title: The potential impact of local excision for T1 colonic cancer in elderly and comorbid populations: a decision analysis.
abstract: BACKGROUND
  Population-based bowel cancer screening has resulted in increasing numbers of patients with T1 colonic cancer. The need for colectomy in this group is questioned due to the low risk of lymphatic spread and increased treatment morbidity, particularly for elderly, comorbid patients. This study examined the quality-of-life benefits and risks of endoscopic resection compared with results after colectomy, for low-risk and high-risk T1 colonic cancer.
  
  
  METHODS
  Decision analysis using a Markov simulation model was performed; patients were managed with either endoscopic resection (advanced therapeutic endoscopy) or colectomy. Lesions were considered high risk according to accepted national guidelines. Probabilities and utilities (perception of quality of life) were derived from published data. Hypothetical cohorts of 65- and 80-year-old, fit and unfit patients with low-risk or high-risk T1 colonic cancer were studied. The primary outcome was quality-adjusted life expectancy (QALE) in life-years (QALYs).
  
  
  RESULTS
  In low-risk T1 colonic neoplasia, endoscopic resection increases QALE by 0.09 QALYS for fit 65-year-olds and by 0.67 for unfit 80-year-olds. For high-risk T1 cancers, the QALE benefit for surgical resection is 0.24 QALYs for fit 65-year-olds and the endoscopic QALE benefit is 0.47 for unfit 80-year-olds. The model findings only favored surgery with high local recurrence rates and when quality of life under surveillance was perceived poorly.
  
  
  CONCLUSIONS
  Under broad assumptions, endoscopic resection is a reasonable treatment option for both low-risk and high-risk T1 colonic cancer, particularly in elderly, comorbid patients. Exploration of methods to facilitate endoscopic resection of T1 colonic neoplasia appears warranted.
authors.affiliation: Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK.
authors.forename: Andrew C
authors.initials: AC
authors.lastname: Currie
authors.affiliation: Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK.
authors.forename: Alan
authors.initials: A
authors.lastname: Askari
authors.affiliation: Department of Surgery, Queen Elizabeth Hospital, Woolwich, London, UK.
authors.forename: Christopher
authors.initials: C
authors.lastname: Rao
authors.affiliation: Wolfson Department of Endoscopy, St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK; Department of Surgery and Cancer, Imperial College London, London, UK.
authors.forename: Brian P
authors.initials: BP
authors.lastname: Saunders
authors.affiliation: Department of Surgery and Cancer, Imperial College London, London, UK.
authors.forename: Thanos
authors.initials: T
authors.lastname: Athanasiou
authors.affiliation: Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK; Department of Surgery and Cancer, Imperial College London, London, UK.
authors.forename: Omar D
authors.initials: OD
authors.lastname: Faiz
authors.affiliation: Department of Surgery, St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK; Department of Surgery and Cancer, Imperial College London, London, UK.
authors.forename: Robin H
authors.initials: RH
authors.lastname: Kennedy
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003082:Colectomy; D003110:Colonic Neoplasms / Q000473:pathology* / Q000601:surgery*; D015897:Comorbidity; D003198:Computer Simulation; D003661:Decision Support Techniques; D018572:Disease-Free Survival; D000069916:Endoscopic Mucosal Resection; D006801:Humans; D008390:Markov Chains; D009367:Neoplasm Staging; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D015996:Survival Rate