Impact of Minimally Invasive Approach on Attainment of a Textbook Oncologic Outcome Following Colectomy for Colon Cancer-A Review of the National Cancer Database

Impact of Minimally Invasive Approach on Attainment of a Textbook Oncologic Outcome Following Colectomy for Colon Cancer-A Review of the National Cancer Database | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of Minimally Invasive Approach on Attainment of a Textbook Oncologic Outcome Following Colectomy for Colon Cancer-A Review of the National Cancer Database Monique Motta, Gabriela L. Aitken, Tamara V. Damrel, Shenae Samuels, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6285481/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Textbook oncologic outcome is a composite measure achieved when all desired short-term quality metrics are met following an oncologic operation. This study aimed to determine the impact of surgical approach on textbook oncologic outcome achievement after colectomy for colon cancer. Methods We queried the 2010-2017 National Cancer Database for patients with non-metastatic colon cancer who underwent colectomy, then stratified them by surgical approach: open colectomy vs laparoscopic colectomy vs robotic colectomy. Textbook oncologic outcome was defined by six metrics: resection with negative margins (R0), adequate lymphadenectomy (≥ 12), no prolonged length of stay (< 50th percentile by year), no 30-day readmission, no 30-day mortality, and timely initiation of adjuvant chemotherapy (≤ 12 weeks). Surgical approaches were categorized as open, laparoscopic, and robotic colectomy. Results The open group had the lowest textbook oncologic outcome attainment (open = 27.7%, LC = 45%, RC = 41.9%) and also performed poorly on five of the six TOO criteria: R0 resection (94.4%), adequate lymphadenectomy (88.3%), minimal length of stay (41.0%), no 30-day readmission (92.1%), and timely adjuvant chemotherapy (86.3%). Multivariate logistic regression suggested that laparoscopic colectomy (AOR = 2.04; p < 0.001) and robotic colectomy (AOR = 1.69; p < 0.001) were associated with increased likelihood of textbook oncologic outcome attainment. Conclusions Achieving TOO is a crucial predictor of long-term survival across all surgical approaches for colon cancer. Our findings suggest that a robotic surgical approach may offer significant advantages in attaining TOO following colectomy. TOO Colon Cancer Colectomy Oncologic Outcome Figures Figure 1 Introduction The quality of patient healthcare, especially in surgical settings, is inherently multifactorial, influenced by various interrelated factors. In surgical patients, the quality of care is often quantified by the achievement of desired postoperative outcomes, with the concept of a "textbook outcome" representing an ideal scenario where all expected outcomes are realized. Achieving a textbook outcome is influenced by a complex interplay of variables, including hospital characteristics, surgical technique, individual patient factors such as comorbidities, and the underlying disease. Thus, assessing quality of care extends beyond single metrics, requiring composite measures that encapsulate multiple dimensions of patient outcomes. In surgical oncology, the textbook oncologic outcome (TOO) includes a comprehensive evaluation assessing the realization of desired short-term quality metrics following cancer surgery. TOO was first introduced in the context of colon cancer in 2013, where it evaluated the proportion of patients meeting critical perioperative quality indicators. 1 This study found that 49% of patients achieved TOO following colectomy, with significant variability between hospitals. Since then, TOO has gained traction as a tool for assessing surgical performance and identifying areas for improvement in cancer care. Current studies indicate that colon cancer surgery achieves a high TOO rate, ranging from 49–67%, notably higher than rates seen in other cancers, such as gastric and pancreatic cancers, which are 35.3% and 16.8%, respectively. 2 – 4 Research has consistently shown a positive correlation between achieving TOO and improved survival after colon cancer surgery; however, data on the impact of specific surgical approaches on TOO are limited. This study evaluates how different surgical approaches affect TOO achievement in patients undergoing colectomy for colon cancer. By examining this relationship, we aim to provide insights into how surgical technique may influence short-term outcomes, ultimately contributing to better quality metrics and enhancing the overall care of colon cancer patients. Materials & Methods This study aimed to determine if surgical approach is associated with achieving TOO among patients diagnosed with non-metastatic colon cancer. We queried the 2010–2017 National Cancer Database (NCDB) for patients with non-metastatic colon cancer who underwent colectomy. The analysis was limited to the years 2010 to 2017 because the surgical approach variable is available only for diagnosis years 2010 and later. Patients were identified using surgical primary site codes 30 and 40 for partial and extended colectomy, respectively. Non-metastatic colon cancer was identified using histology codes 8010, 8140, 8210, and 8261–8263, 8480, and 8490. Categorical variables were analyzed using Pearson’s chi-square test or Fisher’s exact test, presented as proportions and frequencies. Continuous variables were analyzed using Mood’s median test and presented as medians and interquartile ranges (IQR) or one-way ANOVA with means and standard deviations. Overall survival (OS) was defined as the time (in months) between diagnosis and death or last contact. Patients achieving optimal oncologic care were said to have attained TOO. The dichotomous composite outcome was defined as “achieved” when all five individual oncologic criteria were met: resection with negative microscopic margins, adequate lymphadenectomy (LAD) based on AJCC compliant lymph node evaluation (i.e., 12 or more lymph nodes examined), no extended LOS (i.e., LOS ≤ 50th percentile by year), no 30-day readmission, and no 30-day mortality. Surgical approach cohorts included open colectomy (OC), laparoscopic (LC) colectomy, and robotic colectomy (RC). To assess the association of surgical approach with TOO attainment, multivariate logistic regression models adjusting for demographics, facility characteristics, and clinical factors were employed. As a secondary analysis, Kaplan-Meier (KM) method with log-rank tests was used to compare and estimate OS among six cohorts based on surgical approach and TOO status (Open TOO, Lap TOO, Robotic TOO, Open non-TOO, Lap non-TOO, and Robotic non-TOO). All analyses were conducted using Stata/SE 15.1. Results A total of 271,606 patients with available surgical approach data underwent colectomy for non-metastatic colon cancer. Among them, 47.8% underwent OC, 46.1% LC, and 6.1% RC. Table 1 presents the characteristics of patients stratified by surgical approach, with all observed differences being statistically significant. The OC cohort had the highest median age of 71 years, and while the majority of patients were White, the OC cohort had the highest proportion of Black patients (OC: 13.1% vs. LC: 11.3% vs. RC: 11.5%). Furthermore, the OC cohort had the highest proportion of patients without insurance (OC: 3.5% vs. LC: 2.0% vs. RC: 1.4%) and the highest proportion of patients with two or more comorbidities (C: 12.0% vs. LC: 11.4% vs. RC: 9.8%). As measured by the Crowfly distance, patients in the RC cohort traveled the furthest for treatment (OC: 20.7 vs. LC: 21.5 vs. RC: 23.2). In assessing treatment characteristics, the RC cohort had the longest mean time to surgery (OC: 17.6 days vs. LC: 23.0 days vs. RC: 29.9 days). Most treatment occurred in comprehensive community cancer programs; however, the LC cohort had the highest proportion of patients treated in academic/research cancer programs. Patients in the OC cohort were more likely to be seen in facilities with low annual case volume (30.1%), while LC (28.8%) and RC (30.5%) cohorts were seen in facilities with very high annual case volume. Among surgical approaches, the OC cohort had the highest proportion of patients who underwent extended colectomy (OC: 65.7% vs. LC: 64.1%; RC: 60.2%) and the highest likelihood of having pathologic Stage 3, T4, N2 disease, undifferentiated histology, lymphovascular invasion, and positive surgical margins. The OC cohort also had the highest mean number of positive nodes examined, while the RC cohort had the highest mean number of nodes assessed. In terms of systemic therapy, patients in the OC cohort were most likely to receive adjuvant chemotherapy and had the shortest mean time to chemotherapy (OC: 67.1 days vs. LC: 67.8 days vs. RC: 71.7 days. Textbook Oncologic Outcomes Table 2 examines TOO proportions by surgical approach, revealing statistically significant differences. Patients undergoing OC were least likely to achieve TOO (27.7%) and fell short on following TOO criteria: R0 resection (94.4%), adequate LAD (88.3%), no extended LOS (41.0%), no 30-day readmission (92.1%) and timely adjuvant chemotherapy (86.3%). Patients in the OC cohort however demonstrated the highest rates of no 30-day mortality (86.6%), while those in the RC cohort had the lowest (70.1%). The robotic approach had the highest proportion of patients meeting timely adjuvant chemotherapy (91.5%), along with superior performance in the following TOO criteria: no extended LOS (73.2%), adequate LAD (91.3%), R0 resection (97.4%), and no 30-day readmission (94.2%). In terms of TOO attainment, the laparoscopic approach yielded the highest proportion of patients achieving TOO (LC: 45.0% vs. RC: 41.9% vs. OC: 27.7%). Overall Survival by TOO Status and Surgical Approach Figure 1A and Table 3 illustrate that patients achieving TOO had a higher median OS compared to those without TOO (111.9 vs. 82.3 months; P < 0.001). Among TOO patients, the OC TOO cohort had the highest median OS followed by the RC TOO cohort (111.9 vs. 109.5 months; P < 0.001). Notably, the median OS for the LC TOO cohort was not estimable, and the OC non-TOO cohort had the shortest median OS (71.2 months). Association of Surgical Approach and TOO Table 4 presents results from multivariate logistic regression models examining associations between surgical approach and TOO attainment. Compared to OC, LC (AOR = 2.04; P < 0.001) and RC (AOR = 1.69; P < 0.001) approaches were associated with increased likelihood of achieving TOO, with LC having the highest odds. Discussion Numerous studies across gastrointestinal malignancies have investigated the attainment of TOO and its correlation with long-term survival. 