Andrew J. Smith, MD, University of Toronto, Toronto, Canada
The purpose of the James IV Fellowship is to foster closer ties among surgeons of the world. The travelling fellowship not only promotes the exchange of surgical knowledge but is also meant to foster friendships. As the 2009 Canadian traveller, I sought to visit individuals and units with world-wide impact in colorectal cancer (CRC) management. Broadly, I had two specific aims. First, I sought out leaders who have achieved success leading change or improvement in CRC care across an entire state or country. Secondly, I was interested in the management of locally advanced and locally recurrent rectal cancer, a complex problem which is usually managed in specialized units. My visits delivered on this vision and exceeded my expectations in many respects. Upon reflection, I returned from my travels feeling alternately inspired and humbled by what I had seen and experienced. In the pages that follow I will detail the highlights of my travels with emphasis on the lessons learned and the ideas that have been sparked by the people I met. In addition, I have included reflection on my personal experience and what we have done collectively in Toronto and in Ontario. More importantly, I have speculated on what we ought to do in the future to emulate others who are excelling. How can we do better in caring for CRC patients? Furthermore, I seek to highlight some of the many individuals I encountered and the impact they had on my ideas and the success of my journey.
My travelling fellowship was divided into two parts, conducted in May and December 2009. Appendix 1 summarizes my James IV itinerary. I am also including some specific programs that my hosts provided. My travels took me to Sweden, England, Scotland, Australia and Hong Kong. At each stop I had a terrific experience and was greeted with wonderful hospitality from James IV members as well as many individuals who had only a passing familiarity with the Fellowship.
Stockholm
I began my journey in Sweden, a world leader in delivering high quality rectal cancer care. No country on earth has been more lauded for its success in countryĴwide quality improvement in rectal cancer surgery. In the 1980s, the Swedes were already world leaders in trials on radiation therapy in rectal cancer and led in the collection of national data on rectal cancer outcomes. At that time, they were confronted with evidence of deficiency in the surgical management of rectal cancer. Local recurrence rates and rates of permanent colostomy were judged to be too high. Importantly, the Swedish surgical community was able to focus on principles being promulgated by Professor Bill Heald from England and they widely implemented systematic training for the optimal method for rectal cancer surgery, total mesorectal excision (TME). Part of the Swedish success was due to the decision to reduce the number of surgeons who were performing rectal cancer surgery and also a decision to have all surgeons performing rectal cancer surgery specially trained to insure the quality of the work they were doing. The Swedes also developed, and continuously improve, a prospectively collected national database to monitor quality in rectal cancer care, focusing on the hospital as the unit of analysis.
In Stockholm, I had opportunity to see Swedish expertise first hand at the Karolinska Institute where I spent time with Professors Tjobjorn Holm and Dr. Anna Martling. I was privileged to be able to operate with Professor Holm on a locally advanced rectal cancer. Preoperatively, we spent time with Dr. Leonard Lundquist, a radiologist and international leader in MRI of rectal cancer. Dr. Lundquist, a soft spoken, thoughtful man, has been directly involved with the MERCURY group and is dedicated to optimizing the role of MRI in the management of rectal cancer. Dr. Lundquist reviewed beautiful images that predicted 2 suspicious pelvic side wall nodes that we subsequently resected as a part of the operation. The case went well and it was readily evident why Dr. Tjobjorn Holm is regarded as a master rectal cancer surgeon. In addition Tjobjorn is a delightful, humble man and we were able to discuss a range of issues germane to the performance of technically excellent rectal cancer surgery. Postoperatively, I watched as Tjobjorn entered information digitally into the Swedish Rectal Cancer registry. Interestingly, it is only recently that digital entry has been possible for the registry, indicating that substantial human resource was required for many years. This speaks to the importance that the Swedes have placed on the investment in accurate, prospectively collected data as a quality improvement tool. Dr. Martling spent time with me going over the structure of the database and discussing the elements collected. The elements were very similar to those of interest worldwide and it was noteworthy that it was an extensive range of information collected, requiring an appropriate investment of time. I was impressed.
The idea of precision surgery for rectal cancer surgery was not invented by Professor Heald or the Swedes. Similarly, the notion that prospectively collected data can be useful to drive quality is not especially novel or complex. Nonetheless, the Swedes deserve credit for translating knowledge into action and being able to implement processes to effect change on a national level as well as reporting on the effect of the changes. In many ways, the Swedes remain the gold standard by which we can judge ourselves when assessing quality on a large scale. It was evident from my travels that similar success is evolving in the UK and Australia where significant gains have been made in collecting timely, national data to successfully drive quality improvement.
Swedish success in CRC management undoubtedly has many root causes. One factor would appear to be the excellent spirit of collaboration between surgeons and other CRC experts. My visit coincided with the 10th Annual Karolinska Conference on Colorectal Cancer (Appendix 2). Because of this, I was able to formally and informally interact with some of the Swedish leaders responsible for the success Sweden has had, including Professors Lars Pahlman (surgery) and Bengt Glimelius (radiation oncology). Professor Soren Lauberg from Denmark also was present at the conference and reflected the close bond, similarity of thought as well as friendly competition among the Scandinavian countries. Additionally, there were keynote speakers from the UK at the conference, reflective of the special relationship that has existed between British opinion leaders in CRC and the Swedes. In many ways, the ideas of Britons such as Professors Heald (precision rectal cancer surgery), Phil Quirke (pathologists role in assessing quality in rectal cancer surgery) and Gina Brown (MRI to direct multimodal therapy in rectal cancer) have been embraced and implemented first in Sweden and other parts of Scandinavia in advance of widespread acceptance in the UK and the rest of the world. The Karolinska conference provided an opportunity to hear world leaders formally present ideas that I subsequently was able consolidate with personal visits with leading thinkers when I visited the UK.
