Commentary on “Does Local Excision Without Salvage Surgery Affect the Prognostic Outcome of Patients With Malignant Colorectal Polyp? A Long‐Term Survival Analysis”

Dear Editor,

1.

I read with great interest the recent article by Ng et al. that looked at the longer term oncological outcomes of local excision alone versus local excision with salvage surgery in patients with malignant colorectal polyps. It is important that the authors have taken up a problem of great clinical interest, namely, the management of T1 colorectal cancer in which attempts to achieve oncological safety and reduce the morbidity of radical surgery are frequently not balanced. Propensity score matching, extended follow‐up, and evaluation of disease‐free, cancer‐specific, and overall survival offer important evidence for individual treatment strategies. The results of their work make a significant contribution to the expanding literature in favor of organ preservation in appropriately selected patients and warrant recognition for stimulating further discussion in this rapidly developing area [1].

However, some methodological issues need to be discussed prior to widespread application of these results in clinical practice. First, even though the propensity score matching made the groups comparable, the assignment of treatment was still not randomized. The matching algorithm did not take into account important issues that may influence the decision not to proceed with salvage surgery such as frailty, patient preference, socioeconomic factors, endoscopist experience, multidisciplinary decision‐making, and functional status. These residual confounders could have impacted treatment choice and long‐term results. Second, it is important to consider the findings of the conclusion of noninferiority with some caution as it was not a formal non‐inferiority trial. The relatively small matched cohort (79 pairs), the very low number of recurrence events, and wide confidence intervals in the multivariable analyses all point to low statistical power, meaning that clinically important differences may not have been detected, and thus, a Type II error may have occurred. Third, there was a great deal of variation in the intensity of the surveillance between the treatment groups. Local excision alone was followed by earlier and more frequent endoscopic surveillance, while cross‐sectional imaging was performed when clinically indicated and not in a set protocol. This means that the type of surveillance (and hence when and how the disease is detected) varies, which can lead to detection bias and therefore impact on the recurrence time and estimates of disease‐free survival. Fourth, patients included in the study were managed across a 22‐year period (from 2000 to 2022), a time period during which there had been significant improvements in the imaging of endoscopes, ESD techniques, standards of pathological reporting, MRI staging, and perioperative care. Temporal improvements in diagnosis and treatment could have led to era related bias which is not accounted for in the analysis. Finally, although individual risk assessment is stressed, a detailed evaluation of some of the emerging prognostic biomarkers, such as mismatch repair status, molecular alterations, and a standardized evaluation of the tumor budding in all cases, was not performed. Increased molecular risk stratification is becoming an integral part of modern management of colorectal cancer, and the absence of these may have limited the accuracy of selecting patients for whom a salvage surgery would have been unnecessary [2, 3, 4].

This study is important from my point of view as it moves towards a more personalized approach to the management of colon cancer associated with polyps instead of outright recommendations for omitting a salvage operation. Multicenter prospective registries with uniform surveillance protocols and central pathological review, modern molecular markers, patient‐reported quality‐of‐life measures, and validated prediction models for lymph node metastasis could provide greater insight to inform treatment decisions beyond the scope of traditional histopathological risk factors. This level of risk stratification may help reduce the number of radical surgeries performed, ensuring maximum oncologic safety while advancing precision medicine in the early management of CRC [5].

Funding

The author has nothing to report.

Ethics Statement

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Conflicts of Interest

The author declares no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.