RAMPing Up the Quality of Rectal Cancer Surgery

Although the incidence of rectal cancer has been in modest decline over the last decade, it remains a common cancer that is associated with substantial morbidity and mortality. Furthermore, disparities in survival among patients with rectal cancer persist across geographic regions, racial groups, and socioeconomic strata. Because optimal treatment of rectal cancer is complex and often requires multidisciplinary management—radiation, surgery, and chemotherapy—there are several potential targets for quality improvement that may improve patient outcomes. For example, some have argued that use of neoadjuvant radiotherapy for stageappropriate cancers is an important measure of treatment quality. Because there are numerous reasons that patients do not undergo so-called indicated radiotherapy (advanced age, multimorbidity, previous pelvic radiotherapy, and patient preference), receipt of radiotherapy is not an ideal measure of treatment quality. Others have focused on rates of sphincter preservation as an indication of surgical quality. However, unmeasured patient and tumor variables may preclude sphincter-preserving surgery and therefore make it a poor global measure for surgical quality. Despite numerous studies that document variation in treatment and outcomes for rectal cancer in the United States, population-based strategies to improve quality of care and outcomes remain controversial and difficult to define. In the article that accompanies this editorial, Massarweh et al report on an evaluation of their proposed hospital-level quality indicator for rectal cancer: risk-adjusted margin positivity rate (RAMP). Using data from the National Cancer Data Base (NCDB) that included over 30,000 patients with rectal cancer, they evaluated the association between RAMP outlier status and overall risk of death at 5 years. They observed substantially higher rates of 5-year survival at hospitals with low RAMP rates: 80% at low RAMP outliers versus 65% at high RAMP outliers. Significant differences in survival persisted after adjustment for patient and tumor characteristics and after exclusion of T4 tumors from the analysis. Furthermore, the authors found that hospitals with low RAMP rates performed better on other proposed rectal cancer treatment quality measures that focus on structure (high hospital volume, facility type), process (number of nodes evaluated, timing of radiation therapy), and outcome (30-day mortality, hospital readmission, survival). The investigators concluded that hospital RAMP outlier status is a valid and actionable quality indicator for rectal cancer treatment that takes into account patient and tumor factors. This well-designed retrospective analysis offers a compelling argument that the quality of the resected rectal cancer specimen should be adopted as a measure of quality. Although the NCDB is plagued with high rates of missing data, the investigators carefully explored the possibility of bias from missing data through both multiple imputation and several sensitivity analyses. Although the NCDB registry does not include data from all hospitals that perform surgery for rectal cancer, it contains information about more than 70% of newly diagnosed cancers in the United States. However, compared with nonparticipating hospitals, hospitals in the NCDB are larger, more likely to be located in urban centers, and have more cancer-related services available. These limitations will have to be accounted for if RAMP outlier status is to be implemented as a quality indicator for rectal cancer. Focusing on the quality of the resected rectal cancer specimen as a quality measure is nothing new. Heald et al pioneered the concept of total mesorectal excision in the 1980s, and the technique is associated with lower rates of local recurrence and improved survival. In the 1990s, the surgical communities in Norway and Sweden launched national rectal cancer initiatives that required surgeons performing rectal cancer resections to undergo total mesorectal excision training, and patient outcomes were tracked using national rectal cancer databases. In Sweden, 5-year local recurrence rates decreased from 20% to 8%, and 5-year cancer-specific survival increased from 66% to 77%. More recently, the Spanish Society of Surgeons initiated a total mesorectal excision training initiative across a network of hospitals that serve nearly half of the national population. Among nearly 5,000 patients with rectal cancer who underwent surgery after the initiative, 5-year local recurrence rates were 5%, and 5-year survival was 88%. However, European models for quality improvement in rectal cancer that often have the backing of a national health system may not be realistic in the large, heterogeneous, decentralized US health care system. Despite decades of evidence indicating that patients who undergo complex cancer surgery in the United States fare better when treated by providers with greater experience, there has not been (nor is there likely to be) a broad, centralized effort to either improve performance across all hospitals or regionalize rectal cancer care. For some high-risk cancer surgeries, however, there is evidence that more patients are undergoing procedures at high-volume centers. It is unclear whether this so-called trickle-down regionalization is the result of patients with cancer responding to information about hospital volume or whether low-volume hospitals are essentially removing themselves from complex cancer care. The proposed hospital RAMP measure is an attractive starting point to improve the quality of rectal cancer surgery in the United States. It is a validated hybrid process-outcome measure that takes into account hospital case mix by incorporating clinically important JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 32 NUMBER 27 SEPTEMBER 2