Surgical volume and long-term survival following surgery for colorectal cancer in the Veterans Affairs Health-Care System

OBJECTIVE: The objective of this study was to examine the relationship between hospital surgical volume and long-term survival in patients with a new diagnosis of colorectal cancer who underwent surgical resection during fiscal years 1991-2000 in the Veterans Affairs (VA) health-care system. METHODS: This research was a cohort study of patients admitted to all VA hospitals with a new diagnosis of colorectal cancer who underwent surgical resection between October 1990 and September 2000 and followed through September 2001. Overall 5-yr cumulative survival was calculated from Kaplan-Meier estimates, while adjusted risk of death was estimated using a Cox proportional hazards model. Adjustment was made for differences in patient characteristics including comorbidity, receipt of therapy, and year of surgery. RESULTS: We identified 34,888 individuals with a new diagnosis of colorectal cancer in VA hospitals during fiscal years 1991-2000, of whom 22,633 (65%) underwent surgical resection. The majority (98.5%) were men, the mean age was 68 yr, and the two largest race/ethnic groups were whites (75%) and blacks (17%). The 5-yr cumulative survival was greater among those who received surgery in high surgical volume hospitals as defined by 25 or more procedures per year (52.1%) than among those who received surgery in low volume hospitals (48.3%). After adjusting for differences in patient characteristics, comorbidity, receipt of adjuvant therapy, and year of surgery, we found 7% and 11% increases in 5-yr survival for patients with colon and rectal cancers, respectively, who underwent surgical resection in high volume hospitals compared with those who had surgery in low volume hospitals. CONCLUSIONS: Greater hospital surgical volume is an independent predictor of prolonged long-term survival following surgery for both colon and rectal cancer in the VA health-care system. The volume-long-term mortality relationship is greater for rectal than for colon cancer patients, perhaps reflecting the fact that surgery for rectal cancer is more technically demanding. Future studies are needed to discover what aspects of clinical management explain these differences.     

The changing distribution and survival of colorectal carcinoma: an epidemiological study in an area of northern Italy

OBJECTIVE: This study analyses the inter-relations of anatomical tumour location, gender, age and incidence rates for colorectal cancer from 1978 to 1999 in an area of northern Italy: the Parma district. METHODS: Data were obtained from the Parma Cancer Registry. Age-adjusted incidence rates were analysed by gender, age and colorectal cancer subsites. In addition, 5 year observed survival rates were determined. RESULTS: In the Parma area, the incidence of colorectal cancer is rising. We have observed a true increase in the rate of the age standardized incidence of right colon cancer, linked to an increased incidence of left colon cancer, while the incidence of rectal cancer has remained constant. The frequency of right-sided colon cancer was higher in aged patients, and in women. Age-standardized relative survival of patients after diagnosis of colorectal cancer between 1992 and 1996 was found to be significantly higher than age-standardized relative survival after diagnosis between 1978 and 1982. CONCLUSIONS: In the Parma area there has been an increased incidence of right colon cancer, linked to an increased incidence of left colon cancer, while the incidence of rectal cancer has remained constant. We feel that this shift, whatever the reason for it, has important implications for the choice of screening techniques.     

Conditional survival estimates in 34,963 patients with invasive carcinoma of the colon

PURPOSE: We report colon cancer survival rates that are conditioned on patients having already survived one or more years after diagnosis. These rates have more meaning clinically, because they consider those patients who have already survived a given period of time after treatment. METHODS: The life table method was used to compute conditional survival rates, using population-based data obtained from the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute. Patients were diagnosed between 1983 and 1987 and followed up through 1994. Relative and observed survival rates are considered. RESULTS: Survival rates up to ten years after diagnosis are reported by stage of disease, gender, and race for colon cancer patients who survived from one to five years after diagnosis. Survival rates are also reported by lymph node involvement. CONCLUSIONS: Five-year and ten-year survival in colon cancer patients having already survived between one and five years after diagnosis continues to be influenced significantly by stage and race.     