5 – 8 For example, an analysis from the Canadian Population Registry of Esophageal and Stomach Tumors of Ontario (PRESTO) revealed that 22% of 1,836 patients undergoing gastrectomy achieved TOO, resulting in a 41% reduction in mortality compared to those who did not meet this benchmark. 6 On a broader scale, a review of 34,688 patients from the NCDB conducted by Cibulas et al. reported a TOO attainment rate of 23.8% following gastrectomy for gastric cancer, which was associated with a significantly lower risk of death (HR = 0.82, P < .001) and improved median OS (80.5 vs. 35.3 months; P < .001). 7 In pancreatic cancer, a study involving 171 patients who underwent pancreaticoduodenectomy found that 25.7% achieved TOO, which correlated with enhanced median OS (32 vs. 20 months; P = 0.034) and improved recurrence-free survival (19 vs. 13 months; P = 0.053). 8 These findings are consistent with studies examining TOO attainment in colorectal cancer. A review of 508,312 patients in the NCDB (2004–2017) indicated that 34% achieved TOO, which was associated with a significantly higher median OS compared to those who did not attain TOO (148.2 vs. 84.2 months; P < 0.001). 9 Additionally, Manatakis et al. demonstrated that those who achieved TOO experienced significantly better 5-year overall and cancer-specific survival rates (81% vs. 59%, P = 0.009, and 86% vs. 65%, P = 0.02, respectively). 2 In our study, 36.5% of patients achieved TOO, which was associated with significantly improved OS, revealing a median OS of 111.9 months compared to 82.3 months in patients who did not attain TOO (P < 0.001). As evidenced by both existing literature and our findings, achieving TOO represents a crucial treatment goal that significantly contributes to improved OS across all gastrointestinal malignancies. Minimally invasive colectomy has emerged as a widely accepted curative procedure for non-metastatic colon cancer, with numerous studies investigating its advantages relative to OC. For example, Zheng et al. analyzed data from the NCDB and found that LC was associated with lower 30-day mortality rates, reduced LOS, and an increased likelihood of receiving adjuvant chemotherapy compared to OC. 10 Similarly, Ohtani et al. demonstrated that LC results in decreased intraoperative blood loss, a shorter time to resumption of regular activities, and fewer complications during the immediate postoperative period. 11 While the advantages of minimally invasive surgical techniques over open surgery are well-documented, its impact on TOO attainment remains less explored, with mixed results reported. For instance, in the context of pancreaticoduodenectomy, the surgical approach did not significantly influence TOO attainment. Sweigert et al. conducted an NCDB study involving 12,854 patients and found no significant differences in the likelihood of achieving TOO, R0 resection, adequate LAD, readmission rates, 30-day mortality, or LOS (P > .05). However, this study did identify improved median overall OS in patients who achieved TOO (TOO = 27.6 months vs. non-TOO = 21.3 months; P < .001). 12 Conversely, in gastrectomy for gastric cancer, the minimally invasive surgical approach was associated with an increased likelihood of achieving TOO. An NCDB study by Avila et al. reported a significant enhancement in TOO attainment among patients who underwent laparoscopic gastrectomy. 5 Our findings align with this literature, as LC yielded the highest proportion of patients achieving TOO (45.0%), followed by RC (41.9%) and OC (27.7%). These results suggest that minimally invasive approaches may enhance surgeons' ability to attain TOO in gastrointestinal cancers. The use of robotics in colorectal surgery has steadily increased, with RC rising from 0.7% in 2010 to 10.9% in 2016. 13 As this surgical method gains popularity, research has sought to compare its outcomes with those of laparoscopic and open procedures. However, due to its higher costs, skepticism about its role persists. Robotic surgery can be up to 25% more expensive and approximately $ 3,000 costlier than LC. Consequently, studies have focused on evaluating the potential benefits of robotic surgery. 14 Huang et al. compared OC, LC, and RC for colon cancer in 211 patients and found that those undergoing RC had shorter operation times (P < 0.001) and reduced LOS (P = 0.005) without compromising survival benefits. 14 Avila et al. evaluated patients who underwent gastrectomy for gastric cancer indicating that those with robotic non-TOO had similar median OS (43.8 months) compared to laparoscopic non-TOO patients (45 months), significantly improving upon the median OS of those undergoing open non-TOO (33.6 months). 5 In our study, we observed that among patients who did not achieve TOO, RC resulted in the longest median OS (105.5 months), compared to 71.2 months for OC and 93.8 months for LC. These findings suggest that robotic surgery may confer survival benefits in patients independent of TOO status. Upon examining the factors contributing to the attainment of TOO, we found that patients in the OC cohort were significantly more likely to require adjuvant chemotherapy compared to those in the LC and RC cohorts (OC: 35.8% vs. LC: 31.7% vs. RC: 32.5%, P < 0.001). This disparity may be partially attributed to a higher prevalence of adverse pathological features in the OC cohort, including undifferentiated histology, lymphovascular invasion, T4 and N2 disease, and positive margins. Interestingly, despite the minimally invasive cohorts demonstrating improved performance in metrics such as no prolonged length of stay (LOS) and no prolonged admission, the OC cohort experienced the shortest mean time to chemotherapy initiation (OC: 67.1 days vs. LC: 67.8 days vs. RC: 71.7 days, p < 0.001). This expedited initiation may be linked to the OC cohort's shorter travel distance for surgery (OC: 20.7 miles vs. LC: 21.5 miles vs. RC: 23.2, p < 0.001), which likely contributed to their earlier time to surgery (OC: 17.6 days vs. LC: 23.0 days vs. RC: 29.9 days, p < 0.001) and, ultimately, the shortest mean time to chemotherapy initiation. These findings imply that reducing the time to surgery may have a more pronounced effect on time to systemic therapy than the benefits associated with a minimally invasive approach. It follows that optimal outcomes may be achieved through strategies that both minimize the time to surgery and expedite postoperative recovery. However, it is important to note that despite the established advantages of LC and RC regarding postoperative recovery, not all patients underwent a minimally invasive procedure. The NCDB does not specify the reasons for choosing an open approach, but one reasonable assumption is that that many cases were urgent and not suitable for minimally invasive techniques. The data additionally indicates that patients who underwent LC and RC traveled further for care, were predominantly White, had private insurance, exhibited the highest proportion of patients without comorbidities, and required adjuvant systemic therapy less frequently. These findings point to underlying socioeconomic disparities that may enhance healthcare access and the ability to afford travel for treatment, thus facilitating the use of LC and RC. Addressing these socioeconomic disparities may significantly improve access to minimally invasive surgery and its associated benefits. Although our analysis demonstrated that patients who achieved TOO had significantly higher overall OS compared to those who did not, notable differences were evident within the matched cohorts. Specifically, the median OS was highest in the OC TOO cohort, followed closely by the RC TOO cohort (111.9 vs. 109.5 months; P < 0.001). The reasons behind the OC cohort's superior OS remain unclear; however, this observation suggests that attaining TOO may be independently associated with improved OS. Further subgroup analysis of the OC TOO group may provide additional insights into this phenomenon. Lastly, we were intrigued by the observed no 30-day mortality rates in our study, which appear lower than anticipated based on clinical practice. Further assessment suggests this finding can potentially be attributed to the inclusion of patients with unknown variables in our analysis. By utilizing a larger denominator that encompasses these unknowns, the proportions of patients exhibiting no 30-day mortality are diluted compared to analyses that exclude unknowns, as likely practiced by previous authors. Ultimately, the discrepancies observed may also stem from differences in coding practices regarding unknown variables and the potential variations in patient populations and coding methodologies between the years of the respective studies, underscoring the complexity of interpreting mortality rates across different datasets. Our study is subject to several limitations. Firstly, the NCDB captures approximately 70% of all Commission on Cancer (CoC) accredited hospitals' cancer diagnosis and treatment data. Consequently, we cannot account for potential variations in practice patterns at non-CoC accredited institutions. While the NCDB is a prospectively gathered database, there are inherent limitations in how the data is collected and reported. Although our study demonstrates favorable outcomes associated with achieving TOO, it is important to note