Pathologic response grade after long-course neoadjuvant chemoradiation does not influence morbidity in locally advanced mid-low rectal cancer resected by laparoscopy

Purpose

Patients with locally advanced rectal cancer and pathologic complete response to neoadjuvant chemoradiation therapy have lower rates of recurrence compared to those who do not. However, the influences of the pathologic response on surgical complications and survival remain unclear. This study aimed to investigate the influence of neoadjuvant therapy for rectal cancer on postoperative morbidity and long-term survival.

Methods

This was a comparative study of consecutive patients who underwent laparoscopic total mesorectal excision for rectal cancer in two European tertiary hospitals between 2004 and 2014. Patients with and without pathologic complete responses were compared in terms of postoperative morbidity, mortality, and survival.

Results

Fifty patients with complete response (ypT0N0) were compared with 141 patients who exhibited non-complete response. No group differences were observed in the postoperative mortality or morbidity rates. The median follow-up time was 57 months (range 1–121). Over this period, 11 (5.8 %) patients, all of whom were in the non-complete response group, exhibited local recurrence. The 5-year overall survival and disease-free survival were significantly better in the complete response group, 92.5 vs. 75.3 % (p = 0.004) and 89 vs. 73.4 % (p = 0.002), respectively.

Conclusions

Postoperative complication rate after laparoscopic total mesorectal excision is not associated with the pathologic response grade to neoadjuvant chemoradiation therapy.

     

PET/CT and Histopathologic Response to Preoperative Chemoradiation Therapy in Locally Advanced Rectal Cancer

Purpose

The objective of this study was to investigate the possibility of using positron emission tomography/computer tomography to predict the histopathologic response in locally advanced rectal cancer treated with preoperative chemoradiation.

Methods

The study included 30 patients with locally advanced rectal adenocarcinoma treated with a combination of radiotherapy and concurrent Uftoral® (uracil, tegafur) and leucovorine. All patients were evaluated by positron emission tomography/computer tomography scan seven weeks after end of chemoradiation, and the results were compared to histopathologic tumor regression as the “standard.” The pathologic response was quantified by tumor regression grade.

Results

Positron emission tomography/computer tomography correctly identified six of eight patients (specificity 75 percent) with complete pathologic response. However, the sensitivity of positron emission tomography/computer tomography was only 45 percent and the accuracy 53 percent. The positive and negative predictive values were 83 and 33 percent, respectively.

Conclusions

We conclude that positron emission tomography/computer tomography performed seven weeks after the end of chemoradiation is not able to predict the histopathologic response in locally advanced rectal cancer. There is an obvious need for other complementary methods especially with respect to the low sensitivity of positron emission tomography/computer tomography.

     

Do clinical criteria reflect pathologic complete response in rectal cancer following neoadjuvant therapy?

Background

Clinical complete response (cCR) in rectal cancer is being evaluated as a tool to identify patients who would not require surgery in the curative management of rectal cancer. Our study reviews mucosal changes after neoadjuvant therapy for rectal cancer in patients treated at our center.

Methods

Pathology reports were retrieved for patients treated with neoadjuvant chemoradiation therapy (CRT) or high-dose rate brachytherapy (HDRBT). The macroscopic appearance of the specimen was compared with pathologic staging.

Results

This study included 282 patients: 88 patients underwent neoadjuvant CRT and 194 patients underwent HDRBT; all patients underwent total mesorectal excision (TME). There were 160 male and 122 female patients with a median age of 65 years (range 29–87). The median time between neoadjuvant therapy and surgery was 50 and 58 days. Sixty patients (21.2%) were staged as ypT0N0, 21.2% had a pathologic complete response (pCR), and only 3.2% had a cCR. Of the 67 patients with initial involvement of the circumferential radial margin (CRM), 44 converted to pathologic CRM?. Two hundred seventy-three patients (96.8%) had mucosal abnormalities. Of the 222 patients with residual tumor, 70 patients had no macroscopic tumor visualized but an ulcer in its place.

