Changing trends in the management of colorectal cancers and its impact on cancer waiting times

OBJECTIVE: The aim of this study was to compare the differences in the presentation, management and waiting times for new colorectal cancer (CRC) patients over 5 years in a single metropolitan cancer centre. METHODS: A retrospective comparative study of new patients with CRC presenting in the years 1998 and 2003. The groups were compared for referral type, Dukes' stage, site, cancer waiting times and primary treatment. RESULTS: There were 72 new patients in 1998 and 77 in 2003. In 1998 33% were seen urgently and 28% as emergencies whereas in 2003 55% of patients were seen as urgent or target wait patients and 16% as emergencies. The 2-week target for urgent referrals was met in 50% of cases in 1998 and 90% in 2003. In 2003 a higher proportion of patients received adjuvant or neoadjuvant treatment. Stage at diagnosis was similar in both groups, except stage 'D' which was 21% in 1998 and only 12% in 2003. The 31-day Cancer Waiting Time (CWT) target from decision to treat to first treatment would have been met in 81% of cases in 1998 and 79% in 2003. The 62-day overall CWT target from referral to first treatment for urgent GP referrals would have been met in 46% of cases in 1998 and 57% in 2003. CONCLUSION: More CRC patients were referred urgently in 2003. Most, but not all of these were referred as target waits. The time taken for the patient's journey did not improve between the two cohorts, possibly in part, because more complex treatments are now provided. Further work and perhaps new thinking are needed in order to achieve Cancer Waiting Time targets.     

Not an equal opportunity disease - a sex and gender-based review of colorectal cancer in men and women: Part I

This paper reviews the literature on colorectal cancer from a sex and gender-based perspective. Colorectal cancer is a major cause of death in the developed world, with rates increasing in developing countries. Although described by some writers as an ‘equal opportunity’ disease, it presents more risk to men than women. Both biological, or sex-linked factors, and gender-linked factors play a part in the aetiology of the disease, while gender differences in the use of screening and treatment also help shape the mortality gap between women and men for this condition. Without an appreciation of the part played by sex and gender in the risk of colorectal cancer, and without a gender-sensitive approach to screening in particular, it is possible that the mortality gap between men and women for this condition will widen in the future.     

Not an equal opportunity disease – a sex and gender-based review of colorectal cancer in men and women: Part II

This paper reviews the literature on colorectal cancer from a sex and gender-based perspective. Colorectal cancer is a major cause of death in the developed world, with rates increasing in developing countries. Although described by some writers as an ‘equal opportunity’ disease, it presents more risk to men than women. Both biological, or sex-linked factors, and gender-linked factors play a part in the aetiology of the disease, while gender differences in the use of screening and treatment also help shape the mortality gap between women and men for this condition. Without an appreciation of the part played by sex and gender in the risk of colorectal cancer, and without a gender-sensitive approach to screening in particular, it is possible that the mortality gap between men and women for this condition will widen in the future.     

The potential use of extended criteria donors and eligible recipients in liver transplantation for unresectable colorectal liver metastases in Central Sweden

BackgroundUnresectable colorectal liver metastases (CRLM) is a condition with poor prognosis. A recent treatment alternative improving survival in patients with unresectable CRLM, has emerged with the introduction of liver transplantation (LT), yet not uncontroversial with the current organ shortage. This study aimed to retrospectively investigate the potential of declined donors with acceptable risk as liver graft donors and patients with unresectable CRLM as potential recipients.MethodsAll declined donors in central Sweden and all patients with CRLM discussed at multidisciplinary team conference at Karolinska University Hospital, January 2013–October 2018, were identified. Donors were classified according to the European Committee Guide to the quality and safety of organs for transplantation and potential recipients were evaluated by selection criteria, based on studies on the Norwegian Secondary Cancer study database.ResultsOut of 1,462 evaluated potential donors, 62 (2.7 pmp) donors were identified, corresponding to 6–18% of the utilized donor pool. Out of 1,008 included patients with CRLM, 25 (2.1 pmp) potential recipients were recognized. Eligibility for LT and left-sided colon cancer were favorable prognostic factors.ConclusionsToday’s donor pool could increase with the use of extended criteria donors, which is sufficient and display an acceptable risk-benefit ratio for patients with unresectable CRLM. With current selection criteria a small subset of patients with unresectable CRLM are eligible recipients. This subset of patients has a better survival compared to patients ineligible for LT.     

