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Murshed I, Dinger TL, de Gaay Fortman DPE, Traeger L, Bedrikovetski S, Hunter A, Kroon HM, Sammour T. Outcomes of rectal cancer treatment in rural Australia and New Zealand: analysis of the bowel cancer outcomes registry. ANZ J Surg 2024. [PMID: 39205431 DOI: 10.1111/ans.19194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 06/26/2024] [Accepted: 07/28/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND The demographics and geography of Australia and New Zealand (ANZ), with few metropolitan centres and vast, sparsely populated rural areas, represent a challenge to providing equal care to all patients. This study aimed to compare rectal cancer care at rural and urban hospitals in ANZ. METHODS From the Bowel Cancer Outcomes Registry (BCOR, formerly known as the Bi-National Colorectal Cancer Audit; BCCA), rectal cancer patients treated between 2007 and 2020 were compared based on hospital location (urban versus rural). Propensity-score matching was performed to correct for differences in baseline characteristics between groups. RESULTS A total of 9385 rectal cancer patients were identified from the BCOR: 1329 (14.2%) were treated at rural hospitals and 8056 (85.8%) at urban hospitals. Propensity-score matching resulted in 889 patients in each group, matched for age, ASA score, hospital type (public/private), tumour height from the anal verge, and pre-treatment cT- and cAJCC-stage. Rural patients had fewer pre-treatment MRIs (67.9% versus 74.7%; P = 0.002), and underwent less neoadjuvant therapy (44.7% versus 50.9%; P = 0.01). Rural patients underwent fewer ULARs (39.4% versus 45.6%; P = 0.03), and fewer anastomoses were formed (67.9% versus 74.4%; P = 0.05). CRM rates and postoperative AJCC stages (P = 0.19) were similar between groups (P = 0.87). Fewer rural patients received adjuvant chemotherapy (37.8% versus 43.3%; P = 0.02). CONCLUSION There are significant differences in pre-treatment MRI rates, (neo)adjuvant treatment rates and surgical procedures performed between rectal cancer patients treated at rural and urban hospitals in ANZ, while CRM rates and postoperative AJCC stages are similar.
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Affiliation(s)
- Ishmam Murshed
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Tessa L Dinger
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Department of Surgery, St. Antonius Hospital, Utrecht, The Netherlands
| | - Duveke P E de Gaay Fortman
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Department of Internal Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Luke Traeger
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Sergei Bedrikovetski
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Andrew Hunter
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Hidde M Kroon
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Tarik Sammour
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
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2
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Lee KC, Zhao B, Pianka K, Liu S, Eisenstein S, Ramamoorthy S, Lopez NE. Current trends in nonoperative management for rectal adenocarcinoma: An unequal playing field? J Surg Oncol 2022; 126:1504-1511. [PMID: 36056914 DOI: 10.1002/jso.27082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 07/28/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES Increasing evidence suggests patient-oriented benefits of nonoperative management (NOM) for rectal cancer. However, vigilant surveillance requires excellent access to care. We sought to examine patient, socioeconomic, and facility-level factors associated with NOM over time. METHODS Using the National Cancer Database (2006-2017), we examined patients with Stage II-III rectal adenocarcinoma, who received neoadjuvant chemoradiation and received NOM versus surgery. Factors associated with NOM were assessed using multivariable logistic regression with backward stepwise selection. RESULTS There were 59,196 surgical and 8520 NOM patients identified. NOM use increased from 12.9% to 15.9% between 2006 and 2017. Patients who were Black (adjusted odds ratio [aOR]: 1.36, 95% confidence interval [CI]: 1.26-1.47), treated at community cancer centers (aOR: 1.22, 95% CI: 1.12-1.30), without insurance (aOR: 1.87, 95% CI: 1.68-2.09), and with less education (aOR: 1.53, 95% CI: 1.42-1.65) exhibited higher odds of NOM. Patients treated at high-volume centers (aOR: 0.79, 95% CI: 0.74-0.84) and those who traveled >25.6 miles for care (aOR: 0.59, 95% CI: 0.55-0.64) had lower odds of NOM. CONCLUSIONS Vulnerable groups who traditionally have difficulty accessing comprehensive cancer care were more likely to receive NOM, suggesting that healthcare disparities may be driving utilization. More research is needed to understand NOM decision-making in rectal cancer treatment.
