ORIGINAL ARTICLE
CURRENT STATUS OF THE APPROACH TO PATIENTS WITH RECTAL CANCER IN LATIN AMERICA
RESULTS OF THE CARELA SURVEY INCLUDING 385 SURGEONS FROM 18 COUNTRIES IN THE REGION
Nicolás Avellaneda1; Juan Carlos Patrón Uriburu2; Marcelo Viola Malet3,4; Juan Carlos Reyes5; Fabio Leiro6.
LATAM Colorectal Surgery Collaborative Consortium
1: General Surgery Service, Hospital Universitario CEMIC, Argentina. 2: Colorectal Surgery Service, Hospital Británico, Argentina. 3: Department of General Surgery, Médica Uruguaya, Uruguay. 4: Department of Colorectal Surgery, Hospital Pasteur, Uruguay. 5: Colorectal Surgery Service, Fundación Abood Shaio, Colombia. 6: Colorectal Surgery Service, Fundación Favaloro, Argentina.
The authors declare no conflicts of interest.
Nicolás Avellaneda: n.avellaneda86@gmail.com
Received: July 2022. Accepted: December 2022
LATAM Colorectal Surgery Collaborative Consortium: https://orcid.org/0000-0002-3679-7280
Nicolás Avellaneda: https://orcid.org/0000-0002-6802-7125
Juan Carlos Patrón Uriburu: https://orcid.org/0000-0001-5893-4429
Marcelo Viola Malet: https://orcid.org/0000-0003-2733-5276
Juan Carlos Reyes: http://orcid.org/0000-0002-1758-7149
Fabio Leiro: https://orcid.org/0000-0002-9477-2997
ABSTRACT
Introduction: The multidisciplinary team (MDT) approach in high-volume centers is the gold standard for the treatment of patients with rectal cancer (RC). There are no population data in Latin America that reflect the treatment of these patients in the region.
Objective: To carry out a survey that includes Latin American countries, covering different critical issues in the management of patients with RC.
Material and methods: During May, 2022, surgeons from countries within the region were invited to complete a survey covering issues on the management of patients with RC: annual volume of patients treated and complexity of the center, surgical technique and availability of MDT and types of cancer treatment. The participating surgeons were categorized according to the number of patients with RC treated at their institution: low (LVC), medium (MVC) and high volume center (HVC).
Results: Three hundred eighty-five responses to the survey (100/210/75 from LVC/MVC/HVC, respectively), corresponding to centers in 18 Latin American countries were included. MVCs and HVCs had a higher incidence of specialized surgeons and 67.79% of the centers have access to minimally invasive techniques, more frequently in MVCs and HVCs. Neoadjuvant therapy was used in 93.51% of advanced tumors, with 60.78% adherence to the watch and wait protocols. MVCs and HVCs presented higher rates of MDT approach to patients. Lastly, adherence to strategies of total neoadjuvant treatment and short-course radiotherapy is low, with a higher prevalence in MVCs and HVCs.
Conclusions: This survey is the first to provide information on RC treatment in different centers and countries in Latin America. Future studies should analyze the impact of differences between centers on the treatment outcome.
Keywords: cancer, rectum, MDT, neoadjuvant treatment, Latin America
INTRODUCTION
Colorectal cancer (CRC) is the third most common malignancy worldwide and the second leading cause of cancer-related death.1
Numerous studies have been published on the care of patients with CRC in low-volume and high-volume centers (according to the number of patients treated annually), demonstrating that the latter obtain better morbidity and mortality and long term outcome. 2-4 For this reason, some countries and regions have made the decision to centralize patient care in highly specialized institutions.5,6
The specialization of the treating center seems to be particularly important when dealing with rectal cancer (RC) patients, since currently this type of tumor can be subjected to different treatments, including radiotherapy, chemotherapy and surgery.7,8 In turn, an adequate total mesorectal excision (TME) obtaining an adequate surgical specimen is directly related to the oncologic prognosis of these patients.
In order to make appropriate decisions for each patient, it is important to have a multidisciplinary team (MDT) including specialists in diagnostic imaging, pathology, colorectal surgery, radiotherapy, clinical oncology, among others.9,10
However, there are few data on management strategies for patients with RC in Latin America. The availability of MDT, the surgeon training level and surgical specialty, the complexity of the centers involved, and the surgical technique used are questions that to date have not been described at the population level in the region and there are only some data from high-volume academic centers.11-13
The objective of this study is to present the results of a survey carried out among surgeons from countries throughout the region, covering the most relevant aspects of the approach to patients with RC.
