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Naffouje SA, Ali MA, Kamarajah SK, White B, Salti GI, Dahdaleh F. Assessment of Textbook Oncologic Outcomes Following Proctectomy for Rectal Cancer. J Gastrointest Surg 2022; 26:1286-1297. [PMID: 35441331 DOI: 10.1007/s11605-021-05213-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 11/20/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Outcomes of rectal adenocarcinoma vary considerably. Composite "textbook oncologic outcome" (TOO) is a single metric that estimates optimal clinical performance for cancer surgery. METHODS Patients with stage II/III rectal adenocarcinoma who underwent single-agent neoadjuvant chemoradiation and proctectomy within 5-12 weeks were identified in the National Cancer Database (NCDB). TOO was defined as achievement of negative distal and circumferential resection margin (CRM), retrieval of ≥ 12 nodes, no 90-day mortality, and length of stay (LOS) < 75th percentile of corresponding year's range. Multivariable logistic regression was used to identify predictors of TOO. RESULTS Among 318,225 patients, 8869 met selection criteria. Median age was 62 years (IQR 54-71), and 5550 (62.6%) were males. Low anterior resection was the most common procedure (LAR, 6,037 (68.1%) and 3084 (34.8%) were treated at a high-volume center (≥ 20 rectal resections/year). TOO was achieved in 3967 patients (44.7%). Several components of TOO were achieved commonly, including negative CRM (87.4%), no 90-day mortality (98.0%), no readmission (93.0%), and no prolonged hospitalization (78.8%). Logistic regression identified increasing age, non-private insurance, low-volume centers, open approach, Black race, Charlson score ≥ 3, and abdominoperineal resection (APR) as predictors of failure to achieve TOO. Over time, TOOs were attained more commonly which correlated with increased minimally invasive surgery (MIS) adoption. TOO achievement was associated with improved survival. CONCLUSIONS Rectal adenocarcinoma patients achieve TOO uncommonly. Treatment at high-volume centers and MIS approach were among modifiable factors associated with TOO in this study.
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Affiliation(s)
- Samer A Naffouje
- Department of Surgical Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Muhammed A Ali
- Department of Surgery, Queen Elizabeth Hospital Birmingham, University Hospital Birmingham NHS Trust, Birmingham, UK
| | - Sivesh K Kamarajah
- Department of Surgery, Queen Elizabeth Hospital Birmingham, University Hospital Birmingham NHS Trust, Birmingham, UK
| | - Bradley White
- Department of General Surgery, University of Illinois Hospital and Health Sciences System, Chicago, IL, USA
| | - George I Salti
- Department of General Surgery, University of Illinois Hospital and Health Sciences System, Chicago, IL, USA.,Department of Surgical Oncology, Edward-Elmhurst Health, 120 Spalding Drive, Ste 205, Naperville, IL, 60540, USA
| | - Fadi Dahdaleh
- Department of Surgical Oncology, Edward-Elmhurst Health, 120 Spalding Drive, Ste 205, Naperville, IL, 60540, USA.
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Invited commentary on: Variation in the volume-outcome relationship after rectal cancer surgery in the United States: Retrospective study with implications for regionalization. Surgery 2022; 172:1048-1049. [DOI: 10.1016/j.surg.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 04/04/2022] [Indexed: 11/22/2022]
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Rivard SJ, Vu JV, Kanters AE, Park J, Berho M, Hendren S. Interactive Training Program Improves Surgeon and Pathologist Comfort Level With Total Mesorectal Excision Grading for Rectal Cancer. Dis Colon Rectum 2022; 65:238-245. [PMID: 34759249 DOI: 10.1097/dcr.0000000000002288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Total mesorectal excision for rectal cancer has been shown to decrease local recurrence and improve survival, and specimen grading is recommended as a best practice. However, specimen grading remains underutilized in the United States potentially because of the lack of surgeon and pathologist training in the technique. OBJECTIVE This study aimed to determine whether an interactive webinar improves physician comfort with mesorectal grading. DESIGN To test the effect of the program, participants completed a survey before and after participating. SETTINGS Twelve Michigan Surgical Quality Collaborative hospitals volunteered to participate in a Total Mesorectal Excision Project. PARTICIPANTS Total mesorectal excision grading training program participants were surgeons, surgery residents, pathologists, and pathology assistants from 12 hospitals. MAIN OUTCOME MEASURES Comfort with grading total mesorectal excision specimens was our main outcome measure. Prewebinar surveys also measured familiarity, previous experience, and training in grade assignment, as well as interest in the training program. Postwebinar surveys measured webinar relevance and effectiveness as well as participant intention to use content in practice. RESULTS A total of 34 participants completed the prewebinar survey and 28 participants completed the postwebinar survey. The postwebinar overall median comfort level with specimen grading of 3.64 was significantly higher than the prewebinar overall median comfort level of 2.94 (95% CI, 3.32-3.96 versus 95% CI 2.56-3.32; p = 0.007). When evaluated separately, both surgeons and pathologists reported significantly higher comfort levels with total mesorectal excision grading after the webinar. LIMITATIONS Six participants did not complete the postwebinar survey. Surgery residents and pathology assistants were analyzed with practicing surgeons and pathologists. The pre- and postwebinar surveys were deidentified, so paired analysis was not possible. CONCLUSIONS Our total mesorectal excision grading training program improved the comfort level of both surgeons and pathologists with specimen grading. Survey results also demonstrate that providers are interested in receiving training in rectal cancer specimen grading. See Video Abstract at http://links.lww.com/DCR/B766.PROGRAMA DE ENTRENAMIENTO INTERACTIVO