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Significant decrease of the pathological stage I rectal carcinoma in the era of neoadjuvant therapy—A matter of concern

  • Sigmar Stelzner
    Correspondence
    Corresponding author: Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Friedrichstr. 41, D-01067 Dresden, Germany. Fax: +49/351/4801149.
    Affiliations
    Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technische Universität Dresden, Friedrichstr. 41, D-01067 Dresden, Germany

    Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Hospital of Leipzig, Liebigstr. 20, D-04103 Leipzig, Germany
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  • Erik Puffer
    Affiliations
    Department of Pathology, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technische Universität Dresden, Friedrichstr. 41, D-01067 Dresden, Germany
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  • Joerg Zimmer
    Affiliations
    Department of Radiation Oncology, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technische Universität Dresden, Friedrichstr. 41, D-01067 Dresden, Germany
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  • Dorothea Bleyl
    Affiliations
    Department of Medical Oncology, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technische Universität Dresden, Friedrichstr. 41, D-01067 Dresden, Germany
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  • Thomas Kittner
    Affiliations
    Department of Radiology, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technische Universität Dresden, Friedrichstr. 41, D-01067 Dresden, Germany
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  • Matthias Kuhn
    Affiliations
    Institute for Medical Informatics and Biometry, Carl Gustav Carus Faculty of Medicine, Technische Universität Dresden, Blasewitzer Str. 86, D-01307 Dresden, Germany
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  • Christiane Jakob
    Affiliations
    Department of Pathology, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technische Universität Dresden, Friedrichstr. 41, D-01067 Dresden, Germany
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  • Helmut Witzigmann
    Affiliations
    Department of General and Visceral Surgery, Hospital Erlabrunn, Am Märzenberg 1A, D-08359 Breitenbrunn, Germany
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  • Soeren T. Mees
    Affiliations
    Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technische Universität Dresden, Friedrichstr. 41, D-01067 Dresden, Germany
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Published:November 17, 2021DOI:https://doi.org/10.1016/j.ejca.2021.10.017

      Highlights

      • Indication for neoadjuvant therapy depends on accurate clinical staging.
      • Overstaging of stage I tumours results in overtreatment and a ‘yp’ classification.
      • In this series, proportion of UICC stage pI tumours decreased significantly over time.
      • This trend correlated with a significant increase in the use of neoadjuvant therapy.
      • Better criteria to select patients with rectal cancer for neoadjuvant treatment are needed.

      Abstract

      Background

      Neoadjuvant treatment (nTx) for rectal cancer is commonly reserved for UICC stages II/III. Patients with stage I tumours (T1-2N0M0) are not candidates for nTx. The accuracy of treatment allocation depends on the precision of clinical staging, which is liable to understaging and overstaging. The study aimed at exploring changes in the proportion of stage pI patients with the introduction of nTx over a 26-year period.

      Materials and methods

      All consecutive patients with histologically proven rectal cancer excluding carcinoma in situ were retrieved from a prospective database of our colorectal unit. Time periods were defined as per the use of nTx: baseline phase 1994–1997; implementation phase 1998–2005 and guideline phase 2006–2019. Trends over time regarding proportion of applied nTx and stage pI tumours were investigated.

      Results

      Overall, 1468 patients met the inclusion criteria. There were no major differences in patients’ characteristics, especially proportion of synchronous metastases (stage IV) over time. nTx was applied to 1.2% of patients without metastases in the baseline phase, to 29.6% in the implementation phase, and to 59.6% in the guideline phase (p < 0.001). Corresponding proportions for patients with stage pI were 31.0%, 26.3% and 14.2%, respectively (p < 0.001).

      Conclusion

      With a stable proportion of stage IV carcinomas indicating no major changes in the patient cohorts, we could document a significant decrease of stage pI patients with increasing use of nTx. This trend clearly signals overtreatment caused by clinical T- and N-staging. More precise criteria are needed to better select patients with rectal cancer for nTx.

      Keywords

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