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Vol. 95. Issue 10.
Pages 577-587 (December 2017)
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Vol. 95. Issue 10.
Pages 577-587 (December 2017)
Original article
DOI: 10.1016/j.cireng.2017.08.005
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Oncological Results of the Educational Rectal Cancer Project in Spain 10 Years After Its Implementation
Resultados oncológicos del Proyecto docente del Cáncer de Recto en España 10 años después de su inicio
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Antonio Codina Cazadora,
Corresponding author
acodinac.girona.ics@gencat.cat

Corresponding author.
, Sebastiano Biondob, Eloy Espin Basanyc, Jose Maria Enriquez-Navascuesd, Eduardo Garcia-Graneroe, Jose Vicente Roig Vilaf, Maria Buxóg, en representación de los centros participantes en el Proyecto del Cáncer de Recto de la Asociación Española de Cirujanos
a Hospital Universitario Dr. Josep Trueta, Girona, Spain
b Hospital Universitario Bellvitge, Barcelona, Spain
c Hospital Universitario Vall d’Hebron, Barcelona, Spain
d Hospital Universitario Donostia, Donostia, Spain
e Hospital Universitario La Fe, Valencia, Spain
f Hospital Nisa, Valencia, Spain
g Instituto de Investigación Biomédica de Girona (IDIBGI), Girona, Spain
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Tables (4)
Table 1. Description of the Patient Sample (n=4508).
Table 2. Influence of the Confounding Variables on Overall Survival.
Table 3. Influence of the Confounding Variables on Local Recurrence.
Table 4. Influence of the Confounding Variables on Metastasis.
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Abstract
Introduction

The objective of this observational, prospective, multicenter and multilevel study was to evaluate the oncological outcomes (local recurrence, metastasis and overall survival) of the Rectal Cancer Project of the Spanish Association of Surgeons (AEC) 10 years after its initiation, comparing the results with Scandinavian registries.

Methods

The AEC teaching project database includes 17620 patients to date, of which 4508 were operated on with a potentially curative resection between March 2006 and December 2010. All of them come from the first 59 hospitals included in the project, and therefore followed for at least 5 years, and are the subject of the present study.

Results

The cumulative incidence of local recurrence was 7.3 (95% CI: 8.2–6.5), metastasis 21.0 (CI 95%: 22.4–19.7) and overall survival 72.3 (CI 95%: 80.3–77.6). The multilevel regression analysis with the hospital variable as a random effect, showed a significant variation among the hospitals for the cancer outcome variables: general survival, local recurrence and metastasis (δ2=0.053).

Conclusions

This study indicates that the results observed in the AEC’ Rectal Cancer Project are inferior than those observed in the Scandinavian registries that we tried to emulate and that this is attributable to the variability of practice in some centers.

Keywords:
Rectal cancer
Local recurrence
Metastases
Overall survival
Resumen
Introducción

El objetivo de este estudio observacional, prospectivo, multicéntrico y multinivel ha sido evaluar los resultados oncológicos (recidiva local, metástasis y supervivencia global) del Proyecto del Cáncer de Recto de la Asociación Española de Cirujanos (AEC) 10 años después de su inicio, comparando los resultados con los registros escandinavos.

Métodos

La base de datos del proyecto docente de la AEC incluye hasta la fecha a 17.620 pacientes, de los cuales 4.508 fueron operados con una resección potencialmente curativa entre marzo de 2006 y diciembre de 2010. Todos ellos son provenientes de los primeros 59 hospitales incluidos en el proyecto, y por tanto seguidos al menos durante 5 años, y constituyen el objeto del presente estudio.

Resultados

La incidencia acumulada de recidiva local fue 7,3 (IC 95%: 8,2-6,5), la de metástasis fue 21.0 (IC 95%: 22,4-19,7) y la de supervivencia global, 72,3 (IC 95%: 80,3-77,6). El análisis de regresión multinivel, con la variable hospital como un efecto aleatorio, mostró una variación significativa entre los hospitales para las variables de resultado oncológico: supervivencia general, recidiva local y metástasis (δ2=0,053).

Conclusiones

Este estudio indica que los resultados observados en el Proyecto del Cáncer de Recto de la AEC son inferiores a los observados en los registros de Escandinavia a los que tratamos de emular y que ello es atribuible a la variabilidad de la práctica en algunos centros.