Conclusion

Most patients undergoing neoadjuvant therapy for rectal cancer have residual mucosal abnormalities which preclude to a cCR as per published criteria from Brazil. Further studies are required to optimize clinical evaluation and MRI imaging in selected patients.

     

The influence of hospital volume on long-term oncological outcome after rectal cancer surgery

Purpose

The association between hospital volume and outcome in rectal cancer surgery is still subject of debate. The purpose of this study was to assess the impact of hospital volume on outcomes of rectal cancer surgery in the Netherlands in 2011.

Methods

In this collaborative research with a cross-sectional study design, patients who underwent rectal cancer resection in 71 Dutch hospitals in 2011 were included. Annual hospital volume was stratified as low (< 20), medium (20–50), and high (≥ 50).

Results

Of 2095 patients, 258 patients (12.3%) were treated in 23 low-volume hospitals, 1329 (63.4%) in 40 medium-volume hospitals, and 508 (24.2%) in 8 high-volume hospitals. Median length of follow-up was 41 months. Clinical tumor stage, neoadjuvant therapy, extended resections, circumferential resection margin (CRM) positivity, and 30-day or in-hospital mortality did not differ significantly between volume groups. Significantly, more laparoscopic procedures were performed in low-volume hospitals, and more diverting stomas in high-volume hospitals. Three-year disease-free survival for low-, medium-, and high-volume hospitals was 75.0, 74.8, and 76.8% (p = 0.682). Corresponding 3-year overall survival rates were 75.9, 79.1, and 80.3% (p = 0.344). In multivariate analysis, hospital volume was not associated with long-term risk of mortality.

Conclusions

No significant impact of hospital volume on rectal cancer surgery outcome could be observed among 71 Dutch hospitals after implementation of a national audit, with the majority of patients being treated at medium-volume hospitals.

     

Establishing a General Medical Outpatient Clinic for Cancer Survivors in a Public City Hospital Setting

INTRODUCTION

Many cancer centers and community hospitals are developing novel models of survivorship care. However, few are specifically focused on services for socio-economically disadvantaged cancer survivors.

AIMS

To describe a new model of survivorship care serving culturally diverse, urban adult cancer patients and to present findings from a feasibility evaluation.

SETTING

Adult cancer patients treated at a public city hospital cancer center.

PROGRAM DESCRIPTION

The clinic provides comprehensive medical and psychosocial services for patients within a public hospital cancer center where they receive their oncology care.

PROGRAM EVALUATION

Longitudinal data collected over a 3-year period were used to describe patient demographics, patient needs, and services delivered. Since inception, 410 cancer patients have been served. Demand for services has grown steadily. Hypertension was the most frequent comorbid condition treated. Pain, depression, cardiovascular disease, hyperlipidemia, and bowel dysfunction were the most common post-treatment problems experienced by the patients. Financial counseling was an important patient resource.

DISCUSSION

This new clinical service has been well-integrated into its public urban hospital setting and constitutes an innovative model of health-care delivery for socio-economically challenged, culturally diverse adult cancer survivors.

     

Indistinguishable T2/T3-N0 rectal cancer on rectal magnetic resonance imaging: comparison of surgery-first and neoadjuvant chemoradiation therapy-first strategies

Purpose

We compared the treatment outcome between surgery-first and neoadjuvant chemoradiation therapy (nCRT)-first strategies in patients with indistinguishable T2/T3-N0 rectal cancer on rectal magnetic resonance imaging (MRI).

Methods

Our institutional review board approved this retrospective study, and informed consent was waived. Among 1910 patients who underwent rectal MRI between 2008 and 2012, 79 patients (mean age, 59.4 years, 49 men and 30 women) who had indistinguishable T2/T3-N0 rectal cancer on rectal MRI were included. Local recurrence-free survival (LRFS), recurrence-free survival (RFS), overall survival (OS), and disease-specific survival (DSS) were compared between the two groups. Treatment-related complications were evaluated.

