title: The management of patients with T1 adenocarcinoma of the low rectum: a decision analysis.
abstract: BACKGROUND
  Decision making for patients with T1 adenocarcinoma of the low rectum, when treatment options are limited to a transanal local excision or abdominoperineal resection, is challenging.
  
  
  OBJECTIVE
  The aim of this study was to develop a contemporary decision analysis to assist patients and clinicians in balancing the goals of maximizing life expectancy and quality of life in this situation.
  
  
  METHODS
  We constructed a Markov-type microsimulation in open-source software. Recurrence rates and quality-of-life parameters were elicited by systematic literature reviews. Sensitivity analyses were performed on key model parameters.
  
  
  METHODS
  Our base case for analysis was a 65-year-old man with low-lying T1N0 rectal cancer. We determined the sensitivity of our model for sex, age up to 80, and T stage.
  
  
  METHODS
  The main outcome measured was quality-adjusted life-years.
  
  
  RESULTS
  In the base case, selecting transanal local excision over abdominoperineal resection resulted in a loss of 0.53 years of life expectancy but a gain of 0.97 quality-adjusted life-years. One-way sensitivity analysis demonstrated a health state utility value threshold for permanent colostomy of 0.93. This value ranged from 0.88 to 1.0 based on tumor recurrence risk. There were no other model sensitivities.
  
  
  CONCLUSIONS
  Some model parameter estimates were based on weak data.
  
  
  CONCLUSIONS
  In our model, transanal local excision was found to be the preferable approach for most patients. An abdominoperineal resection has a 3.5% longer life expectancy, but this advantage is lost when the quality-of-life reduction reported by stoma patients is weighed in. The minority group in whom abdominoperineal resection is preferred are those who are unwilling to sacrifice 7% of their life expectancy to avoid a permanent stoma. This is estimated to be approximately 25% of all patients. The threshold increases to 12% of life expectancy in high-risk tumors. No other factors are found to be relevant to the decision.
authors.affiliation: Department of Clinical Decision Making and Health Care, University Health Network and Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Calvin F
authors.initials: CF
authors.lastname: Johnston
authors.forename: George
authors.initials: G
authors.lastname: Tomlinson
authors.forename: Larissa K
authors.initials: LK
authors.lastname: Temple
authors.forename: Nancy N
authors.initials: NN
authors.lastname: Baxter
mesh_terms: D000230:Adenocarcinoma / Q000473:pathology / Q000601:surgery*; D003125:Colostomy; D003657:Decision Making; D003661:Decision Support Techniques; D006801:Humans; D008390:Markov Chains; D057240:Patient Preference; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D012004:Rectal Neoplasms / Q000473:pathology / Q000601:surgery*