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Affiliation(s)
- Katherine C Lee
- Department of Surgery, University of California, San Diego, La Jolla, California, USA
| | - Beiqun Zhao
- Department of Surgery, University of California, San Diego, La Jolla, California, USA
| | - Kurt Pianka
- Department of Surgery, University of California, San Diego, La Jolla, California, USA
| | - Shanglei Liu
- Department of Surgery, University of California, San Diego, La Jolla, California, USA
| | - Samuel Eisenstein
- Department of Surgery, University of California, San Diego, La Jolla, California, USA
| | - Sonia Ramamoorthy
- Department of Surgery, University of California, San Diego, La Jolla, California, USA
| | - Nicole E Lopez
- Department of Surgery, University of California, San Diego, La Jolla, California, USA
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Soriano C, Bahnson HT, Kaplan JA, Lin B, Moonka R, Pham HT, Kennecke HF, Simianu V. Contemporary, national patterns of surgery after preoperative therapy for stage II/III rectal adenocarcinoma. World J Gastrointest Oncol 2022; 14:1148-1161. [PMID: 35949222 PMCID: PMC9244989 DOI: 10.4251/wjgo.v14.i6.1148] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 04/11/2022] [Accepted: 05/22/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Contemporary treatment of stage II/III rectal cancer combines chemotherapy, chemoradiation, and surgery, though the sequence of surgery with neoadjuvant treatments and benefits of minimally-invasive surgery (MIS) is debated. AIM To describe patterns of surgical approach for stage II/III rectal cancer in relation to neoadjuvant therapies. METHODS A retrospective cohort was created using the National Cancer Database. Primary outcome was rate of sphincter-sparing surgery after neoadjuvant therapy. Secondary outcomes were surgical approach (open, laparoscopic, or robotic), surgical quality (R0 resection and 12+ lymph nodes), and overall survival. RESULTS A total of 38927 patients with clinical stage II or III rectal adenocarcinoma underwent surgical resection from 2010-2016. Clinical stage II patients had neoadjuvant chemoradiation less frequently compared to stage III (75.8% vs 84.7%, P < 0.001), but had similar rates of total neoadjuvant therapy (TNT) (27.0% vs 27.2%, P = 0.697). Overall rates of total mesorectal excision without sphincter preservation were similar between clinical stage II and III (30.0% vs 30.3%) and similar if preoperative treatment was chemoradiation (31.3%) or TNT (30.2%). Over the study period, proportion of cases approached laparoscopically increased from 24.9% to 32.5% and robotically 5.6% to 30.7% (P < 0.001). This cohort showed improved survival for MIS approaches compared to open surgery (laparoscopy HR 0.85, 95%CI 0.78-0.93, and robotic HR 0.82, 95%CI 0.73-0.92). CONCLUSION Sphincter preservation rates are similar across stage II and III rectal cancer, regardless of delivery of preoperative chemotherapy, chemoradiation, or both. At a national level, there is a shift to predominantly MIS approaches for rectal cancer, regardless of whether sphincter sparing procedure is performed.
