Treatment in certified cancer centers is related to better survival in patients with colon and rectal cancer: evidence from a large German cohort study.

BACKGROUND: Certified cancer centers aim to ensure high-quality care by establishing structural and procedural standards according to evidence-based guidelines. Despite the high clinical and health policy relevance, evidence from a nation-wide study for the effectiveness of care for colorectal cancer in certified centers vs. other hospitals in Germany is still missing. METHODS: In a retrospective cohort study covering the years 2009-2017, we analyzed patient data using demographic information, diagnoses, and treatments from a nationwide statutory health insurance enriched with information on certification. We investigated whether patients with incident colon or rectal cancer did benefit from primary therapy in a certified cancer center. We used relative survival analysis taking into account mortality data of the German population and adjustment for patient and hospital characteristics via Cox regression with shared frailty for patients in hospitals with and without certification. RESULTS: The cohorts for colon and rectal cancer consisted of 109,518 and 51,417 patients, respectively, treated in a total of 1052 hospitals. 37.2% of patients with colon and 42.9% of patients with rectal cancer were treated in a certified center. Patient age, sex, comorbidities, secondary malignoma, and distant metastases were similar across groups (certified/non-certified) for both colon and rectal cancer. Relative survival analysis showed significantly better survival of patients treated in a certified center, with 68.3% (non-certified hospitals 65.8%) 5-year survival for treatment of colon cancer in certified (p < 0.001) and 65.0% (58.8%) 5-year survival in case of rectal cancer (p < 0.001), respectively. Cox regression with adjustment for relevant covariates yielded a lower hazard of death for patients treated in certified centers for both colon (HR = 0.92, 95% CI = 0.89-0.95) and rectal cancer (HR = 0.92, 95% CI = 0.88-0.95). The results remained robust in a series of sensitivity analyses. CONCLUSIONS: This large cohort study yields new important evidence that patients with colorectal cancer have a better chance of survival if treated in a certified cancer center. Certification thus provides one powerful means to improve the quality of care for colorectal cancer. To decrease the burden of disease, more patients should thus receive cancer care in a certified center.

Treatment of Colorectal Cancer in Certified Centers: Results of a Large German Registry Study Focusing on Long-Term Survival.

(1) Background: The WiZen study is the largest study so far to analyze the effect of the certification of designated cancer centers on survival in Germany. This certification program is provided by the German Cancer Society (GCS) and represents one of the largest oncologic certification programs worldwide. Currently, about 50% of colorectal cancer patients in Germany are treated in certified centers. (2) Methods: All analyses are based on population-based clinical cancer registry data of 47.440 colorectal cancer (ICD-10-GM C18/C20) patients treated between 2009 and 2017. The primary outcome was 5-year overall survival (OAS) after treatment at certified cancer centers compared to treatment at other hospitals; the secondary endpoint was recurrence-free survival. Statistical methods included Kaplan-Meier analysis and multivariable Cox regression. (3) Results: Treatment at certified hospitals was associated with significant advantages concerning 5-year overall survival (HR 0.92, 95% CI 0.89, 0.96, adjusted for a broad range of confounders) for colon cancer patients. Concentrating on UICC stage I-III patients, for whom curative treatment is possible, the survival benefit was even larger (colon cancer: HR 0.89, 95% CI 0.84, 0.94; rectum cancer: HR 0.91, 95% CI 0.84, 0.97). (4) Conclusions: These results encourage future efforts for further implementation of the certification program. Patients with colorectal cancer should preferably be directed to certified centers.

Influence of Laparoscopic Surgery on Cellular Immunity in Colorectal Cancer: A Systematic Review and Meta-Analysis.

Colorectal cancer (CRC) is the third most common cancer worldwide. The main treatment options are laparoscopic (LS) and open surgery (OS), which might differ in their impact on the cellular immunity so indispensable for anti-infectious and antitumor defense. MEDLINE, Embase, Web of Science (SCI-EXPANDED), the Cochrane Library, Google Scholar, ClinicalTrials.gov, and ICTRP (WHO) were systematically searched for randomized controlled trials (RCTs) comparing cellular immunity in CRC patients of any stage between minimally invasive and open surgical resections. A random effects-weighted inverse variance meta-analysis was performed for cell counts of natural killer (NK) cells, white blood cells (WBCs), lymphocytes, CD4+ T cells, and the CD4+/CD8+ ratio. The RoB2 tool was used to assess the risk of bias. The meta-analysis was prospectively registered in PROSPERO (CRD42021264324). A total of 14 trials including 974 participants were assessed. The LS groups showed more favorable outcomes in eight trials, with lower inflammation and less immunosuppression as indicated by higher innate and adaptive cell counts, higher NK cell activity, and higher HLA-DR expression rates compared to OS, with only one study reporting lower WBCs after OS. The meta-analysis yielded significantly higher NK cell counts at postoperative day (POD)4 (weighted mean difference (WMD) 30.80 cells/µL [19.68; 41.92], p < 0.00001) and POD6-8 (WMD 45.08 cells/µL [35.95; 54.21], p < 0.00001). Although further research is required, LS is possibly associated with less suppression of cellular immunity and lower inflammation, indicating better preservation of cellular immunity.

