Survival after surgical treatment of cancer of the rectum

Influence of Certification Program on Treatment Quality and Survival for Rectal Cancer Patients in Germany: Results of 13 Certified Centers in Collaboration with AN Institute

INTRODUCTION

The certification of oncological units as colorectal cancer centers (CrCCs) has been proposed to standardize oncological treatment and improve the outcomes for patients with colorectal cancer (CRC). The proportion of patients with CRC in Germany that are treated by a certified center is around 53%. Lately, the effect of certification on the treatment outcomes has been critically discussed.

AIM

Our aim was to investigate the treatment outcomes in patients with rectal carcinoma at certified CrCCs, in German hospitals of different medical care levels.

METHODS

We performed a retrospective analysis of a prospective, multicentric database (AN Institute) of adult patients who underwent surgery for rectal carcinoma between 2002 and 2016. We included 563 patients from 13 hospitals of different medical care levels (basic, priority, and maximal care) over periods of 5 years before and after certification.

RESULTS

The certified CrCCs showed a significant increase in the use of laparoscopic approach for rectal cancer surgery (5% vs. 55%, p < 0.001). However, we observed a significantly prolonged mean duration of surgery in certified CrCCs (161 Min. vs. 192 Min., p < 0.001). The overall morbidity did not improve (32% vs. 38%, p = 0.174), but the appearance of postoperative stool fistulas decreased significantly in certified CrCCs (2% vs. 0%, p = 0.036). Concerning the overall in-hospital mortality, we registered a positive trend in certified centers during the five-year period after the certification (5% vs. 3%, p = 0.190). The length of preoperative hospitalization (preop. LOS) was shortened significantly (4.71 vs. 4.13 days, p < 0.001), while the overall length of in-hospital stays was also shorter in certified CrCCs (20.32 vs. 19.54 days, p = 0.065). We registered a clear advantage in detailed, high-quality histopathological examinations regarding the N, L, V, and M.E.R.C.U.R.Y. statuses. In the performed subgroup analysis, a significantly longer overall survival after certification was registered for maximal medical care units (p = 0.029) and in patients with UICC stage IV disease (p = 0.041). In patients with UICC stage III disease, we registered a slightly non-significant improvement in the disease-free survival (UICC III: p = 0.050).

CONCLUSIONS

The results of the present study indicate an improvement in terms of the treatment quality and outcomes in certified CrCCs, which is enforced by certification-specific aspects such as a more differentiated surgical approach, a lower rate of certain postoperative complications, and a multidisciplinary approach. Further prospective clinical trials are necessary to investigate the influence of certification in the treatment of CRC patients.

Are Colon and Rectal Cancer Two Different Tumor Entities? A Proposal to Abandon the Term Colorectal Cancer

Colon cancer (CC) and rectal cancer (RC) are synonymously called colorectal cancer (CRC). Based on our experience in basic and clinical research as well as routine work in the field, the term CRC should be abandoned. We analyzed the available data from the literature and results from our multicenter Research Group Oncology of Gastrointestinal Tumors termed FOGT to confirm or reject this hypothesis. Anatomically, the risk of developing RC is four times higher than CC, while physical activity helps to prevent CC but not RC. Obvious differences exist in molecular carcinogenesis, pathology, surgical topography and procedures, and multimodal treatment. Therefore, we conclude that CC is not the same as RC. The term "CRC" should no longer be used as a single entity in basic and clinical research as well as other areas of classification.

Trends in presentation, treatment and survival of 1777 patients with colorectal cancer over a decade: a Biobank study

BACKGROUND

Most survival data in colorectal cancer (CRC) is derived from clinical trials or register-based studies. Hospital Biobanks, linked with hospital electronic records, could serve as a data-gathering method based on consecutively collected tumor samples. The aim of this Biobank study was to analyze survival of colorectal patients diagnosed and treated in a single-center university hospital over a period of 12 years, and to evaluate factors contributing to outcome.

MATERIAL AND METHODS

A total of 1777 patients with CRC treated during 2001-2012 were identified from the Auria Biobank, Turku, Finland. Longitudinal clinical information was collected from various hospital electronic records and date and cause of death obtained from Statistics Finland.

RESULTS

Cancer-specific, overall and disease-free survival was higher in patients diagnosed during 2004-2008 as compared with patients diagnosed in 2001-2003. Further improvement was not seen during years 2009-2012. Potential factors contributing to the improvement were introduction of multidisciplinary meetings, centralization of rectal cancer surgery, use of adjuvant chemotherapy and systematic preoperative radiotherapy of rectal cancer. The proportion of patients with stage I-IV CRC remained similar over the study period, but a marked decrease in non-metastatic rectal cancer with biopsy only (locally advanced disease) was observed. In stage I-III rectal cancer, Cox multivariate analysis suggested age, comorbidity, R1 resection, T staging and tumor grade as prognostic factors. In colon cancer, prognostic factors were age, comorbidity, gender and presence of lymph node metastases.