Biopsychosocial predictors of sexual function and quality of sexual life: a study among patients with colorectal cancer

Objective

A low sexual function (SF) has been reported in patients with colorectal cancer. However, research often focusses on clinical predictors of SF, hereby omitting patients’ subjective evaluation of SF [i.e., the quality of sexual life (QoSL)] and psychosocial predictors of SF and QoSL. In addition, research incorporating a biopsychosocial approach to SF and QoSL is scarce. Therefore, this study aimed to evaluate (I) relatedness between SF and the QoSL, (II) the course of SF and QoSL, and (III) biopsychosocial predictors of SF and QoSL.

Methods

Patients completed questionnaires assessing sociodemographic factors (i.e., age, sex) and personality characteristics (i.e., neuroticism, trait anxiety) before surgery. Questionnaires assessing psychological (i.e., anxious and depressive symptoms, body image, fatigue) and social (i.e., sexual activity, SF, non-sensuality, avoidance of sexual activity, non-communication, relationship function) aspects were measured preoperative and 3, 6, and 12 months after surgery. Clinical characteristics were obtained from the Eindhoven Cancer Registry (ECR). Bivariate correlations evaluated relatedness between SF and QoSL. Linear mixed-effects models examined biopsychosocial predictors of SF and QoSL.

Results

SF and QoSL are related constructs (r=0.206 to 0.642). Compared to preoperative scores, SF did not change over time (P>0.05). Overall, patients’ QoSL decreased postoperatively (P=0.001). A higher age (β=−0.02, P=0.006), fatigue (β=−0.02, P=0.034), not being sexually active (β=−0.081, P<0.001), and having a stoma (β=0.37, P=0.035) contributed to a lower SF. Having rectal cancer (β=−1.64, P=0.003), depressive symptoms (β=−0.09, P=0.001), lower SF (β=1.05, P<0.001), and more relationship maladjustment (β=−0.05, P=0.027) contributed to a lower QoSL (P<0.05). In addition, partners’ SF (β=0.24, P<0.001) and QoSL (β=0.30, P<0.001) were predictive for patients’ SF and QoSL, respectively. A significant interaction between time and gender was reported for both outcomes (P’s=0.002).

Conclusions

SF and QoSL are related but distinctive constructs. The course of SF and QoSL differed. Different biopsychosocial predictors were found for SF and QoSL. The contribution of partner-related variables to patients’ outcomes suggests interdependence between patients and partners. Men and women showed different SF and QoSL trajectories. We recommend that health care professionals, when discussing sexuality, realize that SF and QoSL are no interchangeable terms and should, therefore, be discussed as two separate entities. In addition, it is favored that clinicians focus not only on biological predictors of SF and QoSL, but obtain a broader perspective in which they also pay attention to psychosocial factors that may impair SF and QoSL. More in depth research on interdependence between patients and partners, biopsychosocial predictors of partners’ SF and QoSL, and gender effects is needed.     

中国部分市县前列腺癌发病趋势比较研究

目的 探讨中国大陆前列腺癌发病的流行病学特征.方法收集整理中国大陆30个肿瘤登记处1988-2002年15年间前列腺癌发病登记的数据资料,选取数据较为齐全的北京、天津、上海、武汉、哈尔滨、河北磁县、江苏肩东、浙江嘉善、广西扶绥、福建长乐、河南林州11个登记处的资料,按5年1个时段分为1988-1992、1993-1997、1998-2002年3个时间段,比较分析前列腺癌发病率、病死率,采用美国癌症研究所开发的统计软件Joinpoint Regression Program 3.3.1分析其流行趋势.通过对发病率的对数转换线性回归分析计算年度变化百分比.结果 30个登记处1988-1992、1993-1997、1998-2002年前列腺癌的发病率分别为1.96/10万、3.09/10万、4.36/10万,发病率有明显上升趋势.但与美国、加拿大、欧洲部分国家和地区比仍处于较低水平.结论 我国前列腺癌发病率呈现逐年上升趋势,将成为影响我国居民健康的主要恶性肿瘤之一,需引起重视.     

