Is routine gastrointestinal endoscopy required in every woman with mucinous ovarian cancer? An analysis of survival rates and metastatic tumours in a cancer centre.

INTRODUCTION: Mucinous ovarian cancer (MOC) represents a rare entity of ovarian malignant neoplasms. The true incidence could be as low as 3% of all ovarian cancers. The aim of this study is to compare and understand the clinicopathological characteristics of patients with mucinous ovarian cancer, report on the survival rates and evaluate the role of gastrointestinal (GI) endoscopy as part of the peri-operative investigations and the impact it has on the survival rates. METHODOLOGY: This is a retrospective data collection on patients with MOC operated in Nottingham gynaecological oncology centre over a 10-year period. Data were analysed using SPSS software. RESULTS: 43 cases were included in the final analysis. The median maximal tumour diameter was 180 mm. 32 (74.5 %) and 11 (25.5 %) women presented with unilateral and bilateral tumours respectively. 30 patients (69.7 %) presented with stage 1 disease, 1 (2.3 %) presented with stage 2 disease, 7 women (16.4 %) had stage 3 disease and 1 woman (11.6 %) had stage 4 disease. 41 women had staging surgical procedures and 2 women had limited surgery due to poor performance status. After final histology, 5 cases found to have metastatic disease to the ovary rather than primary MOC. 14 women had GI endoscopy as part of their investigation. The total estimated cost of the endoscopies that have been performed is £5635. Primary GI cancer was diagnosed in 1 case during the endoscopy (1 case of gastric cancer). The 5-year overall survival of the women included in this study is 62.8 %. The 5-year overall survival of the women in the endoscopy and non-endoscopy groups was 60 % and 64.3 % respectively (p-value: 0.767). CONCLUSION: The findings of this study show that the survival rates of patients treated for mucinous ovarian cancer in our centre are similar to other published studies. Our findings do not support the routine use of GI endoscopy in the peri-operative investigations of every patient with MOC due to the non-statistically significant difference in the overall survival.

Impact of deprivation on short- and long-term outcomes after colorectal cancer surgery.

BACKGROUND: The aim of the study was to determine the association between short- and long-term outcomes and deprivation for patients undergoing operative treatment for colorectal cancer in the Northern Region of England. METHODS: This was a retrospective analytical study based on the Northern Region Colorectal Cancer Audit Group database for the period 1998-2002. The Index of Multiple Deprivation 2004, an area-based measure, was recalibrated and used to quantify deprivation. Patients were ranked based on their postcode of residence and grouped into five categories. RESULTS: Of 8159 patients in total, 7352 (90·1 per cent) had surgery; 6953 (94·6 per cent) of the 7352 patients underwent tumour resection and 4935 (67·7 per cent) of 7294 had a margin-negative (R0) resection. Deprivation was not associated with age, sex, tumour site, stage or other tumour-related factors. Compared with the most affluent group, the most deprived patients had fewer elective operations (72·9 versus 76·4 per cent; P = 0·014), more adverse co-morbidity (P < 0·001) and fewer curative resections (65·5 versus 71·2 per cent; P < 0·001). In multivariable analysis, deprivation was not an independent predictor of postoperative death (odds ratio (OR) 0·72, 95 per cent confidence interval 0·48 to 1·06; P = 0·101) but it was a predictor of curative resection (OR 1·24, 1·01 to 1·52; P = 0·042), overall survival (HR 0·83, 0·73 to 0·95; P = 0·006) and relative survival (HR 0·74, 0·58 to 0·95; P = 0·023). CONCLUSION: Deprivation, both independently and by influencing other surgical predictors, impacts on short- and long-term outcomes of patients with colorectal cancer.

Volume-outcome analysis of colorectal cancer-related outcomes.

BACKGROUND: Significant associations between caseload and surgical outcomes highlight the conflict between local cancer care and the need for centralization. This study examined the effect of hospital volume on short-term outcomes and survival, adjusting for the effect of surgeon caseload. METHODS: Between 1998 and 2002, 8219 patients with colorectal cancer were identified in a regional population-based audit. Outcomes were assessed using univariable and multivariable analysis to allow case mix adjustment. Surgeons were categorized as low (26 or fewer operations annually), medium (27-40) or high (more than 40) volume. Hospitals were categorized as low (86 or fewer), medium (87-109) or high (more than 109) volume. RESULTS: Some 7411 (90.2 per cent) of 8219 patients underwent surgery with an anastomotic leak rate of 2.9 per cent (162 of 5581), perioperative mortality rate of 8.0 per cent (591 of 7411) and 5-year survival rate of 46.8 per cent. Medium- and high-volume surgeons were associated with significantly better operative mortality (odds ratio (OR) 0.74, P = 0.010 and OR 0.66, P = 0.002 respectively) and survival (hazard ratio (HR) 0.88, P = 0.003 and HR 0.93, P = 0.090 respectively) than low-volume surgeons. Rectal cancer survival was significantly better in high-volume versus low-volume hospitals (HR 0.85, P = 0.036), with no difference between medium- and low-volume hospitals (HR 0.96, P = 0.505). CONCLUSION: This study has confirmed the relevance of minimum volume standards for individual surgeons. Organization of services in high-volume units may improve survival in patients with rectal cancer.

Involvement of surgical trainees in surgery for colorectal cancer and their effect on outcome.

OBJECTIVE: Surgical training in the UK is undergoing substantial changes. This study assessed: 1) the training opportunities available to trainees in operations for colorectal cancer, 2) the effect of colorectal specialization on training, and 3) the effect of consultant supervision on anastomotic complications, postoperative stay, operative mortality and 5-year survival. METHOD: Unadjusted and adjusted comparisons of outcomes were made for unsupervised trainees, supervised trainees and consultants as the primary surgeon in 7411 operated patients included in the Northern Region Colorectal Cancer Audit between 1998 and 2002. RESULTS: Surgery was performed in 656 (8.8%) patients by unsupervised trainees and in 1578 (21.3%) patients by supervised trainees. Unsupervised operations reduced from 182 (12.4%) in 1998 to 82 (6.1%) in 2002 (P < 0.001). Consultants with a colorectal specialist interest were more likely than nonspecialists to be present at surgical resections (OR 1.35, 1.12-1.63, P = 0.001) and to provide supervised training (OR 1.34, 1.17-1.53, P < 0.001). Patients operated on by unsupervised trainees were more often high-risk patients, however, consultant presence was not significantly associated with operative mortality (OR 0.83, 0.63-1.09, P = 0.186) or survival (HR 1.02, 0.92-1.13, P = 0.735) in risk-adjusted analysis. Supervised trainees had a case-mix similar to consultants, with shorter length of hospital stay (11.4 vs 12.4 days, P < 0.001), but similar mortality (OR 0.90, 0.71-1.16, 0.418) and survival (HR 0.96, 0.89-1.05, P = 0.378). CONCLUSION: One third of patients were operated on by trainees, who were more likely to perform supervised resections in colorectal teams. There was no difference in anastomotic leaks rates, operative mortality or survival between unsupervised trainees, supervised trainees and consultants when case-mix adjustment was applied. This study would suggest that there is considerable underused training capacity available.