This study was carried out to identify possible factors that influence the use of en bloc MVR in patients with LAACRC. Overall, the principles of en bloc MVR were similarly violated in more than 50% of eligible LAACRC patients in two Canadian provinces. Newer physicians were significantly more likely to perform MVR than older physicians. Patient factors such as age and comorbidity were not predictive of MVR performance. In contrast, our SEER-based study found that one-third of eligible patients undergoing surgery during a time period similar to this cohort study received MVR, and this was associated with younger patient age and geographic region.14
No other studies have examined predictors of MVR, but it is known that age bias can influence receipt of recommended therapy for other types of cancer, as can surgeon factors such as years in practice, teaching status, and cancer volume.27–30
This research is inconsistent with the findings of our cohort study, but more detailed information of greater relevance to ongoing quality improvement can be gleaned from qualitative analysis of both operative notes and interview transcripts.
Several elements of surgical decision-making appeared to differ between surgeons who did and did not perform en bloc MVR including mental readiness, risk assessment, and intraoperative decision-making. Both mental readiness (preoperative treatment planning) and risk assessment (intraoperative consultation/assistance) were challenged by capacity issues, for example, some hospitals did not have onsite imaging technology. To enhance mental readiness through preoperative decision-making, surgeons underscored the importance of tumor boards, or multidisciplinary cancer conferences (MCCs). These are regularly scheduled multidisciplinary meetings to prospectively review individual cancer patients and formulate appropriate management plans.31
Several observational studies suggest that MCCs can improve compliance with guideline recommendations and patient care outcomes.32–36
We explored the benefits of an MCC linking surgeons at six hospitals by videoconference.37
Participating surgeons said that sharing of clinical experience improved decision-making for complex cancer cases, and through exposure to decision-making for more cases than they would see in their own practices, clinical expertise was developed that could be applied to future cases.
Whether identified preoperatively or intraoperatively, many surgeons indicated a preference for referring LAACRC patients to specialists at tertiary care centers due to little experience with, or desire to engage in these complex, lengthy operations, and suggested the need for greater human and technologic infrastructure. First, they expressed concern over difficulties in arranging appointments for LAACRC patients with specialist surgeons who may be overwhelmed with the volume of referrals. Second, access to specialist surgeons could remotely provide just-in-time intraoperative consultation when unexpected or emergent cases arose, thereby alleviating the need for referral in some cases. Participants of an exploratory study of telehealth delivery of medical care in remote regions of Quebec, Canada also emphasized the need for dedicated human and technologic resources, and health professional remuneration in order to integrate such activities into regular practice.38
Further research is required to examine referral patterns for MVR, and evaluate the effectiveness of technology for enabling intraoperative communication between community and academic centers.
Perhaps more importantly, this study identified that individual surgeon judgment was influential in the care received by patients with LAACRC because it seemed to mediate all elements of surgical decision-making. Judgments were made about resectability according to tumor characteristics and personal views on surgical success. During interviews surgeons said they would utilize MVR if adhesion or invasion were uncertain, but operative notes demonstrated that judgments about the nature of adhesions were frequently the reason for MVR not being performed. Furthermore, judgments on personal technical ability influenced whether a patient was referred for neoadjuvant care or to specialist surgeons, and may also predict whether a surgeon arranges for intraoperative support from other specialties, a factor associated with the use of MVR. Surgical judgment, largely based on personal assessments about technical ability, knowledge, and experience, may not be amenable to modification using traditional continuing education approaches due to the limited time and capacity of physicians for reflective practice without external triggers or guidance.39,40
To promote greater awareness of personal MVR practice, a more promising intervention may be audit and feedback. A Cochrane review of 118 trials found that audit and feedback can improve clinical practice when individuals are able to compare their own performance with that of peers, and data is provided periodically on an ongoing basis and is delivered verbally or by senior colleagues.41
Further research is required to determine whether audit and feedback is an effective approach for improving MVR in patients with LAACRC.
This study had several limitations. Operative notes may be incomplete sources of information on decision-making because they are meant to capture the technical details of surgery and only contain details that the physician chooses to dictate. Regardless, we were able to extract detailed information from operative notes on all elements of surgical decision-making proposed by Yule.20
Interview findings may be influenced by small sample size and volunteer bias, wherein participating surgeons are those most compliant with recommended practice. However, surgeons interviewed were diverse with respect to jurisdiction, practice setting, and experience, and provided very similar responses. Analysis of operative notes was also based on a small sample size, but patients were sampled in a population-based manner. Despite the care taken to mitigate these limitations, decision-making factors or capacity issues found to influence MVR practice may not apply to other jurisdictions. However, these concepts can now form the hypothesis in larger, more descriptive studies, both in Canada and elsewhere. In particular, we found that situation awareness and anticipation were joint cognitive intraoperative processes, and that individual judgment mediated the entire continuum of nontechnical surgical skills proposed by Yule, as did organizational and system capacity.20
In summary, we identified factors that appear to contribute to low rates of MVR among patients with LAACRC, including surgical decision-making (preoperative planning and readiness, intraoperative assessment of the need for MVR, and choice of surgical approach, all mediated by judgment about resectability and personal skill) and capacity issues (access to diagnostic imaging, availability of surgical specialties in both community and academic settings, systems to enable preoperative multidisciplinary planning). Further research is required to examine the effectiveness of tumor boards, and audit and feedback on improving rates of MVR in patients with LAACRC. Further research is also required to examine whether these key elements of surgical decision-making apply to conditions other than LAACRC.