In Ontario, we lag behind the Swedes in our efforts to have timely, accurate data to direct quality improvement for rectal cancer management. Nonetheless, we are heading in the right direction. First, we have high quality, evidence based guidelines on CRC management that have been developed through a rigorous process which includes input from practitioners across the province1. Furthermore, Cancer Care Ontario (CCO) data reflecting oncological metrics and performance are increasingly available and varied approaches to disseminating the data are being explored. To effect optimal quality improvement, our challenge will be to develop a way to obtain good quality data on a wider range of metrics relevant to oncologic and functional outcomes through improved information technology. The development of synoptic operative reports to complement advances in pathology reporting holds promise in this regard. Furthermore, data must be summarized and returned to users in a usable form to optimize knowledge translation and QI efforts. This point was emphasized on my Australian visit in December. To our credit in Ontario, we have successfully developed and nurtured a collegial, multidisciplinary community of practice which is a necessary underpinning for QI initiatives in any setting but especially in a vast, diverse province like Ontario.
Socially, I had a wonderful time interacting with the faculty at the Stockholm meeting. Operating and interacting informally with Professor Holm was the highlight of my visit. The sumptuous dinners with, among others, Anna Martling, Tjobjorn Holm, Sauren Lauberg and British James IV Traveller, Des Winter were memorable. Stockholm is beautiful and I particularly enjoyed the water based geography of the archipelago as well as my visit to the Vasa museum.
1Smith AJ, Driman D, Spithoff K, Hunter A, McLeod R, Simunovic M, Langer B. Guideline for optimization of colorectal cancer surgery and pathology. J Surg Onc 2010;101:5-12
Leeds
From Stockholm, I travelled to Leeds, England with the explicit purpose of meeting with Professor Phil Quirke. Professor Quirke is arguably the best known CRC pathologist in the world and continues to be a thought leader on colorectal cancer quality. He has emphasized the pathologists role in assessing circumferential radial margin status and total mesorectal excision (TME) quality. Additionally, Quirke has closely aligned his thinking and efforts with surgical and radiology experts.
Phil Quirke in his element
Phil met me early Saturday morning at my hotel and drove us to his home, a 19th century stone house, in the Yorkshire countryside. We went on a long, fast paced walk through the beautiful countryside and discussed key issues in CRC. The walk was memorable as Phil chronicled the years of his involvement in CRC care and emphasized opinions on key individuals in the evolution of CRC management and his thoughts on where we ought to focus our efforts in the coming years. Our walk concluded at the local pub where we had a few pints together with Judy, Phils wife who is an academic physician. We compared notes about the realities of having a family comprised of 2 busy doctors and active children. Later we sat in the garden before having dinner together with Phils family and the friends of his two teenagers. We talked about a range of issues in CRC and life in general.
It was interesting and instructive to hear Phil document his perspectives on CRC and the history of interaction of key individuals in the Swedish CRC establishment, Bill Heald and Gina Brown (radiology). The crucial areas of CRC management that we delved into most extensively were:
- The importance of the pathologist being rigorous in assessment of CRC specimens. In addition to good surgery, specific pathology techniques are required to evaluate the results of resection. Multidisciplinary teamwork, communication and a commitment to scrutinizing resection specimens in a way that is meaningful for audit and feedback is essential. For example, implementation of sophisticated preoperative decision-making, including state of the art MRI, leading to selective (as opposed to automatic) use of neoadjuvant therapy in T3 rectal cancers requires close scrutiny of the rate of positive resection margins. Once a unit is certain of the quality of resection specimens, preoperative strategies aimed at sparing toxic adjuvant radiation treatment for many patients is possible. Gina Browns leading work in radiological assessment of rectal cancer is important in this regard.
- The problem of high positive-CRM rate in patients undergoing APR. Many units have documented high rates of positive margins in APR patients. Quirke and others have suggested that this undesirable outcome is due to an inherent oncological inferiority of the traditional abdominoperineal excision procedure, which might be explained by the unique anatomical features of the low rectum and the lack of clearly defined anatomical excision planes. Although APR rates will ideally be low, when it is necessary, Quirke and others have convincingly made the case that cylindrical or extralevator APR is an improved way to approach this operation. This involves transferring the patient from the lithotomy position to the prone position intraoperatively to do the perineal dissection. The oncological results make this worthwhile although it is not an easy technique to master. In Sweden, I had watched Professor Holm perform the cylindrical operation at the Karolinska meeting and it was evident that pitfalls were possible, even in highly skilled hands.
- Quality assessment of surgical excisions in colon cancer (as opposed to rectal cancer). Hohenberger and colleagues in Erlangen, Germany have worked closely with Quirke to develop data showing the importance of standardized surgery for colonic cancer, including complete mesocolic excision and central ligation. In rectal cancer surgery, the TME technique is focused on an intact package of the tumour and its main lymphatic drainage. This concept can be translated into colon cancer surgery, as fascia akin to mesorectal fascia covers the mesocolon and its lymph nodes like envelopes. Analogous to the concept of TME for rectal cancer, Quirke has championed the concept of complete mesocolic excision (CME) for colonic cancer. This technique aims at the separation of the mesocolic from the parietal plane and true central ligation of the supplying arteries and draining veins right at the vascular root. Using this approach, the Germans have demonstrated decreased rates of local recurrence for colon cancer and also improved survival. Focus on the quality of colon cancer surgery promises to attract increasing attention in the coming years.
