Current trends in nonoperative management for rectal adenocarcinoma: An unequal playing field?

Abstract

Background and Objectives Increasing evidence suggests patient‐oriented benefits of nonoperative management (NOM) for rectal cancer. However, vigilant surveillance requires excellent access to care. We sought to examine patient, socioeconomic, and facility‐level factors associated with NOM over time. Methods Using the National Cancer Database (2006–2017), we examined patients with Stage II–III rectal adenocarcinoma, who received neoadjuvant chemoradiation and received NOM versus surgery. Factors associated with NOM were assessed using multivariable logistic regression with backward stepwise selection. Results There were 59,196 surgical and 8520 NOM patients identified. NOM use increased from 12.9% to 15.9% between 2006 and 2017. Patients who were Black (adjusted odds ratio [aOR]: 1.36, 95% confidence interval [CI]: 1.26–1.47), treated at community cancer centers (aOR: 1.22, 95% CI: 1.12–1.30), without insurance (aOR: 1.87, 95% CI: 1.68–2.09), and with less education (aOR: 1.53, 95% CI: 1.42–1.65) exhibited higher odds of NOM. Patients treated at high‐volume centers (aOR: 0.79, 95% CI: 0.74–0.84) and those who traveled >25.6 miles for care (aOR: 0.59, 95% CI: 0.55–0.64) had lower odds of NOM. Conclusions Vulnerable groups who traditionally have difficulty accessing comprehensive cancer care were more likely to receive NOM, suggesting that healthcare disparities may be driving utilization. More research is needed to understand NOM decision‐making in rectal cancer treatment.

Operative trends following the adoption of nonoperative management of rectal cancer

“…It has been suggested that the MRI report should include precise prose description of internal and external sphincter muscle invasion, that invasion of the internal sphincter muscle and intersphincteric space should not be assigned a cT stage, and that invasion of the external sphincter complex, puborectalis, or levator muscle should be staged cT4b. 7,12 Clinical TN and MRF restaging by MRI after NT has been shown…”

“…Interpreting depth of extramural tumor invasion in the lowermost rectum is challenging because of the close proximity of the internal sphincter, intersphincteric plane, and external sphincter muscles. It has been suggested that the MRI report should include precise prose description of internal and external sphincter muscle invasion, that invasion of the internal sphincter muscle and intersphincteric space should not be assigned a cT stage, and that invasion of the external sphincter complex, puborectalis, or levator muscle should be staged cT4b 7,12 …”