Malignancy load on general surgeons: the need to change the general surgical training curriculum

Malignancy load on general surgeons: the need to change the general surgical training curriculum

European Journal of Surgical Oncology 1999; 25: 306–310 FOR DEBATE Malignancy load on general surgeons: the need to change the general surgical trai...

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European Journal of Surgical Oncology 1999; 25: 306–310

FOR DEBATE

Malignancy load on general surgeons: the need to change the general surgical training curriculum M. Pandey∗, C. Varghese†, A. Mathew†, M. K. Nair‡, A. Gautam¶ and V. K. Shukla¶ Divisions of ∗Surgical Oncology, †Epidemiology and Clinical Research and ‡Radiation Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala and ¶Department of Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India

Aims: With the advent of newer diagnostic modalities more and more cancer patients are being diagnosed each year. The rising detection rate and greater public awareness have immensely increased the load on already overburdened and increasingly fewer surgical oncology units. As a result a large number of these cases are being dealt with by general surgeons. Methods: We have used a retrospective case count from a single surgical unit, based at the University Hospital, Varanasi, and data from the Hospital Based Cancer Registry (HBCR), Regional Cancer Centre (RCC), Trivandrum, from 1990 to 1994, to define the malignancy load on general surgical units and to define the number and sites of malignancies commonly encountered by general surgeons. Results: A total of 28,136 patients were registered at the RCC, the commonest malignancy being oral cavity (16.35%), followed by lung (12.7%) and breast (23.8%) among men and women, respectively. On the other hand, in the 2123 patients with malignancy who were treated at the Medical College (MCH) in Trivandrum, the commonest sites encountered were stomach (11.68%), thyroid (10.31%) and colorectal (9.5%). This was quite similar to the frequencies observed at Varanasi, where colorectal cancer constituted 10.26% and stomach 6.98%. Only 13.6% of the patients reporting to RCC were treated by surgery alone or in combination, while this figure was 48.1% for MCH. Similarly 2056 (7.3%) patients presenting to RCC had completed treatment prior to being referred to RCC; almost all of these patients were treated by surgery at referral institutions by general surgeons. Conclusions: The results clearly indicate an increased demand on the surgical oncology units, or alternatively an urgent need to redefine the postgraduate curriculum for the better training of general surgeons in understanding malignant disease, especially in the developing countries. We recommend a minimum of 6 months training in surgical oncology for each general surgery postgraduate. Key words: surgical audit; malignancy; cancer; health management; education.

Introduction With the inevitable and desirable progression towards specialization and superspecialization, the surgeon may learn fewer operative procedures than his predecessors, though these include techniques that are far more complex.1 With increasing patient awareness of malignant diseases, commonly called cancers, more and more patients are being detected and this has led to an increased load on fewer, hard-pressed and overburdened oncology units, available

Correspondence to: Dr Manoj Pandey, MS, Assistant Professor, Division of Surgical Oncology, Regional Cancer Centre, Medical College P.O., Thiruvananthapuram, 695 011, India. Fax: +91 47144 74 54/44 13 94; E-mail: [email protected] 0748–7983/99/030306+05 $12.00/0

only at the apex medical institutions of a country. This increasing load has been shared, to a great extent, by general surgery and general medicine units. In developing countries such as India, the situation is far more grim. Surgical oncology as a speciality is only available at select centres and most malignant diseases are still being managed by general surgeons. The MCh training in surgical oncology was previously available at only four centres in India. One of these is now derecognized and thus the MCh is now available at only three centres. The Medical Council of India (MCI) does not recognize the MCh (Surgical Oncology) training programme and hence in the MCI list detailing 36 specialities and superspecialities, surgical oncology is not mentioned.2 Presently, the training curriculum for MS (General Surgery) prescribes 2 months of rotatory training in surgical oncology and other  1999 W.B. Saunders Company Limited

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Malignancy load and general surgeons superspecialities. As most of the medical colleges in India do not offer surgical oncology, the postgraduates from these centres forego this training. Of the five Medical Colleges in Kerala, postgraduates of only one (Trivandrum) come to the Regional Cancer Centre (RCC), Trivandrum for 6 weeks’ training in surgical oncology. In the other four Colleges there is no provision for such training. Similarly, in the state of Uttar Pradesh (UP), where there are 11 Medical Colleges, nine of which have an MS (General Surgery) curriculum, only two (King George Medical College, Lucknow and the Institute of Medical Sciences, Varanasi) provide 2 months’ training in surgical oncology to postgraduates. The situation in other states is similar or even worse. On average, only 10–20% of general surgery trainees have exposure to surgical oncology before they are awarded their Master’s degree in surgery. Here, we use case counts to define the malignancy load on a single general surgical unit, based at the University Hospital, Varanasi, and to compare it with load on surgical units based at MCH, TVM and a specialized unit in RCC.

