VOLUME

33



NUMBER

12



APRIL

20

2015

JOURNAL OF CLINICAL ONCOLOGY

C O R R E S P O N D E N C E

Do We Still Need Proxies for Quality Control in Rectal Cancer Surgery?

for example, on the income and education of its host. RAMP and outlier status are methods of making a simple thing complicated, but we are not convinced that this is the most effective way to indicate quality and improvement.

TO THE EDITOR: Massarweh et al1 used the National Cancer Data Base to determine a risk-adjusted margin positivity rate (RAMP) as a quality indicator, stating that patients treated in hospitals that perform better than expected have better outcomes than patients treated in hospitals that perform worse than expected. The analysis concerns 32,354 patients treated within 3 years in 1,349 hospitals resulting in 7.99 resections per hospital per year. The complicated scoring system2 taken as the basis for the RAMP calculation includes different structure, process, and outcome parameters. Nonoutlier hospitals treated 91.4% of the patients. However, the rationale behind this approach remains unclear. The pathologic margin is determined by only two factors—the ability of the operating surgeon and the local extent of the tumor determined by magnetic resonance imaging (MRI).3,4 The determination of margin positivity in patients correctly diagnosed with negative circumferential margin by MRI is not a question of income and social status, it is a surgical error. RAMP, as a quality indicator for margin positivity, encourages acceptance of inferior results for the same tumor condition depending on the place of treatment. In the accompanying editorial, Finlayson5 states that Europe, with publicly supported quality initiatives, can afford a better system. However, publicly supported programs are available only in a minority of European countries.6 The rest of Europe conducts voluntary self-financed projects7,8 or does not have quality programs at all. However, it is incomprehensible why this most obvious and easiest parameter of quality in rectal cancer surgery cannot be described directly as, for example, a comparison of standardized MRI results9 with a standardized pathologic report,10 without any proxies and outliers. From the European perspective, the United States, which has a health system with enormous reach, is a place where this kind of quality control could be implemented without limitations. We agree that economic status and different elements of structure and process quality do have an impact on survival, but we cannot agree that the same rectal cancer with negative mesorectal fascia involvement should have a different probability of negative-margin resection depending,

Łukasz Dziki Medical University Łódz´, Łódz´, Poland

Paweł Mroczkowski Otto-von-Guericke-University of Magdeburg, Magdeburg, Germany

AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Disclosures provided by the authors are available with this article at www.jco.org. REFERENCES 1. Massarweh NN, Hu CY, You YN, et al: Risk-adjusted pathologic margin positivity rate as a quality indicator in rectal cancer surgery. J Clin Oncol 32:2967-2974, 2014 2. Russell MC, You YN, Hu CY, et al: A novel risk-adjusted nomogram for rectal cancer surgery outcomes. JAMA Surg 148:769-777, 2013 3. van de Velde CJ, Boelens PG, Tanis PJ, et al: Experts reviews of the multidisciplinary consensus conference colon and rectal cancer 2012: Science, opinions and experiences from the experts of surgery. Eur J Surg Oncol 40:454-468, 2014 4. Wibe A, Law WL, Fazio V, et al: Tailored rectal cancer treatment: A time for implementing contemporary prognostic factors? Colorectal Dis 15:1333-1342, 2013 5. Finlayson E: RAMPing up the quality of rectal cancer surgery. J Clin Oncol 32:2938-2939, 2014 6. van Gijn W, van den Broek CB, Mroczkowski P, et al: The EURECCA project: Data items scored by European colorectal cancer audit registries. Eur J Surg Oncol 38:467-471, 2012 7. Mroczkowski P, Kube R, Schmidt U, et al: Quality assessment of colorectal cancer care: An international online model. Colorectal Dis 13:890-895, 2011 8. Mroczkowski P, Hac´ S, Mik M, et al: Preliminary results of the first quality assurance project in rectal cancer in Poland. Pol Przegl Chir 83:144-149, 2011 9. Tudyka V, Blomqvist L, Beets-Tan RG, et al: EURECCA consensus conference highlights about colon & rectal cancer multidisciplinary management: The radiology experts review. Eur J Surg Oncol 40:469-475, 2014 10. Loughrey MB, Quirke P, Shepherd NA: The Royal College of Pathologists: Standards and datasets for reporting cancers. Dataset for colorectal cancer histopathology reports July 2014. http://www.rcpath.org/Resources/RCPath/ Migrated%20Resources/Documents/G/G049_ColorectalDataset_July14.pdf

DOI: 10.1200/JCO.2014.58.9622; published online ahead of print at www.jco.org on March 23, 2015

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Journal of Clinical Oncology, Vol 33, No 12 (April 20), 2015: pp 1411

© 2015 by American Society of Clinical Oncology

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1411

Correspondence

AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Do We Still Need Proxies for Quality Control in Rectal Cancer Surgery? The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I ⫽ Immediate Family Member, Inst ⫽ My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or jco.ascopubs.org/site/ifc. Lukasz Dziki No relationship to disclose

© 2015 by American Society of Clinical Oncology

Pawel Mroczkowski No relationship to disclose

JOURNAL OF CLINICAL ONCOLOGY

Downloaded from jco.ascopubs.org on November 15, 2015. For personal use only. No other uses without permission. Copyright © 2015 American Society of Clinical Oncology. All rights reserved.

Do we still need proxies for quality control in rectal cancer surgery?

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