Association between Serum β2-Microglobulin Level and Infectious Mortality in Hemodialysis Patients

Background and objectives: Secondary analysis of the Hemodialysis Study showed that serum β₂-microglobulin levels predicted all-cause mortality and that high-flux dialysis was associated with decreased cardiac deaths in hemodialysis patients. This study examined the association of serum β₂-microglobulin levels and dialyzer β₂-microglobulin kinetics with the two most common causes of deaths: Cardiac and infectious diseases.Cox regression analyses were performed to relate cardiac or infectious deaths to cumulative mean follow-up predialysis serum β₂-microglobulin levels while controlling for baseline demographics, comorbidity, residual kidney function, and dialysis-related variables.Results: The cohort of 1813 patients experienced 180 infectious deaths and 315 cardiac deaths. The adjusted hazard ratio for infectious death was 1.21 (95% confidence interval 1.07 to 1.37) per 10-mg/L increase in β₂-microglobulin. This association was independent of the prestudy years on dialysis. In contrast, the association between serum β₂-microglobulin level and cardiac death was not statistically significant. In similar regression models, higher cumulative mean Kt/V of β₂-microglobulin was not significantly associated with either infectious or cardiac mortality in the full cohort but exhibited trends suggesting an association with lower infectious mortality (relative risk 0.93; 95% confidence interval 0.86 to 1.01, for each 0.1-U increase in β₂-microglobulin Kt/V) and lower cardiac mortality (relative risk 0.93; 95% confidence interval 0.87 to 1.00) in the subgroup with >3.7 prestudy years of dialysis.Conclusions: These results generally support the notion that middle molecules are associated with systemic toxicity and that their accumulation predisposes dialysis patients to infectious deaths, independent of the duration of maintenance dialysis.The Hemodialysis (HEMO) Study was a randomized clinical trial designed to examine the impact of two treatment parameters on clinical outcomes of maintenance hemodialysis patients. These parameters were the dialysis dosage based on the clearance of urea (molecular weight [MW] 60 Da) and membrane porosity or flux based on the clearance of β₂-microglobulin (β₂M; MW 11,800 Da) (1). The primary analysis of the HEMO Study did not show a statistically significant reduction in the rate of the primary outcome, all-cause mortality, or any of the predefined secondary outcomes associated with high flux. In secondary analyses, however, a 20% decrease in cardiac death (hazard ratio [HR] 0.80; 95% confidence interval [CI] 0.65 to 0.99) was observed for the high-flux group compared with the low-flux group. In the subgroup of patients who had been on dialysis for >3.7 yr (the mean for the entire cohort) before enrollment in the HEMO Study, high flux was associated with lower all-cause mortality (HR 0.68; 95% CI 0.53 to 0.86), cardiac deaths (HR 0.63; 95% CI 0.43 to 0.92) (1,2), and cerebrovascular events (3).Although these are results of secondary analyses and must be interpreted cautiously because of the multiple hypotheses that were tested (4), they are consistent with the notion that high-flux dialysis may have certain beneficial effects. In the HEMO Study, membrane flux was defined by the clearance of β₂M, taken as a surrogate for the clearance of middle molecules. As a result of the higher clearance, the cumulative mean predialysis serum β₂M level during follow-up in the high-flux arm was statistically significantly lower than that in the low-flux arms (33.6 versus 41.5 mg/L) (5). Further secondary analysis of the data showed that predialysis serum β₂M levels predicted all-cause mortality in the HEMO Study cohort, with an 11% increase in mortality for each 10-mg/L increase in β₂M level, even after adjustment for years on dialysis and residual kidney function (5). The specific causes of death that account for this increased mortality have not been determined.In addition to a number of other middle molecules, in vitro studies have identified proteins from the circulating plasma of maintenance dialysis patients, with homology or MW similar to β₂M, that have neutrophil-inhibitory effects (6,7). The accumulation of these proteins leads to higher serum β₂M concentrations and may predispose the patients to infectious complications. Furthermore, because randomization to high flux was associated with a decrease in cardiac deaths in the HEMO Study and an even greater reduction in patients who were on dialysis for >3.7 yr before the study (1,2), it would be reasonable to hypothesize that serum β₂M levels are also predictive of cardiac death, especially in the long-term dialysis subgroup. In this report, we examined the association of serum β₂M levels and dialyzer β₂M kinetics with cause-specific mortality in the HEMO cohort, focusing on cardiac and infectious deaths.     