Patients and methods Under the National Cancer Control Programme (NCCP) in India, 11 radiotherapy departments, mostly based in various state capitals, were identified and upgraded to Regional Cancer Centres. The facilities were expanded and various other departments such as Surgical Oncology, Medical Oncology, Epidemiology, Pathology, Community Oncology, Radiodiagnosis and Imaging and Cancer Research divisions were later added. The Department of Radiotherapy, Medical College Hospital (MCH), Trivandrum (TVM), was upgraded to RCC, Trivandrum in 1982. RCC is a state-of-the-art superspeciality hospital with a present bed strength of 300. It caters for a population of 38 million in the states of Kerala and adjoining Tamilnadu. It maintains two population-based registries (PBCR) and one hospital-based cancer registry (HBCR), under the National Cancer Registry Program. All three registries have separate staff and are supervised by the Department of Epidemiology and Clinical Studies. The HBCR registers about 9000 new cases each year. All descriptive and clinical data are entered into a central mainframe computer using Ingress software (Ingress Corp. California, USA), which can be easily accessed from any of the terminals. The Division of Surgical Oncology has 30 beds and operates 15 tables per week. It has a staff strength of 10: two Associate Professors; five Assistant Professors; and three Lecturers. This division performs about 700 major and 800 minor diagnostic and therapeutic procedures as well as about 200 endoscopic procedures. The data in the present paper are from the HBCR3–5 and variables such as prior treatment and treatment at our centres were recorded. The University Hospital at Varanasi is an apex 1000-bed superspeciality hospital, providing tertiary care to referral as well as fresh cases. The hospital has a 14-bed Surgical Oncology Unit manned by a single consultant, a 20-bed Radiotherapy Unit with five consultants providing tele-, brachy- and chemotherapy, a 10-bed Medical Oncology

Table 1. Distribution of sites of malignancy in three hospitals Sites Head and neck GI tract Hepatobiliary Lung Breast (men and women) Bone and connective tissue Skin Urogenital Total

RCC n (%) 8214 (29.19) 2520 (8.95) 718 (2.55) 2120 (7.53) 3169 (11.26) 717 (2.55) 475 (1.68) 4614 (16.4) 28136

MCH n (%) 362 (17.05) 539 (25.38) 244 (11.5) 55 (2.6) 139 (6.54) 38

(2.15)

118 (5.55) 255 (12.01) 2123

BHU n (%) 61 103 95 0 98

(12.52) (21.14) (19.5) (0) (20.12)

27

(5.54)

17 (3.49) 61 (12.5) 487

RCC: Regional Cancer Centre, Trivandrum; MCH: Medical College Hospital, Trivandrum; BHU: University Hospital, Banaras Hindu University, Varanasi.

Unit with one consultant and a 10-bed Haematology Unit manned by one haematologist. Besides the University Hospital, Varanasi also has a Railway Cancer Hospital, providing all aforesaid facilities to railway employees and, to a limited extent, to the local population. Despite the availability of these superspeciality units, a large number of cases with malignant diseases are still being dealt with by general surgeons. A systematic collection of clinical data was begun for all patients admitted to a single surgical unit at University Hospital, Banaras Hindu University, Varanasi, in January 1990, and is being carried out manually. The unit has 22 beds. There are two consultant surgeons, one senior resident and three to four resident doctors posted on rotation. The data collection is being carried out by resident doctors and the whole team participates in weekly meetings. The work of the unit covers the full range of general surgery and surgical specialities, excluding neuro- and cardiothoracic surgery. After discharge, all patients are recalled for periodic follow-up and their progress is recorded. Any complication occurring within a 30-day period is noted and is later included as a post-operative complication. Patients with malignant disease are followedup for life. Data in the present article are presented in the form of frequency tables and bar graphs.

Results During the study period (1990–1994), a total of 28,136 patients were registered at the RCC, of which 14,978 (53.23%) were men. Overall, the commonest malignancy encountered was of the oral cavity (16.35%). Among men, lung cancer (12.77%) was the commonest site while the breast was the most common for women (23.85%) (Table 1). Of 28,136 new cases, 2056 (7.3%) had received complete treatment externally prior to being referred to the RCC. While 3916 (13.92%) received additional treatment at the RCC in the form of radiotherapy, chemotherapy, hormonal therapy or combination treatment, only 6892 (24.5%) patients received treatment only at the RCC (Tables 2,3).