Palabras clave:
Cáncer de recto
Recidiva local
Metástasis
Supervivencia global
Full Text
Introduction

In order to determine the oncological results of rectal cancer treatment in Spain and whether these outcomes could be improved, the Spanish Association of Surgeons (Association Española de Cirujanos, AEC) introduced a project1 in 2006 inspired by the Norwegian Colon and Rectal Cancer Project.2 The objective of this teaching initiative was to disseminate and systematize mesorectal excision surgery initially, and later extended abdominoperineal excision,3 to the multidisciplinary groups of the 105 hospitals of the National Healthcare System that requested it and fulfilled the required conditions from 2006 to 2012 (Appendix).

The aim of this study was to evaluate the oncological results achieved by this teaching initiative 10 years after its inception and to determine whether these results have achieved the quality standards observed in the registries of the Scandinavian countries, which this project attempts to imitate.

Methods

This multicenter observational study was carried out using the prospective database of the Rectal Cancer Project of the AEC.

Patient selection. Included for study were patients who had been treated with elective surgery at the first 59 hospitals included in the project, between March 1, 2006 and December 1, 2010, with curative resections of the rectum and with or without restoration of intestinal continuity: anterior resection (AR); abdominoperineal resection (APR) and Hartmann procedure.

We excluded non-surgical patients and those treated with non-resective operations: exploratory laparotomy or laparoscopy, stoma, and diversions. Also excluded were those who underwent the following techniques: local resection, proctocolectomy, and pelvic exenteration. Excluded as well were patients whose operations were not considered curative and patients with involvement of the distal histopathological margin and patients with urgent surgery.

Study variables. The study outcome variables were: local recurrence, metastases that appeared during follow-up, and overall survival. Confounding variables included: sex, age categorized into 3 groups (<65, 65–80, >80 years), surgical risk (measured by the ASA anesthetic risk level), tumor location classified into 3 groups from the anal margin (0–6, 7–12, 13–15cm), type of mesorectal excision (partial or total), type of operation performed (AR, APR, Hartmann procedure), intraoperative perforation of the tumor or rectum, status of the circumferential resection margin (CRM) (free or tumor invasion), use of neoadjuvant and adjuvant treatment, and the pathological stage of the tumor.

Definitions and standards. According to the Clasificación Internacional de Enfermedades (CIE10-C20), rectal tumors were defined as those situated in the last 15cm measured from the anal margin using rigid rectoscope or magnetic resonance imaging (MRI).4

A resection was considered potentially curative in those cases in which a locally radical procedure was performed with free distal and circumferential margins or with microscopic invasion of these margins (R0 and R1) in the absence of metastasis.

The pathologic tumor stage was classified with the fifth edition of the TNM classification (American Joint Committee on Cancer stages IIV; fifth edition).5 Intraoperative perforation was defined as any defect of the rectal wall caused by the operation that brought the lumen of the rectum into contact with the surface. The CRM was considered invaded if neoplastic cells were found 1mm or less away.

Local recurrence was defined as the reappearance of the disease in the pelvis, including: the anastomosis and perineal wound, regardless of whether the patient had distant metastasis. Isolated recurrence in the ovaries was considered metastasis.

Given the anonymity of hospitals and patients, approval by the ethics committees of the centers included was not considered necessary, although the project had been endorsed by these committees.

Statistical Analysis

Before conducting the analyses, an exploratory analysis of the data was used to detect extreme cases, non-response and lost cases. A univariate descriptive analysis was carried out, where the quantitative variables were summarized by means and standard deviation and the categorical variables by frequencies and percentages. The results related with the incidence of recurrence, metastasis and overall survival were presented as the total number of events and 95% confidence interval (95% CI). Patients were considered at risk for experiencing the indicated events until death, loss of follow-up due to change of city of residence or end of follow-up after 5 years. The incidence of these events was estimated using the Kaplan–Meier method.

Confounding variables that had a significant impact on overall survival, local recurrence and metastasis at follow-up were identified with Cox proportional hazards models. The adjustment was considered necessary to correct the confounding bias if the change between the adjusted and unadjusted effect was greater than 10%. The assumption of proportional risks was evaluated by the Therneau-Grambsch approach. The results were expressed as the hazard ratio (HR) and its 95% CI.

