ASCO GU 2018: Between-surgeon variation in surgical quality performance as an indicator of outcomes in radical cystectomy for bladder cancer

San Francisco, CA ( Dr. Rudzinski and colleagues presented their findings of between surgeon variation in surgical quality performance after radical cystectomy. Indeed, radical cystectomy for bladder cancer is a complex surgical oncology procedure and given the degree of skill required to perform the procedure, it is plausible that outcomes may vary among surgeons. The objective of this study was to determine whether between-surgeon variation (ie. heterogeneity) exists for urologic surgeons practicing at a Canadian academic center.

This study involved a retrospective analysis of data from the University of Alberta radical cystectomy database. Between September 1994 and August 2017, 1,031 consecutive patients underwent curative-intent radical cystectomy for histologically proven bladder urothelial carcinoma (cTanyN1-3M0) by 1 of 11 urologic surgeons. The survival outcomes included overall survival (OS) and 90-day mortality rate, a surrogate for cancer control was number of lymph nodes evaluation, and a perioperative surrogate was blood transfusion rate.

The median age of patients was 65 years (range 35-86), 78% were male, 40% were ≤pT2N0, 1% received neoadjuvant chemotherapy, and 78% of patients received an ileal conduit. There was a statistically significant (p<0.0001) difference in OS outcomes between surgeons, with two surgeons having a 2-year OS rate of >69%, whereas five surgeons had a 2-year OS rate of <60%. Similarly, there were differences in number of lymph nodes evaluated, with two surgeons have ≥18 lymph nodes evaluated and four surgeons with <10. The authors found between-surgeon variation in the 90-day mortality rate (unadjusted range, 0.9% to 13.1%). Four surgeons had 90-day mortality rates ≤ 3% whereas three surgeons had 90-day mortality rates ≥ 8%. Finally, two surgeons had transfusion rates <20%, whereas three surgeons had transfusion rates >50%.

Dr. Rudzinski concluded that a patient’s likelihood of achieving an optimal perioperative outcome may differ depending on which urologic surgeon performs the radical cystectomy. Based on these results, the authors argue that studies examining the mechanism(s) underlying surgical heterogeneity in perioperative outcomes after radical cystectomy are needed.

Speaker: Jan Rudzinski, University of Alberta, Edmonton, AB, Canada

Co-Authors: Niels Jacobsen, Sunita Ghosh, Adrian S Fairey

Written by: Zachary Klaassen, MD, Clinical Fellow, University of Toronto, Princess Margaret Cancer Centre, Twitter: @zklaassen_md at the 2018 American Society of Clinical Oncology Genitourinary (ASCO GU) Cancers Symposium, February 8-10, 2018 - San Francisco, CA

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