardized technique?

• Sufficient training?

• Surgeons volume?

• Quality evaluation?

• MDT?

• Pathology service?


..who should operate colon ca?

• This is not only a question about quality….

• It is also politics and an employment issue in the local community


Conclusion

• Distances doesn’t matter!

• Patients should be offered optimal treatment for colon cancer independent of distance to hospital.

• A dedicated specialist in colorectal cancer surgery should operate the patient.


Thank you for your attention!


What about the results?

• Our results 2010:

• 65 colon resections for colon cancer


• Right sided hemicolectomi (incl ileocoecal resection) 28• Sigmoidresection 25• Left sided resection 9• Others 3

• 24 laparsocopic (37%)• 1 anastomotic leak• 1 uretral damage• 3 wound dehiscence• 1 internal hernia• 3 death (apoplexia after reoperation for wound dehiscence, thoracal aneurysm

rupture, duodenal leak after locally advanced colon cancer resection)• 13 nodes (mean) in specimens


References

• Rogers SO Jr, Ayanian JZ, Ko CY, Kahn KL, Zaslavsky AM, Sandler RS, Keating NL. Surgeons' volume of colorectal cancer procedures and collaborative decision-making about adjuvant therapies. Ann Surg. 2009 Dec;250(6):895-900.

• Borowski DW, Bradburn DM, Mills SJ, Bharathan B, Wilson RG, Ratcliffe AA, Kelly SB; Northern Region Colorectal Cancer Audit Group (NORCCAG). Volume-outcome analysis of colorectal cancer-related outcomes. Br J Surg. Sept 2010 Sep;97(9):1416-30.

• van Gijn W, Gooiker GA, Wouters MW, Post PN, Tollenaar RA, van de Velde CJ. Volume and outcome in colorectal cancer surgery. Eur J Surg Oncol. 2010 Sep;36 Suppl 1:S55-63. Epub 2010 Jul 7. (systematisk review)

• Nationellt kvalitetsregister. Cancer recti 2009. http://www.oc.umu.se/rekti/rektpdf.htm

• Iversen LH, Wille-Jørgensen P, Borowski D, Archampong D. Workload and surgeon´s speciality for outcome after colorectal cancer surgery. Cochrane Library Protocol. June 2010

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Rogers%20SO%20Jr%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Ayanian%20JZ%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Ko%20CY%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Kahn%20KL%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Zaslavsky%20AM%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Sandler%20RS%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Keating%20NL%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Borowski%20DW%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Bradburn%20DM%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Mills%20SJ%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Bharathan%20B%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Wilson%20RG%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Ratcliffe%20AA%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Kelly%20SB%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Northern%20Region%20Colorectal%20Cancer%20Audit%20Group%20(NORCCAG)%22%5BCorporate%20Author%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22van%20Gijn%20W%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Gooiker%20GA%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Wouters%20MW%22%5BAuthor%5D


Low or high volume?

• Borowsky et al, Br J Surg 2010:

• Low volum hospital: <86/operations/year

• High volume surgeon: >40 operations/year

• Significant correlations between long term survival and hospital and surgeon volume


Low or high volume?

• Swedish colorectal registry, 2009• (Nationellt kvalitetsregister. Cancer recti 2009.

http://www.oc.umu.se/rekti/rektpdf.htm)

• Low volum hospital: <11/operations/year• High volume hospital: >25 operations/year

• Only small differences in most outcome measures between low and high volume hospitals


How to overcome long distances?Long distances doesn’t matter in elective surgery!


Av 144 pasienter i 2009, ble 69 operert i Tromsø eller Bodø og 74 på de øvrige 8 sykehusene. Det diskuteres nå hvorvidt kirurgi på tykktarmkreft også skal funksjonsfordeles på færre sykehus. Både enkeltstudier (Borowski , Br J Surg, 2010) og systematiske gjennomganger (van Gijn W, Eur J Surg Oncol, 2010) viser en positiv sammenheng mellom langtidsoverlevelse og antall opererte pasienter per sykehus og per kirurg. Definisjonen på hva som er lavt eller høyt volum varierer fra studie til studie. I studien til Borowski er mindre enn 86 inngrep per sykehus og 40 inngrep per kirurg definert som lav-volum. I følge den definisjonen er alle sykehus i Helse Nord lav-volumsykehus. I rapporten fra colorektalcancerregisteret i Sverige defineres < 11 inngrep per sykehus per år som lav-volum og > 25 som høy-volum (Nationellt kvalitetsregister. Cancer recti 2009). Denne rapporten viser liten forskjell mellom høy- og lavvolum på de fleste endepunkt. The Cochrane Library har nettopp påbegynt en kunnskapsoppsummering med dette som tema;


Annual ca coli casesTabell 1. Antall nye krefttilfeller per år i for bosatte i Helse Nord fordelt på krefttype

Kreftform / Diagnose ICD-10 kodeÅrlig forekomst Helse Nord, KRG

Kreft i spiserør C15 21Kreft i magesekk C16 71Kreft i tykktarm C18 229Kreft i endetarm C19, C20 115Leverkreft C22 16Kreft i bukspyttkjertel C25 64Brystkreft C50 247Kreft i livmorhals C53 61Kreft i livmor C54, C55 62Kreft i eggstokk C56 42Kreft i eggledere/ vulva C57, C51 12Prostatakreft C61 411Kreft i nyre C64, C65 74Kreft i blære/ urinleder C67, C66 148Kreft i skjoldbruskkjertel C73 25Totalantall 1537

Ca oesophagiCa ventriculi

Ca coliCa recti

Average new cases/year in Northern Norway

CancerIncidence in

Northern Norway

Ca hepatisCa pancreatis


Conclusion

• Coloncancer patients should be offered optimal treatment and operated by a dedicated specialist in colorectal surgery.

Optimal treatment means:

• enhanced recovery protocol (ERAS)

• laparoscopic technique

• total mesocolic excision

Long distances in Northern Norway. Implications for the patients and who should operate him?

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