Discussion
colorectal cancer, patientsAnastomotic leakage, toxicities, colorectal surgeons, colon cancer, colorectal resection
COLORECTAL CANCER, GASTROINTESTINAL CANCERS, RECURRENCE, POSTOPERATIVE COMPLICATIONS, COLON CANCER, STRICTURE, SURGICAL COMPLICATIONS, LEAKAGE, COMPLICATIONS
Traditionally, AC is initiated between 4 and 8 weeks after radical surgery for colon cancer to achieve the balance between postoperative recovery and therapeutic effect. Although many studies have reported a correlation between poor prognosis and late initiation of AC (more than 8 weeks postoperatively)In the era of minimally invasive surgery and ERAS, it is necessary to re-evaluate traditional chemotherapy regimens. The traditional concept of AC after a minimum of 4 weeks after surgery was formed several decades ago when open surgery was generally performed for gastrointestinal cancers. This demanded longer hospitalization, recovery time (until returning to oral intake), and wound management. However, minimally invasive surgery for colorectal cancer has now become the standard of care for the majority of patientsAnastomotic leakage, one of the worst complications following colorectal surgery, is usually diagnosed between 3 and 8 days after surgeryA potential concern after the early introduction of cytotoxic agents is late anastomotic complications. In this study, two patients in the EAC arm showed leakage on POD 16 and a stricture on POD 18 respectively, and both required surgical intervention. Although it is generally considered that anastomotic healing is completed by POD 10–12, the rate of late anastomotic leakage after general recovery was reported to be 6 to 7.7 per cent in colorectal resection, regardless of the timing of ACThere were five cases of recurrence during AC in the CAC arm and no cases in the EAC arm. These findings need to be evaluated further with longer-term follow-up and to investigate if patients with adverse features should be considered for earlier AC.In the present study, postoperative QoL was investigated to evaluate if a shorter interval between surgery and following AC impairs general condition and daily living according to a patient’s subjective feelings, in addition to surgical complications. AC affects the QoL of patients who undergo colon cancer surgery, not only during AC, but also after its completionThis study has limitations. The time interval between the two arms according to the study design was only 2 weeks. Due to the short interval between the two arms and various medical and personnel issues, there was an overlap of the time interval. Consequently, interpretation of the results should be made with some caution as 58 patients (25 in the EAC arm and 33 in the CAC arm) were excluded from the safety analyses because of protocol violations. Among them, 15 patients were enrolled in the study by surgeons immediately after recovery from surgery, but all declined to receive chemotherapy after discussions with medical oncologists. Another 40 patients chose a chemotherapy regimen other than FOLFOX. However, the outcomes of variables (chemotherapy dose, compliance, and toxicities) analysed in the safety population were similar when analyses including those patients were performed.This study was performed in tertiary hospitals with sub-specialist colorectal surgeons, high rates of minimally invasive surgery, and low rates of surgical complications. This might impact the generalizability of the results to other centres nationally or internationally. Early initiation of AC is not appropriate for all patients and may not be appropriate for those who have open surgery, frail patients, or those with postoperative complications.