that the median OS for the LC TO cohort was not estimable due to a limited number of events in this subgroup. Treatment decisions for colon cancer, as well as the timing of therapy, are influenced by various factors, including patient characteristics, disease specifics, and institutional practices, which are not fully captured in the database. Furthermore, the static nature of the NCDB data, which spans from 2010 to 2017, may limit the applicability of our findings to current clinical practice patterns. Lastly, the retrospective design of our study may introduce selection bias, which should be considered when interpreting our results. Conclusion Achieving TOO is a predictor of long-term survival across all surgical approaches for colon cancer. Our findings suggest that a RC may offer significant advantages in attaining TOO following colectomy. However, it is important to note that only a small subset of patients with colon cancer currently undergo robotic colectomy. Therefore, concerted efforts to address the socioeconomic disparities that limit access to minimally invasive surgical options are essential to enhance patient outcomes and ensure equitable care for all individuals affected by this disease. Declarations The authors declare that they have no conflict of interest. Funding Support: None This manuscript has not nor will be a podium or poster meeting presentation. Author Contribution All authors contributed to the study conception and design. Material preparation, data collection, and writing of the original draft were performed by M.M., G.A., and T.D. Data analysis and preparation of tables and figures were performed by M.M., G.A., T.D., and S.S. Resources and supervision were provided by G.O., C.G., and O.L. All authors reviewed and edited previous versions of the manuscript. All authors read and approved the final manuscript. 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World J Surg Onc 20:345. https://doi.org/10.1186/s12957-022-02796-8 Tables Table 1 Characteristics of patients undergoing colectomy stratified by surgical approach Minimally Invasive Open (%) Laparoscopic (%) Robotic (%) P-Value N (%) 129,693 (47.8) 125,232 (46.1) 16,681 (6.1) - Median Age, (IQR) a 71 (61–81) 69.5 (59–79) 68 (58–76) < 0.001 Gender < 0.001 Male 61,726 (47.6) 61,093 (48.8) 8,500 (51.0) Female 67,967 (52.4) 64,139 (51.2) 8,181 (49.0) Race/Ethnicity < 0.001 White 101,251 (81.4) 98,597 (82.9) 12,847 (81.9) Black 16,347 (13.1) 13,492 (11.3) 1,805 (11.5) Hispanic 6,871 (5.5) 6,860 (5.8) 1,031 (6.6) Insurance Status < 0.001 Uninsured 4,508 (3.5) 2,462 (2.0) 233 (1.4) Private Insurance 35,317 (27.6) 42,642 (34.4) 6,449 (39.0) Government Insurance 88,010 (68.9) 78,930 (63.6) 9,840 (59.6) Crowfly, Mean ± SD b 20.7 ± 84.5 21.5 ± 85.4 23.2 ± 99.0 0.001 Charlson-Deyo Score < 0.001 0 84,574 (65.2) 83,237 (66.5) 11,684 (70.0) 1 29,566 (22.8) 27,738 (22.2) 3,361 (20.2) 2 + 15,553 (12.0) 14,257 (11.4) 1,636 (9.8) Time to Surgery in Days, Mean ± SD b 17.6 ± 32.5 23.0 ± 31.6 29.9 ± 35.8 < 0.001 Facility / Cancer Program Type < 0.001 Community 19,985 (15.7) 11,353 (9.2) 1,293 (7.9) Comprehensive Community 59,525 (46.8) 58,380 (47.5) 7,367 (45.2) Academic/Research 30,390 (23.9) 34,029 (27.7) 4,824 (29.6) Integrated Network 17,399 (13.7) 19,146 (15.6) 2,824 (17.3) Case-Volume Per Year Quartiles < 0.001 Low (1.00–25.07) 39,009 (30.1) 25,220 (20.1) 3,322 (19.9) Intermediate (25.14–38.29) 32,967 (25.4) 29,982 (23.9) 4,082 (24.5) High (38.36–57.29) 29,614 (22.8) 33,986 (27.1) 4,185 (25.1) Very High (57.79–206.57) 28,103 (21.7) 36,044 (28.8) 5,092 (30.5) Extent of colectomy < 0.001 Partial 44,506 (34.3) 44,963 (35.9) 6,638 (39.8) Extended 85,187 (65.7) 80,269 (64.1) 10,043 (60.2) Pathologic Stage < 0.001 1 28,991 (22.4) 40,150 (32.1) 5,678 (34.0) 2 50,833 (39.2) 43,621 (34.8) 5,467 (32.8) 3 49,869 (38.5) 41,461 (33.1) 5,536 (33.2) Pathologic T Stage < 0.001 T1 14,160 (11.0) 22,731 (18.2) 3,272 (19.7) T2 19,843 (15.4) 23,746 (19.0) 3,342 (20.1) T3 74,212 (57.4) 65,886 (52.8) 8,430 (50.7) T4 21,013 (16.3) 12,425 (10.0) 1,578 (9.5) Pathologic N Stage < 0.001 N0 80,215 (61.9) 83,959 (67.0) 11,156 (66.9) N1 32,212 (24.8) 28,602 (22.8) 3,865 (23.2) N2 17,266 (13.3) 12,671 (10.1) 1,660 (10.0) Grade < 0.001 Well differentiated (I) 13,811 (11.0) 13,685 (11.3) 1,955 (12.1) Moderately differentiated (II) 87,875 (69.9) 87,106 (72.0) 11,875 (73.6) Poorly differentiated (III) 20,283 (16.1) 16,928 (14.0) 1,940 (12.0) Undifferentiated (IV) 3,840 (3.1) 3,324 (2.8) 357 (2.2) Lymphovascular Invasion < 0.001 Present 32,672 (25.2) 28,185 (22.5) 3,755 (22.5) Not Present 87,594 (67.5) 88,441 (70.6) 11,729 (70.3) Unknown 9,427 (7.3) 8,606 (6.9) 1,197 (7.2) # Nodes, Mean ± SD b 19.8 ± 10.0 20.3 ± 9.9 20.5 ± 9.9 < 0.001 # Nodes Positivity, Mean ± SD b 1.4 ± 3.3 1.1 ± 2.7 1.1 ± 2.7 < 0.001 Surgical Margins After Resection < 0.001 Positive 6,742 (5.2) 3,177 (2.5) 394 (2.4) Negative 122,423 (94.4) 121,670 (97.2) 16,244 (97.4) Unknown 528 (0.4) 385 (0.3) 43 (0.3) Adjuvant Chemotherapy < 0.001 No 69,309 (64.2) 75,189 (68.3) 10,187 (67.5) Yes 38,638 (35.8) 34,830 (31.7) 4,912 (32.5) Time to Chemotherapy in Days, Mean ± SD b 67.1 ± 44.2 67.8 ± 41.3 71.7 ± 37.8 < 0.001 IQR = Interquartile Range Proportions may not add to 100% due to rounding error, missing or unknown data, and data not presented due to NCDB data use agreement. a Computed p-value from Mood’s median test. b Computed p-value represents between group differences from one-way ANOVA test. Boldface font denotes statistical significance at P < 0.05. Table 2 Summary of textbook oncologic outcome criteria by surgical approach Open (%) Laparoscopic (%) Robotic (%) P-Value Negative Margin 122,423 (94.4) 121,670 (97.2) 16,244 (97.4) < 0.001 12 + Lymph Nodes 114,503 (88.3) 113,574 (90.7) 15,234 (91.3) < 0.001 No Prolonged LOS (50 percentile) 50,699 (41.0) 79,567 (65.5) 11,799 (73.2) < 0.001 No 30-Day Readmission 119,429 (92.1) 116,733 (93.2) 15,716 (94.2) < 0.001 No 30-Day Mortality 112,324 (86.6) 105,011 (83.9) 11,696 (70.1) < 0.001 Initiation of ACT (≤ 12 weeks) 32,450 (86.3) 30,810 (89.8) 4,349 (91.5) < 0.001 Textbook Oncologic Outcome 35,900 (27.7) 56,392 (45.0) 6,982 (41.9) < 0.001 ACT = Adjuvant chemotherapy, LOS = Length of Stay. Proportions may not add to 100% due to rounding error, missing or unknown data, and data not presented due to NCDB data use agreement. Boldface font denotes statistical significance at P < 0.05. Table 3 Median overall survival (months) among patients by surgical approach and TOO Status Colectomy/TOO Status N Median OS (95% CI) TOO 110,129 111.9 (111.2, NE) Open TOO 35,897 111.9 (111.2, NE) Laparoscopic TOO † 56, 389 NE (111.1, NE) Robotic TOO 6,982 109.5 (109.5, NE) Non-TOO 160,758 82.3 (81.5, 83.3) Open Non-TOO 82,250 71.2 (70.2, 72.2) Laparoscopic Non-TOO 51,330 93.8 (92.2, 96.0) Robotic Non-TOO 4,970 105.5 (95.7, NE) Total 237,818 102.4 (101.6, 103.6) NE = Not Estimable. 95% CI = 95% Confidence Interval † Median OS could not be calculated due to the small number of events in this cohort Table 4 Logistic regression examining the association of obtaining TOO and colectomy surgical approach Outcomes OR (95% CI) P-Value AOR a (95% CI) P-Value a TOO Open Ref Ref Ref Ref Laparoscopic 2.14 (2.11, 2.18) < 0.001 2.04 (2.00, 2.07) < 0.001 Robotic 1.88 (1.82, 1.94) < 0.001 1.69 (1.63, 1.75) < 0.001 OR = Odds Ratio. AOR = Adjusted Odds Ratio. 95% CI = 95% Confidence Interval Boldface font denotes statistical significance at P < 0.05 a . Estimates based on adjusted models adjusting for age, gender, race/ethnicity, insurance status, facility type, case-volume per year quartiles, extent of colectomy, disease stage group and Charlson-Deyo comorbidity score Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6285481","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":443964565,"identity":"b3265859-5116-4455-bdea-688dd7935505","order_by":0,"name":"Monique Motta","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAlklEQVRIiWNgGAWjYPACGwYDUpQzNhxgSCNdy2EStOhOO3z88Yea89Hm/AcYP3zMIUKL2e20xIYDx27n7pyRwCw5cxtRWnIMGw6w3c7dcIOBjZmXeC3/zuVuOH+AFC0H2w7kbjiQQLSWtMQZZ/uSgQ5LbCbWL8kHPlR8swM67PDBDx+J0YIEGBtIUz8KRsEoGAWjADcAABBqP5uFJSKUAAAAAElFTkSuQmCC","orcid":"","institution":"Memorial Healthcare System","correspondingAuthor":true,"prefix":"","firstName":"Monique","middleName":"","lastName":"Motta","suffix":""},{"id":443964566,"identity":"155a321e-0b4e-4ee5-bfae-04f218925459","order_by":1,"name":"Gabriela L. Aitken","email":"","orcid":"","institution":"Memorial Healthcare System","correspondingAuthor":false,"prefix":"","firstName":"Gabriela","middleName":"L.","lastName":"Aitken","suffix":""},{"id":443964567,"identity":"7679e8f6-c818-47dd-afda-f675407e89c4","order_by":2,"name":"Tamara V. Damrel","email":"","orcid":"","institution":"Memorial Healthcare System","correspondingAuthor":false,"prefix":"","firstName":"Tamara","middleName":"V.","lastName":"Damrel","suffix":""},{"id":443964568,"identity":"1f4f95e7-7169-4f22-a7b1-195101bf44cb","order_by":3,"name":"Shenae Samuels","email":"","orcid":"","institution":"Memorial Healthcare System","correspondingAuthor":false,"prefix":"","firstName":"Shenae","middleName":"","lastName":"Samuels","suffix":""},{"id":443964569,"identity":"f3989a63-2bd0-4357-86e0-fa7d4f7bea0f","order_by":4,"name":"Gabriel Ologun","email":"","orcid":"","institution":"Memorial Healthcare System","correspondingAuthor":false,"prefix":"","firstName":"Gabriel","middleName":"","lastName":"Ologun","suffix":""},{"id":443964570,"identity":"8bded89b-f8eb-4eae-be28-76c1e9e58a1c","order_by":5,"name":"Christopher J. Gannon","email":"","orcid":"","institution":"Memorial Healthcare System","correspondingAuthor":false,"prefix":"","firstName":"Christopher","middleName":"J.","lastName":"Gannon","suffix":""},{"id":443964571,"identity":"8e47783f-6a77-4d20-9337-8706f7d0aa38","order_by":6,"name":"Omar H. Llaguna","email":"","orcid":"","institution":"Memorial Healthcare System","correspondingAuthor":false,"prefix":"","firstName":"Omar","middleName":"H.","lastName":"Llaguna","suffix":""}],"badges":[],"createdAt":"2025-03-22 21:08:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6285481/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6285481/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":81698929,"identity":"cae840b0-af51-490b-9515-588a4090e9ef","added_by":"auto","created_at":"2025-04-30 12:58:26","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":37902,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier survival functions by receipt of textbook oncologic outcome. A. Survival curves for study population by receipt of textbook oncologic outcome. B. Survival curves for survival study population by procedure performed and receipt of textbook oncologic outcome.