Oncological Outcomes After Anastomotic Leakage After Surgery for Colon or Rectal Cancer: Increased Risk of Local Recurrence.

OBJECTIVE: The aim of this study was to evaluate oncological outcome for patients with and without anastomotic leakage after colon or rectal cancer surgery. SUMMARY OF BACKGROUND DATA: The role of anastomotic leakage in oncological outcome after colorectal cancer surgery is still topic of debate and impact on follow-up and consideration for further treatment remains unclear. METHODS: Patients included in the international, multicenter, non-inferior, open label, randomized, controlled trials COLOR and COLOR II, comparing laparoscopic surgery for curable colon (COLOR) and rectal (COLOR II) cancer with open surgery, were analyzed. Patients operated by abdominoperineal excision were excluded. Both univariate and multivariate analyses were performed to investigate the impact of leakage on overall survival, disease-free survival, local and distant recurrences, adjusted for possible confounders. Primary endpoints in the COLOR and COLOR II trial were disease-free survival and local recurrence at 3-year follow-up, respectively, and secondary endpoints included anastomotic leakage rate. RESULTS: For colon cancer, anastomotic leakage was not associated with increased percentage of local recurrence or decreased disease-free-survival. For rectal cancer, an increase of local recurrences (13.3% vs 4.6%; hazard ratio 2.96; 95% confidence interval 1.38-6.34; P = 0.005) and a decrease of disease-free survival (53.6% vs 70.9%; hazard ratio 1.67; 95% confidence interval 1.16-2.41; P = 0.006) at 5-year follow-up were found in patients with anastomotic leakage. CONCLUSION: Short-term morbidity, mortality, and long-term oncological outcomes are negatively influenced by the occurrence of anastomotic leakage after rectal cancer surgery. For colon cancer, no significant effect was observed; however, due to low power, no conclusions on the influence of anastomotic leakage on outcomes after colon surgery could be reached. Clinical awareness of increased risk of local recurrence after anastomotic leakage throughout the follow-up is mandatory.Trial Registration: Registered with ClinicalTrials.gov, number NCT00387842 and NCT00297791.

Transanal total mesorectal excision: short- and long-term results of the first hundred cases of a certified colorectal cancer center in Germany.

BACKGROUND: Since 2010, laparoscopic transanal total mesorectal excision (TaTME) has been increasingly used for low and very low rectal cancer. It is supposed to improve visibility and access to the dissection planes in the pelvis. This study reports on short- and long-term outcomes of the first 100 consecutive patients treated with TaTME in a certified German colorectal cancer center. PATIENTS AND METHODS: Data were derived from digital patient files and official cancer registry reports for patients with TaTME tumor surgery between July 2014 and January 2020. The primary outcome was the 3-year local recurrence rate and local recurrence-free survival (LRFS). Secondary endpoints included overall survival (OAS), disease-free survival (DFS), operation time, completeness of local tumor resection, lymph node resection, and postoperative complications. The Kaplan-Meier method was employed for the survival analyses; competing risks were considered in the time-to-event analysis. RESULTS: During the observation period, the average annual operation time decreased from 272 to 178 min. Complete local tumor resection was achieved in 97% of the procedures. Major postoperative complications (Clavien-Dindo 3-4) occurred in 11% of the cases. At a median follow-up time of 2.7 years, three patients had suffered from a local recurrence. Considering competing risks, this corresponds to a 3-year cumulative incidence rate for local recurrence of 2.2% and a 3-year LRFS of 81.9%. 3-year OAS was 82.9%, and 3-year DFS was 75.7%. CONCLUSION: TaTME is associated with favorable short and long-term outcomes. Since it is technically demanding, structured training programs and more research on the topic are indispensable.

Benefit of adjuvant chemotherapy in high-risk colon cancer: A 17-year population-based analysis of 6131 patients with Union for International Cancer Control stage II T4N0M0 colon cancer.