Having a pint with Phil & Judy
On Monday, I visited the Leeds Infirmary and St. James Hospital and the Leeds Institute for Molecular Medicine (LIMM). This stop was notable for attending the local DMT or tumour board. The Leeds unit reviews a wide range of CRC cases and has effective involvement the radiologists and pathologists. Medical oncology and Radiation oncology were also involved in this meeting which was as good as any I have ever seen. In Ontario, we have made a considerable effort to implement and improve tumour boards and I made a point of attending Tumour Board conferences throughout my travels. We have done increasingly well in Ontario at engaging multidisciplinary input into tumour boards and adopting the tumour board to diverse practice and geographic circumstances (e.g. videoconferencing in geographically large regions). My opinion is that universal availability of imaging studies at diverse sites and improved methods of recording tumour board discussions are areas deserving of particular attention in our system. Compared to some of the international sites that I visited, our IT shortcomings in Ontario are significant! A further highlight this day was the tour Phil Quirke and his research fellow Dr. Nick West provided at the LIMM. Phils work and publication record has had a major impact on international thought in CRC. In the laboratory, the Leeds group is exploring a wide range of cutting edge pathological techniques; I enjoyed the opportunity to listen to and comment on presentations by the research fellows.
In summary, surgical quality assurance is a central issue in the treatment of rectal cancer. The themes from the Leeds visit echoed those from Sweden. Increasingly good methods of quality assurance and improvement are being developed including prospective quality registries, synoptic operative reports, and pathology audits. It is imperative that measures of quality, other than volume, be implemented to audit our own practices, hospitals and regions with the goal of identifying issues that will improve outcomes for rectal cancer patients. In Ontario, we have recognized this challenge and the work led by CCO Surgical Oncology Program is consistent with achieving these goals. The James IV visit has helped consolidate my conviction that we are heading in the right direction in Ontario and also that the standard for excellence is being set increasingly high internationally.
After a day trip to the Bronte home in Haworth (I reread Wuthering Heights), I concluded my Leeds visit and then travelled to London.
Dr. Nick West and Colleague
London
After two days in Leeds, I flew to London to spend time at Imperial College and Basingstoke as well as to attend a meeting of the MERCURY group where long term data of the group was to be formally presented Professor Ara Darzis team at Imperial College arranged my itinerary in London. During my visit with Professor Darzi I had an opportunity to learn and reflect about cutting edge surgical technology, surgical education and surgical administrative leadership at the highest level.
Ara Darzi, who holds the Hamlyn Chair of Surgery, specializes in the field of minimally invasive and robot-assisted surgery and has pioneered many new techniques and technologies. My visit to Imperial coincided with the Imperial College Robotics Symposium. I was able to participate in many of the demonstrations and met with participants from a range of backgrounds. Topics covered at the conference included a wide spectrum of engineering and basic sciences research topics including Medical Image Computing, Biomedical Engineering, Clinical Safety, and Robotics. The technology presented was impressive and left one with the impression that the future is here! It is interesting to reflect just how far technology has advanced in the past decade and to muse about the challenges of implementing and adopting an increasing range of complex and expensive technology.
Surgical Education is a major focus in Professor Darzis unit as evidenced by the terrific facilities and significant human resource that they have devoted to this. I walked across Hyde Park from my hotel to St. Marys Hospital on a glorious English spring morning and visited with the surgical education research fellows, listened to research presentations and toured the unit. Many of the themes were familiar to me and it was heartening to hear the high regard with which the education research from our Department at the University of Toronto is held. Upon reflection, it is clear that much progress has been made worldwide in areas such as surgical simulation and evidence-based assessment of surgical skills. It seems increasingly clear that the next vista is to take the lessons learned and transform them into major changes in the curriculum for surgical training. We have begun a competency based training program in orthopedic surgery at the University of Toronto and it is quite likely that General Surgery will soon follow in this path. Thus, this aspect of the visit was highly relevant to me in my new role as University Divisional Chair at U of T. Professor Darzi has provided leadership at the highest level of healthcare administration. He was appointed Parliamentary Under-Secretary of State (Lords) at the Department of Health by the Prime Minister, Gordon Brown. He was created a life peer on 12 July 2007 as Baron Darzi of Denham, of Gerrards Cross in the County of Buckinghamshire. His appointment was part of Brown’s Government of all the talents. While in London I had an opportunity to be present at question period at the House of Lords. This was a special treat as Lord Darzi handled questions on key health policy questions about cancer during the session I attended.
As in Ontario, Lord Darzi has proposed a greater emphasis on quality in measuring NHS performance. Furthermore, his vision regarding a) patient centered care and b) care that is integrated over the continuum of the cancer journey is highly resonant with the direction we are pursuing in Ontario through the Disease Pathway Management initiative at Cancer Care Ontario. I have led the Colorectal Cancer DPM team in Ontario for the past 2 years. As with many themes encountered on my travels, there are common directions being pursued at the population level in the countries I visited. The main differences relate to the degree of resource devoted to the challenges and the extent of accomplishment of tangible goals.
Left – Lord Ara Darzi
While in London, I was allowed to attend the meeting at which data from the Mercury Study Group was presented to the international investigators involved in the study . The Mercury group, led by radiology Professor Gina Brown of the Royal Marsden Hospital, was created to assess the accuracy of preoperative MRIstaging of rectal cancer with magnetic resonance imaging to predict surgical circumferential resection margins. This group, comprised of investigators from 11 colorectal units in four European countries is notable because of its extensive, rigorous, prospective observational studies of rectal cancers treated by colorectal multidisciplinary teams over the past decade.