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6285481/v1/a2ae2278134715e0edf8671f.png"},{"id":84707509,"identity":"471f4cc6-513c-448f-9b59-33777aad32b4","added_by":"auto","created_at":"2025-06-16 12:39:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":858879,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6285481/v1/c436b7b8-66dc-4184-bbf8-009a277a47d1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eImpact of Minimally Invasive Approach on Attainment of a Textbook Oncologic Outcome Following Colectomy for Colon Cancer-A Review of the National Cancer Database\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe quality of patient healthcare, especially in surgical settings, is inherently multifactorial, influenced by various interrelated factors. In surgical patients, the quality of care is often quantified by the achievement of desired postoperative outcomes, with the concept of a \"textbook outcome\" representing an ideal scenario where all expected outcomes are realized.\u003c/p\u003e \u003cp\u003eAchieving a textbook outcome is influenced by a complex interplay of variables, including hospital characteristics, surgical technique, individual patient factors such as comorbidities, and the underlying disease. Thus, assessing quality of care extends beyond single metrics, requiring composite measures that encapsulate multiple dimensions of patient outcomes. In surgical oncology, the textbook oncologic outcome (TOO) includes a comprehensive evaluation assessing the realization of desired short-term quality metrics following cancer surgery.\u003c/p\u003e \u003cp\u003eTOO was first introduced in the context of colon cancer in 2013, where it evaluated the proportion of patients meeting critical perioperative quality indicators.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e This study found that 49% of patients achieved TOO following colectomy, with significant variability between hospitals. Since then, TOO has gained traction as a tool for assessing surgical performance and identifying areas for improvement in cancer care. Current studies indicate that colon cancer surgery achieves a high TOO rate, ranging from 49\u0026ndash;67%, notably higher than rates seen in other cancers, such as gastric and pancreatic cancers, which are 35.3% and 16.8%, respectively.\u003csup\u003e\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Research has consistently shown a positive correlation between achieving TOO and improved survival after colon cancer surgery; however, data on the impact of specific surgical approaches on TOO are limited. This study evaluates how different surgical approaches affect TOO achievement in patients undergoing colectomy for colon cancer. By examining this relationship, we aim to provide insights into how surgical technique may influence short-term outcomes, ultimately contributing to better quality metrics and enhancing the overall care of colon cancer patients.\u003c/p\u003e"},{"header":"Materials \u0026 Methods","content":"\u003cp\u003eThis study aimed to determine if surgical approach is associated with achieving TOO among patients diagnosed with non-metastatic colon cancer. We queried the 2010\u0026ndash;2017 National Cancer Database (NCDB) for patients with non-metastatic colon cancer who underwent colectomy. The analysis was limited to the years 2010 to 2017 because the surgical approach variable is available only for diagnosis years 2010 and later. Patients were identified using surgical primary site codes 30 and 40 for partial and extended colectomy, respectively. Non-metastatic colon cancer was identified using histology codes 8010, 8140, 8210, and 8261\u0026ndash;8263, 8480, and 8490. Categorical variables were analyzed using Pearson\u0026rsquo;s chi-square test or Fisher\u0026rsquo;s exact test, presented as proportions and frequencies. Continuous variables were analyzed using Mood\u0026rsquo;s median test and presented as medians and interquartile ranges (IQR) or one-way ANOVA with means and standard deviations.\u003c/p\u003e \u003cp\u003eOverall survival (OS) was defined as the time (in months) between diagnosis and death or last contact. Patients achieving optimal oncologic care were said to have attained TOO. The dichotomous composite outcome was defined as \u0026ldquo;achieved\u0026rdquo; when all five individual oncologic criteria were met: resection with negative microscopic margins, adequate lymphadenectomy (LAD) based on AJCC compliant lymph node evaluation (i.e., 12 or more lymph nodes examined), no extended LOS (i.e., LOS\u0026thinsp;\u0026le;\u0026thinsp;50th percentile by year), no 30-day readmission, and no 30-day mortality. Surgical approach cohorts included open colectomy (OC), laparoscopic (LC) colectomy, and robotic colectomy (RC). To assess the association of surgical approach with TOO attainment, multivariate logistic regression models adjusting for demographics, facility characteristics, and clinical factors were employed. As a secondary analysis, Kaplan-Meier (KM) method with log-rank tests was used to compare and estimate OS among six cohorts based on surgical approach and TOO status (Open TOO, Lap TOO, Robotic TOO, Open non-TOO, Lap non-TOO, and Robotic non-TOO). All analyses were conducted using Stata/SE 15.1.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 271,606 patients with available surgical approach data underwent colectomy for non-metastatic colon cancer. Among them, 47.8% underwent OC, 46.1% LC, and 6.1% RC. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the characteristics of patients stratified by surgical approach, with all observed differences being statistically significant. The OC cohort had the highest median age of 71 years, and while the majority of patients were White, the OC cohort had the highest proportion of Black patients (OC: 13.1% vs. LC: 11.3% vs. RC: 11.5%). Furthermore, the OC cohort had the highest proportion of patients without insurance (OC: 3.5% vs. LC: 2.0% vs. RC: 1.4%) and the highest proportion of patients with two or more comorbidities (C: 12.0% vs. LC: 11.4% vs. RC: 9.8%). As measured by the Crowfly distance, patients in the RC cohort traveled the furthest for treatment (OC: 20.7 vs. LC: 21.5 vs. RC: 23.2).\u003c/p\u003e \u003cp\u003eIn assessing treatment characteristics, the RC cohort had the longest mean time to surgery (OC: 17.6 days vs. LC: 23.0 days vs. RC: 29.9 days). Most treatment occurred in comprehensive community cancer programs; however, the LC cohort had the highest proportion of patients treated in academic/research cancer programs. Patients in the OC cohort were more likely to be seen in facilities with low annual case volume (30.1%), while LC (28.8%) and RC (30.5%) cohorts were seen in facilities with very high annual case volume.\u003c/p\u003e \u003cp\u003eAmong surgical approaches, the OC cohort had the highest proportion of patients who underwent extended colectomy (OC: 65.7% vs. LC: 64.1%; RC: 60.2%) and the highest likelihood of having pathologic Stage 3, T4, N2 disease, undifferentiated histology, lymphovascular invasion, and positive surgical margins. The OC cohort also had the highest mean number of positive nodes examined, while the RC cohort had the highest mean number of nodes assessed. In terms of systemic therapy, patients in the OC cohort were most likely to receive adjuvant chemotherapy and had the shortest mean time to chemotherapy (OC: 67.1 days vs. LC: 67.8 days vs. RC: 71.7 days.\u003c/p\u003e\n\u003ch3\u003eTextbook Oncologic Outcomes\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e examines TOO proportions by surgical approach, revealing statistically significant differences. Patients undergoing OC were least likely to achieve TOO (27.7%) and fell short on following TOO criteria: R0 resection (94.4%), adequate LAD (88.3%), no extended LOS (41.0%), no 30-day readmission (92.1%) and timely adjuvant chemotherapy (86.3%). Patients in the OC cohort however demonstrated the highest rates of no 30-day mortality (86.6%), while those in the RC cohort had the lowest (70.1%). The robotic approach had the highest proportion of patients meeting timely adjuvant chemotherapy (91.5%), along with superior performance in the following TOO criteria: no extended LOS (73.2%), adequate LAD (91.3%), R0 resection (97.4%), and no 30-day readmission (94.2%). In terms of TOO attainment, the laparoscopic approach yielded the highest proportion of patients achieving TOO (LC: 45.0% vs. RC: 41.9% vs. OC: 27.7%).\u003c/p\u003e\n\u003ch3\u003eOverall Survival by TOO Status and Surgical Approach\u003c/h3\u003e\n\u003cp\u003eFigure 1A and Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e illustrate that patients achieving TOO had a higher median OS compared to those without TOO (111.9 vs. 82.3 months; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Among TOO patients, the OC TOO cohort had the highest median OS followed by the RC TOO cohort (111.9 vs. 109.5 months; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Notably, the median OS for the LC TOO cohort was not estimable, and the OC non-TOO cohort had the shortest median OS (71.2 months).