Introduction
Materials and methods
The study group
Invited colorectal surgeons to IRCSG
The questionnaire
Study logistics
Review of national guidelines
NCCN USA 2009 | World Congress 2007 | French Guidelines 2007 | Norwegian Guidelines 2008 | ESMO 2008 | Danish Guidelines 2009 | |
---|---|---|---|---|---|---|
Radiological T staging
| ||||||
MRI | Either MRI or ERUS all patients | All patients (best to assess CRM, but ERUS + CT can also be used) | All T3–T4 or N+ after ERUS | All patients | MRI on all T3–T4 | All patients |
ERUS | Either MRI or ERUS all patients | ERUS + MRI or ERUS + CT | All patients | ERUS on all early tumors (T1–T2) | ERUS on all early tumors (cT1–T2) | ERUS on all early tumors |
CT | CT abdomen/thorax all patients not recommended for T staging | CT abdomen/thorax all patients | CT thorax/abdomen all patients | CT pelvis is an alternative to MRI when no access to MRI | CT abdomen/thorax all patients (alternatively chest X-ray and ultrasound of liver) | CT thorax/abdomen all patients |
PET scan | Not routinely indicated | Indicated only when lesions in liver | Not routinely indicated | NA | NA | Only indicated when suspicion of extrahepatic metastasis |
Neoadjuvant treatment
| ||||||
T1–2, N0 | No neoadjuvant treatment | RCT T2 | No neoadjuvant treatment | No neoadjuvant treatment | No neoadjuvant treatment | No neoadjuvant treatment |
T3, N0 or T any, N1–2 (stage II or III) | RCT | Radiation alone or RCT | Radiation alone or RCT (no treatment to T3N0 with CRM >1 mm) | See CRM | No RCT early T3. Radiation alone or RCT | RCT midrectal T3 with CRM <5 mm. All low rectal T3 |
T4 | RCT | RCT | Radiation alone or RCT | RCT | RCT | RCT to mid and low T4 |
CRM | NA | NA | Radiation or RCT when CRM <1 mm | CRM <3 mm RCT | NA | See T3 |
Statistics
Results
Demographics (Table 2)
US [n (%)] | Non-US [n (%)] | Total [n (%)] | |
---|---|---|---|
Hospital location
| |||
City | 1 (2.3) | 11 (13.9) | 12 (9.8) |
Rural | 1 (2.3) | 0 | 1 (0.8) |
Private | 7 (15.9) | 7 (8.8) | 14 (11.4) |
University | 35 (79.5) | 61 (77.2) | 96 (78.0) |
Experience
| |||
<5 years | 4 (9.1) | 4 (5.0) | 8 (6.5) |
5–10 years | 12 (27.3) | 17 (21.5) | 29 (23.6) |
11–20 years | 16 (36.4) | 27 (34.1) | 43 (35.0) |
>20 years | 12 (27.3) | 31 (39.2) | 43 (35.0) |
RC surgeries/year
| |||
<10 | 2 (4.5) | 3 (3.7) | 5 (4.1) |
10–20 | 10 (22.7) | 18 (22.7) | 28 (22.8) |
21–30 | 10 (22.7) | 24 (30.3) | 34 (27.6) |
31–50 | 14 (31.8) | 18 (22.7) | 32 (26.0) |
>50 | 8 (18.2) | 16 (20.2) | 24 (19.5) |
Hospital caseload
| |||
<10 | 0 | 2 (2.5) | 2 (1.6) |
11–30 | 4 (9.1) | 4 (5.0) | 8 (6.5) |
31–50 | 11 (25.0) | 16 (20.2) | 27 (22.0) |
51–70 | 7 (15.9) | 13 (16.4) | 20 (16.3) |