BACKGROUND: The benefit of adjuvant chemotherapy in Union for International Cancer Control (UICC) stage III colon cancer has been demonstrated in numerous studies. While adjuvant chemotherapy is generally not recommended in stage II patients, its role in high-risk UICC stage II disease (e.g. T4 tumours) remains controversial. METHODS: The present population-based multicenter cohort study investigated the influence of adjuvant chemotherapy on survival and recurrence rates in high-risk UICC stage II T4N0M0 tumours. Based on an anonymised nationwide ADT data set from 31 clinical cancer registries, we identified a total of 6651 patients with a T4 tumour of the colon, of whom 6131 were eligible for survival analysis. A matched-pair analysis based on propensity scores (PSM) was performed with a subset of 3986 patients. RESULTS: Multivariable analyses demonstrated a significant benefit of adjuvant chemotherapy for overall survival (OS) (hazard ratio [HR]: 0.711, 95% confidence interval [CI]: 0.643-0.785, p < 0.001), cumulative recurrence rate (HR: 0.780, 95% CI: 0.681-0.893, p < 0.001), and recurrence-free survival (HR: 0.715, 95% CI: 0.652-0.785, p < 0.001) further confirmed by the matched-pair cohort. CONCLUSION: This large and representative study demonstrated a significant advantage of adjuvant chemotherapy for patients with T4 UICC stage II colon cancer in terms of OS, recurrence rate, and relapse-free survival. Based on these results, adjuvant chemotherapy should be recommended for these patients.

Diagnosing deficits in quality of life and providing tailored therapeutic options: Results of a randomised trial in 220 patients with colorectal cancer.

BACKGROUND: The implementation of quality of life (QoL) concepts in routine care, is still an open matter. We followed the Medical Research Council framework for complex interventions to implement a model of QoL diagnosis and therapeutic options, and investigated its effectiveness in patients with colorectal cancer. METHODS: This randomised, single-blind, multicentre, clinical trial enrolled patients diagnosed with primary colorectal cancer aged 18 years or older who were surgically treated in one of four recruiting hospitals in Germany. All patients received aftercare from one of 178 coordinating practitioners (CPs) who had access to 75 healthcare professionals providing tailored therapies. QoL was measured (EORTC QLQ-C30, QLQ-CR29) in all patients after surgery (baseline) and during aftercare (3, 6, 12, 18 months). Patients were randomised (1:1) into two groups: a care pathway, including QoL-profiles consisting of 13 QoL scales plus specific therapeutic recommendations forwarded to the patient's CP or standard postoperative care adhering to the German national guideline for colorectal cancer (control). The primary endpoint was the proportion of patients in each group with a need for QoL therapy 12 months after surgery. Analyses were done in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NCT02321813 and closed to accrual. FINDINGS: Between Jan 13, 2014, and Oct 28, 2015, 220 patients were enrolled and randomly assigned (n = 110 per group). At baseline (in hospital after surgery), a need for QoL therapy was diagnosed in 92/103 (89%) of intervention and 86/104 (83%) of control group patients. At 12 months (primary endpoint) the proportion of patients with a need for QoL therapy was 35/83 (42%; 95% CI 31-54%) in the intervention group versus 50/87 (57%; 95% CI: 46-68%) in the control group (p = 0·046, number needed to treat = 7; 95% CI 3-225). INTERPRETATION: Patients profited from the diagnosis of QoL deficits and tailored therapeutic options in their treatment of colorectal cancer. This trial confirmed the results of a previous RCT in breast cancer patients. The implementation of QoL concepts should become standard in treatment guidelines on cancer care. FUNDING: Federal Ministry of Education and Research (BMBF; grant no. 01GY1339). CLINICAL TRIAL INFORMATION: NCT02321813.

Correction to: Laparoscopic and open surgery in rectal cancer patients in Germany: short and long-term results of a large 10-year population-based cohort.

The article, "Laparoscopic and open surgery in rectal cancer patients in Germany: short and long­term results of a large 10-year population-based cohort," written by Valentin Schnitzbauer, Michael Gerken, Stefan Benz, Vinzenz Völkel,, Teresa Draeger, Alois Fürst, and Monika Klinkhammer-Schalke was originally published electronically on the publisher's internet portal (currently SpringerLink) on 30 May 2019 without open access. With the author(s)' decision to opt for Open Choice the copyright of the article changed on September 18, 2019 to © The Author(s) [Year] and the article is forthwith distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, duplication, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit original author(s) and the source, provide a link to the Creative Commons licence and indicate if changes were made.