Results

Among 79 patients, 51 were treated by surgery first and 28 were treated by nCRT first. In comparison of survival of the surgery- and nCRT-first groups at 5 years, the LRFS rate was 95.6 and 96.3%, RFS rate was 91.0 and 92.4%, OS rate was 93.7 and 92.6%, and DSS rate was 98.0 and 92.6%, respectively. LRFS, RFS, OS, and DSS showed no significant difference between the two groups (p?=?0.862, 0.677, 0.953, and 0.479). The complication rate was not significantly different between the groups (20.0% for surgery-first group vs. 10.7% for nCRT-first group, p?=?0.357).

Conclusion

Treatment outcomes were not significantly different between surgery-first and nCRT-first strategies for indistinguishable T2/T3-N0 rectal cancer on rectal MRI.

     

Survival analysis in rectal carcinoma after neoadjuvant chemoradiation: various methods with different results

Purpose

Survival is an important indicator of outcome quality in rectal carcinoma. The 5-year survival rate is the typical outcome measurement. In patients with neoadjuvant chemoradiation followed by curative surgery, 7 years of follow-up is recommended. Different methods of survival analysis lead to different results. Here, we compared four different methods.

Methods

The data of 439 patients with rectal carcinoma treated with neoadjuvant chemoradiation followed by curative total mesorectal excision (TME) surgery between 1995 and 2010 were analysed. After stratifying by stage, relative survival (RS), cancer-related survival (CRS), overall survival (OS) and disease-free survival (DFS) were compared. In particular, the 3-year disease-free survival rate was compared to the 5- and 7-year overall survival rates.

Results

In the total cohort, the 5-year survival rates ranged from 90% (RS), over 84% (CRS) and 83% (OS) to 72% (DFS). Depending on the stage of disease, the differences between the 5-year survival rates varied between 10 and 32 percentage points. The differences were lowest in UICC stage y0 and highest in UICC stage yIV. The 3-year DFS-rate was always lower (worse) than the 5-year OS rate and higher (better) than the 7-year OS rate, with the exception of stage yIV.

Conclusions

Comparisons of survival are only meaningful if the same methods are applied. The 3-year rate of DFS was always worse than the rate of 5-year OS. Therefore, the 3-year rate of DFS appears to be a useful surrogate indicator in rectal carcinoma treatment studies.

     

Functional outcome following rectal surgery—predisposing factors for low anterior resection syndrome

Purpose

Developments in surgical techniques and neoadjuvant treatment have enabled an increasing proportion of patients with rectal cancer to undergo sphincter-sparing resections. The avoidance of a permanent stoma can come at the cost of poor bowel function which can significantly impact patients’ quality of life. The objective of this study was to identify the incidence and risk factors for the development of bowel dysfunction following rectal cancer surgery.

Methods

Patients undergoing anterior resection for rectal cancer between January 2009 and January 2015 were identified from a rectal cancer database at a single centre. All patients who had bowel continuity restored and underwent curative resection were sent a validated low anterior resection syndrome (LARS) questionnaire. Pre-, inter- and postoperative factors were compared between patients with major LARS and those with minor or no LARS using conditional logistic regression.

Results

There was an 80% response rate (n = 68). Thirty-eight patients (56%) had major LARS symptoms. Neoadjuvant radiotherapy, predominantly long-course chemoradiotherapy (LCCRT), was an independent risk factor for development of major LARS symptoms, while restoration of bowel continuity within 6 months was protective.

Conclusions

The use of neoadjuvant radiotherapy (LCCRT) and timing of stoma reversal are risk factors for the development of severe bowel dysfunction. The potential for long-term poor functional results after LCCRT should be discussed with patients and form a part of the decision-making in individual treatment plans. The timing of the ileostomy closure, where safe and feasible, should be performed within 6 months to improve outcome.

