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Aim: Local excision (LE) for T1 rectal cancer may be recommended in those with low-risk disease, while resection is typically recommended in those with a high risk of luminal recurrence or lymph node metastasis. The aim of this work was to compare survival between resection and LE., Method: This was a population-based retrospective cohort study set in the Canadian province of Ontario. Patients were individuals with T1Nx rectal cancer between 2010 and 2014 and demographics, disease characteristics, treatments and outcomes were determined using linked administrative databases. This study does not include clinical information regarding individual patient treatment decisions. The main outcome measure was overall survival (OS)., Results: A total of 719 patients were identified, including 359 with upfront resection, 113 with LE and immediate resection (<90 days) and 247 with LE with definitive intent. The majority of LEs were performed via colonoscopy. Piecemeal excision (42% vs. 49%, p = 0.28) and positive margin (50% vs. 77%, p < 0.01) rates were high in both LE groups, with the highest rate in those with immediate resection. The prevalence of poor differentiation (<5%, p = 0.70) and lymphovascular invasion (LVI) (14%, p = 0.80) was similar across groups. In those with LE with definitive intent, 21% ultimately underwent resection (median 150 days, interquartile range 114-181 days) and 4% received radiation. There was no difference in 5-year OS between groups (resection 83.2% vs. LE and immediate resection 82.3% vs. definitive LE 83.3%; p = 0.33). Adjusted analyses demonstrated no association between approach and survival [definitive intent LE hazard ratio (HR) 0.97 (95% CI 0.70-1.35), LE and immediate resection HR 0.97 (95% CI 0.60-1.45), upfront resection HR 1 (Ref); p = 0.98]. Differentiation, piecemeal excisions and LVI were not associated with OS in the LE groups., Conclusion: There were no observed differences in survival between those who underwent resection, LE and immediate resection and definitive intent LE. Although, these are observational data, they call into question the reflexive decision to offer radical resection for those with suspected T1 rectal cancer., (© 2025 The Author(s). Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland.)

Background: Institutions providing care to individuals with cancer are organized based on available resources and treatments offered. It is presumed that increasing levels of care will result in improved quality of care and outcomes. The objective is to determine whether Cancer Level Designation is associated with guideline adherent care and/or survival., Methods: This is a retrospective study of individuals within the Ontario Rectal Cancer Cohort, a population-level database including all adults undergoing surgical resection for rectal cancer between 2010 - 2019 were included in Ontario, Canada. The primary exposure was Cancer Centre Level Designation as defined by Cancer Care Ontario (i.e., Level 1/2 = regional cancer center; Level 3 = affiliate cancer center; Level 4 = satellite cancer center). The primary outcomes were guideline adherent care and survival. Associations were determined using one-way analysis of variances and a multivariable Cox proportional hazards model., Results: 12,399 patients were included with 54 % from a Level 1/2 centre, 33 % from a Level 3 centre and 13 % from a Level 4+ centre. All assessed aspects of guideline adherent care were associated with cancer centre level designation. Unadjusted 5-year overall survival was associated with cancer centre level designation (Level 1/2 79.5 % vs. Level 3 79.1 % vs. Level 4/non-designated 75.4 %, P = 0.003). Adjusted Cox Proportional Hazard Analysis for overall survival found the following: Level 4/5 HR 1.11 (95 %CI 0.99 - 1.25); Level 3 HR 1.01 (95 % CI 0.93 - 1.11); Level 1/2 1 [Referent group]., Conclusions: Increasing Cancer Centre Level Designation was associated with higher likelihood of receiving the appropriate investigations and treatments in those with rectal cancer and may also be associated with survival., Policy Summary: Future work should consider the centralization of complex rectal cancer care as well as quality improvement initiatives aimed at enhancing guideline adherent care across all centres managing rectal cancer., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper, (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)