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JCO Exclusive: Laparoscopic Versus Open Colectomy: Geography Makes a Difference

Nov 03, 2014

        Key Points
  • An analysis of 93,786 patients with colon cancer found that the percentage of patients who received open colectomy versus laparoscopic colectomy varied widely based on geographical location of treatment, but not based on the patient’s sex, race, or coexisting diseases.
  • Since the majority of hospitals in the study owned the equipment to perform laparoscopic surgery, the researchers suggested that the variability is due to the individual surgeons’ choices about whether to perform the surgery, choice that may be influenced by the differing ability of surgeons to perform laparoscopy and differing eligibility criteria for patients.

By Shira Klapper, Senior Writer/Editor

A study out of the University of Michigan examined data on 93,786 patients with colon cancer and found that the percentage of patients who received open colectomy versus laparoscopic colectomy varied widely based on geographical location of treatment, but not based on the patient’s sex, race, or coexisting diseases. According to first author, Bradley N. Reames, MD, MS, the study, “Geographic Variation in Use of Laparoscopic Colectomy for Colon Cancer,” is “the first study to look at geographical variability as a factor in determining whether patients have access to minimally invasive surgery.” The study was published in the Journal of Clinical Oncology (JCO) online, ahead of print, October 6.

Open colectomy refers to colon surgery that is performed by creating a large incision which exposes the colon for open surgery, whereas laparoscopic surgery is performed by way of multiple small incisions and a camera which magnifies the surgical field. Numerous studies have confirmed that the two surgical approaches are equal in terms of safety and cancer outcomes, however, patients who receive the less-invasive laparoscopic colectomy have an advantage post-surgery: they need fewer painkillers, have a shorter hospital stay, and recover more quickly. In 2009, 40 to 50% of all patients with colon cancer received laparoscopic surgery.

Laparoscopy use varies from 0-60%

The JCO study used data from the 2009 and 2010 files of the Medicare Provider Analysis and Review (MEDPAR) to identify patients between 65 and 99 years of age who underwent colectomy. Hospitals were grouped by one of 306 hospital referral regions (HRRs)—a system that organizes hospitals geographically, with each HRR typically including a major referral center. Analysis of the data showed wide variation between HRRs in terms of how often laparoscopy was used. For example, in Yakima, Washington, laparoscopy was used to perform colectomies 0% of the time, whereas in San Luis Obispo, California, laparoscopy was used 60% of the time. In addition, in many instances, rates of use of laparoscopy varied from lowest to highest among adjacent HRRs.

Bradley N. Reames,

Surgeons’ choice might explain variability

According to Dr. Reames, the wide geographic variation in laparoscopy is not due to the fact that some hospitals own the technology to perform laparoscopic surgery and others do not.

“The vast majority of the hospitals we evaluated all have the structural resources, technology and equipment necessary to perform laparoscopic surgery,” said Dr. Reames.  

This gap between the universally high rates of equipment ownership and the varying rates of use led to an obvious question: Why isn’t laparoscopy performed more equally across hospitals? Dr. Reames said the answer is not due to patient preference.

“In this case, I think it’s safe to assume that the majority of patients who are offered a minimally invasive approach to colectomy are going to choose it,” said Dr. Reames. “So we believe that this variation must be due to the preferences and practice styles of surgeons at the individual hospitals.”

Surgeons are choosing whether to perform laparoscopic colectomy based on several different factors.

 “One factor is certainly ability, skill, and technique,” said Dr. Reames. “Some doctors may have been trained to do this procedure, while others may not have been and as a result do not feel as comfortable with a laparoscopic approach.”

In addition, surgeons may use differing eligibility criteria to determine whether patients are candidates for laparoscopic surgery. “Some surgeons may be much more restrictive with their personal eligibility criteria,” said Dr. Reames.

Increasing access to laparoscopic colectomy

Dr. Reames said any interventions aimed at increasing the rates of laparoscopic colectomy would have to target individual surgeons and patients.

“It’s a process that would take years, but the best way to address this variation and the disparities that some patients seem to experience is by providing training to individual surgeons, and educating patients about their surgical options, so they don’t unknowingly forego the potential benefits of laparoscopy.”

Bradley N. Reames is a general surgery resident at the University of Michigan. He has been an ASCO member since 2012.



Read the abstract.


Read the PDF of the original JCO article.

Reames BN, Sheetz KH, Waits SA, et al. geographic variation in use of laparoscopic colectomy for colon cancer. J Clin Oncol. Epub 2014 Oct 6.

The Exclusive Coverage series on ASCO.org highlights selected research from JCO and JOP with additional perspective provided by the lead or corresponding author.

@ 2014 American Society of Clinical Oncology

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