Left- Leonard Lundquist
Right – Gina Brown
In particular, the Mercury group has evaluated the accuracy of thin-section magnetic resonance (MR) imaging (in-plane resolution, 0.6 × 0.6 mm) in the preoperative assessment of the depth of extramural tumor infiltration, which is a major prognostic indicator in rectal cancer. Numerous lessons have been learned but it is increasingly clear that preoperative thin-section MR imaging accurately indicates the tumor stage of rectal cancer and depth of extramural tumor infiltration. It provides valuable information for identifying T3 tumors for preoperative adjuvant therapy in patients who are at high risk of failure of complete excision. This result is important because it allows for selective application of neoadjuvant radiation in rectal cancer patients. In Ontario and elsewhere in North America we have mostly pursued a strategy, supported by randomized trials, of applying radiation in all patients shown to have T3 or 4 or node positive rectal cancer. Proponents of the Mercury approach- and they are increasing in number world wide- have argued that this results in overtreatment of many patients. In an era of excellent preoperative MRI assessment, tumour board review and precision surgery we ought to be able to avoid radiation in many cases and thus spare the attendant morbidity that radiation causes in this patient group.
The conclusions of the Mercury group have profound implications and challenged me to question whether we ought to radically change direction in Ontario. Importantly, we have begun a major effort in Ontario (under the leadership of James IV member Robin McLeod) to optimally integrate radiologists and MRI into tumour boards across Ontario. This is an important first step before we can advocate for selective treatment of rectal cancer broadly. I came away from the visit in Sweden and England thinking that this ought to be the direction we ultimately pursue.
Basingstoke
No individual has had a bigger worldwide impact on improving rectal cancer surgery than Bill Heald. Although he did not invent the technique of total mesorectal excision (TME), he has done more than anyone to insure its implementation. As someone with a primary interest in rectal cancer, no visit to London would be complete without a making the pilgrimage to Basingstoke to visit Bill Healds unit.
Professor Bill Heald and Ms. Emma Hayward
It took an hour by train to get from Waterloo Station in central London to Basingstoke. There I was met by Emma, Bills assistant, and taken to the Pelican Centre. The formation of The Pelican Cancer Foundation in 2000 was based around the pioneering work At Pelican that day, Professor Heald and his colleague Professor Brendan Moran were running a course teaching TME and laparoscopic techniques to a group of community based surgeons. Bill showed me the unit while discussing an array of issues germane to modern rectal cancer surgery. He is delightfully engaging and enthusiastic about the topic and I benefitted from his unique telling of the history of the development of modern rectal cancer surgery as well as his opinions on the issues today. We talked about abdominoperineal resection, the evolution of preoperative decision making in rectal cancer as well as the difference of opinions on each side of the Atlantic Ocean regarding rectal cancer management.
Improved APR technique
With the introduction of improved surgical techniques such as TME and autonomic nerve preservation during the last two decades, a corresponding decrease in local recurrence rates and increase in overall survival of patients with rectal cancer has been observed. Despite the broad implementation of these techniques, local recurrence and survival after an abdominoperineal resection (APR) have not improved to the same degree as that seen after an anterior resection. This difference has been attributed, in part, to relative smaller tissue volumes around the tumour and higher rates of cancer at circumferential resection margins (CRM) after an APR compared with an anterior resection. Because of this, a number of investigators have called for a change in the technical approach of the APR. Heald is one of a group that has adopted and championed the use of the cylindrical (extended APR) to achieve better results in these cases.
The novelty of this approach and the additional time required will likely impair implementation of the cylindrical approach for a large number of surgeons. Nonetheless, Healds vision is that, in the modern era, APR should rarely be employed. When it is required, this superior technical approach ought to be done but confined to the practices of a relatively few surgeons. Better preoperative selection may allow for omission of neoadjuvant chemoradiotherapy.
A UK study showed that the rate of cancer being present at the surgical margins was significantly reduced in patients who underwent treatment following multidisciplinary team (MDT) discussion of pre-operative MRI scans. Patients with clear margins on MRI underwent surgery alone and patients with threatened margins received pre-operative treatment e.g. chemoradiotherapy to downsize the cancer prior to surgery. This approach is consistent with an increasingly individualized or refined approach to rectal cancer care. We have not yet evolved such a selective decision making process across Ontario, but the visit to Basingstoke convinced me we are heading in the correct direction. I spent a day feeling quite energized at Basingstoke. Ultimately it appeared that I was about to miss my train back to central London but Bill took me speedily, and with great aplomb in his new green Jaguar, to the station, arriving just in time!
Edinburgh
From London, I flew to Edinburgh where a superb program had been set up with the help of James IV member Professor James Garden. Once again, I met some terrific people and was alternately inspired and humbled by what I saw. In particular regard to colorectal cancer management, Scotland afforded me a chance to visit a highly functioning individual colorectal unit and to gain insight into the detailed workings of process changes meant to help an entire population.
In Edinburgh, colorectal services have been centralized into one unit at the Western General Hospital. Here there is a 100 bed unit with 11 colorectal surgeons under the leadership of Professor Malcolm Dunlop. I spent a significant time with Malcolm and his team. It was interesting to see how colorectal cancer management for a city of 1.1 million has been centralized. This arrangement has many benefits for quality assessment and improvement, education and research. The WGH has urology as well as colorectal surgery but does not, for example have hepatobiliary surgery. HPB is all contained at James Gardens unit at the Royal Infirmary. Although this system requires transfer of patients between units at times, it seems to work. The benefit of having concentration of activity in a single unit has been discussed worldwide and the group at WGH was enthusiastic about the arrangement.