Do Geographic and Educational Factors Influence the Quality of Life in Rectal Cancer Patients With a Permanent Colostomy?

PURPOSE This study was designed to evaluate possible social and geographic factors that could have an impact on quality of life in patients after abdominoperineal excision of the rectum. Although the number of patients with rectal cancer who need to be treated with abdominoperineal excision of the rectum and construction of permanent colostomy has greatly decreased in the past, there is still controversy about the influence on quality of life caused by this procedure. METHODS In a prospective trial, patients operated on for low rectal cancer by abdominoperineal excision of the rectum were evaluated by a quality of life questionnaire, modified from The American Society of Colon and Rectal Surgeons questionnaire, to assess fecal incontinence. The results for the four domains of quality of life (lifestyle, coping behavior, embarrassment, depression), as well as for subjective general health, were evaluated with regard to age, gender, education, and geographic origin in univariate and multivariate analyses. RESULTS Thirteen institutions in 11 countries included data from 257 patients. Although the analysis of general health did not reveal any significant differences, the analysis of the four quality of life domains showed the significant influence of geographic origin. The presence of a permanent colostomy showed a consistently negative impact on patients in southern Europe as well as for patients of Arabic (Islamic) origin. On the other hand, age, gender, and educational status did not reveal a statistically significant influence. CONCLUSIONS This is the first study to show the influence of geographic origin on quality of life of patients with a permanent colostomy. Possible factors that may influence the outcome of patients after surgical treatment of rectal cancer, such as weather, religion, or culture, should be taken into account when quality of life evaluations are considered. Supported by the Ludwig Boltzmann Research Institute for Surgical Oncology, Danube Hospital, Vienna, Austria.     

Assessment of Myeloperoxidase and Oxidative α1-Antitrypsin in Patients on Hemodialysis

Background and objectives: The present study assesses the effects of the oxidative stress marker, myeloperoxidase (MPO), and the possible MPO-related oxidative stress marker, oxidative α₁-antitrypsin (oxAT), on carotid intima-media thickness (CIMT) and protein-energy wasting (PEW) in patients on hemodialysis (HD).Design, setting, participants, & measurements: Blood samples were obtained from 383 patients before HD to measure WBC count, serum albumin, lipids, high-sensitivity C-reactive protein (CRP), α₁-antitrypsin (AT), interleukin-6, oxidative LDL-C, MPO, and oxAT. We assessed both CIMT and the geriatric nutritional risk index (GNRI) in this cross-sectional competitive study.Results: Levels of MPO and oxAT correlated. Myeloperoxidase was associated with max-CIMT, and oxAT correlated with max-CIMT and GNRI. Multivariate linear regression models showed that MPO and oxAT were independent predictors of increasing max-CIMT, whereas oxAT, but not MPO, independently correlated with GNRI. In four combined MPO and oxAT groups classified according to median values, a multinomial logistic regression model showed that high MPO together with high oxAT was independently associated with increased max-CIMT. Moreover, the OR for max-CIMT with positive PEW and high MPO was significantly increased in the four groups with combined MPO and PEW.Conclusions: High MPO with high oxAT and high MPO with PEW seem to contribute to plaque formation in patients on HD, whereas elevated MPO or oxAT alone might not predict increasing CIMT. In contrast, a high oxAT value seems to be an independent predictor of PEW in patients on HD.Ahigh prevalence of cardiovascular disease (CVD) events and of protein-energy wasting (PEW) is significantly associated with increased mortality and morbidity among patients undergoing hemodialysis (HD) (1). The progression of atherosclerosis and PEW in such patients is accelerated by various factors, in particular oxidative stress and inflammation. Oxidative stress is closely associated with advancing atherosclerosis (2) and is a principal risk factor for cardiovascular mortality in patients on HD (3). Such patients develop uremic syndrome per se or factors associated with uremia and an excessively inflamed state with marked hypoalbuminemia (4). Increased oxidative stress and higher levels of C-reactive protein (CRP) and pro-inflammatory cytokines contribute to increased protein catabolism in these states.Myeloperoxidase (MPO) is a hemoprotein that is secreted during the activation of neutrophils and of reactive species-generating enzyme, which acts in host defense by catalyzing the production of hypochloric acid (HOCl) (5). Neutrophil-derived MPO induces vascular injury responses such as endothelial dysfunction and thus MPO might play an important role in vascular injury and atherogenesis (6). Elevated levels of MPO are associated with coronary heart disease and predict risk in patients with acute coronary syndromes (7,8). Myeloperoxidase influences atherosclerosis not only in nonuremic patients, but also in patients with end-stage renal disease (ESRD), especially when under HD therapy. During HD sessions, MPO might be released in association with biocompatibility factors such as deleterious effects induced in the blood during dialysis (9). A high MPO value, as well as hepatic acute phase proteins and increased expression of pro-inflammatory interleukins, is associated with CVD among patients on HD (10), and increased levels of MPO are closely linked to mortality in such patients (11). Moreover, MPO influences PEW in patients on HD (12).However, MPO levels are not associated with atherosclerosis progression in nonuremic patients (13), which suggests that serum MPO levels do not always reflect MPO catalysis of HOCl.Free radicals released from activated neutrophils oxidize the 52-kD acute-phase protein α₁-antitrypsin, which is a typical serine proteinase inhibitor (14). Thus, oxidized α₁-antitrypsin (oxAT) is a potential marker of activated neutrophil-associated oxidation including MPO catalyzing HOCl production (15).The present competitive study was designed to estimate MPO and oxAT values to predict carotid intima-media thickness (CIMT) and PEW in patients on HD.     

Malnutrition–Inflammation Complex Syndrome and Hepatitis C in Maintenance Hemodialysis Patients

Protein-energy malnutrition and inflammation are among the leading causes of poor outcome in hemodialysis patients. Hepatitis C virus (HCV) infection is accompanied by elevated proinflammatory mediators, also found in dialysis patients with malnutrition–inflammation complex syndrome. We aimed to study the rate and characteristics of malnutrition–inflammation complex syndrome (MICS) in hemodialysis patients, especially those with hepatitis C. The study included 147 patients (mean age 55.1 ± 12.9 years), 24.5% of whom were HCV-positive, undergoing adequate hemodialysis three times a week for the last 52.7 ± 52.5 months. Parameters of nutrition and inflammation were investigated to evaluate MICS. HCV-positive vs. HCV-negative patients had significantly higher hematocrit (29.6 ± 4.5 g/dL vs. 28.1 ± 4.3, P < 0.05), uric acid (345.8 ± 96.5 vs. 321.3 ± 118.8 µmol/mL, P < 0.05), aspartate aminotransferase (AST, also known as serum glutamic oxaloacetic transaminase [SGOT]) (23.3 ± 14.9 vs. 17.8 ± 9 U/L, P < 0.008), alanine aminotransferase (ALT, also known as serum glutamic pyruvic transaminase [SGPT]) (41.2 ± 28.7 vs. 26.6 ± 17.1 U/L, P < 0.0003), serum creatinine (980.4 ± 219.1 vs. 888.4 ± 202.9 µmol/mL, P < 0.022), intact parathyroid hormone (329.7 ± 630.5 vs. 110.2 ± 145.3 pg/mL, P < 0.002), malnutrition–inflammation score (7.4 ± 5.2 vs. 5.6 ± 4.1, P < 0.038), and Charlson comorbidity index (4.5 ± 1.5 vs. 4 ± 1.4, P < 0.05). MICS had a prevalence of 20–40% in our study. HCV-positive patients had a significantly higher prevalence of MICS than HCV-negative patients (30–40% vs. 20–30%).     

Endogenous Testosterone and Mortality in Male Hemodialysis Patients: Is It the Result of Aging?

Background and objectives: Low serum testosterone levels in hemodialysis (HD) patients have recently been associated with cardiovascular risk factors and increased mortality. To confirm this observation, we investigated the predictive role of serum total testosterone levels on mortality in a large group of male HD patients from Turkey.Design, settings, participants, & measurements: A total of 420 prevalent male HD patients were sampled in March 2005 and followed up for all-cause mortality. Serum total testosterone levels were measured by ELISA at baseline and studied in relation to mortality and cardiovascular risk profile.Results: Mean testosterone level was 8.69 ± 4.10 (0.17 to 27.40) nmol/L. A large proportion of patients (66%) had testosterone deficiency (<10 nmol/L). In univariate analysis, serum testosterone levels were positively correlated with creatinine and inversely correlated with age, body mass index, and lipid parameters. During an average follow-up of 32 months, 104 (24.8%) patients died. The overall survival rate was significantly lower in patients within the low testosterone tertile (<6.8 nmol/L) compared with those within the high tertile (>10.1 nmol/L; 64 versus 81%; P = 0.004). A 1-nmol/L increase in serum testosterone level was associated with a 7% decrease in overall mortality (hazard ratio 0.93; 95% confidence interval 0.89 to 0.98; P = 0.01); however, this association was dependent on age and other risk factors in adjusted Cox regression analyses.Conclusions: Testosterone deficiency is common in male HD patients. Although testosterone levels, per se, predicted mortality in this population, this association was largely dependent on age.Low serum testosterone levels have been associated with several components of metabolic syndrome, including cardiovascular disease (CVD), hypertension, abdominal obesity, insulin resistance, and inflammatory markers in male individuals without uremia, independent of age decline (1,2). Also, it has been shown that low endogenous testosterone levels are associated with increased risk for both all-cause and cardiovascular mortality (3–12). Evidence from short-term studies indicated that testosterone replacement therapy may improve some specific cardiovascular risk factors, such as visceral obesity, insulin resistance, lipid and inflammatory profiles, and exercise-induced cardiac ischemia (13).Testosterone deficiency is a common finding in hemodialysis (HD) patients, most probably as a result of altered sex-hormone metabolism (14); however, the prevalence of male hypogonadism and the involvement of testosterone deficiency in the risk profile of HD patients are not well explored. In a small study that included male HD patients without diabetes, low testosterone levels were associated with endothelial dysfunction and atherosclerosis (15). Interestingly, Carrero et al. (16) recently demonstrated in a Swedish HD cohort that low serum testosterone levels were significant predictors of mortality, irrespective of age and inflammation, but this was abolished after correction for serum creatinine, used there as a surrogate of muscle mass (16). In light of the exceedingly elevated (cardiovascular) mortality of HD patients (17), this possibility is an attractive and therapeutically modifiable idea. We aimed in this study to investigate the prevalence of testosterone deficiency as well as its impact on overall outcome in a large prospective cohort of prevalent male Turkish patients who were undergoing HD.     

Association of Performance-Based and Self–Reported Function–Based Definitions of Frailty with Mortality among Patients Receiving Hemodialysis

Background and objectives

Frailty is common among patients on dialysis and increases vulnerability to dependency and death.

Design, setting, participants, & measurements

We examined the predictive ability of frailty on the basis of physical performance and self-reported function in participants of a US Renal Data System special study that enrolled a convenience sample of 771 prevalent patients on hemodialysis from 14 facilities in the Atlanta and northern California areas from 2009 to 2011. Performance-based frailty was assessed using direct measures of grip strength (weakness) and gait speed along with weight loss, exhaustion, and low physical activity; poor self–reported function was substituted for weakness and slow gait speed in the self–reported function–based definition. For both definitions, patients meeting three or more criteria were considered frail.

Results

The mean age of 762 patients included in analyses was 57.1±14.2 years old; 240 patients (31%) met the physical performance–based definition of frailty, and 396 (52%) met the self–reported function–based definition. There were 106 deaths during 1.7 (interquartile range, 1.4–2.4) years of follow-up. After adjusting for demographic and clinical characteristics, the hazard ratio (HR) for mortality for the performance-based definition (2.16; 95% confidence interval [95% CI], 1.41 to 3.29) was slightly higher than that of the self–reported function–based definition (HR, 1.93; 95% CI, 1.24 to 3.00). Patients who met the self-report–based definition but not the physical performance definition of frailty (n=192) were not at statistically significantly higher risk of mortality than those who were not frail by either definition (n=330; HR, 1.41; 95% CI, 0.81 to 2.45), but those who met both definitions of frailty (n=204) were at significantly higher risk (HR, 2.46; 95% CI, 1.51 to 4.01).

Conclusions

Frailty, defined using either direct tests of physical performance or self–reported physical function, was associated with higher mortality among patients receiving hemodialysis. Future studies are needed to determine the utility of assessing frailty in clinical practice.     

Beyond Comorbidity Counts: How Do Comorbidity Type and Severity Influence Diabetes Patients’ Treatment Priorities and Self-Management?

BACKGROUND The majority of older adults have 2 or more chronic conditions and among patients with diabetes, 40% have at least three. OBJECTIVE We sought to understand how the number, type, and severity of comorbidities influence diabetes patients’ self-management and treatment priorities. DESIGN Cross-sectional observation study. PATIENTS A total of 1,901 diabetes patients who responded to the 2003 Health and Retirement Study (HRS) diabetes survey. MEASUREMENTS We constructed multivariate models to assess the association between presence of comorbidities and each of 2 self-reported outcomes, diabetes prioritization and self-management ability, controlling for patient demographics. Comorbidity was characterized first by a count of all comorbid conditions, then by the presence of specific comorbidity subtypes (microvascular, macrovascular, and non-diabetes related), and finally by severity of 1 serious comorbidity: heart failure (HF). RESULTS 40% of respondents had at least 1 microvascular comorbidity, 79% at least 1 macrovascular comorbidity, and 61% at least 1 non-diabetes-related comorbidity. Patients with a greater overall number of comorbidities placed lower priority on diabetes and had worse diabetes self-management ability scores. However, only macrovascular and non-diabetes-related comorbidities, but not microvascular comorbidities, were associated with lower diabetes prioritization, whereas higher numbers of microvascular, macrovascular, and non-diabetes-related conditions were all associated with lower diabetes self-management ability scores. Severe, but not mild, HF was associated with lower diabetes prioritization and self-management scores. CONCLUSIONS The type and severity of comorbid conditions, and not just the comorbidity count, influence diabetes patients’ self-management. Patients with severely symptomatic comorbidities and those with conditions they consider to be unrelated to diabetes may need additional support in making decisions about care priorities and self-management activities.     

Stroke Mortality and Race: Does Access to Care Influence Outcomes?

BACKGROUND: Stroke is the third leading cause of death in the United States. We investigated racial differences in death after hospital discharge for ischemic stroke in a large cohort of Veterans Health Affairs (VHA) stroke patients. We hypothesized that having access to VA care would ameliorate the excess stroke mortality rates in African-Americans (AA) reported in non-VA studies. METHODS: Hospital administrative data were used to identify all patients discharged from any VA hospital between October 1990 and September 1997 with a primary discharge diagnosis of ischemic stroke (ICD-9-CM codes 434 and 436). We obtained demographic data and clinical data recorded during the index hospitalization and after discharge, including deaths, from VA clinical and administrative databases. The Charlson comorbidity index was constructed for each patient from the index admission's discharge diagnoses. Patients were followed through 1998. RESULTS: Of 55,094 VHA stroke patients discharged after ischemic strokes, 34,579 (63%) were white and 11,530 (21%) were AA. Charlson index was similar between the groups. One-year mortality rate was significantly higher for whites: Adjusting for demographic and clinical differences, being white remained predictive of higher mortality rates (multivariable hazard ratio, 1.06; 95% CI, 1.02 to 1.10). From Kaplan-Meier estimates, the probability that whites would survive for 1 year was 0.86 compared with 0.87 for AA. CONCLUSIONS: Despite having similar severity of illness and adjusting for other clinical differences, mortality rate was marginally lower in AA after being discharged from VA hospitals after ischemic strokes. This is contrary to prior reports from non-VA hospitals and suggests the possibility of access to care playing a role in stroke deaths.     

What Do Patients Want?

PURPOSE: Clinicians often make decisions for their patients, despite evidence that suggests that correspondence between patient and clinician decision making is poor. The management of colorectal cancer presents difficult decisions because the impact of treatment on quality of life might overshadow its survival efficacy. This study investigated whether patients are able to trade survival for quality of life as a means to express their preference for treatment options and to compare their preferences with those expressed by clinicians. METHODS: Patients undergoing curative surgery for colorectal cancer were interviewed postoperatively to elicit their preferences in four hypothetical treatment scenarios. A questionnaire was mailed to all Australian colorectal surgeons and medical oncologists that asked them to respond as if they themselves were patients. RESULTS: One hundred patients (91 percent), 43 colorectal surgeons (77 percent), and 103 medical oncologists (50 percent) participated. In all four scenarios, patients were able to trade survival for quality of life. Patients' responses varied between scenarios, both in willingness to trade and the average amount traded. There were significant differences between patients and clinicians. Clinicians were more willing than patients to trade survival to avoid a permanent colostomy in favor of chemoradiotherapy. Patients' strongest preference was to avoid chemotherapy, more than to avoid a permanent colostomy. CONCLUSIONS: Patients are able to trade survival as a measure of preference for quality of life and can do so differentially between treatment scenarios. Patients' preferences do not always accord with those of clinicians. Unless patients' preferences are explicitly sought and incorporated into clinical decision making, patients may not receive the treatment that is best for them.     

Recommendations Regarding Dietary Intake and Caffeine and Alcohol Consumption in Patients With Cardiac Arrhythmias: What Do You Tell Your Patients To Do or Not To Do?

OPINION STATEMENT: The etiology of arrhythmias including atrial fibrillation is multifactorial. Most arrhythmias are associated with comorbid illnesses like hypertension, diabetes, thyroid disease, or advanced age. Although it is tempting to blame a stimulant like caffeine as a trigger for arrhythmias, the literature does not support this idea. There is no real benefit to having patients with arrhythmias limit their caffeine intake. Caffeine is a vasoactive substance that also may promote the release of norepinephrine and epinephrine. However, acute ingestion of caffeine (as coffee or tea) does not cause atrial fibrillation. Even patients suffering a myocardial infarction do not have an increased incidence of ventricular or other arrhythmias after ingesting several cups of coffee. Large epidemiologic studies have also failed to find a connection between the amount of coffee/caffeine used and the development of arrhythmias. As such, it does not make sense to suggest that patients with palpitations, paroxysmal atrial fibrillation, or supraventricular tachycardia, abstain from caffeine use. Energy drinks are a new phenomenon on the beverage market, with 30-50?% of young adults and teens using them regularly. Energy drinks are loaded with caffeine, sugar, and other chemicals that can stimulate the cardiac system. There is an increasing body of mainly anecdotal case reports describing arrhythmias or even sudden death triggered by exercise plus using energy drinks. Clearly, there must be more study in this area, but it is wise to either limit or avoid their use in patients with arrhythmias. Moderate to heavy alcohol use seems to be associated with the development of atrial fibrillation. The term "holiday heart" was coined back in 1978, to describe patients who had atrial fibrillation following binge alcohol use. Thus, it is reasonable to recommend to patients with arrhythmias that they limit their alcohol use, although unfortunately this treatment will likely not completely resolve their arrhythmia.     

Can Serum Gdf-15 be Associated with Functional Iron Deficiency in Hemodialysis Patients?

Functional iron deficiency (FID) incidence is gradually increasing in hemodialysis (HD) patients. Recently, high levels of GDF-15 supressed the iron regulatory protein hepcidin and GDF-15 expression increased in iron-deficient patients. The relationship between FID, GDF-15, and hepcidin is currently unknown. The present study aimed to evaluate the association between GDF-15, hepcidin, and FID in chronic HD patients. Serum GDF-15 and hepcidin concentrations were measured in 105 HD patients and 40 controls. FID is defined as serum ferritin >800 ng/mL, TSAT <25 %, Hb levels <11 g/dL, and reticulocyte haemoglobin content (CHr) <29 pg. Serum GDF-15 and hepcidin levels were increased significantly in HD patients with FID, compared to HD patients without anemia and controls. GDF-15 correlated with ferritin, hepcidin, and CRP in the entire cohort. GDF-15 was related to ferritin and CRP in HD patients with FID. GDF-15 is better diagnostic marker than hepcidin for detection of FID [AUC = 0.982 (0.013) versus AUC = 0.921 (0.027); P = 0.0324]. GDF-15 appears to be a promising tool for detection of FID. High levels of ferritin and CRP correlated with GDF-15. Our results support GDF-15 as a new mediator of FID via hepcidin, chronic inflammation, or unknown pathways.     

Are the Hemodynamic Changes in Elderly Hypertensive Patients of Clinical Importance? Do They Influence the Choice of Medication?

Despite the fact that elderly hypertensive patients have numerous concomitant diseases and changes in physiologic responses compared to middle-aged or younger individuals, they generally repond well to antihypertensive drug therapy without significant adverse reactions-provided that medication is started at low dosages and that dosages are increased slowly. There is little doubt that the benefit of treatment outweighs the risk.     

Are Survival Rates Different for Young and Older Patients With Rectal Cancer?

PURPOSE Although it is generally believed that young patients with rectal cancer have worse survival rates, no comprehensive analysis has been reported. This study uses a national-level, population-based cancer registry to compare rectal cancer outcomes between young vs. older populations.METHODS All patients with rectal carcinoma in the Surveillance, Epidemiology, and End Results cancer database from 1991 to 1999 were evaluated. Young (range, 20–40 years; n = 466) and older groups (range, 60–80 years; n = 11,312) were compared for patient and tumor characteristics, treatment patterns, and five-year overall and stage-specific survival. Cox multivariate regression analysis was performed to identify predictors of survival.RESULTS Mean ages for the groups were 34.1 and 70 years. The young group was comprised of more black and Hispanic patients compared with the older group (P < 0.001). Young patients were more likely to present with late-stage disease (young vs. older: Stage III, 27 vs. 20 percent respectively, P < 0.001; Stage IV, 17.4 vs. 13.6 percent respectively, P < 0.02). The younger group also had worse grade tumors (poorly differentiated 24.3 vs. 14 percent respectively, P < 0.001). Although the majority of both groups received surgery (85 percent for each), significantly more young patients received radiation (P < 0.001). Importantly, overall and stage-specific, five-year survival rates were similar for both groups (P = not significant).CONCLUSIONS Although previous studies have found young rectal cancer patients to have poorer survival compared with older patients, this population-based study shows that young rectal cancer patients seem to have equivalent overall and stage-specific survival.Supported in part by The American Society of Colon and Rectal Surgeons Limited Project Grant.Presented at the meeting of the Association for Academic Surgery, Sacramento, California, November 13 to 15, 2003.