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Anderson CE, Liska D. Treatment of Microsatellite-Unstable Rectal Cancer in Sporadic and Hereditary Settings. Clin Colon Rectal Surg 2024; 37:233-238. [PMID: 38882941 PMCID: PMC11178385 DOI: 10.1055/s-0043-1770717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
Microsatellite instability is rare in rectal cancer and associated with younger age of onset and Lynch syndrome. All rectal cancers should be tested for microsatellite instability prior to treatment decisions. Patients with microsatellite instability are relatively resistant to chemotherapy. However, recent small studies have shown dramatic response with neoadjuvant immunotherapy. Patients with Lynch syndrome have a hereditary predisposition to cancer and thus an elevated risk of metachronous cancer. Therefore, while "watch and wait" is a well-established practice for sporadic rectal cancers that obtain a complete clinical response after chemoradiation, its safety in patients with Lynch syndrome has not yet been defined. The extent of surgery for patients with Lynch syndrome and rectal cancer is controversial and there is significant debate as to the relative advantages of a segmental proctectomy with postoperative endoscopic surveillance versus a therapeutic and prophylactic total proctocolectomy. Surgical decision making for the patient with Lynch syndrome and rectal cancer is complex and demands a multidisciplinary approach, taking into account both patient- and tumor-specific factors. Neoadjuvant immunotherapy show great promise in the treatment of these patients, and further maturation of data from prospective trials will likely change the current treatment paradigm. Patients with Lynch syndrome and rectal cancer who do not undergo total proctocolectomy require yearly surveillance colonoscopies and should consider chemoprophylaxis with aspirin.
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Affiliation(s)
- Cristan E. Anderson
- Department of Colon and Rectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - David Liska
- Department of Colon and Rectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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2
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Krasnick BA, Kalady MF. Management of Rectal Cancer in Lynch Syndrome: Balancing Risk Reduction and Quality of Life. Clin Colon Rectal Surg 2024; 37:180-184. [PMID: 38606049 PMCID: PMC11006439 DOI: 10.1055/s-0043-1770730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
Patients with Lynch syndrome are predisposed to developing colorectal cancer and a variety of extracolonic malignancies, at a young age. The management of rectal cancer in the setting of Lynch syndrome is a complex clinical scenario that requires the expertise of a multidisciplinary management team. In this review, we delve into the approach for rectal cancer in these patients, and specifically focus on several key aspects of treatment. Some unique aspects of rectal cancer in Lynch syndrome include the decision between proctectomy alone versus total proctocolectomy with or without an ileal pouch, the utility of chemotherapy and immunotherapy, nonoperative rectal cancer management, and the management of rectal polyps. Throughout, we highlight the delicate interplay between future cancer risk reduction and quality of life optimization.
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Affiliation(s)
- Bradley A. Krasnick
- Division of Colorectal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Matthew F. Kalady
- Division of Colorectal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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3
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Asai M, Dobesh KD. Combined Resection Approaches: Decision Making for Synchronous Resection, Timing of Staged Intervention to Optimize Outcome. Clin Colon Rectal Surg 2024; 37:96-101. [PMID: 38322604 PMCID: PMC10843888 DOI: 10.1055/s-0043-1761475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Advancement in systemic and regional radiation therapy, surgical technique, and anesthesia has provided a path for increased long-term survival and potential cure for more patients with stage IV rectal cancer in recent years. When patients have resectable disease, the sequence for surgical resection is classified in three strategies: classic, simultaneous, or combined, and reversed. The classic approach consists of rectal cancer resection followed by metastatic disease at a subsequent operation. Simultaneous resection addresses both rectal and metastatic disease in a single surgery. The reversed approach treats metastatic disease first, followed by the primary tumor in several months. Simultaneous resection is appropriate for selected patients to avoid delay of definitive surgery, and reduce number of surgeries, hospital stay, and cost to the health care system. It may also improve patients' psychological effect. Multidisciplinary discussions including colorectal and liver surgeons to review patients' baseline medical conditions, tumor biology and behavior, and disease burden and distribution is imperative to guide proper patient selection for simultaneous resection and perioperative treatments.