Decision analysis in the surgical treatment of patients with familial adenomatous polyposis: a Dutch-Scandinavian collaborative study including 659 patients

BACKGROUND AND AIMS: The choice of colorectal surgery in patients with familial adenomatous polyposis lies between the morbidity of proctocolectomy and ileum-pouch-anal anastomosis (IPAA) and the mortality from rectal cancer after total colectomy and ileorectal anastomosis (IRA). The aims of the present study were: (1) to assess the risk of dying from rectal cancer after IRA, (2) to compare the life expectancy between patients with an IRA and those with an IPAA, and (3) to investigate whether regular endoscopic examination of the rectum leads to detection of cancer at an earlier stage. METHODS: Clinical and pathological data on 659 patients who underwent colectomy and ileorectal anastomosis were collected from four national polyposis registries-that is, in Denmark, Finland, Sweden, and the Netherlands. Data were analysed using survival analysis methods. Decision analysis was used to compare the life expectancy between patients with an IRA and those with an IPAA. RESULTS: A total of 47 patients developed rectal cancer after IRA. The risk of dying from rectal cancer was 12.5% (95% confidence interval 7.1--17.9%) by age 65. Compared with IRA, IPAA would lead to an increase in life expectancy of 1.8 years. Seventy five per cent of patients with rectal cancer had a negative rectoscopy within 12 months before the diagnosis. CONCLUSION: IRA is associated with substantial mortality due to rectal cancer. Follow up examinations of the rectum does not have sufficient preventive effect on morbidity and mortality of rectal cancer.     

Relations between amount and type of alcohol and colon and rectal cancer in a Danish population based cohort study

BACKGROUND: There may be a weak association between total alcohol intake and colorectal cancer but the effect of different types of alcohol and effect on colon subsites have not been investigated satisfactorily. AIMS: To investigate the relationship between amount and type of alcohol and the risk of colon and rectal cancer. SUBJECTS: A population based cohort study with baseline assessment of weekly intake of beer, wine, and spirits, smoking habits, body mass index, educational level, and leisure time physical activity in Copenhagen, Denmark. The study included a random sample of 15 491 men and 13 641 women, aged 23-95 years. Incident cases of colorectal cancer were identified in the nationwide Danish Cancer Register. RESULTS: During a mean follow up of 14.7 years, we observed 411 colon cancers and 202 rectal cancers. We observed a dose-response relationship between alcohol and rectal cancer. Drinkers of more than 41 drinks a week had a relative risk of rectal cancer of 2.2 (95% confidence limits 1.0-4.6) compared with non-drinkers. Drinkers of more than 14 drinks of beer and spirits a week, but not wine, had a risk of 3.5 (1.8-6.9) of rectal cancer compared with non-drinkers, while those who drank the same amount of alcohol but including more than 30% of wine had a risk of 1.8 (1.0-3.2) of rectal cancer. No relation between alcohol and colon cancer was found when investigating the effects of total alcohol, beer, wine, and spirits, and percentage of wine of total alcohol intake. CONCLUSION: Alcohol intake is associated with a significantly increased risk of rectal cancer but the risk seems to be reduced when wine is included in the alcohol intake.     

Level of hospital care and outcome of gastric cancer: a population-based evaluation of the Munich Cancer Registry

Background

Gastric cancer accounts for 5 % of cancer deaths. Successful implementation of guideline-recommended treatment procedures should result in population-based outcome improvements despite the still poor prognosis. In this context, the objective of this study was to compare the outcome of gastric cancer by different levels of hospital care.

Materials and methods

Total of 8,601 patients with invasive gastric cancer documented between 1998 and 2012 by the Munich Cancer Registry were evaluated. Tumour and therapy characteristics and outcome were analysed in regard to five levels of hospital care: three levels were defined for general hospitals (level I–III), while university hospitals and speciality hospitals were grouped as separate classes. Survival was investigated using the Kaplan–Meier-method, computing relative survival, and by multivariate Cox proportional hazard regression.

Results

The average age differed between 66 years in university hospitals and 75 years in hospitals providing a basic level of care (level I). No survival differences were found for patients treated in different levels of hospital care in 75 % of the patient cohort, namely the M0 patients. A better survival could only be shown for patients with M1 at diagnosis when treated in a university or level III hospital compared to those treated in other hospitals.

Conclusion

The outcome difference of M1 patients is most likely caused by selection effects concerning health status differences and not by processes of health care attributable to level of hospital care. Thus, this study demonstrates and confirms appropriate treatment and care of gastric cancer over all levels of hospital care.     

