The Swedish quality assurance register for rectal cancer surgery

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Published: 21 Oct 2010
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Prof Lars Pahlman - University Hospital, Uppsala, Sweden
Prof Lars Pahlman speaks about the quality assurance register for Swedish rectal cancer patients, introduced 20 years ago in response to the high rate of local recurrences. Prof Pahlman explains how this transparent report of the surgery standards and a more centralised setup were necessary steps in order to achieve higher quality rectal cancer surgery.

15th Congress of the European Society of Surgical Oncology (ESSO), 15–17 September 2010, Bordeaux

Professor Lars Pahlman – University Hospital, Uppsala, Sweden

The Swedish quality assurance register for rectal cancer surgery

Hello, this is and we are in Bordeaux at the European Society of Surgical Oncology meeting, Professor Lars Pahlman is with me. Lars, you’ve been taking advantage of the wonderful registry opportunities in your country, Sweden. You’re from Uppsala University, what have you been doing? Now specifically you’re talking this morning about rectal cancer, what’s going on?

We had a big problem in Sweden, if you go back some twenty years, with lots of local recurrences and we were not really aware of why; then we had the new era of surgery with a TME technique. Then we decided to start a quality assurance registry in rectal cancer in Sweden, just to check if this new idea and hypothesis would change the outcome. So that was the start, more than fifteen years ago.

And, of course, in Sweden many, many patients are entered into this registry?

Yes, we have 100% and all hospitals decided to join us and actually, according not to Swedish law but the Swedish system, it’s more or less compulsory to join this quality registry in our country. I think this is extremely important because if you don’t put in everyone, you will lose some and those ones you lose are often those with the worst outcome.

Now total mesorectal excision, sphincter preservation, the use of pre-operative radiotherapy, the use of chemotherapy, these are all factors. How have you found these all affect outcomes?

That’s not out of the register actually. We have guidelines in Sweden and all those new data which we have adopted and we’ve started is based upon randomised trials. But when we write our guidelines we check if the Swedish surgeons are following the guidelines, and that’s what we can do in this register. For instance, the important finding of at least twelve lymph nodes, when we started to discuss that it was just some 50% of the patients had twelve lymph nodes; nowadays, some ten years later, almost all of them have twelve lymph nodes in the specimen. So that’s just a typical way of how we work.

Can you give me some kind of feel for just how much rectal surgery has improved and how much it can improve in good hands?

It has improved enormously in Sweden because if you go back thirty years, the survival has changed from 40% to more than 60%. We had, over all those years, colon cancer patients did better than rectal cancer patients but since we started this programme in Sweden, now rectal cancer patients are doing better than colon cancer patients despite the fact, at least in the surgeon’s view, it’s easier to operate upon colon cancer than rectal cancer. So we have changed the outcomes, so rectal cancer patients are doing better now.

And what’s happened to quality of life in your rectal cancer patients?

We have some registration of that too. We have changed our sphincter preserving procedures so there are not so many anymore. You can always preserve a sphincter but the quality of life, being incontinent and not working well, is not what Swedish patients accept. But this has become a quality parameter – how many sphincter preserving procedures you do, but in Sweden we actually look more for quality than if you can avoid a stoma.

So avoiding a colostomy is not necessarily the be all and end all?

No, definitely not, definitely not.

Your talk here today is about what can we do on outcomes. What should doctors be pulling out of all of this?

When you follow the results in our register you can see the trends, how we are changing our technique and, as I mentioned, when we introduce new techniques or new ideas and we put them in our guidelines, then we check how quickly guidelines are adopted in Sweden. I think that’s the most important thing because we have lots of data supporting that it takes too long a time. If you go for classic surgical things like prevention for thromboembolic events, antibiotics in bowel surgery, use of nasogastric tubes and all things like that, once the evidence is there it used to take more than fifteen years until more than 95% of the units are using it. So by that quality register it goes much quicker. So that is one of the real advantages, to use it in this way.

In Sweden you’re extremely well organised. What would you say to other places to help them to get as well organised as you are in your country?

That’s a very difficult question. First of all, Sweden has more or less a complete state based system which means that there is no profit for each surgeon to do things, which you have in many other countries. Unfortunately, in my view, lots of patients are, to be a bit rude, more an economical tool for the doctors than to do a perfect operation. So they do everything. In Sweden we have stopped that, we have closed hospitals that are not good enough in rectal cancer, for instance. So we concentrated to fewer hospitals and that’s the same in Norway and Denmark where we have the same registrations. So the first thing is to go back and look at your own data; if you are not good enough then you have to change. If you cannot change, due to the numbers being too few, you should stop. That’s to do specific procedures.

How do you do that sort of naming and shaming without upsetting the whole medical community?

We decided to have a transparent report and before that we addressed those hospitals that were not good enough and told them that you have to do something. Stop operating or change. And many centres stopped doing that surgery when we had this discussion. They were too small and they decided, OK, we’ve stopped doing it now. And you have seen exactly the same, as I said, in Norway and Denmark too.

Some people then may be rather disappointed but is there a plus side to this? Are there people who are feeling more fulfilled because of these quality assurance measures?

I think we started this and said to people that you should not operate upon those cases, of course they were angry, some of them and I must say that some were extremely good. They performed better than some other big units so it was in one way, perhaps we did the wrong thing in some centres but it was relying upon one good surgeon. The interesting thing now, we are still debating this in Sweden, so the difference between a good, small volume unit is less against a high volume unit than the difference between high volume units. So we have bad healthcare providers in the high volume units because there you can disappear in the unit, in the volume, as a surgeon. So this is a tricky thing, actually.

Can you sum up what practising clinicians should pull out of all of this?

You must be aware of your outcome every year. You must know and follow it. You should start to know your own registry in whatever disease you treat and then check against guidelines – are we following the guidelines and also check the results with the international literature.

Lars, it’s very good to have you with us today. Thank you for joining us here in Bordeaux at the European Society of Surgical Oncology. I wish you lots of luck in the future with your excellent work and thank you for being on