Impact of Staging Concordance and Downstaging After Neoadjuvant Therapy on Survival Following Resection of Intrahepatic Cholangiocarcinoma: A Bayesian Analysis

INTRODUCTION

Concordance between clinical and pathological staging, as well as the overall survival (OS) benefit associated with neoadjuvant therapy (NAT) remain ill-defined. We sought to determine the impact of staging accuracy and NAT downstaging on OS among patients with intrahepatic cholangiocarcinoma (ICC).

METHODS

Patients treated for ICC between 2010 and 2018 were identified using the National Cancer Database. A Bayesian approach was applied to estimate NAT downstaging. OS was assessed relative to staging concordant/overstaged disease treated with upfront surgery, understaged disease treated with upfront surgery, no downstaging, and downstaging after NAT.

RESULTS

Among 3384 patients, 2904 (85.8%) underwent upfront surgery, whereas 480 (14.2%) received NAT and 85/480 (18.4%) were downstaged. Patients with cT3 (odds ratio [OR] 2.12, 95% confidence interval [CI] 1.34-3.34), cN1 (OR 2.47, 95% CI 1.71-3.58) disease, and patients treated at high-volume facilities (OR 1.63, 95% CI 1.13-2.36) were more likely to receive NAT (all p < 0.05). Median OS was 40.1 months (95% CI 38.6-43.4). Patients with cT1-2N1 (NAT: 31.5 months vs. upfront surgery: 22.4 months; p = 0.04) and cT3-4N1 (NAT: 27.8 months vs. upfront surgery: 14.4 months; p = 0.01) disease benefited most from NAT. NAT downstaging decreased the risk of death among patients with cT3-4N1 disease (hazard ratio [HR] 0.35, 95% CI 0.15-0.82). In contrast, understaged patients with cT1-2N0/X (HR 2.15, 95% CI 1.83-2.53) and cT3-4N0/X (HR 1.71, 95% CI 1.06-2.74) disease treated with upfront surgery had increased risk of death.

CONCLUSIONS

Patients with N1 ICC treated with NAT demonstrated improved OS compared with upfront surgery. Downstaging secondary to NAT conferred survival benefits among patients with cT3-4N1 versus upfront surgery. NAT should be considered in ICC patients with advanced T disease and/or nodal metastases.

Predictors and Outcomes of Upstaging in Rectal Cancer Patients Who Did Not Receive Preoperative Therapy

BACKGROUND

Preoperative chemoradiation is indicated for clinical stage II and III rectal cancers; however, the accuracy of clinical staging with preoperative imaging is imperfect.

OBJECTIVE

The study aimed to better characterize the incidence and management of clinical and pathologic stage discordances in patients who did not receive preoperative chemoradiation.

DESIGN

This was a retrospective cohort analysis.

SETTINGS

The source of data was the National Cancer Database from 2006 to 2015.

PATIENTS

We identified patients who underwent resection with curative intent for clinical stage I rectal adenocarcinoma without preoperative chemotherapy or radiation.

MAIN OUTCOME MEASURES

We evaluated the characteristics of "upstaged" patients-those with T3/T4 tumors found on pathology (pathologic stage II) and/or with positive regional nodes in the resection specimen (pathologic stage III) compared with those patients who were not upstaged (pathologic stage I). We then used a mixed-effects multivariable survival model to compare overall survival between these groups.

RESULTS

Among 7818 clinical stage I rectal cancer patients who did not receive preoperative therapy, tumor upstaging occurred in 819 (10.6%) and nodal upstaging occurred in 1612 (20.8%). Upstaged patients were more likely than those not upstaged to have higher grade tumors and positive margins. Survival was worse in upstaged patients (hazard ratio [HR], 1.64; 95% CI, 1.4-1.9) but improved among those upstaged patients who received either chemotherapy (HR, 0.71; 95% CI, 0.6-0.9) or chemoradiation (HR, 0.62; 95% CI, 0.5-0.7).

LIMITATIONS

In addition to the inherent limitations of a retrospective cohort study, the National Cancer Database does not record functional outcomes, local recurrence, or disease-specific survival, so we are restricted to the evaluation of overall survival as an oncologic outcome.

