The role of multidisciplinary care in the outcomes of patients treated for colorectal cancer in the West of Scotland

The aim of this thesis was to investigate the impact of the Managed Clinical Network (MCN) for colorectal cancer in the West of Scotland on outcomes for its patients. The alternative hypothesis was that greater changes to patient outcome had occurred over time than those that would have been expected in the absence of a Managed Clinical Network service structure. The study was a retrospective cohort study merging locally derived clinical audit and nationally held Cancer Registry datasets. This facilitated a comprehensive examination of patient characteristics and survival outcomes in varied cohorts of patients suffering from colorectal cancer in the West of Scotland. I employed longitudinal, cross sectional, univariate and multivariate methods of data analysis. Following a review of the current literature a baseline demographic summary of the population was produced. This allowed an examination of temporal changes in both survival and practice in the region in order to evaluate the key determinants underpinning differences before and after the inception of the new service structure. I went on to study specific aspects of patient management on outcome including effects of surgeon specialisation, effects of mechanical bowel preparation on short and long term outcomes and degree of equity of surgical provision for patients with rectal cancer. These aspects of care are thought to be measures of quality in patients with colorectal cancer and could be influenced by the inception of a Managed Clinical Network Evaluation of the current literature regarding effects of Managed Clinical Network on outcomes for colorectal cancer patients demonstrated a paucity of studies investigating the alternative hypothesis. Overall it appears that the introduction of the MCN has lead to improvements in survival for particular groups of patients only. We analysed the records of 37,890 colorectal cancer patients in the West of Scotland over a 25-year period and confirmed expected proportions of colonic to rectal lesions as well as equal sex distribution. We also report a higher ascertainment for data regarding Dukes’ stage when compared to other published series. Trends in relation to volume of work undertaken by surgeons on colorectal cancer patients in the West of Scotland demonstrate that there was increasing specialisation over the period under study. This is evidenced by the increase in proportion of resections performed by higher volume surgeons and is encountered in both colon and, to a lesser extent rectal cancer surgery. It seems that increasing specialisation has had resultant effects on overall survival for colon cancer patients but not for rectal cancer patients thus far. With regard to specific aspects of patient care we were able to show that specialisation has increased with time in our region and that mechanical bowel preparation has no effect on either immediate or long-term outcome in patients undergoing surgery for colon cancer. We also showed that in the West of Scotland we provide a surgical service to rectal cancer patients that is unbiased with regard to sex and degree of socioeconomic deprivation. This contrasts to previous findings in England