Michigan Surgical Quality Collaborative Teams with BCBSM Foundation to Improve Colorectal Cancer Surgery Outcomes Statewide

Originally published by Blue Cross Blue Shield of Michigan. Read the original here. 

For many cancers, one of the most important aspects of cancer surgery is removing 100% of the cancer cells. This may sound like a basic concept, but it doesn’t always happen, resulting in what is known as a positive surgical margin.

“When cancer is not removed completely and cancer cells are identified at the edge of a specimen taken out, that’s called a positive margin,” explains Dr. Calista Harbaugh, MS, MD. “And it can mean that cancer cells remain in the body after surgery.”

Harbaugh, a Board-certified colon and rectal surgeon and health services researcher at the University of Michigan’s Rogel Cancer Center, is leading the charge to help reduce as many positive margin instances among Michigan colorectal cancer patients as possible. Harbaugh said patients that experience a positive margin may suffer from poor health outcomes like:

• Requiring additional treatments after surgery.
• Having a higher risk of cancer recurrence.
• Having a higher risk of cancer that spreads to other parts of the body.

In 2023, Harbaugh’s “Leveraging the Michigan Surgical Quality Collaborative (MSQC) to Improve Statewide Colorectal Cancer” project was awarded a $50,000 Investigator Initiated Research grant from the Blue Cross Blue Shield of Michigan (BCBSM) Foundation.

Before there is even potential for positive margins to cause harm, it is important for everyone to understand that colorectal cancer is preventable and can be survivable if treated early.

“The hard part is that colon and rectal cancers can sometimes be silent, and that’s why it’s so important that everybody gets screened.”

Regular colorectal cancer screening should begin for everyone once they turn 45, according to the United States Preventive Services Task Force (USPSTF) Some signs that indicate you need to be screened sooner could include

• Persistent abdominal discomfort, including gas, cramps or pain.
• Rectal bleeding or blood in the stool.
• Changes in bowel habits, including persistent diarrhea, constipation or a change in stool consistency.
• A feeling that your bowel doesn't empty completely.

How the MSQC and the BCBSM Foundation are teaming up to improve colorectal cancer outcomes

The MSQC is a longstanding BCBSM-sponsored statewide Collaborative Quality Initiative (CQI) founded in 2005. It consists of the 69 Michigan hospitals that perform surgery on most of colorectal cancers in Michigan. A recent study conducted by the MSQC that documented cancer removal surgeries of more than 4,000 patients across 42 participating Michigan hospitals found that positive margin rate ranged from 0% at some hospitals to nearly 30% across others.

Harbaugh mentioned some variables that could affect those statistics.

“We have to understand that those measures in and of themselves don’t account for the fact that some patients come in sicker or with more advanced disease,” she said. “And there may be situations where positive margins inevitably have to occur.”

BCBSM Foundation funding has been divvied up across numerous areas of this important research to help improve the overall quality of colon and rectal cancer care in Michigan. The first of three phases revolved around examining factors associated with experiencing a positive margin, which included:

• Patients that came in with larger tumors that invaded other organs.
• Patients that came in sicker needing an emergency operation.
• Patients with cancer that had already spread to other parts of their body.

“The numbers don’t tell us the whole picture, though,” Harbaugh said. “We have embarked on the second phase of the project, to understand why (these instances occur) … the numbers tell us there are opportunities for improvement, but they don’t tell us why.”

Harbaugh said she and the MSQC have spent much of the past 10 months interviewing surgeons who regularly perform colorectal cancer surgery, including those that perform emergency surgeries.

“This is to understand what colorectal cancer surgery looks like in a variety of settings,” Harbaugh said. “We are currently in the process of analyzing that, but it’s elucidated some really important insights as to why positive margins occur. I’d say one of the most important areas emerging is that we often think of positive margins as a technical error. Like, I, in the operating room made a mistake. But what we’ve learned is it’s not a mistake and it’s not just a surgeon problem. There are systems opportunities to prevent positive margins from the time patients are first diagnosed.”

BCBSM funds have helped compensate all surgeons and team members that have given their time to help the MSQC understand what care looks like across the state. The third phase of the project begins in 2024, explained Harbaugh, who said the MSQC will visit hospitals – large and small – that are most adept at reducing positive margins, to learn from what they’re doing.

“This project will help us translate those lessons across the state,” said BCBSM Foundation Executive Director and Chief Executive Officer, Audrey Harvey.

“Colorectal cancer is one of the leading causes of cancer-related deaths in the United States, and we know that some counties and populations in Michigan have an elevated risk of being diagnosed with colorectal cancer,” said BCBSM Foundation Senior Program Officer, Myra Tetteh. “Evidence-based programs like the project launched by the Michigan Surgical Quality Collaborative Team are so important because they can help our state improve the quality of colorectal care across the state, and ultimately, save lives.”

The Investigator Initiated Research Award Program from the Blue Cross Blue Shield of Michigan Foundation supports doctoral-level researchers focused on areas like addressing critical gaps in health-related research; examining factors that may prevent or reduce risk for disease; and health care cost-analysis studies. Learn more about the grant, eligibility and the application process by visiting this link.