title: Sphincter preservation rates after radical resection for rectal cancer in the United States veteran population: opportunity for improvement in early disease.
abstract: BACKGROUND
  Sphincter preservation (SP) is an important goal of rectal cancer surgery. We hypothesized that SP rates among veteran patients have increased and are comparable to national rates, and that a subset of patients with early disease still undergo non-SP procedures.
  
  
  METHODS
  Patients with nonmetastatic primary rectal adenocarcinoma who underwent curative-intent rectal resection were identified from the Veterans Affairs Central Cancer Registry (VACCR) database (1995-2010). SP trends over time were described and compared to the Surveillance, Epidemiology, and End-Results (SEER) population. Subset analysis was performed in patients with nonirradiated, pathologic stage 0-I rectal cancers, a population that may qualify for novel SP strategies.
  
  
  RESULTS
  Of 5,145 study patients, 3,509 (68 %) underwent SP surgery. The VACCR SP rate increased from 59.9 % in 1995-1999 to 79.3 % in 2005-2010, when it exceeded that of SEER (76.9 %, p = 0.023). On multivariate analysis, recent time period was independently associated with higher likelihood of SP (odds ratio [OR] 2.64, p < 0.001). Preoperative radiotherapy (OR 0.51, p < 0.001) and higher pathologic stage (OR 0.37, stage III, p < 0.001) were negative predictors. In patients with nonirradiated pathologic stage 0-I cancers, SP rates also increased, but 25 % of these patients underwent non-SP procedures. Within this subset, patients with clinical stage 0 and I disease still had significant rates of abdominoperineal resection (7.7 and 17.0 %, respectively).
  
  
  CONCLUSIONS
  SP rates among veterans have increased and surpass national rates. However, an unacceptable proportion of patients with stage 0-I rectal cancers still undergo non-SP procedures. Multimodal treatment with local excision may further improve SP rates in this subset of patients.
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, Houston, TX, USA.
authors.forename: Somala
authors.initials: S
authors.lastname: Mohammed
authors.forename: Daniel A
authors.initials: DA
authors.lastname: Anaya
authors.forename: Samir S
authors.initials: SS
authors.lastname: Awad
authors.forename: Daniel
authors.initials: D
authors.lastname: Albo
authors.forename: David H
authors.initials: DH
authors.lastname: Berger
authors.forename: Avo
authors.initials: A
authors.lastname: Artinyan
mesh_terms: D000230:Adenocarcinoma / Q000453:epidemiology / Q000473:pathology / Q000601:surgery*; D000368:Aged; D001003:Anal Canal / Q000473:pathology / Q000601:surgery*; D013505:Digestive System Surgical Procedures; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D009367:Neoplasm Staging; D059351:Organ Sparing Treatments; D010502:Perineum / Q000473:pathology / Q000601:surgery*; D011379:Prognosis; D012004:Rectal Neoplasms / Q000453:epidemiology / Q000473:pathology / Q000601:surgery*; D018426:SEER Program; D014481:United States / Q000453:epidemiology; D014728:Veterans