Survival after non-resection of colorectal cancer: the argument for including non-operatives in consultant outcome reporting in the UK

Abstract

Introduction Although the mainstay of colorectal cancer treatment remains operative, a significant proportion of patients end up without surgery. This is because they are either deemed to have no oncological benefit from the resection (too much disease) or to be unfit for major surgery (too frail). The aim of this study was to assess the proportion and survival of these two groups among the totality of practice in a tertiary unit and to discuss the implications on the conceptual understanding of outcome measures. Methods Data was collected over two study periods with the total duration of four years. Patient demographics, comorbidities, cancer staging and management pathways were all recorded. The primary endpoint was all-cause mortality. Results The total of 909 patients were examined. In the 29% who did not undergo resectional surgery, 6.5% had too little disease, 13.8% had too much disease, while 8.7% were deemed too frail. The highest two-year mortality was observed in the too much (83.2%) and too frail (75.9%) groups, whereas in patients with too little cancer the rate was 5.1%, and in those undergoing a resection it was 19.2% (P < 0.001). Conclusions The study has expectedly shown poor survival in the too much and too frail groups. We believe that understanding the prognosis in these subgroups is vital, as it informs complex decisions on whether to operate. Moreover, an overall reporting taking into account the proportion of these groups in an multidisciplinary team practice (the non-surgical index) is proposed to render individual surgeon's mortality results meaningful as a comparative measure.

Frailty screening by Geriatric-8 and 4-meter gait speed test is feasible and predicts postoperative complications in elderly colorectal cancer patients

“…Patients who did not undergo surgery were probably those who were frail. [29] The current study shows that frailty screening identifies a large proportion of patients with anaemia and consequently patients who require blood transfusions postoperatively. Anaemia in colorectal cancer patients is common; prevalence is estimated at 30%.…”

Risk factors of short-term survival in the aged in elective colon cancer surgery: a population-based study

“…Corresponding numbers from 2016 in Finland were 60% for patients of 75 years and 66% for all ages [1]. In the oldest patients, however, the survival benefit of operative treatment (compared with other treatments) is only apparent after the first two postoperative years due to the risks of surgery [8][9][10].…”

Frailty and Colorectal Surgery: Review and Concept of Cancer Frailty

“…In such cases, the survival rate with non-surgical treatment tends to be poor. Thus, the interpretations of the referenced studies [44][45][46][47][48][49][50] require caution and should not be misused to guide patients and families to undergo surgery (Table 1). A large study of 20,423 patients aged >70 years with colorectal cancer was conducted in the Netherlands [45].…”