MEJORA EL NIVEL DE COMODIDAD DEL CIRUJANO Y DEL PATÓLOGO CON LA CLASIFICACIÓN DE LA ESCISIÓN TOTAL DEL MESORRECTO PARA EL CÁNCER DE RECTO. ANTECEDENTES Se ha demostrado que la escisión total del mesorrecto para el cáncer de recto disminuye la recurrencia local y mejora la supervivencia, y se recomienda la clasificación de la muestra como buena práctica de rutina. Sin embargo, sigue siendo poco utilizado en los Estados Unidos debido principalmente a la falta de formación en la técnica de cirujanos y patólogos. OBJETIVO Determinar si un seminario interactivo en línea mejora la comodidad del médico con la clasificación mesorrectal. DISEO Para probar el efecto del programa, los participantes completaron una encuesta antes y después de haber participado de la misma. MARCO Doce hospitales en cooperación sobre la calidad quirúrgica de Michigan se ofrecieron como voluntarios para participar en el proyecto de Escisión Total de Mesorrecto. PARTICIPANTES Los participantes del programa de entrenamiento en la clasificación de escisión total de mesorrecto fueron cirujanos, residentes de cirugía, patólogos y asistentes de patología de doce hospitales. PRINCIPALES RESULTADOS MEDIDOS La comodidad con la clasificación de las muestras de escisión total de mesorrecto fue nuestro principal resultado de medición. Las encuestas previas al seminario en línea también midieron la familiaridad, la experiencia y entrenamiento previo en la clasificación, así como el interés en el programa de entrenamiento. Las encuestas posteriores midieron la relevancia y la eficacia del seminario web, así como la intención de los participantes de utilizar en la practica el contenido. RESULTADOS Un total de 34 participantes completaron la encuesta previa, y 28 de ellos la completaron con posterioridad al seminario en línea.La mediana del nivel de comodidad general, posterior al seminario en línea, con respecto a la clasificación de la pieza de 3,64 fue significativamente mayor con respecto al valor de 2,94 previo al seminario (IC del 95%: 3,32 - 3,96 versus IC 2,56 - 3,32, respectivamente; valor de p = 0,007).Cuando fueron evaluados de manera separada, tanto los cirujanos como los patólogos reportaron niveles de comodidad significativamente más altos con la clasificación de escisión total de mesorrecto (TME) después del seminario en línea. LIMITACIONES Seis participantes no completaron la encuesta posterior al seminario en línea. Los residentes de cirugía y los asistentes de patología fueron analizados conjuntamente con los cirujanos y patólogos en ejercicio, respectivamente. Las encuestas previas y posteriores al seminario en línea fueron anónimas, anulándose la identificación, por lo que no fue posible realizar un análisis por pares. CONCLUSIONES Nuestro programa de entrenamiento en la clasificación de escisión total de mesorrecto mejoró el nivel de comodidad tanto de los cirujanos como de los patólogos con la clasificación de las muestras. Los resultados de la encuesta también demuestran que el personal involucrado está interesado en recibir capacitación en la clasificación de muestras de cáncer de recto. Consulte Video Resumen en http://links.lww.com/DCR/B766. (Traducción-Dr Osvaldo Gauto).
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Affiliation(s)
| | | | | | | | - Mariana Berho
- Department of Pathology and Laboratory Medicine Institute, Cleveland Clinic Florida, Weston, Florida
| | - Samantha Hendren
- Department of Colorectal Surgery, Michigan Medicine, Ann Arbor, Michigan
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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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Kröll D, Borbély YM, Dislich B, Haltmeier T, Malinka T, Biebl M, Langer R, Candinas D, Seiler C. Favourable long-term survival of patients with esophageal cancer treated with extended transhiatal esophagectomy combined with en bloc lymphadenectomy: results from a retrospective observational cohort study. BMC Surg 2020; 20:197. [PMID: 32917177 PMCID: PMC7488573 DOI: 10.1186/s12893-020-00855-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 08/26/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Although considered complex and challenging, esophagectomy remains the best potentially curable treatment option for resectable esophageal and esophagogastric junction (AEG) carcinomas. The optimal surgical approach and technique as well as the extent of lymphadenectomy, particularly regarding quality of life and short- and long-term outcomes, are still a matter of debate. To lower perioperative morbidity, we combined the advantages of a one-cavity approach with extended lymph node dissection (usually achieved by only a two-cavity approach) and developed a modified single-cavity transhiatal approach for esophagectomy. METHODS The aim of this study was to evaluate the outcome of an extended transhiatal esophageal resection with radical bilateral mediastinal en bloc lymphadenectomy (eTHE). A prospective database of 166 patients with resectable cancers of the esophagus (including adenocarcinomas of the AEG types I and II) were analyzed. Patients were treated between 2001 and 2017 with eTHE at a tertiary care university center. Relevant patient characteristics and outcome parameters were collected and analyzed. The primary endpoint was 5-year overall survival. Secondary outcomes included short-term morbidity, mortality, radicalness of en bloc resection and oncologic efficacy. RESULTS The overall survival rates at 1, 3 and 5 years were 84, 70, and 61.0%, respectively. The in-hospital mortality rate after eTHE was 1.2%. Complications with a Clavien-Dindo score of III/IV occurred in 31 cases (18.6%). A total of 25 patients (15.1%) had a major pulmonary complication. The median hospital stay was 17 days (interquartile range (IQR) 12). Most patients (n = 144; 86.7%) received neoadjuvant treatment. The median number of lymph nodes resected was 25 (IQR 17). The R0 resection rate was 97%. CONCLUSION In patients with esophageal cancer, eTHE without thoracotomy resulted in excellent long-term survival, an above average number of resected lymph nodes and an acceptable postoperative morbidity and mortality.
