No longer is there room for eminence-based complacency or misguided arrogance in healthcare delivery. The day of the autonomous clinician is gone with a vogue towards standardised, evidence-based clinical excellence. Cynics would erroneously attribute this to a parallel increase in litigation but increasing patient knowledge and expectations with a move toward subspecialisation are the main catalysts driving change. When offered operative intervention, the question frequently asked by the patient is “How many of these have you done before?” This article aims to critically analyse recent literature and explore the correlation between volume and clinical outcome in the context of cancer care. Background 1 2 The literature 3 4 5 1 6 , 7 Table 1. Colorectal cancer outcome: high- and low-volume units  High volume Low volume Ref. APR versus LAR ↓ APR ↑ APR 19 ↑ LAR ↓ LAR Sphincter preservation ↑ ↑ ↓ 20 30-day postoperative mortality ↔ ↔ 21 Survival (overall and cancer specific) ↑ ↓ 21 Permanent stoma formation ↓ ↑ 22 Colonic pouch formation ↑ ↓ 22 APR, abdominoperineal resection; LAR, low anterior resection. ↑ increased, ↓ decreased, ↔ no variation. 8 9 10 11 12 The Flaws 13 14 15 16 17 The Surgeon To identify procedure volume in a single institution is easy but not so for quantifying specific operations done by a single surgeon, many of whom practise in several centres. Without asking individuals to record caseload prospectively, obtaining accurate figures may be very difficult. Surely significant bias could occur in that those willing to share details of operations may be confident of their own justification in performing such procedures. Furthermore, who counts as more experienced: a mature surgeon who has performed two colonic resections a week for 20 years but now does only two a month or a younger, specialist trained surgeon who performs three a week? How do you weight lifetime experience against current volume? Should a centralised database of surgeons’ logbooks exist, and should permission to operate be granted or denied based on this? What governing body should be afforded such a task? Should operating surgeons be ranked in their ability or would this border on defamation for the less fortunate ones? Regarding referral pattern, does volume attract quantity or do excellent clinicians attract patients? Many studies have compared the significance of surgeon experience to unit volume with varied conclusions as to which has more impact. Do excellent surgeons naturally aggregate in excellent high-volume units, thus giving a self-propagating explanation for improved outcome? The Institution Many papers allude to the importance of the multidisciplinary approach in cancer care. Higher-volume units are far more likely to have subspecialised radiologists, radiation and medical oncologists, high dependency and intensive care units, cancer specialist nurses, dedicated psychologists and palliative care support. Anecdotally, the involvement of such services translates into better patient outcome regardless of unit volume, thus confounding results. The resounding evidence in favour of the volume–outcome relationship pertains to those cancers requiring adjuvant therapy: oesophagus, pancreas and advanced colorectal. It seems, therefore, that good surgical technique or individual surgeon experience do not exclusively guarantee positive outcomes and that much depends on availability of radiation and medical oncology. 1 18 Fig. 1. Volume–outcome relationship.  The Patient 17 The Future The literature supports a correlation between surgical volume and improved clinical outcome in cancer care. However, a rather simplistic approach is evident in many studies and much potential remains for unbiased, prospective, statistically sound investigations with the aim of numerically stratifying appropriate volume and its impact on disease specific cancer outcomes. 1 1