The Impact of an Enhanced Recovery Protocol in a High-Risk Population Undergoing Colon Cancer Surgery.

OBJECTIVE: Enhanced Recovery ERP protocols (ERP) have improved surgical outcomes in patients undergoing elective colon cancer (CC) surgery; however, efficacy in different populations may vary. We examined the impact of an ERP in a population with high rates of obesity and multiple comorbidities. METHODS: We performed a retrospective analysis of factors associated with postoperative complications (PoC) and length of stay (LOS) following CC surgery from 2011 to 2019 in a 5-hospital healthcare system which serves a population with higher rates of obesity (body mass index ≥30kg/m2) and multi-comorbidities, as compared to published studies. Univariable and multivariable analyses were performed. RESULTS: A total of 408 elective CC surgery patients with complete oncologic surgical data were identified. Of these, 191 (46.81%) were under ERP. Factors independently associated with PoC included obesity (OR=1.66, P=.029), laparoscopic (OR=.52, P=.020), and hybrid (OR=.38, P=.012) versus open surgery and ASA (American Society of Anesthesiologists) class ≥3 (OR=1.98, P=.006). ERP did not impact PoC but was associated with a reduction in LOS (ß=-1.02 days, 95%CI: -1.75 - -.30, P=.006). ERP had an impact on LOS in both the non-obese and obese groups (P<.001 and P=.034, respectively). PoC significantly increased LOS (ß=6.67 days, 95%CI: 5.41-7.03, P<.001). CONCLUSIONS: Following elective CC surgery, obesity and medical comorbidities were associated with increased PoC and in turn, as expected, increased LOS. ERP was associated with a reduction in LOS in both obese and non-obese patients. In high-risk populations, application of ERP may be particularly important to optimize surgical outcomes following CC surgery.

Adherence to neoadjuvant therapy guidelines for locally advanced rectal cancers in a region with sociodemographic disparities.

BACKGROUND: Practice guidelines recommend neoadjuvant chemoradiation (NCR) for locally advanced rectal cancer (LARC). We examined guideline adherence in a healthcare system serving a region with socioeconomic disparities and poor cancer outcomes. METHODS: Retrospective analysis of factors associated with guideline adherence. RESULTS: 63.1% of stage II/III LARC patients received NCR. Factors associated with adherence included white race (OR = 2.15, p = 0.024), private insurance (OR = 2.70, p = 0.005), employed status (OR = 2.30, p = 0.031), age at diagnosis (OR = 0.74, p = 0.032), appropriate local staging (OR = 9.17, p < 0.0001), and diagnosis later in the study period (OR per 1 year = 1.20, p = 0.006). By multivariate analysis, private insurance (OR = 2.51, p = 0.023), younger age (OR per 10 years = 0.72, p = 0.048) and appropriate local staging (OR = 6.67, p < 0.0001) were associated with adherence. CONCLUSION: Guideline adherence for LARC in our system is low and is impacted by employment, race and insurance status. Standard of care compliance remains an important target for improvement efforts in this underserved region of the nation's Mid-South.

What Is the Utility of Restaging Imaging for Patients With Clinical Stage II/III Rectal Cancer After Completion of Neoadjuvant Chemoradiation and Prior to Proctectomy?

BACKGROUND: In the United States, patients with clinical stage II or III rectal cancer typically receive neoadjuvant chemoradiation therapy (chemo/XRT) over a 5-6 week period followed by a 6-10 week break prior to proctectomy. In the current study, we evaluate the utilization of restaging studies performed and detection of disease progression during this window. METHODS: A retrospective review of patients with clinical stage II/III rectal cancer was performed. Medical records were analyzed to collect clinicopathologic data and the performance and results of preoperative, early postoperative, and first surveillance CT and/or PET/CT in patients completing long course neoadjuvant chemo/XRT and undergoing proctectomy. RESULTS: Between 2005 and 2017, 176 patients with clinical stage II or III rectal adenocarcinoma completed neoadjuvant chemo/XRT and underwent proctectomy. Preoperative restaging with CT CAP and/or CT/PET was performed in 72 (40.9%) patients with no detection of disease progression. Of the 104 patients without preoperative restaging, 1 had intraoperative detection of liver metastases and 31 had early postoperative reimaging (within 30 days of proctectomy) of which 2 had detection of new pulmonary metastases. Among 72 patients with no preoperative or early postoperative reimaging, first surveillance imaging was available in 47 and detected new metastases in 8 (17%). DISCUSSION: In patients with clinical stage II/III rectal cancer who undergo long course neoadjuvant chemo/XRT, perioperative reimaging with CT CAP and/or PET/CT detects new metastases in a small percentage of patients. A multi-institutional, prospective analysis using standardized staging protocols is warranted to better determine the value of preoperative restaging in these patients.

Restaging Patients with Rectal Cancer Following Neoadjuvant Chemoradiation: A Systematic Review.

BACKGROUND: In the USA, most patients with clinical stage II/III rectal cancer receive neoadjuvant chemoradiation (chemo/XRT) over 5-6 weeks followed by a 6-10-week break before proctectomy. As chemotherapy is delivered at radio-sensitizing doses, there is essentially a 3-month window during which potential systemic disease is untreated. Evidence regarding the utility of restaging patients prior to proctectomy is limited. METHODS: PubMed, Scopus, Web of Science, and the Cochrane Library were searched for studies evaluating the utility of restaging patients with rectal cancer after completion of long-course chemo/XRT, and reporting associated changes in management. Studies that were non-English, included <50 patients, or examining the diagnostic accuracy of imaging modalities were excluded. Study quality was evaluated using the modified Newcastle Ottawa Scale. RESULTS: Eight studies were identified including a total of 1251 patients restaged between completion of chemo/XRT and proctectomy. All studies were retrospective. Restaging identified new metastatic disease in 72 (6.0%) patients, with 4 studies reporting specific sites: liver (n = 28), lung (n = 8), adrenal (n = 1), bone (n = 1), and multiple sites (n = 7). Overall progression (distant or local) was detected in 88 (7.0%) patients and resulted in a change in management in 77 (87.5%) of these patients. Tumor-related prognostic characteristics were inconsistently reported among studies, precluding meta-analysis. CONCLUSIONS: Although restaging between completion of neoadjuvant chemo/XRT and proctectomy detects disease progression in only a small percentage of patients, findings alter the treatment plan in the vast majority of these patients. Multi-institutional collaboration with analysis of well-defined prognostic variables may better identify patients most likely to benefit from restaging.