High incidence of clinically significant concomitant prostate cancer in patients undergoing radical cystectomy for bladder cancer: A 10-year single-center experience

Aim

To analyze prostate cancer (PCa) incidence, clinical significance, and recurrence in 213 patients who underwent radical cystectomy (RC) for advanced bladder cancer (BC).

Reported symptoms, diagnostic delay and stage of colorectal cancer: a population-based study in Denmark

OBJECTIVE: The primary prognostic factor for colorectal cancer (CRC) is stage. Any association between symptoms, diagnostic delay and stage may have implications for the clinical course of the disease. We examined the association between symptoms and diagnostic delay and between symptoms and stage, and assessed whether the associations differed for colon cancer (CC) and rectal cancer (RC). PATIENTS AND METHODS: Population-based prospective observational study based on 733 Danish CRC patients. Diagnostic delay and patients' reported symptoms were determined through questionnaire-interviews. Dukes' stage was obtained from medical records and pathology forms. Diagnostic delay was categorized into three delay groups: < or = 60, 61-150 and > 150 days. Stage was classified into nonadvanced (Dukes' A and B) or advanced (Dukes' C and D) cancers. We calculated the frequency of the most frequently reported initial symptom or symptom complex for CC and RC patients, and evaluated the frequency of patients with different initial symptoms/symptom complexes in the three delay groups. For the most frequent initial symptoms/symptom complexes, we calculated the frequencies according to stage, and estimated the relative risk of having an advanced stage, with 95% confidence intervals. RESULTS: The most frequent initial symptoms/symptom complexes were very vague symptoms for CC and rectal bleeding for RC. For both CC and RC, rectal bleeding was significantly associated with nonadvanced stage. The relative risk of having an advanced cancer was 0.6 for monosymptomatic rectal bleeding and 0.7 for rectal bleeding combined with other symptoms. CONCLUSIONS: Initial symptoms of CC were often very vague, making it difficult to identify a precise start date. The most frequent initial symptom/symptom complex for RC - rectal bleeding - was better defined. Rectal bleeding was significantly associated with nonadvanced CC and RC and a significantly decreased relative risk of having an advanced cancer.     

Natural orifice specimen extraction in laparoscopic colorectal cancer surgery: A case series study

IntroductionIn recent years, natural orifice specimen extraction (NOSE) has been attracting attention as a further minimally invasive operation for colorectal cancer, and not only improvement of appearance, but also reduction of pain and wound-related complications due to abdominal wall destruction has been reported. However, NOSE is technically complicated and difficult, and it has not yet been widely used. The aim of this study was to confirm the feasibility, safety, and short-term outcomes of total laparoscopic colon cancer surgery with NOSE.Case presentationFrom May 2018 to October 2019, eight patients with stage 0 or I colon cancer underwent NOSE surgery in our hospital. Transanal specimen extraction was performed in six cases, and transvaginal specimen extraction was performed in two cases. All operations were successfully accomplished without conversion to open surgery. The anastomosis method was double stapling technique in three cases and overlap method in five cases. The median operative time was 224 min. The median blood loss was 10 mL. The median time to first flatus was 1 day, and the median time to first stool was 2 days. The median postoperative observation period was 18 months, but there was no recurrence. There were no postoperative complications in these cases.ConclusionTotal laparoscopic colon cancer surgery with NOSE appears to be feasible, safe, and show promising efficacy for selected patients.     

Exfoliated colonocyte DNA levels and clinical features in the diagnosis of colorectal cancer: a cohort study in patients referred for investigation