I presented at the colorectal rounds at WGH on Colorectal Cancer Management in Ontario. One major difference is that we have not centralized or concentrated care of patients with colon or rectal cancer. This is in contrast to our approach to low volume, high complexity cases such as pancreatic, esophageal and thoracic cancer surgery which we have actively sought to, and successfully have, centralized. In Ontario, the vision is to insure that high volume, lower complexity cancers such as breast and colorectal are treated to a high standard in whichever size of unit practitioners are present. I believe that rectal cancer actually falls somewhere between these two groups. In Ontario, my own feeling is that we are seeing changes in referral patterns so that many surgeons, all of whom have lots of work, happily refer low rectal cancers to higher volume units. Upon reflection, I think there would be wisdom in us making efforts to have rectal cancer virtually managed in fewer units. Thus, it may not be that all cases are done in the same hospital in Toronto but that there would be strong practical connections between fewer units doing this type of work. I am increasingly convinced that there are benefits to nurturing a community of practice of surgeons for rectal cancer surgery. Increased accountability and collaborative efforts at quality assessment and improvement combined with development of ancillary medical services needed for optimal outcomes (e.g. stomal therapy) are but a few reasons to justify this approach.
The visit with Malcolm Dunlop had special resonance with me. Some years ago, my colleague and former teacher Steven Gallinger visited Malcolm and the visit resulted in collaborative research on the genetics of colorectal cancer. Both Steve and Malcolm have world class research labs. Because of my own work with Steven Gallinger on CRC genetics, it was a treat to visit with Malcolms extensive research team and to see the impressive work going on here. Malcolm and his fellows have routinely published in the highest impact journals such as Nature Genetics. Rather than counting the number of papers he has in these journals, Malcolm, a tireless type A academic surgeon, counts the number of times his teams work has been honoured by being on the cover of such journals! These covers are framed in the hallway of the research unit. In addition to research effort, I had a first hand look at the clinical work at WGH. Another day was spent working in the operating room with Malcolm who is a superb clinical surgeon.
Following a busy operative schedule, we went for a fine dinner with several colleagues and then we spent time (nearly too much time!) visiting bars in the old part of Edinburgh and sampling examples of Scotch whiskey. Of course, such convivial times provide an excellent opportunity to exchange thoughts and opinions on issues that are germane in both of our practices and countries.
In addition to the Western General, I had a chance to spend time at James Gardens unit at the Royal Infirmary. In addition to presenting rounds, I spent time with a range of students, fellows and consultants discussing a wide range of surgical issues. Of course, James Garden himself was a highlight. His hospitality to James IV Travellers is legendary and I experienced this personally. James was a delight to spend time with, discussing a myriad of issues. We discussed the history of the James IV Society and the Royal College. In addition, we compared the strengths and weaknesses, similarities and differences of our health care systems and academic institutions. It is interesting that Scotland has well thought out processes of care for CRC management yet still grapples with a high CRC mortality rate when compared to other developed countries. In addition to a time at the hospital, I was treated to fine dinners and left feeling grateful indeed for the time of Edinburgh.
Dinner at “The New Club” with Professors Garden and Parks (2004 James IV Traveller)
Dundee
Left – Professor Bob Steele
From Edinburgh, I travelled to Dundee where I was met by Professor Bob Steele. Bob has helped lead the organization of a state-wide colorectal cancer screening in Scotland. This is of particular interest to me because Ontario recently became the first of several Canadian provinces to adopt population-based CRC screening based on fecal occult blood testing and colonoscopy. This is similar to the Scottish program.
It was very instructive to visit the central processing unit for the Scottish program and to speak with the individuals involved in administering the program. In addition, it is clear that all aspects of the screening program are being thoughtfully researched and the lessons learned presented widely. My Canadian colleague, Linda Rabeneck, the architect of the Ontario program, has lauded the leadership of the Scots in CRC screening; the thoughtful discussions I had while visiting Dundee made clear why the Scottish program is succeeding in adoption of CRC screening. In Ontario, the CRC screening (by any method) rate before the implementation of the program was less than 20%. It is a positive development that Ontario now has a method to audit and feedback on rates of screening. Recent data demonstrate increased screening rates and it is our goal to exceed 50% screening of eligible patients by 2011. Quality assessment and improvement in CRC management is an area of active interest for CCO and the observations I made in Scotland inspired me that we ought to keep working diligently in this area if we are to keep pace! The bar is held high.
While visiting Dundee, I met with Sir Alfred Cuchieri and toured the impressive research unit, the Institute for Medical Science and Technology (IMSaT), that he has developed on the campus. A great deal of effort has been put into imaging research, an area of active interest in my institution of Sunnybrook at U of T. Furthermore, I toured the surgical skills centre at Dundee and observed the heightened focus and investment in simulation. From Dundee, I drove back to Edinburgh with Bob Steel and his wife who were en route to a conference in the US. I resolved that I have been too North American in my focus when choosing conferences. Bob invited me to consider a conference in Scotland next year. I shall strongly consider this! From Edinburgh I flew to London and then back to Toronto having completed the first half of my James IV travels.
Dinner at the home of Professor Garden was enhanced by wine from the vineyard of James IV Association of Surgeons President Murray Brennan
Sydney
In late November 2009, I travelled to Sydney, Australia. Arrangements had been made for me to stay in an apartment hotel in Camperdown, close to Newtown. Newtown is remarkable for an eclectic blend of cultures, many nice eateries along King Street, the University of Sydney and the Royal Prince Alfred Hospital. You can see downtown and the harbour from the hilltop.
Left-Bruce Barraclough Right-Cliff Hughes
On my first day, I visited the Clinical Excellence Commission in downtown Sydney with Professors Bruce Barraclough and Cliff Hughes. Bruce, a former breast and endocrine surgeon and Cliff, a former cardiac surgeon, are contemporaries of James IV Association President Murray Brennan, a major mentor of mine. They serve as the Chairman and Chief Executive Officer respectively of the Commission which was founded in 2005. The mission of the commission is to build confidence in healthcare in NSW by making it demonstrably better and safer for patients and a more rewarding workplace for healthcare workers. The CECs vision is to be a driving force providing the people of NSW with assurance of improvement in the safety and quality of health care. I chatted at length with the 2 men at the CEC offices, located in a tony bank building 5 minutes walk from the Sydney harbour bridge. I was struck by the dual commitment to patient safety and also insuring that the healthcare workers were treated in a positive way so as to make it a positive experience working in healthcare.
