Absence of socioeconomic variation in survival from colorectal cancer in patients receiving surgical treatment in one health district: cohort study

OBJECTIVE: To examine whether there is an association between patient deprivation status and survival from colorectal cancer among patients receiving treatment of the same type and quality. PATIENTS AND METHODS: A survival study was conducted of all colorectal cancer patients diagnosed between 1991 and 1997 who received surgery either in the NHS district general hospital or the private hospital of one UK health district. The five-year survival rates, both all cause and colorectal cancer specific, were calculated for subgroups defined by patient age, gender, stage and deprivation status using Kaplan-Meier curves. Cox proportional hazards models were used to examine the influence of deprivation on five-year survival after adjusting for age, gender and stage. RESULTS: There were 603 consecutive colorectal patients during the study period. Five-year all-cause and colorectal cancer-specific survival rates were 41% and 53%, respectively. There was no association between deprivation status and stage at diagnosis (P = 0.308). Multivariable proportional hazards modelling (adjusting for gender, age and tumour stage) demonstrated no association between deprivation status and survival. CONCLUSION: In this single district study, no relationship between patient socioeconomic status and survival from colorectal cancer could be demonstrated. Consistency in the type and quality of treatment offered to patients by the same clinical teams may have been responsible for the equitable survival outcomes.     

Screen detection is a survival predictor independent of pathological grade in colorectal cancer. A prospective cohort study

IntroductionPatients with screened detected colorectal cancer (CRC) have a better survival than patients referred with symptoms. This may be because of cancers being identified in a younger population and at an earlier stage. In this study, we assess whether screened detected CRC has an improved outcome after controlling for key pathological and patient factors known to influence prognosis.MethodThis is a cohort study of all CRC patients diagnosed in NHS Grampian. Patients aged 51–75 years old between June 2007 and July 2017 were included. Data were obtained from a prospectively maintained regional pathology database and outcomes from ISD records. All-cause mortality rates at 1 and 5 years were examined. A Cox proportional hazards regression model was used to estimate the effect of screening status, age, gender, Duke stage, tumour location, extramural venous invasion (EMVI) status and lymph node ratio (LNR) on overall survival.ResultsOf 1618 CRC cases, 449 (27.8%) were screened and 1169 (72.2%) were symptomatic. Screened CRC patients had improved survival compared to non-screened CRC at 1 year (88.9% vs 83.9% p < 0.001) and 5-years (42.5% vs 36.2%; p < 0.001). On multivariable analysis of patients who had no neoadjuvant therapy (n = 1272), screening had better survival (HR 0.57; 95% CI 0.44–0.74; p < 0.001). EMVI (HR 2.22; CI 1.76 to 2.79; p < 0.001) and tumour location were found to affect outcome.ConclusionPatients referred through screening had improved survival compared with symptomatic patients. Further research could be targeted to determine if screened CRC cases are pathologically different to symptomatic cancers or if the screening cohort is inherently more healthy.     

Prediction of overall survival following colorectal cancer surgery in elderly patients

BACKGROUND With advanced age and chronic illness,the life expectancy of a patient with colorectal cancer(CRC) becomes less dependent on the malignant disease and more on their pre-morbid condition.Justifying major surgery for these elderly patients can be challenging.An accurate tool demonstrating post-operative survival probability would be useful for surgeons and their patients.AIM To integrate clinically significant prognostic factors relevant to elective colorectal surgery in the elderly into a validated pre-operative scoring system.METHODS In this retrospective cohort study,patients aged 70 and above who underwent surgery for CRC at Singapore General Hospital between 1 January 2005 and 31 December 2012 were identified from a prospectively maintained database.Patients with evidence of metastatic disease,and those who underwent emergency surgery or had surgery for benign colorectal conditions wereexcluded from the analysis.The primary outcome was overall 3-year overall survival(OS) following surgery.A multivariate model predicting survival was derived and validated against an equivalent external surgical cohort from Kyungpook National University Chilgok Hospital,South Korea.Statistical analyses were performed using Stata/MP Version 15.1.RESULTS A total of 1267 patients were identified for analysis.The median post-operative length of stay was 8 [interquartile range(IQR) 6-12] d and median follow-up duration was 47(IQR 19-75) mo.Median OS was 78(IQR 65-85) mo.Following multivariate analysis,the factors significant for predicting overall mortality were serum albumin 35 g/dL,serum carcinoembryonic antigen ≥ 20 μg/L,T stage 3 or 4,moderate tumor cell differentiation or worse,mucinous histology,rectal tumors,and pre-existing chronic obstructive lung disease.Advanced age alone was not found to be significant.The Korean cohort consisted of 910 patients.The Singapore cohort exhibited a poorer OS,likely due to a higher proportion of advanced cancers.Despite the clinicopathologic differences,there was successful validation of the model following recalibration.An interactive online calculator was designed to facilitate post-operative survival prediction,available at http://bit.ly/sgh_crc.The main limitation of the study was selection bias,as patients who had undergone surgery would have tended to be physiologically fitter.CONCLUSION This novel scoring system generates an individualized survival probability following colorectal resection and can assist in the decision-making process.Validation with an external population strengthens the generalizability of this model.     

