Most solid organ cancers require surgical expertise to provide the best chance for the cure of the patient. At the Syme Oration in 1998, entitled, ‘The surgeon as leader in Cancer Care’ Sir Murray Brennan made the point that surgeons should be taking the lead and guiding our patients. Leadership included being prepared to reflect on the care and the outcomes we have provided, but also the overall care from diagnosis to completion of all treatment.1 Typically, the broad assessment of ‘quality of health care’, is based on the Donabedian model of Quality Assurance which examines three aspects across a system: Structure (State, Hospital and resources); Process (actual care given); and Outcomes (morbidity, satisfaction and costs).2 When Birkmeyer and colleagues explored the use of these principles, focusing on the quality of surgery, they reported the model provided a good overview but when assessing surgery, notably cancer surgery, there was a lack of acknowledgment from the impact of the volume of the pathology and the complexity of the surgery. These variables have an impact, to a different degree, across and within the three components of the Donabedian model.3 This is illustrated in Figure 1, copied from their article, with melanoma and breast cancer surgery added as illustrative examples of high caseload and low baseline risk. For these cancers ‘Process’ would appear to have a greater impact on quality whereas ‘Structure (volume)’ is more likely to impact low caseload, and complex surgery, such as oesophagectomy. Using the Donabedian principles, for cancer surgery, we need more specific elements that provide a guide to the overall quality of care. This needs to be relevant to Australia and New Zealand where patients may have reduced access to surgical care and need to travel large distances for treatment for high caseload and low case-load cancers. Although the latter two measures are directly related to the surgeon, for the patient with cancer, the assessment of quality must be more than a good outcome from the operation. For high case-load cancers with less complex surgery, such as breast and melanoma, it is likely the impact of timeliness to surgery and access to oncology-based treatments will have a significant impact. These measures need to be an integral component of the measurement of quality of care. Low incidence cancers requiring complex surgery, in the recent past, have had quality assessed using the surrogate of operative mortality. There is so much more to quality surgery than operative mortality. There needs to be a focus on multiple measures of quality for a procedure as these may impact on the patient's oncological outcome, having survived the operation. The surgeon needs to be aware of the impact of lesser quality of care, beyond the operation, that may have a detrimental effect on the patient's outcome. As highlighted by Baum et al. in 2022, ‘surgical quality is a multidimensional parameter that cannot be defined by a single measure’.4 For complex surgery the concept of a ‘textbook outcome’ (TBO) has gained momentum. This utilizes multiple important surgical parameters which are combined to assess the outcome from the procedure. This was first reported, in 2017, in the Netherlands, using the Dutch Upper Gastro-intestinal Cancer database.5 This is a national database of all patients having surgery for oesophageal and gastric cancer. Ten quality outcomes were described and the rate where all 10 were achieved was assessed, with operative mortality being one component. Since that report the rate of achievement of a TBO has been shown to assess hospital performance6, 7 with the higher rates achieved in high-volume centres and associated with improved cancer survival.6-9 Using population data in Queensland, assessment of outcomes from complex upper gastro-intestinal cancer was made using a modification of the TBO labelled ‘High Quality Surgery’ (HQS).10 This included 6 of the 10 Dutch TBO elements. Higher rates of HQS for pancreaticoduodenectomy, oesophagectomy and total gastrectomy occurred in high-volume centres and were associated with higher rates of cancer survival.10-12 Others have described composite measures relevant to specific cancer surgery for gall balder and rectal cancers with high rates of the composite outcomes being associated with higher cancer survival.13, 14 For complex surgery, a composite incorporating outcomes that assess the elements of patient selection, pathology surrogates for an oncologically sound operation, along with morbidity appears to act as a better discriminator for ‘surgical performance’ beyond the technical aspects of the operation itself, and simply assessing operative mortality and complication rates. This does not diminish the need for equitable and timely treatment, and the need for access to appropriate perioperative oncology-based treatments which will impact on the survival in patients who successfully navigate the operation. For high caseload cancers requiring less complex surgery, there will be quality indicators for an operation that may impact the oncological outcome, however it is likely these are not technically difficult to achieve. For these cancers, potentially, there may be more impact on the outcome from quality indicators such as: access to the achievement of timely surgery; and timely, effective access to perioperative oncology-based treatments. An example is breast cancer surgery where quality indicators include timely access to surgery from diagnosis, breast conservation versus mastectomy rates, breast reconstruction rates, access to multidisciplinary care with timely adjuvant radiotherapy and systemic therapy. A population study from Queensland reported a higher risk of death at 5 years in women who were socio-economically middle or disadvantaged compared with the affluent population. As well a delay to completion of the whole treatment regimen, including surgery and postoperative adjuvant therapy beyond 37 weeks increased the number of deaths from cancer at 5 years, with commencing chemotherapy beyond 6.9 weeks from diagnosis being an independent adverse factor.15 Using melanoma as another high case-load example, the quality indicators for the surgery should include timely surgery from diagnosis, sentinel node biopsy where appropriate, quality indicators for sentinel node biopsy (SNB), such as identification rate and false negative rates,16 appropriate regional surgery,17 and referral for adjuvant therapy.18 As an access, as well as effective surgery issue, the SNB is an important staging procedure with the outcome impacting on the eligibility for patients to for adjuvant systemic therapy, which will impact on disease recurrence.18 Using the Australian guidelines for the indication for SLNB, in Queensland, in 2009, 14.2% of eligible patients had the procedure, increasing to 36.8% in 2019.19 Even accepting that it would never be 100% it is clear there were a number of eligible patients who have not had the opportunity to consider receiving adjuvant therapy. In Australia, in 2021, the rate of cancer diagnosis was 486/100000, having increased by 100/100000 from 1982. There was a higher risk of cancer in indigenous, regional/rural, and socio-economically disadvantaged populations, and all had lower survivals rates20 Similarly, in New Zealand, in 2020, the rate of cancer was 438/100000, with higher rates and worse survival in the Māori and socio-economically disadvantaged populations.21 Achieving equitable and timely diagnosis and treatment would go some way to improving those outcomes. The collaborations needed to assess and improve the quality outcomes needs to come from health service policy makers, the health districts, the local hospitals, and those of us treating the patients. The ‘system’ will impact on important patient outcomes: access to diagnosis and assessments; timely surgery and timely non-surgical oncology-based treatments. There needs to be support for the collection of data to allow assessment of all the factors that impact on patients with a surgically treatable cancer accepting there are interactions that impact between equitable care, access to care, effective and safe care leading to the overall quality of care (Fig. 2). It is acknowledged that the importance of patient reported outcomes has not been addressed in this article. That is not to diminish the importance of the patient's perspective being an aspect of quality that needs assessment. Patient quality of life or perception of a quality outcome is not necessarily aligned with the medical assessment, and this assessment may be cancer specific particularly when assessing surgery outcomes. Also, many of the generic assessments of quality of life related to cancer treatments, often do not reflect impact of the surgery. This is an area for parallel assessment as we progress to assess and improve the surgical outcomes. Being integral to the optimal outcomes for patients with solid organ cancer we surgeons should provide quality in the operation we perform. We should be assessing our own procedural outcomes, using modern assessments of perioperative quality applied for specific procedures. However, being responsible for the definitive surgical management should not abrogate the need for advocacy for patients to have timely access to care that is close to their home, and for investigations, where appropriate, to occur in the regional centres. No matter where we practice, we should be advocates for the delivery of all the aspects that make up ‘quality of care’ for the individual and more generally within our community. Open access publishing facilitated by The University of Queensland, as part of the Wiley - The University of Queensland agreement via the Council of Australian University Librarians.