Patient safety is the prime directive and collection of good data is a central tool involved in this. I met many members of the CEC team. Notably there seemed to be a lot of bright physician researchers working right on the site. In talking to the members of the team there was obvious attention to insuring that good data was collected but also that it was presented in an attractive, useful way. Effort has been directed at studying the science of data presentation. Andre Jenkins, the Director of Information Management was particularly thoughtful about this and recommended me to Edward Tuftes book Beautiful Evidence. He made the compelling case that how data is presented will have a big impact on how useful it is and indeed whether or not it actually is used. As I reflect and compare to our CCO foci, I left feeling that there was a similar degree of rigor applied to data presentation in this unit as that which we apply to developing guidelines with our PEBC partners at McMaster University. Professor Hughes indicated that there was less attention in their unit on guideline development; rather they were content to rely on other well done evidence based guidelines and instead focus on effecting change. The wisdom of this approach is noteworthy! Implementation of change is a tough challenge. Data is important, but communication of that data is crucial. We talked about the different approaches to communicating and looking at the data. Bundles for central line infection were an example. Tony Burrell spent time with me on this topic.
Mark Zacka and I discussed the M and M conference. It is not clear what an ideal M and M conference looks like but basics like having identifiable minutes, recommendations, follow- up plans were discussed. What is the optimal frequency of the conference? How can you make turnaround rapid for recommendations?
Other projects we discussed were related to blood transfusion, hand hygiene and recognizing the deteriorating patient. This latter topic is a major investment for the CEC and it is clear a great deal of work is being done to engage key opinion leaders throughout the state to make it successfully adopted. They explained the between the flags approach to me and gave me a copy of the new, soon to be state-wide mandated, SAGO vitals charts that give automatic triggers for healthcare workers to call for help. It is clear that there have already been measurable success stories related to blood transfusion metrics and hand hygiene.
I was impressed by the emphasis on the worker in healthcare. A happy worker is an effective worker and Happy staff = happy patients. I was recommended to read the book If Disney ran your Hospital (Fred Lee) and we talked about the hierarchy of insuring safe care, courteous care, show and efficiency.
We talked about the Institute of Medicines six dimensions of quality care (safe, effective, patient-centered, timely efficient, equitable) and reflected on different approaches throughout the world. In addition, we discussed the writing of James Gilmore and Joseph Pine about customer experience and how this had relevance to modern healthcare. In summary, I viewed the day as a lesson in the NSW approach to knowledge translation. Effort has been applied to do increasingly excellent audit and feedback. This has been shown in a Cochrane review to be partially effective in driving improvement. In addition though, effort is applied to developing communities of practice and opinion leadership which are other knowledge translation approaches.
A central purpose of my visit to Sydney was to see Michael Solomons unit at Royal Prince Alfred Hospital. Michael is an Aussie who went to medical school in Ireland and did colorectal surgery fellowship training in Toronto with Zane Cohen and Robin McLeod. Royal Prince Alfred is a major teaching hospital associated with the University of Sydney. Interestingly, it is covered in a reality TV show called RPA. Solomon and his colleagues perform a large and increasing volume of extensive pelvic surgery for locally advanced and recurrent colorectal cancer. Together with 4 partners, he has led the development of a multidisciplinary program with a country-wide catchment area. They are now garnering additional government funding to support this burgeoning program. The team involves close relationships with urology, plastics and orthopaedic colleagues as well as ample interprofessional supports. Together with the urologists and the General Surgeons we discussed many issues and nuances of this challenging problem.
Austin KK, Solomon MJ. Pelvic exenteration with en bloc iliac vessel resection for lateral pelvic wall involvement. Dis Colon Rectum 2009 Jul; 52 (7):1223-33
It was especially rewarding to scrub on cases while at RPA. Michael had arranged for a series of complex pelvic cancer cases to be on while I was visiting. Cases included a local recurrence of CRC in a patient who had a previous exenteration who now had a solitary mass associated with his colon conduit, and two locally advanced primary rectal cancers, one with significant sacral involvement. I was able to scrub on these cases and enjoyed a rich experience in discussing this complex problem. We spoke about issues germane to locally recurrent rectal cancer and in particular the important work on the technical aspects of pelvic cancer surgery. Michaels paper on pelvic exenteration with en bloc iliac vessel resection for lateral pelvic wall involvement has influenced my own approach to this disease and it was terrific to have a first hand look at the technique.
Lateral pelvic recurrence of rectal cancer is considered a poor prognostic variable and a relative contraindication to surgery because of the difficulty in achieving clear margins. Solomon outlined a surgical approach to lateral pelvic sidewall involvement and has assessed the oncologic and long-term outcomes. Careful preoperative radiologic assessment and a multidisciplinary approach are paramount to achieving clear margins1. We also spent time in Michaels SOuRCe unit (Surgical Outcomes Resource Centre). This is a well funded, well staffed unit that drives the research enterprise for his team. Michael conceived and drove the development of this unit. In addition, he has created a Masters in Surgery program which has exceed expectations and enrolled numerous surgeons from across the country. I marvelled at the scope and success of Michaels research team. At Sunnybrook we are about to appoint a new chair of surgical oncology research. The Hanna Family Chair is richly endowed and the expectation is that the holder with catalyze further development in our Surgical Oncology led research. SOuRCe provides an excellent model to emulate. Close collaboration with full time scientists and an emphasis on clinical epidemiology were notable facets of the research program.
