Surgical Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA.
Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA.
J Gastrointest Surg. 2019 Apr;23(4):659-669. doi: 10.1007/s11605-019-04107-1. Epub 2019 Jan 31.
Neoadjuvant therapy (NT) is the standard of care for clinical stage II-III rectal adenocarcinoma, but utilization remains suboptimal. We aimed to determine the underlying reasons for omission of local staging and NT.
We conducted a retrospective study of patients with clinical stage II-III or undocumented clinical stage/pathologic stage II-III rectal adenocarcinoma who were treated in 2010-2016 in one of nine Intermountain Healthcare hospitals. The outcomes of omission of local staging and NT were examined with multivariable models. Risk- and reliability-adjusted rates of local staging and NT were calculated for surgeons who treated ≥ 3 patients. Pathologic and long-term outcomes were examined after excluding patients who were not resected or who underwent local excision (N = 11).
Local staging was omitted in 43/240 (17.9%) patients and NT was omitted in 41/240 (17.1%). The strongest risk factors for local staging and NT omission were upper rectal tumors and surgeons who treated ≤ 3 cases/year. Thirty-six of 41 (87.8%) cases of omitted NT had local staging omitted. Adjusted surgeon-specific local staging rates varied 1.6-fold (56.3-92.4%) and NT rates varied 2.8-fold (34.1-97.1%). Surgeon local staging and NT rates were strongly correlated (r = 0.92). NT was associated with lower rates of positive circumferential radial margins (7.9 vs. 20.0%; P = 0.02), node positivity (33.3 vs. 55.0%; P = 0.01), and local recurrences (7.6 vs. 14.9% at 5 years; P = 0.0176).
NT omission should be understood as a consequence of surgeon failure to perform local staging in most cases. Quality improvement efforts should focus on improving utilization of local staging.
新辅助治疗（NT）是临床 II-III 期直肠腺癌的标准治疗方法，但利用率仍不理想。我们旨在确定局部分期和 NT 缺失的根本原因。
我们对 2010 年至 2016 年期间在 Intermountain Healthcare 九家医院之一接受治疗的临床 II-III 期或未记录临床/病理 II-III 期直肠腺癌患者进行了回顾性研究。使用多变量模型检查局部分期和 NT 缺失的结果。对于治疗≥3 例患者的外科医生，计算了局部分期和 NT 的风险和可靠性调整率。排除未行切除或行局部切除的患者（n=11）后，检查了病理和长期结果。
43/240（17.9%）例患者未行局部分期，41/240（17.1%）例患者未行 NT。局部分期和 NT 缺失的最强危险因素是高位直肠肿瘤和每年治疗≤3 例的外科医生。41 例（87.8%）遗漏 NT 中有 36 例遗漏了局部分期。调整后的外科医生特异性局部分期率差异 1.6 倍（56.3-92.4%），NT 率差异 2.8 倍（34.1-97.1%）。外科医生的局部分期和 NT 率呈强相关（r=0.92）。NT 与较低的环周切缘阳性率（7.9% vs. 20.0%；P=0.02）、淋巴结阳性率（33.3% vs. 55.0%；P=0.01）和局部复发率（5 年时为 7.6% vs. 14.9%；P=0.0176）相关。
在大多数情况下，NT 遗漏应被理解为外科医生未能进行局部分期的结果。质量改进工作应侧重于提高局部分期的利用率。