MATERIAL AND METHODS
Study design
During April 2022, four surgeons (FL, JPU, MVM, JCR) from three Latin American countries (Argentina, Colombia, Uruguay) with experience in treating patients with CR, designed a survey based on their expert opinion intended to cover four areas of the approach to patients with rectal cancer:
1) Characteristics of the center and the surgeon training level and surgical specialty 2) Characteristics of the surgical technique.
3) Characteristics of staging, adoption of neoadjuvant treatment and different types of cancer treatment.
4) Adoption of MDT and its characteristics.
Participants and data collection
The inclusion criterion for the center was that it assists patients with rectal cancer.
To circulate the survey, the scientific societies of each country were contacted and social networks (Twitter, Instagram, Facebook, Linkedin) and WhatsApp groups were also used, including channels previously used for other collaborative studies (ESCP's EAGLE Study, FRAIL-Latam study , EAST of DAMASCUS study).
Stratification of centers according to surgical volume
According to the information provided by the respondents to the survey, the participating centers were divided into 3 categories taking into account the volume of patients with rectal cancer seen annually, using a pre-established classification:14
● Low volume center (LVC): Less than 20 patients per year.
● Medium volume center (MVC): Between 20 and 50 patients per year.
● High volume center (HVC): More than 50 patients per year.
Variables analyzed
Data from the respondent and the center: field of action (public/private/independent group), number of beds in the institution, surgeon training level, access to minimally invasive surgery (abdominal and/or transanal).
Characteristics of the surgical technique: mobilization of the splenic flexure during TME surgery, level of ligation of the inferior mesenteric vessels (high: ligation of the mesenteric artery less than 2 cm from its origin in the aorta),15 management of an ultra-low rectal/supraanal tumor (Bordeaux classification type I),16 use of defunctioning ostomies, excision of the lateral pelvic compartment.
Staging characteristics, adoption of neoadjuvant treatment and different types of cancer treatment: imaging method used for local (pelvis) staging, use of neoadjuvant therapy for locally advanced tumors, adoption of the watch & wait (W&W) protocol in the face of suggestive evidence of a complete clinical response (CCR) after neoadjuvant treatment17, use of short-term radiotherapy18 and total neoadjuvant treatment (TNT).19
Adoption of MDT and its characteristics: Availability of MDT in the institution, frequency of meetings and whether they are specific for rectal tumors or in conjunction with other tumors, surgeon participation in oncologic treatment decisions.
Finally, questions related to the respondent's participation in scientific societies and their intention to participate in prospective registries on the treatment of rectal cancer and/or retrospective studies of results in the region were included.
Statistic analysis
Statistical analysis was performed using Stata® software (v11.1, Statacorp, College Station, Texas USA). Categorical variables were described as percentages and continuous variables as mean and range. As this is an opinion study (survey) and not a study with patient data, statistical methods were not used to search for significance in the differences between groups.
RESULTS
During May 2022, 398 surgeons responded to the survey, 13 of them were excluded for not working in centers that care for patients with RC and 385, from 18 Latin American countries, were included in this study. The mean age was 43.78 years. The number of responses by type of center was 100 (25.97%), 210 (54.55%), and 75 (19.48%) for LVCs, MVCs, and HVCs, respectively.
Respondent and facility information
Fig. 1 summarizes the number of respondents by country, their specialty and training level. Argentina was the country with the highest number of respondents (33.25%) and the majority were colorectal surgeons (46.49%) followed by general surgeons (28.83%).
Figure 1. Respondents by country and specialty
Table 1 presents the level of care in the centers where the respondents work. The majority of surgeons (42.08%) work in the public and private setting, while 10.39% carry out their activity in several private centers (not in a specific hospital).
The LVCs most frequently (68%) have fewer than 100 beds, while the majority of the HVCs (50.67%) have more than 300 beds. Regarding the level of training of the surgeon, in HVCs 66.67% are strictly colorectal surgeons, while this percentage drops to 29% in LVCs.
