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©The Author(s) 2022.
World J Gastrointest Oncol. Jun 15, 2022; 14(6): 1148-1161
Published online Jun 15, 2022. doi: 10.4251/wjgo.v14.i6.1148
Published online Jun 15, 2022. doi: 10.4251/wjgo.v14.i6.1148
Table 1 Patient and facility demographics of patients with clinical stage II/III rectal cancer, stratified total mesorectal excision and sphincter preservation
| Local excision (n = 1442) | TME with sphincter preservation (n = 25737) | TME without sphincter preservation (n = 11748) | Total (n = 38927) | P value | |
| Age at diagnosis | < 0.0011 | ||||
| mean ± SD | 66.2 ± 14.13 | 60.3 ± 12.47 | 61.6 ± 12.72 | 60.9 ± 12.67 | |
| Sex | < 0.0012 | ||||
| Male | 787 (54.6%) | 15810 (61.4%) | 7251 (61.7%) | 23848 (61.3%) | |
| Charleson Comorbidity Score | < 0.0012 | ||||
| 0 | 1057 (73.3%) | 19828 (77.0%) | 8828 (75.1%) | 29713 (76.3%) | |
| 1 | 278 (19.3%) | 4486 (17.4%) | 2206 (18.8%) | 6970 (17.9%) | |
| 2+ | 107 (7.4%) | 1423 (5.5%) | 714 (6.1%) | 2244 (5.8%) | |
| Race3 | < 0.0012 | ||||
| Black | 185 (12.8%) | 2006 (7.8%) | 1108 (9.4%) | 3299 (8.5%) | |
| Other | 61 (4.2%) | 1501 (5.8%) | 562 (4.8%) | 2124 (5.5%) | |
| White | 1183 (82.0%) | 22054 (85.7%) | 10012 (85.2%) | 33249 (85.4%) | |
| Insurance status3 | < 0.0012 | ||||
| Medicare/medicaid/other government | 852 (59.1%) | 11308 (43.9%) | 5825 (49.6%) | 17985 (46.2%) | |
| Not insured | 38 (2.6%) | 1019 (4.0%) | 663 (5.6%) | 1720 (4.4%) | |
| Private insurance/managed care | 518 (35.9%) | 13117 (51.0%) | 5066 (43.1%) | 18701 (48.0%) | |
| Living location3 | < 0.0012 | ||||
| Metropolitan | 1164 (83.2%) | 20618 (82.2%) | 9142 (79.4%) | 30924 (81.4%) | |
| Rural | 30 (2.1%) | 548 (2.2%) | 295 (2.6%) | 873 (2.3%) | |
| Urban | 205 (14.7%) | 3916 (15.6%) | 2083 (18.1%) | 6204 (16.3%) | |
| Facility type3 | < 0.0012 | ||||
| Academic/research program | 540 (37.4%) | 9852 (38.3%) | 4536 (38.6%) | 14928 (38.3%) | |
| Community cancer program | 95 (6.6%) | 1453 (5.6%) | 711 (6.1%) | 2259 (5.8%) | |
| Comprehensive community cancer program | 562 (39.0%) | 9593 (37.3%) | 4538 (38.6%) | 14693 (37.7%) | |
| Integrated network cancer program | 193 (13.4%) | 3689 (14.3%) | 1451 (12.4%) | 5333 (13.7%) | |
| Facility geographic region3 | < 0.0012 | ||||
| Midwest | 343 (24.7%) | 6883 (28.0%) | 3528 (31.4%) | 10754 (28.9%) | |
| Northeast | 313 (22.5%) | 5040 (20.5%) | 2027 (18.0%) | 7380 (19.8%) | |
| South | 533 (38.3%) | 8522 (34.7%) | 3983 (35.4%) | 13038 (35.0%) | |
| West | 201 (14.5%) | 4142 (16.8%) | 1698 (15.1%) | 6041 (16.2%) |
Table 2 Tumor characteristics and surgical quality by surgical approach
| Open (n = 19830) | Laparoscopic (n = 12144) | Robotic (n = 6953) | Total (n = 38927) | P value | |