CONCLUSIONS

Inaccurate preoperative staging remains a common clinical challenge in the management of rectal cancer. Survival among upstaged patients is improved among those who receive recommended postoperative chemotherapy and/or chemoradiation, yet many patients do not receive guideline-concordant care. See Video Abstract at https://links.lww.com/DCR/B999 .

PREDICTORES Y RESULTADOS DE SOBRE ESTADIFICACIN EN PACIENTES CON CNCER DE RECTO QUE NO RECIBIERON TERAPIA PREOPERATORIA

ANTECEDENTES:La quimio radiación preoperatoria está indicada para los estadios clínicos II y III del cáncer rectal; sin embargo, la precisión de la estadificación clínica con imágenes preoperatorias es imperfecta.OBJETIVO:El objetivo fue mejorar la caracterización de la incidencia y el manejo de la discordancia del estadio clínico y patológico en pacientes que no recibieron quimio radiación preoperatoria.DISEÑO:Este fue un análisis de cohorte retrospectivo.CONFIGURACIÓN:La fuente de datos fue de la Base de datos Nacional del Cáncer entre los años 2006-2015.PACIENTES:Identificamos pacientes que fueron sometidos a resección con intención curativa por adenocarcinoma rectal en estadio clínico I, sin quimioterapia o radiación preoperatoria.PRINCIPALES MEDIDAS DE RESULTADO:Evaluamos las características de los pacientes "sobre estadificados": aquellos con tumores T3/T4 encontrados en patología (estadio patológico II) y/o con ganglios regionales positivos en la muestra de resección (estadio patológico III), en comparación con aquellos pacientes que no fueron sobre estadificados (estadio patológico I). Luego usamos un modelo de supervivencia multivariable de efectos mixtos para comparar la supervivencia general entre estos grupos.RESULTADOS:De entre 7818 pacientes con cáncer de recto, en estadio clínico I, y que no recibieron tratamiento preoperatorio, se produjo una sobre estadificación tumoral en 819 (10,6%) y una sobre estadificación ganglionar en 1612 (20,8%). Los pacientes sobre estadificados tenían más probabilidades que los no sobre estadificados de tener tumores de mayor grado y márgenes positivos. La supervivencia fue peor en los pacientes sobre estadificados (HR 1,64, IC del 95% [1,4, 1,9]), pero mejoró entre los pacientes sobre estadificados que recibieron quimioterapia (HR 0,71, IC del 95% [0,6, 0,9]) o quimio radiación (HR 0,62, 95% IC [0,5, 0,7]).LIMITACIONES:Además de las limitaciones inherente a un estudio de cohorte de tipo retrospectivo, la Base de datos Nacional del Cáncer no registra resultados funcionales, la recurrencia local o la supervivencia específica de la enfermedad, por lo que estamos restringidos a la evaluación de la supervivencia general como un resultado oncológico.CONCLUSIONES:La estadificación preoperatoria inexacta sigue siendo un desafío clínico común en el tratamiento del cáncer de recto. La supervivencia entre los pacientes con sobre estadificación mejora en aquellos que reciben la quimioterapia y/o quimio radioterapia postoperatoria recomendada, aunque muchos pacientes no reciben atención acorde con las guías. Consulte Video Resumen en http://links.lww.com/DCR/B999 . (Traducción-Dr. Osvaldo Gauto ).

Consensus Quality Measures and Dose Constraints for Rectal Cancer From the Veterans Affairs Radiation Oncology Quality Surveillance Program and American Society for Radiation Oncology (ASTRO) Expert Panel

PURPOSE

Ensuring high quality, evidence-based radiation therapy for patients with cancer is of the upmost importance. To address this need, the Veterans Affairs (VA) Radiation Oncology Program partnered with the American Society for Radiation Oncology and established the VA Radiation Oncology Quality Surveillance program. As part of this ongoing effort to provide the highest quality of care for patients with rectal cancer, a blue-ribbon panel comprised of rectal cancer experts was formed to develop clinical quality measures.

METHODS AND MATERIALS

The Rectal Cancer Blue Ribbon panel developed quality, surveillance, and aspirational measures for (a) initial consultation and workup, (b) simulation, treatment planning, and treatment, and (c) follow-up. Twenty-two rectal cancer specific measures were developed (19 quality, 1 aspirational, and 2 surveillance). In addition, dose-volume histogram constraints for conventional and hypofractionated radiation therapy were created.

