Rates of abdominoperineal excision declining among patients with rectal cancer, though substantial variation still exists, study data suggest

The use of abdominoperineal excision (APE) in patients with rectal cancer decreased from 1998 to 2004, though there may be substantial variation in its application, which could affect colostomy rates, according to a study conducted in the United Kingdom. "Whilst [APE] may be the only option in patients with very low rectal tumors, for the majority the more modern technique of anterior resection can be performed, which allows the retention of the sphincter and so may be preferable to the...

The use of abdominoperineal excision (APE) in patients with rectal cancer decreased from 1998 to 2004, though there may be substantial variation in its application, which could affect colostomy rates, according to a study conducted in the United Kingdom.

"Whilst [APE] may be the only option in patients with very low rectal tumors, for the majority the more modern technique of anterior resection can be performed, which allows the retention of the sphincter and so may be preferable to the patient," the authors of the study wrote.

To examine variation in rectal cancer surgery, the researchers retrospectively analyzed a population-based dataset that comprised cancer registry and hospital episode statistics data derived from all the United Kingdom's National Health Service (NHS) providers within England from 1998 to 2004. Overall, 31,223 eligible patients received a diagnosis of rectal cancer and underwent a major abdominal procedure during the study period. The primary endpoint of the study was the rate and odds of use of APE in relation to the patient case-mix and each patient's managing surgeon, NHS hospital trust, and cancer network.

There was a significant (P<.01) reduction in the rate of APE use during the study period; specifically, the rate of APE procedures fell from 30.5% in 1998 to 23.0% in 2004. The investigators noted that the rate of APE was significantly greater in men than in women (28.5% vs 25.3%; P<.01), and women were significantly more likely to undergo anterior resection than men were (P<.01).

Further, socioeconomic status significantly affected the rates of APE; patients in the lowest quintile of income received APE in 30.9% of cases compared with 24.1% among the most affluent quintile (P<.01).

Additionally, rates of APE use varied among cancer networks, from 20.1% to 39.3%, and even more so among NHS hospital trusts, from 8.5% to 52.6% (P<.01). There was also extensive variation among surgical teams, with rates varying from 0% to 67.6% (P<.01), although this difference was less pronounced among surgeons who had an annual median workload of >=14 cases per year (APE rate range, 5.4% to 44.3%; P<.01).

Based on these data, each increasing year of diagnosis was associated with a statistically significant 4% reduction in the odds of APE use (OR, 0.96; 95% CI, 0.94-0.97), whereas female sex imparted a significant 15% reduction in the odds of APE use (OR, 0.85; 95% CI, 0.80-0.89) and emergency hospital admission imparted a significant 18% reduction (OR, 0.82; 95% CI , 0.71-0.94).

Being in the lowest quintile of socioeconomic status relative to the most affluent quintile imparted a 37% increase in the odds of APE use (OR, 1.37; 95% CI, 1.24-1.50), whereas being operated on by a team led by a consultant with an annual work load of >=7 cases per year reduced the odds of APE use by a significant 23% (OR, 0.77; 95% CI, 0.71-0.83) relative to a team led by a consultant with a smaller work load. (Morris E, et al. Gut 2008;57:1690-1697.)

"In practice, the way to reduce APE rates and improve treatment outcomes is not by focusing on percentages alone, but rather on achieving optimal surgical clearance of tumor while minimizing treatment morbidity" remarked Dr. Monica Bertagnolli of Brigham and Women's Hospital in an accompanying editorial. "Methods available to improve performance must be routinely employed." (Gut 2008;57:1643-1645.)