How can we utilize local excision to help, not harm, geriatric patients with rectal cancer?

Local vs radical resection of stage I-III rectal cancer in very elderly patients: an exact matched analysis of the National Cancer Database

BACKGROUND

Treatment of elderly patients with cancer is challenging as they can be overtreated with respect to frailty or undertreated because of advanced age. Maintaining a good quality of life is essential for this population. This study aimed to assess the difference in overall survival and short-term outcomes according to the extent of rectal cancer resection in patients aged ≥80 years.

METHODS

In this retrospective cohort study, very elderly patients with stage I-III rectal cancer aged ≥80 years were identified from the National Cancer Database (2004-2019). Patients were divided into 2 groups: radical resection and local excision. The groups were matched using exact matched analysis for clinical T and N stage, tumor size, and neoadjuvant treatment. The main outcome measures were overall survival, hospital stay, 30-day unplanned readmissions, and short-term mortality.

RESULTS

A total of 9634 patients were included (local excision = 2710; radical resection = 6924). After matching, 1106 patients were included in each group with a median follow-up of 49.9 and 51.7 months, respectively. The radical resection group had statistically significantly longer overall survival than did the local excision group (60 vs 57.2 months, P = .026). Local excision was associated with shorter length of stay (1 vs 7 days. P < .001), lower 30-day mortality (odds ratio: 0.43; 95% CI: 0.25-0.75, P = .003), lower 90-day mortality (odds ratio: 0.47, 95% CI: 0.32-0.68, P < .001), and lower 30-day readmission (odds ratio: 0.49, 95% CI: 0.33-0.74, P < .001). A subgroup analysis of matched patients with cTis-T2 and N0 tumors who underwent curative surgery revealed similar results.

CONCLUSION

Radical resection of rectal cancer in very elderly patients has a modest survival benefit, whereas local excision has lower odds of readmission and short-term mortality.

Functional Outcomes after Transanal Surgery

Transanal surgery has gained in popularity during the latter part of the last decade for both rectal cancer and benign disease. The current role for local excision of early rectal neoplastic lesions has expanded due to better understanding of risk factors for lymph node metastasis and heightened awareness for the long-term sequelae of radical surgery. Transanal resection of the rectum (both for cancer or inflammatory bowel diseases) has now been established as a successful procedure that overcomes some of the limitations of the abdominal approaches. Once the feasibility, safety, and the oncologic results of transanal minimally invasive approaches for patients with rectal cancer have been acknowledged, quality of life and functional outcomes have become increasingly important issues. This article provides an overview of the different techniques currently available for the minimally invasive transanal treatment of rectal lesions, particularly focusing on functional outcomes.