| Clinical stage | < 0.0011 | ||||
| II | 9286 (46.8%) | 5477 (45.1%) | 2906 (41.8%) | 17669 (45.4%) | |
| III | 10544 (53.2%) | 6667 (54.9%) | 4047 (58.2%) | 21258 (54.6%) | |
| Pathological stage | < 0.0011 | ||||
| 0 | 508 (3.2%) | 323 (3.4%) | 222 (3.9%) | 1053 (3.4%) | |
| 1 | 3801 (23.8%) | 2736 (28.7%) | 1669 (29.6%) | 8206 (26.3%) | |
| 2 | 5416 (33.9%) | 2941 (30.8%) | 1669 (29.6%) | 10026 (32.2%) | |
| 3 | 6107 (38.2%) | 3480 (36.5%) | 2044 (36.3%) | 11631 (37.3%) | |
| 4 | 152 (1.0%) | 57 (0.6%) | 29 (0.5%) | 238 (0.8%) | |
| Chemotherapy sequence | < 0.0011 | ||||
| No chemotherapy | 2031 (10.2%) | 1397 (11.5%) | 459 (6.6%) | 3887 (10.0%) | |
| Chemotherapy after surgery | 1864 (9.4%) | 1210 (10.0%) | 421 (6.1%) | 3495 (9.0%) | |
| Chemotherapy before and after surgery | 5435 (27.4%) | 3691 (30.4%) | 2256 (32.4%) | 11382 (29.2%) | |
| Chemotherapy before surgery | 10481 (52.9%) | 5840 (48.1%) | 3810 (54.8%) | 20131 (51.7%) | |
| Radiation sequence | < 0.0011 | ||||
| No radiation | 2449 (12.3%) | 1713 (14.1%) | 651 (9.4%) | 4813 (12.4%) | |
| Radiation after surgery | 1470 (7.4%) | 911 (7.5%) | 315 (4.5%) | 2696 (6.9%) | |
| Radiation before surgery | 15911 (80.2%) | 9515 (78.4%) | 5987 (86.1%) | 31418 (80.7%) | |
| Total neoadjuvant therapy | 2194 (28.1%) | 1262 (25.1%) | 846 (28.0%) | 4302 (27.1%) | < 0.0011 |
| Surgery type | < 0.0011 | ||||
| TME with sphincter preservation | 12118 (61.1%) | 8633 (71.1%) | 4986 (71.7%) | 25737 (66.1%) | |
| TME without sphincter preservation | 7061 (35.6%) | 2760 (22.7%) | 1927 (27.7%) | 11748 (30.2%) | |
| Conversion to open | 0 (0.0%) | 1760 (14.5%) | 480 (6.9%) | 2240 (11.7%) | < 0.0011 |
| Residual tumor | < 0.0011 | ||||
| R0 | 18012 (91.9%) | 11174 (93.6%) | 6568 (95.1%) | 35754 (93.0%) | |
| R1 | 806 (4.1%) | 413 (3.5%) | 193 (2.8%) | 1412 (3.7%) | |
| R2 | 782 (4.0%) | 352 (2.9%) | 148 (2.1%) | 1282 (3.3%) | |
| Number of lymph nodes examined (mean ± SD) | 14.7 ± 9.7 | 14.8 ± 9.8 | 15.7 ± 9.0 | 14.9 ± 9.6 | < 0.0011 |
| 12 or more lymph nodes examined | 13198 (67.1%) | 8148 (67.7%) | 5088 (73.6%) | 26434 (68.4%) | < 0.0011 |
Table 3 Unadjusted (univariate) and adjusted (multivariate) factors associated with overall survival
| Variable | n | Events | 5-yr survival% (95%CI) | Cox univariate HR (95%CI) | Cox univariate score P value | Cox multivariate HR (95%CI) | Cox multivariate likelihood ratio P value (n = 15618) |
| Age at diagnosis | 27114 | 5281 (19%) | 73.3 (72.6, 74.0) | 1.03 (1.03, 1.04) | < 0.0001 | 1.02 (1.02, 1.02) | < 0.0001 |
| Sex | < 0.0001 | < 0.0001 | |||||
| Female | 10502 | 1869 (18%) | 75.5 (74.4, 76.6) | ||||
