Teach Your Children Well: Stage IV Colorectal Cancer and Variability in Practice Patterns

Training surgeons, like raising children, involves a certain element of uncertainty—the mentor, or the parent, provides the ingredients necessary for success, and the progeny are then released into the world, fingers crossed. Generally, things work out as planned, and while there are many different pathways to success, the important lessons and the core values do not waiver—like surgical training programs, no two families are the same but the fundamentals do not vary. The recipe for training surgeons, like parenting, has been essentially a trial-and-error process, evolving over time, during which the essential elements required have been forged. Whereas training programs have changed and adapted in response to changes in surgical practice, the basic principles, or core values, remain. The clinical problems and operative approaches may change, but the clinical judgment and reasoning skills required for mature surgical decision-making do not. Clearly, no amount of training can provide exposure to every possible situation that one might encounter, nor can it account for changes in practice that normally occur over time. Like a parent raising a child the most that a training program can hope to accomplish is to provide the necessary foundation to adapt appropriately to a changing world. In the current issue of Annals of Surgical Oncology, Nathan et al. analyze practice patterns among surgeons treating patients with stage IV colorectal cancer. In this interesting and well-conducted investigation, the authors presented practicing surgeons, reportedly with an ‘‘interest’’ in liver surgery, with several clinical scenarios and analyzed the responses. The study population of 219, which was derived from an initial email invitation list of 1,032, was largely from academic centers (79 %), fellowship trained (51 % surgical oncology, 25 % HPB, and 21 % transplant), clinically oriented (75 % time in clinical care), and reasonably experienced (median of 12 years in practice and 30 self-reported liver resections per year for all indications). In general, responses appeared to be within the main stream of attitudes, with the overwhelming majority agreeing that hepatic resection is potentially curative therapy (99 %) but a much smaller proportion (67 %) conferring the same degree of efficacy to ablative therapy. Appropriately, the disease extent did have some impact on the respondents’ choice of therapy: liver resection, chemotherapy followed by liver resection (‘‘neoadjuvant’’), ablation, or palliative chemotherapy. Although there was no consensus regarding the use of neoadjuvant chemotherapy versus initial surgery, when the former was recommended, the respondent’s displayed a good understanding of its role, with the overwhelming majority recommending a limited course and not treatment to maximal response. With more in-depth analysis, greater variability became apparent. The authors noted that different clinical characteristics influenced treatment recommendations to varying degrees, with timing of metastatic disease presentation, tumor number and location, as well as the presence of extrahepatic disease having the largest impact. In general, there was a greater preference for initial chemotherapy in patients with synchronous liver metastases and more advanced disease, whereas there was a strong aversion to recommending hepatic resection in patients with extrahepatic disease at any site. A major finding of the study was the identification of physician-related variables that impacted treatment recommendations. Specifically, the authors found that surgical oncology-trained surgeons were more likely to recommend Society of Surgical Oncology 2012