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Affiliation(s)
- Megumi Asai
- Division of Colon and Rectal Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Kaitlyn D. Dobesh
- Division of Colon and Rectal Surgery, Henry Ford Hospital, Detroit, Michigan
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4
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Liang JT, Chen TC, Liao YT, Huang J, Hung JS. Impact of positron-emission tomography on the surgical treatment of locoregionally recurrent colorectal cancer. Asian J Surg 2024; 47:923-932. [PMID: 38042659 DOI: 10.1016/j.asjsur.2023.10.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/09/2023] [Accepted: 10/27/2023] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND The effect of positron emission tomography (PET) on the surgical treatment of locoregionally recurrent colorectal cancer (LRRCRC) remains unclear and warrants further investigation. MATERIAL AND METHODS A total of 193 patients with LRRCRC were identified from a prospectively maintained institutional database, of whom 134 LRRCRCs were deemed resectable and underwent resection with curative intent, whereas the remaining 59 LRRCRCs were unresectable. Patients with resectable LRRCRC were further classified according to whether recurrence was detected solely by PET (n = 35, PET-only group) or by a combination of computed tomography (CT)/magnetic resonance imaging (MRI) and PET (n = 99, CT/MRI/PET group). Clinicopathologic features, operative morbidity/mortality, and overall survival were compared between the patient groups based on long-term follow-up for at least 5 years. RESULTS Patients in the PET-only group tended to have less extensive organ resection (p = 0.0074), less blood loss (p < 0.0001), and shorter operation time and hospitalization (p < 0.0001), but surgical complication and readmission rates were not significantly different (p > 0.05) compared with the CT/MRI/PET group. Although the PET-only group had significantly higher R0 resection rate (80 % vs. 54.55 %, p = 0.0079), they also had a higher risk (17.14 % vs. 2.02 %, p = 0.0011) of sham operation. The estimated 5-year and 10-year survival rates significantly decreased in order (p < 0.0001) from PET-only (85.71 % and 57.98 %) and CT/MRI/PET (41.41 % and 15.93 %) to unresectable group of patients (16.95 % and 1.88 %). Subset analysis of the CT/MRI/PET group indicated that PET improved surgical decision-making because 24 (24.2 %) LRRCRCs that manifested on CT/MRI as equivocal lesions were later confirmed by PET as resectable recurrences, while 18 (19.4 %) LRRCRCs that manifested on CT/MRI as resectable lesions were later diagnosed by PET as more disseminated unresectable recurrences and precluded futile surgery. CONCLUSION PET alone can identify a subset (20.9 %) of LRRCRCs with less tumor burden for timely surgery; PET in combination with CT/MRI can better define the resectability of LRRCRCs. The positive impacts of PET can translate into better surgical outcomes, with enhanced safety and patient survival.
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Affiliation(s)
- Jin-Tung Liang
- Division of Colorectal Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan.
| | - Tzu-Chun Chen
- Department of Surgical Oncology, National Taiwan University Cancer Center, Taiwan
| | - Yu-Tso Liao
- Division of Colorectal Surgery, Department of Surgery, National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu, Taiwan
| | - John Huang
- Division of Colorectal Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Ji-Shiang Hung
- Division of Colorectal Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
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Nofal S, You YN, Chang GJ, Grubbs EG, Bednarski B. Development of an Online Curriculum for Surgeons on the Use of Pelvic Magnetic Resonance Imaging in Rectal Cancer and Results of a Pilot Study. J Surg Res 2022; 270:279-285. [PMID: 34717261 PMCID: PMC8712389 DOI: 10.1016/j.jss.2021.08.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 07/19/2021] [Accepted: 08/28/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND High-resolution pelvic magnetic resonance imaging (MRI) is a critical tool in the management of patients with rectal cancer. An on-line curriculum was developed for surgical trainees on the interpretation of pelvic MRI in rectal cancer for clinical staging and surgical planning. METHODS The online curriculum was developed using the six-step approach to curriculum development for medical education. The curriculum incorporated case-based learning, annotated videos, and narrated presentations on key aspects of pelvic MRI in rectal cancer. A pilot study was conducted to assess curriculum effectiveness among Complex General Surgical Oncology (CGSO) fellows using pre- and post-intervention assessments. RESULTS Of 15 eligible fellows, nine completed the pilot study (60%). The fellows' median confidence score after completing the online curriculum (40, IQR: 33-46) was significantly higher than their baseline median confidence score (23, IQR: 14-30), P = 0.0039. The total practical assessment score significantly increased from a pre-median score of 9 (IQR: 8-11) to a post-median score of 14 (IQR: 13-14), P = 0.0078. A subgroup analysis revealed a significant change in the knowledge assessment with a median score of 7 compared to a baseline median score of 4, Z = 2.64, P = 0.0078. However, the skills assessment showed no significant change. CONCLUSIONS The case-based online curriculum had a positive impact on CGSO fellows' knowledge and confidence in the utilization of pelvic MRI for patients with rectal cancer. This unique on-line curriculum demonstrates a mechanism to enhance shared educational collaboration across CGSO fellowships and other surgical training programs.
