Providence St John's Cancer Institute, Santa Monica, California.
Providence Health and Services, Beaverton, Oregon.
JAMA Surg. 2022 Nov 1;157(11):e224456. doi: 10.1001/jamasurg.2022.4456. Epub 2022 Nov 9.
The number of older patients (80 years and older) diagnosed with locally advanced rectal cancer (LARC) is expected to increase. Although current guidelines recommend neoadjuvant chemoradiation therapy (NACRT) followed by resection, little is known about management and outcomes in this older population.
To assess the trends in management of older patients diagnosed with LARC who had a surgical resection.
DESIGN, SETTING, AND PARTICIPANTS: Patients 80 years and older who had a surgical resection for LARC were identified in the 2004-2016 National Cancer Database. Patients were grouped based on therapy sequence: (1) surgery followed by adjuvant therapy (AT), ie, chemotherapy or radiation; (2) surgery alone; or (3) NACRT followed by surgical resection. Data were analyzed in May 2021.
NACRT followed by surgery, and surgery with or without AT.
Overall survival (OS) was assessed using Kaplan-Meier analyses with inverse probability of treatment weighting (IPTW) and Cox proportional hazards regression were performed to examine the association of NACRT with the risk of death.
Of 3868 patients with LARC who underwent surgical resection, 2042 (52.8%) were male, and the mean (SD) age was 83.4 (3.0) years. A total of 2273 (58.8%) received NACRT followed by surgical resection. Factors independently associated with NACRT were more recent diagnosis, age 80 to 85 years (vs 86 years and older), fewer comorbidities, larger tumors, and node-positive disease. The Kaplan-Meier analyses with IPTW showed that 3-year and 5-year OS for NACRT (3-year: 68.9%; 95% CI, 67.0-70.8; 5-year: 51.1%; 95% CI, 49.0-53.4) vs surgery with AT (3-year: 64.4%; 95% CI, 59.0-70.2; 5-year: 43.0%; 95% CI, 37.4-49.5) vs surgery alone (3-year: 55.8%; 95% CI, 52.0-60.0; 5-year: 34.7%; 95% CI, 30.8-39.0) was significantly different (P < .001). After adjusting for confounders, patients who received NACRT were more likely to undergo an R0 resection (adjusted odds ratio, 2.16; 95% CI, 1.62-2.88), which independently improved OS (P < .001). Moreover, receipt of NACRT was independently associated with a 25% decreased risk of death (adjusted hazard ratio, 0.75; 95% CI, 0.69-0.82) compared with alternative treatment sequences.
Approximately 40% of older patients with LARC did not receive the current standard of care. In this cohort, NACRT was associated with a higher likelihood of an R0 resection and improved OS. Clinicians should advocate for receipt of NACRT in older patients with LARC.
预计被诊断患有局部晚期直肠癌（LARC）的老年患者（80 岁及以上）人数将会增加。尽管目前的指南建议采用新辅助放化疗（NACRT）后进行切除术，但对于这一年龄段患者的管理和结局知之甚少。
评估接受手术切除的 LARC 老年患者的管理趋势。
设计、地点和参与者：在 2004-2016 年国家癌症数据库中，确定了 80 岁及以上接受 LARC 手术切除的患者。根据治疗顺序将患者分为三组：（1）手术+辅助治疗（即化疗或放疗），（2）单纯手术，或（3）NACRT+手术。数据于 2021 年 5 月进行分析。
NACRT+手术，手术+或不+AT。
采用 Kaplan-Meier 分析法和逆概率治疗加权（IPTW）评估总生存率（OS），并采用 Cox 比例风险回归分析评估 NACRT 与死亡风险的关系。
在 3868 例接受手术切除的 LARC 患者中，2042 例（52.8%）为男性，平均（SD）年龄为 83.4（3.0）岁。共有 2273 例（58.8%）接受了 NACRT+手术。与 NACRT 相关的独立因素包括较晚的诊断、年龄 80-85 岁（vs 86 岁及以上）、较少的合并症、较大的肿瘤和淋巴结阳性疾病。经 IPTW 校正的 Kaplan-Meier 分析显示，NACRT 组的 3 年和 5 年 OS 分别为 68.9%（95%CI，67.0-70.8）和 51.1%（95%CI，49.0-53.4），手术+AT 组分别为 64.4%（95%CI，59.0-70.2）和 43.0%（95%CI，37.4-49.5），单纯手术组分别为 55.8%（95%CI，52.0-60.0）和 34.7%（95%CI，30.8-39.0），差异有统计学意义（P<0.001）。在校正混杂因素后，接受 NACRT 的患者更有可能接受 R0 切除术（调整后的优势比，2.16；95%CI，1.62-2.88），这独立改善了 OS（P<0.001）。此外，与其他治疗序列相比，接受 NACRT 与死亡风险降低 25%相关（调整后的危险比，0.75；95%CI，0.69-0.82）。
约 40%的 LARC 老年患者未接受当前的标准治疗。在这组患者中，NACRT 与更高的 R0 切除率和改善的 OS 相关。临床医生应倡导在 LARC 老年患者中接受 NACRT。
