1. Specialist surgery “Some surgeons perform less than optimal surgery. Some are less competent technically than their colleagues; and some fail to supervise surgeons in training adequately. … If by more meticulous attention to detail, the results of surgery could be improved, and our results suggest that this would not be difficult, the impact on survival might be greater than that of any of the adjuvant therapies currently under study.” McArdle and Hole, BMJ 1991;302:1501-5

2. The surgeon as a prognostic factor in rectal cancer Variability among 13 consultant surgeons (%) Curative resection (R0) 40 – 76 Anastomotic leakage0 – 25 Postoperative mortality 8 – 30 Local recurrence0 – 21 Survival20 – 63

3. Importance of training and team effort Surgical oncology is top-class sport Training and (multidisciplinary) team effort essential

4. Effect of surgical trainee program in Sweden Stockholm I (n = 686) Stockholm II (n = 481) TME project (n = 381) p-value Local recurrence103 (15%)66 (14%)21 (6%)<0.0001 Cancer specific death 104 (15%)77 (16%)35 (9%)0.002 Abdominoperineal resection 414 (60%)266 (55%)101 (27%)<0.0001 Martling et al. Lancet, 2000; 356: 93 - 96

5. Results of the Norwegian program

6. Percentage of CRM+ in MRC CRO7 trial 0 5 10 15 20 25 19981999200020012002200320042005 Year P. Quirke et al. ASCO 2006

7. Trials have a large educational effect

8. The impact of hospital volume on outcome of rectal cancer surgery (1995-2003) Swedish cancer registry 2006 0 1 2 3 4 5 6 7 8 9 10 250 249-200 199-150 149-120 119-100 99-8584-7069-5554-40 39-25 <25 postoperative mortality % annual no of op

9. Variability of outcome related to case volume High-volume teamLow-volume teamp-value Mean no. of operations / year>120-12 Curative surgery245 (78)277 (82) Median (range) of follow-up (months) 41 (24-59)43 (24-59) Local recurrence9 (4)27 (10)0.02 Distant metastasis39 (16)54 (19)0.33 Rectal cancer death26 (11)51 (18)0.007 Martling et al, Br J Surg 2002;89:1008-13

10. Centers of excellence are needed

11. Outcomes-based quality improvement Outcomes registry Concurrent assessments of structure and process of care –Registry-based, site visits Analyses aimed at identifying best practices Broad implementation of such practices Outcomes tracking to confirm improvements Current development of European audit of colorectal cancer treatment