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Affiliation(s)
- Sara Nofal
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Y. Nancy You
- Department of Colon and Rectal Surgery, University of Texas MD Anderson Cancer Center, Houston, TX
| | - George J. Chang
- Department of Colon and Rectal Surgery, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elizabeth G. Grubbs
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Brian Bednarski
- Department of Colon and Rectal Surgery, University of Texas MD Anderson Cancer Center, Houston, TX,Corresponding Author: Brian K. Bednarski, MD, 1400 Pressler Street, Unit 1484, Houston, TX 77030,
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Bajpai S, Wood L, Cannon JA, Chu DI, Hollis RH, Gunnells DJ, Hardiman KM, Kennedy GD, Morris MS. Multidisciplinary clinics for colorectal cancer may not provide more efficient coordination of care. Am J Surg 2021; 223:1167-1171. [PMID: 34895698 DOI: 10.1016/j.amjsurg.2021.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 11/22/2021] [Accepted: 11/29/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND This retrospective study compares a multidisciplinary clinic (MDC) to standard care for time to treatment of colorectal cancer. METHODS We queried our institutional ACS-NSQIP database for patients undergoing surgery for colorectal cancer from 2017 to 2020. Patients were stratified by initial clinic visit (MDC vs control). Primary endpoint was the time to start treatment (TST), either neoadjuvant therapy or surgery, from the date of diagnosis by colonoscopy. RESULTS A total of 405 patients were evaluated (115 MDC, 290 Control). TST from diagnosis was not significantly shorter for the MDC cohort (MDC 30 days, Control 37 days; p = 0.07) even when stratified by type of initial treatment of neoadjuvant therapy (MDC 30, Control 34 days; p = 0.28) or surgery (MDC 32.5 days, Control 38 days; p = 0.35). CONCLUSION Implementation of an MDC provides insignificant reduction in delay to start treatment for colorectal cancer patients as compared to standard care colorectal surgery clinics. CLASSIFICATION Colorectal.
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Affiliation(s)
- Swara Bajpai
- Department of Surgery, University of Alabama at Birmingham, AL, USA.
| | - Lauren Wood
- Department of Surgery, University of Alabama at Birmingham, AL, USA
| | - Jamie A Cannon
- Department of Surgery, University of Alabama at Birmingham, AL, USA
| | - Daniel I Chu
- Department of Surgery, University of Alabama at Birmingham, AL, USA
| | - Robert H Hollis
- Department of Surgery, University of Alabama at Birmingham, AL, USA
| | - Drew J Gunnells
- Department of Surgery, University of Alabama at Birmingham, AL, USA
| | - Karin M Hardiman
- Department of Surgery, University of Alabama at Birmingham, AL, USA
| | | | - Melanie S Morris
- Department of Surgery, University of Alabama at Birmingham, AL, USA
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The Effects of Multidisciplinary Team Meetings on Clinical Practice for Colorectal, Lung, Prostate and Breast Cancer: A Systematic Review. Cancers (Basel) 2021; 13:cancers13164159. [PMID: 34439312 PMCID: PMC8394238 DOI: 10.3390/cancers13164159] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/29/2021] [Accepted: 08/16/2021] [Indexed: 02/06/2023] Open
Abstract
Simple Summary Multidisciplinary team meetings have increasingly been implemented in cancer care worldwide to ensure timely, accurate and evidence-based diagnosis, and treatment plans. Nowadays, multidisciplinary team meetings are generally considered indispensable. However, they are considered time-consuming and expensive, while the effects of multidisciplinary team meetings are not yet fully understood. The aim of this systematic review is to update and summarize the literature and create an overview of the existing knowledge. Cancer types such as colorectal, lung, prostate and breast cancer with rapidly increasing incidence rates will inevitably impact the workload of clinicians. Understanding the effects of the widely implemented multidisciplinary team meetings in oncology care is fundamental in order to