CHARACTERISTICS AND OUTCOMES OF T2 N0 RECTAL ADENOCARCINOMA WITH DEFINITIVE ABDOMINAL RESECTION VERSUS LOCAL EXCISION IN THE ELDERLY (80+ YEARS)
Deirdre A. Dulak*1, Majed El Hechi1, Sara E. Berkey1, Ali Preetha1, Zhifei Sun1,2, Brian Bello1
1Colorectal Surgery, MedStar Washington Hospital Center, Washington, ; 2MedStar Georgetown University Hospital, Washington,
Background: Although the incidence of rectal cancer is increasing in younger patients, the majority of those diagnosed with it are older. However, patients over 80 years of age are typically excluded from clinical trials. Due to comorbidities and frailty, providers may recommend adjustments to National Comprehensive Cancer Network (NCCN) guidelines in these patients. We aimed to characterize the demographics and outcomes of elderly patients (80+ years) with T2 N0 rectal adenocarcinoma treated with preferred transabdominal resections versus those treated with less aggressive localized excision.
Methods: We conducted a retrospective review of the National Cancer Database (NCDB) for patients 80 years of age and older with clinical T2 N0 (stage I) rectal adenocarcinoma from 2004 to 2017. Patients were divided into two cohorts based on whether they underwent local excision versus definitive abdominal resection. Multivariable logistic regression was used to examine the adjusted association between the type of procedure and mortality and readmission rates.
Results: A total of 2,076 patients aged 80 and older with clinical T2 N0 rectal adenocarcinoma met inclusion criteria for the study. Of these, 765 (37%) underwent local excision while 1,311 (63%) had transabdominal resections. On univariate analysis, younger age (median age 83 versus 84 years, p<0.001) and male sex (52.9% versus 45.8%, p<0.002) were significantly associated with transabdominal resection. Race, ethnicity, facility type and region, insurance status, education level, geographic location, distance from facility, Charles-Deyo score, tumor grade, and radiation treatment were not significantly different between the two groups. In terms of post-operative mortality, 30 day mortality (0.9% in local excision versus 3.2% in formal resection, p<0.001) and 90 day mortality (3.9% in local excision versus 6.2% in formal resection, p<0.024) were significantly lower in the local excision group. However, months between diagnosis and last contact/death (a marker for longer term survival) was significantly higher in the abdominal resection group (49.6 months versus 41.9 months, p<0.001). Unplanned readmission within 30 days was not significantly different between the two groups. On multivariable logistic regression, only 30 day mortality maintained significance (OR 3.34, 95% CI 1.51-7.81, p<0.003).
Conclusions: On multivariable analysis, 30 day mortality was the only improved outcome in the local excision group. For the frail, elderly rectal cancer patient with T2 N0 disease, local excision with or without radiation therapy may be a reasonable alternative with only mildly diminished survival benefit but much improved perioperative risk profile. Future research should address rates of morbidity, recurrence, and long term mortality, as well as combinations of radiation and chemotherapy.
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