| Male | 16612 | 3412 (21%) | 71.9 (70.9, 72.8) | 1.19 (1.13, 1.26) | 1.23 (1.14, 1.32) | ||
| Charleson comorbidity score | < 0.0001 | < 0.0001 | |||||
| 0 | 20949 | 3656 (17%) | 75.7 (74.9, 76.5) | ||||
| 1 | 4792 | 1202 (25%) | 67.4 (65.6, 69.1) | 1.43 (1.34, 1.53) | 1.25 (1.14, 1.36) | ||
| 2+ | 1373 | 423 (31%) | 58.5 (55.0, 62.0) | 2.00 (1.81, 2.22) | 1.59 (1.38, 1.82) | ||
| Race | < 0.0001 | 0.3372 | |||||
| Black | 2307 | 508 (22%) | 69.7 (67.1, 72.2) | 1.18 (1.08, 1.29) | 1.04 (0.92, 1.19) | ||
| Other | 1542 | 246 (16%) | 76.6 (73.6, 79.5) | 0.85 (0.74, 0.96) | 1.01 (0.85, 1.20) | ||
| White | 23091 | 4498 (19%) | 73.4 (72.7, 74.2) | ||||
| Insurance status | < 0.0001 | < 0.0001 | |||||
| Insurance status unknown | 382 | 64 (17%) | 71.8 (64.8, 78.8) | 1.46 (1.14, 1.88) | 0.93 (0.62, 1.39) | ||
| Medicare/medicaid/other government | 11607 | 3039 (26%) | 64.8 (63.6, 66.0) | 2.12 (2.01, 2.25) | 1.33 (1.22, 1.46) | ||
| Not insured | 1357 | 294 (22%) | 71.1 (67.9, 74.2) | 1.61 (1.42, 1.82) | 1.14 (0.97, 1.33) | ||
| Private insurance/managed care | 13768 | 1884 (14%) | 80.8 (79.9, 81.7) | ||||
| Living location | 0.0407 | 0.3867 | |||||
| Metropolitan | 21521 | 4134 (19%) | 73.7 (72.9, 74.5) | ||||
| Rural | 611 | 117 (19%) | 72.9 (68.2, 77.6) | 1.01 (0.84, 1.22) | 0.85 (0.67, 1.08) | ||
| Urban | 4344 | 900 (21%) | 71.7 (69.9, 73.5) | 1.10 (1.02, 1.18) | 0.98 (0.89, 1.08) | ||
| Facility type | < 0.0001 | 0.5531 | |||||
| Academic/research program | 10235 | 1850 (18%) | 75.4 (74.2, 76.5) | ||||
| Community cancer program | 1624 | 384 (24%) | 67.4 (64.4, 70.5) | 1.37 (1.22, 1.53) | 1.00 (0.86, 1.17) | ||
| Comprehensive community cancer program | 10158 | 2097 (21%) | 71.6 (70.4, 72.8) | 1.17 (1.10, 1.25) | 1.06 (0.98, 1.15) | ||
| Integrated network cancer program | 3719 | 761 (20%) | 72.2 (70.2, 74.1) | 1.17 (1.07, 1.27) | 1.04 (0.93, 1.16) | ||
| Facility geographic region | 0.0008 | 0.0971 | |||||
| Midwest | 7378 | 1455 (20%) | 73.6 (72.2, 74.9) | 0.91 (0.85, 0.97) | 0.926 (0.846, 1.014) | ||
| Northeast | 5058 | 967 (19%) | 74.1 (72.4, 75.7) | 0.87 (0.80, 0.94) | 0.912 (0.820, 1.014) | ||
| South | 9090 | 1885 (21%) | 71.2 (69.9, 72.4) | ||||
| West | 4210 | 785 (19%) | 74.0 (72.2, 75.8) | 0.89 (0.82, 0.97) | 0.878 (0.783, 0.986) | ||
| Pathological stage | < 0.0001 | < 0.0001 | |||||
| 0 | 782 | 66 (8%) | 89.2 (86.4, 92.1) | ||||
| 1 | 5631 | 604 (11%) | 84.8 (83.5, 86.1) | 1.277 (0.990, 1.646) | 1.11 (0.84, 1.46) | ||
| 2 | 6861 | 1399 (20%) | 72.1 (70.6, 73.5) | 2.48 (1.94, 3.17) | 1.97 (1.50, 2.57) | ||
| 3 | 8247 | 2338 (28%) | 61.6 (60.2, 63.1) | 3.74 (2.93, 4.77) | 3.32 (2.55, 4.33) | ||
| 4 | 136 | 82 (60%) | 25.1 (15.6, 34.6) | 10.93 (7.90, 15.11) | 8.70 (5.97, 12.67) | ||