optimize care pathways and allocate resources in the rapidly diversifying landscape of cancer therapies. Abstract Objective: The aim of our systematic review is to identify the effects of multidisciplinary team meetings (MDTM) for lung, breast, colorectal and prostate cancer. Methods: Our systematic review, performed following PRISMA guidelines, included studies examining the impact of MDTMs on treatment decisions, patient and process outcomes. Electronic databases PUBMED, EMBASE, Cochrane Library and Web of Science were searched for articles published between 2000 and 2020. Risk of bias and level of evidence were assessed using the ROBINS-I tool and GRADE scale. Results: 41 of 13,246 articles were selected, evaluating colorectal (21), lung (10), prostate (6) and breast (4) cancer. Results showed that management plans were changed in 1.6–58% of cases after MDTMs. Studies reported a significant impact of MDTMs on surgery type, and a reduction of overall performed surgery after MDTM. Results also suggest that CT and MRI imaging significantly increased after MDTM implementation. Survival rate increased significantly with MDTM discussions according to twelve studies, yet three studies did not show significant differences. Conclusions: Despite heterogeneous data, MDTMs showed a significant impact on management plans, process outcomes and patient outcomes. To further explore the impact of MDTMs on the quality of healthcare, high-quality research is needed.
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Wexner SD. High-Intensity vs Low-Intensity Knowledge Translation and Performance Metrics in Patients With Rectal Cancer. JAMA Netw Open 2021; 4:e2119393. [PMID: 34269811 DOI: 10.1001/jamanetworkopen.2021.19393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston
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9
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Basendowah M, Awlia AM, Alamoudi HA, Ali Kanawi HM, Saleem A, Malibary N, Hijazi H, Alfawaz M, Alzahrani AH. Impact of optional multidisciplinary tumor board meeting on the mortality of patients with gastrointestinal cancer: A retrospective observational study. Cancer Rep (Hoboken) 2021; 4:e1373. [PMID: 33739628 PMCID: PMC8388160 DOI: 10.1002/cnr2.1373] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/17/2021] [Accepted: 02/21/2021] [Indexed: 12/24/2022] Open
Abstract
Background Multidisciplinary tumor board meetings (MDTs) have shown a positive effect on patient care and play a role in the planning of care. However, there is limited evidence of the association between MDTs and patient mortality and in‐hospital morbidity for mixed cases of gastrointestinal (GI) cancer. Aim To evaluate the influence of optional MDTs on care of patients with cancer to determine potential associations between MDTs and patient mortality and morbidity. Methods and results This was a retrospective observational study at the referral center of King Abdulaziz University Hospital, Jeddah, Kingdom of Saudi Arabia. Among all adult patients diagnosed with GI cancer from January 2017 to June 2019, 130 patients were included. We categorized patients into two groups: 66 in the control group (non‐MDT) and 64 in the MDT group. The main outcome measure was overall mortality, measured by survival analysis. The follow‐up was 100% complete. Four patients in the MDT group and 13 in the non‐MDT group died (P = .04). The median follow‐up duration was 294 days (interquartile range [IQR], 140‐434) in the non‐MDT group compared with 176 days (IQR, 103‐466) in the MDT group (P = .20). There were no differences in intensive care unit or hospital length‐of‐stay or admission rates. The overall mortality at 2 years was 13% (95% confidence interval [CI], 0.06‐0.66) in the MDT group and 38% (95% CI, 0.10‐0.39) in the non‐MDT group (P = .08). The MDT group showed a 72% (adjusted hazard ratio [HR], 0.28; 95% CI, 0.08‐0.90; P = .03) decrease in mortality over time compared with the non‐MDT group. Conclusions MDTs were associated with decreased mortality over time. Thus, MDTs have a positive influence on patient care by improving survival and should be incorporated into care.
