Patterns of care and surgical outcomes for early-stage rectal cancer in the United States

Abstract

Background

Although limited trials have demonstrated the feasibility of rectal-preserving approaches in clinical T1-3N0 adenocarcinoma, local excision after neoadjuvant therapy has been associated with high rates of morbidity. We hypothesized that this strategy would be comparable to the standard, total mesorectal excision. The aim of this study was to describe trends of early-stage rectal cancer management.

Methods

cT1-3N0 rectal cancers in the National Cancer Database (2006–2018) were grouped into 5 treatments: total mesorectal excision, total neoadjuvant therapy + local excision, neoadjuvant chemoradiotherapy + local excision, total neoadjuvant therapy + total mesorectal excision, and neoadjuvant chemoradiotherapy + total mesorectal excision. Morbidity was defined as a combination of readmissions and 30- and 90-day mortality.

Results

We identified 22,793 patients. Neoadjuvant chemoradiotherapy + local excision had the highest proportion of patients ≥70 years (41%) and those with comorbidities (Charlson-Deyo score ≥2, 9%). Median stay was 1 day for local excision and 5 days for total mesorectal excision. Overall composite morbidity was 9%, which, after adjustment, was not statistically different between local excision and total mesorectal excision (odds ratio = 0.45, 95% confidence interval: 0.17–1.19). Among local excision patients, 56% had pathologic complete response, 33% were pStage I, and 12% pStage II-III. In multivariable analysis, all strategies had similar overall survival compared with total mesorectal excision, except for neoadjuvant chemoradiotherapy + local excision, which was associated with worse prognosis (hazard ratio = 1.57, 95% confidence interval: 1.21–2.03).

Conclusion

Although infrequent, neoadjuvant chemoradiotherapy/total neoadjuvant therapy + local excision were associated with high rates of tumor downstaging, suggesting that rectal-preserving strategies are feasible. However, 1 in 8 patients had more advanced disease, which may have compromised future total mesorectal excision planes. Together with the similar morbidity and relatively worse prognosis of neoadjuvant chemoradiotherapy + local excision, these observations should prompt careful patient selection for this approach, while cautioning against its widespread use.