Since patients at the same hospital are more likely to have similar oncological outcomes (depending on patient and tumor characteristics) than those observed at other hospitals, the logistic regression was extended with the hospital variable as a random effect to correct for the non-independence of the data.

The analyses were made with the statistical packages by IBM SPSS (version 24), R (version 3.3.2) and STATA IC13, with a level of significance of 0.05.

Results

Between 2006 and 2012, the multidisciplinary groups (MDG) of 105 hospitals were trained in 10 courses. Of these, 23 abandoned the project and 6 hospitals have merged, leaving 3 in their place. In total, and to date, the 79 participating centers have included 17620 patients in the database.

The results presented in this study were observed in patients treated electively with curative rectal resection in the 59 participating centers between March 1, 2006 and December 31, 2010, thus having a minimum of 5 years of follow-up. In this period, once the exclusion criteria indicated in the flow chart were applied (Fig. 1), 4716 consecutive patients were treated with curative rectal resection, 4508 of which survived the operation and were included in the analysis of the oncological results.

Fig. 1.

Flow diagram of the patients included in the project and in the study.

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The characteristics of this cohort of patients are shown in Table 1. In 3085 (68.4%) patients AR was performed, 1058 (23.5%) were treated with APR, and 365 (8.1%) with the Hartmann procedure.

Table 1.

Description of the Patient Sample (n=4508).

  n  (%) 
Sex
Female  1552  (34.4) 
Male  2956  (65.6) 
Age (yrs)
<65  1702  (37.8) 
65–80  2204  (48.9) 
> 80  600  (13.3) 
ASA
ASA I  276  (6.1) 
ASA II  2451  (54.4) 
ASA III  1631  (36.2) 
ASA IV  150  (3.3) 
Tumor location (cm)
15–13  512  (11.4) 
12–7  2199  (48.8) 
0–6  1797  (39.9) 
Surgical technique
Resection  3085  (68.4) 
Amputation  1058  (235) 
Hartmann  365  (8.1) 
Mesorectal excision
Partial  939  (20.8) 
Total  3569  (79.2) 
Intraoperative perforation
No  4282  (95.0) 
Yes  226  (5.0) 
Invasion of the CRM
Free  4090  (90.7) 
Affected  418  (9.3) 
Neoadjuvant treatment
No  1810  (40.2) 
Yes  2698  (59.8) 
Adjuvant treatment
No  1668  (37.0) 
Yes  2816  (62.5) 
No data  24  (0.5) 
Pathologic tumor stage
I  1299  (28.8) 
II  1355  (30.1) 
III  1415  (31.4) 
195  (4.3) 
No data  244  (5.4) 

With a follow-up of at least 5 years, the cumulative incidence of local recurrence was 7.3% (95% CI: 6.5–8.2) (Fig. 2), the rate of metastasis at follow-up was 21% (95% CI: 19.7–22.4) (Fig. 3) and overall survival was 72.3% (95% CI: 70.9–73.8) (Fig. 4).

Fig. 2.

Accumulated incidence of local recurrence.

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Fig. 3.

Accumulated incidence of metastasis.

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Fig. 4.

Accumulated incidence of mortality.

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The results of the univariate and multivariate analyses performed to determine the influence of confounding variables on the oncological results are shown in Tables 2–4. Intraoperative perforation, CRM invasion, advanced tumor stages and the Hartmann procedure negatively influenced the 3 outcome variables: local recurrence, metastasis in follow-up and overall survival. Male sex also negatively influenced local recurrence and overall survival. In addition, advanced patient age and higher ASA risk negatively influenced overall survival.

Table 2.

Influence of the Confounding Variables on Overall Survival.

