Non-Operative Management of Rectal or Anal Canal Adenocarcinoma: National Cancer Database Analysis of the Impact of Disease, Treatment, and Social Determinants of Health on Overall Survival.
Int J Radiat Oncol Biol Phys 2023;
117:e336. [PMID:
37785179 DOI:
10.1016/j.ijrobp.2023.06.2392]
[Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S)
For select patients with rectal or anal canal adenocarcinoma (RA-ACA), a non-operative management (NOM) strategy utilizing definitive radiotherapy (RT) has emerged as an option with the goal to improve quality of life compared with surgical management while maintaining similar oncologic outcomes. Disease and treatment characteristics as well as social determinants of health have been associated with access to care and health outcomes, and we hypothesized that such factors would impact overall survival (OS) amongst patients who received a NOM approach. The purpose of this study was to explore the influence of patient demographics, disease characteristics, and social determinants of health on OS amongst those receiving NOM utilizing the National Cancer Database (NCDB).
MATERIALS/METHODS
We identified patients at least 18 of years of age diagnosed with clinical stage 1-3 RA-ACA from 2004-2018. The NOM cohort included patients who received RT and either refused surgery or surgery was not recommended in their treatment. Patients were excluded if receipt of chemotherapy or RT were unknown, received RT to a site outside of the pelvis, or received palliative-intent treatment. OS was estimated using the Kaplan-Meier method. Univariable and multivariable (MVA) Cox proportional hazards model was used to assess characteristics associated with OS. Analyses were performed using STATA (version 17, College Station, TX). A p<0.05 was considered statistically significant.
RESULTS
A total of 12,409 patients were identified as the NOM cohort. The median OS was 48.8 months (95% CI: 46.8-50.6). On MVA, variables associated with poorer OS included age ≥ 70 vs 50-69, male sex, Charlson-Deyo Score ≥ 1 vs 0, insurance status (no insurance, Medicaid or Medicare vs. private), geographical region (South, Midwest or West vs. Northeast), rural urban density vs metro/urban, treatment in a community facility vs academic, year of diagnosis (2004-2011 vs. 2012-2018), clinical T4 vs T1, clinical N1 or N2 vs N0, and grade 3 vs 1 (all p<0.05). Treatment with a RT dose < 45 Gy vs. 45-54 Gy (HR: 2.24, 95% CI: 2.07-2.44), but not > 55 Gy vs. 45-54 Gy, and omission of chemotherapy (HR: 1.28, 95% CI: 1.16-1.43) were associated with poorer OS.
CONCLUSION
Patient, disease, treatment, and social determinants of health may influence OS amongst patients with RA-ACA who receive a NOM approach. Further work is needed to determine if the influence on OS can be explained, in part, by patients' lack of access to the intense surveillance necessary and/or the potential need for subsequent surgical management. Heightened awareness of these differential outcomes is needed to assist in patient selection and to successfully address barriers in access to optimize outcomes for patients who receive NOM.
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