71–90 | 11 (25.0) | 21 (26.5) | 32 (26.0) |
>90 | 11 (25.0) | 23 (29.1) | 34 (27.6) |
Rectal surgery experience (Table 2)
Preoperative staging (Table 3)
US [n (%)] | Non-US [n (%)] | Total [n (%)] | p value | |
---|---|---|---|---|
MRI | ||||
Never | 7 (17.9) | 5 (5.0) | 13 (11.8) | NS |
Selected | 24 (61.5) | 35 (49.2) | 59 (53.6) | NS |
All | 8 (20.5) | 30 (42.2) | 38 (34.5) | 0.03 |
ERUS | ||||
Never | 2 (5.1) | 10 (14.0) | 12 (10.9) | NS |
Selected | 20 (51.3) | 46 (64.7) | 66 (60.0) | NS |
All | 17 (43.6) | 15 (21.1) | 32 (29.1) | 0.01 |
CT | ||||
Never | 6 (15,4) | 13 (18.3) | 19 (17.3) | NS |
Selected | 11 (28,2) | 20 (28.1) | 31 (28.2) | NS |
All | 22 (56,4) | 38 (53.5) | 60 (54.5) | NS |
PET scan | ||||
Never | 10 (25.6) | 38 (53.5) | 48 (43.6) | 0.005 |
Selected | 28 (71,8) | 33 (46.4) | 61 (55.5) | 0.01 |
All | 1 (2.6) | 0 (0.0) | 1 (0.9) | NS |
DRE under GA | ||||
Never | 20 (51.3) | 43 (60.5) | 63 (57.3) | NS |
Selected | 16 (41.0) | 18 (25.3) | 34 (30.9) | NS |
All | 3 (7.7) | 10 (14.0) | 13 (11.8) | NS |
Total (missing) | 39 (5) | 71 (8) | 110 (13) |
Indications for preoperative chemoradiotherapy (CRT) (Table 4)
US [n (%)] | Non-US [n (%)] | Total [n (%)] | p value | |
---|---|---|---|---|
All RC | 0 | 1 | 1 (0.9) | NS |
Stage II and III RC | 36 (92.3) | 31 (43.6) | 67 (60.9) | 0.001 |
CRM ≤1 mma
| 13 (33.3) | 27 (38.0) | 40 (36.4) | NS |
CRM ≤2 mma
| 10 (25.6) | 28 (39.4) | 38 (34.5) | NS |
CRM ≤3 mma
| 4 (10.3) | 17 (23.9) | 21 (19.1) | NS |
Mesorectal growth ≥5 mma
| 5 (12.8) | 16 (22.5) | 21 (19.1) | NS |
Mesorectal growth ≥5 mm ≤15 mma
| 2 (5.1) | 5 (7.0) | 7 (6.4) | NS |
Any RC in distal third of rectum | 4 (10.3) | 11 (15.4) | 15 (13.6) | NS |
Any RC in distal two-thirds of rectum | 3 (7.7) | 2 (2.8) | 5 (4.5) | NS |
Any RC with poor differentiation | 10 (25.6) | 5 (7.0) | 15 (13.6) | 0.008 |
Total (missing) | 39 (5) | 71 (8) | 110 (13) |
Neoadjuvant treatment and other preoperative considerations (Table 5)
US [n (%)] | Non-US [n (%)] | Total [n (%)] | p value | |
---|---|---|---|---|
Threatened CRM as an indication for neoadjuvant therapy | 26 (66.7) | 55 (77.4) | 81 (73.6) | NS |
Short-course radiation therapy (5 Gy × 5)a
| 4 (10.3) | 12 (16.9) | 16 (14.5) | NS |
Long-term chemoradiation regimen (1.8–2 Gy × 25)a
| 37 (94.9) | 64 (90.1) | 101 (91.87) | NS |
Other neoadjuvant therapy | 2 (5.1) | 11 (15.4) | 13 (11.8) | NS |
Radiation therapy available | 35 (89.7) | 53 (74.6) | 88 (80.0) | 0.04 |
Intraoperative radiation therapy available | 11 (28.2) | 14 (19.7) | 25 (22.7) | NS |
Internal sphincter-saving surgery in case of complete tumor response after neoadjuvant therapy | 22 (56.4) | 34 (47.8) | 56 (50.9) | NS |