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Affiliation(s)
- Celine Soriano
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
| | - Henry T Bahnson
- Benaroya Research Institute, Seattle, WA 98101, United States
| | - Jennifer A Kaplan
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
| | - Bruce Lin
- Department of Hematology Oncology, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
| | - Ravi Moonka
- Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
| | - Huong T Pham
- Department of Radiation Oncology, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
| | - Hagen F Kennecke
- Department of Medical Oncology, Providence Cancer Instititute, Portland, OR 97213, United States
| | - Vlad Simianu
- Section of Colon and Rectal Surgery, Department of Surgery, Virginia Mason Medical Center, Seattle, WA 98101, United States
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Lau LW, Kethman WC, Bingmer KE, Ofshteyn A, Steinhagen E, Charles R, Dietz D, Stein SL. Evaluating disparities in delivery of neoadjuvant guideline-based chemoradiation for rectal cancer: A multicenter, propensity score-weighted cohort study. J Surg Oncol 2021; 124:810-817. [PMID: 34159619 DOI: 10.1002/jso.26572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 05/26/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Despite guideline recommendations, some patients still receive care inappropriate for their clinical stage of disease. Identification of factors that contribute to variation in guideline base care may help eradicate disparities in the treatment of early and locally advanced rectal cancer. METHODS The American College of Surgeons National Cancer Database from 2010 to 2015 was analyzed with propensity score weighting to identify factors associated with delivery and omission of neoadjuvant guideline-based chemoradiation (GBC) for those with early and locally advanced rectal cancer. RESULTS Only 74% of patients with rectal cancer received stage-appropriate neoadjuvant chemoradiation; 4544 (88%) of those with early stage disease and 8675 (68%) in locally advanced disease. Chemotherapy and radiotherapy were not planned in 27% and 34% respectively, of those who did not receive GBC. Factors associated with receipt of non-guideline-based neoadjuvant chemoradiation were age >65 years, Medicare insurance, treatment at a community facility, West-South-Central geography, having locally advanced disease, and Charlson-Deyo score >3. Receipt of ideal guideline-based neoadjuvant chemoradiation conferred a survival benefit at 5 years. CONCLUSION Patient and non-patient factors contribute to disparities in guideline-based delivery of neoadjuvant chemoradiation in the treatment of rectal cancer. Identification of these risk factors are important to help standardize care and improve survival outcomes.
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Affiliation(s)
- Lung W Lau
- UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - William C Kethman
- UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Katherine E Bingmer
- UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Asya Ofshteyn
- UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Emily Steinhagen
- UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Ronald Charles
- UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - David Dietz
- UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Sharon L Stein
- UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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5
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Van den Broeck T, Oprea-Lager D, Moris L, Kailavasan M, Briers E, Cornford P, De Santis M, Gandaglia G, Gillessen Sommer S, Grummet JP, Grivas N, Lam TBL, Lardas M, Liew M, Mason M, O'Hanlon S, Pecanka J, Ploussard G, Rouviere O, Schoots IG, Tilki D, van den Bergh RCN, van der Poel H, Wiegel T, Willemse PP, Yuan CY, Mottet N. A Systematic Review of the Impact of Surgeon and Hospital Caseload Volume on Oncological and Nononcological Outcomes After Radical Prostatectomy for Nonmetastatic Prostate Cancer. Eur Urol 2021; 80:531-545. [PMID: 33962808 DOI: 10.1016/j.eururo.2021.04.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 04/19/2021] [Indexed: 12/13/2022]
Abstract
CONTEXT The impact of surgeon and hospital volume on outcomes after radical prostatectomy (RP) for localised prostate cancer (PCa) remains unknown. OBJECTIVE To perform a systematic review on the association between surgeon or hospital volume and oncological and nononcological outcomes following RP for PCa. EVIDENCE ACQUISITION Medline, Medline In-Process, Embase, and the Cochrane Central Register of Controlled Trials were searched. All comparative studies for nonmetastatic PCa patients treated with RP published between January 1990 and May 2020 were included. For inclusion, studies had to compare hospital or surgeon volume, defined as caseload per unit time. Main outcomes included oncological (including prostate-specific antigen persistence, positive surgical margin [PSM], biochemical recurrence, local and distant recurrence, and cancer-specific and overall survival) and nononcological (perioperative complications including need for blood transfusion, conversion to open procedure and within 90-d death, and continence and erectile function) outcomes. Risk of bias (RoB) and confounding assessments were undertaken. Both a narrative and a quantitative synthesis were planned if the data allowed. EVIDENCE SYNTHESIS Sixty retrospective comparative studies were included. Generally, increasing surgeon and hospital volumes were associated with lower rates of mortality, PSM, adjuvant or salvage therapies, and perioperative complications. Combining group size cut-offs as used in the included studies, the median threshold for hospital volume at which outcomes start to diverge is 86 (interquartile range [IQR] 35-100) cases per year. In addition, above this threshold, the higher the caseload, the better the outcomes, especially for PSM. RoB and confounding were high for most domains. CONCLUSIONS Higher surgeon and hospital volumes for RP are associated with lower rates of PSMs, adjuvant or salvage therapies, and perioperative complications. This association becomes apparent from a caseload of >86 (IQR 35-100) per year and may further improve hereafter. Both high- and low-volume centres should measure their outcomes, make them publicly available, and improve their quality of care if needed. PATIENT SUMMARY We reviewed the literature to determine whether the number of prostate cancer operations (radical prostatectomy) performed in a hospital affects the outcomes of surgery. We found that, overall, hospitals with a higher number of operations per year have better outcomes in terms of cancer recurrence and complications during or after hospitalisation. However, it must be noted that surgeons working in hospitals with lower annual operations can still achieve similar or even better outcomes. Therefore, making hospital's outcome data publicly available should be promoted internationally, so that patients can make an informed decision where they want to be treated.
