Quality assurance of surgery in gastric and rectal cancer.

Multimodality and quality controlled treatment result in improved treatment outcome in patients with solid tumours. Quality assurance focuses on identifying and reducing variations in treatment strategy. Treatment outcome is subsequently improved through the introduction of programs that reduce treatment variations to an acceptable level and implement standardised treatment. In chemotherapy and radiotherapy, such programmes have been introduced successfully. In surgery however, there has been little attention for quality assurance so far. Surgery is the mainstay in the treatment of patients with gastric and rectal cancer. In gastric cancer, the extent of surgery is continuously being debated. In Japan, extended lymph node dissection is favoured whereas in the West this type of surgery is not routinely performed with two large European trials concluding that there is no survival benefit from regional lymph node clearance. Post-operative chemoradiation is part of the standard treatment in the United States, although its role in combination with adequate surgery has not been established yet. These global differences in treatment policy clearly relate to the extent and quality of surgical treatment. As for gastric cancer, surgical treatment of rectal cancer patients determines patient's prognosis to a large extent. With the introduction of total mesorectal excision, local control and survival have improved substantially. Most rectal cancer patients receive adjuvant treatment, either pre- or post-operatively. The efficacy of many adjuvant treatment regimens has been investigated in combination with conventional suboptimal surgery. Traditional indications of adjuvant treatment might have to be re-examined, considering the substantial changes in surgical practise. Quality assurance programs enable the introduction of standardised and quality controlled surgery. Promising adjuvant regimens should be investigated in combination with optimal surgery.