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Detection of grade 3–4 extra mural venous invasion (mrEMVI) on magnetic resonance imaging (MRI) is associated with an increased distant metastases (DM)-rate. This study aimed to determine the impact of different grades of mrEMVI and their disappearance after neoadjuvant therapy. A Dutch national retrospective cross-sectional study was conducted, including patients who underwent resection for rectal cancer in 2016 from 60/69 hospitals performing rectal surgery. Patients with a cT3-4 tumour ≤8 cm from the anorectal junction were selected and their MRI-scans were reassessed by trained abdominal radiologists. Positive mrEMVI grades (3 and 4) were analyzed in regard to 4-year local recurrence (LR), DM, disease-free survival (DFS) and overall survival (OS). The 1213 included patients had a median follow-up of 48 months (IQR 30–54). Positive mrEMVI was present in 324 patients (27%); 161 had grade 3 and 163 had grade 4. A higher mrEMVI stage (grade 4 vs grade 3 vs no mrEMVI) increased LR-risk (21% vs 18% vs 7%, <0.001) and DM-risk (49% vs 30% vs 21%, p < 0.001) and decreased DFS (42% vs 55% vs 69%, p < 0.001) and OS (62% vs 76% vs 81%, p < 0.001), which remained independently associated in multivariable analysis. When mrEMVI had disappeared on restaging MRI, DM-rate was comparable to initial absence of mrEMVI (both 26%), whereas LR-rate remained high (22% vs 9%, p = 0.006). The negative oncological impact of mrEMVI on recurrence and survival rates was dependent on grading. Disappearance of mrEMVI on restaging MRI decreased the risk of DM, but not of LR. [ABSTRACT FROM AUTHOR]

The revised Dutch colorectal cancer guideline (2014), led to an overall decrease in preoperative radiotherapy (RT) use. This study evaluates hospital variation in RT use for resectable rectal cancer and the influence of guideline revision, including the nationwide impact of changing RT application on short term outcomes. Data of surgically resected rectal cancer patients registered in the Dutch ColoRectal Audit were extracted between 2011 and 2017. Patients were divided into groups based on time of guideline revision (<2014 and ≥ 2014). Primary outcome was guideline adherence at hospital level regarding RT application, stratified for three stage groups. Secondary outcomes included positive circumferential resection (CRM+) and 30-day complicated postoperative course. The groups consisted of 7364 and 12,057 patients, respectively. In total, 6772 patients did not receive RT (17.6% (<2014) vs. 45.7% (≥2014), p < 0.001). The largest increase of surgery alone was observed for cT1-2N0 stage rectal cancer (35.1% vs. 91.8%, p < 0.001), with a substantial decrease in hospital variation (IQR 22.2–50.0% vs. IQR 87.6–98.0%). For cT1-3N1MRF- stage rectal cancer, a substantial amount of hospital variation in short course RT remained after guideline revision (IQR 26.8–54.1% vs. IQR 26.2–50.0%). A significant decrease in CRM+ (5.8% vs. 4.2%, p < 0.001) and complicated course (22.5% vs. 18.5%, p < 0.001) was observed. Radiotherapy for early-stage rectal cancer was uniformly abandoned after guideline revision, while substantial hospital variation remained for intermediate risk resectable rectal cancer in the Netherlands. The substantial nationwide decrease in the use of RT for rectal cancer treatment did not negatively impact CRM involvement. [ABSTRACT FROM AUTHOR]

Optimized treatment of primary rectal cancer might have influenced treatment characteristics and outcome of locally recurrent rectal cancer (LRRC). Subgroup analysis of the Dutch TME trial showed that preoperative radiotherapy (PRT) for the primary tumour was an independent poor prognostic factor after diagnosis of LRRC. This cross-sectional population study aimed to evaluate treatment and overall survival (OS) of LRRC patients, stratified for prior preoperative radiotherapy (PRT) and intention of treatment of LRRC. All patients developing LRRC were selected from a collaborative Snapshot study on 2095 surgically treated rectal cancer patients from 71 Dutch hospitals in the year 2011. Cox proportional hazard analysis was performed to determine predictors for OS. A total of 107 LRRC patients (5.1%) were included, of whom 88 (82%) underwent PRT for their primary tumour. LRRC was treated with initial curative intent in 31 patients (29%), with eventual resection in 20 patients (19%). Median OS was 22 and 8 months after curative and palliative intent treatment, respectively (p < 0.001). Initial CRM positivity and palliative intent treatment were associated with worse OS after LRRC, while prior PRT was not. This cross-sectional study revealed that rectal cancer patients, who underwent curative resection in the Netherlands in 2011 and subsequently developed local recurrence, were amenable for again curative intent treatment in 29%, with a corresponding median survival of 22 months. Prior PRT was not significantly associated with survival after diagnosis of LRRC. [ABSTRACT FROM AUTHOR]

