Use of Minimally Invasive Colorectal Cancer Surgery Increases at NCCN Centers, but Wide Variation Exists
A recent study on the use of minimally invasive surgery for colorectal cancer at National Comprehensive Cancer Network (NCCN) centers has found that although laparoscopic colectomy results in equivalent oncologic outcomes compared to open colectomy, its adoption nationally has been slow. An analysis of data obtained from chart review of medical records for 4,032 patients undergoing surgery for colon and rectal cancer at NCCN centers showed that the use of minimally invasive surgery increased from 2006 to 2010. “However, there was statistically significant variation in adoption of minimally invasive surgery technique among centers,” Yeo et al reported in the Journal of the National Cancer Institute.
The study cohort included patients with stage I to IV colon or rectal cancer diagnosed between 2005 and 2010 who had received primary surgical care at one of eight geographically diverse institutions participating in the NCCN Colorectal Cancer Outcomes project. Among the 2,493 patients who had colon surgery, 51% were female, and the median age was 62.6 years. Among the 1,539 patients who had rectal surgery, 56% were male, and the median age was 55.9 years.
Increased Minimally Invasive Surgery Rates for Stage I to III Disease
Looking at trends from 2006 to 2010 (when complete years of data were available), investigators found that the rate of patients with stage I to III colon cancer undergoing minimally invasive surgery increased from 35% to 51%. For patients with stage I to III rectal cancer, use of minimally invasive surgery increased from 14% to 37%. “[Minimally invasive surgery] for stage IV colon and rectal cancer has been relatively stable over time,” the researchers reported.
Although patients with stage IV disease are less likely to be managed with minimally invasive surgery, “these are the patients who may benefit from it most,” the investigators noted. “[Minimally invasive surgery] is strongly associated with less short-term morbidity and the potential to begin adjuvant therapy sooner. As techniques improve, combined procedures may become more feasible, increasing the number of stage IV patients who are [minimally invasive surgery] candidates. As surgeons gain technical proficiency, use of [minimally invasive surgery] is likely to increase—even in this higher-risk population.”
Factors Associated With Minimally Invasive Surgery
“On multivariable analysis, factors associated with minimally invasive surgery for colon cancer patients who had surgery at an NCCN institution were older age (P = .02), male sex (P = .006), fewer comorbidities (P ≤ .001), lower final T-stage (P < .001), median household income greater than or equal to $80 000 (P < .001), ECOG performance status = 0 (P = .02), and NCCN institution (P ≤ .001),” the investigators reported. After controlling for other factors, NCCN institution was a statistically significant predictor of minimally invasive surgery, the authors noted.
Rates of minimally invasive surgery at individual NCCN centers ranged from 15% to 86% of patients across the entire time period and from 23% to 79% in the last 2 years. “Variation in use of minimally invasive surgery among NCCN institutions is intriguing. All employ highly trained, specialized surgeons. The lag may be related, as many surgeons require retraining in laparoscopic techniques,” the authors noted. An additional reason for delay may be the investment in laparoscopic equipment required to support an minimally invasive surgery program.
“Given the much smaller proportion of rectal cancer patients undergoing [minimally invasive surgery] and the complex controversy in the use of [minimally invasive surgery] for rectal cancer, which is not yet recommended by NCCN guidelines, we did not do a multivariable analysis on this group,” the authors wrote. Although the benefits of minimally invasive surgery not as clear in rectal cancer, “recent retrospective studies have shown that total mesenteric excision can be safely performed using [minimally invasive surgery], with no statistically significant differences in survival compared with an open approach,” the authors pointed out.
Martin R. Weiser, MD, FACS, of Memorial Sloan Kettering Cancer Center, is the corresponding author for the Journal of the National Cancer Institute article.
The study was funded in part by the cancer center core grant P30 CA008748. The study authors reported no potential conflicts of interest.
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