Improving the quality of surgery for gastric cancer—Are surgeons aware of the relevant quality indicators?

Abstract

4048 Background: Gastric cancer survival in the West is inferior to that achieved in Asian centers. While differences in tumor biology may play a role, poor quality surgery contributes to understaging. In our evaluation, adequate lymph node (LN) assessment (≥15) was achieved in only one third of patients and independently predicted survival across Surveillance, Epidemiology and End Results (SEER) regions (ASCO 2005, Abstract # 4004). The standard proximal margin of resection is recommended to be ≥5 cm; revision based on intraoperative frozen section is of benefit. We hypothesize that the majority of surgeons performing gastric cancer surgery in a North American setting are unaware of the recommended standards. Methods: Using the Ontario College of Physicians and Surgeons registry, surgeons who potentially include gastric cancer surgery in their scope of practice were identified. A questionnaire was mailed to 559, 55% responded. 203surgeons reported managing gastric cancer. Results were evaluated by chi-square and logistic regression; p<0.05 was considered significant. Results: 86% of respondents were male; 59% in urban non-academic practice, and 30% in academic. 42% of surgeons operate on 2–5 cases/yr and 18 % on >5. One third of surgeons identified ≤ 4 cm to be the desired proximal margin. Frozen section is used by 52% to evaluate proximal margin status. 20% were unsure of the number of LN needed to accuratly stage, the median number reported by the remainder was 10 (range 0 - 30). 99% refer for adjuvant therapy. This was less likely for patients in poor medical condition, poor nutritional status, or age >70 years. Young patients, those with bulky LN or positive margins were more likely to be referred. Overall, only 16 of 203identified the need for both a ≥5 cm proximal margin and ≥15LN; this was too small a group to analyze for demographic associations. Surgeons who do >5 gastric resections/yr were more likely to report performing a D2 resection (p = 0.008). Conclusions: The majority of surgeons operating on gastric cancer in Ontario did not identify standard quality indicators of gastric cancer surgery. A continuing medical education program should be designed to address the knowledge gap, aiming to improve the quality of surgery and outcome of multidisciplinary management. No significant financial relationships to disclose.