CONCLUSIONS

The quality measures and dose-volume histogram for rectal cancer serves as a guideline to assess the quality of care for patients with rectal cancer receiving radiation therapy. These quality measures will be used for quality surveillance for veterans receiving care both inside and outside the VA system to improve the quality of care for these patients.

Variation in the volume-outcome relationship after rectal cancer surgery in the United States: Retrospective study with implications for regionalization

BACKGROUND

Previous studies have demonstrated improved outcomes for patients with rectal cancer treated at higher-volume hospitals. However, little is known whether heterogeneity in this effect exists. The objective was to test whether the effect of increased annual rectal cancer resection volume on outcomes is consistent across all hospitals treating rectal cancer.

METHODS

Adult stage I to III patients who underwent surgical resection for rectal adenocarcinoma from 2004 to 2016 were identified in the National Cancer Database.

RESULTS

We included 120,522 patients treated at 763 hospitals in this retrospective cohort study. Higher volume was linearly and incrementally related to outcomes in unadjusted analyses. In adjusted models, for an average patient at the average hospital, the effect of increasing the annual caseload of rectal cancer resections by 20 resections per year was associated with 8%, (hazard ratio = 0.92, 95% confidence interval = 0.87, 0.97), 18% (odds ratio = 0.82, 95% confidence interval = 0.70, 0.98), and 16% (odds ratio = 0.84, 95% confidence interval = 0.73, 0.95) relative reductions in 5-year overall survival, 30-, and 90-day mortality, respectively, and with a 19% (odds ratio = 1.19, 95% confidence interval = 1.04, 1.36) relative increase in the rate of neoadjuvant chemoradiation. These effects varied by individual hospitals such that 39% of hospitals do not see any benefit in 5-year overall survival associated with higher volumes. Increased volume was associated with lower positive circumferential resection margin rates at 19% of the hospitals.

CONCLUSION

This study confirms that higher-volume hospitals have improved outcomes after rectal cancer surgery. However, there exists significant variation in these effects induced by individual within-hospital effects. Regionalization policies may need to be flexible in identifying the hospitals that would achieve enhanced benefits from treating a larger volume of patients.

Centralisation of rectal cancer care has improved patient survival in the republic of Ireland

BACKGROUND

Centralisation of rectal cancer surgery to designated centres was a key objective of the Irish national cancer control program. A national audit of rectal cancer surgery indicated centralisation was associated with improved early surgical outcomes. This study aimed to determine the impact of implementation of the national cancer strategy on survival from rectal cancer.

MATERIALS AND METHODS

Data were collected from the National Cancer Registry of Ireland to include all patients with Stage I-III rectal cancer undergoing rectal cancer surgery with curative intent between 2003 and 2012. Five-year overall survival and cancer-specific survival was compared between patients in the pre-centralisation (2003-2007) and post-centralisation period (2008-2012) and between patients receiving surgery in designated cancer centres and non-cancer centres.

RESULTS

The proportion of rectal cancer surgery performed in a designated cancer centre increased from 42% during 2003-2007 to 58% during 2008-2012. Five-year overall survival increased from 66.1% in 2003-2007 to 73.5% in 2008-2012 (p < 0.001). Five-year cancer-specific survival increased from 75.3% in 2003-2007 to 81.9% in 2008-2012 (p < 0.001). Surgery in a cancer centre and surgery post-centralisation were significantly associated with overall and cancer specific survival using Cox proportional hazards regression.

CONCLUSION

Survival following resection of rectal cancer was significantly improved following implementation of a national cancer strategy incorporating centralisation of rectal cancer surgery.

Omission of or Poor Response to Preoperative Chemoradiotherapy Impacts Radial Margin Positivity Rates in Locally Advanced Rectal Cancer

BACKGROUND

In the setting of multidisciplinary standardized care of locally advanced rectal cancer, preoperative chemoradiotherapy and total mesorectal excision have become the mainstay treatment.

OBJECTIVE

This study aimed to evaluate whether the lack of preoperative chemoradiotherapy or poor response to it is associated with higher radial margin disease involvement in patients with locally advanced rectal cancer.

DESIGN

This is a retrospective cohort study using a publicly available database.

