A Novel Risk-Adjusted Nomogram for Rectal Cancer Surgery Outcomes

Abstract

Context Circumferential resection margin is the primary determinant of local recurrence and a major factor in survival in rectal cancer. Neither chemotherapy nor chemoradiation compensates for a positive margin. Objective To identify treatment-related factors associated with hospital margin-positive resection and to develop a tool that could be used by individual hospitals to assess their outcomes based on their unique mix of patient and tumor characteristics. Design Retrospective review of the National Cancer Data Base, 1998–2007. Settings Community and academic/research hospitals. Patients Histologically confirmed localized rectal/rectosigmoid adenocarcinoma. Outcome measures Rate of margin positivity determined and adjusted for patient- and tumor-related factors to calculate expected margin positivity per hospital. An observed/expected ratio was calculated based on patient and tumor factors to identify treatment associated variation. Results Overall margin-positive resection rate was 5.2%. Patients with positive margins were more likely to be older, male, and African American; not have private insurance; and have their cancer diagnosed later in the study period. Associated tumor factors include rectal location, higher American Joint Committee on Cancer stage, signet/mucinous histology, and poor/undifferentiated grade. Among hospitals that were significantly low outliers, 47% were comprehensive community hospitals and 43.9% were academic/research hospitals; of those that were significantly high outliers, 52.3% were comprehensive community hospitals and 17.8% were academic/research hospitals. High-volume centers made up 80% of significantly low-outlier hospitals and 17% of significantly high outliers. Rates of chemotherapy and radiation were similar, but low-outlier hospitals gave more neoadjuvant radiation (26.3% vs 17%). Conclusions After adjustment for patient and tumor factors we identified both low and high outliers for margin positivity at resection as well as potentially modifiable risk factors. The nomogram created in this model allows evaluation of observed and expected event rates for individual hospitals, providing a hospital self-assessment tool for identifying targets for improvement.

ExtraLevatory AbdominoPerineal Excision (ELAPE) Does Not Result in Reduced Rate of Tumor Perforation or Rate of Positive Circumferential Resection Margin

“…16 Also, a recent large-scale database study with 85,190 patients with rectal cancer found a small but significantly increased risk of CRM+ in men. 17 This possibly increased risk in men could be due to the anatomy of the male pelvis. After univariate analysis in the present study, N-stage was associated with increased risk of CRM+, but after controlling for other risk factors by multivariate analysis, N-stage was no longer a significant risk factor.…”

Risk-Adjusted Margin Positivity Rate as a Surgical Quality Metric for Non-Small Cell Lung Cancer

“…Expected surgical margin-positivity cases were predicted based on patient demographic and clinical characteristics in each facility using multivariate logistic regression models. Using previously-specified methodology [18,19], we determined the significance of the O/E ratio by binominal function and used this to define facility performance status (details in supplemental methodology, supplemental Table 1). Facilities were categorized as outperforming (O/E ratio<1, p<0.05), non-outlier (p>=0.05), and underperforming (O/E ratio>1, p<0.05).…”

High Rate of Positive Circumferential Resection Margins Following Rectal Cancer Surgery

“…Tumor size was categorized into 3 groups: <1cm, between 1 and 2cm, and greater than 2cm in concordance with prior papers published on rectal cancer margin status NCDB. 22,23 The NCDB defines type of rectal surgery as a partial or total proctectomy. A partial proctectomy includes but is not limited to an anterior resection, Hartmann’s operation, low anterior resection (LAR), or trans sacral rectosigmoidectomy whereas total proctectomy includes abdominoperineal resections (APR), pelvic exenteration, and total proctocolectomy, NOS.…”