Regarding the availability and use of the minimally invasive approach in elective surgery, adherence was 67.79% for the entire group; more frequent (76%) in HVCs, it falls to 56% in LVCs. The overall percentage of centers using robotic platforms was 1.82%.
Regarding the transanal approach to local tumors, adherence to minimally invasive platforms (TEM, TAMIS, TEO, etc.) was 50.65%, being more frequent in HVCs (64%) and decreasing to 30% in LVCs.
Table 1. Data about the surgeon, type of center and access to minimally invasive surgery
|
Variable |
Total 385 (100%) |
Low Volume 100 (25.97%) |
Medium Volume 210 (54.55%) |
High Volume 75 (19.48%) |
|
Age |
43.78 (23-79) |
41.8 (23-79) |
45.34 (26-71) |
42.07 (28-71) |
|
Training level of respondent |
|
|
|
|
|
General surgeon |
111 (28.83) |
44 (44) |
58 (27.62) |
9 (12) |
|
Colorectal surgeon |
179 (46.49) |
31 (31) |
104 (49.52) |
44 (58.67) |
|
Resident |
36 (9.35) |
14 (14) |
16 (7.62) |
6 (8) |
|
Colorectal surgeon in training |
21 (5.45) |
4 (4) |
13 (6.19) |
4 (5.33) |
|
Oncology surgeon |
23 (5.97) |
0 |
12 (5.71) |
11 (14.67) |
|
Gastrointestinal surgeon |
15 (3.90) |
7 (7) |
7 (3.33) |
1 (1.33) |
|
Setting |
|
|
|
|
|
Public hospital |
66 (17.14) |
25 (25) |
29 (13.81) |
12 (16) |
|
Private hospital |
117 (30.39) |
29 (29) |
70 (33.33) |
18 (24) |
|
Public and private hospital |
162 (42.08) |
36 (36) |
89 (42.38) |
37 (49.33) |
|
Independent group |
40 (10.39) |
10 (10) |
22 (10.48) |
8 (10.67) |
|
Number of beds of the institution |
|
|
|
|
|
0 – 100 |
140 (36.36) |
68 (68) |
60 (28.57) |
12 (16) |
|
101 - 300 |
144 (37.40) |
26 (26) |
93 (44.29) |
25 (33.33) |
|
Más de 300 |
101 (26.23) |
6 (6) |
57 (27.14) |
38 (50.67) |
|
Surgical specialty of surgeon in charge |
|
|
|
|
|
General surgeon |
48 (12.47) |
24 (24) |
21 (10) |
3 (4) |
|
Colorectal surgeon |
174 (45.19) |
29 (29) |
95 (45.24) |
50 (66.67) |
|
Mostly general surgeon |
56 (14.55) |
22 (22) |
30 (14.29) |
4 (5.33) |
|
Mostly colorectal surgeon |
107 (27.79) |
25 (25) |
64 (30.48) |
18 (24) |
|
Surgical approach |
|
|
|
|
|
Convectional |
117 (30.39) |
44 (44) |
57 (27.14) |
16 (21.33) |
|
Laparoscopic |
261 (67.79) |
56 (56) |
148 (70.48) |
57 (76) |
|
Robotic |
7 (1.82) |
0 |
5 (2.38) |
2 (2.67) |
|
Transanal approach to local tumors |
|
|
|
|
|
Conventional |
190 (49.35) |
70 (70) |
93 (44.29) |
27 (36) |
|
Minimally invasive (TEM. TAMIS. etc.) |
195 (50.65) |
30 (30) |
117 (55.71) |
48 (64) |
Characteristics of the surgical technique
Table 2 shows the data related to the surgical technique.
Before performing a TME and subsequent primary anastomosis, the mobilization of the splenic flexure is routinely performed in 50.91% of the centers (74.67% in HVCs and 35% in LVCs).
The ligation of the inferior mesenteric vessels is performed at the central level in the majority of centers (88.83%).
In the case of supra-anal rectal tumors, the decision to perform TME and spare the sphincter complex (avoiding abdominoperineal resection) is 71.95% for the entire group, being 80% for HVCs and 63% for LVCs. The transanal approach (Ta-TME) for this type of patients is overall 20%, with few differences between centers of different volumes.
