Regional Variation in Laparoscopy Use for Elective Colon Cancer Treatment in Canada: The Importance of Fellowship Training Sites Academic Article uri icon

  • Overview
  • Research
  • Identity
  • Additional Document Info
  • View All


  • BACKGROUND: Over the last decade utilization of laparoscopy for the treatment of colon cancer has been variable despite evidence of benefit; possibly reflecting surgeon expertise, rather than other factors. OBJECTIVE: To examine the spatial variation in the use of laparoscopy for colon cancer surgery and determine what factors may influence utilization. DESIGN: Population-based retrospective analysis from April 2008 - March 2015. SETTINGS: All Canadian provinces (excluding Quebec). PATIENTS: All patients ≥18 years undergoing elective colectomy for colon cancer. MAIN OUTCOME MEASURES: The primary outcome was laparoscopy utilization rates. Predictors of use included patient and disease characteristics, year of surgery, rurality, hospital and surgeon volumes, and distance from a colorectal fellowship training center. RESULTS: A total of 34,725 patients were identified, 42% underwent laparoscopic surgery. Significant spatial variations in laparoscopy-use were identified, with 95% of high-use clusters located ≤100 km, and 98% of low-use clusters located >100 km, from a colorectal fellowship center. There were no high-use clusters located around large academic centers without colorectal fellowships. At the individual level, patients living within 25 km and 26-100 km of a fellowship center were 2.6 and 1.6 times more likely to undergo laparoscopic surgery respectively, compared to those >100 km away (95% CI 2.47-2.79, p<0.00; 95% CI 1.53-1.71, p<0.001). Surgeon and hospital volumes were associated with increased rates of laparoscopy utilization (p<0.001). LIMITATIONS: Data were obtained from an administrative database and despite 85-95% published validity it remains subject to misclassification, response and measurement bias. CONCLUSIONS: Significant spatial variations in the use of laparoscopy for colon cancer surgery exists. After adjusting for patient and system factors, proximity to a colorectal fellowship training center remained a strong predictor of laparoscopy use. There remain regional variations in colon cancer treatment, with discrepancies in the surgical care offered to Canadian patients based solely on location. See Video Abstract at


  • Logie, Kathleen
  • Doumouras, Aristithes G
  • Springer, Jeremy E
  • Eskicioglu, Cagla
  • Hong, Dennis

publication date

  • October 2021