title: Surgery has a key role for quality assurance of colorectal cancer screening programs: impact of the third level multidisciplinary team on lymph nodal staging.
abstract: OBJECTIVE
  From 2011 to 2013 in the area of the Naples 3 public health district (ASL-NA3), a colorectal cancer screening program (CCSP) was developed. In order to stress the need of quality assurance procedures for surgery and pathology, a third level oncologic pathway was added and set up at a referral colorectal cancer center (RC). Lymph nodal (LN) harvesting, as a process indicator, and nodal positivity were adopted for an interim analysis.
  
  
  METHODS
  The program was implemented by a series of audit meetings and a double type of multidisciplinary team (MDT): "horizontal" and "vertical." Three hundred and forty colorectal cancer (CRC) patients underwent surgery: 119 chose to be operated at the RC (Gr In), 65 were operated at 22 district hospitals (DH) (Gr Out), and 156 symptomatic not screened patients were operated at the RC (Gr Sym).
  
  
  RESULTS
  Statistical analysis revealed differences between Gr In and Gr Out colon groups both for LN harvesting (median of 26 and 11, respectively, P = 0.0001), and for nodal positivity after the first screening round (34.78 and 19.45%, respectively, P = 0.0169). Results were all the more significant in a subset analysis on early T stage colon subgroups (In vs Out) both for LN harvesting (P < 0.0001) and nodal positivity (P < 0.0001).
  
  
  CONCLUSIONS
  xSignificant differences between RC and DHs were found, particularly for early-stage CRC patients. LN harvesting should be considered as a surrogate marker of quality assurance for at least screening hospitals for "minimum best" standard of care. This should lead to set up a third level in any CCSP.
authors.affiliation: Department of Surgical Oncology, Istituto Nazionale per lo studio e la cura dei tumori "Fondazione Giovanni Pascale" - IRCCS, Via M. Semmola, 80131, Naples, Italy. bianco.bar@tin.it.
authors.forename: Francesco
authors.initials: F
authors.lastname: Bianco
authors.affiliation: Department of Surgical Oncology, Istituto Nazionale per lo studio e la cura dei tumori "Fondazione Giovanni Pascale" - IRCCS, Via M. Semmola, 80131, Naples, Italy.
authors.forename: Silvia
authors.initials: S
authors.lastname: De Franciscis
authors.affiliation: Department of Surgical Oncology, Istituto Nazionale per lo studio e la cura dei tumori "Fondazione Giovanni Pascale" - IRCCS, Via M. Semmola, 80131, Naples, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Belli
authors.affiliation: Department of Surgical Oncology, Istituto Nazionale per lo studio e la cura dei tumori "Fondazione Giovanni Pascale" - IRCCS, Via M. Semmola, 80131, Naples, Italy.
authors.forename: Maria
authors.initials: M
authors.lastname: Di Lena
authors.affiliation: Department of Medical Oncology, Istituto Nazionale per lo studio e la cura dei tumori "Fondazione Giovanni Pascale" - IRCCS, Naples, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Avallone
authors.affiliation: Gastroenterology and Digestive Endoscopy, Maresca Hospital, Torre Del Greco, Italy.
authors.forename: Maria Antonia
authors.initials: MA
authors.lastname: Bianco
authors.affiliation: Gastroenterology and Digestive Endoscopy, Apicella Hospital, Pollena Trocchia, Italy.
authors.forename: Sabato
authors.initials: S
authors.lastname: Di Marzo
authors.affiliation: Epidemiology and Prevention Unit, ASL NA3sud, Naples, Italy.
authors.forename: Letizia
authors.initials: L
authors.lastname: Gigli
authors.affiliation: Gastroenterology and Digestive Endoscopy, Maresca Hospital, Torre Del Greco, Italy.
authors.forename: Gianluca
authors.initials: G
authors.lastname: Rotondano
authors.affiliation: Epidemiology and Prevention Unit, ASL NA3sud, Naples, Italy.
authors.forename: Silvana Russo
authors.initials: SR
authors.lastname: Spena
authors.affiliation: Department of Pathology, Istituto Nazionale per lo studio e la cura dei tumori "Fondazione Giovanni Pascale" - IRCCS, Naples, Italy.
authors.forename: Fabiana
authors.initials: F
authors.lastname: Tatangelo
authors.affiliation: Department of Endoscopy, Istituto Nazionale per lo studio e la cura dei tumori "Fondazione Giovanni Pascale" - IRCCS, Naples, Italy.
authors.forename: Alfonso
authors.initials: A
authors.lastname: Tempesta
authors.affiliation: Department of Surgical Oncology, Istituto Nazionale per lo studio e la cura dei tumori "Fondazione Giovanni Pascale" - IRCCS, Via M. Semmola, 80131, Naples, Italy.
authors.forename: Giovanni Maria
authors.initials: GM
authors.lastname: Romano
mesh_terms: D000368:Aged; D015179:Colorectal Neoplasms / Q000601:surgery*; D055088:Early Detection of Cancer / Q000592:standards*; D005260:Female; D006801:Humans; D033183:Interdisciplinary Communication; D008198:Lymph Nodes / Q000473:pathology*; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D011785:Quality Assurance, Health Care; D012017:Referral and Consultation
keywords: Colorectal cancer screening; Lymph nodal harvesting; Multidisciplinary team; Quality assurance; Referral centre; Third level surgery