Association of Adenoma Detection Rate and Adenoma Characteristics With Colorectal Cancer Mortality After Screening Colonoscopy

Background & AimsThe adenoma detection rate (ADR) and characteristics of previously resected adenomas are associated with colorectal cancer (CRC) incidence and mortality. However, the combined effect of both factors on CRC mortality is unknown.Patients and methodsUsing data of the Austrian quality assurance program for screening colonoscopy, we evaluated the combined effect of ADR and lesion characteristics on subsequent risk for CRC mortality. We analyzed mortality rates for individuals with low-risk adenomas (1–2 adenomas <10 mm), individuals with high-risk adenomas (advanced adenomas or ≥3 adenomas), and after negative colonoscopy (negative colonoscopy or small hyperplastic polyps) performed by endoscopists with an ADR <25% compared with ≥25%. Cox regression was used to determine the association of combined risk groups with CRC mortality, adjusted for age and sex.ResultsWe evaluated 259,885 colonoscopies performed by 361 endoscopists. A total of 165 CRC-related deaths occurred during the follow-up period, up to 12.2 years. In all risk groups, CRC mortality was higher when colonoscopy was performed by an endoscopist with an ADR <25%. Compared with negative colonoscopy with an ADR ≥25%, CRC mortality was similar for individuals with low-risk adenomas irrespective of ADR (for ADR ≥25%: adjusted hazard ratio [HR], 1.22; 95% confidence interval [CI], 0.59–2.49; for ADR <25%: adjusted HR, 1.25; 95% CI, 0.64–2.43) and after negative colonoscopy with ADR <25% (adjusted HR, 1.27; 95% CI, 0.81–2.00). Individuals with high-risk adenomas were at significantly higher risk for CRC death if colonoscopy was performed by an endoscopist with an ADR <25% (adjusted HR, 2.25; 95% CI, 1.18–4.31) but not if performed by an endoscopist with an ADR ≥25% (adjusted HR, 1.35; 95% CI, 0.61–3.02).ConclusionsOur study adds important evidence for mandatory assessment and monitoring of performance quality in screening colonoscopy. High-quality colonoscopy was associated with a lower risk for CRC death, and the impact of ADR was strongest for individuals with high-risk adenomas.     

Impact of Visceral Fat on Survival and Metastasis of Stage III Colorectal Cancer

Background/AimsPrevious studies have investigated the relationship between visceral obesity and the risk of colorectal tumors. Visceral obesity may affect the outcome of colorectal cancer (CRC), including survival and metastasis. We investigated the associations between visceral adipose tissue and oncologic outcomes in stage III CRC.MethodsFour hundred seventy-two patients with stage III CRC were identified. Subcutaneous and visceral adipose tissue areas were measured volumetrically via computed tomography for each patient at different levels of the lumbar spine. After adjusting for age, sex, and other clinical factors, the effects of visceral adipose tissue area on mortality and recurrence were assessed using Cox proportional hazard regression.ResultsIn univariate and multivariate analyses, a higher visceral adipose tissue to total adipose tissue (VT) ratio (hazard ratio [HR], 1.041; 95% CI, 1.008 to 1.075; p=0.015) and higher visceral adipose tissue to subcutaneous adipose tissue (VS) ratio (HR, 1.016; 95% CI, 1.005 to 1.028; p=0.006) were both associated with poor CRC-specific survival. Interestingly, in the evaluation of each site of recurrence, a higher VT ratio (HR, 1.069; 95% CI, 1.010 to 1.131; p=0.020) and higher VS ratio (HR, 1.024; 95% CI, 1.003 to 1.045; p=0.023) were both related to a higher risk of peritoneal seeding and tumor recurrence. The VT ratio at the L3–L4 level was significantly associated with a higher risk of peritoneal seeding and tumor recurrence (HR, 4.969; 95% CI, 1.303 to 18.949; p=0.019), while other levels showed no such relationship.ConclusionsVisceral obesity is closely related to increased risks of CRC-specific mortality and peritoneal seeding metastasis in stage III CRC patients.     

Evaluation of a risk score based on dietary and lifestyle factors to target a population at risk in colorectal cancer screening

BackgroundThe aim of our study was to assess three risk scores to predict lesions, advanced neoplasia (high-risk adenomas and colorectal cancer (CRC)) and CRC in individuals who participate to colorectal cancer screening.MethodsThe data of dietary and lifestyle risk factors were carried out during 2 mass screening campaigns in France (2013–2016) and the FOBT result was collected until December 2018. The colonoscopy result in positive FOBT was recovered. Three risk scores (Betés score, Kaminski score and adapted-HLI) were calculated to detect individuals at risk of lesions.ResultsThe Betés score had an AUROC of 0.63 (95% CI, [0.61–0.66]) for lesions, 0.65 (95% CI, [0.61–0.68]) for advanced neoplasia and 0.65 (95% CI, [0.58–0.72]) for predicting screen-detected CRC.The adapted HLI score had an AUROC of 0.61 (95% CI, [0.58–0.65]) for lesions, 0.61 (95% CI, [0.56–0.65]) for advanced neoplasia and 0.55 (95% CI, [0.45–0.65]) for predicting screen-detected CRC.The Kaminski score had an AUROC of 0.65 (95% CI, [0.63–0.68]) for lesions, 0.65 (95% CI, [0.61–0.68]) for advanced neoplasia and 0.69 (95% CI, [0.62–0.76]) for predicting screen-detected CRC.ConclusionA simple questionnaire based on CRC risk factors could help general practitioners to identify participants with higher risk of significant colorectal lesions and incite them to perform the fecal occult blood test.     

Histopathological growth patterns and positive margins after resection of colorectal liver metastases

BackgroundHistopathological growth patterns (HGPs) of colorectal liver metastases (CRLM) may be an expression of biological tumour behaviour impacting the risk of positive resection margins. The current study aimed to investigate whether the non-desmoplastic growth pattern (non-dHGP) is associated with a higher risk of positive resection margins after resection of CRLM.MethodsAll patients treated surgically for CRLM between January 2000 and March 2015 at the Erasmus MC Cancer Institute and between January 2000 and December 2012 at the Memorial Sloan Kettering Cancer Center were considered for inclusion.ResultsOf all patients (n = 1302) included for analysis, 13% (n = 170) had positive resection margins. Factors independently associated with positive resection margins were the non-dHGP (odds ratio (OR): 1.79, 95% confidence interval (CI): 1.11–2.87, p = 0.016) and a greater number of CRLM (OR: 1.15, 95% CI: 1.08–1.23 p < 0.001). Both positive resection margins (HR: 1.41, 95% CI: 1.13–1.76, p = 0.002) and non-dHGP (HR: 1.57, 95% CI: 1.26–1.95, p < 0.001) were independently associated with worse overall survival.ConclusionPatients with non-dHGP are at higher risk of positive resection margins. Despite this association, both positive resection margins and non-dHGP are independent prognostic indicators of worse overall survival.     

Efecto de la demora atribuible al sistema sanitario en el pronóstico del cáncer colorrectal

ObjectivesTo analyse the effect of a delay attributable to the healthcare system on a consecutive cohort of outpatients diagnosed with colorectal cancer in the healthcare area of Ourense (Spain).Patients and methodsWe performed a retrospective cohort study that included patients diagnosed between 2009 and 2017. Delay attributable to the healthcare system was defined as the time between the first consultation with symptoms and the diagnostic confirmation. A logistic regression model was performed to evaluate the relationship between stage IV CRC and diagnostic delay. To analyse which variables were associated independently with overall mortality and mortality due to CRC we used a Cox regression model.Results575 patients were included (men 64.5%, age 71.9 ± 11.5 years), with a delay attributable to the healthcare system of 115 ± 153 days. None of the variables analysed were associated with tumour stage at diagnosis. With a mean follow-up of 30.6 ± 21 months, 121 patients died (79.3% due to CRC). The variables independently associated with CRC-related mortality were metastatic CRC (HR 50.65, 95% CI 12.28-209), age (HR 1.04, 95% CI 1.02-1.05) and colonoscopy requested from the Primary Healthcare level (HR 0.55, 95% CI 0.36-0.88).ConclusionsDiagnostic delay attributable to the healthcare system is not related to the prognosis or stage of CRC. However, a direct referral to colonoscopy from the Primary Healthcare level reduces the risk of mortality in our patients.     

The impact of hepatic arterial infusion pump chemotherapy on hepatic recurrences and survival in patients with resected colorectal liver metastases

BackgroundThe objective was to investigate the impact of adjuvant hepatic arterial infusion pump (HAIP) chemotherapy on the rates and patterns of recurrence and survival in patients with resected colorectal liver metastases (CRLM).MethodsRecurrence rates, patterns, and survival were compared between patients treated with and without adjuvant HAIP using competing risk analyses.Results2128 patients were included, of which 601 patients (28.2%) received adjuvant HAIP and systemic chemotherapy (HAIP + SYS). The overall recurrence rate was similar with HAIP + SYS or SYS (63.5% versus 64.2%,p = 0.74). The 5-year cumulative incidence of initial intrahepatic recurrences was lower with HAIP + SYS (22.9% versus 38.4%,p < 0.001). The 5-year cumulative incidence of initial extrahepatic recurrences was higher with HAIP + SYS (48.5% versus 40.3%,p = 0.005), because patients remained at risk for extrahepatic recurrence in the absence of intrahepatic recurrence, which was largely attributable to more pulmonary recurrences with HAIP + SYS (33.6% versus 23.7%,p < 0.001). HAIP was an independent prognostic factor for DFS (adjusted HR 0.69, 95% CI 0.60–0.79, p < 0.001), and OS (adjusted HR 0.67, 95% CI 0.57–0.78,p < 0.001).ConclusionAdjuvant HAIP chemotherapy is associated with lower intrahepatic recurrence rates and better DFS and OS after resection of CRLM.     

Proportional incidence of interval colorectal cancer in a large population-based faecal immunochemical test screening programme

BackgroundThe European guidelines for quality assurance in colorectal cancer (CRC) screening recommend that interval cancer rate be expressed as a proportion of background incidence rate.AimTo determine the crude and adjusted proportional incidence of interval CRC in an Italian regional two-yearly faecal immunochemical test (FIT) screening programme.MethodsThe programme (year of implementation, 2005) is targeted at over 1,000,000 people aged 50–69 years. The test is a one-sample OC-Sensor (Eiken Chemical Co., Tokyo, Japan). The study covered one-third of the regional area. Excerpts of 434,295 eligible negative FIT records dated 2005–2012 from 193,193 subjects were retrieved from the regional CRC screening data warehouse. By 31 December 2013, the cohort accumulated 198,302 man-years and 235,370 woman-years. Interval CRCs were identified by record-linkage with the local population-based cancer registry. Their number was divided by the expected number, estimated with age-period-cohort models, to obtain the proportional incidence.ResultsThe proportional incidence of interval CRC for men and women was, respectively, 0.06 (95% confidence interval (CI), 0.04–0.09) and 0.17 (95% CI, 0.13–0.23) in the first interval year, and 0.21 (95% CI, 0.16–0.26) and 0.28 (95% CI, 0.22–0.36) in the second year.ConclusionsThe results were acceptable and in line with previous studies.     

Vegetarian diets and incidence of diabetes in the Adventist Health Study-2

AimTo evaluate the relationship of diet to incident diabetes among non-Black and Black participants in the Adventist Health Study-2.Methods and ResultsParticipants were 15,200 men and 26,187 women (17.3% Blacks) across the U.S. and Canada who were free of diabetes and who provided demographic, anthropometric, lifestyle and dietary data. Participants were grouped as vegan, lacto ovo vegetarian, pesco vegetarian, semi-vegetarian or non-vegetarian (reference group). A follow-up questionnaire after two years elicited information on the development of diabetes. Cases of diabetes developed in 0.54% of vegans, 1.08% of lacto ovo vegetarians, 1.29% of pesco vegetarians, 0.92% of semi-vegetarians and 2.12% of non-vegetarians. Blacks had an increased risk compared to non-Blacks (odds ratio [OR] 1.364; 95% confidence interval [CI], 1.093–1.702). In multiple logistic regression analysis controlling for age, gender, education, income, television watching, physical activity, sleep, alcohol use, smoking and BMI, vegans (OR 0.381; 95% CI 0.236–0.617), lacto ovo vegetarians (OR 0.618; 95% CI 0.503–0.760) and semi-vegetarians (OR 0.486, 95% CI 0.312–0.755) had a lower risk of diabetes than non-vegetarians. In non-Blacks vegan, lacto ovo and semi-vegetarian diets were protective against diabetes (OR 0.429, 95% CI 0.249–0.740; OR 0.684, 95% CI 0.542–0.862; OR 0.501, 95% CI 0.303–0.827); among Blacks vegan and lacto ovo vegetarian diets were protective (OR 0.304, 95% CI 0.110–0.842; OR 0.472, 95% CI 0.270–0.825). These associations were strengthened when BMI was removed from the analyses.ConclusionVegetarian diets (vegan, lacto ovo, semi-) were associated with a substantial and independent reduction in diabetes incidence. In Blacks the dimension of the protection associated with vegetarian diets was as great as the excess risk associated with Black ethnicity.     

Risk factors of nonadherence to colonoscopy surveillance after polypectomy and its impact on clinical outcomes: a KASID multicenter study

Background

An optimal surveillance program is important to prevent advanced colorectal neoplasm. In this context, we have evaluated the cumulative risk of high-risk adenoma (HRA) or colorectal cancer (CRC) according to surveillance interval time after polypectomy. In addition, we assessed risk factors for late surveillance to determine whether late surveillance can impact the risk of subsequent advanced colorectal neoplasm.

Methods

This was a multicenter retrospective cohort study involving 3562 subjects who had undergone removal of at least one adenoma at the index colonoscopy and who subsequently underwent a surveillance colonoscopy. The subjects were classified into an early, appropriate or late group depending on the timing of the surveillance colonoscopy, performed using modified U.S. guidelines.

Results

With 3% of the study population with LRA and HRA at the index colonoscopy going on to develop HRA or CRC, the estimated surveillance intervals calculated would be 6.3 [95% confidence interval (CI) 5.42–7.10] years and 3.1 (95% CI 2.61–4.45) years, respectively. The predictors of late surveillance were female gender [odd ratio (OR) 1.21; 95% CI 1.04–1.40], having undergone the procedure in small-to-medium-sized cities (OR 1.92; 95% CI 1.36–2.72) and HRA at index colonoscopy (OR 1.37; 95% CI 1.19–1.59). The risk factors for subsequent HRA or CRC were late surveillance (OR 1.34; 95% CI 1.03–1.74), male gender (OR 2.13; 95% CI 1.54–2.95), having undergone the procedure in small-to-medium-sized cities (OR 1.63; 95% CI 1.11–2.40) and HRA at index colonoscopy (OR 2.60; 95% CI 2.04–3.33).

Conclusions

Women, having undergone the procedure in small-to-medium-sized cities and the presence of an HRA at the index colonoscopy were found to be independent risk factors for late surveillance colonoscopy. Late surveillance is significantly predictive of subsequent HRA or CRC.

     

The risk of developing a mismatch repair deficient colorectal cancer after undergoing cholecystectomy

Objectives: Mismatch repair deficient (dMMR) colorectal cancer (CRC) is caused by inactivation of the MMR DNA repair system, most commonly via epigenetic inactivation of the MLH1 gene, and these tumors occur most frequently in the right colon. The objective was to determine whether cholecystectomy (CCY) increases the risk of a dMMR CRC by comparing CCY incidence in patients with dMMR CRC and proficient MMR (pMMR) CRC to unaffected controls.

Materials and methods: All patients diagnosed with CRC in Iceland from 2000 to 2009 (n?=?1171) were included. They had previously been screened for dMMR by immunohistochemistry (n?=?129 were dMMR). Unaffected age- and sex-matched controls (n?=?17,460) were obtained from large Icelandic cohort studies. Subjects were cross-referenced with all pathology databases in Iceland to establish who had undergone CCY. Odds ratios were calculated using unconditional logistic regression.

Results: Eighteen (13.7%) dMMR CRC cases and 90 (8.7%) pMMR CRC cases had undergone CCY compared to 1532 (8.8%) controls. CCY-related odds ratios (OR) were 1.06 (95% CI 0.90–1.26, p?=?.577) for all CRC, 1.16 (95% CI 0.66–2.05 p?=?.602) for dMMR CRCand 1.04 (95% CI 0.83–1.29, p?=?.744) for pMMR CRC. Furthermore, OR for dMMR CRC was 0.51 (95% CI 0.16–1.67, p?=?.266), 2.04 (95% CI 0.92–4.50, p?=?.080) and 1.08 (95% CI 0.40–2.89, p?=?.875)?<10 years, 10–20 years and?>20 years after a CCY, respectively.

Conclusions: There was no evidence of increased risk of developing dMMR CRC after CCY although a borderline significantly increased 2-fold risk was observed 10–20 years after CCY. Larger studies are warranted to examine this further.     

Synchronous resection of colorectal cancer primary and liver metastases: an outcomes analysis

BackgroundConcurrent resection of the primary cancer and synchronous colorectal cancer liver metastases (CRCLM) was evaluated for differences in outcomes following stratification of both the liver and colorectal resection.MethodsConsecutive cases of synchronous resection of both the CRC primary and CRCLM were reviewed retrospectively at a single, high-volume institution over a 17-year period (2000–2017).Results273 patients underwent simultaneous resection of CRCLM. The distribution of the primary lesion was similar between the colon (52.4%) and rectum (47.6%), while 46.9% of patients had bilobar liver disease. Major liver/major colorectal resection (n = 24) were significantly more likely to experience colorectal specific morbidity (OR 3.98, 95% CI 1.56–10.15, p = 0.004), liver specific morbidity (OR 7.4, 95% CI 2.22–24.71, p = 0.001), total morbidity (OR 2.91, 95% CI 1.18–7.18, p = 0.020) and 90-day mortality (OR 5.50, 95% CI 1.27–23.81, p = 0.023). Failure to receive adjuvant chemotherapy secondary to postoperative morbidity was associated with significantly worsened survival (HR for death 5.91, 95% CI 1.59–22.01, p = 0.008).ConclusionsPostoperative morbidity precluding the administration of adjuvant chemotherapy is associated with an increase in mortality. Combining a major liver with major colorectal resection is associated with a significant increase in major morbidity and 90-day mortality, and should be avoided.     

The impact of portal pedicle clamping on survival from colorectal liver metastases in the contemporary era of liver resection: a matched cohort study

IntroductionPortal pedicle clamping (PPC) may impact micro‐metastases’ growth. This study examined the association between PPC and survival after a hepatectomy for colorectal liver metastases (CRLM).MethodsA matched cohort study was conducted on hepatectomies for CRLM at a single institution (2003–2012). Cohorts were selected based on PPC use, with 1:1 matching for age, time period and the Clinical Risk Score. Outcomes were overall and recurrence‐free survival (OS and RFS). Cox regression was performed to assess the association between PPC and survival.ResultsOf 481 hepatectomies, 26.9% used PPC. One hundred and ten pairs of patients were matched in the cohorts. There was no significant difference in OS [hazard ratio (HR) 1.18; 95% confidence interval (CI): 0.76–1.83], with a 5‐year OS of 57.8% (95%CI: 52.4–63.2%) with PPC versus 62.3% (95%CI: 57.1–67.5%) without. Five‐year RFS did not differ (HR 0.98; 95%CI: 0.71–1.35) with 29.7% (95%CI: 24.9–34.5%) with PPC versus 28.0% (95%CI: 23.2–32.8%) without. When adjusting for extent of resection, transfusion, operative time and surgeon, there was no difference in OS (HR 0.91; 95%CI: 0.52–1.60) or RFS (HR: 0.86; 95%CI: 0.57–1.30).ConclusionsPPC was not associated with a significant difference in OS or RFS in a hepatectomy for CRLM. PPC remains a safe technique during hepatectomy.     

Survival after repeat hepatectomy for recurrent colorectal liver metastasis: A review and meta-analysis of prognostic factors

BackgroundFrequent recurrent hepatic metastasis after hepatic metastasectomy is a major obstacle in the treatment of colorectal liver metastasis (CRLM). We performed the present systematic review to evaluate the short- and long-term outcomes after repeat hepatectomy for recurrent CRLM and determine factors associated with survival in these patients.Data sourcesAn electronic search of PubMed database was undertaken to identify all relevant peer-reviewed papers published in English between January 2000 and July 2018. Hazard ratios (HR) with 95% confidence interval (95% CI) were calculated for prognostic factors of overall survival (OS).ResultsThe search yielded 34 studies comprising 3039 patients, with a median overall morbidity of 23% (range 8%–71%), mortality of 0 (range 0–6%), and 5-year OS of 42% (range 17%–73%). Pooled analysis showed that primary T3/T4 stage tumor (HR = 1.94; 95% CI: 1.04–3.63), multiple tumors (HR = 1.49; 95% CI: 1.10–2.01), largest liver lesion ≥5 cm (HR = 1.89; 95% CI: 1.11–3.23) and positive surgical margin (HR = 1.80; 95% CI: 1.09–2.97) at initial hepatectomy, and high serum level of carcinoembryonic antigen (HR = 1.87; 95% CI: 1.27–2.74), disease-free interval ≤12 months (HR = 1.34; 95% CI: 1.10–1.62), multiple tumors (HR = 1.64; 95% CI: 1.32–2.02), largest liver lesion ≥5 cm (HR = 1.85; 95% CI: 1.34–2.56), positive surgical margin (HR = 2.25; 95% CI: 1.39–3.65), presence of bilobar disease (HR = 1.62; 95% CI: 1.19–2.20), and extrahepatic metastases (HR = 1.60; 95% CI: 1.23–2.09) at repeat hepatectomy were significantly associated with poor OS.ConclusionsRepeat hepatectomy is a safe and effective therapy for recurrent CRLM. Long-term outcome is predicted mainly by factors related to repeat hepatectomy.     

Prevalence of colorectal adenomas in asymptomatic young adults: a window to early intervention?

Objective The prevalence of colorectal adenoma is increasing in the average-risk population. However, little research is available on colorectal adenoma in young adults under age 40. The aim of this study was to investigate the prevalence and risk factors of colorectal adenoma in 20- to 39-year-old adults. Methods We evaluated 4286 asymptomatic young adults aged 20 to 39 years who underwent first colonoscopy screening as part of an employer-provided health wellness programme at the Health Promotion Centre of Samsung Changwon Hospital, Korea from January 2011 to December 2013. Logistic regression modelling was used to identify risk factors for colorectal adenoma in asymptomatic young adults. Results The prevalence of colorectal adenoma and advanced adenoma was 11.6% (497/4286) and 0.9% (39/4286), respectively. By age group, the prevalence of colorectal adenoma was 5.4% (33/608) in participants aged 20 to 29 years and 12.6% (464/3678) in participants aged 30 to 39. Colorectal adenoma was found in 13.1% (403/3072) of men and 7.7% (94/1214) of women. Increased risk of colorectal adenoma was associated with age over 30 years (OR, 2.37; 95% CI, 1.64–3.42), current smoker status (OR, 1.48; 95% CI, 1.14–1.91), and alcohol consumption (OR, 1.29; 95% CI, 1.03–1.63). Conclusions Our findings indicate that even if the prevalence of colorectal adenoma was low in young adults aged 20 to 39, being over 30, cigarette smoking, and alcohol consumption can affect young adults who have no other CRC risks.     

Multi-target stool DNA test in the surveillance of inflammatory bowel disease: a cross-sectional cohort study

Background and aim: Colonoscopic surveillance is recommended in patients with longstanding inflammatory bowel disease (IBD) as they are at increased risk of colorectal cancer (CRC). Non-invasive surveillance may improve compliance and access. Multi-target stool DNA (MT-sDNA) has been validated for screening of sporadic CRC but has not been assessed in IBD. Our aim was to assess the performance of a MT-sDNA test in a real-life surveillance setting of patients with longstanding IBD.

Material and methods: A total of 192 IBD patients enrolled from two prospective cohorts submitted an EDTA buffered stool sample and underwent chromo- or white light colonoscopy. Stools were assayed for methylated BMP3 &; NDRG4, mutant KRAS and β-actin by a laboratory blinded to clinical data.

Results: The multitarget-sDNA panel was positive in 2/2 CRC and 5/15 low-grade dysplasia (LGD)?Conclusion: The MT-sDNA panel detected CRC in IBD. Sensitivity for sub-centimeter colorectal neoplasms in IBD patients appears similar to that observed in the general population. The test may be a valuable tool for detection of malignancy during structured surveillance of long-term IBD in a first line hospital setting.     

Temporal trend in relative risk of second primary colorectal cancer

BACKGROUND: Patients with colorectal cancer (CRC) are at a higher risk for developing a second primary. Factors (such as survival rate, rate of receipt of surveillance procedures, and the overall incidence of CRC) with potential impact on the risk for second primary CRC have changed over the last three decades. Thus, it is likely that the risk for second primary CRC also has changed over the years. OBJECTIVES: We used the Surveillance, Epidemiology, and End Results public-use database to assess whether the relative risk of second primary CRC has changed in patients with initial primary CRC. METHODS: The temporal trend in the standardized incidence ratio (SIR) for a second primary CRC was estimated. Also, the clinical features of the second primary CRC were compared in two subgroups based on the year of diagnosis of the first primary CRC: Group A (1973-1977) and Group B (1988-1992). RESULTS: During the period of 1973 to 2002, 216,751 patients developed a primary CRC and over a follow-up period of 1,250,687 person-years, 5,595 of these patients developed a second primary CRC, with an SIR of 1.36 (95% CI 1.32-1.39). In a Cox regression model, the period of diagnosis of the first primary CRC was an independent risk factor for a subsequent primary CRC, with a relative hazard of second colon cancer in Group B compared with Group A being 1.18 (95% CI 1.06-1.31), after controlling for age at diagnosis, site, stage of first primary, gender, and race. CONCLUSION: The relative risk of the second primary CRC has increased since early 1990s. These subsequent cancers are being diagnosed at an earlier stage. Increased surveillance may be one of the factors contributing to this temporal difference.     

Clinically confirmed type 2 diabetes mellitus and colorectal cancer risk: a population-based, retrospective cohort study

OBJECTIVES: Patients with type 2 diabetes mellitus (DM) may be at increased colorectal cancer (CRC) risk. However, existing data are inconsistent. We investigated CRC risks, overall and by anatomic subsite, within a population-based inception cohort of clinically confirmed type 2 DM subjects. METHODS: All residents of Rochester, Minnesota who first met standardized criteria for type 2 DM from 1970 to 1994 (997 men and 978 women) were identified and followed forward in time until emigration, death, or December 31, 1999. Incident CRC cases were identified by review of inpatient and outpatient medical records. Standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) were estimated to compare CRC incidence within the type 2 DM inception cohort with previously published rates for the Rochester general population. RESULTS: Over 19,158 person-years of follow-up, 51 incident CRC cases were identified within the type 2 DM cohort, while only 36.8 cases were expected (SIR = 1.39, 95% CI 1.03-1.82). Among men, type 2 DM was associated with increased overall (SIR = 1.67, 95% CI 1.16-2.33) and proximal (SIR = 1.96, 95% CI 1.16-3.10) CRC risks; distal CRC risk was also increased, but the point estimate was not statistically significant (SIR = 1.43, 95% CI 0.82-2.32). Among women, type 2 DM was not a risk factor for overall, proximal, or distal CRC (SIR = 1.03, 95% CI 0.60-1.66; SIR = 1.17, 95% CI 0.58-2.09; and SIR = 0.74, 95% CI 0.24-1.72, respectively). Within the type 2 DM cohort, current and former cigarette smokers were at higher CRC risk (SIR = 1.77, 95% CI 1.24-2.47) than never smokers (SIR = 0.99, 95% CI 0.57-1.61) and the interaction between type 2 DM and cigarette smoking status was statistically significant (p= 0.05). CONCLUSIONS: In this population-based, retrospective cohort study, clinically confirmed type 2 DM was associated with increased CRC risk, predominantly among men. Cigarette smoking appeared to positively modify DM-associated CRC risk, which to our knowledge has not been previously reported. These data suggest that further investigation of potential interactions between endogenous and exogenous factors involved in colorectal carcinogenesis may help to clarify the magnitude and extent of CRC risk experienced by persons with type 2 DM.     

Association between irritable bowel syndrome and colorectal cancer: A nationwide population-based study

ObjectivesTo determine whether irritable bowel syndrome (IBS) is associated with an increased risk for the subsequent colorectal cancer (CRC).MethodsWe identified 91,746 patients who were diagnosed with IBS between 2000 and 2010 from the Taiwan National Health Insurance Research Database (NHIRD) as the study cohort, and randomly extracted the data of 183,492 patients matched by sex, age, and baseline year for the comparison cohort. The follow-up period was terminated after CRC development, withdrawal from the national health insurance (NHI) system, or at the end of 2010. Cumulative incidences and hazard ratios (HRs) of CRC development were determined.ResultsDuring the first 2 years of follow-up, the subsequent CRC incidence rates in the IBS and comparison cohorts were 37.3 and 5.61 per 10,000 person-years, respectively (adjusted HR, 6.72; 95% CI, 5.70–7.92; p < .0001). Thereafter, the risk did not differ significantly between the 2 cohorts (adjusted HR, 1.08; 95% CI, 0.93–1.26); the participants in the IBS cohort commonly underwent more colonoscopies/sigmoidoscopies than did the non-IBS cohort.ConclusionsIBS was not associated with the long-term development of CRC in Taiwan. The increased risk of CRC in the first 2 years may have occurred because some CRC patients were initially misclassified as IBS patients.     

A comparison of the simultaneous,liver-first,and colorectal-first strategies for surgical treatment of synchronous colorectal liver metastases at two major liver-surgery institutions in Sweden

BackgroundThe optimal treatment strategy for patients with synchronous colorectal liver metastases (CRLM) is unclear. The aim of this study was to compare the outcome of the simultaneous, liver-first, and colorectal-first surgical approaches.MethodsAll consecutive patients who had been resected with curative intent for CRLM were included. A Cox regression model was constructed, and an intention-to-treat analysis was performed between the liver-first and the simultaneous approaches, after propensity score matching.Results658 patients were included in the analysis. 92 patients had a simultaneous resection, 163 patients had liver-first, and 403 patients had a colorectal-first approach. Overall survival was 54.9 months (95% CI 39.2–70.4) in the liver-first group, 54.5 months (95% CI 46.8–62.3) in colorectal-first group, and 59.6 months (95% CI 42.2–77.0) in the simultaneous group (log-rank p =0.850). In the matched cohort there were no differences in Clavien-Dindo 3a (p = 0.992) or 3b and greater (p = 0.999). Median overall survival was for liver-first group 42.2 months (95% CI 26.3–58.2), and for the simultaneous group 56.2 months (95% CI 47.1–65.4) (stratified log-rank p = 0.455).ConclusionA simultaneous approach was not associated with worse overall survival or morbidity compared to a liver-first approach.     

Incidence of cancer (other than gastric cancer) in pernicious anaemia: A systematic review with meta-analysis

BackgroundPernicious anaemia (PA) is associated with increased gastric cancer risk, but the evidence is conflicting regarding the associated risk of other cancers.AimTo systematically determine the incidence rates of gastro-intestinal cancers other than gastric cancers (GI-other-than-GC) and non-gastrointestinal cancers (non-GIC) in PA adults, globally and per tumour site, and the risk associated with PA for GI-other than GC and non-GIC.MethodsStudies of PA patients reporting the incidence of GI-other-than-GCs and non-GICs were identified with MEDLINE (PubMed)-EMBASE (from first date available to April 2017). A meta-analysis of annual cancer incidence rates was performed. The outcome was the cumulative incidence of GI-other-than-GCs and non-GICs (ratio between the numbers of new cancer cases identified during the follow-up period and the number of PA patients) and the incidence rate expressed as the rate of events-per-time-unit (person-years).ResultsOf 82,257 PA patients, the pooled incidence rates/100 person-years for non-GCs and non-GICs of 0.27 (95% CI:0.16–0.42) and 0.23 (95% CI:0.22–0.25) were calculated by meta-analysis. Compared to the GLOBOCAN data for the general population from the countries of the included studies, the meta-analysis showed an overall relative risk (RR) of cancer in PA of 0.68 (95% CI:0.48–0.95). PA patients had a lower RR of colorectal, breast, liver, oesophageal, lung, thyroid, ovary, non-melanoma skin and kidney cancers but had a higher RR of biliary tract cancer (1.81:1.21–2.70), multiple myeloma (2.83:1.76–4.55), Hodgkin’s lymphoma (3.0:1.35–6.68), non-Hodgkin’s lymphoma (2.08: 1.58–2.75), and leukaemia (1.56:1.16–2.12).ConclusionAn overall lower RR of cancers-other-than-gastric-cancer in PA patients but an increased RR of biliary tract cancers and haematological malignancies was observed.