In addition to the visit with Michael, I spent time at the Prince of Wales Hospital, associated with University of New South Wales. There I rounded and exchanged ideas with the colorectal team including Drs. Shing Wong and Graham Newstead. Shing is a young attending who trained with Michael Solomon. He is a laparoscopic enthusiast and did 2 cases while I was there. In addition, Shing spent time helping me understand the Australian version of a blended public and private health care system. Canada is one of 3 nations on earth that has an exclusively public system. In contrast, all of the countries I visited as part of the JIV Fellowship have a blended system. My impression as to how well things worked varied between countries.
Dr. Shing Wong, Graham Newstead and colleagues
Nowhere did I detect greater happiness with the state of affairs than in Australia. More than one physician explained to me that the public and private system seem to push each other. If one improves or adopts a new, improved practice it seems to nudge the other to improve. Wait times or egregious shortcomings seemed to be nonĴexistent in either system. I left Australia ultimately feeling that this system, with built-in competition, seemed to work well. The major objection that resonates with me when contemplating adopting this in Canada relates to our proximity to the USA. Australia is relatively isolated. In contrast, we exist in close proximity, geographically and otherwise, to the US and one must speculate that it is possible that some of the ills that plague the US healthcare system might infect any private system that we implemented in Canada. Nonetheless, my visit to Australia in particular incited a renewed interest in considering whether we would be better served by a blended system. 
Graham Newstead was a terrific host. He is head of the Colorectal Surgical Society of Australia and New Zealand. After rounding with the colorectal team, Graham took me on a drive to explore the various beaches on the coast of Sydney. We went for an enjoyable lunch and discussed a wide variety of topics including Jewish history in Australia, the surgical life, exchange of fellows across our countries and the relevance of societies such as CSSANZ. My impression is that we have a long history of having Australian fellows in Canada and North America but a lesser record of exchange in the opposite direction. Michael Solomon for example trained as a fellow in the colorectal fellowship at University of Toronto. Graham trained at the Cleveland Clinic. I am hopeful that the relationships I was able to build on the James IV travels will help catalyze increased exchange between our 2 countries. The superb work in pelvic cancer at RPA and the highly advanced laparoscopic unit at Brisbane would provide enormous enrichment for our trainees and our programs.
Another notable moment of my visit with Graham Newstead occurred when we discussed my travels to date and plans for the final weeks. It is well known that the James IV designation is instrumental in opening doors wherever you go. It is difficult and perhaps undesirable to plan every last detail before travelling. This was no exception. Graham alerted me that Russell Stitz was doing his last case in Brisbane at the Royal Brisbane Hospital. Graham made some calls to have my itinerary changed and also to connect me with Andrew Stevenson at Brisbane. This would prove to be a key connection. Although Andrew was quite unaware of the James IV fellowship, he would prove to be a superb resource and host when I went to Brisbane.
In addition to the enriching academic aspects of my stay in Sydney, I had a memorable time socially. Dinner at the Australia Club with Ted Reeve and Bruce Barraclough was a highlight. I went from a major pelvic case at RPA to join Professors Barraclough and Reeve and their wives. We had a wonderful dinner chatting about people and surgical history. It was especially nice for me to hear these men reflect on Murray Brennan, one of my most significant surgical mentors. Murrays journey from surgical trainee to the pinnacle of American and worldwide surgery is well known to me but it was pleasurable for me to hear these Antipodeans reflect on this in a casual way. It is often said, that one of the great aspects of academic surgery is the opportunities it affords you to meet new people from around the world and to share ideas and reflect on common experiences. This certainly was the case at dinner. After dinner I went back to the RPA where Michael and the team were finishing the sacrectomy.
A further highlight was the weekend I spent in Sydney. Michaels wife had to suddenly leave town to address a family matter and I was conscripted to join Michael at his summer home on one of Sydneys beautiful north beaches. Thus I joined Michael, his 14 year old daughter and 7 of her friends and spent a relaxing weekend boating, swimming, and hanging out reading and watching Australia edge the West Indies in cricket. Michael tried to teach me to surf but, in truth, the picture here is about as close as I got to resembling a surfer!
Later the following week, I would join Michael and his wife for dinner at their Sydney home and it was pleasant to reflect on many aspects of life including our common Toronto training and the impact such mentors as Zane Cohen and Robin McLeod have had on our careers.
Brisbane
I flew to Brisbane in time to join a small laparoscopic course at the Royal Brisbane Hospital. In addition, my visit coincided with the last operation that Russell Stitz was doing at the Royal Brisbane. Professor Stitz impact on laparoscopic surgery and development of a world leading unit was evident. It was inspiring to hear that Russell came to laparoscopy late in his career. He did not adopt it until the late 80s when he was in his mid 40s. Nonetheless, he was able to become a world leader in the field. He gravitated to laparoscopic colon work and accelerated forward over the next 2 decades. In addition he has surrounded himself with younger experts such as John Lumley and Andrew Stevenson. Quite simply, these were the most capable laparoscopic rectal surgeons I have ever seen. The work of these surgeons in both the public and private hospitals was very inspiring and gave me a full sense of where we need to head in Toronto. The visit to Brisbane gave me an opportunity to see the public system and private system in action, working seemingly in harmony. Facilities at the public hospital Royal Brisbane are state of the art (see picture below) although it is clear that much of Dr. Stevensons clinical work occurs at the highly efficient private hospital.
As with all of my stops, I enjoyed terrific hospitality. In Brisbane, Andrew Stevenson and his family invited me to dinner and we discussed a myriad of topics ranging from MIS surgery and colorectal cancer referral patterns to the Stevensons passion for skiing in the Canadian Rockies.
Hong Kong
Professors Sheung-tat Fan and Wai Lun Law arranged my program in Hong Kong at the Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital. I had met Professor Law previously and we had dinner several years ago in Toronto. I was able to extensively discuss and reflect upon the evolution of rectal cancer surgery while in Hong Kong.
