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26-02-2013 | Surgery | Article

Local excision in elderly poor for rectal cancer survival


Free abstract

medwireNews: Swedish data suggest that older patients with early rectal cancer should not be selected for local excision (LE) solely on the basis of their age.

While LE has been posited as the favored surgical treatment in this age group, study results showed that it leads to poor long-term survival and a high recurrence rate.

"Local excision appears to be an inferior alternative to AR [anterior resection] in the elderly patient group," say authors Deborah Saraste (Karolinska University Hospital, Stockholm, Sweden) and colleagues.

The study, published in the European Journal of Surgical Oncology, included 3630 patients with stage I (T1-T2N0M0) disease operated on between 1995 and 2006. In all, 53.6% underwent AR, 27.1% abdominoperineal resection (APR), 7.0% Hartmann's procedure, and 12.3% LE.

The local 5-year recurrence rate among patients undergoing LE was 11.5%, compared with 2.2%, 3.5%, and 7.2% in patients undergoing AR, APR, and Hartmann's procedure, respectively.

The relative 5-year survival was 0.81 in patients who underwent LE, compared with 0.95 in patients who underwent AR. And, for patients aged 80 years and over, the relative 5-year survival for LE was only 0.74, which contrasted with rates of 0.99, 0.95, and 0.91 for patients who underwent AR, APR, and Hartmann's procedure, respectively.

Multivariate analyses showed that LE was independently associated with a 58% increased risk for death within 5 years of surgery compared with AR. Preoperative radiation was associated with a 24% reduction in the risk for death.

While radiotherapy was recommended by national guidelines at the time, only 2% of LE-treated patients received preoperative irradiation in contrast to 48%, 68%, and 35% of patients undergoing, AR, APR, and Hartmann's procedure, respectively. The authors say this could reflect the frailty of patients undergoing LE, and that cancers in this group may have been discovered accidentally, precluding preoperative therapy.

They add that, because lymph nodes are not resected during LE, the approach may lead to understaging of the disease, further contributing to poor outcomes.

However, Saraste and colleagues say that their findings do not rule out the use of the technique, especially given advances in imaging since 2006.

"With careful patient selection and improvements in radiology giving better preoperative T-staging accuracy than during the study period… there may be grounds for reconsideration," they conclude.

medwireNews ( is an independent clinical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2013

By Kirsty Oswald, medwireNews Reporter

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