Routine use of defunctioning ostomies for colorectal anastomoses after TME was overall 51.69%, more common (58.67%) in HVCs, whereas surgeons primarily perform ostomies selectively (48%) in LVCs. In 7% of LVCs, ostomies are never performed, while in HVCs this rate drops to 1.33%.
Finally, regarding dissection of the lateral pelvic compartment (in the presence of lymph nodes with suspected disease), 38.80% of the centers never perform this type of surgery. This procedure is performed selectively in 74.67% of HVCs and in 54% of LVCs.
Table 2. Surgical technique data
|
Variable |
Total (385) |
Low Volume (100) |
Medium Volume (210) |
High Volume (75) |
|
Splenic flexure mobilization during TME |
|
|
|
|
|
Never |
2 (0.52) |
2 (2) |
0 |
0 |
|
Selectively |
187 (48.57) |
63 (63) |
105 (50) |
19 (25.33) |
|
Allways |
196 (50.91) |
35 (35) |
105 (50) |
56 (74.67) |
|
Inferior mesenteric vessels ligation |
|
|
|
|
|
Peripheral |
43 (11.17) |
18 (18) |
23 (10.95) |
2 (2.67) |
|
Central |
342 (88.83) |
82 (82) |
187 (89.05) |
73 (97.33) |
|
Management of ultra-low rectal tumors |
|
|
|
|
|
Abdominoperineal resection |
108 (28.05) |
37 (37) |
56 (26.67) |
15 (20) |
|
TME Abdominal |
200 (51.95) |
44 (44) |
109 (51.90) |
47 (62.67) |
|
Ta-TME |
77 (20) |
19 (19) |
45 (21.43) |
13 (17.33) |
|
Defunctioninfg ostom y for primary anastomosis post TME |
|
|
|
|
|
Never |
11 (2.86) |
7 (7) |
3 (1.43) |
1 (1.33) |
|
Selectively |
175 (45.45) |
48 (48) |
97 (46.19) |
30 (40) |
|
Allways |
199 (51.69) |
45 (45) |
110 (52.38) |
44 (58.67) |
|
Excision of lateral pelvic compartment |
|
|
|
|
|
Never |
149 (38.80) |
46 (46) |
85 (40.48) |
19 (25.33) |
|
Selectively |
236 (61.20) |
54 (54) |
125 (59.52) |
56 (74.67) |
Information on tumor staging, use of MDT and cancer treatment
Table 3 includes data on staging of rectal tumors, availability of MDT, and use of neoadjuvant therapy and its different regimens.
The use of high-resolution MRI for local staging is 84.16% overall, 73% in LVCs. On the other hand, endorectal ultrasound is used by very few centers in the region (2.60%).
Similarly, the use of neoadjuvant therapy for locally advanced rectal tumors is high in the region, both in LVCs, MVCs and HVCs. On the other hand, adherence to W&W strategies in patients with evidence suggestive of post-neoadjuvant CCR ranges from 50% in LVCs to 63% in HVCs.
Regarding the availability of MDT, most of the HVCs (93.33%) use this resource for the discussion of patients with rectal tumors, against 72% of the LVCs. In turn, it is more common for the HVCs to have a specific committee for patients with RC and to meet weekly, while in the LVCs the discussion is usually shared with other types of tumors and less frequently.
The participation of the surgeon in the indications for oncologic neoadjuvant or adjuvant treatment is more frequent in HVCs (84%), while only 52% of LVCs involve the surgeon in this type of decision.
Lastly, the adoption of new neoadjuvant treatment strategies is high in the region and occurs more frequently in HVCs.
Table 3. Use of neoadjuvant therapy and MDT.
