A randomized controlled trial to improve lymph node assessment in stage II colon cancer.

HYPOTHESIS: Physicians seem to learn best from their peers, yet the impact of opinion leaders on physician behavior is unclear. Because colon cancer staging has been identified as being suboptimal in Ontario, Canada, we sought to evaluate the influence of expert and local opinion leaders for colon cancer on optimizing colon cancer lymph node assessment. DESIGN, SETTING, PARTICIPANTS: A cluster-randomized trial including all hospitals in Ontario that identified a local opinion leader with intervention between January 5 and June 17, 2004. INTERVENTION: All 42 centers received a standardized lecture about colon cancer lymph node assessment delivered by an expert opinion leader in colon cancer. The 21 intervention hospitals also received academic detailing of a local opinion leader by the expert opinion leader and a toolkit. MAIN OUTCOME MEASURES: Mean number of lymph nodes assessed in patients with stage II colon cancer and the proportion of cases staged with a minimum of 12 lymph nodes before and after a standardized lecture were assessed. RESULTS: Patient demographic and tumor factors were similar in both groups before and after the standardized lecture. Lymph node assessment significantly improved after the standardized lecture at intervention and control sites (P < .001). No additional benefit of academic detailing and toolkit provision in the intervention was demonstrated. CONCLUSIONS: In-person provision of information by an expert opinion leader in colon cancer may stimulate performance regarding lymph node assessment for colon cancer. Academic detailing of a local opinion leader did not further improve lymph node assessment.

Surgery as a bridge to palliative chemotherapy in patients with malignant bowel obstruction from colorectal cancer.

BACKGROUND: Malignant bowel obstruction (MBO) is a feature of the clinical course of 10-28% of colorectal cancer (CRC) patients and is associated with a poor prognosis. Recent advancements in palliative chemotherapy regimens have prolonged survival in patients with stage IV CRC. Few reports exist that describe outcomes in patients who have had surgery for MBO and subsequent chemotherapy as part of their treatment. The objective of this study was to review surgical outcomes in patients with MBO for CRC and to evaluate the extent to which surgery can serve as a bridge to palliative chemotherapy. METHODS: Patients who presented with MBO and had surgical treatment were identified from a prospectively kept database at a single tertiary care center between 09/99 and 08/04. Charts were retrospectively reviewed and clinical and outcomes data were abstracted. RESULTS: Forty-seven patients were identified who had surgery as part of the treatment for MBO from CRC. Operations included resections, bypasses and stoma creation. Overall, 80% of patients were able to tolerate solid food post-operatively and return home. The median survival for the entire cohort was 3.5 months. Seven patients died within 30 days of surgery. Of the remainder, 24 patients were palliated with surgery alone and 16 patients ultimately received palliative chemotherapy. Survival in the final cohort was significantly prolonged (P < 0.001). CONCLUSION: Surgery can adequately palliate a substantial proportion of patients with MBO from CRC with acceptable morbidity and mortality. In addition, in a subset of patients it can facilitate palliative chemotherapy that is associated with improved overall survival.

A blended knowledge translation initiative to improve colorectal cancer staging [ISRCTN56824239].

BACKGROUND: A significant gap has been documented between best practice and the actual practice of surgery. Our group identified that colorectal cancer staging in Ontario was suboptimal and subsequently developed a knowledge translation strategy using the principles of social marketing and the influence of expert and local opinion leaders for colorectal cancer. METHODS/DESIGN: Opinion leaders were identified using the Hiss methodology. Hospitals in Ontario were cluster-randomized to one of two intervention arms. Both groups were exposed to a formal continuing medical education session given by the expert opinion leader for colorectal cancer. In the treatment group the local Opinion Leader for colorectal cancer was detailed by the expert opinion leader for colorectal cancer and received a toolkit. Forty-two centres agreed to have the expert opinion leader for colorectal cancer come and give a formal continuing medical education session that lasted between 50 minutes and 4 hours. No centres refused the intervention. These sessions were generally well attended by most surgeons, pathologists and other health care professionals at each centre. In addition all but one of the local opinion leaders for colorectal cancer met with the expert opinion leader for colorectal cancer for the academic detailing session that lasted between 15 and 30 minutes. DISCUSSION: We have enacted a unique study that has attempted to induce practice change among surgeons and pathologists using an adapted social marketing model that utilized the influence of both expert and local opinion leaders for colorectal cancer in a large geographic area with diverse practice settings.

Barriers to optimal assessment of lymph nodes in colorectal cancer specimens.

Lymph node (LN) retrieval and assessment is critically important for accurate staging and treatment planning in colorectal cancer (CRC). Practicing pathologists in Ontario were identified and surveyed by phone to identify barriers to optimal retrieval and assessment. Of the pathologists surveyed, 57.9% were aware of guidelines for LN retrieval in CRC, but only 25.0% identified that a minimum of 12 LNs are necessary for accurate designation of node negativity. An important role exists for an education strategy aimed at bridging the knowledge gap among practicing pathologists and surgeons regarding optimal LN assessment in CRC specimens.

Identifying educationally influential specialists: issues arising from the use of "classic" criteria.

INTRODUCTION: Educationally influential physicians (EIPs) are identified by their colleagues as people who (1) encourage learning and enjoy sharing their knowledge, (2) are clinical experts and always seem up to date, and (3) treat others as equals. We aimed to identify surgical and pathologist EIPs for colorectal cancer (CRC) in Ontario as part of a blended knowledge transfer program. METHODS: A population-based cohort of surgeons (n = 794) and pathologists (n = 449) were sent surveys modeled on the Hiss method for identifying EIPs. Four formal mailings (including incentives) and telephone calls and faxes were completed. This labor-intensive process identified "general" EIPs and surgery or pathology EIPs for CRC. The characteristics of EIPs in these groups were studied. RESULTS: The response rate was 41% for surgeons and 42% for pathologists. One hundred eighteen general EIPs were identified and substantially more surgical EIPs for CRC (n = 63) than pathology EIPs for CRC (n = 6) were recognized. Forty-two of 81 medical centers in Ontario identified an EIP We also identified a cohort of "domain experts, " physicians whose opinion was valued for CRC but who did not meet the Hiss EIP criteria. This cohort of "domain experts" was larger than the cohort of ElPs for CRC for both surgeons (63 vs. 154) and pathologists (6 vs. 154). DISCUSSION: In this population study, we identified EIPs for CRC using the Hiss method, although significantly more surgical than pathology EIPs for CRC were recognized. The educational influence of domain experts who do not fulfill the Hiss characteristics compared with EIPs for CRC remains to be determined.