Increased use of multidisciplinary treatment modalities adds little to the outcome of rectal cancer treated by optimal total mesorectal excision

Integrated care pathway for rectal cancer treatment: cross-sectional post-implementation study using a logic model framework

BACKGROUND

Management of rectal cancer has become more complex with multimodality therapy (neoadjuvant chemoradiotherapy and surgery) and this has led to the need to organize multidisciplinary teams. The aim of this study was to report on the planning, implementation and evaluation of an integrated care pathway for neoadjuvant treatment of middle and lower rectal cancer.

DESIGN AND SETTING

This was a cross-sectional post-implementation study that was carried out at a public university cancer center.

METHODS

The Framework for Program Evaluation in Public Health of the Centers for Disease Control and Prevention (CDC) was used to identify resources and activities; link results from activities and outcomes with expected goals; and originate indicators and outcome measurements.

RESULTS

The logic model identified four activities: stakeholders' engagement, clinical pathway development, information technology improvements and training programs; and three categories of outcomes: access to care, effectiveness and organizational outcomes. The measurements involved 218 patients, among whom 66.3% had their first consultation within 15 days after admission; 75.2% underwent surgery < 14 weeks after the end of neoadjuvant treatment and 72.7% completed the treatment in < 189 days. There was 100% adherence to the protocol for the regimen of 5-fluorouracil and leucovorin.

CONCLUSIONS

The logic model was useful for evaluating the implementation of the integrated care pathways and for identifying measurements to be made in future outcome studies.

Clinical assessment and identification of immuno-oncology markers concerning the 19-gene based risk classifier in stage IV colorectal cancer

BACKGROUND

Genomic profiling of tumors has contributed to the understanding of colorectal cancer (CRC), facilitating diagnosis, prognosis and selection of treatments, including targeted regimens. A report suggested that a 19-gene-based risk classifier (TCA19) was a prognostic tool for patients with stage III CRC. The survival outcomes in patients with stage IV CRC are still poor and appropriate selection of targeted therapies and immunotherapies is challenging.

AIM

To assess clinical implication of TCA19 in patients with stage IV CRC, and to identify TCA19 with involvement in immune-oncology.

METHODS

A retrospective review of the medical records of 60 patients with stage IV CRC was conducted, assessing clinicopathological variables and progression-free survival (PFS). TCA19 gene expression was determined by quantitative polymerase chain reaction (qPCR) in matched normal and tumor tissues taken from the study cohort. Expression of potential immune-oncology regulatory proteins and targets was examined by immunohistochemistry (IHC), western blot, immunofluorescence staining in tissues from a validation cohort of 10 patients, and in CRC cell lines co-cultured with monocyte in vitro.

RESULTS

In the patients with TCA19 score higher than the median, the PFS rates of eight patients who received the targeted regimens were significantly higher than the PFS rates of four patients who received 5-fluorouracil-based regimen (P = 0.041). In multivariate analysis, expression of signaling lymphocytic activation molecule family, member 7 (SLAMF7) and triggering receptor expressed on myeloid cells 1 (TREM1) was associated with PFS in the 60-patient cohort. After checking another 10 validate set, the expression of the IHC, the level of real-time qPCR, and the level of western blot were lower for SLAMF7 and higher for TREM7 in primary and metastatic tumors than in normal tissues. In CRC cells expressing SLAMF7 that were co-cultured with a monocytic cell line, levels of CD 68 and CD 73 were significantly lower at day 5 of co-culture than at day 0.

CONCLUSION

The TCA19 score might be prognostic for target-regimen-specific PFS in stage IV CRC. Down-regulation of SLAMF7 and up-regulation of TREM1 occur in primary and metastatic tumor tissues.

Impact of a Multidisciplinary Team Approach for Managing Advanced and Recurrent Colorectal Cancer

BACKGROUND

The wide variety of treatment strategies makes clinical decision-making difficult in advanced and recurrent colorectal cancer cases. Many hospitals have started multidisciplinary team (MDT) meetings comprising a team of dedicated specialists for discussing cases. MDTs for selected cases that are difficult to diagnose and treat are alternatives to regular MDTs. This study's aim was to determine the impact of a MDT for colorectal cancer on clinical decision-making.

METHODS

Cases were discussed when clinical specialists had difficulty making decisions alone. All processes done by the MDT were then recorded in prospectively designed medical case forms.

RESULTS

From Jan 2011 to Dec 2014, 1383 cases were discussed. A total of 549 (39.8%) case forms were completed for patients with newly diagnosed colorectal cancer, whereas 833 (60.2%) were completed for those with recurrent diseases. The MDT altered the proposed treatment of the referring physician in 179 (13%) cases. In 85 of the 179 (47.5%) altered cases, the radiologist's review of clinical information affected the diagnosis and decision. Furthermore, 152 of the 1383 MDT decisions were not implemented. Treatment intent, therapeutic plan, and alteration of decision were important reasons for not following the MDT's recommendation.

CONCLUSION

Case discussions in MDT meetings resulted in altered clinical decisions in >10% cases. Implementation rates after MDT discussions might be affected by the treatment decision-making process. Imperfect decisions made by individual physicians can be decreased by the multidisciplinary decision-making process.

Integrated care pathway for rectal cancer treatment: health care resource utilization, costs, and outcomes

AIM

Managed Flow C20 (MFC20) is an integrated care pathway (ICP) for rectal cancer implemented at a public teaching hospital. This study aims to quantify resource utilization and estimate direct costs and outcomes associated with the use of this ICP.

METHODS

We evaluated consecutive rectal cancer patients treated with neoadjuvant chemoradiotherapy (nCRT) followed by surgery, comparing the period before the ICP implementation (Pre-MFC20 group) and after (MFC20 group). We assessed times between treatment steps and quantified the resources utilized, as well as their costs.

RESULTS

There were 112 patients in the Pre-MFC20 group and 218 in the MFC20 group. The mean treatment intervals were significantly shorter in the MFC20 group - from the first medical consultation to nCRT (48.3 vs. 87.5 days; P < 0.001); and from nCRT to surgery (14.8 vs. 23.0 weeks; P < 0.001) - as was the mean total treatment time (192.0 vs. 290.2 days; P < 0.001). Oncology consultations, computed tomography, MRI, and radiotherapy sessions were utilized more frequently in the Pre-MFC20 group (P < 0.001). The median per-patient cost was US$11 180.92 in the Pre-MFC20 group, compared with US$10 412.88 in the MFC20 group (P = 0.125). Daily hospital charges and consultations were the major determinants of the total cost of the treatment. There was no statistical difference in overall survival in the time periods examined.

CONCLUSION:

Implementation of a rectal cancer ICP reduced all treatment intervals and promoted rational utilization of oncology consultations and imaging, without increment in per-patient costs or detrimental effects in overall survival.

Prognostic Significance of Tumor Regression in Locally Advanced Rectal Cancer after Preoperative Radiochemotherapy

Background

The majority of rectal cancers are discovered in locally advanced forms (UICC stage II, III). Treatment consists of preoperative radiochemotherapy, followed by surgery 6–8 weeks later and finally by postoperative chemotherapy. The aim of this study was to find out if tumor regression affected long-term survival in patients with localy advanced rectal cancer, treated with neoadjuvant radiochemotherapy.

Patients and methods

Patients with rectal cancer stage II or III, treated between 2006 and 2010, were included in a retrospective study. Clinical and pathohistologic data were acquired from computer databases and information about survival from Cancer Registry. Survival was estimated according to Kaplan-Meier method. Significance of prognostic factors was evaluated in univariate analysis; comparison was carried out with log-rank test. The multivariate analysis was performed according to the Cox regression model; statistically significant variables from univariate analysis were included.

Results

Two hundred and two patients met inclusion criteria. Median follow-up was 53.2 months. Stage ypT0N0 (pathologic complete response, pCR) was observed in 14.8% of patients. Pathohistologic stage had statistically significant impact on survival (p = 0.001). 5-year survival in patients with pCR was>90%. Postoperative T and N status were also found to be statistically significant (p = 0.011 for ypT and p < 0.001 for ypN). According to multivariate analysis, tumor response to neoadjuvant therapy was the only independent prognostic factor (p = 0.003).

Conclusions

Pathologic response of tumor to preoperative radiochemotherapy is an important prognostic factor for prediction of long-term survival of patients with locally advanced rectal cancer.

The effect of multidisciplinary teams for rectal cancer on delivery of care and patient outcome: has the use of multidisciplinary teams for rectal cancer affected the utilization of available resources, proportion of patients meeting the standard of care, and does this translate into changes in patient outcome?

BACKGROUND

We hypothesized that mandatory multidisciplinary team (MDT) participation improves process evaluation, outcomes, and technical aspects of surgery for rectal cancer in a stable practice of colorectal surgery.

METHODS

A retrospective review of MDT data was conducted of all patients with colorectal cancer since 2010. Demographic, clinical stage, process evaluation, quality of surgery, and outcome data were collected. Total mesorectal excision and MDT required participation started 2013.

RESULTS

One hundred thirty patients were included in this study: 47 patients in 2014; 41 patients in 2013; and 42 patients pre-MDT. Improvements were seen in 12 of the 14 preoperative process variables, 6 significantly. Improvement in the completeness of total mesorectal excision (0% to 76%) was significant. Local recurrence occurred in 10% of the pre-MDT group, and follow-up is ongoing in the MDT groups.

CONCLUSIONS

MDT participation improves care of patients with rectal cancer. Preoperative clinical staging, multimodality treatment, pathologic staging, and technical aspects of surgery have improved.

Therapeutic management and outcome of locoregional recurrence after curative colorectal cancer therapy-a single-center analysis

Locoregional tumor recurrence after curative therapy for colorectal cancer is therapeutically challenging and associated with poor prognosis. Goal of this single-center study was to analyze patients with locoregional recurrence with regard to therapeutic strategies and outcome for colon and rectal cancer each. Charts of all patients surgically treated for colorectal cancer in the period from 2000 to 2011 (n = 1296) were examined; patients with locoregional recurrence (n = 86) were then further analyzed. Fifty-three (10.2%) patients with rectal and 33 (5.6%) patients with colon cancer developed a locoregional recurrence, median 24.5 months after first diagnosis. Recurrence-specific therapy was applied in the majority of the patients (84.8% colon, 90.7% rectum); a surgical approach was undertaken in 82.1% (colon) and in 56.3% (rectum). Five-year overall survival after locoregional recurrence was 13% for rectal cancer and 9% for colon cancer. Itemized analysis for the approached therapeutic regimens revealed that radical recurrence resection (R0) significantly prolongs overall survival (p = 0.003) in rectal cancer, as does a surgical approach itself, as compared to conservative treatment modalities. If feasible, oncologic radical resection of the relapse (R0) significantly influences patient outcome and overall survival in rectal cancer.

Chronological improvement in survival following rectal cancer surgery: a large-scale, single-center study

BACKGROUND

Total mesorectal excision (TME) and preoperative chemoradiation therapy (PCRT) for rectal cancer are used sequentially in our center. The aim of this study was to evaluate survival of patients with stage II/III rectal cancer chronologically and to determine whether therapeutic advances associated with TME and PCRT have improved patient survival.

METHODS

A retrospective review of 2,197 patients from July 1989 to December 2006 was conducted. The time period (P) for this study was divided into three groups: P1 (1989-1995), P2 (1996-2001) for TME, P3 (2002-2006) for PCRT. Cancer-specific survival (CSS), disease-free survival (DFS), and recurrences among the three periods were investigated.

RESULTS

A total of 293 patients in P1, 836 patients in P2, and 1,068 patients in P3 were enrolled. The 5-year CSS in stages II and III was statistically different between P1/P2 and P3 (stage II, p = 0.008; stage III, p < 0.001). The 5-year DFS was significantly different between P1/P2 and P3 for stage III (p = 0.001). The local recurrence and systemic recurrence rates decreased during P3, but there was no significant difference between the three periods for stage II. For stage III, local recurrence was significantly different between the three periods (P1 vs. P2, p = 0.002; P1 vs. P3, p < 0.001; P2 vs. P3, p = 0.008).

CONCLUSIONS

We identified an improvement in survival for stage II/III rectal cancer and a decrease in local recurrence for stage III rectal cancer during P3, the most recent period. This may be due to frequent application of PCRT based on the TME.

Optimizing adjuvant treatment decisions for stage t2 rectal cancer based on mesorectal node size: a decision analysis

RATIONALE AND OBJECTIVES

The aim of this study was to optimize treatment decisions for patients with suspected stage T2 rectal cancer on the basis of mesorectal lymph node size at magnetic resonance imaging.

MATERIALS AND METHODS

A decision-analytic model was developed to predict outcomes for patients with stage T2 rectal cancer at magnetic resonance imaging. Node-positive patients were assumed to benefit from chemoradiation prior to surgery. Imperfect magnetic resonance imaging performance for primary cancer and mesorectal nodal staging was incorporated. Five triage strategies were considered for administering preoperative chemoradiation: treat all patients; treat for any mesorectal node >3, >5, and >7 mm in size; and treat no patients. If nodal metastases or unsuspected stage T3 disease went untreated preoperatively, postoperative chemoradiation was needed, resulting in poorer outcomes. For each strategy, rates of acute and long-term chemoradiation toxicity and of 5-year local recurrence were computed. Effects of input parameter uncertainty were evaluated in sensitivity analysis.

RESULTS

The optimal strategy depended on the outcome prioritized. Acute and long-term chemoradiation toxicity rates were minimized by triaging only patients with nodes >7 mm to preoperative chemoradiation (18.9% and 10.8%, respectively). A treat-all strategy minimized the 5-year local recurrence rate (5.6%). A 7-mm nodal triage threshold increased the 5-year local recurrence rate to 8.0%; when no patients were treated preoperatively, the local recurrence rate was 10.1%. With improved primary tumor staging, all outcomes could be further optimized.

CONCLUSIONS

Mesorectal nodal size thresholds for preoperative chemoradiation should depend on the outcome prioritized: higher size thresholds reduce chemoradiation toxicity but increase recurrence rates. Improvements in nodal staging will have greater impact if primary tumor staging can be improved.