title: Treatment by specialist surgical neurooncologists improves survival times for patients with malignant glioma.
abstract: OBJECTIVE
  Surgeries for CNS tumors are frequently performed by general neurosurgeons and by those who specialize in surgical neurooncology. Subspecialization in neurosurgical practice has become common and may improve patient morbidity and mortality rates. However, the potential benefits for patients of having their surgeries performed by surgical neurooncologists remain unclear. Recently, a shift in patient care to those who practice predominantly surgical neurooncology has been promoted. Evidence for this practice is lacking and therefore requires fundamental investigation.
  
  
  METHODS
  The authors conducted a case-control study of neurooncology patients who underwent surgery for glioblastoma and anaplastic astrocytoma during 2006-2009. Outcomes were compared for patients whose surgery was performed by general neurosurgeons (generalists) or by specialist neurooncology neurosurgeons (specialists). An electronic record database and a picture archiving and communication system were used to collect data and assess the extent of tumor resection. Mortality rates and survival times were compared. Patient comorbidity and postoperative morbidity were assessed by using the Waterlow, patient handling, and falls risk assessment scores. Effects of case mix were adjusted for by using Cox regression and a hazards model.
  
  
  RESULTS
  Outcomes for 135 patients (65 treated by generalists and 70 by specialists) were analyzed. Survival times were longer for patients whose surgery was performed by specialists (p=0.026) and after correction for case mix (p=0.019). Extent of tumor resection was greater when performed by specialists (p=0.005) and correlated with increased survival times (p=0.004). There was a trend toward reduced surgical deaths when surgery was performed by specialists (2.8%) versus generalists (7%) (p=0.102), and inpatient stays were significantly shorter when surgery was performed by specialists (p=0.008).
  
  
  CONCLUSIONS
  The prognosis for glioblastoma multiforme remains dire, and improved treatments are urgently needed. This study provides evidence for a survival benefit when surgery is performed by specialist neurooncology neurosurgeons. The benefit might be attributable to increased tumor resection. Furthermore, specialist neurooncology surgical care may reduce the number of surgical patient deaths and length of inpatient stay. These findings support the recommendations for subspecialization within surgical neurooncology and advocate for care of these patients by specialists.
authors.affiliation: Department of Neurosurgery, Greater Manchester Neurosciences Centre, Salford Royal Hospital, Salford; and.
authors.forename: Ursalan A
authors.initials: UA
authors.lastname: Khan
authors.forename: Amar
authors.initials: A
authors.lastname: Bhavsar
authors.forename: Hasan
authors.initials: H
authors.lastname: Asif
authors.forename: Konstantina
authors.initials: K
authors.lastname: Karabatsou
authors.forename: James R S
authors.initials: JR
authors.lastname: Leggate
authors.forename: Ajit
authors.initials: A
authors.lastname: Sofat
authors.forename: Ian D
authors.initials: ID
authors.lastname: Kamaly-Asl
mesh_terms: D001932:Brain Neoplasms / Q000175:diagnosis / Q000401:mortality* / Q000601:surgery*; D016022:Case-Control Studies; D005260:Female; D005910:Glioma / Q000175:diagnosis / Q000401:mortality* / Q000601:surgery*; D006801:Humans; D053208:Kaplan-Meier Estimate; D007902:Length of Stay; D008297:Male; D008495:Medical Oncology; D008875:Middle Aged; D009493:Neurosurgery; D011379:Prognosis; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D013038:Specialization; D015996:Survival Rate; D013997:Time Factors; D016896:Treatment Outcome
keywords: AA = anaplastic astrocytoma; GBM = glioblastoma multiforme; MRC = Medical Research Council; glioblastoma multiforme; glioma; neurooncology; oncology; subspecialization