Long distances in Northern Norway. Implications for the patients and who should operate him?

1. Long distances in Northern Norway. Implications for the patients and who should operate him? Rolv-Ole Lindsetmo MD, PhD, MPH Head Department of Gastroenterological Surgery University Hospital of North Norway, Tromsø Kirurgi, kreft og kvinnehelseklinikken

2. Long distances? Kirurgi, kreft og kvinnehelseklinikken

3. Kirurgi, kreft og kvinnehelseklinikken

4. 17 32 25 27 29 3 5 3 4 8 1 1 0 1 3 1 1 0 1 1 Total: 130 23 6 4 Helse Finnmark HF Universitetssykehuset Nord-Norge HF Nordlandssykehuset HF Helgelandssykehuset HF 11 Kirurgi, kreft og kvinnehelseklinikken

5. Long distances? Travel time/distances from community to operating hospital, 2005-2008, 707 patients operated for colon cancer minutes km Mean 119 141,7 Long distances should not be of any concern in elective surgery Kirurgi, kreft og kvinnehelseklinikken

6. Practical approach to work-up and follow-up when patients have to travel long distances: • All hospitals have CT and endoscopy service. “Local work-up - centralized treatment” • Pathology service/lab in two hospitals • Telemedical connections between all hospitals • Follow-up at GP or nearest hospital according to national guidelines. Kirurgi, kreft og kvinnehelseklinikken

7. Who should do the follow-up? Knut M Augestad, Barthold Vonen, Ranveig Aspevik, Torunn Nestvold, Unni Ringberg, Roar Johnsen, Jan Norum and Rolv-Ole Lindsetmo Should the surgeon or the general practitioner (GP) follow up patients after surgery for colon cancer? A randomized controlled trial protocol focusing on quality of life, cost- effectiveness and serious clinical events BMC Health Serv Res. 2008; 8: 137 Kirurgi, kreft og kvinnehelseklinikken

8. Hospital volume of ca coli operations in hospitals in Northern Norway Ca coli operations 2008 2009 2010 (until 01.08) Hammerfest 18 11 9 Kirkenes 8 5 6 UNN, Tromsø 49 35 65 (whole year) UNN, Harstad 23 21 ? UNN, Narvik 9 10 ? Bodø 32 34 19 Vesterålen 10 14 11 Lofoten 9 2 2 Mo i Rana 25 18 20 Sandnessjøen 12 18 7 Mosjøen 0 0 0 Kirurgi, kreft og kvinnehelseklinikken

9. Hospital volume Ca coli operations in hospitals in Northern Norway 2007-2009 Kirurgi, kreft og kvinnehelseklinikken

10. Who should operate the patient? • From the Norwegian Guidelines 2010: • Surgical treatment of cancer in the large bowel and in the rectum should be performed by specialists in gastrointestinal surgery. • Institutions with single specialists or ”hired in/short term specialists” based solutions should avoid elective treatment of colorectal cancer • Institutions giving treatment to patients with colorectal cancer should establish MDT for discussing investigation and treatment plans Kirurgi, kreft og kvinnehelseklinikken

11. Hospitals performing ca coli operations in Northern Norway in 2011 2008 2009 2010 til 01.08. Hammerfest 18 11 9 Kirkenes 8 5 6 Unn Tromsø 49 35 65 (whole year) UNN, Harstad 23 21 ? UNN, Narvik 9 10 ? Bodø 32 34 19 Vesterålen 10 14 11 Lofoten 9 2 2 Mo i Rana 25 18 20 Sandnessjøen 12 18 7 Mosjøen 0 0 0 Kirkenes 8 5 6 UNN, Narvik 9 10 ? Vesterålen 10 14 11 Lofoten 9 2 2 Mosjøen 0 0 0 Kirurgi, kreft og kvinnehelseklinikken

12. What about the results? • Comparative data available in 2012 • Adherence to guidelines? • Standardized technique? • Sufficient training? • Surgeons volume? • Quality evaluation? • MDT? • Pathology service? Kirurgi, kreft og kvinnehelseklinikken

13. ..who should operate colon ca? • This is not only a question about quality…. • It is also politics and an employment issue in the local community Kirurgi, kreft og kvinnehelseklinikken

14. Conclusion • Distances doesn’t matter! • Patients should be offered optimal treatment for colon cancer independent of distance to hospital. • A dedicated specialist in colorectal cancer surgery should operate the patient. Kirurgi, kreft og kvinnehelseklinikken

15. Thank you for your attention! Kirurgi, kreft og kvinnehelseklinikken

16. What about the results? • Our results 2010: • 65 colon resections for colon cancer Kirurgi, kreft og kvinnehelseklinikken