A comparison of transanal excision and endoscopic resection for early rectal cancer

AIM: To compare the outcomes of endoscopic resection with transanal excision in patients with early rectal cancer.METHODS: Thirty-two patients with early rectal cancer were treated by transanal excision or endoscopic resection between May 1999 and December 2007. The patients were regularly re-examined by means of colonoscopy and abdominal computed tomography after resection of the early rectal cancer. Complications, length of hospital-stay, disease recurrence and follow up outcomes were assessed.RESULTS: Sixteen patients were treated by endoscopic resection and 16 patients were treated by transanal excision. No significant differences were present in the baseline characteristics. The rate of complete resection in the endoscopic resection group was 93.8%, compared to 87.5% in the transanal excision group (P = 0.544). The mean length of hospital-stay in the endoscopic resection group was 2.7 ± 1.1 d, compared to 8.9 ± 2.7 d in the transanal excision group (P = 0.001). The median follow up was 15.0 mo (range 6-99). During the follow up period, there was no case of recurrent disease in either group.CONCLUSION: Endoscopic resection was a safe and effective method for the treatment of early rectal cancers and its outcomes were comparable to those of transanal excision procedures.     

Age and Colorectal Cancer With Focus on the Elderly: Trends in Relative Survival and Initial Treatment From a Danish Population-Based Study

PURPOSE Elderly patients with colorectal cancer undergo surgery with curative intent less frequently than younger patients, and survival declines with increasing age. We compared relative survival of colorectal cancer among patients older than 75 years with that of younger patients in Denmark during the period 1977 to 1999. We also examined trends in choice of initial treatment.METHODS From the files of the nationwide population-based Danish Cancer Registry, we identified all cases of colorectal cancer diagnosed between 1977 and 1999. We then linked this data to information on survival obtained from the Danish Register of Causes of Death and from the Central Population Register.RESULTS During the entire study period, short-term and long-term relative survival improved for patients of all ages, but the improvement was more pronounced among elderly patients (>75 years). Radical resection was increasingly chosen as the initial treatment for elderly patients; during the 1995 to 1999 period it was performed on approximately 50 percent of such patients, almost as frequently as among younger patients.CONCLUSIONS Relative survival of elderly colorectal cancer patients (>75 years) improved in Denmark between 1977 and 1999. In the most recent period studied, 1995 to 1997, only minor differences in five-year relative survival were observed among younger, middle-aged, and elderly patients. A simultaneous increase in the rate of radical resection among elderly patients, reflecting more effective treatment, may underlie this finding.Supported by the Western Danish Research Forum for Health Sciences and the Leo and Ingeborg Dannin Foundation for Scientific Research.Presented at the spring meeting of the Danish Society of Surgery, Copenhagen, Denmark, April 7 to 8, 2005.Reprints are not available.     

Increased Risk of Esophageal Varices,Liver Cancer,and Death in Patients With Alcoholic Liver Disease

Background and Aims: During the last decades, a multitude of different treatments for chronic liver disease have been introduced. New surveillance programs have been established to detect esophageal varices and liver cancer. The aims of our study were to assess whether the prognosis for patients hospitalized with liver diseases between 1969 and 2006 had improved and to study the differences in mortality and complications between patients with alcoholic liver disease and nonalcoholic liver diseases. Methods: We used the Swedish Hospital Discharge Register and Cause of Death Register at the National Board of Health and Welfare in Sweden between 1969 and 2006 to identify and follow‐up a cohort of patients with liver disease according to the International Classification of Diseases‐8, ‐9, and ‐10. Results: There were 36,462 patients hospitalized with alcoholic and 95,842 with nonalcoholic liver diseases. The main finding was that patients hospitalized with alcoholic liver disease had an increased mortality risk, compared to patient with nonalcoholic liver disease, 1.89 (1.85 to 1.92). In addition, the patients with alcoholic liver disease had an increased risk for esophageal varices and liver cancer. There was a reduced risk for hospitalization with esophageal varices for patients with nonalcoholic liver disease up to 1998. Conclusions: We found that the prognosis for patients hospitalized with chronic liver diseases had not improved. Patients with alcoholic liver disease have an increased risk of complications, which suggest that the disease is more aggressive and are in need of closer follow‐up than other chronic liver diseases.     

