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International Journal of Colorectal Disease

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Open Access 01-05-2019 | Rectal Cancer | Original Article

Laparoscopic and open resection of rectal cancer—is age an effect modifier for short- and long-term survival?

Authors: Teresa Draeger, Vinzenz Völkel, Valentin Schnitzbauer, Michael Gerken, Stefan Benz, Monika Klinkhammer-Schalke, Alois Fürst

Published in: International Journal of Colorectal Disease | Issue 5/2019

Abstract

Introduction

Rectal cancer is a frequently diagnosed tumor worldwide. Various studies have shown the noninferiority or even slight superiority of laparoscopic resection. However, there is no clear recommendation on whether age should influence the choice of surgical approach.

Materials and methods

This study compared outcomes of laparoscopic and open surgery in rectal cancer patients. Perioperative mortality and 5-year overall, relative, and recurrence-free survival rates were analyzed separately for three age groups. Data originate from 30 regional German cancer registries that cover approximately one quarter of the German population. All primary nonmetastatic rectal adenocarcinoma cases with surgery between 2005 and 2014 were eligible for inclusion. To compare survival rates, Kaplan–Meier analysis, a relative survival model, and multivariable Cox regression were used; a sensitivity analysis assessed bias by exclusion.

Results

Ten thousand seven hundred fifty-four patients were included in the analysis. The mean laparoscopy rate was 23.0% and increased over time. Analysis of 30-day postoperative mortality rates revealed advantages for laparoscopically treated patients, although the significance level was not reached in any age group. Regarding 5-year overall survival, laparoscopy generally seems to be the superior approach, whereas for recurrence-free survival, an age-dependent gradient in effect size was observed: with a hazard ratio (HR) of 0.703 for laparoscopy, patients under 60 years benefitted more from the minimally invasive approach than older patients (septuagenarians, HR 0.923).

Conclusion

Laparoscopy shows similar results to the open approach in terms of postoperative survival in all age groups. Concerning long-term outcomes, younger patients benefitted most from the minimally invasive approach.

Robert Koch-Institut (2016) Bericht zum Krebsgeschehen in Deutschland 2016. https://doi.org/10.17886/rkipubl-2016-014

Stewart BW, Wild CP (2014) World Cancer Report 2014, Online-Ausg. EBL-Schweitzer. International Agency for Research on Cancer/World Health Organization, Lyon

Bonjer HJ, Deijen CL, Abis GA, Cuesta MA, van der Pas M, de Lange-de Klerk ES, Lacy AM, Bemelman WA, Andersson J, Angenete E, Rosenberg J, Fuerst A, Haglind E, COLOR II Study Group (2015) A randomized trial of laparoscopic versus open surgery for rectal cancer. N Engl J Med 372(14):1324–1332. https://doi.org/10.1056/NEJMoa1414882 CrossRefPubMed

Draeger T, Völkel V, Gerken M, Klinkhammer-Schalke M, Fürst A (2018) Long-term oncologic outcomes after laparoscopic versus open rectal cancer resection: a high-quality population-based analysis in a Southern German district. Surg Endosc 32:4096–4104. https://doi.org/10.1007/s00464-018-6148-6 CrossRefPubMedPubMedCentral

Kuhry E, Schwenk WF, Gaupset R et al. (2008) Long-term results of laparoscopic colorectal cancer resection. Cochrane Database Syst Rev(2): CD003432. https://doi.org/10.1002/14651858.CD003432.pub2

Mroczkowski P, Hac S, Smith B, Schmidt U, Lippert H, Kube R (2012) Laparoscopy in the surgical treatment of rectal cancer in Germany 2000-2009. Color Dis 14(12):1473–1478. https://doi.org/10.1111/j.1463-1318.2012.03058.x CrossRef

van der Pas MH, Haglind E, Cuesta MA et al (2013) Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol 14(3):210–218. https://doi.org/10.1016/S1470-2045(13)70016-0 CrossRefPubMed

Spinelli A, D’Hoore A, Panis Y, Bemelman WA, Jayne DG, Fürst A (2017) Critical appraisal of two randomized clinical trials on pathologic outcomes. coloproctology 39(4):277. https://doi.org/10.1007/s00053-017-0178-8 CrossRef

Steele SR, Park GE, Johnson EK, Martin MJ, Stojadinovic A, Maykel JA, Causey MW (2014) The impact of age on colorectal cancer incidence, treatment, and outcomes in an equal-access health care system. Dis Colon Rectum 57(3):303–310. https://doi.org/10.1097/DCR.0b013e3182a586e7 CrossRefPubMed

10.

