Minimally Invasive Colorectal Cancer Surgery in Europe: Implementation and Outcomes

Abstract

Minimally invasive surgery (MIS) of colorectal cancer (CRC) was first introduced over 20 years ago and recently has gained increasing acceptance and usage beyond clinical trials. However, data on dissemination of the method across countries and on long-term outcomes are still sparse.In the context of a European collaborative study, a total of 112,023 CRC cases from 3 population-based (N = 109,695) and 4 institute-based clinical cancer registries (N = 2328) were studied and compared on the utilization of MIS versus open surgery. Cox regression models were applied to study associations between surgery type and survival of patients from the population-based registries. The study considered adjustment for potential confounders.The percentage of CRC patients undergoing MIS differed substantially between centers and generally increased over time. MIS was significantly less often used in stage II to IV colon cancer compared with stage I in most centers. MIS tended to be less often used in older (70+) than in younger colon cancer patients. MIS tended to be more often used in women than in men with rectal cancer. MIS was associated with significantly reduced mortality among colon cancer patients in the Netherlands (hazard ratio [HR] 0.66, 95% confidence interval [CI] (0.63-0.69), Sweden (HR 0.68, 95% CI 0.60-0.76), and Norway (HR 0.73, 95% CI 0.67-0.79). Likewise, MIS was associated with reduced mortality of rectal cancer patients in the Netherlands (HR 0.74, 95% CI 0.68-0.80) and Sweden (HR 0.77, 95% CI 0.66-0.90).Utilization of MIS in CRC resection is increasing, but large variation between European countries and clinical centers prevails. Our results support association of MIS with substantially enhanced survival among colon cancer patients. Further studies controlling for selection bias and residual confounding are needed to establish role of MIS in survival of patients.

FIGURE 1

Age-standardized trend of utilization of MIS in patients with colon (A) and rectal cancer (B) between 2007 and 2014. The by far largest database (NNCR) was used as standard population for age standardization. IJB = Institute Jules Bordet in Brussels, IPO-Porto = Portuguese Institute of Oncology in Porto, NCR = Norwegian Cancer Registry, NCT-HD = National Centre for Tumor Diseases in Heidelberg, NKI = Netherlands Cancer Institute, NNCR = Netherlands National Cancer Registry, SCRCR = Swedish Colorectal Cancer Registry.

FIGURE 2

Survival of patients undergoing minimally invasive surgery (MIS) or open resectional surgery (ORS) estimated from Cox regression models with adjustment for sex, age group, tumor stage, neoadjuvant therapy, examined lymph nodes, colon tumor location (for colon cancer group only) in Netherlands (NNCR), Sweden (SCRCR), and Norway (NCR). Emergent surgeries excluded in SCRCR data (n = 5074; 14%). NCR = Norwegian Cancer Registry, NNCR = Netherlands National Cancer Registry, SCRCR = Swedish Colorectal Cancer Registry.