17. Right sided hemicolectomi (incl ileocoecal resection) 28 • Sigmoidresection 25 • Left sided resection 9 • Others 3 • 24 laparsocopic (37%) • 1 anastomotic leak • 1 uretral damage • 3 wound dehiscence • 1 internal hernia • 3 death (apoplexia after reoperation for wound dehiscence, thoracal aneurysm rupture, duodenal leak after locally advanced colon cancer resection) • 13 nodes (mean) in specimens Kirurgi, kreft og kvinnehelseklinikken

18. References • Rogers SO Jr, Ayanian JZ, Ko CY, Kahn KL, Zaslavsky AM, Sandler RS, Keating NL. Surgeons' volume of colorectal cancer procedures and collaborative decision-making about adjuvant therapies. Ann Surg. 2009 Dec;250(6):895-900. • Borowski DW, Bradburn DM, Mills SJ, Bharathan B, Wilson RG, Ratcliffe AA, Kelly SB; Northern Region Colorectal Cancer Audit Group (NORCCAG). Volume-outcome analysis of colorectal cancer-related outcomes. Br J Surg. Sept 2010 Sep;97(9):1416-30. • van Gijn W, Gooiker GA, Wouters MW, Post PN, Tollenaar RA, van de Velde CJ. Volume and outcome in colorectal cancer surgery. Eur J Surg Oncol. 2010 Sep;36 Suppl 1:S55-63. Epub 2010 Jul 7. (systematisk review) • Nationellt kvalitetsregister. Cancer recti 2009. http://www.oc.umu.se/rekti/rektpdf.htm • Iversen LH, Wille-Jørgensen P, Borowski D, Archampong D. Workload and surgeon´s speciality for outcome after colorectal cancer surgery. Cochrane Library Protocol.June 2010 Kirurgi, kreft og kvinnehelseklinikken

19. Low or high volume? • Borowsky et al, Br J Surg 2010: • Low volum hospital: <86/operations/year • High volume surgeon: >40 operations/year • Significant correlations between long term survival and hospital and surgeon volume Kirurgi, kreft og kvinnehelseklinikken

20. Low or high volume? • Swedish colorectal registry, 2009 • (Nationellt kvalitetsregister. Cancer recti 2009. http://www.oc.umu.se/rekti/rektpdf.htm) • Low volum hospital: <11/operations/year • High volume hospital: >25 operations/year • Only small differences in most outcome measures between low and high volume hospitals Kirurgi, kreft og kvinnehelseklinikken

21. How to overcome long distances? Long distances doesn’t matter in elective surgery! Kirurgi, kreft og kvinnehelseklinikken

22. Av 144 pasienter i 2009, ble 69 operert i Tromsø eller Bodø og 74 på de øvrige 8 sykehusene. Det diskuteres nå hvorvidt kirurgi på tykktarmkreft også skal funksjonsfordeles på færre sykehus. Både enkeltstudier (Borowski , Br J Surg, 2010) og systematiske gjennomganger (van Gijn W, Eur J Surg Oncol, 2010) viser en positiv sammenheng mellom langtidsoverlevelse og antall opererte pasienter per sykehus og per kirurg. Definisjonen på hva som er lavt eller høyt volum varierer fra studie til studie. I studien til Borowski er mindre enn 86 inngrep per sykehus og 40 inngrep per kirurg definert som lav-volum. I følge den definisjonen er alle sykehus i Helse Nord lav-volumsykehus. I rapporten fra colorektalcancerregisteret i Sverige defineres < 11 inngrep per sykehus per år som lav-volum og > 25 som høy-volum (Nationellt kvalitetsregister. Cancer recti 2009). Denne rapporten viser liten forskjell mellom høy- og lavvolum på de fleste endepunkt. The Cochrane Library har nettopp påbegynt en kunnskapsoppsummering med dette som tema; Kirurgi, kreft og kvinnehelseklinikken

23. Annual ca coli cases Tabell 1. Antall nye krefttilfeller per år i for bosatte i Helse Nord fordelt på krefttype Incidence in Northern Norway Cancer Ca oesophagi Ca ventriculi Ca coli Ca recti Ca hepatis Ca pancreatis Average new cases/year in Northern Norway Kirurgi, kreft og kvinnehelseklinikken

24. Conclusion • Coloncancer patients should be offered optimal treatment and operated by a dedicated specialist in colorectal surgery. Optimal treatment means: • enhanced recovery protocol (ERAS) • laparoscopic technique • total mesocolic excision Kirurgi, kreft og kvinnehelseklinikken