VariableOverall SurvivalUnivariate AnalysisMultivariate Analysis
No Event  Event  HR [IC 95%]  P  HR [IC 95%]  P 
n=3334  n=1.169         
Sex
Females  1183 (35.5%)  367 (31.4%)     
Males  2151 (64.5%)  802 (68.6%)  1.17 [1.03–1.32]  .013  1.23 [1.08–1.39]  .001 
Age (yrs)
<65  1421 (42.6%)  279 (23.9%)     
65–80  1610 (48.3%)  593 (50.7%)  1.78 [1.55–2.05]  <.001  1.44 [1.24–1.68]  <.001 
>80  303 (9.1%)  297 (25.4%)  4.02 [3.41–4.74]  <.001  2.49 [2.06–3.00]  <.001 
ASA
ASA I  250 (7.50%)  26 (2.22%)     
ASA II  1965 (58.9%)  483 (41.3%)  2.22 [1.50–3.30]  <.001  1.82 [1.22–2.72]  .003 
ASA III  1039 (31.2%)  590 (50.5%)  4.70 [3.17–6.96]  <.001  2.90 [1.93–4.35]  <.001 
ASA IV  80 (2.40%)  70 (5.99%)  6.72 [4.28–10.54]  <.001  3.43 [2.15–5.48]  <.001 
Tumor location (cm)
15–13  391 (11.7%)  121 (10.4%)     
12–7  1646 (49.4%)  549 (47.0%)  1.11 [0.91–1.35]  .289  1.09 [0.84–1.40]  .521 
6–0  1297 (38.9%)  499 (42.7%)  1.27 [1.04–1.54]  .020  1.17 [0.87–1.57]  .302 
Surgical technique
Resection  2406 (722%)  675 (57.7%)     
APR  733 (22.0%)  324 (27.7%)  1.52 [1.33–1.74]  <.001  1.17 [0.98–1.39]  .092 
Hartmann  195 (5.85%)  170 (14.5%)  2.82 [2.38–3.34]  <.001  1.59 [1.33–1.90]  <.001 
Mesorectal excision
Partial  711 (21.3%)  228 (19.5%)     
Total  2623 (78.7%)  941 (80.5%)  1.12 [0.97–1.29]  .127  1.12 [0.91–1.37]  .295 
Intraoperative perforation
No  3213 (96.4%)  1064 (91.0%)     
Yes  121 (3.63%)  105 (8.98%)  2.16 [1.77–2.64]  <.001  1.39 [1.13–1.72]  .002 
Invasion of the CRM
Free  3126 (93.8%)  959 (82.0%)     
Invasion  208 (6.24%)  210 (18.0%)  2.73 [2.35–3.17]  <.001  1.84 [1.57–2.16]  <.001 
Neoadjuvant treatment
No  1269 (38.1%)  541 (46.3%)     
Yes  2065 (61.9%)  628 (53.7%)  0.74 [0.66–0.83]  <.001  1.04 [0.92–1.19]  .517 
Adjuvant treatment
No  1177 (35.3%)  489 (41.8%)     
Yes  2139 (64.2%)  674 (57.7%)  0.77 [0.69–0.87]  <.001  0.82 [0.72–0.94]  .005 
No data  18 (0.54%)  6(0.51%)  1.20 [0.54–2.68]  .659  1.09 [0.49–2.46]  .827 
Pathologic tumor stage
I  1074 (32.2%)  224 (19.2%)     
II  1026 (30.8%)  329 (28.1%)  1.49 [1.26–1.77]  <.001  1.38 [1.16–1.64]  <.001 
III  837 (25.1%)  574 (49.1%)  2.79 [2.39–3.25]  <.001  2.68 [2.27–3.17]  <.001 
180 (5.40%)  15 (1.28%)  0.42 [0.25–0.71]  .001  0.50 [0.29–0.84]  .009 
No data  217 (6.51%)  27 (2.31%)  0.64 [0.43–0.96]  .031  0.75 [0.50–1.13]  .168 
Table 3.

Influence of the Confounding Variables on Local Recurrence.