Laparoscopic and open surgery in rectal cancer patients in Germany: short and long-term results of a large 10-year population-based cohort.

BACKGROUND: Rectal cancer is frequent in Germany and worldwide. Several studies have assessed laparoscopic surgery as a treatment option and most have shown favorable results. However, long-term oncologic safety remains a controversial issue. METHODS: The current dataset derives from 30 clinical cancer registries in Germany and includes 16,378 patients diagnosed with rectal cancer between 2007 and 2016. Outcomes were 90-day mortality, overall survival (OS), local recurrence-free survival (RFS) and relative survival of patients treated with either open or laparoscopic surgery. Multivariable logistic regression was used to evaluate factors that affected the probability of a patient undergoing laparoscopic surgery as well as to evaluate short-term mortality. OS and RFS were analyzed by Kaplan-Meier plots and multivariable Cox regression conducted separately for UICC stages I-III, tumor location, and sex as well as by propensity score matching followed by univariable and multivariable survival analysis. RESULTS: Of 16,378 patients, 4540 (27.7%) underwent laparoscopic surgery, a trend which increased during the observation period. Patients undergoing laparoscopy attained better results for 90-day mortality (odds ratio, OR 0.658, 95% confidence interval, CI 0.526-0.822). The 5-year OS rate in the laparoscopic group was 82.6%, vs. 76.6% in the open surgery group, with a hazard ratio (HR) of 0.819 in multivariable Cox regression (95% CI 0.747-0.899, p < 0.001). The laparoscopic group showed a better 5-year RFS, with 81.8 vs. 74.3% and HR 0.770 (95% CI 0.705-0.842, p < 0.001). The 5-year relative survival rates were also in favor of laparoscopy, with 93.1 vs. 88.4% (p = 0.012). CONCLUSION: Laparoscopic surgery for rectal cancer can be performed safely and, according to this study, is associated with an oncological outcome superior to that of the open procedure. Therefore, in the absence of individual contraindications, it should be considered as a standard approach.

Surgical treatment of rectal cancer patients aged 80 years and older-a German nationwide analysis comparing short- and long-term survival after laparoscopic and open tumor resection.

BACKGROUND: Minimally invasive removal of rectal tumors has proven to be a safe alternative to the open approach. Despite increased use of laparoscopy, its eligibility for older adults requires further exploration. This study compares perioperative mortality and 5-year overall, disease-free, and relative survival after laparoscopic and open surgery in rectal cancer patients aged ≥80 years. MATERIALS AND METHODS: Data derive from 30 German regional cancer registries and cover approximately one quarter of the entire German population. All primary nonmetastatic rectal adenocarcinoma cases with surgery between 2005 and 2014 were eligible for inclusion. To compare survival rates, Kaplan-Meier analysis, a relative survival model, and multivariable Cox regression were applied; a sensitivity analysis assessed bias by exclusion. RESULTS: 1532 patients were included, of whom 17.1% underwent laparoscopic procedures. 30 days after surgery, 2.7% of the laparoscopy patients had died compared to 7.0% in the open surgery group. The multivariable analysis confirmed that minimally invasive procedures are followed by a lower 30-day postoperative mortality risk (odds ratio, OR, 0.352; 95% confidence interval, CI, 0.161-0.771; p = 0.009). With a 5-year disease-free survival rate of 52.0 vs. 47.6% (p = 0.557), only an nonsignificant long-term advantage of the minimally invasive approach was observed. CONCLUSION: Given the results of this study, older rectal cancer patients are likely to benefit from the laparoscopic approach in the short term, and there are also no disadvantages in terms of long-term survival. Therefore, laparoscopy should be considered a standard procedure for older adults as well.

Laparoscopic and open resection of rectal cancer-is age an effect modifier for short- and long-term survival?