Carboplatin and paclitaxel as first‐line treatment of unresectable or metastatic esophageal or gastric cancer

Survival in patients with metastatic esophageal and gastric cancer is dismal. No standard treatment has been established. Carboplatin/paclitaxel is active in both advanced gastric and esophageal cancer. Here we retrospectively present our single center experience. Between 1998 and 2013, a total of 134 patients with metastatic esophageal and gastric adenocarcinoma treated with carboplatin/paclitaxel (carboplatin predominantly area under the curve 5 and paclitaxel predominantly 175 mg/m²) every 3 weeks as first‐line therapy were identified. Baseline characteristics, response to therapy, toxicities, and survival in this patient population were evaluated. Overall survival was defined as date from diagnosis to death or last follow up, and progression‐free survival was defined at time from cycle 1 to, progression or last follow up. Kaplan–Meier curves were fit to estimate overall and progression‐free survival. Of the 134 patients evaluated, the median age at diagnosis was 65 years. Disease control rate was 62.6% (complete response: 11%, partial response: 28%, stable disease: 33%). Median overall survival from date of initial diagnosis was 15.5 months (95% confidence interval [CI] 1.06–1.5). Median progression‐free survival from date of initiation of carboplatin and paclitaxel was 5.3 months (95% CI 0.34–0.5). Grade III or greater toxicity occurred in 26.1% of patients. The most common grade III toxicities were neutropenia and neuropathy, present in 14.2% and 3.7% of the total study population, respectively. In patients with metastatic or unresectable esophageal or gastric cancer, the combination of carboplatin and paclitaxel is well tolerated with comparable overall survival and progression‐free survival to existing regimens in this population.     

Survival and incidence of colorectal cancer in patients with ulcerative colitis in Funen county diagnosed between 1973 and 1993

BACKGROUND: The aim of the study was to determine the death rate and the risk of developing colorectal cancer in patients with ulcerative colitis in Funen County. METHODS: The medical records of 801 patients with ulcerative colitis diagnosed in 1973-93 in Funen County were scrutinized with regard to colectomy, survival, and colorectal cancer, and in 1998 a follow-up was carried out. RESULTS: The patients were managed at nine different hospitals: one university hospital, one central hospital, and seven smaller hospitals. The mean age at diagnosis was 41 years, and the mean duration of disease was 10.11 years. Sixty-one per cent of the patients were classified as having proctosigmoiditis, 21% as having left-sided colitis, and 18% as having pancolitis. In 127 patients who underwent proctocolectomy during the study period lethal complications occurred in 8 cases: 5 of 110 in Odense University hospital and 3 of 17 in the other hospitals. One hundred and twenty patients in the cohort died during the period of observation, nine of them of colitis-related causes. There was a slightly increased risk of early death in the cohort after 15 years of disease. Six colorectal cancers were found, whereas four were expected, giving a standard incidence ratio of 1.665. The cumulative cancer risk after 20 years' disease duration was 5.3% in the observed group, contrasting with an expected rate of 0.49%, and 10.1% after 25 years. CONCLUSION: In this cohort of ulcerative colitis patients the mortality and the risk of developing colorectal cancer were slightly higher than expected compared with the background population.     

Overview of colorectal cancer in Japan

BACKGROUND AND PURPOSE: In Japan, the incidence of colorectal cancer has increased remarkably since World War II, and interest in this cancer has grown rapidly among Japanese clinicians and pathologists. As a result, the Japanese Society for Cancer of the Colon and Rectum started a multi-institutional registry of colorectal cancer in 1980. The purpose of this report is to present an overview of the actual state of surgical and pathologic aspects of colorectal cancer treated in the leading hospitals in Japan. MATERIALS AND METHODS: Registry files of clinical and pathologic findings for 38,369 patients treated between 1974 and 1986 with five-year follow-up information and 26,360 patients treated between 1991 and 1994 with no follow-up information were reviewed. RESULTS: Numbers of registered patients have increased annually, reflecting a trend toward an increasing incidence of this cancer in Japan. Colon cancer increased more than rectal cancer in both genders. Resection of the primary lesion was achieved in more than 97 percent of patients who underwent surgical operation recently. The curative resection rate has improved from 65.1 to 79.1 percent for colon cancer and from 71.4 to 80.4 percent for rectal cancer between the 1974 and 1979 and the 1991 and 1994 periods, and operative mortality of those has decreased from 1.8 and 2 percent to 0.5 and 0.5 percent, respectively. There was a trend toward a decrease in locally advanced cancer in terms of cancer invasion into the bowel wall. Stage IV colon cancer also decreased from 22.9 to 16.6 percent with time. The five-year survival rate of each pTNM stage has gradually been improving and was especially evident for patients with Stages I, II, and III of rectal cancer. Overall five-year survival rates for colorectal cancer patients currently exceeds 60 percent. CONCLUSION: The overall incidence of colorectal cancer and the ratio of colon cancer to rectal cancer patients in Japan are increasing. Results of surgical treatment are satisfactory with respect to curative resection rate, operative mortality, and the five-year survival rate. Registry data of the Japanese Society for Cancer of the Colon and Rectum are useful for reporting the actual state of diagnosis, treatment, and end results of colorectal cancer in Japan.     

