The Unintended Consequences of Centralisation of Colon Cancer Surgery

Written by Mr Desmond Toomey MD, FRCSI, Consultant General & Colorectal Surgeon – Regional Hospital Mullingar & Mater Misericordiae University Hospital; UCD Associate Clinical Professor; RCSI (Hon) Clinical Senior Lecturer

Centralisation of cancer care into specific Model IV hospitals with the appropriate resources, skillsets, equipment and ethos improves outcomes and survival. In Ireland, rectal cancer was centralised to the eight cancer centres a decade ago and the benefits for this cohort of patients is evident. It has been proposed that colon cancer surgery should be similarly centralised. Would this colon cancer policy be suitable for the Irish system or would it have unintended, negative consequences for other patients and Irish surgery? Could a colon cancer plan be tailored with lessons learned from rectal cancer and our experiences with hybrid working / colocation during the pandemic?

The population of colorectal patients is far greater than just those with cancer. There are many other colorectal diseases, such as inflammatory bowel disease and diverticular disease that dramatically impact on quality of life, often at a younger age and over a more chronic period. There is significant overlap between the skillsets for colorectal cancer surgery and complex benign disease. Surgery for these benign conditions can be more technically challenging than many cancer cases and requires skilled, experienced surgeons and multidisciplinary input. The “C word” inspires such fear in people that cancer care tops the political and medical agendas despite the sustained burden of IBD on economic and societal metrics. Are geographically rigid, cancer centric policies detrimental to care for other non cancer patients and possibly the health system as a whole?

In the Irish public healthcare system, services commonly have to be developed before resources are allocated – the cart is put before the horse. Consultants are being appointed and increasing amounts of cancer work are being done in the eight cancer centres. However, the beds, theatres and other resources lag behind and it is difficult to see how the necessary development will be financed and staff recruited. As increasing numbers of cancer patients are centralised into these eight hospitals we already see the knock on detrimental effects on other patients, unscheduled care and the trolley count.

If we cannot resource these Model IV cancer centres sufficiently then perhaps we should explore other options and capacity. We learned during the COVID pandemic to utilise remote and hybrid working models and this experience could be extrapolated to the cancer treatment system. Is the value of the cancer centre, particularly for the less complex cancer work, in the locating of these staff in a single geographical location or is it joint care and decision making from a cohesive team of high volume specialists? If the latter is true then why does all the surgery need to be performed in the same building? Appropriate consultant surgeons should be collocated across Model III & IV hospitals, should be an integral part of the MDT and, subject to measures of the quality of their treatment, should be trusted to treat their patients in the right place at the right time making the most efficient uses of all the resources available.

There is a crisis in surgical recruitment and retention in Model III hospitals, in part due to the relocation of services to the cancer centres. Further geographical centralisation will likely exacerbate the draining of surgeons with complex colorectal skillsets away from these hospitals. This impacts on both cancer and non cancer colorectal patients. Up to 30% of colon cancers present as an emergency needing urgent surgery or considered decision making by a surgical oncologist. These are some of the most challenging cases and commonly present outside of the eight cancer centres. In the Model III hospital, the presence of a colorectal surgeon allows expedient, appropriate, surgical oncological intervention without the need to transfer to an already overloaded Model IV where the oncall surgeon may not even be colorectal. The skill drain also affects the non malignant cases who present emergently, who encounter intestinal difficulty during other procedures or abdominal complications while admitted under medical and other specialities. These patients have an equal right to the appropriate expertise and there are numerous examples of poor outcomes in such cases where the appropriate expertise was not available.

In my experience most patients would prefer not to travel long distances for care if an equivalent service was available locally. This in itself should not have a major bearing on policy decisions in a resource poor environment. However, even when patients do travel for treatment in a cancer centre under the current system they frequently present back to the Model III if they encounter difficulties after stepdown or discharge. If the Model III hospital becomes downgraded by attrition of skilled staff then these complicated patients cannot be managed locally and face delay in their care with the associated detrimental outcomes. This staff attrition also prevents complex benign patients from accessing surgery locally and they are then de facto centralised to the cancer centres where they struggle to compete for resources.

If as a country and a health service we were to start again, then we would build the appropriate hospitals in the appropriate places with room and resources for all. We are not in that situation. Centralisation of care is the correct thing to do but are we trying to ram a square peg into a round hole? Unless we can adequately resource our Model IV hospitals to service the needs of all of our colorectal patients then we should tailor our centralisation policy to maximally utilise the existing resources that are available to the benefit of all of our patients.

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