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M. Pandey et al. Table 2. Treatment in female patients registered at the RCC and the MCH by site RCC

Site Prior Tt Head and neck Gastrointestinal Hepatobiliary Lung Bone and connective tissue Skin Breast Urogenital Thyroid Haematological Others Total

Prior Tt + RI

MCH RI only

Prior Tt

Prior Tt + RI

RI only

45 50 3 5 36 48 428 172 296 27 89

82 84 3 7 69 44 1360 422 140 65 249

1308 367 32 106 134 56 1095 2366 249 604 565

0 0 0 0 0 0 1 0 0 0 0

0 1 0 0 0 0 5 0 2 2 2

12 77 5 2 5 30 129 2 151 32 46

1199

2615

6892

1

12

491

Tt: Treatment; RI: Registering institution; RCC: Regional Cancer Centre; MCH: Medical College Hospital.

Table 3. Treatment in male patients registered at the RCC and the MCH by site RCC Site

MCH

Prior Tt

Prior Tt + RI

RI only

Prior Tt

Prior Tt + RI

RI only

Head and neck Gastrointestinal Hepatobiliary Lung Bone and connective tissue Skin Breast Urogenital Thyroid Haematological Others

152 119 12 61 53 63 2 112 84 59 140

153 170 5 37 100 47 17 186 52 101 399

3612 962 165 1107 201 126 7 160 109 1187 1052

0 0 0 1 0 1 0 0 0 1 0

2 0 0 0 0 1 0 0 1 0 0

30 158 23 15 23 76 0 170 50 24 93

Total

857

1301

8688

3

4

662

Tt: Treatment; RI: Registering institution; RCC: Regional Cancer Centre; MCH: Medical College Hospital.

Of the patients receiving treatment at the RCC, only 3823 (13.59%) were treated with surgery alone or in combination (Fig. 1). The commonest modality of treatment was radiotherapy, in 8561 (30.4%), followed by multimodality, in 5102 (18.1%), chemotherapy alone, in 2397 (8.51%), and surgery alone, in 1182 (5.34%) (Fig. 2). Table 4 shows the distribution of patients by sex and site at the two institutions treated either by surgery alone or in combination. This shows that the majority of the head and neck, gastrointestinal, bone and connective tissue, breast and genitourinary malignancies were operated at the RCC (Table 4). On the other hand, in the Medical College Hospital, Trivandrum, a total of 2123 cases of malignancy were registered during the same period. Of these, 1330 (62.6%) were men. The commonest site encountered overall was the stomach, in 248 (11.68%), followed by thyroid, in 219 (10.31%), and colorectal, in 202 (9.5%) (Table 1). Among men the stomach was the commonest site, with 190 (14.29%) cases, followed by prostate with 162 (12.18%) patients. Among women the commonest site encountered was thyroid, in 164 (20.68%), followed by breast, in 138 (17.4%), and stomach, in 58 (7.31%) patients. Only 20 (0.94%)

patients received treatment prior to being registered at the MCH (Tables 2,3). Of all patients registered at the MCH, 1021 (48.09%) were treated by surgery alone or in combination (Fig. 1). Surgery alone was the commonest form of treatment offered at the MCH in 1008 (47.86%) patients while 90 (4.23%) received combination treatment (Fig. 2). The thyroid and breast were the two commonest sites among women operated at the MCH, while the skin, prostate and thyroid were the commonest sites operated upon among men (Table 4). During the same period, a total of 2720 patients were admitted to the Surgical Unit, University Hospital, Varanasi. Of these, 487 (17.90%) had malignant disease. Among women, breast cancer (98; 20.12%) was the commonest cancer site encountered in this unit. Most of these patients presented at an advanced stage (stages III and IV) and were treated by simple mastectomy and axillary clearance with adjuvant chemohormonal therapy. Locally advanced (T4 a, b and c) lesions received neoadjuvant chemotherapy, followed by modified radical mastectomy and post-operative chemoradiation. The chemotherapy used was CMF (cyclophosphamide, methotrexate and 5-fluorouracil) and was administered by the surgeon.

Malignancy load and general surgeons

Fig. 1. Treatment received by patients at the RCC and MCH. Φ, Surgery; Ε, surgery + radiotherapy; ∆, surgery + chemotherapy; Γ, surgery + chemotherapy + radiotherapy; , surgery + hormonal therapy; ∧, surgery + radiotherapy + hormonal therapy; ;, surgery + chemotherapy + hormonal therapy; Ρ, surgery + radiotherapy + chemotherapy + hormonal therapy.

Fig. 2. Treatment modalities used for treatment at the RCC and MCH. Φ, Surgery; Ε, radiotherapy; ∆, chemotherapy; Γ, combination therapy; , no treatment.

Among other malignancies, gall-bladder cancer was the most common, constituting 16.6% of all malignancies, followed by colorectal (10.26%), and stomach (6.98%) (Table 1). Notable among other malignancies were soft-tissue sarcomas, comprising about 5.55%, carcinoma of the penis (5.13%) and oral cancers (5.96%). There were 15 (3.08%) cases of dermal squamous cell carcinoma and nine (1.85%) cases of thyroid carcinoma (Table 1).

