Decreased Overall Survival of Transanal vs. Transabdominal Resection of Early Rectal Cancer in Treatment Naïve Patients: A National Cancer Data Base Study
Journal of Surgery
Volume 7, Issue 3, June 2019, Pages: 78-86
Received: May 6, 2019;
Accepted: Jun. 6, 2019;
Published: Jul. 1, 2019
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Crystal Koerner, Department of Surgery, Emory University School of Medicine, Atlanta, USA
Xi Sheng, Department of Biostatistics and Bioinformatics, Emory University, Atlanta, USA
Yuan Liu, Department of Biostatistics and Bioinformatics, Emory University, Atlanta, USA
Theresa Gillespie, Department of Hematology & Medical Oncology, Emory University School of Medicine and Winship Cancer Institute, Atlanta, USA
Glen Balch, Division of Colon and Rectal Surgery, Emory University School of Medicine, Atlanta, USA
Virginia Shaffer, Division of Colon and Rectal Surgery, Emory University School of Medicine, Atlanta, USA
Charles Staley, Division of Surgical Oncology, Emory University School of Medicine, Atlanta, USA
Jhanavi Srinivasan, Division of Colon and Rectal Surgery, Emory University School of Medicine, Atlanta, USA
Patrick Sullivan, Division of Colon and Rectal Surgery, Emory University School of Medicine, Atlanta, USA
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Previous data from the National Cancer Database (NCBD) showed increasing rates of transanal local excision for early rectal cancer despite a lack of evidence supporting its oncologic adequacy. The aim of this study is to update national trends, compare overall survival, and determine factors associated with survival in patients with stage I rectal cancer. Survival of 15, 149 patients with stage I rectal adenocarcinoma were examined retrospectively from 2004-2012. The rate of local excision over this time period was sustained at 22% (20.88 - 24.9%; p = 0.077). Five-year overall survival (OS) after transanal local excision was less than transabdominal standard resection (76.6% vs. 80.7%; p < 0.0001). Lower 5-year OS for transanal local excision was maintained with propensity score matching (HR 1.23; CI (1.11-1.36; p < 0.001). Factors associated with decreased OS include positive margins, T2 tumors, tumors > 4 cm, low volume centers, uninsured patients and increasing comorbidities. This is the first study of national data showing sustained use of transanal local excision over the past decade. Local excision has a lower 5-year OS compared to transabdominal standard resection. Transanal excision of early rectal cancer should be offered to select patients only after careful consideration of risk factors balanced against the decrease in overall survival.
Transanal Local Excision, Stage 1 Rectal Cancer, Total Mesorectal Excision
To cite this article
Decreased Overall Survival of Transanal vs. Transabdominal Resection of Early Rectal Cancer in Treatment Naïve Patients: A National Cancer Data Base Study, Journal of Surgery.
Vol. 7, No. 3,
2019, pp. 78-86.
Copyright © 2019 Authors retain the copyright of this article.
This article is an open access article distributed under the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/
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Howlader N, Noone AM, Krapcho M, et al. SEER Cancer Statistics Review, 1975-2014. National Cancer Institute. Bethesda, MD, https://seer.cancer.gov/csr/1975_2014/
Althumairi AA, Gearhart SL. Local excision for early rectal cancer: transanal endoscopic microsurgery and beyond. J Gastrointest Oncol 2015; 6: 296-306.
Elmessiry MM, Van Koughnett JAM, Maya A, et al. Local excision of T1 and T2 rectal cancer: proceed with caution. Colorectal Dis 2014; 16: 703-709.
Garcia-Aguilar J, Mellgren A, Sirivongs P, et al. Local excision of rectal cancer without adjuvant therapy: a word of caution. Ann Surg 2000; 231: 345-351.
You YN, Baxter NN, Stewart A, Nelson H. Is the increasing rate of local excision for stage I rectal cancer in the United States justified?: a nationwide cohort study from the National Cancer Database. Ann Surg 2007; 245: 726-733.