SETTING

Data were collected from the proctectomy-targeted National Surgical Quality Improvement Project file from 2016 to 2017.

PATIENTS

A total of 1161 patients were analyzed. They were categorized into 3 groups: patients who did not receive any preoperative chemoradiotherapy (28.6%), patients who received and responded to preoperative chemoradiotherapy (41.2%), and patients who received but did not respond to preoperative chemoradiotherapy (30.2%).

MAIN OUTCOME MEASURES

Response to treatment was determined by using the American Joint Committee on Cancer pretreatment and final pathological staging. Circumferential radial margin was extracted from the targeted proctectomy file.

RESULTS

Disease-involved positive circumferential radial margin was found in 86 (7.4%) cases. Positive radial margin was noted in 11 of 479 patients (2.3%) who underwent preoperative chemoradiotherapy and responded to treatment, 30 of 350 patients (8.6%) who did not respond or had a poor response to preoperative chemoradiotherapy, and 45 of 332 patients (13.6%) who did not receive preoperative chemoradiotherapy (p < 0.001). Regression analysis demonstrated that patients who do not receive preoperative chemoradiotherapy or have poor response to it have 6.6 and 4 times higher chances of having a positive radial margin.

LIMITATIONS

There is a risk of selection bias, unidentified confounders, and missing data despite the use of a nationwide cohort.

CONCLUSIONS

Omission of indicated preoperative chemoradiotherapy or poor response to it is associated with increased risk of radial margin positivity. More efforts are needed for standardized rectal cancer care with the appropriate use of preoperative chemoradiotherapy. See Video Abstract at http://links.lww.com/DCR/B467.

LA OMISIN O LA ESCASA RESPUESTA A QUIMIORADIOTERAPIA PREOPERATORIA, AFECTA LAS TASAS DE POSITIVIDAD DEL MARGEN RADIAL, EN EL CNCER RECTAL LOCALMENTE AVANZADO

ANTECEDENTES:En el contexto de la atención multidisciplinaria estandarizada del cáncer rectal localmente avanzado, la quimioradioterapia preoperatoria y la escisión mesorrectal total, se han convertido en el tratamiento principal.OBJETIVO:Evaluar si la omisión de quimioradioterapia preoperatoria o la escasa respuesta, se asocia con mayor enfermedad del margen radial, en pacientes con cáncer rectal localmente avanzado.DISEÑO:Estudio de cohorte retrospectivo utilizando una base de datos disponible públicamente.AJUSTE:Se recopilaron datos del archivo del Proyecto Nacional de Mejora de la Calidad Quirúrgica dirigido a la proctectomía de 2016-2017.PACIENTES:Se analizaron un total de 1161 pacientes. Clasificados en tres grupos: pacientes que no recibieron quimioradioterapia preoperatoria (28,6%), pacientes que recibieron y respondieron a quimioradioterapia preoperatoria (41,2%) y pacientes que recibieron pero no respondieron a la quimioradioterapia preoperatoria (30,2%).PRINCIPALES MEDIDAS DE RESULTADO:La respuesta al tratamiento se determinó utilizando el pre tratamiento y la estatificación patológica final, del American Joint Committee on Cancer. El margen radial circunferencial se extrajo del archivo de proctectomía dirigida.RESULTADOS:Se encontró enfermedad que abarcaba el margen radial circunferencial +, en el 86 (7,4%) casos. Se observó el margen radial +, en 11 de 479 pacientes (2,3%) que se sometieron a quimioradioterapia preoperatoria y respondieron al tratamiento, 30 de 350 pacientes (8,6%) que no respondieron o tuvieron una mala respuesta con quimioradioterapia preoperatoria y en 45 de 332 pacientes (13,6%) que no recibieron quimioradioterapia preoperatoria (p <0,001). El análisis de regresión demostró que los pacientes que no reciben quimioradioterapia preoperatoria o que tienen escasa respuesta, presentan respectivamente, 6,6 y 4 veces más probabilidades de tener un margen radial +.LIMITACIONES:Existe el riesgo de sesgo de selección, factores de confusión no identificados y datos faltantes a pesar del uso de una cohorte nacional.CONCLUSIONES:La omisión de la quimioradioterapia preoperatoria indicada o la escasa respuesta, se asocian a un mayor riesgo de positividad del margen radial. Se necesitan mayores esfuerzos en la atención estandarizada del cáncer rectal, con el uso adecuado de quimioradioterapia preoperatoria. Consulte Video Resumen en http://links.lww.com/DCR/B467.