     

‘Watch and wait’ in rectal cancer: summary of the current evidence

Background

The management of rectal cancer has evolved considerably over the last few decades with increasing use of neoadjuvant chemoradiotherapy (nCRT). Complete clinical response (cCR) and even complete pathological response (pCR) have been noted in a proportion of patients who had surgery after nCRT. This raises the concern that we may have been ‘over-treating’ some of these patients and lead to an increasing interest in ‘watch and wait’ (W&W) approach for patients who had cCR to avoid the morbidity associated with rectal surgery.

Methods

A review of the literature in English pertaining to rectal cancer in the context of W&W, organ preservation and active surveillance.

Results

Evidence available to support W&W approach comes from non-randomised controlled trials (RCTs) with no current consensus on patients’ selection criteria, lack of viable predictors of both cCR and pCR and lack of universal definitions of cCR and pCR. Also, there is no agreed protocol for disease surveillance.

Conclusion

Even though there has been increasing reports on the outcomes of W&W in rectal cancer, the current evidence cannot support its routine use in clinical practice. This approach should be used in clinical trials settings or after thorough counselling with the patient on the outcomes of various treatment options.

     

Anastomotic leakage following low anterior resection for rectal cancer

Aim

Aim of this study is to present the incidence of anastomotic leakage after anterior resection for rectal cancer and to demonstrate the therapeutic approach for the treatment of this complication.

Patients and methods

Between 1990 and 2009, 170 patients underwent low anterior resection with total mesorectal excision (TME).

Results

A total of 14 (8.2%) anastomotic leaks were confirmed. Reoperation was carried out in six patients with major leaks. Eight patients with minor leaks were treated conservatively by nutritional support and antibiotic therapy.

Conclusion

The incidence of anastomotic leakage after anterior resection of the rectum for rectal cancer is relatively low.

     

Robot-guided neuromapping during nerve-sparing taTME for low rectal cancer

Purpose

Intraoperative pelvic neuromapping with electrophysiological evaluation of autonomic nerve preservation during robotic total mesorectal excision (TME) for rectal cancer is conventionally performed by the bedside assistant with a hand-guided probe. Our goal was to return autonomy over the neuromonitoring process to the colorectal surgeon operating the robotic console.

Methods

A recently described prototype microfork electrostimulation probe was evaluated intraoperatively during abdominal robotic-assisted transanal TME (taTME) surgery for low rectal cancer in three consecutive male patients.

Results

An intraoperative video demonstrates the good control and maneuverability of the prototype probe with electrophysiological confirmation of bilateral pelvic autonomic nerve preservation.

Conclusions

This study presents the first in situ application of a new microfork probe for fully robot-guided neuromapping in three patients undergoing TME surgery for low rectal cancer.

     

A single institution’s long-term follow-up of patients with pathological complete response in locally advanced rectal adenocarcinoma following neoadjuvant chemoradiotherapy

Purpose

This paper aimed to study the long term follow-up of patients with primary rectal adenocarcinoma receiving neoadjuvant chemoradiotherapy who obtained a pathological complete response (pCR) and identify factors predicting complete response.

Methods

Retrospective review of notes, histology, pre-operative full blood count and imaging of patients with primary rectal adenocarcinoma diagnosed in our institute from 2000 to 2012 from a prospectively maintained database were used. SPSS version 22.0 was used for statistical analysis.

Results

Three hundred eighty patients diagnosed with primary rectal adenocarcinoma were identified, 277 received neoadjuvant chemoradiotherapy followed by curative resection. Forty-six patients obtained a pCR (ypT0N0) with no local recurrence and two metastatic recurrences on follow-up. Patients with a pCR have a significantly improved overall survival and disease-free survival compared to a non-pCR (150.0 and 136.1 vs 77.5 and 84.7 months, p = 0.001). On univariate analysis, increased tumour height above anal verge, low lymph node yield, high pre-operative haemoglobin and a low neutrophil-lymphocyte ratio are significant factors identifying a pCR. Multivariable analysis of the above factors confirmed tumour height above anal verge as significant in obtaining a pCR.