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Affiliation(s)
| | - Daniela Oprea-Lager
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centres, VU University, Amsterdam, The Netherlands
| | - Lisa Moris
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Philip Cornford
- Department of Urology, Liverpool University Hospitals, Liverpool, UK
| | - Maria De Santis
- Department of Urology, Charité University Hospital, Berlin, Germany; Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Giorgio Gandaglia
- Unit of Urology, Division of Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Silke Gillessen Sommer
- Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Università della Svizzera Italiana, Lugano, Switzerland
| | - Jeremy P Grummet
- Department of Surgery, Central Clinical School, Monash University, Australia
| | - Nikos Grivas
- Department of Urology, Hatzikosta General Hospital, Ioannina, Greece
| | - Thomas B L Lam
- Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Michael Lardas
- Department of Urology, Metropolitan General Hospital, Athens, Greece
| | - Matthew Liew
- Department of Urology, Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan, UK
| | - Malcolm Mason
- Division of Cancer & Genetics, School of Medicine Cardiff University, Velindre Cancer Centre, Cardiff, UK
| | - Shane O'Hanlon
- Medicine for Older People, Saint Vincent's University Hospital, Dublin, Ireland
| | | | | | - Olivier Rouviere
- Hospices Civils de Lyon, Department of Urinary and Vascular Imaging, Hôspital Edouard Herriot, Lyon, France
| | - Ivo G Schoots
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands; Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Derya Tilki
- Martini-Klinik Prostate Cancer Centre, Hamburg, Germany; Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | | | - Henk van der Poel
- Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Thomas Wiegel
- Department of Radiation Oncology, University Hospital Ulm, Ulm, Germany
| | - Peter-Paul Willemse
- Department of Oncological Urology, University Medical Centre, Utrecht Cancer Centre, Utrecht, The Netherlands
| | - Cathy Y Yuan
- Department of Medicine, Health Science Centre, McMaster University, Hamilton, Ontario, Canada
| | - Nicolas Mottet
- Department of Urology, University Hospital, St. Etienne, France
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Stringfield SB, Fleshman JW. Specialization improves outcomes in rectal cancer surgery. Surg Oncol 2021; 37:101568. [PMID: 33848763 DOI: 10.1016/j.suronc.2021.101568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/24/2021] [Accepted: 03/28/2021] [Indexed: 01/23/2023]
Affiliation(s)
- Sarah B Stringfield
- Baylor University Medical Center, Department of Surgery, 3500 Gaston Ave, Dallas, TX, 75246, USA.