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Affiliation(s)
- Dino Kröll
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany. .,Department of Visceral Surgery and Medicine, Inselspital Bern, Bern University Hospital and University of Bern, 3010, Bern, Switzerland.
| | - Yves Michael Borbély
- Department of Visceral Surgery and Medicine, Inselspital Bern, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Bastian Dislich
- Institute of Pathology, Department of Clinical Pathology, Inselspital Bern, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Tobias Haltmeier
- Department of Visceral Surgery and Medicine, Inselspital Bern, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Thomas Malinka
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Matthias Biebl
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Rupert Langer
- Institute of Pathology, Department of Clinical Pathology, Inselspital Bern, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Daniel Candinas
- Department of Visceral Surgery and Medicine, Inselspital Bern, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Christian Seiler
- Department of Visceral Surgery and Medicine, Inselspital Bern, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
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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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Son GM, Kye BH, Kim MK, Kim JG. Reconsideration of the Safety of Laparoscopic Rectal Surgery for Cancer. Ann Coloproctol 2019; 35:229-237. [PMID: 31725997 PMCID: PMC6863006 DOI: 10.3393/ac.2019.10.16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 10/16/2019] [Indexed: 12/13/2022] Open
Abstract
The oncological outcomes of laparoscopic rectal cancer surgery were evaluated in recent multicenter randomized clinical trials (RCTs). The MRC-CLASSIC, COLOR II, and COREAN trials found no differences in local recurrence or diseasefree survival rate between laparoscopic and open surgery. However, the noninferiority of laparoscopic surgery with respect to open surgery for rectal cancer was not established on statistical analysis in the ACOSOG Z6051 and the ALaCaRT trials. Quality of total mesorectal excision (TME) is one of the most important prognostic factors. Incomplete TME had unfavorable oncologic outcomes compared to complete TME. Although TME quality can be clearly identified on pathologic evaluation, there is controversy regarding the acceptable range of oncologically safe TME for laparoscopic surgery. It is not certain whether near-complete TME has an unfavorable oncologic impact and whether laparoscopic surgery with near-complete TME is an oncological threat. Therefore, the surgical community will be interested in the long-term outcomes and meta-analyses of ongoing large-scale RCTs. Laparoscopic rectal cancer surgery has been steadily improving its safety for oncology surgery, which has been reported consistently in various multicenter RCTs. To improve surgical quality, colorectal surgeons should choose the most appropriate surgical technique, including laparoscopic surgery.
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Affiliation(s)
- Gyung Mo Son
- Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University College of Medicine, Busan, Korea
| | - Bong-Hyeon Kye
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University, Seoul, Korea
| | - Min Ki Kim
- Department of Surgery, Myongji Hospital, Hanyang University College of Medicine, Goyang, Korea
| | - Jun-Gi Kim
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Hill SS, Chung SK, Meyer DC, Crawford AS, Sturrock PR, Harnsberger CR, Davids JS, Maykel JA, Alavi K. Impact of Preoperative Care for Rectal Adenocarcinoma on Pathologic Specimen Quality and Postoperative Morbidity: A NSQIP Analysis. J Am Coll Surg 2019; 230:17-25. [PMID: 31672638 DOI: 10.1016/j.jamcollsurg.2019.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/18/2019] [Accepted: 09/16/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Comprehensive and multidisciplinary care are critical in rectal cancer treatment. We sought to determine if completeness of preoperative care was associated with pathologic specimen quality and postoperative morbidity. STUDY DESIGN Clinical stage I-III rectal adenocarcinoma patients who underwent elective low anterior resection or abdominoperineal resection were identified from the 2016-2017 American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) database. The 3 preoperative NSQIP variables (colonoscopy, stoma marking, and neoadjuvant chemoradiation) were used to divide patients into 2 cohorts: complete vs incomplete preoperative care. The primary outcome was a composite higher pathologic specimen quality score (>12 lymph nodes, negative circumferential, and negative distal margins). The secondary outcome was 30-day morbidity. Preoperative characteristics were compared with ANOVAs and chi-square tests. Outcomes measures were evaluated with logistic regression. RESULTS We identified 1,125 patients: 591 (52.5%) complete and 534 (47.5%) incomplete. The complete group was younger, had more women, lower-third rectal tumors, clinical stage III disease, and neoadjuvant treatment. The complete group had higher odds of better pathologic specimen quality after adjusting for age, sex, tumor location, stage, and neoadjuvant therapy (adjusted odds ratio [aOR] 1.75, p = 0.001). The complete group had decreased rates of transfusions (odds ratio [OR] 0.47, p < 0.001), postoperative ileus (OR 0.67, p = 0.01), sepsis (OR 0.32, p = 0.01), and readmissions (OR 0.60, p = 0.003). Other complications did not statistically differ between groups. CONCLUSIONS Complete preoperative care in rectal adenocarcinoma is associated with higher pathologic specimen quality and reduced postoperative morbidity. This highlights the importance of adherence to guideline-directed care.
