Treatment Utilization and Outcomes for Locally Advanced Rectal Cancer in Older Patients

Abstract

ImportanceThe number of older patients (80 years and older) diagnosed with locally advanced rectal cancer (LARC) is expected to increase. Although current guidelines recommend neoadjuvant chemoradiation therapy (NACRT) followed by resection, little is known about management and outcomes in this older population.ObjectiveTo assess the trends in management of older patients diagnosed with LARC who had a surgical resection.Design, Setting, and ParticipantsPatients 80 years and older who had a surgical resection for LARC were identified in the 2004-2016 National Cancer Database. Patients were grouped based on therapy sequence: (1) surgery followed by adjuvant therapy (AT), ie, chemotherapy or radiation; (2) surgery alone; or (3) NACRT followed by surgical resection. Data were analyzed in May 2021.ExposuresNACRT followed by surgery, and surgery with or without AT.Main Outcomes and MeasuresOverall survival (OS) was assessed using Kaplan-Meier analyses with inverse probability of treatment weighting (IPTW) and Cox proportional hazards regression were performed to examine the association of NACRT with the risk of death.ResultsOf 3868 patients with LARC who underwent surgical resection, 2042 (52.8%) were male, and the mean (SD) age was 83.4 (3.0) years. A total of 2273 (58.8%) received NACRT followed by surgical resection. Factors independently associated with NACRT were more recent diagnosis, age 80 to 85 years (vs 86 years and older), fewer comorbidities, larger tumors, and node-positive disease. The Kaplan-Meier analyses with IPTW showed that 3-year and 5-year OS for NACRT (3-year: 68.9%; 95% CI, 67.0-70.8; 5-year: 51.1%; 95% CI, 49.0-53.4) vs surgery with AT (3-year: 64.4%; 95% CI, 59.0-70.2; 5-year: 43.0%; 95% CI, 37.4-49.5) vs surgery alone (3-year: 55.8%; 95% CI, 52.0-60.0; 5-year: 34.7%; 95% CI, 30.8-39.0) was significantly different (P < .001). After adjusting for confounders, patients who received NACRT were more likely to undergo an R0 resection (adjusted odds ratio, 2.16; 95% CI, 1.62-2.88), which independently improved OS (P < .001). Moreover, receipt of NACRT was independently associated with a 25% decreased risk of death (adjusted hazard ratio, 0.75; 95% CI, 0.69-0.82) compared with alternative treatment sequences.Conclusions and RelevanceApproximately 40% of older patients with LARC did not receive the current standard of care. In this cohort, NACRT was associated with a higher likelihood of an R0 resection and improved OS. Clinicians should advocate for receipt of NACRT in older patients with LARC.

Neoadjuvant Chemoradiation Therapy for All Elderly Patients With Locally Advanced Rectal Cancer?

“…Of equal concern is their decision to use binary logistic regression to compare 2 arbitrary groups (NACRT vs surgery ± adjuvant therapy) instead of the 3 individual treatments. Therefore, we take issue with their usage of the words “independently associated ” because they do not actually compare the 3 treatment options independently; at best, there is an association.…”

“…Nassoiy et al 3 state that there is substantial room for improvement by offering more NACRT to elderly individuals. However, in their study, there was a trend toward increased use of NACRT in elderly individuals during the later years of study.…”

“…However, in their study, there was a trend toward increased use of NACRT in elderly individuals during the later years of study. 3 Similarly, Bergquist et al 4 Exactly what incremental delivery of NACRT to elderly patients with rectal cancer should we aspire for is the central question. This is best determined by comparing the added early morbidity and mortality potentially encountered with NACRT to the long-term oncological benefit in this unique population with increased likelihood of frailty and risk for incurring complications with any therapy while possibly facing a limited overall life expectancy.…”

“…Nassoiy et al, using the National Cancer Data Base in a multicenter retrospective design, demonstrate that only 58.8% of patients older than 80 years diagnosed with a locally advanced rectal cancer between 2004 and 2016 received neoadjuvant chemoradiation therapy (NACRT). Their secondary analysis led them to conclude that NACRT is associated independently with a 25% decreased risk of death compared with alternate treatment sequences (surgery + adjuvant therapy or surgery alone).…”

“…Their secondary analysis led them to conclude that NACRT is associated independently with a 25% decreased risk of death compared with alternate treatment sequences (surgery + adjuvant therapy or surgery alone). However, their conclusion is based on an analysis of groups that, according to Table 1 in their article, are statistically different. Although inverse probability of treatment weighting methodology was used to balance the groups, the authors do not provide any evidence that the groups were similar after inverse probability of treatment weighting adjustment.…”