Variable  Local RecurrenceUnivariate AnalysisMultivariate Analysis
  No Event  Event  HR [95%CI]  P  HR [95%CI]  P 
  n=4224  n=279         
Sex
Female  1465 (34.7%)  85 (30.5%)     
Male  2759 (65.3%)  194 (69.5%)  1.22 [0.95–1.58]  .124  1.30 [1.01–1.69]  .045 
Age (yrs)
<65  1586 (37.5%)  114 (40.9%)     
65–80  2084 (49.3%)  119 (42.7%)  0.86 [0.67–1.11]  .253  0.76 [0.58–1.00]  .046 
>80  554 (13.1%)  46 (16.5%)  1.45 [1.03–2.04]  .035  0.97 [0.65–1.44]  .880 
ASA
ASA I  264 (6.25%)  12 (4.30%)     
ASA II  2309 (54.7%)  139 (49.8%)  1.37 [0.76–2.48]  .290  1.34 [0.74–2.44]  .334 
ASA III  1511 (35.8%)  118 (42.3%)  1.97 [1.09–3.58]  .025  1.79 [0.96–3.34]  .066 
ASA IV  140 (3.31%)  10 (3.58%)  1.95 [0.84–4.52]  .118  1.53 [0.64–3.67]  .342 
Tumor location (cm)
15–13  487 (11.5%)  25 (8.96%)     
12–7  2070 (49.0%)  125 (44.8%)  1.21 [0.79–1.86]  .383  0.91 [0.53–1.56]  .737 
6–0  1667 (39.5%)  129 (46.2%)  1.57 [1.02–2.41]  .040  1.33 [0.73–2.43]  .350 
Surgical technique
Resection  2927 (69.3%)  154 (55.2%)     
APR  985 (23.3%)  72 (25.8%)  1.46 [1.11–1.94]  .008  0.81 [0.57–1.16]  .260 
Hartmann  312 (7.39%)  53 (19.0%)  3.84 [2.81–5.24]  <.001  2.50 [1.79–3.51]  <.001 
Mesorectal excision
Partial  895 (21.2%)  44 (15.8%)     
Total  3329 (78.8%)  235 (84.2%)  1.45 [1.05–2.00]  .025  1.50 [0.97–2.32]  .071 
Intraoperative perforation
No  4048 (95.8%)  229 (82.1%)     
Yes  176 (4.17%)  50 (17.9%)  4.97 [3.66–6.75]  <.001  2.78 [1.98–3.90]  <.001 
Invasion of the CRM
Free  3881 (91.9%)  204 (73.1%)     
Invasion  343 (8.12%)  75 (26.9%)  4.63 [3.55–6.03]  <.001  2.90 [2.15–3.91]  <.001 
Neoadjuvant treatment
No  1694 (40.1%)  116 (41.6%)     
Yes  2530 (59.9%)  163 (58.4%)  0.90 [0.71–1.14]  .397  1.06 [0.81–1.40]  .655 
Adjuvant treatment
No  1574 (37.3%)  92 (33.0%)     
Yes  2628 (62.2%)  185 (66.3%)  1.13 [0.88–1.46]  .325  0.95 [0.71–1.27]  .722 
No data  22 (0.52%)  2 (0.72%)  1.94 [0.48–7.87]  .355  1.83 [0.45–7.51]  .400 
Pathologic tumor stage
I  1248 (29.5%)  50 (17.9%)     
II  1275 (30.2%)  80 (28.7%)  1.61 [1.13–2.30]  .008  1.28 [0.88–1.84]  .194 
III  1272 (30.1%)  139 (49.8%)  2.99 [2.16–4.13]  <.001  2.22 [1.56–3.14]  <.001 
192 (4.55%)  3 (1.08%)  0.38 [0.12–1.21]  .100  0.37 [0.12–1.20]  .098 
No data  237 (5.61%)  7 (2.51%)  0.74 [0.34–1.64]  .462  0.77 [0.35–1.71]  .523 
Table 4.

Influence of the Confounding Variables on Metastasis.

