Neoadjunctive radiotherapy, hospital factors key for rectal cancer resection

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1. Older age, male sex, African American race and non-private insurance are risk factors for margin positivity following rectal cancer resection. Advanced AJCC (American Joint Committee on Cancer) stage, signet or mucinous histology and high grade were tumor characteristics associated with positive margins. 

2. Hospitals with a higher observed to expected margin positivity ratio or “high outliers” had a lower rate of preoperative radiation, lower hospital volume, were more likely to be community rather than academic institutions. The opposite factors were in effect for “low outliers,” but both high-volume and academic hospitals were included in the “high outlier” group. 

Evidence Rating Level: 2 (Good) 

Study Rundown: Long-term rectal cancer outcomes including overall survival depend significantly on resection margin status. This study identified a number of patient-, tumor- and hospital-related characteristics that are associated with a higher risk of margin positivity after rectal cancer resection. Additionally it created a nomogram using the observed vs. expected margin outcome rate ratio that can be utilized by hospitals to assess their performance adjusting for its patient population. Although a vast number of patients and hospitals were analyzed, this study is limited by its use of the National Cancer Data Base. It is unclear what variables are present at the excluded hospitals and it is likely that this self-selected sample created bias. Additionally, surgeon and healthcare team characteristics were not evaluated and possible regional differences were not assessed.

Click to read the study in JAMA Surgery

Click to read the accompanying editorial in JAMA Surgery

Relevant Reading: Management of early rectal cancer

In-Depth [cohort study]: Data from eighty thousand rectal cancer patients who underwent surgery at over one thousand hospitals was analyzed using the National Cancer Data Base. The major outcome of interest was the rate of margin positivity after rectal cancer resection in each individual hospital when controlling for patient and tumor variables. Older African American men without private insurance and with recently diagnosed disease were found to have a higher risk of margin positivity. Higher AJCC stage, signet or mucinous and undifferentiated histology were tumor risk factors while tumor size was not related to margin positivity. Based on above patient and tumor characteristic distribution, an observed to expected margin positivity rate ratio was calculated for each hospital and compared to statistical probability that the observed rate was equal to the expected rate. The percentages of each hospital type with a low ratio (much less margin positivity than expected) were as follows: 9% were community cancer-specific programs, 47% were general community hospitals and 43.9% were academic institutions. High-ratio hospitals or those with much higher rates of margin positivity than predicted were broken down as follows: 29.9% were community cancer-specific programs, 52.3% were general community hospitals and 17.8% were academic institutions. Low observed to expected ratio was seen in more high-volume hospitals, but 17.8% of hospitals with a high ratio were high-volume as well. In regards to treatment, the order of surgery and radiation was important. Additionally, patients at a hospital with a lower (better) ratio were more likely to receive radiation prior to surgery.

By Asya Ofshteyn and Allen Ho

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