Geographic Trends in Minimally Invasive Surgery for Colorectal Cancer

Emmanuel M Gabriel, MD, PhD, Pragatheeshwar Thirunavukarasu, MD, Kristopher Attwood, PhD, Boris Kuvshinoff, MD, Steven Hochwald, MD, Steven Nurkin, MD. Roswell Park Cancer Institute

Introduction: Studies have shown increasing trends in the use of minimally invasive laparoscopic surgery for the treatment of colorectal cancer (CRC). With the increasing incorporation of robotics into general surgery and surgical oncology, we sought to characterize the national trends of robotic surgery in patients with CRC.

Methods: We utilized the National Cancer Database (NCDB) to identify patients with CRC from 2004 to 2011 who had undergone definitive surgical procedures through either an open, laparoscopic or robotic approach. Multivariate analysis was performed to investigate differences between geographic location and surgical approach. The NCDB divides geographic location into 9 regions within the US. The New England states were used as the reference variable for comparison in our multivariate analysis.

Results: A total of 156,115 patients were identified, of whom 74.1% had cancer of the colon, 7.3% of the rectosigmoid junction and 18.6% of the rectum. Overall, the initial surgical approach included 58.7% open, 39.1% laparoscopic and 2.2% robotic. On multivariate analysis, the New England states (CT, MA, ME, NH, RI, VT) had the highest rates of laparoscopic surgery across each cancer subgroup as indicated by lower odds ratios (OR) for each of the remaining geographic locations. In contrast, the geographic trends for robotic surgery were more diverse. For colon cancer, patients in the East South Central region (AL, KY, MS, TN) were most likely to undergo robotic surgery (OR 1.633, 95% CI 1.117 – 2.388). For rectal cancer, patients in the East North Central region (IL, IN, MI, OH, WI) had the highest likelihood of robotic surgery (OR 1.809, 95% CI 1.262 – 2.594). Patients with rectosigmoid cancer in the Mountain region (AZ, CO, ID, MT, NM, NV, UT, WY) had the highest OR for robotic surgery (OR 2.118, 95% CI 0.895 – 5.0123), although this association was not statistically significant.

Conclusions: Minimally invasive surgical approaches for CRC comprise over 40% of procedures. Patients in the New England region were more likely to have a laparoscopic approach for all CRC. The use of the robotic approach was more varied geographically according to the location of the primary tumor.

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