Long-term trends in the incidence and relative survival of pancreatic cancer in Canada: A population-based study

Background/objectiveThe poor survival among pancreatic cancer patients accounts for a disproportionate number of cancer deaths, and there has been little or no improvement in the long-term survival of these patients. This study examines the long-term trends in incidence and relative survival of patients diagnosed with pancreatic cancer in Canada between 1992 and 2008.MethodsWe used pancreatic cancer data from the Canadian Cancer Registry. Incidence rate per age group was estimated over the aforementioned period. A flexible parametric model was used to estimate trends in one- and five-year relative survival for each age group and sex. Excess mortality rate was estimated to illustrate additional mortality due to a cancer diagnosis.ResultsIn total, 34,577 patients with pancreatic cancer were identified, of which 49.3% were male. Mean age at diagnosis was 70.1 (SD = 12.3) years. Approximately 60.0% of patients were older than 70 years at diagnosis. There has been no change in the incidence rate of pancreatic cancer in Canada; however, it significantly decreased for men (80+) (p = 0.011). Although one-year relative survival increased over time for all patients, five-year relative survival increased only 5% for the youngest age group (<50 years).ConclusionsOverall survival of patients with pancreatic cancer remains low, although advances in chemotherapy and palliative care may have provided some improvement. Excess mortality remains highest shortly after diagnosis, which is likely attributable to the late diagnosis of pancreatic cancer.     

Survival of colorectal cancer patients hospitalized in the Veterans Affairs Health Care System

OBJECTIVES: A recent analysis based on data from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute indicates that no survival benefit occurred, for white or for black individuals, in colorectal cancer diagnosed during 1986-1997, and that blacks fared worse than whites. The objective of this research was to evaluate recent temporal trends in the survival of patients with colorectal cancer admitted to hospitals in the Veterans Affairs (VA) system, which offers equal access to care and facilitates systemwide implementation of prevention and treatment services. METHODS: This research was a cohort study of patients admitted to all VA hospitals with a new diagnosis of colorectal cancer between October, 1987, and September, 1998, and followed through September, 2001. Temporal changes in observed 5-yr survival were evaluated for the periods 1987-1989, 1990-1992, 1993-1995, and 1996-1998. Cumulative survival was obtained from Kaplan-Meier estimates, whereas adjusted risk of death was calculated using a Cox proportional hazards model. Adjustment was made for differences in patient characteristics, including comorbidity. RESULTS: We identified 46,044 individuals with colorectal cancer in VA hospitals during 1987-1998, 98.5% of whom were men. The mean age was 67.7 yr, and the two largest racial/ethnic groups were whites (76.5%) and blacks (17.1%). Significant differences in survival were seen over time (p < 0.001, log rank test) with longer survival in patients diagnosed in the more recent time periods. In the multivariable Cox model, survival showed an 18% increase over time (1987-1998) after adjusting for differences in age, race, comorbidity, cancer site, and extent of disease. There was a small but statistically significant decrease in chance of survival in blacks compared with whites (adjusted relative survival 0.96, 95% CI = 0.92-0.99). CONCLUSIONS: Recent non-VA studies have shown stable survival for colorectal cancer patients over time, coupled with significantly decreased survival for blacks compared with whites. In contrast, in the VA system, survival has improved for both white and black patients; in addition, the racial discrepancy in survival is markedly attenuated. These results suggest that the benefits of prevention and treatment advances may be more readily achieved in the VA's equal access, integrated health care system.     

