Use of Minimally Invasive Colorectal Cancer Surgery Increases at NCCN Centers, but Wide Variation Exists

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“Laparoscopic colectomy has been shown to have equivalent oncologic outcomes to open colectomy for the management of colon cancer, but its adoption nationally has been slow,” Heather Yeo, MD, of Memorial Sloan-Kettering Cancer Center in New York, and colleagues noted in reporting on a study investigating the prevalence and factors associated with minimally invasive surgery for colorectal cancer at National Comprehensive Cancer Network (NCCN) centers.

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. “However, there was statistically significant variation in adoption of minimally invasive surgery technique among centers,” the investigators stated in the Journal of the National Cancer Institute.

“The study cohort consisted of patients with stage I to IV colon or rectal cancer, diagnosed between September 1, 2005, and December 31, 2010, who received primary surgical care at one of eight institutions participating in the NCCN Colorectal Cancer Outcomes Project,” the researchers explained. These institutions “are geographically diverse and represent the composition of patients seen at all 21 NCCN institutions,” the authors added. 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.

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% in 2006 to 37% in 2010. “Minimally invasive surgery for stage IV colon and rectal cancer has been relatively stable over time,” the researchers reported.

Although stage IV patients 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,” the researchers wrote.

Multivariable Analysis

“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), being male (P = .006), fewer comorbidities (P ≤ .001), lower final T stage (P < .001), median household income greater than or equal to $80 000 (P < .001), Eastern Cooperative Oncology Group performance status = 0 (P = .02), and NCCN institution (P ≤ .001),” the investigators stated. “Even after controlling for other parameters, NCCN institution was a statistically significant predictor of minimally invasive surgery,” the authors noted.

“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 in NCCN Guidelines, we did not do a multivariable analysis on this group,” the investigators stated. Although the benefits of minimally invasive surgery are 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.

Rates of minimally invasive surgery at individual NCCN centers ranged from 15% to 86% of patients across the entire period and from 23% to 79% in the past 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 the delay may be the investment in laparoscopic equipment required to support a minimally invasive surgery program. ■

Yeo H, et al: J Natl Cancer Inst 107:362, 2014 (print January 2015).