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Affiliation(s)
- Susanna S Hill
- Division of Colon and Rectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
| | - Sebastian K Chung
- Division of General Surgery, University of Massachusetts Medical School, Worcester, MA
| | - David C Meyer
- Division of Colon and Rectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
| | - Allison S Crawford
- Division of General Surgery, University of Massachusetts Medical School, Worcester, MA
| | - Paul R Sturrock
- Division of Colon and Rectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
| | - Cristina R Harnsberger
- Division of Colon and Rectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
| | - Jennifer S Davids
- Division of Colon and Rectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
| | - Justin A Maykel
- Division of Colon and Rectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
| | - Karim Alavi
- Division of Colon and Rectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA.
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9
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Guideline-Recommended Chemoradiation for Patients With Rectal Cancer at Large Hospitals: A Trend in the Right Direction. Dis Colon Rectum 2019; 62:1186-1194. [PMID: 31490827 PMCID: PMC7263440 DOI: 10.1097/dcr.0000000000001452] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Many patients with rectal cancer are treated at small, low-volume hospitals despite evidence that better outcomes are associated with larger, high-volume hospitals. OBJECTIVES This study aims to examine trends of patients with rectal cancer who are receiving care at large hospitals, to determine the patient characteristics associated with treatment at large hospitals, and to assess the relationships between treatment at large hospitals and guideline-recommended therapy. DESIGN This study was a retrospective cohort analysis to assess trends in rectal cancer treatment. SETTINGS Data from the National Cancer Institute's Surveillance, Epidemiology, and End Results Patterns of Care studies were used. PATIENTS The study population consisted of adults diagnosed with stages II/III rectal cancer in 1990/1991, 1995, 2000, 2005, 2010, and 2015. MAIN OUTCOME MEASURES The primary outcome was treatment at large hospitals (≥500 beds). The receipt of guideline-recommended preoperative chemoradiation therapy and postoperative chemotherapy was assessed for patients diagnosed in 2005+. RESULTS Two thousand two hundred thirty-one patients were included. The proportion treated at large hospitals increased from 19% in 1990/1991 to 27% in 2015 (ptrend < 0.0001). Black race was associated with treatment at large hospitals (vs white) (OR, 1.73; 95% CI, 1.30-2.31), as was being 55 to 64 years of age (vs 75+), and diagnosis in 2015 (vs 1990/1991). Treatment in large hospitals was associated with twice the odds of preoperative chemoradiation, as well as younger age and diagnosis in 2010 or 2015 (vs 2005). LIMITATIONS The study did not account for the change in the number of large hospitals over time. CONCLUSIONS Results suggest that patients with rectal cancer are increasingly being treated in large hospitals where they receive more guideline-recommended therapy. Although this trend is promising, patients receiving care at larger, higher-volume facilities are still the minority. Initiatives increasing patient and provider awareness of benefits of specialized care, as well as increasing referrals to large centers may improve the use of recommended treatment and ultimately improve outcomes. See Video Abstract at http://links.lww.com/DCR/A994. QUIMIORRADIACIÓN RECOMENDADA EN GUÍAS PARA PACIENTES CON CÁNCER RECTAL EN HOSPITALES DE GRAN TAMAÑO: UNA TENDENCIA EN LA DIRECCIÓN CORRECTA: Muchos pacientes con cáncer rectal se tratan en hospitales pequeños y de bajo volumen a pesar de evidencia de que los mejores resultados se asocian con hospitales más grandes y de gran volumen. OBJETIVOS Examinar las tendencias en los pacientes con cáncer rectal que reciben atención en hospitales de gran tamaño, determinar las características de los pacientes asociadas con el tratamiento en hospitales grandes y evaluar la relación entre el tratamiento en hospitales grandes y la terapia recomendada en guías. DISEÑO:: Este estudio fue un análisis de cohorte retrospectivo para evaluar las tendencias en el tratamiento del cáncer de recto. ESCENARIO Se utilizaron datos de los estudios del programa Patrones de Atención, Vigilancia, Epidemiología y Resultados Finales (SEER) del Instituto Nacional de Cáncer (NIH). PACIENTES La población de estudio consistió en adultos diagnosticados con cáncer rectal en estadio II / III en 1990/1991, 1995, 2000, 2005, 2010 y 2015. PRINCIPALES MEDIDAS DE RESULTADO El resultado primario fue el tratamiento en hospitales grandes (≥500 camas). La recepción de quimiorradiación preoperatoria recomendada según las guías y la quimioterapia posoperatoria se evaluaron para los pacientes diagnosticados en 2005 y posteriormente. RESULTADOS Se incluyeron 2,231 pacientes. La proporción tratada en los hospitales grandes aumentó del 19% en 1990/1991 al 27% en 2015 (ptrend < 0.0001). La raza afroamericana se asoció con el tratamiento en hospitales grandes (vs. blanca) (OR, 1.73; IC 95%, 1.30-2.31), al igual que 55-64 años de edad (vs ≥75) y diagnóstico en 2015 (vs 1990/1991). El tratamiento en los hospitales grandes se asoció con el doble de probabilidad de quimiorradiación preoperatoria, así como con una edad más temprana y diagnóstico en 2010 o 2015 (vs 2005). LIMITACIONES El estudio no tomó en cuenta el cambio en el número de hospitales grandes a lo largo del tiempo. CONCLUSIONES Los resultados sugieren que los pacientes con cáncer rectal reciben cada vez más tratamiento en hospitales grandes donde reciben terapia recomendada por las guías mas frecuentemente. Aunque esta tendencia es prometedora, los pacientes que reciben atención en hospitales más grandes y de mayor volumen siguen siendo una minoría. Las iniciativas que aumenten la concientización del paciente y del proveedor de servicios médicos sobre los beneficios de la atención especializada, así como el aumento de las referencias a centros grandes podrían mejorar el uso del tratamiento recomendado y, en última instancia, mejorar los resultados. Vea el Resumen en video en http://links.lww.com/DCR/A994.