|
Variable |
Total (385) |
Low Volume (100) |
Medium Volume (210) |
High Volume (75) |
|
Local staging |
|
|
|
|
|
MRI |
324 (84.16) |
73 (73) |
185 (88.10) |
66 (88) |
|
CT |
51 (13.25) |
23 (23) |
20 (9.52) |
8 (10.67) |
|
Endorectal ultrasound |
10 (2.60) |
4 (4) |
5 (2.38) |
1 (1.33) |
|
Indication for locally advanced rectal tumors. |
|
|
|
|
|
Neoadjuvant treatment |
360 (93.51) |
90 (90) |
197 (93.81) |
73 (97.33) |
|
Surgery |
25 (6.49) |
10 (10) |
13 (6.19) |
2 (2.67) |
|
Managenent of CCR |
|
|
|
|
|
Surgery |
143 (39.22) |
45 (50) |
71 (36.04) |
27 (36.99) |
|
W&W |
217 (60.78) |
45 (50) |
126 (63.96) |
46 (63.01) |
|
MDT |
|
|
|
|
|
No |
60 (15.58) |
28 (28) |
27 (12.86) |
5 (6.67) |
|
Yes |
324 (84.42) |
71 (72) |
183 (87.14) |
70 (93.33) |
|
Type of MDT |
|
|
|
|
|
General |
204 (62.96) |
60 (84.51) |
115 (62.84) |
29 (41.43) |
|
Specific for RC |
120 (37.04) |
11 (15.49) |
68 (37.16) |
41 (58.57) |
|
MDT periodicity |
|
|
|
|
|
Weekly |
164 (50.62) |
27 (38.03) |
86 (46.99) |
51 (72.86) |
|
Biweekly |
59 (18.21) |
10 (14.08) |
40 (21.86) |
9 (12.86) |
|
Monthly |
67 (20.68) |
20 (28.17) |
38 (20.77) |
9 (12.86) |
|
Bimonthly |
23 (7.10) |
12 (16.90) |
11 (6.01) |
1 (1.43) |
|
Quarterly |
11 (3.40) |
2 (2.82) |
8 (4.37) |
|
|
Surgeon participation in cancer treatment decisions (neoadjuvant – adjuvant treatment) |
|
|
|
|
|
No |
129 (33.51) |
48 (48) |
69 (32.86) |
12 (16) |
|
Yes |
256 (66.49) |
52 (52) |
141 (67.14) |
63 (84) |
|
Short-course radiotherapy |
|
|
|
|
|
No |
116 (30.13) |
37 (37) |
63 (30) |
16 (21.33) |
|
Yes, selectively |
173 (44.94) |
32 (32) |
93 (44.29) |
48 (64) |
|
Yes, routinely |
29 (7.53) |
5 (5) |
18 (8.57) |
6 (8) |
|
Don't know |
67 (17.40) |
26 (26) |
36 (17.14) |
5 (6.67) |
|
TNT |
|
|
|
|
|
No |
52 (13.51) |
17 (17) |
32 (15.24) |
3 (4) |
|
Yes, selectively |
198 (51.43) |
44 (44) |
105 (50) |
49 (65.33) |
|
Yes, routinely |
90 (23.38) |
19 (19) |
50 (23.81) |
21 (28) |
|
Don't know |
45 (11.69) |
20 (20) |
23 (10.95) |
2 (2.67) |
Table 4 summarizes the data related to membership in scientific societies, which is high in the region (88.31%). While in LVCs most surgeons are members of general surgery societies, in HVCs they are more frequently members of colorectal surgery societies.
Most of respondents expressed interest in participating in a formal RC patient registry.
Table 4. Respondents' membership in scientific societies and their intention to participate in rectal cancer population registries.
|
Variable |
Total (385) |
Low Volume (100) |
Medium Volume (210) |
High Volume (75) |
|
Member of scientific societies |
|
|
|
|
|
No |
45 (11.69) |
18 (18) |
18 (8.57) |
9 (12) |
|
General surgery |
153 (39.74) |
52 (52) |
85 (40.82) |
16 (21.33) |
|
Colorectal surgery |
166 (43.12) |
26 (26) |
91 (43.33) |
49 (65.33) |
|
Both |
21 (5.45) |
4 (4) |
16 (7.62) |
1 (1.33) |
|
Intention to participate in a national/regional rectal cancer registry |
|
|
|
|
|
No |
11 (2.86) |
5 (5) |
6 (2.86) |
0 |
|
Yes |
327 (84.94) |
79 (79) |
179 (85.24) |
69 (92) |
|
Maybe |
47 (12.21) |
16 (16) |
25 (11.90) |
6 (8) |
DISCUSSION
The results of this survey are interesting, especially since it is the first study based on the approach to patients with RC that includes centers of all volumes and countries.
