In the Journals

Surgeon’s proficiency in esophagectomy affects short- and long-term cancer outcomes

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May 26, 2016

Undergoing esophagectomy with a surgeon who had performed at least 15 surgeries reduced short-term mortality among patients with esophageal cancer, according to results of a population-based, nationwide Swedish cohort study.

Further, patients’ long-term mortality improved after surgeons had performed 59 or more surgeries, results showed.

Jesper Lagergren

Jesper Lagergren

“Our results can guide clinical practice and indicate that a properly organized mentorship and training program should be introduced for esophageal cancer surgery,” Jesper Lagergren, MD, esophageal surgeon in the department of molecular medicine and surgery at Karolinska Institute, Sweden, and professor and chair of upper gastrointestinal cancer at King’s College London, said in a press release. “Surgeons who start operating on esophageal cancer should perform many operations together with a more experienced esophageal cancer surgeon before they begin to operate independently.”

Lagergren and colleagues sought to determine the length of esophagectomy prociency gain curves with regard to mortality among patients with esophageal cancer.

The analysis included data from 1,821 patients who underwent esophagectomy for esophageal cancer by 139 surgeons between 1987 and 2010. Follow-up continued through 2014.

The researchers created prociency gain curves with risk-adjusted cumulative sum analysis to measure all-cause and disease-specific mortality at 30 days, 90 days, 1 year, 3 years and 5 years. In addition, they identified performance-contributing factors of the observed changes in long-term survival.

The change-point in proficiency gain curve for all-cause 30-day mortality was 15 cases, after which mortality decreased from 7.9% to 3.1% (P < .001). Having performed 15 cases also improved 30-day disease-specific mortality (7.3% vs. 2.5%; P .001).

Later change-points for long-term mortality ranged from 35 to 59 cases.

Having performed at least 53 cases reduced the rate of 1-year all-cause (34.9% vs. 27.7%; P = .011) and disease-specific mortality (31.8% vs. 24.7%; P = .01).

Rates of 3-year all-cause mortality improved from 47.4% to 41.5% (P = .049) after 35 cases, and 5-year all-cause mortality decreased from 31.4% to 19.1% (P = .009) after 59 cases. Researchers observed similar change-points in 3-year disease-specific mortality (38 cases), but there was no change-point for improvement in 5-year disease-specific mortality.

Further, resection margin with tumor involvement decreased from 20.9% to 15.2 % (P = .004) after 17 cases, and the reoperation rate reduced from 12.6% to 5% (P < .001) after 55 cases.

“Gaining experience at the expense of patient safety or long-term survival is unacceptable, and every effort must be made to overcome the prociency gain curve for both short- and long-term mortality results,” Lagergren and colleagues concluded.

Disclosure: The study was financed with grants from the Swedish Research Council and the Swedish Cancer Society.