\u003c/p\u003e\n\u003ch3\u003eAssociation of Surgical Approach and TOO\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e presents results from multivariate logistic regression models examining associations between surgical approach and TOO attainment. Compared to OC, LC (AOR\u0026thinsp;=\u0026thinsp;2.04; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and RC (AOR\u0026thinsp;=\u0026thinsp;1.69; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) approaches were associated with increased likelihood of achieving TOO, with LC having the highest odds.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eNumerous studies across gastrointestinal malignancies have investigated the attainment of TOO and its correlation with long-term survival.\u003csup\u003e\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e For example, an analysis from the Canadian Population Registry of Esophageal and Stomach Tumors of Ontario (PRESTO) revealed that 22% of 1,836 patients undergoing gastrectomy achieved TOO, resulting in a 41% reduction in mortality compared to those who did not meet this benchmark.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e On a broader scale, a review of 34,688 patients from the NCDB conducted by Cibulas et al. reported a TOO attainment rate of 23.8% following gastrectomy for gastric cancer, which was associated with a significantly lower risk of death (HR\u0026thinsp;=\u0026thinsp;0.82, P\u0026thinsp;\u0026lt;\u0026thinsp;.001) and improved median OS (80.5 vs. 35.3 months; P\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003csup\u003e7\u003c/sup\u003e In pancreatic cancer, a study involving 171 patients who underwent pancreaticoduodenectomy found that 25.7% achieved TOO, which correlated with enhanced median OS (32 vs. 20 months; P\u0026thinsp;=\u0026thinsp;0.034) and improved recurrence-free survival (19 vs. 13 months; P\u0026thinsp;=\u0026thinsp;0.053).\u003csup\u003e8\u003c/sup\u003e These findings are consistent with studies examining TOO attainment in colorectal cancer. A review of 508,312 patients in the NCDB (2004\u0026ndash;2017) indicated that 34% achieved TOO, which was associated with a significantly higher median OS compared to those who did not attain TOO (148.2 vs. 84.2 months; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003csup\u003e9\u003c/sup\u003e Additionally, Manatakis et al. demonstrated that those who achieved TOO experienced significantly better 5-year overall and cancer-specific survival rates (81% vs. 59%, P\u0026thinsp;=\u0026thinsp;0.009, and 86% vs. 65%, P\u0026thinsp;=\u0026thinsp;0.02, respectively).\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e In our study, 36.5% of patients achieved TOO, which was associated with significantly improved OS, revealing a median OS of 111.9 months compared to 82.3 months in patients who did not attain TOO (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). As evidenced by both existing literature and our findings, achieving TOO represents a crucial treatment goal that significantly contributes to improved OS across all gastrointestinal malignancies.\u003c/p\u003e \u003cp\u003e Minimally invasive colectomy has emerged as a widely accepted curative procedure for non-metastatic colon cancer, with numerous studies investigating its advantages relative to OC. For example, Zheng et al. analyzed data from the NCDB and found that LC was associated with lower 30-day mortality rates, reduced LOS, and an increased likelihood of receiving adjuvant chemotherapy compared to OC.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Similarly, Ohtani et al. demonstrated that LC results in decreased intraoperative blood loss, a shorter time to resumption of regular activities, and fewer complications during the immediate postoperative period.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e While the advantages of minimally invasive surgical techniques over open surgery are well-documented, its impact on TOO attainment remains less explored, with mixed results reported. For instance, in the context of pancreaticoduodenectomy, the surgical approach did not significantly influence TOO attainment. Sweigert et al. conducted an NCDB study involving 12,854 patients and found no significant differences in the likelihood of achieving TOO, R0 resection, adequate LAD, readmission rates, 30-day mortality, or LOS (P\u0026thinsp;\u0026gt;\u0026thinsp;.05). However, this study did identify improved median overall OS in patients who achieved TOO (TOO\u0026thinsp;=\u0026thinsp;27.6 months vs. non-TOO\u0026thinsp;=\u0026thinsp;21.3 months; P\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003csup\u003e12\u003c/sup\u003e Conversely, in gastrectomy for gastric cancer, the minimally invasive surgical approach was associated with an increased likelihood of achieving TOO. An NCDB study by Avila et al. reported a significant enhancement in TOO attainment among patients who underwent laparoscopic gastrectomy.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Our findings align with this literature, as LC yielded the highest proportion of patients achieving TOO (45.0%), followed by RC (41.9%) and OC (27.7%). These results suggest that minimally invasive approaches may enhance surgeons' ability to attain TOO in gastrointestinal cancers.\u003c/p\u003e \u003cp\u003eThe use of robotics in colorectal surgery has steadily increased, with RC rising from 0.7% in 2010 to 10.9% in 2016.\u003csup\u003e \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e \u003c/sup\u003e As this surgical method gains popularity, research has sought to compare its outcomes with those of laparoscopic and open procedures. However, due to its higher costs, skepticism about its role persists. Robotic surgery can be up to 25% more expensive and approximately \u003cspan\u003e$\u003c/span\u003e3,000 costlier than LC. Consequently, studies have focused on evaluating the potential benefits of robotic surgery.\u003csup\u003e \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e \u003c/sup\u003e Huang et al. compared OC, LC, and RC for colon cancer in 211 patients and found that those undergoing RC had shorter operation times (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and reduced LOS (P\u0026thinsp;=\u0026thinsp;0.005) without compromising survival benefits.\u003csup\u003e \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e \u003c/sup\u003e Avila et al. evaluated patients who underwent gastrectomy for gastric cancer indicating that those with robotic non-TOO had similar median OS (43.8 months) compared to laparoscopic non-TOO patients (45 months), significantly improving upon the median OS of those undergoing open non-TOO (33.6 months).\u003csup\u003e \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e \u003c/sup\u003e In our study, we observed that among patients who did not achieve TOO, RC resulted in the longest median OS (105.5 months), compared to 71.2 months for OC and 93.8 months for LC. These findings suggest that robotic surgery may confer survival benefits in patients independent of TOO status.\u003c/p\u003e \u003cp\u003eUpon examining the factors contributing to the attainment of TOO, we found that patients in the OC cohort were significantly more likely to require adjuvant chemotherapy compared to those in the LC and RC cohorts (OC: 35.8% vs. LC: 31.7% vs. RC: 32.5%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This disparity may be partially attributed to a higher prevalence of adverse pathological features in the OC cohort, including undifferentiated histology, lymphovascular invasion, T4 and N2 disease, and positive margins.\u003c/p\u003e \u003cp\u003eInterestingly, despite the minimally invasive cohorts demonstrating improved performance in metrics such as no prolonged length of stay (LOS) and no prolonged admission, the OC cohort experienced the shortest mean time to chemotherapy initiation (OC: 67.1 days vs. LC: 67.8 days vs. RC: 71.7 days, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This expedited initiation may be linked to the OC cohort's shorter travel distance for surgery (OC: 20.7 miles vs. LC: 21.5 miles vs. RC: 23.2, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), which likely contributed to their earlier time to surgery (OC: 17.6 days vs. LC: 23.0 days vs. RC: 29.9 days, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and, ultimately, the shortest mean time to chemotherapy initiation. These findings imply that reducing the time to surgery may have a more pronounced effect on time to systemic therapy than the benefits associated with a minimally invasive approach.\u003c/p\u003e \u003cp\u003eIt follows that optimal outcomes may be achieved through strategies that both minimize the time to surgery and expedite postoperative recovery. However, it is important to note that despite the established advantages of LC and RC regarding postoperative recovery, not all patients underwent a minimally invasive procedure. The NCDB does not specify the reasons for choosing an open approach, but one reasonable assumption is that that many cases were urgent and not suitable for minimally invasive techniques. The data additionally indicates that patients who underwent LC and RC traveled further for care, were predominantly White, had private insurance, exhibited the highest proportion of patients without comorbidities, and required adjuvant systemic therapy less frequently. These findings point to underlying socioeconomic disparities that may enhance healthcare access and the ability to afford travel for treatment, thus facilitating the use of LC and RC. Addressing these socioeconomic disparities may significantly improve access to minimally invasive surgery and its associated benefits.\u003c/p\u003e \u003cp\u003eAlthough our analysis demonstrated that patients who achieved TOO had significantly higher overall OS compared to those who did not, notable differences were evident within the matched cohorts. Specifically, the median OS was highest in the OC TOO cohort, followed closely by the RC TOO cohort (111.9 vs. 109.5 months; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The reasons behind the OC cohort's superior OS remain unclear; however, this observation suggests that attaining TOO may be independently associated with improved OS. Further subgroup analysis of the OC TOO group may provide additional insights into this phenomenon.