Standardization or Centralization: Can One Have One Without the Other? Circumferential Resection Margins and Rectal Cancer

摘要

Dr. Rickles and his colleagues1 from the Consortium for the Optimization of Surgical Treatment of Rectal Cancer (OSTRiCh) present an interesting paper describing the incidence of positive circumferential resection margins (CRMs) following curative resection for rectal cancer using 2010 to 2011 data from the U.S. National Cancer Database. They show a relationship between positive CRM and patient, hospital, tumor, and treatment-related characteristics on both bivariate and multivariate analyses. Facility location, clinical T and N stage, histological type, histological grade, the presence of lymphovascular invasion, the presence of perineural invasion, and the type of operation and operative approach were all variably predictive of a positive CRM on multivariate analysis. It is essential to first define exactly what data are contained within the National Cancer Database (NCDB).2 Approximately 1500 hospitals report their cases to the NCDB; it therefore represents approximately one-third of inpatient hospitalizations in the United States, and approximately 76% rectal cancers are estimated to be reported to this database. The hospitals participating in the National Cancer Database include roughly 20% research and teaching hospitals, 39% comprehensive community cancer centers, 35% community cancer centers, and 6% "other" cancer centers (including Veterans Affairs Medical Centers). In this study, 2859 (17.2%) of 16,619 patients had a positive CRM. The authors found that patients undergoing laparoscopic resection had a 22% lower incidence of a positive CRM, while those undergoing a total proctectomy (ie, abdomino-perineal rectal resection) had a 30% increased risk of a positive CRM. Both of these factors are likely to be surrogates of more expert care. For example, laparoscopic treatment and sphincter-sparing surgery are likely more apt to be performed at larger centers than at smaller hospitals, and also more likely to be performed by surgeons with specialty training.