Abstract: Increased experience with total neoadjuvant therapy for rectal cancer suggests significantly more tumor regression and increased rates of complete clinical response as measured by pathological complete response and clinical complete response. OBJECTIVE: This study aimed to assess outcomes after total neoadjuvant therapy versus standard neoadjuvant chemoradiotherapy for patients with locally advanced rectal cancer. DESIGN: This is a retrospective cohort study. SETTINGS: A database of patients with rectal cancer from 2015 to 2019 at a large integrated health care system was reviewed. PATIENTS: Demographics of the 2 groups revealed no significant difference in clinical stage or patient characteristics. Of 465 patients, 66 patients underwent total neoadjuvant therapy and 399 underwent standard neoadjuvant chemoradiotherapy. Fifty-six patients underwent consolidation chemotherapy, and 10 underwent induction chemotherapy. MAIN OUTCOME MEASURES: Complete clinical response, disease-free survival, proctectomy-free survival, and organ preservation rates were the main outcome measures. RESULTS: Complete clinical response was achieved in 36 patients (58.1%) versus 59 patients (14.8%; p 〈 0.001), favoring the total neoadjuvant therapy group. Three-year overall survival was similar between groups (85.6% standard neoadjuvant chemoradiotherapy versus 86.0% total neoadjuvant therapy). Three-year distant metastasis-free survival was 67.4% in the total neoadjuvant therapy group compared to 77.7% in the standard neoadjuvant chemoradiotherapy group. Three-year proctectomy-free survival was 44% in the total neoadjuvant therapy group compared to 6% in the standard neoadjuvant chemoradiotherapy group. Twenty-two patients (37.3% of complete clinical responders) in the standard neoadjuvant chemoradiotherapy group elected to pursue organ preservation, whereas 31 patients (86.1% of complete clinical responders) from the total neoadjuvant therapy group chose organ preservation. LIMITATIONS: This study is limited by its retrospective nature with a shorter follow-up of 3 years. CONCLUSIONS: Total neoadjuvant therapy for rectal cancer significantly increased complete clinical response. This allowed patients to have greater organ preservation with no significant difference in overall survival or disease control. See Video Abstract at http://links.lww.com/DCR/B934. LA TERAPIA NEOADYUVANTE TOTAL AUMENTA SIGNIFICATIVAMENTE LA RESPUESTA CLÍNICA COMPLETA ANTECEDENTES: La mayor experiencia con la terapia neoadyuvante total para el cáncer de recto sugiere una regresión tumoral significativamente mayor y mayores tasas de respuesta clínica completa, medidas por respuesta patológica completa y respuesta clínica completa. OBJETIVO: Este estudio evaluó los resultados después de la terapia neoadyuvante total versus la quimiorradioterapia neoadyuvante estándar para pacientes con cáncer de recto localmente avanzado. DISEÑO: Este es un estudio de cohorte retrospectivo. ESCENARIO: Se revisó una base de datos de pacientes con cáncer de recto de 2015 a 2019 en un sistema de salud integrado grande. PACIENTES: La demografía de los dos grupos no revela diferencias significativas en el estadio clínico o las características de los pacientes. De 465 pacientes, 66 pacientes recibieron terapia neoadyuvante total y 399 quimiorradioterapia neoadyuvante estándar. Cincuenta y seis se sometieron a quimioterapia de consolidación mientras que 10 pacientes a quimioterapia de inducción. PRINCIPALES MEDIDAS DE RESULTADO: Se midieron la respuesta clínica completa, la sobrevida libre de enfermedad, la sobrevida libre de proctectomía y las tasas de preservación de órgano. RESULTADOS: Se logró una respuesta clínica completa en 36 pacientes (58.1 %) frente a 59 pacientes (14.8 %) (p 〈 0,001) a favor del grupo de terapia neoadyuvante total. La sobrevida general a tres años fue similar entre los grupos (85.6 % quimiorradioterapia neoadyuvante estándar frente a 86.0 % terapia neoadyuvante total). La sobrevida libre de metástasis a distancia a los tres años fue del 67.4 % en el grupo de terapia neoadyuvante total y del 77.7 % en el grupo de quimiorradioterapia neoadyuvante estándar. La sobrevida sin proctectomía a los tres años fue del 44 % en el grupo de terapia neoadyuvante total frente al 6 % en el grupo de quimiorradioterapia neoadyuvante estándar. Veintidós pacientes (37.3 % con respuesta clínica completa) en el grupo de quimiorradioterapia neoadyuvante estándar optaron por la preservación de órgano, mientras que 31 pacientes (86.1 % respuesta clínica completa) del grupo de terapia neoadyuvante total eligieron la preservación de órgano. LIMITACIONES: Este estudio es un estudio retrospectivo con un seguimiento más corto de 3 años. CONCLUSIONES: La terapia neoadyuvante total para el cáncer de recto aumentó significativamente la respuesta clínica completa. Esto permitió a los pacientes tener una mayor preservación de órgano sin diferencias significativas en la sobrevida general o el control de la enfermedad. Consulte Video Resumen en http://links.lww.com/DCR/B934. (Traducción—Dr. Jorge Silva Velazco )

