ORIGINAL ARTICLE – HEALTHCARE POLICY AND OUTCOMES Effect of Surgeon Training, Specialization, and Experience on Outcomes for Cancer Surgery: A Systematic Review of the Literature Karl Y. Bilimoria, MD, MS 1 , Joseph D. Phillips, MD 1 , Colin E. Rock, BA 1 , Amanda Hayman, MD, MPH 1 , Jay B. Prystowsky, MD, MHPE 1,2 , and David J. Bentrem, MD, MS 1,2 1 Northwestern Memorial Hospital, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; 2 Jesse Brown VA Medical Center, Chicago, IL ABSTRACT Background. Outcomes after cancer resections have been shown to be better for high-volume surgeons compared with low-volume surgeons; however, reasons for this relationship have been difficult to identify. The objective of this study was to assess studies examining the effect of surgeon training and experience on outcomes in surgical oncology. Methods. A systematic review of the literature was per- formed to assess articles examining the impact of surgeon training, certification, and experience on outcomes. Studies were included if they examined cancer resections and performed multivariable analyses adjusting for relevant confounding variables. Results. An extensive literature search identified 29 stud- ies: 27 examined surgeon training/specialization, 1 assessed surgeon certification, and 4 evaluated surgeon experience. Of the 27 studies examining training/special- ization, 25 found that specialized surgeons had better outcomes than nonspecialized surgeons. One study found that American Board of Surgery (ABS)-certified surgeons had better outcomes than noncertified surgeons. Of the two studies examining time since ABS certification, both found that increasing time was associated with better outcomes. Of the four studies that examined experience, three studies found that increasing surgeon experience was associated with improved outcomes. Conclusions. Although numerous studies have examined the impact of surgeon factors on outcomes, only a few cancers have been examined, and outcome measures are inconsistent. Most studies do not appear robust enough to support major policy decisions. There is a need for better data sources and consistent analyses which assess the impact of surgeon factors on a broad range of cancers and help to uncover the underlying reasons for the volume– outcome association. Considerable variability has been demonstrated in out- comes after cancer surgery. 1–4 Numerous studies have demonstrated a difference in outcomes after cancer resec- tions according to surgeon volume, where higher volume is associated with lower perioperative mortality, recurrence, and complication rates, as well as higher long-term survival rates. 5–7 However, identification of specific factors under- lying this volume–outcome association has been challenging, and volume has been shown not to be the most important predictor of outcomes. 8,9 Surgical specialization via additional training beyond residency may contribute to differences in outcomes according to surgeon volume. Fellowship-trained surgeons may be more likely to focus on particular disease processes or operations, thus resulting in a more in-depth knowledge of the disease and increased technical expertise, as well as a high-volume practice. Alternatively, it may be that the time in practice since completing training provides sur- geons with the experience in surgical technique and postoperative management which can only be gained with time. Moreover, the volume of the hospital may also affect surgeon outcomes, particularly short-term morbidity and mortality; and it must be considered that the system of care, i.e., anesthesia and intensive care unit (ICU) care, is as Ó Society of Surgical Oncology 2009 First Received: 8 January 2009; Published Online: 15 May 2009 K. Y. Bilimoria, MD, MS e-mail: k-bilimoria@northwestern.edu Ann Surg Oncol (2009) 16:1799–1808 DOI 10.1245/s10434-009-0467-8