| | - James W Fleshman
- Baylor University Medical Center, Department of Surgery, 3500 Gaston Ave, Dallas, TX, 75246, USA
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Scheepers ERM, Schiphorst AH, van Huis-Tanja LH, Emmelot-Vonk MH, Hamaker ME. Treatment patterns and primary reasons for adjusted treatment in older and younger patients with stage II or III colorectal cancer. Eur J Surg Oncol 2021; 47:1675-1682. [PMID: 33563486 DOI: 10.1016/j.ejso.2021.01.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 01/10/2021] [Accepted: 01/29/2021] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE This study aims to assess age-related treatment patterns and primary reasons for adjusted treatment in patients with colorectal cancer. METHODS Patients with colorectal cancer stage II or III diagnosed between 2015 and 2018 in the Netherlands were eligible for this study. Data were provided by the Netherlands Cancer Registry and included socio-demographics, clinical characteristics, treatment patterns and primary reasons for adjusted treatment. Treatment patterns and reasons for adjusted treatment were analysed according to age groups. RESULTS Of all 29,620 patients, 30% were aged <65 years (n = 8994), 34% between 65 and 75 years (n = 10,173), 27% between 75 and 85 years (n = 8102) and 8% were ≥85 years (n = 2349). Irrespective of cancer location or stage, older patients received less frequently a combination of surgery and (neo)adjuvant therapy compared to younger patients (decreasing from 55% to 1% in colon cancer patients, and from 71% to 23% in rectal cancer patients aged <65 years and ≥85 years respectively). Omission of surgical treatment increased with age in both patients with colon cancer (ranging from 1% in patients aged <65 years to 16% in those ≥85 years) and rectal cancer (ranging from 12% in patients aged <65 years to 56% in those ≥85 years). The most common reasons for adjusted treatment were patient preference (27%) and functional status (20%), both reasons increased with advancing age. CONCLUSIONS Guideline non-adherence increased with advancing age and omission of standard treatment was mainly based on patient preference and functional status. These findings provides insight in the treatment decision-making process in patients with colorectal cancer. Future research is necessary to further assess patient's role in the treatment decision-making process.
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Affiliation(s)
- E R M Scheepers
- Department of Internal Medicine, Diakonessenhuis, Utrecht, the Netherlands.
| | - A H Schiphorst
- Department of Surgery, Diakonessenhuis, Utrecht, the Netherlands
| | - L H van Huis-Tanja
- Department of Internal Medicine, Diakonessenhuis, Utrecht, the Netherlands
| | - M H Emmelot-Vonk
- Department of Geriatric Medicine, University Medical Centre Utrecht, the Netherlands
| | - M E Hamaker
- Department of Geriatric Medicine, Diakonessenhuis, Utrecht, the Netherlands
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8
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Morris MC, Winer LK, Lee TC, Shah SA, Rafferty JF, Paquette IM. Omission of Adjuvant Chemotherapy in Rectal Cancer Patients with Pathologic Complete Response: a National Analysis. J Gastrointest Surg 2021; 25:1857-1865. [PMID: 32728821 PMCID: PMC7388436 DOI: 10.1007/s11605-020-04749-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/16/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND An increasing number of patients achieve a pathologic complete response (pCR) after neoadjuvant chemoradiation for locally advanced rectal cancer. Consensus guidelines continue to recommend oncologic resection followed by adjuvant chemotherapy in these patients. We hypothesize that there is significant variability in compliance with this recommendation. METHODS The National Cancer Database was queried from 2006 to 2015 for patients with locally advanced rectal cancer who underwent neoadjuvant chemoradiation followed by oncologic resection with a pCR (ypT0N0). Hierarchical logistic regression models were used to generate risk and reliability-adjusted rates of adjuvant chemotherapy utilization in patients with pCR at each hospital. RESULTS In total, 2421 pCR patients were identified. Five-year overall survival was improved in pCR patients who received adjuvant chemotherapy compared with those who did not (92 vs. 85%, p < 0.01). Multivariate analysis indicated that improvement in overall survival remained associated with adjuvant chemotherapy (HR 0.60, 95% CI 0.44-0.82, p < 0.01). The mean adjuvant chemotherapy utilization rate among hospitals was 32%. There was an upward trend in use over the past decade, but two-thirds still do not receive the recommended therapy. High chemotherapy utilizer hospitals were more likely to be academic centers (54.9 vs. 45.9%, p < 0.01) when compared with low chemotherapy utilizers. CONCLUSION Adjuvant chemotherapy is associated with improved survival in rectal cancer patients with pCR following neoadjuvant chemoradiation and oncologic resection. However, utilization among centers in the USA was only 32% with significant variability across centers. National efforts are needed to standardize treatment patterns according to national guidelines.