Aim Selection of patients for investigation of suspected colorectal cancer is difficult. One possible improvement may be to measure DNA isolated from exfoliated cells collected from the rectum. Method This was a cohort study in a surgical clinic. Participants were aged ≥40 years and referred for investigation of suspected colorectal cancer. Exclusion criteria were inflammatory bowel disease, previous gastrointestinal malignancy, or recent investigation. A sample of the mucocellular layer of the rectum was taken with an adapted proctoscope (the Colonix system). Haemoglobin, mean cell volume, ferritin, carcino‐embryonic antigen and faecal occult bloods were tested. Analysis was by logistic regression. Results Participation was offered to 828 patients, of whom 717 completed the investigations. Three were lost to follow up. Seventy‐two (10%) had colorectal cancer. Exfoliated cell DNA was higher (P < 0.001) in cancer (median 5.4 μg/ml [inter‐quartile range 1.8,12]) compared with those without cancer (2.0 μg/ml [IQR 0.78,5.5]). Seven variables were independently associated with cancer, including age (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.02,1.08; P < 0.001) DNA (OR, 1.05; CI, 1.01,3.6; P = 0.01), mean cell volume (OR, 0.93; CI, 0.89,0.97; P = 0.001), carcino‐embryonic antigen 1.02 per μg/l (CI, 1.00,1.04; P = 0.02), male sex (OR, 2.0; CI, 1.1,3.6; P = 0.02), rectal bleeding (OR, 2.4; CI, 1.3,4.5; P = 0.007) and positive faecal occult blood (OR, 6.7; CI, 3.4, 13; P < 0.001). The area under the receiver‐operating characteristic curve for the DNA score was 0.65 (0.58–0.72) and for the seven variable model 0.88 (CI, 0.84–0.92). Conclusion Quantification of exfoliated DNA from rectal cellular material has promise in the diagnosis of colorectal cancer, but this requires confirmation in a larger study.     

A qualitative study of patient perspectives of health‐related quality of life in colorectal cancer: comparison with disease‐specific evaluation tools

Aim Little is known about the factors that patients with colorectal cancer (CRC) consider as important in shaping their health‐related quality of life (HrQoL) and whether these are adequately represented by currently used HrQoL instruments. The aim of this study was to determine which areas of HrQoL are important to patients with CRC and to establish whether these areas are represented by validated questionnaires. Method Semi‐structured interviews were conducted with 20 patients who were undergoing treatment or follow up for potentially curable CRC. The areas of HrQoL that were important to the patients were identified from the interview data using a qualitative thematic framework analysis. These themes were then compared with the item content of two CRC‐specific HrQoL questionnaires, FACT‐C and QLQ‐C30/CR38. Results The interviews identified 10 themes considered by patients to be important determinants of their HrQoL. These comprised control, normality, fatigue, uncertainty, information, emotional support, self‐image, coping, symptoms and emotionally challenging events. Both HrQoL instruments contained questions that concerned some of the themes identified, but none of the FACT‐C scales and only three from QLQ‐C30/CR38 produced scores from which clinicians could identify problems in these areas. Conclusion Identifying and addressing areas of concern for patients may assist clinicians in improving HrQoL outcomes. However, validated instruments currently used in CRC provide little information with regard to these areas.     

Differences in clinicopathological characteristics of colorectal cancer between younger and elderly patients: an analysis of 322 patients from a single institution

Background

The prognosis of patients with colorectal cancer (CRC) of different onset ages is controversial.

Methods

Data were obtained from a prospective database at Taipei Veterans General Hospital. There were 2,738 newly diagnosed patients with CRC from 2001 to 2006. Two extreme age groups, younger (≤40 years) and elderly (≥80 years), were analyzed to compare clinicopathologic characteristics and prognosis after exclusion of specific cancer syndrome.

Results

A total of 322 patients were enrolled in this prospective study. The younger group consisted of 69 patients with mean age of 33.5 years, and the elderly group consisted of 253 patients with mean age of 83.4 years. Younger patients had a higher incidence of mucinous cell type (14.5% vs 6.3%, P = .05), poorly differentiated adenocarcinoma (26.1% vs 6.3%, P < .001), more advanced disease (82.6% vs 41.9%, P < .001), poorer disease-free survival (67.2% vs 79.3%, P = .048), and cancer-specific survival (44.1% vs 73.1%, P < .001) than elderly patients.

Conclusions

In patients with CRC of younger onset, without relevant predisposing risk factors, younger patients have more advanced stages of disease, more aggressive histopathologic characteristics, and poorer prognoses compared with older patients.     

