Postoperative Outcomes of Screen-Detected vs Non-Screen-Detected Colorectal Cancer in the Netherlands

Abstract

Importance: The nationwide fecal immunochemical test-based screening program has influenced surgical care for patients with colorectal cancer (CRC) in the Netherlands, although these implications have not been studied in much detail so far.

Objective: To compare surgical outcomes of patients diagnosed as having CRC through the fecal immunochemical test-based screening program (screen detected) and patients with non-screen-detected CRC.

Design, setting, and participants: This was a population-based comparative cohort study using the Dutch ColoRectal Audit and analyzed all Dutch hospitals performing CRC resections. Patients who underwent elective resection for CRC between January 2011 to December 2016 were included.

Interventions: Colorectal cancer surgery.

Main outcomes and measures: Postoperative nonsurgical complications, postoperative surgical complications, postoperative 30-day or in-hospital mortality, and complicated course (postoperative complication resulting in a hospital stay >14 days and/or a reintervention and/or mortality). A risk-stratified comparison was made for different postoperative outcomes based on screening status (screen detected vs not screen detected), cancer stage (I-IV), and for cancer stage I to III also on age (aged ≤70 years and >70 years) and American Society of Anesthesiologists score (I-II and III-IV). To determine any residual case-mix-corrected differences in outcomes between patients with screen-detected and non-screen-detected cancer, univariable and multivariable logistic regression analyses were performed.

Results: In total, 36 242 patients with colon cancer and 17 416 patients with rectal cancer were included for analysis. Compared with patients with non-screen-detected CRC, screen-detected patients were younger (mean [SD] age, 68 [5] vs 70 [11] years), more often men (3777 [60%] vs 13 506 [57%]), and had lower American Society of Anesthesiologists score (American Society of Anesthesiologists score III+: 838 [13%] vs 5529 [23%]). Patients with stage I to III colon cancer who were screen detected had a significantly lower mortality and complicated course rate compared with non-screen-detected patients. For patients with rectal cancer, only a significant difference was found in mortality rate in patients with a cancer stage IV disease, which was higher in the screen-detected group. Compared with non-screen-detected colon cancer, an independent association was found for screen-detected colon cancer on nonsurgical complications (adjusted odds ratio, 0.81; 95% CI, 0.73-0.91), surgical complications (adjusted odds ratio, 0.80; 95% CI, 0.72-0.89), and complicated course (adjusted odds ratio, 0.80; 95% CI, 0.71-0.90). Screen-detected rectal cancer had significantly higher odds on mortality.

Conclusions and relevance: Postoperative outcomes were significantly better for patients with colon cancer referred through the fecal immunochemical test-based screening program compared with non-screen-detected patients. These differences were not found in patients with rectal cancer. The outcomes of patients with screen-detected colon cancer were still better after an extensive case-mix correction, implying additional underlying factors favoring patients referred for surgery through the screening program.

Figure 1.. Trends of Postoperative Adverse Outcomes for Non–Screen-Detected, Screen-Detected, and Overall Colorectal Cancer

Trends of different outcomes (complicated course and mortality), separately shown for colon and rectal cancer. From 2014 and on, the outcomes are shown separately for 3 subgroups: (1) overall (all patients), (2) non–screen-detected patients, and (3) screen-detected patients.

Figure 2.. Risk-Stratified Comparison of Postoperative Adverse Outcomes for Non–Screen-Detected and Screen-Detected Colorectal Cancer

Risk-stratified comparison on outcomes (complicated course and mortality) between screen-detected and non–screen-detected patients for colon and rectal cancer separately. A, Colon cancer, differences in outcomes for pathologic (p) tumor stage I to IV (and other) between screening and nonscreening patients. B, Rectal cancer, differences in outcomes for clinical (c) tumor stage I to IV (and other) between screening and nonscreening patients. C, Colon cancer, differences in outcomes of patients with tumor stage I to III (pT1-3N0-2M0) stratified on age (≤70 y vs >70 y) and American Society of Anesthesiologists (ASA) score (I-II vs III-IV). D, Rectal cancer, differences in outcomes of patients with tumor stage I to III (cT1-3N0-2M0) stratified on age (≤70 y vs >70 y) and ASA score (I-II vs III-IV). Missing values in Figure 2C not screen detected, n = 14; screen detected, n = 1. Missing values in Figure 2D not screen detected, n = 9; screen detected, n = 0. ^aSignificant difference (χ²) between screen-detected and non–screen-detected patients.