Imam Israa, Hammarström Klara, Glimelius Bengt
Department of Immunology, Genetics and Pathology, Uppsala University, SE-751 85 Uppsala, Sweden.
Cancers (Basel). 2023 Feb 10;15(4):1154. doi: 10.3390/cancers15041154.
When preoperative radiotherapy (RT) is best used in rectal cancer is subject to discussions and guidelines differ. To understand the selection mechanisms, we analysed treatment decisions in all patients diagnosed between 2010-2020 in two Swedish regions (Uppsala with a RT department and Dalarna without). Information on staging and treatment (direct surgery, short-course RT, or combinations of RT/chemotherapy) in the Swedish Colorectal Cancer Registry were used. Staging magnetic resonance imaging (MRI) permitted a division into risk groups, according to national guidelines. Logistic regression explored associations between baseline characteristics and treatment, while Cohen's kappa tested congruence between clinical and pathologic stages. A total of 1150 patients without synchronous metastases were analysed. Patients from Dalarna were older, had less advanced tumours and were pre-treated less often (52% vs. 63%, < 0.001). All MRI characteristics (T-/N-stage, MRF, EMVI) and tumour levels were important for treatment choice. Age affected if chemotherapy was added. The correlation between clinical and pathological T-stage was fair/moderate and poor for N-stage. The MRI-based risk grouping influenced treatment choice the most. Since the risk grouping was modified to diminish the pre-treated proportion, fewer patients were irradiated with time. MRI staging is far from optimal. A stronger wish to decrease irradiation may explain why fewer patients from Dalarna were irradiated, but inequality in health care cannot be ruled out.
术前放疗（RT）在直肠癌治疗中最佳的使用时机仍存在争议，且指南各不相同。为了解选择机制，我们分析了2010年至2020年期间在瑞典两个地区（设有放疗科的乌普萨拉和没有放疗科的达拉纳）确诊的所有患者的治疗决策。使用了瑞典结直肠癌登记处关于分期和治疗（直接手术、短程放疗或放疗/化疗联合）的信息。根据国家指南，分期磁共振成像（MRI）可将患者分为风险组。逻辑回归分析了基线特征与治疗之间的关联，而科恩kappa检验则用于检测临床分期与病理分期之间的一致性。共分析了1150例无同步转移的患者。达拉纳的患者年龄较大，肿瘤进展程度较低，接受预处理的频率也较低（52%对63%，<0.001）。所有MRI特征（T/N分期、MRF、EMVI）和肿瘤水平对治疗选择都很重要。年龄会影响是否添加化疗。临床T分期与病理T分期之间的相关性为中等，而N分期之间的相关性较差。基于MRI的风险分组对治疗选择影响最大。由于修改了风险分组以减少接受预处理的比例，随着时间的推移，接受放疗的患者越来越少。MRI分期远非最佳。更强烈的减少放疗的意愿可能解释了为什么达拉纳接受放疗的患者较少，但医疗保健方面的不平等也不能排除。
