Preoperative treatment selection in rectal cancer: A population-based cohort study

https://doi.org/10.1016/j.ejso.2014.08.481Get rights and content

Abstract

Background

Preoperative radiotherapy and chemoradiotherapy for rectal cancer reduce local recurrence rates but is also associated with side effects. Thus, it is important to identify patients in whom the benefits exceed the risks. This study assessed the pretherapeutic parameters influencing the selection to preoperative treatment.

Methods

Data on all patients in the Stockholm-Gotland area, Sweden, who underwent elective trans-abdominal surgery for rectal cancer in 2000–2010, was retrieved from the Regional Cancer Registry and the Swedish National Patient Register. Clinical variables were analysed in relation to selected preoperative therapy. Odds Ratios were derived from univariable and multivariable logistic regression models.

Results

In total 2619 patients were included. Of these 1789 (68.3%) received preoperative radiotherapy or chemoradiotherapy. Over time, use of preoperative therapy increased (p < 0.001). In a multivariable model, age (≥80 years) and comorbidity (Charlson Comorbidity Index score ≥2) were strongly correlated to omittance of preoperative treatment (OR: 0.05; 95% CI: 0.04–0.07 and 0.29; 95% CI: 0.21–0.39) but there was no difference between genders. Pre-treatment tumour stage was a strong predictor for selection to preoperative (chemo-) radiotherapy. However, 8.2% of patients with intermediate or advanced tumours were selected to no preoperative treatment while 55.0% of patients with early tumours were selected to preoperative therapy.

Conclusions

The use of preoperative (chemo-) radiotherapy increased over time. Suboptimal adherence to guidelines appears to exist leading to a risk of overtreatment and to a small extent also undertreatment. More robust selection criteria, also including age and comorbidity should be developed.

Introduction

During the past decades treatment of rectal cancer has evolved dramatically. The introduction of total mesorectal excision (TME), has set focus on the importance of surgical technique for survival and local control.1 The Dutch TME trial showed that short-course preoperative radiotherapy (RT) in combination with TME surgery further reduced local recurrence rates while the effect on survival is not yet proven for all patients.2 For locally advanced tumours, long-course RT in combination with chemotherapy (CRT), improves local control and cancer-specific survival.3 However, RT, at least as it has been given during past decades, is also associated with side effects such as impaired healing, anorectal and genitourinary dysfunction, and secondary malignancies.4, 5, 6, 7, 8 Furthermore, because RT is cost and resource demanding it is of vital importance to identify patients in whom the benefits of RT exceed the risks.

Prior to commencement of therapy it is recommended that rectal cancer patients should be discussed at a multidisciplinary team conference (MDT). There are several guidelines, no one universally accepted, regarding the selection to different therapeutic options.9, 10, 11 The European guidelines suggest subdivision of rectal cancer according to the preoperative magnetic resonance imaging (MRI) into 3 groups: early, intermediate or locally advanced. However, the terminology and grouping varies in different guidelines.9, 10, 12 The extent to which guidelines are followed is poorly known and there is also uncertainty about the impact from various preoperative parameters on treatment decisions. Previous studies have reported inequalities regarding gender, ethnicity and socioeconomic status with respect to preoperative therapy.13, 14, 15 Moreover, age and comorbidity have a strong impact on preoperative treatment decisions16, 17 and increasing age and comorbidity among rectal cancer patients further adds complexity into the MDT-process.18 Because patients with advanced comorbidity and old age often are excluded from participation in clinical trials, knowledge on treatment selection in this sub-population is limited.19

This study aimed to investigate the clinical factors affecting the selection to preoperative treatment in a large population-based, prospectively registered cohort of rectal cancer patients.

Section snippets

Study population

The Swedish Rectal Cancer Registry (SRCR) was established in 1995 and has a coverage of >98%. The register is locally administered by the Regional Cancer Centres (RCC) and all patients are registered prospectively. Data on all patients who underwent elective trans-abdominal surgery for rectal cancer between January 2000 and December 2010 in the Stockholm-Gotland area (population 1.9 million) were extracted. Information retrieved included type of surgery, age, gender, date of diagnosis and

Clinical characteristics

A total of 2619 patients underwent elective transabdominal surgery for primary rectal cancer between 2000 and 2010. Descriptive data are shown in Table 2. More patients were operated in high volume centres in 2007–2010 compared to 2000–2002 (46.9% versus 37.2%, p < 0.001).

Preoperative RT (or CRT)

Among all patients 1789 (68.3%) had preoperative RT (or CRT). Table 3 shows the logistic regression analyses of the associations between clinical factors and preoperative treatment. Patients ≥80 years and patients with CCI

Discussion

This population-based study evaluated the associations between clinical characteristics and selection to preoperative oncological treatment in patients undergoing surgery for primary rectal cancer. In accordance with results from multiple studies showing lowered recurrence rates with preoperative (C)RT,2 patients were offered preoperative treatment to a high extent. However, without any obvious reason and despite increased knowledge about late adverse effects the use of preoperative (C)RT

Conflict of interest

None.

Acknowledgements

This work has been funded by the Regional agreement on medical training and clinical research (ALF) between the Stockholm County Council and Karolinska Institutet. Financial support was also provided by the Swedish Cancer Society and the Stockholm Cancer Society. Thanks to Tongplaew Singnomklao, data manager at RCC.

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