Retrospective Cohort Study
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Oncol. Jun 15, 2022; 14(6): 1148-1161
Published online Jun 15, 2022. doi: 10.4251/wjgo.v14.i6.1148
Contemporary, national patterns of surgery after preoperative therapy for stage II/III rectal adenocarcinoma
Celine Soriano, Henry T Bahnson, Jennifer A Kaplan, Bruce Lin, Ravi Moonka, Huong T Pham, Hagen F Kennecke, Vlad Simianu
Celine Soriano, Jennifer A Kaplan, Ravi Moonka, Department of Surgery, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
Henry T Bahnson, Benaroya Research Institute, Seattle, WA 98101, United States
Bruce Lin, Department of Hematology Oncology, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
Huong T Pham, Department of Radiation Oncology, Virginia Mason Franciscan Health, Seattle, WA 98101, United States
Hagen F Kennecke, Department of Medical Oncology, Providence Cancer Instititute, Portland, OR 97213, United States
Vlad Simianu, Section of Colon and Rectal Surgery, Department of Surgery, Virginia Mason Medical Center, Seattle, WA 98101, United States
Author contributions: All authors have made substantial contributions to conception and design of the study, acquisition of data, or analysis and interpretation of data, been actively involved in drafting the article or making critical revisions related to important intellectual content of the manuscript, and have provided final approval of the version of the article to be published.
Institutional review board statement: The study was reviewed and approved for publication by our Institutional Reviewer.
Conflict-of-interest statement: All the Authors have no conflict of interest related to the manuscript.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE statement, and the manuscript was prepared and revised according to the STROBE statement.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Vlad Simianu, FACS, MD, Director, Surgeon, Section of Colon and Rectal Surgery, Department of Surgery, Virginia Mason Medical Center, 1100 Ninth Ave C6-GS, Seattle, WA 98101, United States. vlad.simianu@commonspirit.org
Received: December 29, 2021
Peer-review started: December 29, 2021
First decision: March 13, 2022
Revised: April 11, 2022
Accepted: May 22, 2022
Article in press: May 22, 2022
Published online: June 15, 2022
Processing time: 162 Days and 21.6 Hours
Abstract
BACKGROUND

Contemporary treatment of stage II/III rectal cancer combines chemotherapy, chemoradiation, and surgery, though the sequence of surgery with neoadjuvant treatments and benefits of minimally-invasive surgery (MIS) is debated.

AIM

To describe patterns of surgical approach for stage II/III rectal cancer in relation to neoadjuvant therapies.

METHODS

A retrospective cohort was created using the National Cancer Database. Primary outcome was rate of sphincter-sparing surgery after neoadjuvant therapy. Secondary outcomes were surgical approach (open, laparoscopic, or robotic), surgical quality (R0 resection and 12+ lymph nodes), and overall survival.

RESULTS

A total of 38927 patients with clinical stage II or III rectal adenocarcinoma underwent surgical resection from 2010-2016. Clinical stage II patients had neoadjuvant chemoradiation less frequently compared to stage III (75.8% vs 84.7%, P < 0.001), but had similar rates of total neoadjuvant therapy (TNT) (27.0% vs 27.2%, P = 0.697). Overall rates of total mesorectal excision without sphincter preservation were similar between clinical stage II and III (30.0% vs 30.3%) and similar if preoperative treatment was chemoradiation (31.3%) or TNT (30.2%). Over the study period, proportion of cases approached laparoscopically increased from 24.9% to 32.5% and robotically 5.6% to 30.7% (P < 0.001). This cohort showed improved survival for MIS approaches compared to open surgery (laparoscopy HR 0.85, 95%CI 0.78-0.93, and robotic HR 0.82, 95%CI 0.73-0.92).

CONCLUSION

Sphincter preservation rates are similar across stage II and III rectal cancer, regardless of delivery of preoperative chemotherapy, chemoradiation, or both. At a national level, there is a shift to predominantly MIS approaches for rectal cancer, regardless of whether sphincter sparing procedure is performed.

Keywords: Rectal cancer, Total neoadjuvant therapy, Colorectal surgery, Minimally-invasive surgery, Chemotherapy, Radiation

Core Tip: At a population level, there have been increases in neoadjuvant treatment and minimally-invasive surgical (MIS) approaches for stage II and III rectal cancer. These shifts have are not associated with changes in rates of permanent ostomy which remain about 30%. In contrast to prior trials, this ‘real-world’ cohort showed an association with higher quality surgical resection and improved survival with MIS.