The following is the summary of “Predictors and Outcomes of Upstaging in Rectal Cancer Patients Who Did Not Receive Preoperative Therapy” published in the January 2023 issue of Diseases of the Colon & Rectum by Antunez, et al.

Rectal tumors at clinical stages II and III are good candidates for preoperative chemoradiation, although preoperative imaging has limitations that make precise staging difficult. The purpose of this research was to better describe the occurrence and management of discrepancies between clinical and pathologic stages in individuals who did not get prior chemoradiation. This study was conducted using a retrospective cohort approach. Information was gathered from 2006-2015 using the National Cancer Database. Clinical stage I rectal cancer patients who did not receive radiation therapy or chemotherapy prior to surgery were found.

Researchers compared the characteristics of individuals who were “upstaged” (those with T3/T4 tumors discovered on pathology; pathologic stage II) and those who were not upstaged (those without positive regional nodes in the resection material; pathologic stage III) (pathologic stage I). Finally, they compared overall survival between the groups using a mixed-effects multivariate survival model. Tumor upstaging occurred in 819 (10.6%) and nodal upstaging occurred in 1,612 (20.8%) of 7,818 patients with clinical stage I rectal cancer who did not receive preoperative therapy. Higher grade tumors and positive margins were also more common in patients who had been upstaged. Upstaged patients had a lower 5-year survival rate (HR, 1.64; 95% CI, 1.4-1.9), while those who underwent chemotherapy or chemoradiation had a better outcome (HR, 0.71; 95% CI, 0.6-0.9).

The National Cancer Database does not capture functional outcomes, local recurrence, or disease-specific survival, thus investigators can only evaluate overall survival as an oncologic outcome. Incorrect preoperative staging of rectal cancer is a prevalent clinical problem that has not been adequately addressed. Many patients do not receive care that is in line with guidelines, despite the fact that postoperative chemotherapy and/or chemoradiation improves survival for upstaged patients.