Variable  Metastasis During Follow-UpUnivariate AnalysisMultivariate Analysis
  No Event  Event  HR [95%CI]  P  HR [95%CI]  P 
  n=3673  n=833         
Sex
Females  1274 (34.7%)  277 (33.3%)     
Males  2399 (65.3%)  556 (66.7%)  1.07 [0.93–1.24]  .330  1.11 [0.96–1.29]  .150 
Age (yrs)
<65  1372 (37.4%)  330 (39.6%)     
65–80  1815 (49.4%)  389 (46.7%)  0.96 [0.83–1.11]  .600  0.92 [0.79–1.07]  .278 
>80  486 (13.2%)  114 (13.7%)  1.20 [0.97–1.48]  .094  1.02 [0.80–1.29]  .904 
ASA
ASA I  241 (6.56%)  35 (4.20%)     
ASA II  1989 (54.2%)  461 (55.3%)  1.58 [1.12–2.23]  .009  1.55 [1.09–2.19]  .014 
ASA III  1319 (35.9%)  311 (37.3%)  1.77 [1.25–2.51]  .001  1.65 [1.15–2.38]  .007 
ASA IV  124 (3.38%)  26 (3.12%)  1.75 [1.05–2.91]  .031  1.59 [0.94–2.70]  .082 
Tumor location (cm)
15–13  416 (11.3%)  96 (11.5%)     
12–7  1829 (49.8%)  368 (44.2%)  0.90 [0.72–1.13]  .378  0.84 [0.63–1.13]  .252 
6–0  1428 (38.9%)  369 (44.3%)  1.14 [0.91–1.43]  .241  0.99 [0.71–1.40]  .972 
Surgical technique
Resection  2579 (70.2%)  505 (60.6%)     
APR  819 (22.3%)  238 (28.6%)  1.50 [1.29–1.75]  <.001  1.21 [0.99–1.49]  .067 
Hartmann  275 (7.49%)  90 (10.8%)  1.95 [1.55–2.44]  <.001  1.52 [1.20–1.93]  <.001 
Mesorectal excision
Partial  775 (21.1%)  164 (19.7%)     
Total  2898 (78.9%)  669 (80.3%)  1.09 [0.92–1.29]  .318  1.10 [0.85–1.41]  .474 
Intraoperative perforation
No  3520 (95.8%)  760 (91.2%)     
Yes  153 (4.17%)  73 (8.76%)  2.23 [1.76–2.84]  <.001  1.41 [1.09–1.82]  .008 
Invasion of the CRM
Free  3411 (92.9%)  677 (81.3%)     
Invasion  262 (7.13%)  156 (18.7%)  2.95 [2.48–3.51]  <.001  1.76 [1.46–2.13]  <.001 
Neoadjuvant treatment
No  1492 (40.6%)  318 (38.2%)     
Yes  2181 (59.4%)  515 (61.8%)  1.05 [0.91–1.21]  .507  1.25 [1.07–1.47]  .006 
Adjuvant treatment
No  1420 (38.7%)  247 (29.7%)     
Yes  2232 (60.8%)  583 (70.0%)  1.36 [1.18–1.58]  <.001  0.96 [0.81–1.13]  .618 
No data  21 (0.57%)  3 (0.36%)  1.00 [0.32–3.12]  .998  0.73 [0.23–2.27]  .582 
Pathologic tumor stage
I  1182 (32.2%)  116 (13.9%)       
II  1138 (31.0%)  217 (26.1%)  1.94 [1.55–2.43]  <.001  1.76 [1.40–2.22]  <.001 
III  941 (25.6%)  473 (56.8%)  4.72 [3.85–5.79]  <.001  4.28 [3.45–5.30]  <.001 
187 (5.09%)  8 (0.96%)  0.43 [0.21–0.88]  .021  0.40 [0.19–0.81]  .011 
No data  225 (6.13%)  19 (2.28%)  0.87 [0.54–1.42]  .584  0.82 [0.50–1.33]  .420 

The results of the logistic regression model, with the hospital variable as a random effect, showed a significant variation among the hospitals for all the result variables (Figs. 5–7).

Fig. 5.

Differences in survival rates among the hospitals studied. The hospitals are represented in the vertical axis with their assigned number code for the project. The HR value is shown for each hospital.

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Fig. 6.

Differences in local recurrence rates among the hospitals studied. The hospitals are represented on the vertical axis with the number code assigned to them in the project. The HR value is shown for each hospital.

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Fig. 7.

Differences in the rates of metastasis among the hospitals studied. The hospitals are represented on the vertical axis with the number code assigned to each hospital in the project. The HR value is shown for each hospital.

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Discussion

This study shows a local recurrence rate of 7.3% (95% CI: 6.5–8.2), metastasis during follow-up of 21% (95% CI: 19.7–22.4) and overall survival of 72.3% (95% CI: 70.9–73.8) observed in the Rectal Cancer Project in a cohort of 4508 consecutive patients followed for 5 years.

The greatest weakness of this study has to do with the voluntary nature of inclusion of the data in the AEC Rectal Cancer Project, especially when compared to the registries of the Scandinavian countries,6–8 in which the inclusion of data in the registry is mandatory. However, as already indicated in more detail,9 various initiatives have been taken to avoid voluntary or involuntary inclusion and information biases. Unfortunately, due to the anonymous nature of the data and the lack of other sources to verify the information in our country, the data from this study indicate the recorded rates of local recurrence, metastasis and overall survival.

The risk factors for tumor recurrence, and therefore worse oncological results, coincide with previous descriptions10 (tumor perforation, CRM invasion, advanced tumor stages and Hartmann procedure) with no significant associations.