CONCLUSIONS

Organizational changes in the treatment of CRC patients made since 2004 coincide with improved survival in CRC and a marked reduction in locally advanced rectal cancers. The clinical presentation of CRC has remained similar between 2001 and 2012.

What factors influence 10-year survival after curative resection of a colorectal carcinoma?

BACKGROUND

Ten-year survival rates are only rarely reported and frequently include a large proportion of censored data-that is, most of the patients have not survived the 10 years. We therefore selected patients in a prospectively maintained, hospital-based tumor register who had been operated on for colorectal carcinoma (CRC) more than 10 years earlier and who were classified as long-term survivors.

METHODS

For 589 consecutive CRC patients who underwent R0 resection in the period 1990-1998, we compared prognosis-relevant characteristics and calculated the survival rate as a function of age, sex, location of the tumor, general state of health, urgency of the operation, and pT and pN class. All patients were observed until their death or until at least 10 years after resection. Patients who died of other causes were censored. Overall survival and relative survival (the latter based on tumor-related death) were assessed.

RESULTS

The 10-year survivors were more often female (not significant), younger (p < 0.001), in good general health (p < 0.001), had undergone elective resection (p < 0.001), and had early-stage tumors (p < 0.001). In the univariate analysis emergency operation, impaired general health, invasion beyond the muscularis propria, and lymph-node metastasis were found to reduce relative survival. In the multivariate analysis, location, emergency resection, pT, and pN were found to be statistically independent risk factors.

CONCLUSIONS

Long-term freedom from tumor recurrence, like-short-term, is influenced largely by factors that are beneficially influenced by early recognition. The patient's age at resection is immaterial.

Extended abdominoperineal excision vs. standard abdominoperineal excision in rectal cancer--a systematic overview

BACKGROUND

After introduction of total mesorectal excision (TME) as the gold standard for rectal cancer surgery, oncologic results appeared to be inferior for abdominoperineal excision (APE) as compared to anterior resection. This has been attributed to the technique of standard APE creating a waist at the level of the tumor-bearing segment. This systematic review investigates outcome of both standard and extended techniques of APE regarding inadvertent bowel perforation, circumferential margin (CRM) involvement, and local recurrence.

METHODS

A literature search was performed to identify all articles reporting on APE after the introduction of TME using Medline, Ovid, and Embase. Extended APE was defined as operations that resected the levator ani muscle close to its origin. All other techniques were taken to be standard. Studies so identified were evaluated using a validated instrument for assessing nonrandomized studies. Rates for perforation, CRM involvement, and local recurrence were compared using chi-square statistics.

RESULTS

In the extended group, 1,097 patients, and in the standard group, 4,147 patients could be pooled for statistical analysis. The rate of inadvertent bowel perforation and the rate of CRM involvement for extended vs. standard APE was 4.1% vs. 10.4% (relative risk reduction 60.6%, p = 0.004) and 9.6% vs. 15.4% (relative risk reduction 37.7%, p = 0.022), respectively. The local recurrence rate was 6.6% vs. 11.9% (relative risk reduction 44.5%, p < 0.001) for the two groups.

CONCLUSION

This systematic review suggests that extended techniques of APE result in superior oncologic outcome as compared to standard techniques.

Practicability of quality goals for the treatment of rectal cancer

PURPOSE

In 2007, the German Working Group "Workflow Rectal Cancer II" published 19 quality indicators with 36 quality goals for the treatment of rectal cancer. We investigate whether these parameters are practicable in a specialized coloproctologic unit.

PATIENTS AND METHODS

We included 578 consecutive patients with rectal cancer who were treated in our institution from January 2000 to December 2008. Patient data were collected in a prospective database. Follow-up was conducted in a colorectal tumor clinic. Data were analyzed for the defined reference groups, and the results were compared with the quality goals.

RESULTS

Median follow-up was 54.4 (range 1-116) months. We achieved 19 of the 36 defined quality goals. Among these were important parameters such as the rate of postoperative mortality (0.9%), the rate of intraoperative local tumor perforation (2.2% for anterior resection and 8.5% for abdominoperineal excision), the 5-year local recurrence rate (5.9% stages I-III), and the 5-year overall survival rates for stages yII and II (79.9%), and stages yIII and III (60.7%) for patients with microscopically negative resection margins.

CONCLUSION

Most of the defined quality goals can be achieved in a specialized coloproctologic unit. The debate on quality goals has the potential to enable further improvement in the care of rectal cancer patients.

