Sphincter-preserving surgery for rectal cancer: a controversial measure of quality.

In the last 25 years, the treatment for rectal cancer has improved markedly. Multimodality therapy and higherquality surgery have resulted in low rates of local recurrence (previously a terrible problem) as well as impressive rates of long-term survival that sometimes exceed those for colon cancer. Credit must be given to the important treatment trials and to the quality assessment and improvement programs in Europe and elsewhere that have raised the bar of care quality for rectal cancer. Thus it is appropriate that we turn our attention to preserving function and quality of life for these patients. Rectal cancer is indeed a condition for which treatment may result in extreme long-term effects on patient’s lives. Bowel function, sexual and urinary function, body image, and work and social productivity all are potentially affected for patients rendered cancer free. An oncologic success may be a quality-of-life failure. In this Annals of Surgical Oncology issue, Mohammed and colleagues focus on the most apparent functional aspect of rectal cancer treatment: sphincter-preserving surgery (SPS). In their study, they compare rates of SPS between veteran patients identified in the Veterans Affairs (VA) Central Cancer Registry and patients in the national Surveillance, Epidemiology, and End Results (SEER) registry during the period 1995–2010. They find that the rates of SPS have increased in both populations and that VA rates are now a bit higher than national rates, at 79.3 %. This is seen as a triumph for VA care quality improvement given that older research had indicated higher abdominoperineal resection (APR) rates for the VA than for the private sector. The study then focuses on patients with early-stage rectal cancer (nonirradiated, pathologic stages 0 and 1) and finds that 18 % of these patients undergo an APR. In their discussion, the authors plead for more SPS in this group. The strength of this study is its use of data from parallel national tumor registries, which allows for accurate staging and direct comparisons. It is also a strength that these data are recent because SPS rates are changing with time. However, in interpreting these results, it is important to acknowledge the weaknesses inherent in the data. First, tumor registries lack key clinical information including tumor location and patient’s sphincter function. This weakness is common to most studies on this topic. Second, some patients may be miscategorized as undergoing SPS when their surgery in fact resulted in a permanent colostomy because Hartmann’s-type procedures are included in the procedure category for anterior resection. Third, radiation therapy information in tumor registries is known to be inaccurate, often miscategorizing patients who have had radiation therapy as having not received it. These data limitations may have affected the accuracy of SPS rates and the analysis of early-stage rectal cancers. If prior radiation therapy or surgery had pathologically downstaged these cases, they may not have been overtreated at all. Notwithstanding these limitations, this is an important study of cancer care in the national VA health care system. The authors are almost certainly correct in reporting that quality of cancer care has improved in the VA, which has moved toward increased subspecialty care in recent years and has a strong health care quality research group. A minor point in the study is worth mentioning: the adequacy of lymph node examination remains an opportunity for improvement in the VA, with an average of 9.5 This is an invited editorial to the article available at doi: 10.1245/ s10434-014-4101-z.