The results observed in the AEC Rectal Cancer Project are lower than those observed in the Scandinavian registries that we attempt to emulate. The local recurrence rate (7.3%) is higher than that observed in Norway (5.0%)6 and Sweden (4.0%)7; this result indicator is not evaluated in the Danish registry.8 The overall survival rate in this project (72.3%) is between the rates published by the Norwegian and Swedish registries (81%)7 and the Danish registry (68%).8

In addition, the rate of local recurrence observed in this study, in which the results of 59 hospitals have been used, has been slightly higher than the rate observed in a previous analysis of the data provided by the first 36 hospitals integrated in the study (6.6%).10 However, this negative variation of the results has also been observed in the Norwegian and Swedish registries, in which the local recurrence figures have increased from 3 to 5 and 4%, respectively.7 So, perhaps the explanation of this fact could be attributed to the loss of attention of the multidisciplinary teams of some hospitals and to interhospital differences.

In conclusion, the results of this study indicate that the results observed in the AEC Rectal Cancer Project are inferior to those observed in the Scandinavian registries that we try to emulate, and that this is attributable to the variability of the practice at some hospitals.

Authorship

All the authors have participated in the study design, article composition, critical review and approval of the final version. María Buxó was responsible for the data collection, data analysis and statistical analysis.

Conflict of Interests

The authors have no conflict of interests to declare.

Acknowledgements

The authors would like to thank Dr. Hector Ortiz for his coordination of the Vikingo Project and this pAPR.

Appendix
Workgroup (2006–2012)

Hospital Virgen de la Arrixaca (J.A. Lujan Mompean)

Hospital Universitari de Bellvitge (S. Biondo, D. Fracalvieri)

Hospital Virgen del Camino-Complejo Hospitalario de Navarra (M. de Miguel Velasco, M.A. Ciga Lozano)

Hospital Clínico Universitario de Valencia (A. Espí Macias)

Hospital Universitari de Girona Dr. Josep Trueta (A. Codina Cazador, F. Olivet Pujol)

Hospital de Sagunto (M.D. Ruiz Carmona)

Hospital Universitari Vall d’Hebron de Barcelona (E. Espin Basany, Fancesc Vallribera)

Hospital Universitario La Fe de Valencia (E. Garcia-Granero, R. Palasí Gimenez)

Complejo Hospitalario de Ourense (A. Parajo Calvo)

Hospital Universitari Germans Trias i Pujol de Badalona (I. Camps Ausas, M. Piñol Pascual)

Hospital Lluis Alcanyis de Xàtiva (V. Viciano Pascual)

Complejo Asistencial de Burgos (E. Alonso Alonso)

Hospital del Mar de Barcelona (M. Pera Roman)

Complejo Asistencial de Salamanca (J. Garcia Garcia)

Hospital Gregorio Marañón de Madrid (M. Rodriguez Martin)

Hospital Torrecárdenas de Almería (A. Reina Duarte)

Hospital General Universitario de Valencia (M.J. Garcia Coret, M. Garcia Botella)

Hospital Txagorritxu de Vitoria (J. Errasti Alustiza)

Hospital Donostia (J.A. Múgica Martinera)

Hospital Universitario Reina Sofía de Córdoba (J. Gomez Barbadillo)

Hospital General Juan Ramón Jimenez de Huelva (M. Orelogio Orozco, R. Rada Morgades)

Hospital Arnau de Vilanova de Valencia (N. Uribe Quintana)

Hospital General de Jerez (J. de Dios Franco Osorio)

Hospital General Universitario de Elche (A. Arroyo Sebastian)

Hospital Universitario Arnau de Vilanova de Lleida (J.E. Sierra Grañon)

Hospital Universitari de la Santa Creu i Sant Pau de Barcelona (P. Hernandez Casanovas, M. Martinez, J. Bollo)

Hospital Clínico Universitario de Santiago de Compostela (J. Paredes Cotore)

Complejo Hospitalario de Jaén (G. Martinez Gallego, J. Gutierrez)

Hospital Clínico San Carlos de Madrid (M. Garcia Alonso)

Hospital de Cabueñes de Gijón (G. Carreño Villarreal)

Hospital General de Albacete (J. Cifuentes Tebar)

Hospital Miguel Servet de Zaragoza (J. Monzón Abad)

Hospital Xeral de Lugo (O. Maseda Díaz)