Bentrem DJ, Okabe S, Wong WD, et al. T1 Adenocarcinoma of the Rectum: Transanal Excision or Radical Surgery? Annals of Surgery 2005; 242: 472-479.
Rothenberger DA1, Garcia-Aguilar J. Role of local excision in the treatment of rectal cancer. Semin Surg Oncol 2000; 19: 367-75.
Mellgren A1, Sirivongs P, Rothenberger DA, et al. Is local excision adequate therapy for early rectal cancer? Dis Colon Rectum 2000; 43: 1064-71.
Bhangu A, Brown G, Nicholls RJ, et al. Survival outcome of local excision versus radical resection of colon or rectal carcinoma: A Surveillance, Epidemiology, and End Results (SEER) population-based study. Ann Surg 2013; 258: 563-569.
National Comprehensive Cancer Network. NCCN guideline updates: colon and rectal cancers, version 1.2004. J Natl Compr Canc Netw 2004; 2: 284-5.
Monson JRT, Weiser MR, Buie WD, et al. Standards Practice Task Force of the American Society of Colon and Rectal Surgeons. Practice parameters for the management of rectal cancer. Dis Colon Rectum 2013; 56:535-550.
Nickleach D, Liu Y, Shrewsberry A, Ogan K, Kim S, Wang Z. SAS® Macros to Conduct Common Biostatistical Analyses and Generate Reports. SESUG 2013: The Proceeding of the SouthEast SAS User Group
Austin PC, Grootendorst P, Anderson GM. A comparison of the ability of different propensity score models to balance measured variables between treated and untreated subjects: A Monte Carlo study Stat Med 2007; 26: 734-753.
Austin PC, Stuart EA. Moving towards best practice when using inverse probablility of treatment weighting (IPTW) using propensity score to estimate casual treatment effects in observational studies. Stat Med 2015. 34: 3661-79.
Cole SR, Hernan MA. Adjusted survival curves with inverse probability weights. Comput Methods Programs Biomed 2004; 75: 45-9.
Parsons LS. Reducing bias in a propensity score matched-pair sample using greedy matching techniques. SAS SUGI 2001; 26: 214-226.
Stitzenberg KB, Sanoff HK, Penn DC, et al. Practice Patterns and Long-Term Survival for Early-Stage Rectal Cancer. Journal of Clinial Oncology 2013; 31: 4276-4282.
Gill S, Stetler JL, Patel A, et al. Transanal Minimally Invasive Surgery (TAMIS): Standardizing a Reproducible Procedure. J Gastrointest Surg 2015; 19: 1528-36.
Guerrieri M, Gesuita R, Ghiselli R, et al. Treatment of rectal cancer by transanal endoscopic microsurgery: Experience with 425 patients. World Journal of Gastroenterology 2014; 20: 9556-63.
Borstlap WA, Coeymans TJ, Tanis PJ, et al. Meta-analysis of oncological outcomes after local excision of pT1-2 rectal cancer requiring adjuvant (chemo)radiotherapy or completion surgery. Br J Surg 2016; 103: 1105-16.
Lezoche G, Baldarelli M, Guerrieri M, et al. A prospective randomized study with a 5-year minimum follow-up evaluation of transanal endoscopic microsurgery versus laparoscopic total mesorectal excision after neoadjuvant therapy. Surg Endosc 2008 Feb; 22: 352-8.
Nair RM, Siegel EM, Chen DT, et al. Long-tern results if tranasanal excision after neoadjuvant chemoradiation for T2 and T3 adenocarcinomas of the rectum. J Gastrointest Surg 2008 Oct; 12: 1797-805.
Garcia-Aguilar J, Shi Q, Thomas C, et al. A Phase II Trial of Neoadjuvant Chemoradiation and Local Excision for T2N0 Rectal Cancer: Preliminary Results of the ACOSOG Z6o41 Trial. Ann Surg Onc 2012 Feb; 19: 384-391.