High practice variation in risk stratification, baseline oncological staging, and follow-up strategies for T1 colorectal cancers in the Netherlands

Abstract

Background and study aims Based on pathology, locally resected T1 colorectal cancer (T1-CRC) can be classified as having low- or high-risk for irradicality and/or lymph node metastasis, the latter requiring adjuvant surgery. Reporting and application of pathological high-risk criteria is likely variable, with inherited variation regarding baseline oncological staging, treatment and surveillance. Methods We assessed practice variation using an online survey among gastroenterologists and surgeons participating in the Dutch T1-CRC Working Group. Results Of the 130 invited physicians, 53 % participated. Regarding high-risk T1-CRC criteria, lymphangio-invasion is used by 100 %, positive or indeterminable margins by 93 %, poor differentiation by 90 %, tumor-free margin ≤ 1 mm by 78 %, tumor budding by 57 % and submucosal invasion > 1000 µm by 47 %. Fifty-two percent of the respondents do not perform baseline staging in locally resected low-risk T1-CRC. In case of unoperated high-risk patients, we recorded 61 different surveillance strategies in 63 participants, using 19 different combinations of diagnostic tests. Endoscopy is used in all schedules. Mean follow-up time is 36 months for endoscopy, 26 months for rectal MRI and 30 months for abdominal CT (all varying 3–60 months). Conclusion We found variable use of pathological high-risk T1-CRC criteria, creating risk for misclassification as low-risk T1-CRC. This has serious implications, as most participants will not proceed to oncological staging in low-risk patients and adjuvant surgery nor radiological surveillance is considered. On the other hand, oncological surveillance in patients with a locally resected high-risk T1-CRC who do not wish adjuvant surgery is highly variable emphasizing the need for a uniform surveillance protocol.

Impact of ≥ 0.1-mm free resection margins on local intramural residual cancer after local excision of T1 colorectal cancer

“…First, the relatively short duration and variation of follow-up may have resulted in under-detection of LIRC cases that are yet to develop. The median follow-up in our cohort was 33 months and the follow-up showed significant variation in follow-up strategies 36 . In a recent meta-analysis, 98 % of all recurrent cases were identified within 6 years 29 .…”

The Importance of Being “That” Colorectal pT1: A Combined Clinico-Pathological Predictive Score to Improve Nodal Risk Stratification

“…Lastly, the predictive significance of age at diagnosis is of particular interest since it shows the importance of clinical variables even in this early oncological setting. Moreover, whereas the assessment of histopathological features alone can be hampered by inter-observer variability ( 50 ), age at diagnosis is not. Younger age is also known to be related to more aggressive CRC lesions ( 51 – 54 ).…”

Surgical rather than endoscopic resection of early-stage colorectal cancers promotes excessive imaging surveillance

“…With respect to European recommendations regarding screeningdetected T1 tumours, only those with at-risk tumours not surgically resected should have been J o u r n a l P r e -p r o o f monitored by imaging [5]. A recent survey revealed enormous variation of practice among Dutch physicians surveyed online for follow-up strategies for locally resected high-risk T1 carcinomas [21]. In our study, the imaging monitoring rate was 63.6% for the small group of patients with locally resected high-risk T1 carcinomas.…”