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Affiliation(s)
- Mackenzie C. Morris
- grid.24827.3b0000 0001 2179 9593Department of Surgery, College of Medicine, University of Cincinnati, 2123 Auburn Ave #524, Cincinnati, OH 45219 USA
| | - Leah K. Winer
- grid.24827.3b0000 0001 2179 9593Department of Surgery, College of Medicine, University of Cincinnati, 2123 Auburn Ave #524, Cincinnati, OH 45219 USA
| | - Tiffany C. Lee
- grid.24827.3b0000 0001 2179 9593Department of Surgery, College of Medicine, University of Cincinnati, 2123 Auburn Ave #524, Cincinnati, OH 45219 USA
| | - Shimul A. Shah
- grid.24827.3b0000 0001 2179 9593Department of Surgery, College of Medicine, University of Cincinnati, 2123 Auburn Ave #524, Cincinnati, OH 45219 USA
| | - Janice F. Rafferty
- grid.24827.3b0000 0001 2179 9593Department of Surgery, College of Medicine, University of Cincinnati, 2123 Auburn Ave #524, Cincinnati, OH 45219 USA
| | - Ian M. Paquette
- grid.24827.3b0000 0001 2179 9593Department of Surgery, College of Medicine, University of Cincinnati, 2123 Auburn Ave #524, Cincinnati, OH 45219 USA
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9
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Hayes IP, Milanzi E, Gibbs P, Reece JC. Neoadjuvant Chemoradiotherapy and Tumor Recurrence in Patients with Early T-Stage Cancer of the Lower Rectum. Ann Surg Oncol 2019; 27:1570-1579. [PMID: 31773520 DOI: 10.1245/s10434-019-08105-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND The role neoadjuvant chemoradiotherapy (nCRT) plays in oncological outcomes in early T-stage rectal cancer is uncertain. The present work aims to clarify prognostic outcomes by estimating the effect of nCRT on tumor recurrence prior to major surgery compared with major surgery alone. PATIENTS AND METHODS Prospectively collected data were retrospectively analyzed for patients diagnosed with localized rectal adenocarcinoma ≤ 8 cm from the anal verge, with final histopathology ≤ T2 (≤ ypT2/≤ pT2), regardless of magnetic resonance imaging staging, between 1990 and 2017. As the effect of nCRT on recurrence varied over time, thereby violating the Cox proportional hazards assumption, the effect of nCRT on recurrence hazards was estimated using a time-varying multivariate Cox model over two separate time intervals (≤ 1 year and > 1 year postsurgery) by nCRT. RESULTS Long-course nCRT was associated with a 5.6-fold increase in the hazard of recurrence ≤ 1 year postsurgery [hazard ratio (HR) 5.6; 95% confidence interval (CI) 1.2-24.9; P = 0.02], but there was no increase in recurrence hazards > 1 year (HR 0.84; 95% CI 0.4-2.0; P = 0.70). In subgroup analysis restricted to ≤ mrT2/≤ ypT2 and ≤ pT2 tumors (omitting > mrT2 tumors), the effect of nCRT on recurrence no longer varied over time, indicating that tumor heterogeneity was responsible for the observed increased recurrence hazards ≤ 1 year postsurgery; That is, > mrT2 tumors that were downstaged to ≤ ypT2 after nCRT were responsible for the time-varying effects of nCRT and increased recurrence hazards ≤ 1 year postsurgery. Subsequently, no difference was found in prognostic outcomes either with or without nCRT before surgery in the homogeneous population of ≤ mrT2/≤ ypT2 and ≤ pT2 tumors. CONCLUSIONS No evidence was found to indicate that nCRT prior to surgery reduces tumor recurrence in early T-stage lower rectal cancer compared with surgery alone.