Leitlinienprogramm Onkologie (Deutsche Krebsgesellschaft, Deutsche Krebshilfe, AWMF): S3-Leitlinie Kolorektales Karzinom, Langversion 1.1, 2014, AWMF Registrierungsnummer: 021-007OL, http://leitlinienprogramm-onkologie.de/Leitlinien.7.0.html. Accessed 12 Feb 2019

11.

Wesselmann S, Follmann M (2011) Leitlinien und Zertifizierung im DKG-Qualitätszirkel. Forum 109(26):15–17

12.

Völkel V, Draeger T, Gerken M et al. (2018) Langzeitüberleben von Patienten mit Kolon- und Rektumkarzinomen: Ein Vergleich von Darmkrebszentren und nicht zertifizierten Krankenhäusern (Long-Term Survival of Patients with Colon and Rectum Carcinomas: Is There a Difference Between Cancer Centers and Non-Certified Hospitals?). Gesundheitswesen. https://doi.org/10.1055/a-0591-3827

13.

Arbeitsgemeinschaft Deutscher Tumorzentren e.V. ADT - für Qualitätssicherung in der Onkologie. https://www.tumorzentren.de/. Accessed 12 Feb 2019

14.

Deutsches Institut für Medizinische Dokumentation und Information (DIMDI) im Auftrag des Bundesministeriums für Gesundheit (BMG) unter Beteiligung der Arbeitsgruppe ICD des Kuratoriums für Fragen der Klassifikation im Gesundheitswesen (KKG) (Hrsg.) (2017). ICD-10-GM Version 2017. Systematisches Verzeichnis Internationale statistische Klassifikation der Krankheiten und verwandter Gesundheitsprobleme, 10. Revision - German Modification. https://www.dimdi.de/dynamic/de/klassifikationen/downloads/?dir=icd-10-gm/version2017. Accessed 12 Feb 2019

15.

Majek O, Gondos A, Jansen L, Emrich K, Holleczek B, Katalinic A, Nennecke A, Eberle A, Brenner H, the GEKID Cancer Survival Working Group (2013) Sex differences in colorectal cancer survival: population-based analysis of 164,996 colorectal cancer patients in Germany. PLoS One 8(7):e68077. https://doi.org/10.1371/journal.pone.0068077 CrossRefPubMedPubMedCentral

16.

Silberfein EJ, Kattepogu KM, Hu C-Y, Skibber JM, Rodriguez-Bigas MA, Feig B, Das P, Krishnan S, Crane C, Kopetz S, Eng C, Chang GJ (2010) Long-term survival and recurrence outcomes following surgery for distal rectal cancer. Ann Surg Oncol 17(11):2863–2869. https://doi.org/10.1245/s10434-010-1119-8 CrossRefPubMedPubMedCentral

17.

Konn M, Morita T, Hada R, Yamanaka Y, Sasaki M, Munakata H, Suzuki H, Inoue S, Endoh M, Sugiyama Y, Ono K (1993) Survival and recurrence after low anterior resection and abdominoperineal resection for rectal cancer: the results of a long-term study with a review of the literature. Surg Today 23(1):21–30CrossRefPubMed

18.

Cancer Research UK (2011) Bowel cancer incidence statistics. http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/bowel-cancer/incidence#heading-Two. Accessed 12 Feb 2019

19.

Gunderson LL, Sargent DJ, Tepper JE, Wolmark N, O'Connell MJ, Begovic M, Allmer C, Colangelo L, Smalley SR, Haller DG, Martenson JA, Mayer RJ, Rich TA, Ajani JA, MacDonald JS, Willett CG, Goldberg RM (2004) Impact of T and N stage and treatment on survival and relapse in adjuvant rectal cancer: a pooled analysis. J Clin Oncol 22(10):1785–1796. https://doi.org/10.1200/JCO.2004.08.173 CrossRefPubMed

20.

Wu Y, Liu H, Du XL et al (2017) Impact of neoadjuvant and adjuvant radiotherapy on disease-specific survival in patients with stages II-IV rectal cancer. Oncotarget 8(63):106913–106925. https://doi.org/10.18632/oncotarget.22460 CrossRefPubMedPubMedCentral

21.