The first surprising piece of information is the high prevalence of RC treatment in hospitals that care for less than 20 patients per year. It is widely published in the literature that in oncological surgery and especially in RC, morbidity and mortality as well as medium and long-term results are directly related to the volume of the treating center.20,21
Although this survey does not allow drawing conclusions based on the results, it does show certain trends about what happens in LVCs and HVCs.
In HVCs, the general trend is for CR patients to be cared for by surgeons specializing in colorectal diseases, which is less frequent in LVCs, where they are mostly cared for by general surgeons. In turn, access to minimally invasive surgery is greater in HVCs, both for transanal and abdominal surgery. This in itself is relevant data, since minimally invasive surgery is associated with better short-term results, without negatively affecting oncologic outcomes.22
Although the use of neoadjuvant treatment for locally advanced rectal tumors is high in all groups, the availability of MDT for case discussion, the frequency of meetings, and the participation of surgeons in decision making, not only for surgical indications but also for the indication and selection of different neoadjuvant/adjuvant regimens, is higher in HVCs.
At present, a multidisciplinary approach to patients with RC is important, since new schemes and proposals for surgical and non-surgical treatment emerge daily, which ideally should be discussed by all the professionals in charge of the patient, including radiotherapists, oncologists, colorectal surgeons and diagnostic imaging specialists, among others. For this reason, the American College of Surgeons has launched a program (National Accreditation Program for Rectal Cancer, NAPRC) aimed at laying the foundations for the multidisciplinary management of these patients.23,24 It could be a good tool to promote the use of MDT in Latin America and it is already being used in several centers in charge of CR patients in the region.13
Regarding the surgical technique, in HVCs, mobilization of the splenic flexure is more frequently performed in all patients undergoing TME and anastomosis, while this maneuver is selective in most LVCs. This difference may be due to many factors, including the volume of patients required to perform this practice routinely and safely. However, the need or not to mobilize the splenic flexure in all patients undergoing TME is a current discussion within the specialty.25
On the other hand, in HVCs, patients with lower rectal tumors are more likely to undergo sphincter-sparing surgery and avoid abdominoperineal resection as their first surgery. Although there are few publications on the functional results after this type of surgery in Latin America,26 patients can undergo a low anterior resection without compromising oncologic results.16
It is curious to see the prevalence of centers in the region that perform transanal TME in patients with RC. Although it is a technique that could facilitate surgery mainly in patients with unfavorable pelvic anatomy, its results (especially the oncologic ones) seem to be directly related to the volume of procedures performed periodically.27,28 This has led to publications that advise against its implementation in LVCs without the necessary training.29
Finally, more than 10% of HVCs are surgeons/groups of surgeons with independent activity (not related to a specific health institution). This, and the fact that most
LVCs surgeons are associated with general surgery societies (and not colorectal surgery societies), raises a question about the potential impact of involving these individuals in activities and societies related to the specialty. The latter could promote the standardization of the surgical technique, the implementation of MDT, etc.
This study has limitations inherent to the low level of scientific evidence represented by a survey, which allows generating hypotheses but in no way responding to them.
Another weakness is the heterogeneity of the level of specialization of the respondents and the environment in which they work (public, private, independent).
However, the results of this study are relevant, especially since it is the first to conduct a survey on the treatment of RC in a region with approximately 700 million inhabitants.
Any hypotheses generated by the interpretation of the results of this survey must be proven or refuted with the results of the patient's treatment, which is why the CaReLa retrospective study was launched, with the inclusion of all respondents of this survey.
This study, together with others that are being carried out in the region in a collaborative way, will allow obtaining more information on the results of the treatment of patients with colorectal pathology and eventually proposing possible solutions to the suboptimal indicators that are identified.
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COMMENT
A large number of publications from different parts of the world have dealt with this topic. The difficulty in collecting the data and its heterogeneity are aspects that make it difficult to obtain results with significant impact.
Although it is in high-volume centers that there is a higher proportion of specialized surgeons and where the most modern surgical techniques are practiced, it has not always been feasible to associate these characteristics with better long-term survival. Therefore, to conclude that a high-volume center equates to better oncology outcomes is statistically limited.
This survey allows us at least to have an idea of the current situation in Latin America, which represents a very important first step. The challenge for the future will be to determine with these data how the oncologic results vary in the centers according to the volume of patients operated on and if this variation has statistical significance.