Thresholds and combined quality control in the multimodal treatment of colorectal cancer

Abstract

Solid accumulating evidence proves that comprehensive surgical and adjuvant treatment quality and pathohistologic examination of specimens drive the outcomes for patients with colorectal cancer (CRC). More simply, whether a patient with CRC will be cured or die of cancer recurrence depends, beyond tumor staging and aggressiveness, on the level of medical care provided. Recently, efforts have been made to establish criteria and quality control measurements to rank hospitals according to the level of care provided for patients with CRC. This is very important for physicians and patients aiming to select the hospital, surgeon, and oncologist that can provide a high level of treatment quality. Therapeutic decisions have become very complex given the rapid advances in surgical practice including minimally invasive interventions, systemic adjuvant treatment including targeted therapy for selected patients, and the timing of chemotherapy before or after surgery. These decision have an impact not only survival but also on quality of life (QOL). A recent example of quality control measurement involves the number of lymph nodes resected by surgeon and examined by the pathologist. The total number of lymph nodes examined (TNODS) has been proposed as a quality control measurement in the treatment of CRC. However, surgeons, pathologists, and oncologists are debating. Some surgeons and pathologists propose harvesting at least 12 to 20 or more lymph nodes, whereas oncologists question the number of evaluated nodes required for accurate staging and correct adjuvant treatment decision making. El-Gazzaz et al. [1] highlight this topic in a recent issue of Surgical Endoscopy. These authors investigated whether a difference existed between laparoscopic and open surgery in the number of nodes harvested after the operation. In the current study, 243 patients underwent laparoscopic surgery and 486 patients had open procedures with curative intent. The mean number of lymph nodes retrieved and examined was high (24.8 ± 20.6 per patient, with no significant difference between laparoscopic and open surgery). The high TNODS in this study reflects an adequate standardized lymphadenectomy by the surgeon as well as appropriate lymph node harvesting and examination by the pathologists. But long-term follow-up evaluation was not in the scope of this study, so no conclusion about the impact of TNODS on survival can be drawn. Does the number of lymph nodes examined affect oncologic outcomes? Can a high TNODS result in improved disease-free and overall survival? Many retrospective studies have shown better locoregional tumor control, more accurate nodal staging, more appropriate adjuvant treatment decision making, and higher overall survival rates when a large number of lymph nodes have been evaluated. Based on these and other studies, the American College of Surgeons (ACS), the National Quality Forum (NQF), the National Comprehensive Cancer Network (NCCN), and the American Society for Clinical Oncology (ASCO) have reached the consensus that a minimum of 12 lymph nodes is the standard for hospitalbased performance of colectomy for colon cancer patients [2–4]. In contrast to this recommendation, Wong et al. [5] concluded that ‘‘efforts by payers and professional organizations to increase node examination rates may have limited value as a public health intervention.’’ These authors came to this conclusion based on a retrospective D. H. Roukos (&) G. Baltogiannis C. G. Katsios Surgical Department, University of Ioannina, Ioannina, Greece e-mail: droukos@cc.uoi.gr