INTRODUCTION: Rectal cancer is a frequently diagnosed tumor worldwide. Various studies have shown the noninferiority or even slight superiority of laparoscopic resection. However, there is no clear recommendation on whether age should influence the choice of surgical approach. MATERIALS AND METHODS: This study compared outcomes of laparoscopic and open surgery in rectal cancer patients. Perioperative mortality and 5-year overall, relative, and recurrence-free survival rates were analyzed separately for three age groups. Data originate from 30 regional German cancer registries that cover approximately one quarter of the German population. All primary nonmetastatic rectal adenocarcinoma cases with surgery between 2005 and 2014 were eligible for inclusion. To compare survival rates, Kaplan-Meier analysis, a relative survival model, and multivariable Cox regression were used; a sensitivity analysis assessed bias by exclusion. RESULTS: Ten thousand seven hundred fifty-four patients were included in the analysis. The mean laparoscopy rate was 23.0% and increased over time. Analysis of 30-day postoperative mortality rates revealed advantages for laparoscopically treated patients, although the significance level was not reached in any age group. Regarding 5-year overall survival, laparoscopy generally seems to be the superior approach, whereas for recurrence-free survival, an age-dependent gradient in effect size was observed: with a hazard ratio (HR) of 0.703 for laparoscopy, patients under 60 years benefitted more from the minimally invasive approach than older patients (septuagenarians, HR 0.923). CONCLUSION: Laparoscopy shows similar results to the open approach in terms of postoperative survival in all age groups. Concerning long-term outcomes, younger patients benefitted most from the minimally invasive approach.

[Long-Term Survival of Patients with Colon and Rectum Carcinomas: Is There a Difference Between Cancer Centers and Non-Certified Hospitals?] / Langzeitüberleben von Patienten mit Kolon- und Rektumkarzinomen: Ein Vergleich von Darmkrebszentren und nicht zertifizierten Krankenhäusern.

AIM OF THE STUDY: Hospitals specializing in the treatment of colorectal carcinoma with high quality standards can apply for certification as colorectal cancer centers. The aim of this study was to clarify if there is a substantial difference between certified and non-certified hospitals in terms of long-term survival of patients. METHODS: This is a population-based retrospective cohort study using the data of a clinical cancer registry (Tumorzentrum Regensburg) which covers a southern German region of approximately 1.1 million inhabitants. 4302 patients with colorectal carcinoma who underwent radically surgery between 2004 and 2013 were divided into 4 groups for comparing certified and non-certified centers as well as the situation before and after certification. 3-year overall survival is displayed using Kaplan-Meier analysis, multivariate cox regression and relative survival models. Sensitivity analysis for missing data was conducted. RESULTS: The estimated 3-year survival rates of patients treated at certified compared to non-certified centers were 71.6% and 63.6%, respectively. Even after adjusting for possible confounders, treatment at certified centers was associated with significant survival benefits for patients (HR=0.808, CI: 0.665-0.982). Comparison of colorectal cancer centers before and after certification showed almost identical 3-year survival rates. Cox regression analysis also showed no substantial difference between the two (HR=0.964, CI: 0.848-1.096). CONCLUSION: Patients with colorectal cancer treated in certified compared to non-certified centers show long-term survival benefits. Patients of certified colorectal cancer centers show long-term survival benefits compared to those treated at non-certified centers. Early and successful implementation of high quality standards could explain why survival rates before and after certification do not differ.

Bowel Obstruction and Ventral Hernia After Laparoscopic Versus Open Surgery for Rectal Cancer in A Randomized Trial (COLOR II).

OBJECTIVE: The aim of this study was to evaluate the risk of bowel obstruction, incisional, and parastomal hernia following laparoscopic versus open surgery for rectal cancer. SUMMARY BACKGROUND DATA: Laparoscopic surgery for rectal cancer has been adopted worldwide, after trials reported similar oncological outcomes compared with open surgery. Little is known about long-term morbidity, including bowel obstruction, incisional, and parastomal hernia following surgery. METHODS: Patients included in the international, multicenter, noninferior, open-label, randomized COLOR II trial were followed for five years. Primary endpoint was local recurrence at 3-year follow-up. Secondary endpoints included bowel obstruction, incisional and parastomal hernia within 5 years, and the current article reports on these secondary endpoints. RESULTS: All 1044 patients included in the COLOR II trial were analyzed. There was no difference in risk of bowel obstruction, incisional, or parastomal hernia following laparoscopic or open surgery for rectal cancer. CONCLUSION: Based on long-term morbidity outcomes, laparoscopic surgery for rectal cancer could be considered a routine technique as there are no differences with open surgery.

Personalized management of elderly patients with rectal cancer: Expert recommendations of the European Society of Surgical Oncology, European Society of Coloproctology, International Society of Geriatric Oncology, and American College of Surgeons Commission on Cancer.

