Wide Variation in the Use of Radiotherapy in the Management of Surgically Treated Rectal Cancer Across the English National Health Service

E.J.A Morris,P.J Finan,K Spencer,I Geh,A Crellin,P Quirke,J.D Thomas,S Lawton,R Adams,D Sebag-Montefiore

doi:10.1016/j.clon.2016.02.002

Abstract

AimsRadiotherapy is an important treatment modality in the multidisciplinary management of rectal cancer. It is delivered both in the neoadjuvant setting and postoperatively, but, although it reduces local recurrence, it does not influence overall survival and increases the risk of long-term complications. This has led to a variety of international practice patterns. These variations can have a significant effect on commissioning, but also future clinical research. This study explores its use within the large English National Health Service (NHS). Materials and methodsInformation on all individuals diagnosed with a surgically treated rectal cancer between April 2009 and December 2010 were extracted from the Radiotherapy Dataset linked to the National Cancer Data Repository. Individuals were grouped into those receiving no radiotherapy, short-course radiotherapy with immediate surgery (SCRT-I), short-course radiotherapy with delayed surgery (SCRT-D), long-course chemoradiotherapy (LCCRT), other radiotherapy (ORT) and postoperative radiotherapy (PORT). Patterns of use were then investigated. ResultsThe study consisted of 9201 individuals; 4585 (49.3%) received some form of radiotherapy. SCRT-I was used in 12.1%, SCRT-D in 1.2%, LCCRT in 29.5%, ORT in 4.7% and PORT in 2.3%. Radiotherapy was used more commonly in men and in those receiving an abdominoperineal excision and less commonly in the elderly and those with comorbidity. Significant and substantial variations were also seen in its use across all the multidisciplinary teams managing this disease. ConclusionDespite the same evidence base, wide variation exists in both the use of and type of radiotherapy delivered in the management of rectal cancer across the English NHS. Prospective population-based collection of local recurrence and patient-reported early and late toxicity information is required to further improve patient selection for preoperative radiotherapy.

Highlights

Radiotherapy is an established treatment modality in the multidisciplinary management of rectal cancer
Two recently reported phase III trials have confirmed a halving of the rate of local recurrence when a 1 week short course of radiotherapy was added to surgical resection [2,3]
All individuals diagnosed with a first primary rectal cancer between 1 April 2009 and 31 December 2010 and who underwent a major resection for the disease within the English National Health Service (NHS) were identified [24,26] within the linked cancer registry and Hospital Episode Statistics (HES) component of the National Cancer Data Repository (NCDR) [22]

Summary

Introduction

Radiotherapy is an established treatment modality in the multidisciplinary management of rectal cancer. In the 1990s, phase III trials reported reduced local recurrence and improved overall survival using a combination of postoperative chemotherapy and concurrent chemoradiation (CRT). Two recently reported phase III trials have confirmed a halving of the rate of local recurrence when a 1 week short course of radiotherapy was added to surgical resection [2,3]. Two phase III trials reported reduced local recurrence when preoperative CRT was compared with long-course radiotherapy alone [4,5]. In parallel, improved surgical technique using total mesorectal excision led to low reported rates of local recurrence with surgery alone [8]. This finding was confirmed in the Medical Research Council CR07 trial, where the best planes of surgical excision resulted in the lowest rates of local recurrence [9]

Methods

Results

Conclusion