The long learning curve of gynaecological cancer surgery: an argument for centralisation

OBJECTIVE: To study the development of surgical performance of an unchanging surgical team over 13 years. DESIGN: Prospective, observational study. SETTING: A university hospital, The Netherlands. PARTICIPANTS: Three hundred and eight women who underwent surgical treatment for early cervical cancer. INTERVENTIONS: Radical hysterectomy and pelvic lymphadenectomy between 1 January 1984 and 31 December 1996. RESULTS: The surgical procedure and indication for treatment remained unchanged during the study period. This applied also to the surgical team. The women's age increased significantly during the study years, as was the case with the number of nodes removed. The depth of infiltration by the tumour increased steadily throughout the study, but this failed to reach statistical significance. The distribution of FIGO stages, percentage of positive lymph nodes, radicality of the surgical margins and post-operative morbidity remained the same. Overall, the five year survival rate was 83%; for women with negative nodes 91%, and for women with positive nodes 53%. Survival tended to improve during the course of the study, but this was not statistically significant. Blood loss during surgery decreased consistently during the whole study period, from a mean of 1,515 mL at the beginning of the study to a mean of 1,071 mL at the end (P <0.0001). The operating time also diminished significantly by 8 minutes per year (P <0.0001). In 1985 the average operating time was 270 minutes, compared with 187 minutes in 1996. CONCLUSIONS: These findings indicate that it takes a long time to acquire skill in the surgical treatment of early cervical cancer. Centralisation of relatively infrequent operations for cancer should be encouraged