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Affiliation(s)
- Ian P Hayes
- Colorectal Surgery Unit, Suite 2, Private Medical Centre, Royal Melbourne Hospital, Parkville, VIC, Australia. .,Department of Surgery, The University of Melbourne, Parkville, VIC, Australia.
| | - Elasma Milanzi
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, VIC, Australia.,Victorian Centre for Biostatistics, Melbourne, VIC, Australia
| | - Peter Gibbs
- Personalised Oncology Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia.,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia.,Department of Medical Oncology, Western Health, Melbourne, VIC, Australia
| | - Jeanette C Reece
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, VIC, Australia.,The University of Melbourne Centre for Cancer Research, The University of Melbourne, Parkville, VIC, Australia
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Swords DS, Brooke BS, Skarda DE, Stoddard GJ, Tae Kim H, Sause WT, Scaife CL. Facility Variation in Local Staging of Rectal Adenocarcinoma and its Contribution to Underutilization of Neoadjuvant Therapy. J Gastrointest Surg 2019; 23:1206-1217. [PMID: 30421120 DOI: 10.1007/s11605-018-4039-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 10/25/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Guidelines recommend neoadjuvant therapy (NT) for clinical stage II-III (locally advanced) rectal adenocarcinoma, but utilization remains suboptimal. The causes of NT omission remain poorly understood. METHODS The main outcomes in this study of patients with resected clinically non-metastatic rectal adenocarcinoma in the 2010-2015 National Cancer Database were local staging utilization in patients with non-metastatic tumors (i.e., undocumented clinical stage/pathologic stage I-III) and NT utilization for locally advanced tumors. Multivariable regression was used to examine predictors of these outcomes. Facility-specific risk- and reliability-adjusted local staging and NT rates were calculated. Positive margins and overall survival (OS) were examined as secondary outcomes. RESULTS Local staging was omitted in 7737/43,819 (17.7%) patients with clinically non-metastatic tumors and NT was omitted in 5199/31,632 (16.4%) patients with locally advanced tumors. NT was utilized in 24,826 (91.1%) locally advanced patients who had local staging vs. 1607 (36.6%) patients who did not; 2785 (53.6%) locally advanced patients with NT omitted also had local staging omitted. Treatment at facilities with lowest quintile local staging rates was associated with NT omission (relative risk 2.41, 95% confidence interval 2.11, 2.75). Adjusted facility local staging rates varied sixfold (16.1-98.0%), facility NT rates varied twofold (43.9-95.9%), and they were correlated (r = 0.58; P < 0.001). Local staging omission and NT omission were independently associated with positive margins and decreased OS. CONCLUSIONS Local staging omission is a common care process in over half of cases of omitted NT. These data emphasize the need for quality improvement efforts directed at providing facilities feedback about their local staging rates.
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Affiliation(s)
- Douglas S Swords
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA.
- Surgical Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA.
| | - Benjamin S Brooke
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA
| | - David E Skarda
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA
- Surgical Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Gregory J Stoddard
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - H Tae Kim
- Surgical Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | - William T Sause
- Oncology Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Courtney L Scaife
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA
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Swords DS, Skarda DE, Sause WT, Gawlick U, Cannon GM, Lewis MA, Scaife CL, Gygi JA, Tae Kim H. Surgeon-Level Variation in Utilization of Local Staging and Neoadjuvant Therapy for Stage II-III Rectal Adenocarcinoma. J Gastrointest Surg 2019; 23:659-669. [PMID: 30706375 DOI: 10.1007/s11605-019-04107-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 01/04/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Neoadjuvant therapy (NT) is the standard of care for clinical stage II-III rectal adenocarcinoma, but utilization remains suboptimal. We aimed to determine the underlying reasons for omission of local staging and NT. METHODS We conducted a retrospective study of patients with clinical stage II-III or undocumented clinical stage/pathologic stage II-III rectal adenocarcinoma who were treated in 2010-2016 in one of nine Intermountain Healthcare hospitals. The outcomes of omission of local staging and NT were examined with multivariable models. Risk- and reliability-adjusted rates of local staging and NT were calculated for surgeons who treated ≥ 3 patients. Pathologic and long-term outcomes were examined after excluding patients who were not resected or who underwent local excision (N = 11). RESULTS Local staging was omitted in 43/240 (17.9%) patients and NT was omitted in 41/240 (17.1%). The strongest risk factors for local staging and NT omission were upper rectal tumors and surgeons who treated ≤ 3 cases/year. Thirty-six of 41 (87.8%) cases of omitted NT had local staging omitted. Adjusted surgeon-specific local staging rates varied 1.6-fold (56.3-92.4%) and NT rates varied 2.8-fold (34.1-97.1%). Surgeon local staging and NT rates were strongly correlated (r = 0.92). NT was associated with lower rates of positive circumferential radial margins (7.9 vs. 20.0%; P = 0.02), node positivity (33.3 vs. 55.0%; P = 0.01), and local recurrences (7.6 vs. 14.9% at 5 years; P = 0.0176). CONCLUSIONS NT omission should be understood as a consequence of surgeon failure to perform local staging in most cases. Quality improvement efforts should focus on improving utilization of local staging.
