Providing surgeons feedback and education on their performance significantly improved the quality of bladder cancer operations, finds a new clinical trial led by researchers at UCL, UCLH and the University of Edinburgh.
The RESECT study, published in European Urology, is the first randomized controlled trial to examine whether feedback and education can enhance surgical performance for non-muscle-invasive bladder cancer (NMIBC), which has high rates of recurrence and progression.
Bladder cancer is the tenth most common cancer worldwide, and NMIBC accounts for around 75% of cases. The main form of diagnosis and treatment for NMIBC is surgery, which has been the main treatment for decades, but outcomes are dependent on how well the operation is performed.
Audit of surgical performance involves assessing surgeries against agreed standards, collecting and analyzing data on outcomes, and making recommendations to improve practice. This kind of audit is currently conducted on a national scale in prostate cancer, but there is no large-scale organized audit of bladder cancer in England or in most other countries in the world.
This large-scale trial involved 2,731 surgeons at 220 hospitals worldwide and analyzed data from 14,915 patients who had undergone a type of bladder cancer surgery called transurethral resection of bladder tumor (TURBT).
It compared two approaches, with participating hospitals randomly assigned to adopt one approach: either standard observation (where surgeons entered data on their bladder cancer operations without receiving any feedback or education), or audit combined with feedback and education (where surgeons received tailored feedback as well as educational resources to improve performance).
The research team assessed four key indicators of surgical quality, including documentation of tumor features (such as the number, size and location of tumors) and completeness of tumor removal, as well as whether additional chemotherapy was administered and whether detrusor muscle was sampled during surgery (which helps to accurately stage the cancer). They also assessed this performance at baseline prior to being involved in the study and subsequently after being randomized into one of the study arms.
With feedback and education, the rate of tumor feature documentation increased significantly from 78.5% to 86.7% (meaning surgeons wrote down important details about tumors more often) and the rate of complete tumor removal documentation increased from 84.7% to 90.9% (recording when they had completely removed a tumor).
There were also more modest improvements in these outcomes in the observation arm of the study, where surgeons were observed but not provided feedback.
Being provided with performance feedback and education did not increase rates of chemotherapy use or detrusor muscle sampling, nor did it reduce recurrence rates compared to observation alone.
However, the authors noticed a powerful hidden effect that may explain the lack of difference between the intervention and control groups for cancer recurrence and chemotherapy use. Surgeons in the standard observation arm appeared to perform better during the study than they did at baseline. This effect has been known as the ‘Hawthorne effect’—a phenomenon where performance improves simply because participants know they are being observed. In hospitals that only took part in the observation arm, cancer recurrence rates fell from 25% at baseline to 18%, even without targeted feedback or education.
Professor Veeru Kasivisvanathan, senior author and co-chief investigator of the study from UCL Surgery and Interventional Science and Director of the BURST research collaborative, said, “We know that despite being the cornerstone of care, this bladder cancer procedure can have poor outcomes and how well the procedure is done makes a big difference to how likely it is to cure the cancer.
“The findings revealed that hospitals receiving feedback and education improved documentation of tumor characteristics and completeness of removal, which are both critical for guiding future treatment decisions. But perhaps the most surprising finding from the study was the fact that when surgeons are simply being observed, by taking part in an audit and entering data for their surgeries, outcomes also improve, which resulted in bladder cancer recurrence falling by 25%.
“Given the current financial and resource constraints facing many health care systems, to demonstrate such a large reduction in cancer recurrence by simply being observed is quite a major finding as this is a relatively cheap and straightforward approach which could improve cancer care overnight. This magnitude of reduction in cancer recurrence rates is similar to that achieved by single-instillation chemotherapy drugs which cost many millions of pounds to develop and administer.
“This study demonstrates that large-scale collaboration and structured audit can transform surgical practice. National audits are not common, but they have the potential to deliver significant benefits for patients. Our findings should encourage policymakers and clinicians to adopt these approaches more widely.”
The study highlights the potential for national and international audit programs to raise standards in bladder cancer surgery.
Dr. Kevin Gallagher, co-chief Investigator of the trial from the University of Edinburgh and UCL Surgery and Interventional Science, said, “Our results show that carefully designed audit and feedback can improve documentation practices, which are essential for patient safety and cancer control. Even more striking is the impact of audit alone on recurrence rates. This suggests that simply participating in a well-organized audit can drive meaningful improvements in surgical quality.”
“The RESECT trial provides a blueprint for improving surgical care through implementation science and collaborative audit and feedback. We would recommend that health systems consider implementing national audits for bladder cancer surgery, similar to successful programs in Scotland, which have previously shown reductions in recurrence and progression rates.”
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