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Wells KO, Peters WR. Minimally Invasive Surgery for Locally Advanced Rectal Cancer. Surg Oncol Clin N Am 2019; 28:297-308. [DOI: 10.1016/j.soc.2018.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Association Between Hospital and Surgeon Volume and Rectal Cancer Surgery Outcomes in Patients With Rectal Cancer Treated Since 2000: Systematic Literature Review and Meta-analysis. Dis Colon Rectum 2018; 61:1320-1332. [PMID: 30286023 PMCID: PMC7000208 DOI: 10.1097/dcr.0000000000001198] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Previous reviews and meta-analyses, which predominantly focused on patients treated before 2000, have reported conflicting evidence about the association between hospital/surgeon volume and rectal cancer outcomes. Given advances in rectal cancer resection, such as total mesorectal excision, it is essential to determine whether volume plays a role in rectal cancer outcomes among patients treated since 2000. OBJECTIVE The purpose of this study was to determine whether there is an association between hospital/surgeon volume and rectal cancer surgery outcomes among patients treated since 2000. DATA SOURCES We searched PubMed and EMBASE for articles published between January 2000 and December 29, 2017. STUDY SELECTION Articles that analyzed the association between hospital/surgeon volume and rectal cancer outcomes were selected. INTERVENTION Rectal cancer resection was the study intervention. MAIN OUTCOME MEASURES The outcome measures of this study were surgical morbidity, postoperative mortality, surgical margin positivity, permanent colostomy rates, recurrence, and overall survival. RESULTS Although 2845 articles were retrieved and assessed by the search strategy, 21 met the inclusion and exclusion criteria. There was a significant protective association between higher hospital volume and surgical morbidity (OR = 0.80 (95% CI, 0.70-0.93); I = 35%), permanent colostomy (OR = 0.51 (95% CI, 0.29-0.92); I = 34%), and postoperative mortality (OR = 0.62 (95% CI, 0.43-0.88); I = 34%), and overall survival (OR = 0.99 (95% CI, 0.98-1.00); I = 3%). Stratified analysis showed that the magnitude of association between hospital volume and rectal cancer surgery outcomes was stronger in the United States compared with other countries. Surgeon volume was not significantly associated with overall survival. The articles included in this analysis were high quality according to the Newcastle-Ottawa scale. Funnel plots suggested that the potential for publication bias was low. LIMITATIONS Some articles included rectosigmoid cancers. CONCLUSIONS Among patients diagnosed since 2000, higher hospital volume has had a significant protective effect on rectal cancer surgery outcomes.
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Cirocco WC. Rectal resection following neoadjuvant therapy in a Midwest community hospital setting: The case for standardization over centralization as the means to optimize rectal cancer outcomes in the United States. Am J Surg 2018; 217:430-434. [PMID: 30236488 DOI: 10.1016/j.amjsurg.2018.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 08/31/2018] [Accepted: 09/03/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Incomplete and flawed national databases reveal strikingly inferior outcomes for rectal cancer patients resected at "low" versus "high " volume hospitals, therefore, a study of outcomes of a "high" volume surgeon in a "low" volume Midwest community hospital setting examined this perception in comparison to contemporary studies. METHODS Review of 109 consecutive patients who underwent open resection of rectal cancer following neoadjuvant therapy, 1999-2010. RESULTS Despite the majority of tumors in the low rectum (54%), the rate of abdominoperineal resection was only 39% with R0 resection achieved in 94% and primary anastomosis in 61/109 patients (56%). Disease-free survival (DFS) 73%: stage 0 (complete response)- 100%, stage I- 88%, stage II- 68%, stage III- 50%, stage IV- 0% with recurrence rate of 11% (local recurrence (LR) - 3%, distant - 8%). CONCLUSION Outcomes of rectal cancer resection by a "high" volume surgeon in a "low" volume Midwest community hospital setting were comparable to contemporary studies from tertiary care institutions. Geographic location and hospital capacity matter less than access to multispecialty expertise providing neoadjuvant therapy and following standard principles of oncologic resection, in efforts to optimize rectal cancer outcomes.
