International variation in managing locally advanced or recurrent rectal cancer: prospective benchmark analysis

Background Tumour extension beyond the mesorectal plane (ymrT4) occurs in 5-10 per cent of patients with rectal cancer and 10 per cent of patients develop locally recurrent rectal cancer (LRRC) after primary surgery. There is global variation in healthcare delivery for these conditions. Methods An international benchmark trial of the management of ymrT4 tumours and LRRC was undertaken in France and Australia between 2015 and 2017. Heterogeneity in management and operative decision-making were analysed by comparison of surgical resection rates, blinded intercountry reading of pelvic MRI, quality-of-life assessment and qualitative evaluations. Results Among 154 patients (97 in France and 57 in Australia), 31 center dot 8 per cent had ymrT4 disease and 68 center dot 2 per cent LRRC. The surgical resection rates were 88 and 79 per cent in France and Australia respectively (P = 0 center dot 112). The concordance in operative planning was low (kappa = 0 center dot 314); the rate of pelvic exenteration was lower in France than Australia both in clinical practice (36 of 78versus34 of 40;P < 0 center dot 001) and in theoretical conditions (10 of 25versus50 of 57;P = 0 center dot 002). The R0 resection rate was lower in France than Australia for LRRC (25 of 49versus18 of 21;P = 0 center dot 007) but not for ymrT4 tumours (21 of 26versus15 of 15;P = 0 center dot 139). Morbidity rates were similar. Patients who underwent non-exenterative procedures had higher scores on the mental functioning subscale at 12 months (P = 0 center dot 047), and a lower level of distress at 6 months (P = 0 center dot 049). Qualitative analysis highlighted five categories of psychosocial factors influencing treatment decisions: patient, strategy, specialist, organization and culture. Conclusion This international benchmark trial has highlighted the differences in worldwide treatment of locally advanced and LRRC. Standardized care should improve outcomes for these patients.