Conclusion

Patients with rectal adenocarcinoma who develop a pCR following neoadjuvant chemoradiotherapy have improved overall and disease-free survival. We have identified distance from anal verge, low lymph node yield, high pre-operative haemoglobin and low neutrophil-lymphocyte ratio as significant predictors of developing a pCR.

     

Cancer Risk Communication with Low Health Literacy Patients: A Continuing Medical Education Program

BACKGROUND

Low health literacy (HL) is an important risk factor for cancer health disparities.

OBJECTIVE

Describe a continuing medical education (CME) program to teach primary care physicians (PCP) cancer risk communication and shared decision-making (SDM) with low HL patients and baseline skills assessment.

DESIGN

Cluster randomized controlled trial in five primary care clinics in New Orleans, LA.

PARTICIPANTS

Eighteen PCPs and 73 low HL patients overdue for cancer screening.

INTERVENTION

Primary care physicians completed unannounced standardized patient (SP) encounters at baseline. Intervention physicians received SP verbal feedback; academic detailing to review cancer screening guidelines, red flags for identifying low HL, and strategies for effective counseling; and web-based tutorial of SP comments and checklist items hyperlinked to reference articles/websites.

MAIN MEASURES

Baseline PCP self-rated proficiency, SP ratings of physician general cancer risk communication and SDM skills, patient perceived involvement in care.

RESULTS

Baseline assessments show physicians rated their proficiency in discussing cancer risks and eliciting patient preference for treatment/decision-making as “very good”. SPs rated physician exploration of perceived cancer susceptibility, screening barriers/motivators, checking understanding, explaining screening options and associated risks/benefits, and eliciting preferences for screening as “satisfactory”. Clinic patients rated their doctor’s facilitation of involvement in care and information exchange as “good”. However, they rated their participation in decision-making as “poor”.

DISCUSSION

The baseline skills assessment suggests a need for physician training in cancer risk communication and shared decision making for patients with low HL. We are determining the effectiveness of teaching methods, required resources and long-term feasibility for a CME program.

     

Indocyanine green fluorescence angiography during low anterior resection for low rectal cancer: results of a comparative cohort study

Background

Anastomotic leak (AL) after low anterior resection (LAR) is associated with increased morbidity, mortality, cost and cancer recurrence rates. The aim of this study was to evaluate the impact of fluorescence angiography (FA) on AL following LAR for low rectal cancer.

Methods

This is a single surgeon retrospective cohort study with a historical, consecutively sampled case matched control group. The institution’s prospectively maintained institutional review board (IRB)-approved database was queried for all patients who underwent a laparoscopic LAR for rectal neoplasia with a colorectal or coloanal anastomosis?<?5 cm from the anal verge between 2013 and 2016. Patients were divided into two groups: patients in whom FA was employed (study group, 2015–2016) and those patients in whom it was not (control group, 2013–2015). All patients were diverted with a loop ileostomy. The primary outcome measured was the AL rate and the secondary outcome measured was change in surgical plan following FA.

Results

Sixty patients were included in the study: 30 patients in the FA group and 30 patients in the control group. Patients’ demographics, the use of neoadjuvant chemoradiation, tumor stage, and mean height of anastomosis were comparable between the study groups. FA led to a change in surgical plan in four patients (13.3%) none of who suffered an AL. Two patients in the control group had a clinically and radiologically confirmed AL, whereas there were no leaks in the FA group (6.7% vs. 0%, p?=?0.49).

Conclusions

FA changed the surgical plan in 13.3% of LAR’s, potentially reducing the incidence of AL in these high-risk patients.

     

Robotic-assisted total mesorectal excision (TME) for rectal cancer results in a significantly higher quality of TME specimen compared to the laparoscopic approach—report of a single-center experience

Aim

Robotic surgery allows for a better visualization and more precise dissection especially in the narrow male pelvis and mid and lower third of the rectum. However, superiority to laparoscopic TME has yet to be proven. We therefore analyzed short-term outcomes of laparoscopic and robotic low anterior rectal resection for rectal cancer.