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Affiliation(s)
- Mohammed Basendowah
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
| | - Alaa M Awlia
- Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
| | - Hanin A Alamoudi
- Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
| | - Hala M Ali Kanawi
- Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
| | - Abdulaziz Saleem
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
| | - Nadim Malibary
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
| | - Hussam Hijazi
- Radiology Department, Radiation Oncology Unit, Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
| | - Mohammed Alfawaz
- Department of Medicine, University of Jeddah, Jeddah, Kingdom of Saudi Arabia
| | - Anas H Alzahrani
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.,Clinical Research Education Program, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Biju K, Zhang GQ, Stem M, Sahyoun R, Safar B, Atallah C, Efron JE, Rajput A. Impact of Treatment Coordination on Overall Survival in Rectal Cancer. Clin Colorectal Cancer 2021; 20:187-196. [PMID: 33618972 DOI: 10.1016/j.clcc.2021.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 01/15/2021] [Accepted: 01/17/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Rectal cancer treatment is often multimodal, comprising of surgery, chemotherapy, and radiotherapy. However, the impact of coordination between these modalities is currently unknown. We aimed to assess whether delivery of nonsurgical therapy within same facility as surgery impacts survival in patients with rectal cancer. METHODS A patient cohort with rectal cancer stages II to IV who received multimodal treatment between 2004 and 2016 from National Cancer Database was retrospectively analyzed. Patients were categorized into three groups: (A) surgery + chemotherapy + radiotherapy at same facility (surgery + 2); (B) surgery + chemotherapy or radiotherapy at same facility (surgery + 1); or (C) only surgery at reporting facility (chemotherapy + radiotherapy elsewhere; surgery + 0). The primary outcome was 5-year overall survival (OS), analyzed using Kaplan-Meier curves, log-rank tests, and Cox proportional-hazards models. RESULTS A total of 44,716 patients (16,985 [37.98%] surgery + 2, 12,317 [27.54%] surgery + 1, and 15,414 [34.47%] surgery + 0) were included. In univariate analysis, we observed that surgery+2 patients had significantly greater 5-year OS compared to surgery + 1 or surgery + 0 patients (5-year OS: 63.46% vs 62.50% vs 61.41%, respectively; P= .002). We observed similar results in multivariable Cox proportional-hazards analysis, with surgery + 0 group demonstrating increased hazard of mortality when compared to surgery + 2 group (HR: 1.09; P< .001). These results held true after stratification by stage for stage II (HR 1.10; P= .022) and stage III (HR 1.12; P< .001) but not for stage IV (P= .474). CONCLUSION Greater degree of care coordination within the same facility is associated with greater OS in patients with stage II to III rectal cancer. This finding illustrates the importance of interdisciplinary collaboration in multimodal rectal cancer therapy.
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Affiliation(s)
- Kevin Biju
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - George Q Zhang
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Miloslawa Stem
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rebecca Sahyoun
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Bashar Safar
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Chady Atallah
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jonathan E Efron
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ashwani Rajput
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
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Wong DL, Hendrick LE, Guerrero WM, Monroe JJ, Hinkle NM, Deneve JL, Dickson PV, Glazer ES, Shibata D. Adherence to neoadjuvant therapy guidelines for locally advanced rectal cancers in a region with sociodemographic disparities. Am J Surg 2020; 222:395-401. [PMID: 33279169 DOI: 10.1016/j.amjsurg.2020.11.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 11/17/2020] [Accepted: 11/25/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Practice guidelines recommend neoadjuvant chemoradiation (NCR) for locally advanced rectal cancer (LARC). We examined guideline adherence in a healthcare system serving a region with socioeconomic disparities and poor cancer outcomes. METHODS Retrospective analysis of factors associated with guideline adherence. RESULTS 63.1% of stage II/III LARC patients received NCR. Factors associated with adherence included white race (OR = 2.15, p = 0.024), private insurance (OR = 2.70, p = 0.005), employed status (OR = 2.30, p = 0.031), age at diagnosis (OR = 0.74, p = 0.032), appropriate local staging (OR = 9.17, p < 0.0001), and diagnosis later in the study period (OR per 1 year = 1.20, p = 0.006). By multivariate analysis, private insurance (OR = 2.51, p = 0.023), younger age (OR per 10 years = 0.72, p = 0.048) and appropriate local staging (OR = 6.67, p < 0.0001) were associated with adherence. CONCLUSION Guideline adherence for LARC in our system is low and is impacted by employment, race and insurance status. Standard of care compliance remains an important target for improvement efforts in this underserved region of the nation's Mid-South.