Delayed Treatment for Rectal Cancer

PURPOSE Reports of the relationship between length of delay before diagnosis of rectal cancer and stage of the disease have been mixed. The present study documented the magnitude and medical ramifications of delay in diagnosing rectal cancer.METHODS One hundred twenty patients who had been recently diagnosed with rectal cancer provided information regarding history of symptoms and initial perceptions of those symptoms. Patients also estimated the time elapsed from onset of symptoms until their first consultation with a physician, as well as time elapsed from consultation until the diagnosis of rectal cancer was made. Stage information was gathered from patient charts.RESULTS For 106 of the patients, the first sign of rectal cancer was in the form of symptoms, and the most common first symptom was rectal bleeding. For the remaining 14 patients, their cancer was first discovered through routine examination. Over 75 percent of patients with symptoms did not initially believe that they were caused by cancer or any other serious problem, and over 50 percent attributed their symptoms to hemorrhoids. There was a clear trend, albeit statistically nonsignificant, toward worsening disease with longer delays. Median delay times in weeks were Stage I (10.0 weeks), Stage II (14.0 weeks), Stage III (18.5 weeks), and Stage IV (26.0 weeks).CONCLUSIONS Delayed diagnosis for rectal cancer remains a significant problem, with instances of delay attributable to both patient and physician. Delayed diagnosis can result in more serious disease and, when attributable to the physician, can result in damaged trust and sometimes legal action.Supported by the Alvin J. Siteman Cancer Center, National Cancer Institute Grant No. 1R03 CA84845 01, and The American Society of Colon and Rectal Surgeons (LPG 073).Reprints are not available.     

Infliximab and newly diagnosed neoplasia in Crohn's disease: a multicentre matched pair study

BACKGROUND AND AIMS: The widespread use of anti-tumour necrosis factor alpha antibody (Infliximab) in Crohn's disease (CD) raises concerns about a possible cancer risk in the long term. In a matched pair study, we assessed whether Infliximab is associated with an increased risk of neoplasia. METHODS: In a multicentre matched pair study, 404 CD patients treated with Infliximab (CD-IFX) were matched with 404 CD patients who had never received Infliximab (CD-C). Cases and controls were matched for sex, age (+/-5 years), site of CD, age at diagnosis (+/-5 years), immunosuppressant use, and follow up. New diagnoses of neoplasia from April 1999 to October 2004 were recorded. RESULTS: Among the 404 CD-IFX, neoplasia was diagnosed in nine patients (2.22%) while among the 404 CD-C, seven patients developed neoplasia (1.73%) (odds ratio 1.33 (95% confidence interval 0.46-3.84); p=0.40). The survival curve adjusted for patient year of follow up showed no differences between CD-IFX and CD-C (p=0.90; log rank test). In the CD-IFX group, there was one cholangiocarcinoma, three breast cancers, one skin cancer, one leukaemia, one laryngeal cancer, and two anal carcinomas. Among the 7/404 (1.73%) CD-C, there were three intestinal adenocarcinomas (two caecum, one rectum), one basalioma, one spinalioma, one non-Hodgkin's lymphoma, and one breast cancer. Age at diagnosis of neoplasia did not differ between groups (CD-IFX v CD-C: median 50 (range 40-70 years) v 45 (27-72); p=0.50). CONCLUSION: In our multicentre matched pair study, the frequency of a new diagnosis of neoplasia in CD patients treated with Infliximab was comparable with CD patients who had never received Infliximab.     

Preoperative serum levels of c-erbB-2 do not seem to be useful in management of patients with rectal cancer

Background and aim Soluble c-erbB-2 oncoprotein has been proven as a useful marker in the management of breast cancer patients, but its value in diagnostics and follow-up of colorectal cancer patients remains controversial. The aim of this study was to evaluate the usefulness of serum c-erbB-2 monitoring in diagnostics and prediction of disease outcome in rectal cancer patients. Materials and methods Serum samples from 88 patients with rectal adenocarcinoma before surgery and from 41 healthy controls were tested for the presence of c-erbB-2 oncoprotein by ELISA, and the patients were followed up for at least 5 years after the surgery. Results Preoperative serum c-erbB-2 levels were significantly higher in stage IV patients than in healthy controls (P<0.001) and did not show correlation with preoperative CEA levels. Elevated preoperative serum c-erbB-2 levels showed relatively high specificity (88%) and low sensitivity (44%) in the diagnosis of rectal cancer. Elevated preoperative oncoprotein levels were predictive neither for overall survival nor for development of local recurrence/distant metastases. Conclusion Although preoperative serum c-erbB-2 levels were significantly higher in rectal cancer patients than in healthy controls, the soluble c-erbB-2 does not seem to be useful in the diagnosis of rectal cancer due to its low sensitivity. Preoperative serum levels of this oncoprotein were predictive neither for overall survival nor for local recurrence/distant metastases in rectal cancer patients.     