Patients and methods

From 2011 to 2016, 44 robotic (RTME) and 41 laparoscopic (LTME) low anterior rectal resection with total mesorectal excision were performed at a single institution. Specimen quality was assessed and reported by an independent pathologist following international guidelines.

Results

The groups did not differ significantly regarding gender, age, ASA stage, BMI, and distance of the lower tumor margin from the anal verge. More patients in the RTME group underwent preoperative chemoradiation (43.2 vs. 19.5%, p?=?0.019). The quality of the TME specimen was significantly better in the RTME group (complete/nearly complete/incomplete for RTME 97/0/3% and for LTME 78/17/5%, p?=?0.03). The conversion rate tended to be lower in the RTME group (7 vs. 17%, p?=?0.143). There was no difference in CRM positivity between the groups.

Conclusion

Robotic surgery is safe and can improve the quality of TME for rectal cancer compared to laparoscopy. Any effect on long-term survival remains to be established.

     

Receipt of Provider Advice for Smoking Cessation and Use of Smoking Cessation Treatments Among Cancer Survivors

BACKGROUND

As the number of cancer survivors increases, the assessment and intervention for smoking among survivors are increasingly important.

OBJECTIVE

This study examined the extent to which cancer survivors reported being asked and advised about smoking by health-care providers and their use of smoking cessation treatments during quit attempts.

DESIGN

The data were drawn from the 2005 National Health Interview Survey, an annual health survey of US adults.

PARTICIPANTS

The participants were 1,825 individuals who reported being diagnosed with cancer at least 1 year previously and provided data regarding their current smoking status.

MEASUREMENTS

Participants completed items assessing demographics, health and health-care factors, and smoking-related variables.

MAIN RESULTS

More than three-quarters of participants (81.0%) reported that their smoking status was known by a health-care provider. Among current smokers (17.6%) who visited a health-care provider in the past year, 72.2% reported being advised to quit smoking by a provider. Factors associated with a higher rate of receiving advice to quit included greater cigarette consumption (P=0.008), more medical comorbidities (P=?0.001), high psychological distress (P=?0.003), and lack of health-care insurance (P?=?0.03). Among current smokers who tried to quit in the last year, 33.5% used pharmacotherapy cessation treatment and 3.8% used an evidence-based behavioral treatment.

CONCLUSIONS

This study reveals considerable missed opportunities for health-care providers to advise cancer survivors about smoking and provide evidence-based interventions. Systematic efforts are needed to increase the provision of smoking cessation advice and use of cessation treatments among cancer survivors.

     

Do Changes in Post-acute Care Use at Hospitals Participating in an Accountable Care Organization Spillover to All Medicare Beneficiaries?

Background

While early evidence suggests that Medicare accountable care organizations (ACOs) may reduce post-acute care (PAC) utilization for attributed beneficiaries, whether these effects spill over to all beneficiaries admitted to hospitals participating in ACOs stray is unknown.

Objective

The objective of this study was to evaluate whether changes in PAC use and Medicare spending spill over to all beneficiaries admitted to hospitals participating in the Medicare Shared Savings Program (MSSP).

Design

Observational study using a difference-in-differences design comparing changes in PAC utilization and spending among beneficiaries admitted to ACO-participating hospitals before and after the start of the ACO contracts, compared to those admitted to non-ACO hospitals.

Setting

A total of 233 hospitals participate in MSSP ACOs and 3103 non-ACO hospitals.

Participants

A national sample of 11,683,573 Medicare beneficiaries experiencing 26,503,086 hospital admissions from 2010 to 2013.

Exposure

Admission to a hospital participating in an MSSP ACO.

Main Measures

The probability of discharge and Medicare payments to inpatient rehabilitation facilities (IRF), skilled nursing facilities (SNF), and home health agencies (HHA).