Abstract: Studies to date show contrasting conclusions when comparing intracorporeal and extracorporeal anastomoses for minimally invasive right colectomy. Large multi-center prospective studies comparing perioperative outcomes between these two techniques are needed. The purpose of this study was to compare intracorporeal and extracorporeal anastomoses outcomes for robotic assisted and laparoscopic right colectomy. Methods Multi-center, prospective, observational study of patients with malignant or benign disease scheduled for laparoscopic or robotic-assisted right colectomy. Outcomes included conversion rate, gastrointestinal recovery, and complication rates. Results There were 280 patients: 156 in the robotic assisted and laparoscopic intracorporeal anastomosis (IA) group and 124 in the robotic assisted and laparoscopic extracorporeal anastomosis (EA) group. The EA group was older (mean age 67 vs . 65 years, p  = 0.05) and had fewer white (81% vs. 90%, p  = 0.05) and Hispanic (2% vs . 12%, p  = 0.003) patients. The EA group had more patients with comorbidities (82% vs . 72%, p  = 0.04) while there was no significant difference in individual comorbidities between groups. IA was associated with fewer conversions to open and hand-assisted laparoscopic approaches ( p  = 0.007), shorter extraction site incision length (4.9 vs . 6.2 cm; p  ≤ 0.0001), and longer operative time (156.9 vs. 118.2 min). Postoperatively, patients with IA had shorter time to first flatus, (1.5 vs . 1.8 days; p  ≤ 0.0001), time to first bowel movement (1.6 vs . 2.0 days; p  = 0.0005), time to resume soft/regular diet (29.0 vs . 37.5 h; p  = 0.0014), and shorter length of hospital stay (median, 3 vs . 4 days; p  ≤ 0.0001). Postoperative complication rates were comparable between groups. Conclusion In this prospective, multi-center study of minimally invasive right colectomy across 20 institutions, IA was associated with significant improvements in conversion rates, return of bowel function, and shorter hospital stay, as well as significantly longer operative times compared to EA. These data validate current efforts to increase training and adoption of the IA technique for minimally invasive right colectomy.

Abstract: Objectives: Lower socioeconomic status (SES), among other factors, presents a barrier to healthcare delivery and is associated with worse health outcomes. Integrated healthcare systems (IHS) in which barriers to care are minimized would be ideal settings to identify factors associated with mortality disparities. The aim of this study was to compare outcomes of colon cancer cases diagnosed at one of the largest IHS in California, Kaiser Permanente Southern California (KPSC), to other private insurance (OPI) to determine how SES influence differences in mortality. Methods: This retrospective cohort study included all insured adults in Southern California diagnosed with colon cancer between 2009 and 2014 using data from the California Cancer Registry (CCR). The main outcome was all-cause (overall) mortality, and subjects were followed through December 31, 2017. Person-year mortality rates were calculated for the two groups, KPSC and OPI. Multivariate adjusted hazard ratios were calculated for the association between SES and overall mortality within each group. Results: A total of 16,646 patients were diagnosed with colon cancer in Southern California, 4552 patients (27.3 %) within KPSC and 12,094 patients (72.3%) in OPI. 5937 deaths occurred during the follow-up period; 1428 (24.1%) deaths within KPSC, 4509 (75.9%) deaths in non-KPSC. Mortality rates per 1000 year follow-up with 95% confidence interval revealed a lower overall rate of 103.8 (98.5 – 109.3) in KPSC compared to 139.3 (135.2 – 143.4.) in OPI. Compared to the highest SES group, lower SES was not significantly associated with mortality in the KPSC population, even after adjusting for race/ethnicity and other factors (lowest SES HR 1.13 95% CI 0.93-1.38). However, in OPI patients, lower SES was significantly associated with higher HR with the greatest disparity in the lower-middle (HR 1.27 95% CI 1.15-1.40) and lowest (HR 1.26 95% CI 1.13-1.40) SES groups. Conclusions: Comparing mortality rates in an integrated health system such as KPSC to OPI hospitals revealed that lower SES was associated with worse outcomes within the OPI group. However, within KPSC no association was found between SES and overall mortality in patients with colon cancers. Systems that optimize care coordination for all patients may reduce disparities for the most at risk patients. Citation Format: Vikram Attaluri, Robert M. Cooper, Reina Haque, Jay Patel, Joan J. Ryoo, David P. Wu, Joanie WL Chung. Reduced socioeconomic status disparity in colon cancer mortality in an insured population treated in an integrated healthcare system [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-222.

Abstract: Lower socioeconomic status (SES) affects health care delivery and is associated with worse outcomes. Integrated healthcare systems (IHS) may help reduce barriers to health care and affect outcomes. Our aim was to compare outcomes of colon cancer cases diagnosed at the largest IHS in California, Kaiser Permanente Southern California (KPSC), to other insured patients (OI) to determine how SES influences mortality. Methods This retrospective cohort study included insured adults in southern California diagnosed with colon cancer between 2009 and 2014, using data from the California Cancer Registry, and followed through 2017. Main outcome was all-cause mortality. Person-year mortality rates were calculated for two groups, KPSC and OI. Multivariable hazard ratios were calculated for association between SES quintiles and mortality. Results Total of 15 923 patients were diagnosed with colon cancer, 4195 patients (26.3%) within KPSC and 11 728 patients (73.7%) in OI. The overall mortality rate per 1000 person-years (PY) was lower in KPSC [103.8/1000 PY (95% CI:98.5-109.3)] compared to OI [139.3/1000 PY (95% CI:135.2-143.4)] . Compared to the highest SES group, the lowest SES group did not experience higher mortality risk in the KPSC population, after adjusting for race/ethnicity and other factors (HR, 95% CI = 1.13, .93-1.38). However, in OI patients, lowest and lower-middle SES groups had higher mortality risk compared to the highest SES group (HR, 95% CI = 1.26, 1.13-1.40 and 1.28, 1.16-1.41, respectively). Discussion Lower SES was associated with higher mortality risk within the OI group; however, within KPSC no such association was observed. Care coordination in IHS settings mitigate SES-related mortality differences.