The Uptake of Laparoscopic Rectal Cancer Surgery: 2004-2014
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Background: Colorectal cancer is the second most common malignancy in Canadian males, and third most common malignancy in Canadian females; approximately thirty percent of colorectal cancers are tumors of the rectum (rectal cancer). Surgery is the cornerstone of treatment for most patients with rectal cancer, often combined with adjuvant or neoadjuvant chemotherapy and/or radiation. Traditionally, surgery was accomplished through an open approach with a midline abdominal incision (open surgery or OS). Over the past decade, success with laparoscopic colon cancer surgery has led to the introduction of minimally invasive rectal cancer surgery. Laparoscopic rectal cancer surgery (LS) has some clear advantages over OS, including decreased patient morbidity and decreased length of hospital stay. Randomized data has also demonstrated equivalent disease-free survival, overall survival and rates of local recurrence between LS and OS. The use of LS for rectal cancer has increased internationally. Currently, the uptake of LS for rectal cancer in Canada is unknown. Objectives: The overall objective of this study was to describe and better understand the uptake of LS for rectal cancer in Canada. Specific objectives included: 1) To describe the national and provincial uptake of LS for rectal cancer Canada, as defined by the proportion of rectal cancer surgeries performed laparoscopically, from fiscal years 2004-2014; 2) To identify geographic, patient, surgeon and hospital characteristics associated with the use of LS; and 3) To describe the content and timing of provincial policies regarding financial remuneration for LS, and to correlate these with provincial uptake of LS for rectal cancer. Methods: This was a retrospective cohort study using the Discharge Abstract Database held by the Canadian Institute for Health Information. All patients 18 or older with a Canadian postal code who underwent surgery for rectal cancer between 2004-2014 in Canada (except Quebec) were identified. Patients who were pregnant, underwent emergency surgery or a complex resection were excluded. The annual provincial and national uptake of LS was calculated. Univariable and multivariable logistic regression models were created to estimate the effects of geographic, patient, surgeon and hospital factors on the uptake of LS. Province-specific figures graphing the proportion of LS over time were created, with the year of financial incentive indicated. Results: We identified 28,455 patients with rectal cancer who underwent radical rectal resection; 17.6% underwent LS and 82.4% OS. The use of LS for rectal cancer increased in Canada from 5.9% in 2004 to 34.0% in 2014. There was significant interprovincial variation in the use of LS over time. In 2014, uptake of LS was highest in PE, ON and BC. On multivariable analysis, age-category, sex, comorbidity score, urban/rural status, surgeon/hospital volume, type of surgical resection, year and specific province were associated with the uptake of LS. Year and specific province were the strongest predictors of LS. Financial incentive appeared to be associated with the uptake of LS in ON and BC, but not NS. Conclusion: There is marked interprovincial variation in the use of LS for rectal cancer. We have identified several geographic, patient, surgeon and hospital factors associated with the use of LS for rectal cancer. This study provides the first pan-Canadian description of the use of LS for rectal cancer and has identified potential targets for further implementation of LS.