Discussion The audit of the malignancy load on a single general surgical unit based at Varanasi, and on the surgical units at the

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Medical College Hospital, Trivandrum, and its comparison with treatment at a specialized centre demonstrates an increased load of certain malignant diseases on general surgical units, despite the availability of speciality units and treatment facilities in the same city or within the same institution. The load of malignancies on these hospitals is tremendous and the number of specialized beds is scarce. This in turn increases the load on general surgical units. One of the biggest problems in allocating resources for health care concerns the number of doctors to be trained and the proportion to be guided into primary care compared with those encouraged to become consultants in each of the numerous surgical specialities. What are the mechanisms of decision? Firstly, the total number of doctors a country requires is decided, followed by the number required for each speciality. No country has been able to solve this equation to date, thus India is no exception. India had about 146 medical colleges in 1991–1992, producing about 10,000 medical graduates each year.2 Between January and December 1991, a total of 1064 students obtained postgraduate degrees or diplomas. Of these, 379 (35.6%) were in surgery and 26 (2.44%) in surgical specialities (excluding surgical oncology and surgical gastroenterology as these were not recognized by the MCI). The medical council data clearly show that over one-third of the postgraduates are opting for surgery as their speciality and only 5–10% of them finally opt for superspeciality. This has drastically stretched the doctor:population ratio, which ranges from 1:913 in the union territory of Chandigarh to 1:64,178 in the state of Orissa.2 One-third of surgical posts in various government primary health centres and central government health scheme (CGHS) hospitals are lying vacant due to the lack of surgeons. The situation in surgical specialities is even worse. Surgical oncology as a speciality is available only in select centres and most such patients are being operated by general surgeons. Our data, taken from two general surgery departments, clearly show that 25–30% of the general surgeons’ workload consists of malignant disease. However, the type of malignancies operated differ. Our data show that general surgeons in India operate mainly on thyroid, breast and gastrointestinal (GI) tumours, while the specialists deal mainly with head and neck, lung, oesophageal, cervical, bone and soft-tissue tumours. The present audit also highlights the inappropriate allocation of resources. The number of malignant disease cases referred to this hospital by primary and secondary health-care centres clearly outnumbers the speciality beds available. The audit also demonstrates the need for training general surgeons in the management of malignant diseases because surgical oncology as a speciality is available at only a few apex hospitals. As 25–30% of the workload of the general surgeon is malignant disease, we suggest that each surgery postgraduate should spend a minimum of 6 months in surgical oncology. During this period his training could be selectively tailored to suit his needs, concentrating on what he is going to operate in the future. Further emphasis should be laid on diagnostic techniques, biopsy techniques and the need for multimodality treatment. It is impossible for a country such as India to match resources to demand; however, by providing general surgeons with a better

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M. Pandey et al. Table 4. Surgery by sex and site RCC Men Site Head and neck Gastrointestinal Hepatobiliary Lung Bone and connective tissue Skin Breast Genitourinary Thyroid

MCH Women

Men

Women

SA

SC

SA

SC

SA

SC

SA

SC

121 72 7 11 43 71 2 28 75

422 152 15 14 72 17 5 101 25

97 39 7 1 22 26 172 110 156

207 100 7 3 49 9 805 283 57

30 148 28 14 23 76 0 108 50

0 0 0 0 0 0 0 11 0

16 76 10 2 5 30 127 18 150

0 0 0 0 0 0 1 0 1

SA: Surgery alone; SC: surgery in combination; RCC: Regional Cancer Centre; MCH: Medical College Hospital.

understanding of oncological principles we can reduce the gap. The problem will remain in colleges where surgical oncology is not offered and we suggest that this could be addressed by intra-college and intra-institutional exchange programmes. Streamlining the training of general surgeons in the management of cancer is the only way forward. References 1. Karran S, Scott S. Quality assurance in surgical practice audit, surveillance and decision analysis. In: Taylor I, Johnson CD

2. 3. 4. 5.

(eds). Recent Advances in Surgery. London: Churchill Livingstone, 1991; 14: 221–36. Central Bureau of Health Intelligence. Health Information of India. Directorate General of Health Sciences, Ministry of Health and Family Welfare, Government of India, New Delhi, 1994. Hospital Based Cancer Registry. Annual report 1990. Trivandrum: Regional Cancer Centre, 1992. Hospital Based Cancer Registry. Biannual report 1991–1992. Trivandrum: Regional Cancer Centre, 1994. Hospital Based Cancer Registry. Biannual report 1993–1994. Trivandrum: Regional Cancer Centre, 1996.

Accepted for publication 11 December 1998