The management of rectal cancer (RC) has evolved with the introduction of Total Mesorectal Excision Surgery (TME), use of Magnetic Resonance Imaging (MRI) for staging, changes in chemotherapy and radiotherapy and multidisciplinary meetings (MDTs). The timing of therapy for T3/4 and/or node positive RC has also changed with neoadjuvant chemoradiotherapy (CRT) becoming standard based on lower local recurrence rates . Given these changes in management over time, we assessed Disease free survival (DFS), overall survival (OS) and rates of local and distant recurrences of patients treated at The Queen Elizabeth Hospital (TQEH) between 1992 to 2006.
Demographic and outcome data of patients diagnosed with early stage RC from TQEH Cancer Registry from 2 different time cohorts 1992-99 (A) and 2000-06 (B) were analysed. Survival analysis was by Kaplan-Meier method and prognostic factors were analysed using cox proportional hazards regression.
423 patients were identified; 235 in A, 188 in B. Patient characteristics were generally similar. Median age A 68.1 yrs (range 32-94), B was 77.3 yrs (range 25-92). More patients had stage B in cohort A (47%) v B (39%). 56% of patients had surgery alone in cohort A compared to 47% in cohort B. Rates of any “adjuvant” therapy was similar (A=41% v B=46%), although there was a doubling in proportion of patients who received neoadjuvant CRT in the latter cohort (A= 7.2% v B= 16%). There was a significant improvement in rate of 5 year local/distal recurrence; A 87%/71% v B 95%/81%, p<0.0001 5 year. DFS improved over time; A 65.2% v B 73.3%, p = 0. 03. 5 year OS was A 66.1% v B=78.4% and median OS 14.62 years and not reached for cohort B (p=0.007). Stage and cohort B were prognostic for OS while age, sex, preoperative CRT/RT and any chemotherapy were not.
There has been significant improvement in DFS, OS and local and distant recurrence rates in patients diagnosed with early stage RC. The trend to greater use of neoadjuvant CRT in the latter cohort is consistent with changes in practice, and this may be a factor in improved local control, but does not appear to impact on survival. Other factors likely to have improved overall outcomes include: increased TME rates, improved preoperative staging including use of MRI and potentially the introduction of MDTs.