title: Practice patterns and long-term survival for early-stage rectal cancer.
abstract: OBJECTIVE
  Standard of care treatment for most stage I rectal cancers is total mesorectal excision (TME). Given the morbidity associated with TME, local excision (LE) for early-stage rectal cancer has been explored. This study examines practice patterns and overall survival (OS) for early-stage rectal cancer.
  
  
  METHODS
  All patients in the National Cancer Data Base diagnosed with rectal cancer from 1998 to 2010 were initially included. Use of LE versus proctectomy and use of adjuvant radiation therapy were compared over time. Adjusted Cox proportional hazards models were used to compare OS based on treatment.
  
  
  RESULTS
  LE was used to treat 46.5% of patients with T1 and 16.8% with T2 tumors. Use of LE increased steadily over time (P < .001). LE was most commonly used for women, black patients, very old patients, those without private health insurance, those with well-differentiated tumors, and those with T1 tumors. Proctectomy was associated with higher rates of tumor-free surgical margins compared with LE (95% v 76%; P < .001). Adjuvant radiation therapy use decreased over time independent of surgical procedure or T stage. For T2N0 disease, patients treated with LE alone had significantly poorer adjusted OS than those treated with proctectomy alone or multimodality therapy.
  
  
  CONCLUSIONS
  Guideline-concordant adoption of LE for treatment of low-risk stage I rectal cancer is increasing. However, use of LE is also increasing for higher-risk rectal cancers that do not meet guideline criteria for LE. Treatment with LE alone is associated with poorer long-term OS. Additional studies are warranted to understand the factors driving increased use of LE.
authors.affiliation: All authors: University of North Carolina at Chapel Hill; and Karyn B. Stitzenberg, Hanna K. Sanoff, Michael O. Meyers, and Joel E. Tepper, Lineberger Comprehensive Cancer Center, Chapel Hill, NC.
authors.forename: Karyn B
authors.initials: KB
authors.lastname: Stitzenberg
authors.forename: Hanna K
authors.initials: HK
authors.lastname: Sanoff
authors.forename: Dolly C
authors.initials: DC
authors.lastname: Penn
authors.forename: Michael O
authors.initials: MO
authors.lastname: Meyers
authors.forename: Joel E
authors.initials: JE
authors.lastname: Tepper
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016009:Chi-Square Distribution; D013505:Digestive System Surgical Procedures / Q000009:adverse effects / Q000401:mortality / Q000639:trends; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D016017:Odds Ratio; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000639:trends; D016016:Proportional Hazards Models; D018714:Radiotherapy, Adjuvant; D012004:Rectal Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D012042:Registries; D012307:Risk Factors; D059039:Standard of Care; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology