Background: The impact of enhanced recovery pathway (ERP) on survival after colorectal cancer surgery (CCS) remains controversial. Materials and methods: A total of 2865 adults enrolled in a multicenter cohort study (iCral3 study) after CCS were followed up. The percentage adherence to the ERP was recorded, and the patients were grouped according to their quartiles. Other patient-, center-, disease-, and treatment-related factors were considered in a machine learning generalized boosted model (GBM) to estimate the 22 covariates propensity score weights for the binary comparisons between the reference treatment (1st quartile, ERP adherence rates <57.7 %) and the other treatment arms (2nd, 3rd, and 4th quartile). The primary endpoint was overall survival (OS). A GBM-weighted Cox model balanced on the same covariates was used to estimate the hazard ratio (HR) and 95 % confidence interval (95 %CI). Results: Patients in the 4th quartile (ERP adherence rates ≥80.8 %) showed a significant lower risk of death from any cause (HR, 0.69; 95 %CI 0.49–0.96; p = 0.026). Conclusions: High adherence to ERP was associated to a significant impact on long-term overall survival, supporting the efforts towards proper ERP implementation after CCS.
Enhanced recovery and survival after elective surgery for colorectal cancer - propensity score weighting analysis of 2,865 prospective patients / M. Catarci, S. Guadagni, M. Scatizzi, R. De Luca, P. Delrio, G. Ruffo, F. Borghi, F. Masedu, P. Ciano, M. Benedetti, L.A. Montemurro, M.S. Mattei, E. Belloni, M. Di Carlo, D. Apa, M. Clementi, L. Pandolfini, A. Falsetto, M. Simone, U. Pace, A.F. Bucci, E. Bertocchi, G. Masini, M.G. Viola, A. Altamura, F. Rubichi, F. Ficari, F. Giudici, F. Cianchi, F. Pirozzi, A. Sciuto, M. Migliore, A. Patriti, M.L. Ricci, G. Garulli, D. Parlanti, G. Vago, W. Siquini, A. Cardinali, S. D'Ugo, M. Spampinato, S. Scabini, A. Aprile, D. Soriero, M. Caricato, G.T. Capolupo, G. Pignata, J. Andreuccetti, I. Canfora, A. Liverani, G. Lamacchia, C. Franceschilli, R. Campagnacci, A. Maurizi, P. Marini, G.M. Attinà, U. Elmore, L. Gozzini, R. Santoro, P. Amodio, M. Carlini, D. Spoletini, R. Marcellinaro, A. Giuliani, G. Del Vecchio, M. Sorrentino, M. Stefanoni, G. Ferrari, P. Carnevali, G. Baldazzi, D. Cassini, A. Di Leo, L. Crepaz, A. Verzelli, A. Budassi, G. Sica, G. Bagaglini, D. Cavaliere, L. Solaini, G. Ercolani, G.L. Baiocchi, S. Molfino, M. Milone, G.D. De Palma, G. Ciaccio, P. Locurto, G. Tebala, A. Di Cintio, L. Boni, E. Cassinotti, S. Mancini, A. Sagnotta, M. Guerrieri, M. Ortenzi, R. Persiani, A. Biondi, A. Lucchi, G. Vitali, D. Parini, M. De Luca, A. Spinelli, F. Carrano, A. Maroli, M. Genna, F. Fior, V. Bottino, A. Ferronetti, A. Coratti, G. Giuliani, R. Benigni, A. Muratore, P. Marsanic, N.S. Pipitone Federico, M. Pavanello, C. Di Marco, I. Graziosi, U. Rivolta, C.L. Bertoglio, M. Piccoli, F. Pecchini, C. Talarico, V. Greco, A. Carrara, M. Motter, G. Tirone, M. Totis, N. Tamini, M. Braga, F. Roviello, R. Piagnerelli, A. Anastasi, G. Canonico, G. Guercioni, S. Cicconi, G.M. Ettorre, M. Colasanti, M. Montuori, E. Pinotti, P. Mariani, R. Carminati, N. De Manzini, E. Osenda, A. Donini, L. Graziosi, M.F. Armellino, C. De Martino, L. Taglietti, S. Ruggiero, G. Anania, M. Chiozza, M. Di Cosmo, D. Zigiotto, C.V. Feo, F. Pindozzi, P. Millo, M. Grivon, C. Pedrazzani, C. Conti, S. Guerriero, L. Organetti, A. Costanzi, M. Monteleone, N. Vettoretto, E. Botteri, F. Marchesi, G. Dalmonte, G. Longo, S. Santoni. - In: EUROPEAN JOURNAL OF SURGICAL ONCOLOGY. - ISSN 0748-7983. - 51:11(2025 Nov), pp. 110379.1-110379.10. [10.1016/j.ejso.2025.110379]
Enhanced recovery and survival after elective surgery for colorectal cancer - propensity score weighting analysis of 2,865 prospective patients
R. De Luca;G. Ferrari;P. Carnevali;L. Boni;E. Cassinotti;A. Spinelli;U. Rivolta;M. Monteleone;
2025
Abstract
Background: The impact of enhanced recovery pathway (ERP) on survival after colorectal cancer surgery (CCS) remains controversial. Materials and methods: A total of 2865 adults enrolled in a multicenter cohort study (iCral3 study) after CCS were followed up. The percentage adherence to the ERP was recorded, and the patients were grouped according to their quartiles. Other patient-, center-, disease-, and treatment-related factors were considered in a machine learning generalized boosted model (GBM) to estimate the 22 covariates propensity score weights for the binary comparisons between the reference treatment (1st quartile, ERP adherence rates <57.7 %) and the other treatment arms (2nd, 3rd, and 4th quartile). The primary endpoint was overall survival (OS). A GBM-weighted Cox model balanced on the same covariates was used to estimate the hazard ratio (HR) and 95 % confidence interval (95 %CI). Results: Patients in the 4th quartile (ERP adherence rates ≥80.8 %) showed a significant lower risk of death from any cause (HR, 0.69; 95 %CI 0.49–0.96; p = 0.026). Conclusions: High adherence to ERP was associated to a significant impact on long-term overall survival, supporting the efforts towards proper ERP implementation after CCS.
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