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Surgical Success Story

Surgery plays a crucial role in cancer care. For the majority of patients, surgery is the primary intervention to diagnose, stage and treat their cancer. Surgical procedures used for diagnosis and treatment vary, with the exact procedure dependent on cancer type and stage. In Ontario, approximately 60,000 cancer surgeries are performed every year across more than 70 hospitals.

The relationship between surgeon and pathologist is an integral component of the surgical care process. Surgical procedures in cancer care are performed by surgeons who may or may not specialize exclusively in cancer surgery. While surgeons carry out the procedures, pathologists play an important role in ensuring cancer patients receive high-quality care.

The following “bright spot” indicators highlight how an integrated surgeon–pathologist partnership results in high-quality care for cancer surgery patients.

  • Lymph node sampling in colon cancer surgery
  • Margins in rectal cancer surgery
  • Margins in prostate cancer surgery

Lymph Node Sampling in Colon Cancer Surgery

Accurate pathological staging of cancer helps ensure that patients receive the most appropriate care after their surgery (e.g. radiation, chemotherapy or none). It is also important in establishing the patient’s prognosis and course of disease. Patients whose lymph nodes are positive for cancer tend to have a worse prognosis and are more likely to have cancer recurrence (return) or metastasis (spread). 

Examining the lymph nodes for the presence of cancer cells supports accurate cancer staging. Cancer Care Ontario’s best practice quality guidelines to adequately stage colorectal cancer recommend examining a minimum of 12 lymph nodes.

An audit of colorectal cancer resection cases in Ontario in 2005/2006 showed that only 74% of cases had 12 or more lymph nodes examined. In response, Cancer Care Ontario’s Surgical Oncology Program convened an expert panel on colon and rectal cancer surgery and pathology to develop the guideline Optimization of Surgical and Pathological Quality Performance in Radical Surgery for Colon and Rectal Cancer: Margins and Lymph Nodes. Released in 2008, the guideline recommended the 12-lymph node target. Following the release, the program started a number of quality improvement and knowledge transfer activities, including:

  • annual assessment of the guideline to ensure it is current
  • nominal regional funding incentive to support a colorectal-specific quality initiative in each region
  • development of a provincial Colorectal Cancer Community of Practice with champions from each region and
  • audit and feedback of data at the hospital level

Performance has improved since Cancer Care Ontario evidence-based guidelines were released in 2008 recommending the 12-lymph-node target:

  • Over the last 5 years, the vast majority of resection reports in Ontario confirmed that 12 or more lymph nodes had been examined.
  • Ontario’s colon surgery resection report rate exceeds the provincial target of 90%, with the rate increasing from 91% in 2012 to 94% in 2017.
  • Ontario continues to perform very well compared with other jurisdictions, including other Canadian provinces and Scotland.

Margins in Rectal Cancer Surgery

The goal of rectal cancer surgery is the complete removal of cancer cells from the rectum. A “positive margin” means that some cancer cells remain after surgery. Positive margins for rectal surgery have negative implications for localized cancer recurrence and survival. Cancer Care Ontario’s best practice quality guidelines recommend an overall positive margin rate for rectal surgery of less than 10%

An audit of rectal cancer cases in Ontario in 2007/2008 showed that the positive margin rate for rectal cancer patients was high, at 9%. To address the high positive margin rates, Cancer Care Ontario’s Surgical Oncology Program convened an expert panel on colon and rectal cancer surgery and pathology. In 2008, the panel released the guideline Optimization of Surgical and Pathological Quality Performance in Radical Surgery for Colon and Rectal Cancer: Margins and Lymph Nodes, recommending negative surgical margins for rectal cancer patients. Following its release, the program started a number of quality improvement and knowledge transfer activities, including:

  • annual assessment of the guideline to ensure it is current
  • magnetic resonance imaging (MRI) to be performed in all patients with rectal cancer to identify patients who are likely to have a positive margin when the tumour is removed, and therefore should receive radiation before surgery
  • nominal regional funding incentive to support a colorectal-specific quality initiative in each region
  • development of a provincial Colorectal Cancer Community of Practice with champions from each region
  • audit and feedback of data at the hospital level

Performance has improved since Cancer Care Ontario evidence-based guidelines were released in 2008 recommending negative surgical margins for rectal cancer patients:

  • The margin status for rectal cancer has remained stable for the past 5 years.
  • The percentage of rectal surgery reports with positive circumferential margins has been at 7% since 2012 This is within the provincial target of 10%.
  • Ontario continues to perform well compared with other jurisdictions, including Scotland.


Margins in Prostate Cancer Surgery

The goal of radical (or total) prostatectomy is the complete removal of cancer cells from the prostate, while preserving urinary and erectile functions. A “positive margin” means that some cancer cells remain after surgery. Positive margins for radical prostatectomy (pT2) significantly increase the risk of localized cancer recurrence and decrease survival. Cancer Care Ontario’s best practice quality guidelines recommend an overall positive margin rate for radical prostatectomy of less than 20%.

An audit of radical prostatectomy cases in Ontario in 2005/2006 showed that the positive margin rate for pT2 patients was very high, at 31%. In response, Cancer Care Ontario’s Surgical Oncology Program convened an expert panel on prostate cancer surgery and pathology to develop the guideline Optimization of Surgical and Pathological Quality Performance in Radical Prostatectomy in Prostate Cancer Management. Released in 2008, the guideline recommends the goal of radical prostatectomy to be negative margins. Following the release, the program started a number of quality improvement and knowledge transfer activities, including:

  • annual assessment of the guideline to ensure it is current
  • nominal regional funding incentive to support a prostate-specific quality initiative in each region
  • development of a provincial Prostate Cancer Community of Practice with champions from each region
  • audit and feedback of data at the hospital level

Performance has improved since Cancer Care Ontario evidence-based guidelines were released in 2008 recommending an overall positive margin rate for radical prostatectomy of less than 20%:

  • Over the last 5 years, the rate has remained steady.
  • Since 2012, it has been performing close to the provincial target of 20%, with the rate declining from 22% in 2012 to 21% in 2017.
  • Ontario tracks closely with other jurisdictions, including Scotland.