International variation in managing locally advanced or recurrent rectal cancer: prospective benchmark analysis

Abstract

Background: Tumour extension beyond the mesorectal plane (ymrT4) occurs in 5-10 per cent of patients with rectal cancer and 10 per cent of patients develop locally recurrent rectal cancer (LRRC) after primary surgery. There is global variation in healthcare delivery for these conditions. Methods: An international benchmark trial of the management of ymrT4 tumours and LRRC was undertaken in France and Australia between 2015 and 2017. Heterogeneity in management and operative decision-making were analysed by comparison of surgical resection rates, blinded intercountry reading of pelvic MRI, quality-of-life assessment and qualitative evaluations. Results: Among 154 patients (97 in France and 57 in Australia), 31⋅8 per cent had ymrT4 disease and 68⋅2 per cent LRRC. The surgical resection rates were 88 and 79 per cent in France and Australia respectively (P = 0⋅112). The concordance in operative planning was low (= 0⋅314); the rate of pelvic exenteration was lower in France than Australia both in clinical practice (36 of 78 versus 34 of 40; P < 0⋅001) and in theoretical conditions (10 of 25 versus 50 of 57; P = 0⋅002). The R0 resection rate was lower in France than Australia for LRRC (25 of 49 versus 18 of 21; P = 0⋅007) but not for ymrT4 tumours (21 of 26 versus 15 of 15; P = 0⋅139). Morbidity rates were similar. Patients who underwent non-exenterative procedures had higher scores on the mental functioning subscale at 12 months (P = 0⋅047), and a lower level of distress at 6 months (P = 0⋅049). Qualitative analysis highlighted five categories of psychosocial factors influencing treatment decisions: patient, strategy, specialist, organization and culture. Conclusion: This international benchmark trial has highlighted the differences in worldwide treatment of locally advanced and LRRC. Standardized care should improve outcomes for these patients.

Patient‐reported outcomes after pelvic exenteration for colorectal cancer: A systematic review

“…One study was conducted in both Australia and France [20]. Seven studies reported financial support, all provided by the local government or governmental organizations [1,6,10,20–23]. Studies included data on 878 patients.…”

Perineal Wound Closure Following Abdominoperineal Resection and Pelvic Exenteration for Cancer: A Systematic Review and Meta-Analysis

“…Our literature review and meta-analysis showed the necessity to fill the vacuum left by APR to reduce major perineal wound complications. This observation is more difficult to assert for more extensive resections, which are most often for more specialized and less standardized indications such as recurrence of pelvic cancer [4] or rarer neoplasia such as sarcomas. For this reason, we have endeavored to separate the studies of pelvic exenterations, on the one hand, and to standardize the classification of complication outcomes with the Southampton Wound Complication Scale complications, on the other hand.…”

“…Indeed, this specialized center surgery often requires a multidisciplinary team including plastic and pelvic surgeons [39]. This surgery is intended for patients with a long oncological history who have received numerous courses of chemotherapy and often even re-irradiation for pelvic recurrences [4]. Our meta-analysis shows a significant increase in total perineal complications in case of closure with the VRAM flap (OR 2.46, 95% CI 1.39-4.35; p < 0.01; I 2 = 46%) This result is found for major complications, but it was not significant (OR 1.67, 95% CI 0.90-3.08; p = 0.1).…”

“…Furthermore, the standardization of the surgery since the late 2000s and the extra-levator abdomino-perineal resection [2] (ELAPE) technique have led to a larger defect and increased perineal complications. In addition, advances in terms of pelvic oncology make it possible to manage increasingly advanced diseases or cancer recurrence [3], leading to the performance of pelvic exenterations [4].…”

Post-Operative Ileus: a Pharmacological Perspective

“…Indeed, abdominal surgery has made progress to date with minimally invasive surgery and early rehabilitation protocols. However, recent progress in oncology now allows the tumour or tumour recurrence to be managed at advanced stages through often extensive surgery (Denost et al, 2020). These increasingly frequent treatments, such as cytoreductive surgery for peritoneal carcinomatosis or pelvic recurrence, for example, are a source of POI.…”