Mokdad A, Huerta S, Minter RM et al (2017) Effect of adjuvant chemotherapy following pathologic complete response on long-term survival in rectal cancer: a propensity score matched analysis. JCO 35(4_suppl):717. https://doi.org/10.1200/JCO.2017.35.4_suppl.717 CrossRef

22.

Cox D (1972) Regression models and life-tables. Journal of the Royal Statistical Society Series B 34(2):187–220

23.

Pohar M, Stare J (2006) Relative survival analysis in R. Comput Methods Prog Biomed 81(3):272–278. https://doi.org/10.1016/j.cmpb.2006.01.004 CrossRef

24.

Human Mortality Database. University of California, Berkeley (USA), and Max Planck Institute for Demographic Research (Germany). Available at www.mortality.org or www.humanmortality.de. Accessed 02 Sep 2017

25.

von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP (2007) The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 370(9596):1453–1457. https://doi.org/10.1016/S0140-6736(07)61602-X CrossRef

26.

Piccirillo JF, Vlahiotis A, Barrett LB, Flood KL, Spitznagel EL, Steyerberg EW (2008) The changing prevalence of comorbidity across the age spectrum. Crit Rev Oncol Hematol 67(2):124–132. https://doi.org/10.1016/j.critrevonc.2008.01.013 CrossRefPubMedPubMedCentral

27.

van Leersum NJ, Janssen-Heijnen MLG, Wouters MWJM, Rutten HJT, Coebergh JW, Tollenaar RAEM, Lemmens VEPP (2013) Increasing prevalence of comorbidity in patients with colorectal cancer in the South of the Netherlands 1995–2010. Int J Cancer 132(9):2157–2163. https://doi.org/10.1002/ijc.27871 CrossRefPubMed

28.

Nussbaum DP, Speicher PJ, Ganapathi AM, Englum BR, Keenan JE, Mantyh CR, Migaly J (2015) Laparoscopic versus open low anterior resection for rectal cancer: results from the national cancer data base. J Gastrointest Surg 19(1):124–132. https://doi.org/10.1007/s11605-014-2614-1 CrossRefPubMed

29.

Yeo HL, Yeo HL, Abelson JS et al (2016) Minimally invasive surgery and sphincter preservation in rectal cancer. J Surg Res 202(2):299–307. https://doi.org/10.1016/j.jss.2016.01.010 CrossRefPubMed

30.

Kolfschoten NE, van Leersum NJ, Gooiker GA, van de Mheen PJM, Eddes EH, Kievit J, Brand R, Tanis PJ, Bemelman WA, Tollenaar RAEM, Meijerink J, Wouters MWJM (2013) Successful and safe introduction of laparoscopic colorectal cancer surgery in Dutch hospitals. Ann Surg 257(5):916–921. https://doi.org/10.1097/SLA.0b013e31825d0f37 CrossRefPubMed

31.

Landi F, Vallribera F, Rivera JP et al (2015) Morbidity after laparoscopic and open rectal cancer surgery: a comparative analysis of morbidity in octogenarians and younger patients. Color Dis 18(5):459–467. https://doi.org/10.1111/codi.13136 CrossRef

32.

McKay GD, Morgan MJ, S-KC W et al (2012) Improved short-term outcomes of laparoscopic versus open resection for colon and rectal cancer in an area health service: a multicenter study. Dis Colon Rectum 55(1):42–50. https://doi.org/10.1097/DCR.0b013e318239341f CrossRefPubMed

Title: Laparoscopic and open resection of rectal cancer—is age an effect modifier for short- and long-term survival?
Authors: Teresa Draeger
Vinzenz Völkel
Valentin Schnitzbauer
Michael Gerken
Stefan Benz
Monika Klinkhammer-Schalke
Alois Fürst
Publication date: 01-05-2019
Publisher: Springer Berlin Heidelberg
Keywords: Rectal Cancer
Laparoscopy
Rectal Cancer
Minimally Invasive Surgery
Published in: International Journal of Colorectal Disease / Issue 5/2019
Print ISSN: 0179-1958
Electronic ISSN: 1432-1262
DOI: https://doi.org/10.1007/s00384-019-03265-7

At a glance: The STEP trials

Springer Medicine

Laparoscopic and open resection of rectal cancer—is age an effect modifier for short- and long-term survival?

Abstract

Introduction

Materials and methods

Results

Conclusion

At a glance: The STEP trials

Springer Medicine

Abstract

Introduction

Materials and methods

Results

Conclusion

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