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Avoiding Radical Surgery Improves Early Survival in Elderly Patients With Rectal Cancer, Demonstrating Complete Clinical Response After Neoadjuvant Therapy: Results of a Decision-Analytic Model

Smith, Fraser McLean B.Sc. (Hons.), M.D., F.R.C.S.I.1; Rao, Christopher M.R.C.S.2; Perez, Rodrigo Oliva M.D.3,4; Bujko, Krzysztof M.D.5; Athanasiou, Thanos F.R.C.S.2; Habr-Gama, Angelita M.D.3; Faiz, Omar F.R.C.S.2,6

doi: 10.1097/DCR.0000000000000281
Original Contributions: Colorectal/Anal Neoplasia

BACKGROUND: In elderly and comorbid patients with rectal cancer, radical surgery is associated with significant perioperative mortality. Data suggest that a watch-and-wait approach where a complete clinical response is obtained after neoadjuvant chemoradiotherapy might be oncologically safe.

OBJECTIVE: This study aimed to determine whether patient age and comorbidity should influence surgeon and patient decision making where a complete clinical response is obtained.

DESIGN: Decision-analytic modeling consisting of a decision tree and Markov chain simulation was used. Modeled outcome parameters were elicited both from comprehensive literature review and from a national patient outcomes database.

SETTINGS: Outcomes for 3 patient cohorts treated with neoadjuvant therapy were modeled after either surgery or watch and wait.

PATIENTS: Patients included 60-year-old and 80-year-old men with mild comorbidities (Charlson score <3) and 80-year-old men with significant comorbidities (Charlson score >3).

MAIN OUTCOME MEASURES: Absolute survival, disease-free survival, and quality-adjusted life years were measured.

RESULTS: The model found that absolute survival was similar in 60-year-old patients but was significantly improved in fit and comorbid 80-year-old patients at 1 year after treatment where watch and wait was implemented instead of radical surgery, with a survival advantage of 10.1% (95% CI, 7.9–12.6) and 13.5% (95% CI, 10.2–16.9). At all of the other time points, absolute survival was equivalent for both techniques. There were no short- or long-term differences among any patient groups managed either by radical surgery or watch and wait in terms of either disease-free survival or quality-adjusted life years.

LIMITATIONS: Oncologic data for the watch-and-wait approach used for this study is derived from only a small number of studies pertaining to a highly selected group of patients. The 90-day postoperative mortality rate derived from the United Kingdom population-based study might be lower in other countries or individual institutions.

CONCLUSIONS: This study suggests competing effects of oncologic and surgical risk when using watch-and-wait management and that elderly and comorbid patients have the most to gain from this approach.

1Department of Surgery, North Cumbria University Hospitals National Health Service Trust, Carlisle, United Kingdom

2Department of Surgery and Cancer, Imperial College, London, United Kingdom

3Angelita and Joaquim Gama Institute, São Paulo, Brazil

4University of São Paulo School of Medicine, Colorectal Surgery Division, São Paulo, Brazil

5Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Poland

6Epidemiology, Trials and Outcome Centre, St. Mark’s Hospital, Harrow, United Kingdom

Financial Disclosure: None reported.

Presented at the Ficare International Rectal Cancer Forum, São Paolo, Brazil, November 14 to 16, 2013.

Poster presentation at the Tripartite Colorectal Meeting, Birmingham, United Kingdom, June 30 to July 3, 2014.

Correspondence: Fraser M. Smith, B.Sc. (Hons.), M.D., F.R.C.S.I., Department of Surgery, North Cumbria University Hospital, NHS Trust, Newtown Road, Carlisle, CA2 7HY, United Kingdom. E-mail:

© 2015 The American Society of Colon and Rectal Surgeons