Staging Concordance and Guideline-Concordant Treatment for Esophageal Adenocarcinoma

BACKGROUND

Treatment selection for patients with esophageal adenocarcinoma is predicated on clinical staging information, which is inaccurate in 20% to 30% of cases and could impact the delivery of guideline-concordant treatment. We aimed to evaluate the association between staging concordance at the patient and hospital levels with the delivery of guideline-concordant treatment among esophageal adenocarcinoma patients.

METHODS

This was a national cohort study of resected esophageal adenocarcinoma patients in the National Cancer Data Base (2006 to 2015) treated either with upfront resection or neoadjuvant therapy followed by surgery. Patient- and hospital-level clinical and pathologic staging concordance and deviations from treatment guidelines were ascertained. For neoadjuvant therapy patients, staging concordance was predicted through Bayesian analysis. Reliability adjustment was used when evaluating hospital-level concordance.

RESULTS

Among 9393 esophageal adenocarcinoma patients treated at 927 hospitals, 41% had upfront surgery. Among upfront surgery patients, staging concordance was 85.1% for T1N0 and 86.9% for T3-T4N+ disease, but less than 50% for all others. Among patients treated with neoadjuvant therapy, treatment downstaging was observed in 33.9%. Deviations from treatment guidelines were identified in 38.5% of upfront surgery patients and 3.3% of neoadjuvant therapy patients. The proportion of concordantly staged patients ranged from 60.1% to 87.9%, and deviations from treatment guidelines were observed among 14.9% to 22.7% of the patients. Patient staging concordance increased, and deviations from guidelines decreased, as hospital-level concordance increased (trend test, P values less than .001 for all).

CONCLUSIONS

Deviations from treatment guidelines in esophageal adenocarcinoma patients appear to be a function of inaccurate clinical staging information, which should be a new focus for quality improvement efforts.

Quality Assurance, Metrics, and Improving Standards in Rectal Cancer Surgery in the United States

Rectal cancer surgery has seen significant improvement in recent years. This has been possible in part due to focus on surgeon education and training, specific surgical quality metrics, and longitudinal tracking of data through the use of registries. In countries that have implemented such efforts, data has shown significant improvement in outcomes. However, there continues to be significant variation in rectal cancer outcomes and practices worldwide. Just within the United States, county level mortality rates from rectal cancer range from 8-15 per 100,000 to 38-59 per 100,000. In order to continue to improve rectal cancer patient outcomes, there needs to be evidence based guidelines and standards centered around the framework of structure, process, and outcomes. In addition, there must be a feedback system by which programs can continually assess their performance. Obtaining evidence for specific standards and measures can be challenging and requires analyzing available data and literature, some of which may be conflicting. This article evaluates the evolution of metrics and standards used for quality improvement in rectal cancer and ongoing efforts to further improve patient outcomes.

Hospital and surgeon variation in positive circumferential resection margin among rectal cancer patients

BACKGROUND

The objective of this study was to evaluate variation in positive CRM at the surgeon and hospital levels and assess impact on disease-specific survival.

METHODS

Patients with stage I-III rectal cancer were identified in New York State. Bayesian hierarchical regressions estimated observed-to-expected (O/E) ratios for each surgeon/hospital. Competing-risks analyses estimated disease-specific survival among patients who were treated by surgeons/hospitals with O/E > 1 compared to those with O/E ratio ≤ 1.

RESULTS

Among 1,251 patients, 208 (17%) had a positive CRM. Of the 345 surgeons and 118 hospitals in the study, 99 (29%) and 48 (40%) treated a higher number of patients with CRM than expected, respectively. Patients treated by surgeons with O/E > 1 (HR = 1.38, 95% CI = 1.16, 1.67) and those treated at hospitals with O/E > 1 (HR = 1.44, 95% CI = 1.11, 1.85) had worse disease-specific survival.

DISCUSSION

Surgeon and hospital performance in positive CRM is associated with worse prognosis suggesting opportunities to enhance referral patterns and standardize care.