Key Results

For beneficiaries admitted to hospitals that joined an ACO, the likelihood of being discharged to PAC did not change after the hospital joined the ACO compared with non-ACO hospitals over the same period (differential change in probability of discharge to any PAC was 0.000 (P?=?0.89), SNF was 0.000 (P?=?0.73), IRF was 0.000 (P?=?0.96), and HHA was 0.001 (P?=?0.57)). Payments reduced significantly for PAC overall (??$130.41, P?=?0.03), but not for any individual PAC type alone. These results were consistent in samples that were conditional on discharge to any PAC, across conditions with high PAC use nationally, and among ACO-participating hospitals that also had a PAC participant.

Conclusions

Hospital participation in an ACO did not result in spillovers in PAC utilization or payments to all beneficiaries, even when considering high PAC-use conditions and ACO hospitals that also have an ACO-participating PAC.

     

The Economic Consequences of Breast Cancer Adjuvant Hormonal Treatments

RATIONALE

Adjuvant hormone therapy (HT) based on tamoxifen (TX) or aromatase inhibitors (AIs) has become the standard of care for treating hormone receptor -positive (HR+) breast cancer (BC) over the past 20 years. Based on clinical trial results, AI use is recommended by the American Society of Clinical Oncology for treatment of postmenopausal women with HR+ breast cancer. AIs, however, are significantly more expensive than TX, raising concerns about access and use of effective treatment among women of lower socio-economic status.

OBJECTIVES

To examine the relationship between adjuvant HT modality and experience of financial hardship among a cohort of older BC survivors. Also, to examine the extent to which financial concerns affect the probability of switching between adjuvant HT modalities.

DESIGN

Population-based, prospective survey study.

PARTICIPANTS

Elderly (65+) women who had an incident BC surgery in 2003 and who reported receiving adjuvant HT during the first 12 months post-surgery.

METHODS

Multivariate regression models.

RESULTS

Use of AIs was associated with a significantly higher probability of financial hardship. Women who had taken only an AI were more likely to experience financial difficulty than women who took only TX (OR?=?1.4; 95% CI: 1.1–1.7), but women who switched between TX and AI were not more likely to experience financial difficulty. Breast cancer survivors with no drug coverage (OR?=?4.5; 95% CI: 3.3–5.9) or partial drug coverage (OR?=?3.6; 95% CI: 2.8–4.5) were more likely to experience financial difficulty compared to those with full coverage. Lack of drug coverage was also the main factor associated with the likelihood that BC survivors did not switch adjuvant HT modalities.

CONCLUSIONS

Adjuvant HTs have important economic consequences for BC survivors. These consequences are ameliorated by full, but not partial, drug coverage.

     

Similar long-term overall and disease-free survival after conventional and extralevator abdominoperineal excision—a nationwide study

Purpose

The purpose of the present study was to assess, compare, and identify factors of importance for long-term overall (OS) and disease-free (DFS) survival after conventional (cAPE) and extralevator abdominoperineal excision (ELAPE) on a nationwide basis.

Methods

This was a database study based on data from a nationwide colorectal cancer database. Patients undergoing surgery for rectal cancer in the period January 1, 2009 to August 31, 2012 were examined. Factors of importance for disease-free and overall survival were identified by multivariate Cox regressions.

Results

Five hundred patients were included in the final population. Two hundred seventy-six were operated by ELAPE and 224 by APE. Disease-free and overall survival did not differ between groups (4-year DFS 67 and 66 % after cAPE and ELAPE, respectively, (log-rank p?=?0.82); 4-year OS 74 and 77 % after cAPE and ELAPE, respectively, (log-rank p?=?0.59)). In Cox regression, the type of procedure did not affect DFS or OS. Factors of importance for DFS included increasing age, ypN-positive disease and neoadjuvant chemoradiation therapy. Factors of importance for OS included increasing age, circumferential resection margin (CRM) positivity, fixation of the tumor, blood transfusion, and increasing American Society of Anesthesiologists (ASA) score.

Conclusions

In this nationwide study, we did not find any differences in DFS or OS after extralevator versus conventional abdominal perineal excision, and the type of procedure did not affect survival after adjusted analyses.