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Affiliation(s)
- Denise L Wong
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Ave, Suite 300, Memphis, TN, 38163, USA
| | - Leah E Hendrick
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Ave, Suite 300, Memphis, TN, 38163, USA
| | - Whitney M Guerrero
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Ave, Suite 300, Memphis, TN, 38163, USA
| | - Justin J Monroe
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Ave, Suite 300, Memphis, TN, 38163, USA
| | - Nathan M Hinkle
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Ave, Suite 300, Memphis, TN, 38163, USA
| | - Jeremiah L Deneve
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Ave, Suite 300, Memphis, TN, 38163, USA
| | - Paxton V Dickson
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Ave, Suite 300, Memphis, TN, 38163, USA
| | - Evan S Glazer
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Ave, Suite 300, Memphis, TN, 38163, USA
| | - David Shibata
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Ave, Suite 300, Memphis, TN, 38163, USA.
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12
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Gilshtein H, Wexner SD. National Accreditation Program for Rectal Cancer. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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13
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Brenner BM, De Donno MA. Assessing Gaps in Surgical Oncology Training: Results of a Survey of General Surgery Residents. JOURNAL OF SURGICAL EDUCATION 2020; 77:749-756. [PMID: 32063511 DOI: 10.1016/j.jsurg.2020.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 01/16/2020] [Accepted: 01/21/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Many general surgeons devote a significant amount of time and effort to the care of cancer patients. There is currently no standardized, national curriculum in Surgical Oncology for General Surgery residents. The objective of this study was to identify gaps in oncology education among General Surgery residents. DESIGN An anonymous survey design was used in the present study. Residents received an invitation to participate along with a link to an online survey. Interested residents selected the link and completed the 10 minute survey. Binomial logistic regression was performed to ascertain the effects of postgraduate year (PGY) on various perceptions and knowledge relating to surgical oncology. SETTING The participants included residents from 3 General Surgery residency programs including Florida Atlantic University, The University of Iowa and The University of Connecticut. These are all university-based programs, but residents in each program rotate at several sites each, including both university and community hospitals. PARTICIPANTS Participants included clinical PGY 1 to 5 categorical general surgical residents, as well as PGY 1 and 2 General Surgery preliminary residents. A total of 135 residents received the email with the link to the survey. Forty-nine residents from all PGY levels responded to the survey. RESULTS Twenty-one percent of the respondents were familiar with American College of Surgeons Commission on Cancer accreditation, which is a major means of maintaining standards in cancer care across institutions in the United States The majority of residents did not receive formal training in such key areas as chemotherapy and radiation therapy basics, survivorship, palliative care, pain management, and cancer screening regimens. These responses were not significantly different across different levels of training. Most importantly, many residents, particularly those in PGY 3 to 5, do not feel that they will be fully prepared to care for cancer patients at the completion of their training. CONCLUSIONS The present study provides evidence that regardless of PGY year, residents do not achieve adequate exposure to a variety of cancer-related topics. These include both multidisciplinary cancer care and the operation, accreditation and administration of certified cancer centers. Further, it appears residents do not feel well prepared to provide optimal cancer care at the completion of their training. This data supports the development of a more comprehensive Surgical Oncology curriculum for General Surgery trainees.
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Affiliation(s)
- Bruce M Brenner
- Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida.
| | - Michael A De Donno
- Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida
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Pooni A, Schmocker S, Brown C, MacLean A, Williams L, Baxter NN, Simunovic M, Liberman AS, Drolet S, Neumann K, Jhaveri K, Kirsch R, Kennedy ED. The Canadian Partnership Against Cancer Rectal Cancer Project: Protocol for a Pan-Canadian, Multidisciplinary Quality Improvement Initiative to Optimize the Quality of Rectal Cancer Care. JMIR Res Protoc 2020; 9:e15535. [PMID: 32012108 PMCID: PMC7016615 DOI: 10.2196/15535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/27/2019] [Accepted: 09/28/2019] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Over the last 2 decades, the use of multimodal strategies, including total mesorectal excision (TME) surgery, preoperative chemotherapy, multidisciplinary case conference, pelvic magnetic resonance imaging, and pathologic assessment using Quirke method, has led to significant improvements in oncologic outcomes for patients with rectal cancer. Although the literature supports claims on the effectiveness of these multimodal strategies, the uptake of these multimodal strategies varies considerably among centers, suggesting that the best evidence is not always implemented into clinical practice. OBJECTIVE This study aims to perform a quality improvement initiative to (1) identify existing gaps in care for these multimodal strategies and (2) implement knowledge translation (KT) interventions to close these gaps to optimize quality of care for patients with rectal cancer across high-volume centers in Canada. METHODS Process indicators for the selected multimodal strategies to optimize rectal cancer care will be selected and prospectively collected for all patients with stages 1 to 3 rectal cancer undergoing TME surgery. KT interventions, including audit and feedback, opinion leaders, and community of practice, will be implemented to increase the uptake of these clinical strategies. RESULTS The uptake of the process indicators over time and the effect of the uptake of the process indicators on short- and long-term oncologic outcomes will be evaluated for each multimodal strategy. CONCLUSIONS This quality improvement initiative will identify existing gaps in care for the selected multimodal strategies and implement KT interventions to close these gaps. The results of this study will inform further efforts to optimize rectal cancer care. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/15535.
