中国实用外科杂志

中国实用外科杂志 ›› 2023, Vol. 43 ›› Issue (06): 702-707.DOI: 10.19538/j.cjps.issn1005-2208.2023.06.19

• 论著 • 上一篇    下一篇

规范化诊疗行为对中低位直肠癌预后影响研究

孙    振，李珂璇，吴    斌，林国乐，邱辉忠，孙曦羽，牛备战，陆君阳，徐    徕，肖    毅   

  1. 中国医学科学院北京协和医学院 北京协和医院基本外科结直肠专业组，北京 100730
  • 出版日期:2023-06-01 发布日期:2023-06-17

  • Online:2023-06-01 Published:2023-06-17

摘要： 目的    探讨规范化分期评估及治疗模式对预后的影响。方法    回顾性分析2016年1月至2020年8月北京协和医院基本外科直肠癌登记数据库中低位直肠癌病人资料，根据相应时期的美国国家综合癌症网络指南、欧洲肿瘤学会指南、中国临床肿瘤学会指南等来判断病人所接受的诊疗行为是否规范。观察项目包括术前分期评估、新辅助放化疗、辅助化疗情况以及病人的总生存率（OS）、无病生存率（DFS）及局部复发率（LR）。使用Kaplan-Meier曲线和Log-rank检验进行生存分析，使用倾向性评分匹配分析用来调整组间混杂。结果    共有727例病人纳入研究。其中男性470例（64.6%），女性257例（35.4%），中位年龄为61（52~68）岁，中位肿瘤距肛缘距离为6（4~7）cm，BMI平均值为（24.0±3.2），中位随访时间为35（28~45）个月。具有规范分期评估的病人560例，无规范分期评估病人167例。规范分期评估病人后续治疗规范化的比例明显高于无规范分期评估病人（62.7% vs. 29.6%，P＜0.01）。局部进展期直肠癌病人中有283例接受新辅助放化疗，152例病人未接受规范新辅助放化疗。倾向性得分匹配后进行生存分析发现局部进展期规范新辅助治疗病人与未接受新辅助治疗病人的OS（93.0% vs. 88.0%，P=0.146）、DFS（80.0% vs. 74.0%，P=0.281）和LR（5.0% vs. 6.0%，P=0.710）差异均无统计学意义。共有371例病人辅助化疗规范，164例病人术后辅助化疗不规范。倾向性得分匹配后生存分析发现接受规范辅助化疗病人的OS优于未接受辅助化疗的病人（94.3% vs. 82.4%，P=0.001），两组病人的DFS和LR差异无统计学意义（DFS：81.8% vs. 79.2%，P=0.545；LR：3.8% vs. 4.4%，P=0.703）。结论    规范分期评估能够指导后续的规范化治疗，规范新辅助治疗不能改善病人的生存，但是规范辅助放化疗能够改善病人的生存。

关键词: 中低位直肠癌, 规范化诊疗, 生存

Abstract: The effect of standardized diagnosis and treatment on survival for mid-low rectal cancer    SUN Zhen, LI Ke-xuan, WU Bin, et al. Division of Colorectal Surgery, Department of General Surgery, Peking Union Medical College Hospital, Beijing 100730, China
Corresponding author： XIAO Yi, E-mail:xiaoy@pumch.cn
SUN Zhen and LI Ke-xuan are the first authors who contributed equally to the article.
Abstract    Objective    This article aims to investigate the effect of standardized diagnosis and treatment on survival for patients with mid-low rectal cancer. Methods    Information on mid-low rectal cancer patients was collected from the prospective registry database of Rectal Cancer at Peking Union Medical College Hospital（PUMCH）from January 2016 to August 2020. According to the contemporaneous guideline of the National Comprehensive Cancer Network（NCCN）， European Society for Medical Oncology（ESMO）， and Chinese Society for Clinical Oncology（CSCO）， standardized diagnosis and treatment strategies were defined as follows：1.primary clinical stage should be evaluated by MRI or endorectal ultrasound；2.patients with cT3-4 or cN positive should receive neoadjuvant treatment；3. adjuvant chemotherapy is necessary for patients who received neoadjuvant treatment or have been proven pathological stage Ⅲ or pathological stage Ⅱ with high-risk pathological features. The primary endpoints of this study were overall survival（OS），disease-free survival（DFS）， and 3-year local recurrence（LR）rate. Survival was estimated by Kaplan-Meier curves and log-rank tests. The 1∶1 propensity score matching（PSM）method was applied to improve the reliability of the research results. Results    A total of 727 patients with mid-low rectal cancer were included in the study. 470 (64.6%) patients were male, 257 (35.4%) patients were female, the median age was 61 (52-68) years, the mean BMI was 24.0 ± 3.2 kg/m2, the median distance between the lower edge of the tumor and the anal verge was 6 (4-7) cm and the median follow-up was 35 (28-45) months. 560 patients had primary stage evaluation and 167 patients had no stage evaluation. The proportion of standardized treatment in patients with primary stage evaluation was significantly higher than that in patients without primary stage evaluation（62.7% vs. 29.6%， P＜0.01）.283 local advanced patients received standardized neoadjuvant treatment and 241 local advanced patients received surgery without neoadjuvant treatment， this study failed to get the evidence that standardized neoadjuvant treatment could benefit survival（OS：93.0% vs.88.0%， P=0.146； DFS：80.0% vs. 74.0%， P=0.281； LR：5.0% vs. 6.0%， P=0.710）.371 patients received standardized adjuvant chemotherapy and 164 patients received non-standardized adjuvant chemotherapy. After PSM， standardized adjuvant chemotherapy improved OS（94.3% vs. 82.4%，P=0.001）.The two groups had no significant differences in DFS（81.8% vs. 79.2%，P=0.545）and LR（3.8% vs. 4.4%，P=0.703）.Conclusion Standardized primary-stage evaluation is a prerequisite for standardized treatment. Standardized adjuvant chemotherapy could improve survival， while standardized neoadjuvant treatment does not.

Key words: mid-low rectal cancer, standardized diagnosis and treatment, survival