Wide variations in appropriateness of rectal cancer surgery across England

A substantial proportion of rectal cancer patients are receiving inappropriate surgical care, because of wide variations in practice across England, reveals research published ahead of print in the journal Gut.

The variation was not associated with how far the disease had advanced or how old the patient was, the data showed.

The findings are based on information obtained from the eight cancer registries in England, which track the progress of all patients with cancer, and NHS hospital data on admissions and treatment between1998?.

During this period, 58 290 patients were diagnosed with rectal cancer in England, of whom 31 223 underwent major abdominal surgery in 153 hospitals to treat their disease.

Around 13 000 people are diagnosed with rectal cancer every year in the UK, and the disease has an annual death toll of around 5000.

There are several different surgical approaches to rectal cancer treatment, the most common of which used to be abdominoperineal excision, or APE for short.

This involves the removal of the anal sphincter, necessitating the permanent use of a colostomy bag. But mounting evidence indicates that although APE is unavoidable in some patients, it should not be the preferred procedure for most of them.

Furthermore, the evidence shows that APE is also associated with higher rates of recurrence and poorer survival than a procedure called anterior resection, or AR for short.

The Department of Health has published guidance, encouraging surgeons, wherever possible, to use alternative methods and adopt AR, which obviates the need for a colostomy bag.

The figures showed that many surgeons had taken the evidence on board, because rates of APE fell from almost one in three procedures (30.5%) in 1998 to almost one in four (23%) in 2004.

But there were wide variations in the use of APE among different cancer networks, individual surgeons as well as hospital trusts, where rates varied from 8.5% to almost 53%.

In 1998, one in three patients were also operated on a by a surgeon who performed fewer than seven rectal cancer procedures in a year. By 2004, this had fallen to around one in four (26.5%).

Patients treated by a specialist surgeon undertaking seven or more cases of rectal cancer a year were 23% less likely to be treated with APE than those with less experience.

The figures also revealed that those living in the most deprived areas of the country were significantly more likely to receive an APE than those living in the most affluent areas.

There were no obvious clinical reasons for these discrepancies, the findings showed.

APE may not only spell poorer quality of life for patients, but it is also more expensive, in terms of the maintenance costs of colostomies and the treatment of recurrent disease, say the authors.

"These problems must be addressed if the government is to attain its aims of ensuring a high quality of cancer care for all," they conclude.

Source: BMJ-British Medical Journal