\u003c/p\u003e \u003cp\u003eLastly, we were intrigued by the observed no 30-day mortality rates in our study, which appear lower than anticipated based on clinical practice. Further assessment suggests this finding can potentially be attributed to the inclusion of patients with unknown variables in our analysis. By utilizing a larger denominator that encompasses these unknowns, the proportions of patients exhibiting no 30-day mortality are diluted compared to analyses that exclude unknowns, as likely practiced by previous authors. Ultimately, the discrepancies observed may also stem from differences in coding practices regarding unknown variables and the potential variations in patient populations and coding methodologies between the years of the respective studies, underscoring the complexity of interpreting mortality rates across different datasets.\u003c/p\u003e \u003cp\u003eOur study is subject to several limitations. Firstly, the NCDB captures approximately 70% of all Commission on Cancer (CoC) accredited hospitals' cancer diagnosis and treatment data. Consequently, we cannot account for potential variations in practice patterns at non-CoC accredited institutions. While the NCDB is a prospectively gathered database, there are inherent limitations in how the data is collected and reported. Although our study demonstrates favorable outcomes associated with achieving TOO, it is important to note that the median OS for the LC TO cohort was not estimable due to a limited number of events in this subgroup. Treatment decisions for colon cancer, as well as the timing of therapy, are influenced by various factors, including patient characteristics, disease specifics, and institutional practices, which are not fully captured in the database. Furthermore, the static nature of the NCDB data, which spans from 2010 to 2017, may limit the applicability of our findings to current clinical practice patterns. Lastly, the retrospective design of our study may introduce selection bias, which should be considered when interpreting our results.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAchieving TOO is a predictor of long-term survival across all surgical approaches for colon cancer. Our findings suggest that a RC may offer significant advantages in attaining TOO following colectomy. However, it is important to note that only a small subset of patients with colon cancer currently undergo robotic colectomy. Therefore, concerted efforts to address the socioeconomic disparities that limit access to minimally invasive surgical options are essential to enhance patient outcomes and ensure equitable care for all individuals affected by this disease.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003eFunding Support: None\u003c/p\u003e\n\u003cp\u003eThis manuscript has not nor will be a podium or poster meeting presentation.\u003c/p\u003e\n\u003cp\u003eAuthor Contribution\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection, and writing of the original draft were performed by M.M., G.A., and T.D. Data analysis and preparation of tables and figures were performed by M.M., G.A., T.D., and S.S. Resources and supervision were provided by G.O., C.G., and O.L. All authors reviewed and edited previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKolfschoten NE, Kievit J, Gooiker GA, Van Leersum NJ, Snijders HS, Eddes EH, Tollenaar RA, Wouters MW (2013) Marang-Van De Mheen P.J. Focusing on desired outcomes of care after colon cancer resections; hospital variations in \u0026lsquo;textbook outcome\u0026rsquo;. Eur J Surg Oncol 39:156\u0026ndash;163. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ejso.2012.10.007\u003c/span\u003e\u003cspan address=\"10.1016/j.ejso.2012.10.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eManatakis DK, Tzardi M, Souglakos J et al (2023) Achieving a Textbook Outcome in Colon Cancer Surgery Is Associated with Improved Long-Term Survival. 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World J Surg Onc 20:345. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12957-022-02796-8\u003c/span\u003e\u003cspan address=\"10.1186/s12957-022-02796-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCharacteristics of patients undergoing colectomy stratified by surgical approach\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMinimally Invasive\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOpen (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLaparoscopic (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRobotic (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP-Value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e129,693 (47.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e125,232 (46.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16,681 (6.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedian Age, (IQR) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e71 (61\u0026ndash;81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e69.5 (59\u0026ndash;79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68 (58\u0026ndash;76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61,726 (47.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61,093 (48.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8,500 (51.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67,967 (52.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e64,139 (51.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8,181 (49.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRace/Ethnicity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWhite\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e101,251 (81.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e98,597 (82.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12,847 (81.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBlack\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16,347 (13.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13,492 (11.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,805 (11.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHispanic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6,871 (5.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6,860 (5.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,031 (6.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInsurance Status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUninsured\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,508 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,462 (2.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e233 (1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrivate Insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35,317 (27.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42,642 (34.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6,449 (39.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGovernment Insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e88,010 (68.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e78,930 (63.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9,840 (59.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCrowfly, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.7\u0026thinsp;\u0026plusmn;\u0026thinsp;84.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.5\u0026thinsp;\u0026plusmn;\u0026thinsp;85.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.2\u0026thinsp;\u0026plusmn;\u0026thinsp;99.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCharlson-Deyo Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e84,574 (65.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e83,237 (66.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11,684 (70.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29,566 (22.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27,738 (22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,361 (20.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 +\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15,553 (12.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14,257 (11.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,636 (9.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTime to Surgery in Days, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.6\u0026thinsp;\u0026plusmn;\u0026thinsp;32.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.0\u0026thinsp;\u0026plusmn;\u0026thinsp;31.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29.9\u0026thinsp;\u0026plusmn;\u0026thinsp;35.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFacility / Cancer Program Type\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCommunity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19,985 (15.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11,353 (9.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,293 (7.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComprehensive Community\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59,525 (46.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58,380 (47.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7,367 (45.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAcademic/Research\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30,390 (23.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34,029 (27.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,824 (29.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIntegrated Network\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17,399 (13.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19,146 (15.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,824 (17.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCase-Volume Per Year Quartiles\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLow (1.00\u0026ndash;25.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39,009 (30.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25,220 (20.