External sphincter-saving surgery in case of complete tumor response after neoadjuvant treatment | 5 (12.8) | 11 (15.4) | 16 (14,5) | NS |
Alternation of neoadjuvant treatment if synchronous liver metastasis | 20 (51.3) | 28 (39.4) | 48 (43.6) | NS |
Treatment plans within an interdisciplinary team | 37 (94.9) | 60 (84.5) | 97 (86,6) | NS |
Only specialized centers | 33 (84.6) | 60 (84.5) | 93 (83) | NS |
Abdominoperineal resection is a surrogate marker for the quality of RC surgery | 15 (38.5) | 39 (54.9) | 54 (48.2) | NS |
Weekly/monthly RC audits | 20 (51.3) | 53 (74.6) | 73 (65.2) | 0.01 |
Total (missing) | 39 (5) | 71 (8) | 110 (13) |
Institutional radiation rate (Fig. 1)
Impact of multidisciplinary teams and caseload (Table 6)
Relative risk |
p
| 95% confidence interval | |||
---|---|---|---|---|---|
Lower bound | Higher bound | ||||
Staging method
| |||||
MRI | Cload | 1.33 | 0.21 | 0.82 | 2.15 |
Team | 3.62 | 0.06 | 0.93 | 14.03 | |
ERUS | Cload | 0.89 | 0.80 | 0.54 | 1.47 |
Team | 3.12 | 0.23 | 0.65 | 15.03 | |
PET | Cload | 1.24 | 0.11 | 0.93 | 1.66 |
Team | 2.27 | 0.16 | 0.73 | 7.07 | |
CT Pelvis | Cload | 1.30 | 0.14 | 0.96 | 2.06 |
Team | 0.67 | 0.62 | 0.27 | 6.78 | |
DRE | Cload | 1.15 | 0.27 | 0.86 | 1.52 |
Team | 1.17 | 0.79 | 0.38 | 3.61 | |
Indication for neoadjuvant treatment
| |||||
Stg II + III | Cload | 1.24 | 0.07 | 0.91 | 1.68 |
Team | 2.98 | 0.08 | 0.91 | 9.74 | |
CRM | Cload | 1.06 | 0.69 | 0.73 | 1.33 |
Team | 5.67 | 0.003 | 1.80 | 17.89 | |
Mesorectal <5 mm | Cload | 1.09 | 0.60 | 0.77 | 1.55 |
Team | 1.60 | 0.55 | 0.33 | 7.73 | |
Mesorectal 5–15 mm | Cload | 0.99 | 0.99 | 0.55 | 1.78 |
Team | <0.01 | 0.99 | <0.01 | <0.01 | |
Distal 1/3 | Cload | 0.97 | 0.91 | 0.64 | 1.48 |
Team | <0.01 | 0.91 | <0.01 | <0.01 | |
Distal 2/3 | Cload | 1.84 | 0.09 | 0.90 | 3.76 |
Team | <0.01 | 0.99 | <0.01 | <0.01 | |
Poor differentiation | Cload | 0.74 | 0.14 | 0.50 | 1.10 |
Team | 1.71 | 0.45 | 0.41 | 7.14 | |
Other preoperative preferences
| |||||
Pathology report | Cload | 1.17 | 0.45 | 0.77 | 1.76 |
Team | 4.85 | 0.01 | 1.34 | 17.46 | |
IORT | Cload | 1.36 | 0.11 | 0.94 | 1.97 |
Team | <0.01 | 0.99 | <0.01 | <0.01 | |
SSS initial imaging | Cload | 1.00 | 0.88 | 0.76 | 1.34 |
Team | 3.81 | 0.09 | 0.98 | 14.72 | |
New regimen liver met | Cload | 1.38 | 0.03 | 0.52 | 0.97 |
Team | 6.41 | 0.02 | 1.34 | 30.64 | |
One-stage surgery | Cload | 1.23 | 0.17 | 0.91 | 1.64 |
Team | 0.25 | 0.02 | 0.08 | 0.80 | |
APR rate <10% | Cload | 1.00 | 0.91 | 0.72 | 1.39 |
Team | 1.05 | 0.87 | 0.31 | 3.90 | |
IRR >50% | Cload | 0.91 | 0.59 | 0.66 | 1.26 |
Team | 0.22 | 0.01 | 0.62 | 0.78 |