Introduction Bowel resection is the treatment of choice for most patients with colorectal cancer (CRC) but a significant minority are managed non-operatively. The National Bowel Cancer Audit (NBOCA) highlights possible reasons for non-operative treatment; patient frailty, advanced disease or too little cancer to warrant major surgery, but acknowledged some missing data on pre-treatment stage.1This study reviews the reasons for non-resection in a large cohort with a complete dataset.
Method A consecutive series of patients with CRC known to a single NHS Trust with a date of diagnosis 01/04/10 – 31/03/14 were identified from a prospectively populated database. Demographic details and treatment type (formal resection, local resection, non-operative) were exported, along with reasons for non-operative management; Dukes’ stage (i.e. “too little” or “too much” cancer), co-morbidity (“too frail”) and patient preference. Where there was more than one reason for non-operative management, categorisation was hierarchical (Dukes’ stage, then co-morbidity, then patient preference).
Results A total of 1259 patients were ascertained of whom 65 were excluded from further analysis as their treatment took place outside the Trust. Of the remaining 1194 (M:F 1.4:1, mean age 71, range 29–100) the majority had a surgical resection (mean age 70, range 29–96). 382 (32.0%) did not have a major surgical resection (mean age 75, range 39–100). Of these, seventy-one (18.6%) had a local resection and were all Dukes’ stage A (‘too little cancer’). Two hundred and fifteen (56.3%) were patients with advanced disease (‘too much cancer’). Seventy-three (19.1%) had significant co-morbidity (‘too frail’) and the remaining 23 (6.0%) declined surgical resection.
Conclusion The reasons for non-operative treatment can be categorised as disease or patient-specific. In the majority of cases (74.9%) the reason was disease specific, i.e. locally resectable disease not requiring major resection, or advanced disease where resection may not confer survival benefit. Appropriate endoscopic resection is to the patient’s benefit. For those with too much cancer however, there may have been missed opportunities for diagnosis earlier in the natural history of their disease. Further work is on-going to examine this possibility. Assessment of frailty at this trust is currently relatively subjective and may therefore under or overstate risk. The introduction of cardiopulmonary exercise testing is planned which will allow a more objective assessment. Whether or not this will change the proportion of patients in the ‘too frail’ group is as yet unknown.
Disclosure of interest None Declared.
National Bowel Cancer Audit (NBOCA) 2014
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