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,322 (19.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIntermediate (25.14\u0026ndash;38.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32,967 (25.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29,982 (23.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,082 (24.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh (38.36\u0026ndash;57.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29,614 (22.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33,986 (27.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,185 (25.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVery High (57.79\u0026ndash;206.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28,103 (21.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36,044 (28.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,092 (30.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExtent of colectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePartial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44,506 (34.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44,963 (35.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6,638 (39.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExtended\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e85,187 (65.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80,269 (64.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10,043 (60.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePathologic Stage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28,991 (22.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40,150 (32.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,678 (34.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50,833 (39.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43,621 (34.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,467 (32.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49,869 (38.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41,461 (33.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,536 (33.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePathologic T Stage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14,160 (11.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22,731 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,272 (19.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19,843 (15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23,746 (19.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,342 (20.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e74,212 (57.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65,886 (52.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8,430 (50.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21,013 (16.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12,425 (10.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,578 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePathologic N Stage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80,215 (61.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e83,959 (67.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11,156 (66.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32,212 (24.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28,602 (22.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,865 (23.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17,266 (13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12,671 (10.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,660 (10.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGrade\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWell differentiated (I)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13,811 (11.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13,685 (11.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,955 (12.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eModerately differentiated (II)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87,875 (69.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87,106 (72.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11,875 (73.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePoorly differentiated (III)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20,283 (16.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16,928 (14.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,940 (12.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUndifferentiated (IV)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,840 (3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,324 (2.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e357 (2.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLymphovascular Invasion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32,672 (25.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28,185 (22.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,755 (22.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot Present\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87,594 (67.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e88,441 (70.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11,729 (70.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9,427 (7.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8,606 (6.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,197 (7.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e# Nodes, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.8\u0026thinsp;\u0026plusmn;\u0026thinsp;10.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.3\u0026thinsp;\u0026plusmn;\u0026thinsp;9.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e# Nodes Positivity, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSurgical Margins After Resection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePositive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6,742 (5.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,177 (2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e394 (2.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNegative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e122,423 (94.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e121,670 (97.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16,244 (97.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e528 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e385 (0.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43 (0.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdjuvant Chemotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e69,309 (64.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75,189 (68.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10,187 (67.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38,638 (35.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34,830 (31.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,912 (32.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTime to Chemotherapy in Days, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67.1\u0026thinsp;\u0026plusmn;\u0026thinsp;44.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67.8\u0026thinsp;\u0026plusmn;\u0026thinsp;41.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e71.7\u0026thinsp;\u0026plusmn;\u0026thinsp;37.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003eIQR\u0026thinsp;=\u0026thinsp;Interquartile Range\u003c/p\u003e\n \u003cp\u003eProportions may not add to 100% due to rounding error, missing or unknown data, and data not presented due to NCDB data use agreement.\u003c/p\u003e\n \u003cp\u003e\u003csup\u003ea\u003c/sup\u003e Computed p-value from Mood\u0026rsquo;s median test.\u003c/p\u003e\n \u003cp\u003e\u003csup\u003eb\u003c/sup\u003e Computed p-value represents between group differences from one-way ANOVA test.\u003c/p\u003e\n \u003cp\u003eBoldface font denotes statistical significance at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSummary of textbook oncologic outcome criteria by surgical approach\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" style=\"width: 23.3705%;\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 11.3568%;\"\u003e\n \u003cp\u003eOpen (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 16.1435%;\"\u003e\n \u003cp\u003eLaparoscopic (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 10.7936%;\"\u003e\n \u003cp\u003eRobotic (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 7.1332%;\"\u003e\n \u003cp\u003eP-Value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 23.3705%;\"\u003e\n \u003cp\u003eNegative Margin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.3568%;\"\u003e\n \u003cp\u003e122,423 (94.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 16.1435%;\"\u003e\n \u003cp\u003e121,670 (97.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.7936%;\"\u003e\n \u003cp\u003e16,244 (97.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.1332%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 23.3705%;\"\u003e\n \u003cp\u003e12\u0026thinsp;+\u0026thinsp;Lymph Nodes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.3568%;\"\u003e\n \u003cp\u003e114,503 (88.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 16.1435%;\"\u003e\n \u003cp\u003e113,574 (90.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.7936%;\"\u003e\n \u003cp\u003e15,234 (91.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.1332%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 23.3705%;\"\u003e\n \u003cp\u003eNo Prolonged LOS (50 percentile)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.3568%;\"\u003e\n \u003cp\u003e50,699 (41.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 16.1435%;\"\u003e\n \u003cp\u003e79,567 (65.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.7936%;\"\u003e\n \u003cp\u003e11,799 (73.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.1332%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 23.3705%;\"\u003e\n \u003cp\u003eNo 30-Day Readmission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.3568%;\"\u003e\n \u003cp\u003e119,429 (92.