A novel mHealth App (RyPros) for prostate cancer management: an accessibility and acceptability study

BackgroundOver the past decade, there has been a significant increase in research on the use of mobile health (mHealth) apps as disease management tools. However, very few apps are currently available for prostate cancer (PCa) patient management, and the available apps do not combine the needs of physicians with the requirements of patients. This study aimed to describe the development of a mHealth application for PCa survivors called RyPros, which includes dynamic visualization, intelligent reminders, and instant messaging to support decision-making regarding treatment and follow-up and test the initial accessibility and acceptability application.MethodsThe application was developed through a three-step procedure: logical structure design, application programming, and testing. Dynamic visualization, intelligent reminders, and instant messaging were the core functions of RyPros. Twenty-eight participants who had PCa were enrolled in four weeks of follow-up using the RyPros App. We initially evaluated participants’ acceptance of RyPros based on their use of the app (login data, questionnaire completion) and a satisfaction survey.ResultsWe successfully designed and tested the application. A total of 32 participants were enrolled, of whom 28 completed the 4-week follow-up, yielding a participation rate of 87.5%. Each participant logged on an average of 2.82 times and achieved an average of 0.89 questionnaires per week over the four weeks. Most participants (64%) liked the app, and most participants (71%) were satisfied, giving the RyPros app a rating of 4 or 5. More than half of the participants (61%) intended to use the RyPros app regularly, and the majority of participants agreed that the three core functionalities of RyPros were helpful (20/28, 71% for instant messaging; 16/28, 57% for visualization; and 18/28, 64% for reminders and assessments).ConclusionsThe mHealth application we developed for PCa survivor management provided dynamic visualization, reminders, assessments, and instant messaging to support decision-making based on multidisciplinary collaboration. PCa survivors showed high acceptance of the RyPros app.     

结直肠癌淋巴结微转移病灶中CK20检测方法的比较

目的 比较免疫组织化学和逆转录-聚合酶链反应(RT-PCR)方法对结直肠癌淋巴结微转移病灶中CK20的检测价值.方法 对40例结直肠癌患者共326例经HE染色证实无转移的淋巴结,使用RT-PCR技术检测CK20 mRNA,并与免疫组织化学染色检测方法进行比较,以寻找更为敏感的淋巴结微转移检测方法.结果 免疫组织化学法和RT-PCR分别发现41枚和105枚微转移淋巴结,两种方法发现的微转移阳性率分别为12.8%和32.2%,两者差异有统计学意义(P<0.05).结论 RT-PCR法是比免疫组织化学染色法更为敏感的检测结直肠癌淋巴结微转移的方法.     

Blood transfusions in colorectal cancer surgery: incidence,outcomes, and predictive factors: an American College of Surgeons National Surgical Quality Improvement Program analysis

Background

Data analyzing the short-term outcomes and predictors of blood transfusions (BTs) in colorectal cancer (CRC) surgery are limited.

Methods

The American College of Surgeons National Surgical Quality Improvement Program (2005 to 2010) was retrospectively reviewed for CRC cases performed with or without BT. Patient demographics, comorbidities, and operative variables were analyzed. Multivariate regression analysis was performed examining the effect of BT on outcomes. The LASSO algorithm for logistic regression was used to build a predictive model for BT taking into account preoperative and operative variables.

Results

A total of 27,120 patients underwent CRC, and 3,815 (14.07%) had BTs. Transfusions were associated with increased mortality (odds ratio [OR], 1.78), morbidity (OR, 2.38), length of stay (mean difference, 3.52 days), pneumonia (OR, 2.70), and surgical-site infection (OR, 1.45). This effect was “dose dependent,” as patients receiving ≥3 U of blood had increased morbidity (OR, 1.53), lengths of stay (mean difference, 1.82 days), pneumonia (OR, 2.52), and surgical-site infections (OR, 1.60) compared with those receiving 1 to 2 U. Predictors of BT were hematocrit <38%, open surgery, proctectomy, low platelet count, American Society of Anesthesiologists class IV or V, total colectomy, metastatic cancer, emergency, ascites, and infection. All P values were < .05.

Conclusions

BTs are associated with worse short-term outcomes after CRC surgery. Knowledge of predictive factors will help in risk stratification and counseling.     

Systematic follow-up after curative surgery for colorectal cancer in Norway: A population-based audit of effectiveness,costs, and compliance

In this study, we analyzed the Norwegian guidelines for systematic follow-up after curative colorectal cancer surgery in a large single institution. Three hundred fourteen consecutive unselected patients undergoing curative surgery for colorectal cancer between 1996 and 1999 were studied with regard to asymptomatic curable recurrence, compliance with the program, and cost. Follow-up included carcinoembryonic antigen (CEA) interval measurements, colonoscopy, ultrasonography of the liver, and radiography of the chest. In 194 (62%) of the patients, follow-up was conducted according to the Norwegian guidelines. Twenty-one patients (11%) were operated on for curable recurrence, and 18 patients (9%) were disease free after curative surgery for recurrence at evaluation. Four metachronous tumors (2%) were found. CEA interval measurement had to be made most frequently (534 tests needed) to detect one asymptomatic curable recurrence. Follow-up program did not influence cancer-specific survival. Overall compliance with the surveillance program was 66%, being lowest for colonoscopy (55%) and highest for ultrasonography of the liver (85%). The total program cost was € 228,117 (US $ 280,994), translating into € 20,530 (US $ 25,289) for one surviving patient after surgery for recurrence. The total diagnosis yield with regard to disease-free survival after surgery for recurrence was 9%. Compliance was moderate. Whether the continuing implementation of such program and cost are justified should be debated. Supported by the Centre for Clinical Research, Armauer Hansens House, Haukeland University Hospital, Bergen, Norway.     

The incidence and trauma mechanisms of acetabular fractures: A nationwide study in Finland between 1997 and 2014

PurposeInformation on the incidence of acetabular fractures of the pelvis is limited. Epidemiological data is often based on specific trauma registers, individual trauma centres or on trends of all pelvic fractures grouped together. The primary aim of this study was to determine the incidence and trends of hospital-treated acetabular fractures in the Finnish population from 1997 to 2014. The secondary aim was to assess the trauma mechanisms involved.MethodsThe Finnish National Hospital Discharge Register collects inpatient data from all public and private medical institutions in Finland and covers the entire Finnish population of 5.5 million. For this study, we selected all persons 18 years of age or older who were admitted to hospital for the treatment of an acetabular fracture between 1997 and 2014. The main outcome variable was the annual number of patients hospitalised with a main or secondary diagnosis of acetabular fracture of the pelvis.ResultsThe overall crude incidence of acetabular fractures increased slightly (from 6.4/100 000 persons/year to 8.1/100 000 persons/year) from 1997 to 2014 while the age-standardised incidence rate remained at a similar level (7.1/100 000/persons/year in 1997 and 7.2/100 000/persons/year in 2014). An incidence increase was observed in the elderly population, whereas the incidence of acetabular fractures in the younger population (mostly high energy traumas) remained stable. The most frequent trauma mechanism for acetabular fractures was fall on the same level (47%).ConclusionsThe incidence of acetabular fractures increased slightly in Finland between 1997 and 2014. This increase was observed especially in the elderly population and the ageing of the population largely explains the rise. The incidence of acetabular fractures in the younger population decreased. The most common trauma mechanism was falling on the same level.     

The timing of liver resection in patients with colorectal cancer and synchronous liver metastases: a population‐based study of current practice and survival

Aim

There is uncertainty regarding the optimal sequence of surgery for patients with colorectal cancer (CRC) and synchronous liver metastases. This study was designed to describe temporal trends and inter‐hospital variation in surgical strategy, and to compare long‐term survival in a propensity score‐matched analysis.

Method

The National Bowel Cancer Audit dataset was used to identify patients diagnosed with primary CRC between 1 January 2010 and 31 December 2015 who underwent CRC resection in the English National Health Service. Hospital Episode Statistics data were used to identify those with synchronous liver‐limited metastases who underwent liver resection. Survival outcomes of propensity score‐matched groups were compared.

Results

Of 1830 patients, 270 (14.8%) underwent a liver‐first approach, 259 (14.2%) a simultaneous approach and 1301 (71.1%) a bowel‐first approach. The proportion of patients undergoing either a liver‐first or simultaneous approach increased over the study period from 26.8% in 2010 to 35.6% in 2015 (P < 0.001). There was wide variation in surgical approach according to hospital trust of diagnosis. There was no evidence of a difference in 4‐year survival between the propensity score‐matched cohorts according to surgical strategy: bowel first vs simultaneous [hazard ratio (HR) 0.92 (95% CI: 0.80–1.06)] or bowel first vs liver first [HR 0.99 (95% CI: 0.82–1.19)].

Conclusion

There is evidence of wide variation in surgical strategy in dealing with CRC and synchronous liver metastases. In selected patients, the simultaneous and liver‐first strategies have comparable long‐term survival to the bowel‐first approach.