Hospital Universitario de Fuenlabrada (D. Huerga Alvarez)

Hospital Clínico y Provincial de Barcelona (L. Flores)

Hospital Universitari Joan XXIII de Tarragona (M. Millan Schediling)

Hospital Universitario Virgen de las Nieves (I. Segura Jimenez, P. Palma Carazo)

Hospital Nuestra Señora de la Candelaria de Tenerife (J.G. Díaz Mejías)

Complejo Hospitalario de Badajoz (J. Salas Martínez)

Hospital Clínico Universitario San Cecilio de Granada (F. Pérez Benítez)

Hospital de Requena (J.C. Bernal Sprekelsen)

Hospital General Universitario de Alicante (F. Lluis Casajuana)

Hospital Virgen Macarena de Sevilla (L. Capitán Morales, J. Valdés Hernández)

Complejo Hospitalario de Vigo (Xeral + Meixoeiro) (E. Casal Nuñez, N. Cáceres Alvarado)

Hospital Infanta Sofía de Madrid (J. Martinez Alegre, R. Cantero Cid)

Hospital Policlínico Povisa de Vigo (A.M. Estevez Diz)

Hospital Virgen del Rocío de Sevilla (M. Victoria Maestre, J.M. Díaz Pavón)

Hospital San Juan de Dios del Aljarafe de Sevilla (M. Reig Pérez, A. Amaya Cortijo)

Hospital Nuestra Señora de Sonsoles de Ávila (J.A. Carmona Saez)

Hospital Universitario de Getafe (F.J. Jimenez Miramón)

Hospital General de Granollers (D. Ribé Serrat)

Hospital Universitario La Paz de Madrid (I. Prieto Nieto)

Hospital Dr. Peset de Valencia (T. Torres Sanchez, E. Martí Martínez)

Hospital General Rafael Mendez de Murcia (S. Rodrigo del Valle, G.S anchez de la Villa)

Hospital General Reina Sofía de Murcia (P. Barra Baños)

Hospital San Pedro de Alcántara de Cáceres (F. Romero Aceituno)

Hospital Torrevieja Salud (UTE) (A. Garcea)

Hospital de Santa María de Lleida (R. Batlle Solé)

Hospital Virgen del Puerto de Plasencia (J.A. Pérez García)

Hospital de Segovia (G. Ais Conde)

Hospital de Reus (S. Blanco)

Instituto Valenciano de Oncología (IVO) (A. García Fadrique, R. Estevan Estevan)

Hospital de Viladecans (A. Sueiras Gil)

Hospital de Cruces (J.M. García García, A. Lamiquiz Vallejo)

Hospital Universitario Ramón y Cajal de Madrid (J. Die Trill)

Hospital de Manises (A. Solana Bueno)

Hospital La Ribera, Alzira (F.J. Blanco Gonzalez)

Hospital Nuestra Señora del Rosell (A. Lage Laredo)

Hospital de Mérida (J.L. Dominguez Tristancho)

Hospital Universitario Fundación Alcorcón (P. Dujovne Lindenbaum)

Hospital de Henares, Coslada (N. Palencia García)

Hospital de Vinaroz (R. Adell Carceller)

Onkologika de San Sebastian (R. Martinez Pardavila)

Consorci Sanitari Integral (Hospital General de L’Hospitalet y Hospital Moisés Broggi) (L. Ortiz de Zarate)

Complejo Hospitalario de Palencia (A.M. Huidobro Piriz)

Fundación Jimenez Díaz (C. Pastor Idoate)

Hospital de Torrejón (J.A. Garijo Alvarez)

Hospital Puerto Real de Cádiz (M. de la Vega Olías)

Hospital Espíritu Santo de Santa Coloma de Gramanet (M. López Lara)

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Effect of hospital caseload on long-term outcome after standardization of rectal cancer surgery in the Spanish Rectal Cancer Project.

In Appendix you can consult the list of the participating centers in the Project of the Ca’ncer de Recto of the Spanish Association of Surgeons.

Please cite this article as: Codina Cazador A, Biondo S, Basany EE, Enriquez-Navascues JM, Garcia-Granero E, Roig Vila JV, et al. Resultados oncológicos del Proyecto docente del Cáncer de Recto en España 10 años después de su inicio. Cir Esp. 2017;95:577–587.

Copyright © 2017. AEC
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