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 16.1435%;\"\u003e\n \u003cp\u003e116,733 (93.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.7936%;\"\u003e\n \u003cp\u003e15,716 (94.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.1332%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 23.3705%;\"\u003e\n \u003cp\u003eNo 30-Day Mortality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.3568%;\"\u003e\n \u003cp\u003e112,324 (86.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 16.1435%;\"\u003e\n \u003cp\u003e105,011 (83.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.7936%;\"\u003e\n \u003cp\u003e11,696 (70.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.1332%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 23.3705%;\"\u003e\n \u003cp\u003eInitiation of ACT (\u0026le;\u0026thinsp;12 weeks)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.3568%;\"\u003e\n \u003cp\u003e32,450 (86.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 16.1435%;\"\u003e\n \u003cp\u003e30,810 (89.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.7936%;\"\u003e\n \u003cp\u003e4,349 (91.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.1332%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 23.3705%;\"\u003e\n \u003cp\u003eTextbook Oncologic Outcome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 11.3568%;\"\u003e\n \u003cp\u003e35,900 (27.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 16.1435%;\"\u003e\n \u003cp\u003e56,392 (45.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 10.7936%;\"\u003e\n \u003cp\u003e6,982 (41.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.1332%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\" style=\"width: 69.9239%;\"\u003e\n \u003cp\u003eACT\u0026thinsp;=\u0026thinsp;Adjuvant chemotherapy, LOS\u0026thinsp;=\u0026thinsp;Length of Stay. Proportions may not add to 100% due to rounding error, missing or unknown data, and data not presented due to NCDB data use agreement. Boldface font denotes statistical significance at \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eMedian overall survival (months) among patients by surgical approach and TOO Status\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eColectomy/TOO Status\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMedian OS (95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTOO\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e110,129\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e111.9 (111.2, NE)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOpen TOO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35,897\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e111.9 (111.2, NE)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLaparoscopic TOO \u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56, 389\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNE (111.1, NE)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRobotic TOO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6,982\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e109.5 (109.5, NE)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-TOO\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e160,758\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e82.3 (81.5, 83.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOpen Non-TOO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e82,250\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e71.2 (70.2, 72.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLaparoscopic Non-TOO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51,330\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e93.8 (92.2, 96.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRobotic Non-TOO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,970\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e105.5 (95.7, NE)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e237,818\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e102.4 (101.6, 103.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eNE\u0026thinsp;=\u0026thinsp;Not Estimable. 95% CI\u0026thinsp;=\u0026thinsp;95% Confidence Interval\u003c/p\u003e\n \u003cp\u003e\u003csup\u003e\u0026dagger;\u003c/sup\u003e Median OS could not be calculated due to the small number of events in this cohort\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eLogistic regression examining the association of obtaining TOO and colectomy surgical approach\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" style=\"width: 13.9024%;\"\u003e\n \u003cp\u003eOutcomes\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 13.8211%;\"\u003e\n \u003cp\u003eOR (95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 8.1301%;\"\u003e\n \u003cp\u003eP-Value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 14.4715%;\"\u003e\n \u003cp\u003eAOR\u003csup\u003ea\u003c/sup\u003e (95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 9.1057%;\"\u003e\n \u003cp\u003eP-Value\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 13.9024%;\"\u003e\n \u003cp\u003eTOO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.8211%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 8.1301%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.4715%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.1057%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 13.9024%;\"\u003e\n \u003cp\u003eOpen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.8211%;\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 8.1301%;\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.4715%;\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.1057%;\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 13.9024%;\"\u003e\n \u003cp\u003eLaparoscopic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.8211%;\"\u003e\n \u003cp\u003e2.14 (2.11, 2.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 8.1301%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.4715%;\"\u003e\n \u003cp\u003e2.04 (2.00, 2.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.1057%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 13.9024%;\"\u003e\n \u003cp\u003eRobotic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.8211%;\"\u003e\n \u003cp\u003e1.88 (1.82, 1.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 8.1301%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.4715%;\"\u003e\n \u003cp\u003e1.69 (1.63, 1.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.1057%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\" style=\"width: 60.5691%;\"\u003e\n \u003cp\u003eOR\u0026thinsp;=\u0026thinsp;Odds Ratio. AOR\u0026thinsp;=\u0026thinsp;Adjusted Odds Ratio. 95% CI\u0026thinsp;=\u0026thinsp;95% Confidence Interval\u003c/p\u003e\n \u003cp\u003eBoldface font denotes statistical significance at \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\n \u003cp\u003e\u003csup\u003ea\u003c/sup\u003e. Estimates based on adjusted models adjusting for age, gender, race/ethnicity, insurance status, facility type, case-volume per year quartiles, extent of colectomy, disease stage group and Charlson-Deyo comorbidity score\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"TOO, Colon, Cancer, Colectomy, Oncologic, Outcome","lastPublishedDoi":"10.21203/rs.3.rs-6285481/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6285481/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTextbook oncologic outcome is a composite measure achieved when all desired short-term quality metrics are met following an oncologic operation. This study aimed to determine the impact of surgical approach on textbook oncologic outcome achievement after colectomy for colon cancer.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe queried the 2010-2017 National Cancer Database for patients with non-metastatic colon cancer who underwent colectomy, then stratified them by surgical approach: open colectomy vs laparoscopic colectomy vs robotic colectomy. Textbook oncologic outcome \u0026nbsp;was defined by six metrics: resection with negative margins (R0), adequate lymphadenectomy (≥ 12), no prolonged length of stay (\u0026lt; 50th percentile by year), no 30-day readmission, no 30-day mortality, and timely initiation of adjuvant chemotherapy (≤ 12 weeks). Surgical approaches were categorized as open, laparoscopic, and robotic colectomy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe open group had the lowest textbook oncologic outcome attainment (open = 27.7%, LC = 45%, RC = 41.9%) and also performed poorly on five of the six TOO criteria: R0 resection (94.4%), adequate lymphadenectomy (88.3%), minimal length of stay (41.0%), no 30-day readmission (92.1%), and timely adjuvant chemotherapy (86.3%). Multivariate logistic regression suggested that laparoscopic colectomy (AOR = 2.04; p \u0026lt; 0.001) and robotic colectomy (AOR = 1.69; p \u0026lt; 0.001) were associated with increased likelihood of textbook oncologic outcome attainment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAchieving TOO is a crucial predictor of long-term survival across all surgical approaches for colon cancer. Our findings suggest that a robotic surgical approach may offer significant advantages in attaining TOO following colectomy.\u003c/p\u003e","manuscriptTitle":"Impact of Minimally Invasive Approach on Attainment of a Textbook Oncologic Outcome Following Colectomy for Colon Cancer-A Review of the National Cancer Database","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-30 12:00:24","doi":"10.21203/rs.3.rs-6285481/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3cbd9c55-e708-43b8-8561-0d5d012d650e","owner":[],"postedDate":"April 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-29T13:23:23+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-30 12:00:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6285481","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6285481","identity":"rs-6285481","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}