Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Surgery, NYU Langone Health, NYC, NY.
Surgery. 2023 Dec;174(6):1323-1333. doi: 10.1016/j.surg.2023.09.005. Epub 2023 Oct 16.
The traditional treatment paradigm for patients with locally advanced rectal cancers has been neoadjuvant chemoradiation followed by curative intent surgery and adjuvant chemotherapy. This study aimed to assess surgery trends for locally advanced rectal cancers, factors associated with forgoing surgery, and overall survival outcomes.
Adults with locally advanced rectal cancers were retrospectively analyzed using the National Cancer Database (2004-2019). Propensity score matching was performed. Factors associated with not undergoing surgery were identified using multivariable logistic regression. Kaplan-Meier and log-rank tests were used for 5-year overall survival analysis, stratified by stage and treatment type.
A total of 72,653 patients were identified, with 64,396 (88.64%) patients undergoing neoadjuvant + surgery ± adjuvant therapy, 579 (0.80%) chemotherapy only, 916 (1.26%) radiation only, and 6,762 (9.31%) chemoradiation only. The proportion of patients who underwent surgery declined over the study period (95.61% in 2006 to 92.29% in 2019, P trend < .001), whereas the proportion of patients who refused surgery increased (1.45%-4.48%, P trend < .001). Factors associated with not undergoing surgery for locally advanced rectal cancers included older age, Black race (odds ratio 1.47, 95% CI 1.35-1.60, P < .001), higher Charlson-Deyo score (score ≥3: 1.79, 1.58-2.04, P < .001), stage II cancer (1.22, 1.17-1.28, P < .001), lower median household income, and non-private insurance. Neoadjuvant + surgery ± adjuvant therapy was associated with the best 5-year overall survival, regardless of stage, in unmatched and matched cohorts.
Despite surgery remaining an integral component in the management of locally advanced rectal cancers, there is a concerning decline in guideline-concordant surgical care for rectal cancer in the United States, with evidence of persistent socioeconomic disparities. Providers should seek to understand patient perspectives/barriers and guide them toward surgery if appropriate candidates. Continued standardization, implementation, and evaluation of rectal cancer care through national accreditation programs are necessary to ensure that all patients receive optimal treatment.
局部晚期直肠癌患者的传统治疗模式是新辅助放化疗，然后进行根治性手术和辅助化疗。本研究旨在评估局部晚期直肠癌的手术趋势、放弃手术的相关因素以及总体生存结局。
使用国家癌症数据库（2004-2019 年）对局部晚期直肠癌成人患者进行回顾性分析。采用倾向评分匹配。使用多变量逻辑回归识别未行手术的相关因素。采用 Kaplan-Meier 和对数秩检验对不同分期和治疗类型的 5 年总生存率进行分层分析。
共纳入 72653 例患者，其中 64396 例（88.64%）接受新辅助+手术+辅助治疗，579 例（0.80%）仅接受化疗，916 例（1.26%）仅接受放疗，6762 例（9.31%）仅接受放化疗。研究期间接受手术的患者比例下降（2006 年为 95.61%，2019 年为 92.29%，趋势 P <.001），而拒绝手术的患者比例增加（1.45%-4.48%，趋势 P <.001）。局部晚期直肠癌患者未行手术的相关因素包括年龄较大、黑人种族（优势比 1.47，95%置信区间 1.35-1.60，P <.001）、Charlson-Deyo 评分较高（评分≥3：1.79，1.58-2.04，P <.001）、II 期癌症（1.22，1.17-1.28，P <.001）、较低的中位数家庭收入和非私人保险。在未匹配和匹配队列中，新辅助+手术+辅助治疗与最佳 5 年总体生存率相关，无论分期如何。
尽管手术仍然是局部晚期直肠癌治疗的一个重要组成部分，但美国在符合指南的直肠癌手术治疗方面存在令人担忧的下降趋势，并且存在持续的社会经济差异。医生应努力了解患者的观点/障碍，并在适当的情况下引导他们进行手术。通过国家认证项目，持续标准化、实施和评估直肠癌治疗是必要的，以确保所有患者都接受最佳治疗。