Dr. Law performs a robotic proctectomy
Professor Law has been a leader in the field and contributed significantly to the literature in the area. The field is moving quickly. Increasing evidence on the success of laparoscopic resection in colorectal diseases exists. Nonetheless, some clinicians remain skeptical about the application of laparoscopic resection in rectal cancer, although it may benefit patients by resulting in early return of bowel function, reduced postoperative pain, and shorter hospital stay. Rectal cancer surgery is regarded as a technically demanding procedure. However, many colorectal surgeons who practice laparoscopic surgery have appreciated that the improved optics of laparoscopy can provide a much better view of the pelvis, and the Heald principle of meticulous sharp dissection for total mesorectal excision can be performed without compromise. The visit to Hong Kong allowed interchange about laparoscopy and robotic rectal surgery. Dr. Law performed rectal resections by both approaches during my visit.
The visit to Hong Kong held special meaning for me because one of my earliest teachers, and later partners, Hensley Beans Miller, did a fellowship there under the direction of G. B. Ong. Dr. Miller retired a few years ago and Dr. Ong died around the same time. Dr. Miller sent me some poignant reflections by email while I was travelling recounting the significant impact his time in HK had made during his formative years. In addition, he fondly recalled Professor Ongs prodigious ability as a hiker. I was given an opportunity to give surgical rounds and was struck by the highly formal tone of the proceedings as attending and trainees gathered. It was very impressive. My hosts provided me with an excellent overview of the history of Hong Kong University and its impact on academic surgery.
As with my other stops, I had opportunity to reflect on the healthcare system in Hong Kong. Hong Kong has a blended public and private system. Unlike some of the other countries, there seemed to be evidence of shortcomings with the public system and my hosts reported on prodigious wait times, sometimes measured in years, for surgery for benign disease in the public system. As with all nations, healthcare is often in the news in Hong Kong as evidenced by this headline in the local paper during my visit:
I had a very busy and interesting program while in Hong Kong. Many research and clinical trainees gave talks which I enjoyed discussing. I particularly enjoyed the presentation on lymph node assessment in colorectal cancer, a topic that continues to hold interest.
Hong Kong was the final stop on my James IV travels. It was an added treat that my wife, Sharon Sharir, a Urologic Oncologist, was able to join me in Hong Kong. Together we enjoyed some sumptuous meals and convivial times with our Hong Kong hosts including Professor Ronnie T.P. Poon (2007 James IV Traveller). As always, it was a pleasure to be able to reflect on the importance and relevance of the James IV Travelling Fellowship.
Final Thoughts
Above all, I am extraordinarily grateful for having had the opportunity to be a James IV Traveller. The experience will be forever etched in my mind as a wonderful part of an academic surgical career.
I achieved my goal of learning more about colorectal cancer care. At all of the sites I enjoyed the exchange of ideas about the specific management issues relevant to colorectal cancer. In particular, I was struck by the pace of evolution of Minimally Invasive Surgery. Recurrent and locally advanced tumours of the pelvis are a particular clinical interest of mine and I benefitted from discussing this in different countries. Beyond that, the organization of healthcare systems has a significant impact on colorectal cancer care. There is an increasing emphasis on quality improvement in all of the healthcare systems that I visited and it was interesting to reflect on, and observe first- hand, the strengths and weaknesses of the various systems. Certainly, there are things we do very well in Toronto and Ontario while, at the same time, we have much to learn from our colleagues around the world.
In addition to being enriched by the information I gleaned in the various units, I would echo the sentiment that James IV Travellers continually pass on. That is, the James IV Travelling Fellowship is a wonderful way to nurture relationships with extraordinary colleagues in different practice settings throughout the world. It really is a small, collegial community that we are part of globally and it was a terrific opportunity to meet like-minded practitioners and to reflect on our common passion for surgery. Once again, I was thrilled to have been selected as the James IV Traveller for Canada and I would like to express my utmost gratitude to the Association for having provided this once in a lifetime experience.
Appendix
ABBREVIATED ITINERARY – DR. ANDY SMITH
EVENT: JAMES IV TRAVELING FELLOWSHIP SWEDEN AND U.K. – LEG 1
DEPARTURE DATE: MAY 10, 2009
RETURN DATE: MAY 30, 2009
Stockholm, Sweden
(Anna Martling, Torbjorn Holm, Leonard Lundquist)
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Karolinska – operate with T. Holm
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10th Annual Karolinska Conference on Colorectal Cancer
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Vasa Museum
Leeds, England
(Phil Quirke, Gina Brown)
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Day trip to home of Phil Quirke
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Leed Infirmary and St. James Hospital tour
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Leeds Institute for Molecular Medicine (LIMM) tour
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Day trip to Bronte home in Haworth
London, England
(Prof. Heald, Prof. Darzi, Gina Brown, JJ Smith)
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Imperial College Robotics symposium with Prof. Darzi
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House of Lords visit with Prof. Darzi
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Dinner with Prof. Darzi and others
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Basingstoke – Pelican Cancer Foundation with Bill Heald
o A tour of the surgical department at St Mary’s Hospital
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Mercury Follow-up symposium with Gina Brown/Prof. Darzi/Prof. Heald
Edinburgh, Scotland
(O.J. Garden, Malcolm Dunlop)
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Western General Hospital tour
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Present at Colorectal Rounds
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Operating room with Malcolm Dunlop
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Dinner with Prof. Dunlop and colleagues
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Royal Infirmary tour
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Dinners with Prof. Garden and colleagues
Dundee, Scotland
(Prof. Bob Steele, Sir Alfred Cuchieri)
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Scottish Bowel Screening Centre tour
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Institute for Medical Science & Technology (IMSaT) tour
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