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Affiliation(s)
- William C Cirocco
- N711 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210-1228, USA.
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Caycedo-Marulanda A, Chadi S, Patel S, Knol J, Wexner SD. Is a transanal total mesorectal excision programme feasible in a single-team setting? Colorectal Dis 2018; 20:571-573. [PMID: 29963774 DOI: 10.1111/codi.14243] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 04/16/2018] [Indexed: 01/08/2023]
Affiliation(s)
- A Caycedo-Marulanda
- Department of Surgery, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - S Chadi
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - S Patel
- Department of Surgery, Queens University Kingston, Ontario, Canada
| | - J Knol
- Department of Surgery, Jessa Hospital, Hasselt, Belgium
| | - S D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
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Becerra AZ, Wexner SD, Dietz DW, Xu Z, Aquina CT, Justiniano CF, Swanger AA, Temple LK, Noyes K, Monson JR, Fleming FJ. Nationwide Heterogeneity in Hospital-Specific Probabilities of Rectal Cancer Understaging and Its Effects on Outcomes. Ann Surg Oncol 2018; 25:2332-2339. [DOI: 10.1245/s10434-018-6530-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Indexed: 01/09/2023]
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Hoehn RS, Go DE, Hanseman DJ, Shah SA, Paquette IM. Hospital safety-net burden does not predict differences in rectal cancer treatment and outcomes. J Surg Res 2018; 221:204-210. [DOI: 10.1016/j.jss.2017.08.047] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 07/14/2017] [Accepted: 08/30/2017] [Indexed: 01/23/2023]
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Arsoniadis EG, Fan Y, Jarosek S, Gaertner WB, Melton GB, Madoff RD, Kwaan MR. Decreased Use of Sphincter-Preserving Procedures Among African Americans with Rectal Cancer. Ann Surg Oncol 2017; 25:720-728. [PMID: 29282601 DOI: 10.1245/s10434-017-6306-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Improved multimodality rectal cancer treatment has increased the use of sphincter-preserving surgery. This study sought to determine whether African American (AA) patients with rectal cancer receive sphincter-preserving surgery at the same rate as non-AA patients. METHODS The study used the Nationwide Inpatient Sample for years 1998-2012 to compare AA and non-AA patients with rectal cancer undergoing low anterior resection or abdominoperineal resection. The logistic regression model was used to adjust for age, gender, admission type, Elixhauser comorbidity index, and hospital factors such as size, location (urban vs.rural), teaching status, and procedure volume. RESULTS The search identified 22,697 patients, 1600 of whom were identified as AA. After adjustment for age and gender, the analysis showed that AA patients were less likely to undergo sphincter-preserving surgery than non-AA patients [odds ratio (OR) 0.70; 95% confidence interval (CI) 0.63-0.78; p < 0.0001). After further adjustment for the Elixhauser comorbidity index, admission type, hospital-specific factors, and insurance status, the analysis showed that AA patients still were less likely to undergo sphincter-preserving surgery (OR 0.78; 95% CI 0.70-0.87; p < 0.0001). Although the proportion of non-AA patients undergoing sphincter-preserving surgery increased during the study period (p = 0.0003), this trend was not significant for the AA patients (p = 0.13). CONCLUSION In this data analysis, the AA patients with rectal cancer had lower rates of sphincter-preserving surgery than the non-AA patients, even after adjustment for patient- and hospital-specific factors. Further work is required to elucidate why. Eliminating racial disparities in rectal cancer treatment should continue to be a priority for the surgical community.
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Affiliation(s)
- Elliot G Arsoniadis
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, MN, USA. .,Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA.
| | - Yunhua Fan
- Department of Urology, University of Minnesota, Minneapolis, MN, USA
| | - Stephanie Jarosek
- Department of Urology, University of Minnesota, Minneapolis, MN, USA
| | - Wolfgang B Gaertner
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Genevieve B Melton
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, MN, USA.,Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA
| | - Robert D Madoff
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Mary R Kwaan
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
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Liska D, Stocchi L, Karagkounis G, Elagili F, Dietz DW, Kalady MF, Kessler H, Remzi FH, Church J. Incidence, Patterns, and Predictors of Locoregional Recurrence in Colon Cancer. Ann Surg Oncol 2016; 24:1093-1099. [PMID: 27812826 DOI: 10.1245/s10434-016-5643-z] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Locoregional recurrence (LR) in colon cancer is uncommon but often incurable, while the factors associated with it are unclear. The purpose of this study was to identify patterns and predictors of LR after curative resection for colon cancer. METHODS All patients who underwent colon cancer resection with curative intent between 1994 and 2008 at a tertiary referral center were identified from a prospectively maintained institutional database. The association of LR with clinicopathologic and treatment characteristics was determined using univariable and multivariable analyses. RESULTS A total of 1397 patients were included with a median follow-up of 7.8 years; 635 (45%) were female, and the median age was 69 years. LR was detected in 61 (4.4%) patients. Median time to LR was 21 months. On multivariable analysis, the independent predictors of LR were disease stage [hazard ratio (HR) for Stage II 4.6, 95% confidence interval (CI) 1.05-19.9, HR for Stage III 10.8, 95% CI 2.6-45.8], bowel obstruction (HR 3.8, 95% CI 1.9-7.4), margin involvement (HR 4.1, 95% CI 1.9-8.6), lymphovascular invasion (HR 1.9, 95% CI 1.06-3.5), and local tumor invasion (fixation to another structure, perforation, or presence of associated fistula, HR 2.2, 95% CI 1.1-4.5). Adjuvant chemotherapy was not associated with reduced LR in patients with either Stage II or Stage III tumors. CONCLUSIONS Adherence to oncologic surgical principles in colon cancer resection results in low rates of LR, which is associated with tumor-dependent factors. Recognition of these factors can help to determine appropriate postoperative surveillance.