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Affiliation(s)
- Amandeep Pooni
- Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada.,Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, ON, Canada
| | - Selina Schmocker
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, ON, Canada
| | - Carl Brown
- Department of Surgery, St Paul's Hospital, Vancouver, BC, Canada
| | - Anthony MacLean
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lara Williams
- Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Nancy N Baxter
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Department of Surgery and Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Marko Simunovic
- Department of Surgery, McMaster Universtiy, Hamilton, ON, Canada
| | | | - Sebastien Drolet
- Department of Surgery, Université Laval, Quebec City, QC, Canada
| | - Katerina Neumann
- Department of Surgery, Queen Elizabeth II Health Sciences Centre, Victoria General Site, Halifax, NS, Canada
| | - Kartik Jhaveri
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital, Women's College Hospital, Toronto, ON, Canada
| | - Richard Kirsch
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Toronto, ON, Canada
| | - Erin Diane Kennedy
- Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada.,Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, ON, Canada
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15
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Eid Y, Menahem B, Bouvier V, Lebreton G, Thobie A, Bazille C, Finochi M, Fohlen A, Galais M, Dupont B, Lubrano J, Dejardin O, Morello R, Alves A. Has adherence to treatment guidelines for mid/low rectal cancer affected the management of patients? A monocentric study of 604 consecutive patients. J Visc Surg 2019; 156:281-290. [DOI: 10.1016/j.jviscsurg.2019.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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16
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17
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Davis BR, Schlosser KA. Management of locally recurrent rectal cancer. SEMINARS IN COLON AND RECTAL SURGERY 2019. [DOI: 10.1053/j.scrs.2019.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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18
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Ioannidis A, Konstantinidis M, Apostolakis S, Koutserimpas C, Machairas N, Konstantinidis KM. Impact of multidisciplinary tumor boards on patients with rectal cancer. Mol Clin Oncol 2018; 9:135-137. [PMID: 30101009 DOI: 10.3892/mco.2018.1658] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 06/15/2018] [Indexed: 12/24/2022] Open
Abstract
Οncological outcomes in patients with primary rectal cancer have markedly improved over the last few years, mainly due to the widespread application of the total mesorectal excision technique. This improvement should also be largely attributed to multiple specialties, other than colorectal surgery, such as radiology, oncology and pathology. Therefore, a multimodal approach is key to efficient and appropriate rectal cancer management. Multidisciplinary tumor (MDT) boards have become an important asset for the management and treatment of patients with rectal cancer, and a number of studies published to date suggest the beneficial effect of the multidisciplinary approach on the management of such patients. The available evidence demonstrates a modification of the treatment plan, attributed to the MDT implementation, in a non-negligible proportion of these patients. However, more studies are required in order to assess the exact impact of MDT boards on disease-free and overall survival of patients with primary rectal cancer.
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Affiliation(s)
- Argyrios Ioannidis
- Department of General, Laparoscopic, Robotic and Bariatric Surgery, Athens Medical Center, 15125 Athens, Greece
| | - Michael Konstantinidis
- National and Kapodistrian University of Athens, School of Medicine, 11527 Athens, Greece
| | - Sotirios Apostolakis
- Department of Neurosurgery, KAT General Hospital of Attica, 14561 Athens, Greece
| | - Christos Koutserimpas
- Department of Orthopaedics and Traumatology, '251' Hellenic Air Force General Hospital, 11525 Athens, Greece
| | - Nikolaos Machairas
- 3rd Department of Surgery, University Hospital Attikon, National and Kapodistrian University of Athens, 12462 Athens, Greece
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