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MESH Headings
- Adenocarcinoma/mortality
- Adenocarcinoma/pathology
- Adenocarcinoma/therapy
- Adult
- Aged
- Aged, 80 and over
- Chemoradiotherapy, Adjuvant/standards
- Chemoradiotherapy, Adjuvant/statistics & numerical data
- Female
- Follow-Up Studies
- Healthcare Disparities/statistics & numerical data
- Humans
- Male
- Margins of Excision
- Middle Aged
- Neoadjuvant Therapy/standards
- Neoadjuvant Therapy/statistics & numerical data
- Neoplasm Recurrence, Local/epidemiology
- Neoplasm Recurrence, Local/etiology
- Neoplasm Recurrence, Local/prevention & control
- Neoplasm Staging
- Practice Patterns, Physicians'/standards
- Practice Patterns, Physicians'/statistics & numerical data
- Procedures and Techniques Utilization/standards
- Procedures and Techniques Utilization/statistics & numerical data
- Proctectomy
- Quality Assurance, Health Care
- Quality Indicators, Health Care/statistics & numerical data
- Rectal Neoplasms/mortality
- Rectal Neoplasms/pathology
- Rectal Neoplasms/therapy
- Reproducibility of Results
- Retrospective Studies
- Surgeons/standards
- Surgeons/statistics & numerical data
- Treatment Outcome
- United States/epidemiology
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Affiliation(s)
- Douglas S Swords
- Surgical Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA.
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA.
| | - David E Skarda
- Surgical Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA
| | - William T Sause
- Oncology Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Ute Gawlick
- Surgical Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | - George M Cannon
- Oncology Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Mark A Lewis
- Oncology Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Courtney L Scaife
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA
| | - Jesse A Gygi
- Oncology Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | - H Tae Kim
- Surgical Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
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Tinawi G, Gunawardene A, Shekouh A, Larsen PD, Dennett ER. Neoadjuvant therapy in rectal cancer: how are we choosing? ANZ J Surg 2018; 89:68-73. [DOI: 10.1111/ans.14935] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 09/12/2018] [Accepted: 10/02/2018] [Indexed: 12/31/2022]
Affiliation(s)
- Georges Tinawi
- Department of Surgery and Anaesthesia; University of Otago; Wellington New Zealand
| | - Ashok Gunawardene
- Department of Surgery and Anaesthesia; University of Otago; Wellington New Zealand
- Department of General Surgery; Wellington Regional Hospital; Wellington New Zealand
| | - Ali Shekouh
- Department of Surgery and Anaesthesia; University of Otago; Wellington New Zealand
- Department of General Surgery; Wellington Regional Hospital; Wellington New Zealand
| | - Peter D. Larsen
- Department of Surgery and Anaesthesia; University of Otago; Wellington New Zealand
| | - Elizabeth R. Dennett
- Department of Surgery and Anaesthesia; University of Otago; Wellington New Zealand
- Department of General Surgery; Wellington Regional Hospital; Wellington New Zealand
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