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Affiliation(s)
- David Liska
- Department of Colorectal Surgery, Cleveland Clinic, Digestive Disease Institute, Cleveland, OH, USA.
| | - Luca Stocchi
- Department of Colorectal Surgery, Cleveland Clinic, Digestive Disease Institute, Cleveland, OH, USA
| | - Georgios Karagkounis
- Department of Colorectal Surgery, Cleveland Clinic, Digestive Disease Institute, Cleveland, OH, USA
| | - Faisal Elagili
- Department of Colorectal Surgery, Cleveland Clinic, Digestive Disease Institute, Cleveland, OH, USA
| | - David W Dietz
- Department of Colorectal Surgery, Cleveland Clinic, Digestive Disease Institute, Cleveland, OH, USA
| | - Matthew F Kalady
- Department of Colorectal Surgery, Cleveland Clinic, Digestive Disease Institute, Cleveland, OH, USA
| | - Hermann Kessler
- Department of Colorectal Surgery, Cleveland Clinic, Digestive Disease Institute, Cleveland, OH, USA
| | - Feza H Remzi
- Department of Colorectal Surgery, Cleveland Clinic, Digestive Disease Institute, Cleveland, OH, USA
| | - James Church
- Department of Colorectal Surgery, Cleveland Clinic, Digestive Disease Institute, Cleveland, OH, USA
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Aquina CT, Probst CP, Becerra AZ, Iannuzzi JC, Kelly KN, Hensley BJ, Rickles AS, Noyes K, Fleming FJ, Monson JR. High volume improves outcomes: The argument for centralization of rectal cancer surgery. Surgery 2016; 159:736-48. [DOI: 10.1016/j.surg.2015.09.021] [Citation(s) in RCA: 138] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 08/04/2015] [Accepted: 09/23/2015] [Indexed: 11/28/2022]
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Codina-Cazador A, Biondo S. El terciarismo en el cáncer de recto. Cir Esp 2015; 93:273-5. [DOI: 10.1016/j.ciresp.2015.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 03/09/2015] [Indexed: 11/16/2022]
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Probst CP, Becerra AZ, Aquina CT, Tejani MA, Wexner SD, Garcia-Aguilar J, Remzi FH, Dietz DW, Monson JRT, Fleming FJ. Extended Intervals after Neoadjuvant Therapy in Locally Advanced Rectal Cancer: The Key to Improved Tumor Response and Potential Organ Preservation. J Am Coll Surg 2015. [PMID: 26206642 DOI: 10.1016/j.jamcollsurg.2015.04.010] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Many rectal cancer patients experience tumor downstaging and some are found to achieve a pathologic complete response (pCR) after neoadjuvant chemoradiotherapy (nCRT). Previous data suggest that there is an association between the time interval from nCRT completion to surgery and tumor response rates, including pCR. However, these studies have been primarily from single institutions with small sample sizes. The aim of this study was to examine the relationship between a longer interval after nCRT and pCR in a nationally representative cohort of rectal cancer patients. STUDY DESIGN Clinical stage II to III rectal cancer patients undergoing nCRT with a documented surgical resection were selected from the 2006 to 2011 National Cancer Data Base. Multivariable logistic regression analysis was used to assess the association between the nCRT-surgery interval time (<6 weeks, 6 to 8 weeks, >8 weeks) and the odds of pCR. The relationship between nCRT-surgery interval, surgical morbidity, and tumor downstaging was also examined. RESULTS Overall, 17,255 patients met the inclusion criteria. An nCRT-surgery interval time >8 weeks was associated with higher odds of pCR (odds ratio [OR] 1.12, 95% CI 1.01 to 1.25) and tumor downstaging (OR 1.11, 95% CI 1.02 to 1.25). The longer time delay was also associated with lower odds of 30-day readmission (OR 0.82, 95% CI 0.70 to 0.92). CONCLUSIONS An nCRT-surgery interval time >8 weeks results in increased odds of pCR, with no evidence of associated increased surgical complications compared with an interval of 6 to 8 weeks. These data support implementation of a lengthened interval after nCRT to optimize the chances of pCR and perhaps add to the possibility of ultimate organ preservation (nonoperative management).