[Neoadjuvant radiochemotherapy for rectal cancer]

Neoadjuvant radiochemotherapy has become established treatment for rectal cancer. It is indicated when primary R0 resection is not an option, in cases of higher risk of locoregional relapse following surgical treatment alone, and when initially impossible conservation of the anal sphincter becomes possible in conjunction with neoadjuvant radiochemotherapy. The indication for radiochemotherapy in the upper third of the rectum is still controversial. Reevaluation of the tumor situation following neoadjuvant treatment is necessary before decisions on operative strategy. Modern imaging techniques are limited in this respect, as they hardly allow differentiation between living tumor tissue and lesions. In case of doubt clarity is possible only through surgical exploration, taking R1 resection into account. Overall the recognition of lymph node metastasis is not a sufficient indicator of local relapse. The frequency of postoperative complications following neoadjuvant radiochemotherapy is independent of the operative method. The effect of neoadjuvant radiochemotherapy on long-term survival and formation of distant metastases is still not clarified. Current studies seek clarification through the use of new chemotherapies and modified treatment regimes. Further, the correct time interval between the end of neoadjuvant radiochemotherapy and the following surgical therapy has yet to be determined. This applies also to the management of patients following complete remission.

Exactitude of relative survival compared with cause-specific survival and competing risk estimations based on a clinical database of patients with colorectal carcinoma

PURPOSE

Relative survival estimates are widely used by cancer registries. They provide survival rates adjusted for causes of death other than cancer. They have rarely been used in clinical settings. When compared with cause-specific survival rates or competing risks analysis, their applicability is hardly known. This study compares these three outcome measures on the basis of a well-documented clinical database of patients with colorectal cancer.

METHODS

We selected a consecutive series of 1,791 histopathologically completely resected colorectal cancer patients without neoadjuvant therapy from a prospective database from 1981 through 2006. Median follow-up was 4.7 (range, 0-23) years with only 3.1% patients lost. Cause-specific and relative survival are reported as failure rates as is the cumulative incidence in the presence of competing risks.

RESULTS

The analysis comprised 1,081 patients with colon cancer and 710 patients with rectal cancer. Stage distribution was as follows: Stage I, 480 patients; Stage II, 785 patients; Stage III, 472 patients; and Stage IV, 54 patients. The "cause-specific" failure rate, the "relative" failure rate, and the cumulative incidence in the presence of competing risks at five years (95% CI) for all patients were 21.1 (range, 19.0-23.4) %, 22.5 (range, 19.6-25.2) %, and 19.0 (range, 17.0-20.9) %, respectively.

CONCLUSION

Because we could demonstrate almost identical failure rates, we consider relative survival to be a powerful tool in clinical settings in which a comprehensive follow-up is not possible. It is especially useful as a reference parameter for clinical audit.

CT staging of colon cancer

Computer tomography (CT) has been the principal investigation in the staging of colon cancers. The information obtained with routine CT has been limited to identifying the site of the tumour, size of the tumour, infiltration into surrounding structures and metastatic spread. The Foxtrot trial National Cancer Research Institute (NCRI) has been specifically designed to evaluate the efficacy of neoadjuvant treatment in colon cancers by using preoperative chemotherapy with or without an anti-Epidermal Growth Factor Receptor (EGFR) monoclonal antibody to improve outcome in high-risk operable colon cancer. Patients are selected based on their staging CT examination. The criteria for poor prognosis are T4 and T3 tumours with more than 5mm extramural depth. Thus the success of the trial would depend upon the confidence of the radiologist to identify the patients that would receive the neoadjuvant treatment. The aim of this review is to explain the process of identifying high-risk features seen on the staging CT images. This will help to identify a cohort of patients that could truly benefit from neoadjuvant strategies.

Offene Rektumchirurgie

This article describes the individual techniques and strategies of conventional surgery of the rectum, including photographic documentation of the important steps. Our own figures of postoperative complications and long-term oncological results obtained by this approach are added. In our experience, operations for radical surgery of rectal cancer have been the most frequent procedures. In the pelvis, the important planes between which dissection occurs are (1) the mesorectal fascia up to the origin of the inferior mesenteric artery and continuing laterally to the mesosigmoid fascia and (2) on the opposite side the autonomous nerves forming the plexus and web-like layers. Apart from rectal excision, complete mobilisation of the descending colon and the splenic flecture is a prerequisite for tension-free anastomoses and low leakage rates. Again this dissection follows the plane between the mesocolon and the parietal fascia covering the retroperitoneal organs. The greater omentum has to be taken down from the transverse colon with exposure of the entire lesser sac, followed by the division of the transverse mesocolon along the inferior aspect of the pancreas, including central tying of the inferior mesenteric vein.