With an expanding elderly population and median rectal cancer detection age of 70 years, the prevalence of rectal cancer in elderly patients is increasing. Management is based on evidence from younger patients, resulting in substandard treatments and poor outcomes. Modern management of rectal cancer in the elderly demands patient-centered treatment, assessing frailty rather than chronological age. The heterogeneity of this group, combined with the limited available data, impedes drafting evidence-based guidelines. Therefore, a multidisciplinary task force convened experts from the European Society of Surgical Oncology, European Society of Coloproctology, International Society of Geriatric Oncology and the American College Surgeons Commission on Cancer, with the goal of identifying the best practice to promote personalized rectal cancer care in older patients. A crucial element for personalized care was recognized as the routine screening for frailty and geriatrician involvement and personalized care for frail patients. Careful patient selection and improved surgical and perioperative techniques are responsible for a substantial improvement in rectal cancer outcomes. Therefore, properly selected patients should be considered for surgical resection. Local excision can be utilized when balancing oncologic outcomes, frailty and life expectancy. Watch and wait protocols, in expert hands, are valuable for selected patients and adjuncts can be added to improve complete response rates. Functional recovery and patient-reported outcomes are as important as oncologic-specific outcomes in this age group. The above recommendations and others were made based on the best-available evidence to guide the personalized treatment of elderly patients with rectal cancer.

Long-term oncologic outcomes after laparoscopic vs. open colon cancer resection: a high-quality population-based analysis in a Southern German district.

BACKGROUND: Over 20 years after the introduction of laparoscopic surgery for colon cancer, many surgeons still prefer the open approach. Whereas randomized controlled trials (RCTs) have proven the oncologic safety of laparoscopy, long-term data depicting daily clinical routine are scarce. METHODS: This population-based cohort study compares 5-year overall, relative, and recurrence-free survival rates after laparoscopic and open colon carcinoma surgery. Data derive from an independent German cancer registry encompassing all tumor patients within a political district of 1.1 million inhabitants. The final analysis included 2669 patients with major elective resection of primary non-metastatic colonic adenocarcinoma between January 1, 2004 and December 31, 2013. Survival rates were compared using Kaplan-Meier analyses, relative survival models, and multivariate Cox regression. Sensitivity analysis quantified selection bias. RESULTS: The proportion of laparoscopic procedures increased from 9.7 to 25.8% in 2011 and dropped again to 15.8% at the end of observation period. Laparoscopy patients were younger, had a lower tumor stage, and were more likely to receive postoperative chemotherapy. Overall, relative, and recurrence-free survival was significantly superior or equivalent in Kaplan-Meier analysis (5-year overall survival rate open vs. laparoscopic: 69.0 vs. 80.2%, p < 0.001). The superiority of laparoscopy mostly remained stable after adjusting for confounders, although significance was only reached in T1-3 patients without lymph node metastases (overall survival: hazard ratio (HR) 0.654; 95% confidence interval (CI) 0.446-0.958; p = 0.029). CONCLUSION: Laparoscopy is a safe and promising alternative to the open approach in daily clinic practice. These favorable outcomes require future confirmation by high-quality studies outside the setting of RTCs.

Long-term oncologic outcomes after laparoscopic versus open rectal cancer resection: a high-quality population-based analysis in a Southern German district.

BACKGROUND: An increasing number of rectal carcinoma resections in Germany and worldwide are performed laparoscopically. The recently published COLOR II trial demonstrated the oncologic safety of this surgical approach. It remains unclear whether these findings can be transferred to clinical practice. PATIENTS AND METHODS: This population-based retrospective cohort study aimed to evaluate 5-year overall, relative, disease-free, and local recurrence-free survival of rectal cancer patients treated by open surgery and laparoscopy. Data from a southern German region of 1.1 million inhabitants were collected by an official clinical cancer registry. All primary non-metastatic rectal adenocarcinoma cases with surgery between 2004 and 2013 were eligible for inclusion. To compare survival rates, Kaplan-Meier analyses, relative survival models, and multivariate Cox regression were applied; a sensitivity analysis assessed bias by exclusion. RESULTS: Finally, 1507 patients with a median follow-up time of 7.1 years were included. Of these patients, 28.4% underwent laparoscopic procedures, with an increasing rate over time. Patients with tumors of the upper or middle rectum, younger patients, and patients of specialized colorectal cancer centers were more likely to undergo laparoscopy. After 5 years, 80.4% of laparoscopy patients were still alive, compared to 68.6% in the open group (p < 0.001). Moreover, laparoscopy was associated with superior local recurrence-free survival rates. This advantage was also significant in multivariate analysis (HR 0.70, 95% CI 0.52-0.92). CONCLUSION: Laparoscopic rectal cancer surgery can be considered safe in daily clinical practice. This should be confirmed by future studies outside the setting of randomized trials.