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Affiliation(s)
- Christian P Probst
- Surgical Health Outcomes & Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY
| | - Adan Z Becerra
- Surgical Health Outcomes & Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY
| | - Christopher T Aquina
- Surgical Health Outcomes & Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY
| | - Mohamedtaki A Tejani
- Department of Medicine, Hematology/Oncology Division, University of Rochester Medical Center, Rochester, NY
| | - Steven D Wexner
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Florida, Weston, FL
| | | | - Feza H Remzi
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - David W Dietz
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - John R T Monson
- Surgical Health Outcomes & Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY
| | - Fergal J Fleming
- Surgical Health Outcomes & Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY.
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Abstract
Advances in the surgical management of rectal cancer have placed the quality of total mesorectal excision (TME) as the major predictor in overall survival. A standardized TME technique along with quality increases the percentage of patients undergoing a complete TME. Quality measurements of TME will place increasing demands on surgeons maintaining competence with present and future techniques. These efforts will improve the outcome of the rectal cancer patients.
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Affiliation(s)
- Warren E Lichliter
- Division of Colon and Rectal Surgery, Baylor University Medical Center, Dallas, Texas
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Liu M, Liu B, Wang H, Ding L, Shi Y, Ge C, Su X, Liu X, Dong L. Dosimetric comparative study of 3 different postoperative radiotherapy techniques (3D-CRT, IMRT, and RapidArc) for II-III stage rectal cancer. Medicine (Baltimore) 2015; 94:e372. [PMID: 25569661 PMCID: PMC4602855 DOI: 10.1097/md.0000000000000372] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 11/18/2014] [Accepted: 11/22/2014] [Indexed: 01/13/2023] Open
Abstract
Postoperative radiotherapy is critical for reducing local relapse for advanced rectal carcinoma but has many side effects. Our study compared the dose distribution of target volumes, protection of normal organs at risk (OAR), and monitor unit (MU) for 3 radiotherapy techniques (3-dimensional conformal radiation therapy [3D-CRT], intensity-modulated radiation therapy [IMRT], and RapidArc (Varian Medical Systems, Inc., Palo Alto, CA, USA)). The results advocate for the clinical application of RapidArc technique in the future.Thirty postoperative patients with rectal cancer were enrolled. The 3 radiotherapy plans mentioned above were designed for each patient. The target volume coverage indicators included average dose, conformity index (CI), and homogeneity index (HI) of planning tumor volume (PTV). OAR included the bladder, small intestine, colon, and bilateral proximal femurs. The 30 patients were divided into 3 groups (10 cases in each group) for postoperative radiotherapy with the 3D-CRT, IMRT, or RapidArc technique, respectively.Both the IMRT and RapidArc plans have a significantly higher average PTV dose and better CI and HI (P < 0.01) than 3D-CRT. IMRT and RapidArc result in significantly lower doses of irradiation for all the OAR examined. Both the IMRT and RapidArc plans have a significantly lower V40 of the bladder, small intestine, and colon than 3D-CRT (P < 0.01). The IMRT and RapidArc plans can also reduce the maximum dose (Dmax) for the left proximal femur, V30, and V40 of bilateral proximal femurs compared with 3D-CRT (P < 0.01). Compared with IMRT, RapidArc can further reduce the Dmax of the small intestine, the Dmax and V30 of the bilateral proximal femurs, and the V40 of the right proximal femur (P < 0.01). RapidArc reduces MU remarkably compared with IMRT (P < 0.01). Regarding acute side effects, IMRT and RapidArc can greatly reduce the incidence of grade 3 radiation-induced cystitis and grade 2 enteritis.Both IMRT and RapidArc are better than 3D-CRT regarding PTV coverage and OAR protection. Furthermore, RapidArc is superior to IMRT regarding protection of the small intestine and bilateral proximal femurs and requires a reduced treatment time. RapidArc could be widely applied for postoperative radiotherapy for patients with ΙΙ-ΙΙΙ stage rectal cancer.
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Affiliation(s)
- Min Liu
- From the Department of Radiation Oncology (ML, BL, HW, L. Ding, YS, CG, L. Dong), The First Hospital, Jilin University, Changchun; Chinese Center for Medical Response to Radiation Emergency (XS), National Institute for Radiological Protection, China Center for Disease Control, Beijing; and Key Laboratory of Radiobiology (Ministry of Health) (XL), School of Public Health, Jilin University, Changchun, China
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Fleshman JW, Roberts WC. James Walter Fleshman Jr., MD: a conversation with the editor. Proc (Bayl Univ Med Cent) 2014; 27:263-75. [PMID: 24982584 DOI: 10.1080/08998280.2014.11929133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- James W Fleshman
- Departments of Surgery (Fleshman), Pathology (Roberts), and Internal Medicine, Division of Cardiology (Roberts), Baylor University Medical Center at Dallas
| | - William C Roberts
- Departments of Surgery (Fleshman), Pathology (Roberts), and Internal Medicine, Division of Cardiology (Roberts), Baylor University Medical Center at Dallas
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Advancing standards of rectal cancer care: lessons from Europe adapted to the vast expanse of North America. Dis Colon Rectum 2014; 57:260-6. [PMID: 24401890 DOI: 10.1097/dcr.0000000000000021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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