A prolonged time interval between chemoradiation and total mesorectal excision (TME) may render more rectal cancer patients eligible for organ-sparing approaches but may also cause more pelvic fibrosis and surgical morbidity. We estimated the effect of time interval on postoperative complications and other surgical outcomes in rectal cancer patients. This is a population-based cohort study using data of the Dutch Colorectal Audit. Rectal cancer patients treated with chemoradiation followed by TME after an interval of 3–20 weeks were selected (n = 6,268). Time interval from completion of chemoradiation to TME was categorized into 3–6, 7–8, 9–10, 11–12 and 13–20 weeks. Outcomes included postoperative complication (any, and stratified by medical and surgical complications), reintervention, intraoperative complication, incomplete resection, positive circumferential margin (CRM) and pathological complete response (pCR). The interval of 7–8 weeks was the reference group. Prolonged time intervals were not associated with a higher risk of a postoperative complication (any, surgical or medical), reintervention, and incomplete resection. Intraoperative complications were however more common after 11–12 weeks than after 7–8 weeks (odds ratio (OR) = 1.79, 95% confidence interval (CI) = 1.20–2.69). The interval of 9–10 weeks was associated with less CRM positive resections, and 9–10 and 13–20 weeks with more pCR (relative to 7–8 weeks, OR = 0.74, 95%CI = 0.56–0.98; OR = 1.28, 95%CI = 1.04–1.58; and OR = 1.33, 95%CI = 1.04–1.71, respectively). Compared with 7–8 weeks, longer time intervals up to 13–20 weeks between chemoradiation and TME are not associated with more postoperative complications or more positive resection margins. Accordingly, prolonging the interval aiming for organ-sparing treatment is safe. [ABSTRACT FROM AUTHOR]

Background The rate of preoperative radiotherapy (RT) for rectal cancer in the Netherlands has been the highest among European countries. Revision of the national guideline on colorectal cancer, officially published in 2014, specifically focussed on the indication for RT and MRI criteria to evaluate mesorectal lymph nodes. The objective of this study was to evaluate implementation of the revised guideline using a national audit. Methods Data of the Dutch Surgical Colorectal Audit (DSCA) between 2009 and 2014 were used to evaluate RT use and RT regimen for relevant subgroups of cM0 rectal cancer patients, as well as accuracy of pre-operative MRI. Results 14,018 patients were included for analysis. Overall RT use in cT1-4N0-2M0 stage ranged from 81.4% to 84.2% between 2009 and 2013, and decreased to 64.4% in 2014. The absolute decrease in RT use from 2013 to 2014 for cT1N0, cT2N0 and cT3N0 stage was 32.8%, 43.5% and 31.6%, respectively. Short course RT with delayed surgery was used as an alternative to chemoradiotherapy up to 2013 in 30.6% of patients over 80 years, and in 12.1% of patients with an ASA score >2; these percentages increased to 45.8% and 19.9% in 2014, respectively. Specificity of MRI for N-stage decreased from 82.9% in 2009 to 62.9% in 2013, with an increase to 73.2% in 2014. Conclusion The revised national guideline on colorectal cancer was rapidly implemented in the Netherlands with a substantial decrease in RT use for low risk resectable rectal cancer, and increased specificity of MRI for N-staging. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: Internationally, the use of preoperative radiotherapy (RT) for rectal cancer varies largely, related to different decision-making based on the harm-benefit ratio. In the Dutch guideline, RT is indicated in all cT2-4 tumours. We aimed to evaluate the use of RT in the Netherlands and to discuss Dutch practice in the context of current literature. Methods: Data of the Dutch Surgical Colorectal Audit (DSCA) were used and 6784 patients surgically treated for primary rectal cancer in 2009–2011 were included. The application and type of RT were described according to age, comorbidity, tumour localization and tumour stage at population level with analysis of hospital variation for specific subsets. Results: In total, 85% of patients who underwent resection for rectal cancer received RT. Comorbidity (Charlson Comorbidity Index 2+) and older age (≥70 years) were associated with a slight decrease in application of RT (75 and 80% respectively). In stage I tumours, 77% of patients received RT, but large hospital variation existed (0–100%). The proportion chemoradiotherapy of the whole group of RT increased with increasing N-stage, increasing T-stage, decreasing distance from the anus, younger age and less comorbidity with hospital variation from 0 to 73%. Conclusion: From a European perspective, a high percentage of rectal cancer patients are treated with RT in the Netherlands. Considerable hospital variation was observed for RT in stage I and the proportion of chemoradiotherapy among all RT schemes. Data from clinical auditing enable evaluation of national practice and current standards from both a scientific and international perspective. [Copyright &y& Elsevier]