| Chemotherapy (multi or single agent) | < 0.0001 | 0.001 | |||||
| Multiagent chemotherapy | 10043 | 1616 (16%) | 77.9 (76.8, 79.0) | ||||
| Single-agent chemotherapy | 12445 | 2467 (20%) | 72.6 (71.5, 73.6) | 1.31 (1.23, 1.39) | 1.14 (1.06, 1.24) | ||
| Chemotherapy sequence | < 0.0001 | < 0.0001 | |||||
| Chemotherapy after surgery | 2387 | 543 (23%) | 71.7 (69.4, 74.0) | 1.12 (1.02, 1.23) | 0.89 (0.75, 1.06) | ||
| Chemotherapy before surgery | 14351 | 2849 (20%) | 72.6 (71.6, 73.6) | ||||
| Chemotherapy before and after surgery | 8128 | 1134 (14%) | 79.7 (78.5, 80.9) | 0.67 (0.63, 0.72) | 0.73 (0.67, 0.79) | ||
| Radiation sequence | < 0.0001 | 0.3489 | |||||
| Radiation after surgery | 1934 | 463 (24%) | 70.5 (68.0, 73.1) | 1.30 (1.18, 1.43) | 0.92 (0.77, 1.10) | ||
| Radiation before surgery | 22529 | 4054 (18%) | 75.0 (74.2, 75.7) | ||||
| Surgery type | < 0.0001 | < 0.0001 | |||||
| Local excision | 953 | 249 (26%) | 65.0 (61.0, 69.1) | 1.62 (1.42, 1.84) | 1.26 (0.94, 1.68) | ||
| TME with sphincter preservation | 18237 | 3107 (17%) | 76.4 (75.6, 77.2) | ||||
| TME without sphincter preservation | 7924 | 1925 (24%) | 67.5 (66.1, 68.8) | 1.44 (1.36, 1.53) | 1.30 (1.20, 1.40) | ||
| Surgical approach | < 0.0001 | < 0.0001 | |||||
| Laparoscopic | 8510 | 1400 (16%) | 76.8 (75.5, 78.0) | 0.77 (0.72, 0.82) | 0.85 (0.78, 0.93) | ||
| Open | 14207 | 3300 (23%) | 70.7 (69.8, 71.7) | ||||
| Robotic | 4397 | 581 (13%) | 75.7 (73.5, 77.8) | 0.72 (0.66, 0.79) | 0.82 (0.73, 0.92) | ||
| Tumor grade | < 0.0001 | < 0.0001 | |||||
| Other (ND/UNK/NA/high grade dysplasia) | 3918 | 594 (15%) | 77.3 (75.5, 79.2) | 0.87 (0.80, 0.95) | 0.99 (0.88, 1.11) | ||
| Poor/undifferentiated | 3023 | 1004 (33%) | 58.9 (56.7, 61.1) | 1.97 (1.84, 2.11) | 1.67 (1.52, 1.83) | ||
| Well/moderate differentiation | 20173 | 3683 (18%) | 74.8 (74.0, 75.6) | ||||
| Residual tumor | < 0.0001 | < 0.0001 | |||||
| R0 | 24991 | 4432 (18%) | 75.5 (74.8, 76.2) | ||||
| R1 | 932 | 414 (44%) | 44.5 (40.4, 48.6) | 3.03 (2.74, 3.36) | 2.23 (1.96, 2.54) | ||
| R2 | 869 | 347 (40%) | 46.5 (42.2, 50.9) | 2.76 (2.47, 3.08) | 1.99 (1.71, 2.30) | ||
| 12 or more lymph nodes examined | < 0.0001 | < 0.0001 | |||||
| No | 8705 | 1919 (22%) | 70.9 (69.6, 72.1) | 1.19 (1.12, 1.25) | 1.26 (1.17, 1.36) | ||
| Yes | 18176 | 3317 (18%) | 74.5 (73.6, 75.4) |
- Citation: Soriano C, Bahnson HT, Kaplan JA, Lin B, Moonka R, Pham HT, Kennecke HF, Simianu V. Contemporary, national patterns of surgery after preoperative therapy for stage II/III rectal adenocarcinoma. World J Gastrointest Oncol 2022; 14(6): 1148-1161
- URL: https://www.wjgnet.com/1948-5204/full/v14/i6/1148.htm
- DOI: https://dx.doi.org/10.4251/wjgo.v14.i6.1148