Cause-specific mortality in Scottish patients with colorectal cancer with and without type 2 diabetes (2000–2007)

Aims/hypothesis

The objective of this study was to use Scottish national data to assess the influence of type 2 diabetes on (1) survival (overall and cause-specific) in multiple time intervals after diagnosis of colorectal cancer and (2) cause of death.

Methods

Data from the Scottish Cancer Registry were linked to data from a population-based national diabetes register. All people in Scotland diagnosed with non-metastatic cancer of the colon or rectum in 2000–2007 were included. The effect of pre-existing type 2 diabetes on survival over four discrete time intervals (<1, 1–2, 3–5 and >5 years) after cancer diagnosis was assessed by Cox regression. Cumulative incidence functions were calculated representing the respective probabilities of death from the competing causes of colorectal cancer, cardiovascular disease, other cancers and any other cause.

Results

Data were available for 19,505 people with colon or rectal cancer (1,957 with pre-existing diabetes). Cause-specific mortality analyses identified a stronger association between diabetes and cardiovascular disease mortality than that between diabetes and cancer mortality. Beyond 5 years after colon cancer diagnosis, diabetes was associated with a detrimental effect on all-cause mortality after adjustment for age, socioeconomic status and cancer stage (HR [95% CI]: 1.57 [1.19, 2.06] in men; 1.84 [1.36, 2.50] in women). For patients with rectal cancer, diabetes was not associated with differential survival in any time interval.

Conclusions/interpretation

Poorer survival observed for colon cancer associated with type 2 diabetes in Scotland may be explained by higher mortality from causes other than cancer.     

Factors affecting the risk of rectal cancer following rectum-preserving surgery in patients with familial adenomatous polyposis

PURPOSE: Rectum-preserving surgery is one of the most common surgeries for familial adenomatous polyposis (FAP). It is appropriate to analyze factors influencing risk of rectal cancer after rectum-preserving surgery in FAP patients. METHODS: Three hundred twenty-two patients with FAP (169 males, 153 females) who had undergone rectum-preserving surgery and were part of 1050 FAP patients registered at our FAP registry were included in the study. Postoperative survival was investigated and cause of death was elucidated from the death certificate or by inquiry to the hospitals that registered the patients. For risk analysis, log-rank tests were used. RESULTS: Forty-four cases developed invasive cancer within a mean interval of 119 months after surgery. Cumulative risk of rectal cancer was 24.2±7 percent (mean±limit of 95 percent confidence interval) at 15 years. Influencing risk factors for rectal cancer were a postoperative period over ten years or age over 44 years, a rectum longer than 7 cm, and dense polyposis. Other factors such as sex and cancer in the colon at initial surgery were not correlated with risk. CONCLUSION: The rectum may be reasonably preserved in patients with FAP when polyps in the rectum are sparse, ileorectal anastomosis is made on or below the peritoneal reflection, and patients continue having rectal examinations for life.     

Prognosis of chronic ulcerative colitis in a community.

Utilising the population based data resources of the Rochester Epidemiology Project, we estimated survival and risk of subsequent colon cancer in the 182 residents of Rochester, Minnesota, initially diagnosed with chronic ulcerative colitis (CUC) between 1985 and 1979. Twenty five (13.7%) had a proctocolectomy during the course of follow up. Three patients developed colorectal adenocarcinoma after the initial diagnosis of CUC (relative risk = 1.9, 95% CI 0.4-5.4). Excluding proctitis cases, the relative risk of cancer was 2.4 (95% CI 0.3-8.7). At last follow up, 37 (20.3%) were dead; only 10 patients had chronic ulcerative colitis mentioned on the death certificate. Overall survival was similar to that expected for the general population of like age and sex. Our results suggest that chronic ulcerative colitis in the community is typically a milder disease than would appear from hospital or referral centre series.