Abstract: Aim: To provide insight into professionals’ opinions on breast cancer follow-up to facilitate implementation of new follow-up strategies. The study focuses on current practice, purpose and perceived effects, and preferred frequency and duration of follow-up. Design: A 29-item questionnaire on professionals’ demographics, current practice, opinion on the current guideline, preferences in frequency and duration of tailored follow-up, and the purpose and perceived effects of follow-up was sent to 633 Dutch professionals. Results: The current national guideline is followed by 81% of respondents. All different specialists are involved in follow-up. Sixty-nine percent of respondents’ report nurse practitioners to be involved in follow-up. When asked for tailored follow-up, professionals indicate more factors for increased follow-up (age<40 years, pT3-4 tumour, pN2-3, treatment related morbidity, and psychosocial support), than for reduced schedules (age >70 years and DCIS histology). Alternative forms of follow-up are not endorsed by >90% of respondents. Detection of a new primary tumour of the breast is considered the most important purpose of follow-up (98%), 57% still indicates detecting metastases as a goal. Conclusions: Professionals tend towards longer and more intensive follow-up than the current guideline for a large group of patients. Limitations and developments in follow-up need to be considered to facilitate alternative follow-up strategies. [Copyright &y& Elsevier]

Abstract: Aim of the study: In patients from the Dutch TME trial patterns of local recurrence (LR) in rectal cancer were studied. The purpose was to reconstruct the most likely mechanisms of LR and the effect of preoperative radiotherapy. Methods: 1417 patients were analyzed; 713 were randomized into preoperative radiotherapy and total mesorectal excision (RT + TME), 704 into TME alone. Of the 114 patients with LR, the subsites of LR were determined and related to tumor and treatment factors. Results: Overall 5-year LR-rate was 4.6% in the RT + TME group and 11.0% in the TME group. Presacral local recurrences occurred most in both groups. Radiotherapy reduced anastomotic LR significantly, except when after low anterior resection (LAR) distal margins were less than 5 mm. Abdominoperineal resection (APR) mainly resulted in presacral LR. Even after resection with a negative circumferential resection margin, LR-rates were high. Thirty percent of the patients had advanced tumors, which resulted in 58% of all LRs. Lateral LR comprised 20% of all LR. Presacral and lateral LR resulted in a poor prognosis, in contrast to anterior or anastomotic LRs with a relatively good prognosis. Conclusions: RT reduces LR in all subsites and is especially effective in preventing anastomotic LR after LAR. APR-surgery mainly results in presacral LR, which may be prevented by a wider resection. In the TME trial many advanced tumors were included, rather requiring chemoradiotherapy instead of RT. Currently, with good imaging techniques, better selection can take place. Especially lateral LR might be a problem in the future. [Copyright &y& Elsevier]

