Volume 195 - Issue 11
Distance to the closest radiotherapy facility and survival after a diagnosis of rectal cancer in Queensland
Author: Michael D Coory
Med J Aust 2011; 195 (11): 661-662. || doi: 10.5694/mja11.11213
Published online: 12 December 2011
Published online: 12 December 2011
To the Editor: The article by Baade and colleagues1 is valuable, but further research on clinical interventions and outcomes, as well as collaboration with other stakeholders, is required to improve care.
The main result of Baade et al’s analysis of Queensland-wide population-based data was that overall survival of patients with rectal cancer decreases as distance from radiotherapy services increases. The article is important because it documents variation in overall survival of patients with rectal cancer according to where they live. Documenting outcome variation is a necessary first step along the path to improving service delivery. As Baade et al discuss, the next step is to identify the cause(s) of the variation.
This next step could usefully investigate the quality of surgery. Non-randomised studies have shown that high-quality surgery with total mesorectal excision (TME) improves overall survival in patients with rectal cancer.2 In contrast, neoadjuvant or adjuvant radiotherapy has not yet been shown to improve overall survival, although, as Baade et al note, randomised controlled trials (RCTs) have shown reduced rates of local recurrence, with a corresponding improvement in disease-free survival.1
However, some experts have questioned the extent to which decreases in local recurrence rates, as measured in RCTs, lead to improvements in overall survival (given high-quality TME).3,4 Also, radiotherapy is not without risk (eg, sexual dysfunction, incontinence, bowel obstruction). Whether an individual patient (in consultation with his or her doctor) decides to have radiotherapy will depend on how he or she judges the trade-off between benefits and harms.4
In other words, identifying the cause(s) of variation in overall survival for patients with rectal cancer will not be easy because of the subtleties of everyday clinical practice. Moreover, the subsequent and final step in the pathway — implementing interventions to reduce unwarranted variation — is also not easy. We could make faster progress if there were closer collaboration among researchers in universities or institutes (who can generate new knowledge), budget holders in government (who can do something about modifiable causes of variation), and clinicians (who will be at the leading edge of any changes).
A large amount of predictable health-services research is needed, and collaboration among researchers, budget holders and clinicians is as important as developing investigator-initiated ideas for research projects. Faster optimisation of service delivery could be achieved if budget holders were less suspicious of the motives of research groups,5 and if research groups put more emphasis on asking budget holders, “How can we help?”
Competing interests
No relevant disclosures.
References
- Baade PD, Dasgupta P, Aitken JF, Turrell G. Distance to the closest radiotherapy facility and survival after a diagnosis of rectal cancer in Queensland. Med J Aust 2011; 195: 350-354. 0_CHDICFCE
- Martling AL, Holm T, Rutqvist LE, et al. Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm. Stockholm Colorectal Cancer Study Group, Basingstoke Bowel Cancer Research Project. Lancet 2000; 356: 93-96. 0_i1142877
- Meagher AP, Ward RL. Current evidence does not support routine adjuvant radiotherapy for rectal cancer. ANZ J Surg 2002; 72: 835-840. 0_i1142879
- Madoff RD. Rectal cancer: optimum treatment leads to optimum results. Lancet 2009; 373: 790-792. 0_CBBDIBBG
- Holman CD. An end to suppressing public health information. Med J Aust 2008; 188: 435-436. 0_CBBJAJGF