As such, surgeons have employed local excision for these distal early cancers for decades. Early reports in the 1990s were quite promising. Data from the CALGB 8984 trial, which evaluated the efficacy of local excision (TAE) in the treatment of T1 and T2 rectal cancers, revealed a local recurrence rate of 8 % with a distant metastasis rate of 5 % in 59 patients undergoing local excision for T1 tumors [33]. This was associated with an overall survival of 84 %. The recurrence rate for T2 tumors was higher at 18 % with a 12 % distant recurrence rate corresponding to a 66 % overall survival rate. However, reports began to surface demonstrating signifi­cantly higher rates of recurrence. Garcia-Aguilar published the University of Minnesota group’s experience demonstrating an 18 % recurrence rate in 55 T1 lesions with a 98 % survival with a mean of 54 months of follow-up. The recurrence rate for T2 lesions was 37 % [34]. Data from Memorial Sloan-Kettering was similar with a 17 % 10-year local recurrence rate and 74 % 10-year disease-free survival in 74 patients with T1 cancers. In this study, 50 % of recurrences were local recur­rences only, suggesting inadequate resection as the cause of treatment failure [35]. A nationwide cohort study from the National Cancer Database demonstrated a dra­matic increase in the use of local excision for T1 rectal cancers from 27 to 43 % between 1989 and 2003 with an associated increase in local recurrence (12.5 % vs. 6.9 %

for T1 and 22.1 % vs. 15.1 % for T2, p < 0.05) and decline in overall survival as compared to standard resection for T2 tumors (77.4 % vs. 81.7 % for T1, p = 0.09, and 67.6 % and 76.5 % for T2, p < 0.05) [28]. Findings of higher recurrence and lower overall survival were also demonstrated in several other observational studies comparing traditional TAE to radical resection as well [14, 36]. This led to scrutiny for the increasing rate of local excision for Stage I rectal cancer and thus methods to improve TAE.