Abstract: Aim: To elicit surgery preferences of patients who have experience with either low anterior resection (LAR) or abdominoperineal resection (APR) and its outcomes, to support decision-making in future patients with resectable rectal cancer. Methods: One hundred and twenty-two patients were interviewed. Surgery preference was assessed in two ways. In the treatment trade-off method, the certainty of a stoma was hypothetically weighed against the risk of incontinence. In the time trade-off method, remaining life expectancy was traded off to avoid a permanent stoma or faecal incontinence. Results: To avoid APR, LAR patients accepted a much higher risk of incontinence than APR patients. In fact, 71% of the LAR patients chose LAR if they would certainly suffer monthly incontinence, and still 32% if they would certainly suffer daily incontinence. Nevertheless, APR patients would give up less remaining life years to be without a permanent stoma than LAR patients to be without monthly incontinence. Conclusions: Most patients preferred LAR above APR, even if LAR involved a risk of faecal incontinence. This seems to justify that LAR, if surgically possible, is performed in the first instance. However, since APR patients could live well with a permanent stoma, we recommend clearly informing patients before surgery about the surgical options and their potential outcomes. [Copyright &y& Elsevier]

B Background: b Preoperative chemoradiotherapy (CRT) followed by total mesorectal excision is widely accepted as the standard of care for high-risk rectal cancer. All patients in the experimental arm received 5x5 Gy radiotherapy, and 84% of all patients received at least 75% of the prescribed preoperative chemotherapy courses. [Extracted from the article]

B Background: b The Dutch national colorectal cancer guideline was revised in 2014, which led to an overall decrease in radiotherapy (RT) use. For cT1-3N1MRF- stage rectal cancer patients, a substantial amount of hospital variation in preoperative short course RT remained after guideline revision (IQR 28.6-56.0% vs. B Conclusions: b Radiotherapy for early-stage rectal cancer was uniformly abandoned after guideline revision, while substantial hospital variation remained for intermediate risk resectable rectal cancer in the Netherlands. [Extracted from the article]

B Background: b Optimized treatment of primary rectal cancer might have influenced treatment characteristics and outcome of locally recurrent rectal cancer (LRRC). This cross-sectional population study aimed to evaluate treatment and overall survival (OS) of LRRC patients, stratified for prior preoperative radiotherapy (PRT) and intention of treatment of LRRC. B Conclusions b : This cross-sectional study revealed that rectal cancer patients, who underwent curative resection in the Netherlands in 2011 and subsequently developed local recurrence, were amenable for again curative intent treatment in 29%, with a corresponding median survival of 22 months. [Extracted from the article]

Abstract: Background: Aim of this study was to describe treatment patterns and outcome according to region and hospital type and volume among patients with rectal cancer in the Netherlands. Methods: All patients with rectal carcinoma diagnosed in the period 2001–2006 were selected from the Netherlands Cancer Registry. Logistic regression analyses were performed to examine the influence of relevant factors on the odds of receiving preoperative radiotherapy and on the odds of postoperative mortality. Relative survival analysis was used to estimate relative excess risk of dying according to hospital type and volume. Results: In total, 16 039 patients were selected. Patients diagnosed in a teaching or university hospital had a lower odds (OR 0.85; 95% CI 0.73–0.99 and OR 0.70; 95% CI 0.52–0.92) and patients diagnosed in a hospital performing >50 resections per year had a higher odds (OR 1.95; 95% CI 1.09–1.76) of receiving preoperative radiotherapy. A large variation between individual hospitals in rates of preoperative radiotherapy and between Comprehensive Cancer Centre-regions in the administration of preoperative chemoradiation was revealed. Postoperative mortality was not correlated to hospital type or volume. Patients with T1-M0 tumours diagnosed in a hospital with >50 resections per year had a better survival compared to patients diagnosed in a hospital with <25 resections per year (RER 0.11; 95% CI 0.02–0.78). Conclusion: This study demonstrated variation in treatment and outcome of patients with rectal cancer in the Netherlands, with differences related to hospital volume and hospitals teaching or academic status. However, variation in treatment patterns between individual hospitals proved to be much larger than could be explained by the investigated characteristics. Future studies should focus on the reasons behind these differences, which could lead to a higher proportion of patients receiving optimal treatment for their stage of the disease. [Copyright &y& Elsevier]