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.     

Iron deficiency anaemia and delayed diagnosis of colorectal cancer: a retrospective cohort study

Aim The extent to which different referral pathways following a primary care diagnosis of iron deficiency anaemia (IDA) are associated with delay in diagnosis of colorectal cancer (CRC) was determined. Method Eligible patients aged 40 or more years, with IDA diagnosed in primary care, and a subsequent diagnosis of CRC, were studied retrospectively. Referral pathways were identified using the specialty of first recorded GP referral following IDA diagnosis. Differences in time to diagnosis of CRC were assessed by referral specialty. Differences in the proportion of cases referred before and after the re‐issue of the NICE urgent referral guidelines for suspected lower gastrointestinal (GI) cancer were also assessed. Results Of 628 882 eligible patients, 3.1% (n = 19 349) were diagnosed with IDA during the study period; 3.0% (n = 578) were subsequently diagnosed with CRC. Two hundred and fifty‐nine (44.8%) patients had no recorded referral or a referral unrelated to anaemia or the GI tract. Only 35% (n = 201) of patients were referred to a relevant specialty. Median time to CRC diagnosis ranged from 2.5 months (referral to a relevant surgical specialty) to 31.9 months (haematology). Time to diagnosis was longer in patients referred to a medical compared with a relevant surgical specialty (P = 0.024). There was no significant difference in time to CRC diagnosis before and after the NICE guidelines were re‐issued in 2005. Conclusion Significant differences exist between referral specialties in time to CRC diagnosis following a primary care diagnosis of IDA. Despite NICE referral recommendations, a significant proportion of patients are still not managed within recommended care pathways to CRC diagnosis.     

腹腔镜与开腹手术在结直肠癌治疗中的应用对比分析

目的比较腹腔镜与开腹结直肠癌切除术临床疗效,探讨腹腔镜结直肠癌切除术的临床价值。 方法选择2009年6月至2012年1月中山大学孙逸仙纪念医院胃肠外科收治的结直肠癌患者98例作为研究对象,其中52例接受腹腔镜手术,46例接受开腹手术,比较两组结直肠癌患者的手术时间、术中出血量、淋巴结清扫范围、术后腹腔（或盆腔）引流量、术中术后并发症、肛门恢复排气排便时间、术后住院时间等指标。 结果腹腔镜组与开腹组清扫淋巴结数目、术中出血量、术中术后并发症发生率差异均无统计学意义;手术时间、术后腹腔（或盆腔）引流量、术后肛门恢复排气排便时间、术后住院时间等方面差异有统计学意义（P<0.05）。 结论腹腔镜结直肠癌切除术是可行和安全有效的,与开腹手术对比有较多优点,适合在临床进一步推广应用。     

结直肠癌肝转移生存分析

目的分析结直肠癌肝转移病人的生存状况和相关影响因素。方法回顾性分析2000-2010年复旦大学附属中山医院收治的结直肠癌肝转移病人的临床资料、病理、治疗策略等情况,进行生存状况分析,并采用单因素和Cox比例风险回归模型等分析影响结直肠癌肝转移生存的相关因素。结果结直肠癌肝转移病人总体中位生存期22.0个月,5年存活率为16%,其中同时性肝转移为21.2个月和16%,异时性肝转移为30.1个月和23%,同时性肝转移组的存活率明显低于异时性肝转移组(P<0.01)。按治疗方式分组,手术组病人的中位生存期为49.8个月,5年存活率为37%,显著优于化疗组(22.2个月和0)、介入组(19.0个月和11%)、化疗+介入组(22.8个月和10%)、局部治疗组(28.5个月和0)。同时性肝转移、肠癌原发灶分化Ⅲ~Ⅳ级、肝转移灶≥4个、最大肝转移灶≥5cm和肝转移灶非手术处理是影响病人预后的独立危险因素。结论同时性肝转移病人生存期低于异时性肝转移。积极手术治疗可以改善病人存活率。扩大肝转移灶切除的适应证对病人存活率无显著影响。独立危险因素的评分体系可以评估病人的预后。     

The influence of a colorectal service on the outcome of patients with colorectal cancer

Objective To perform a prospective audit of outcomes and survival of all patients presenting to a colorectal service with colorectal cancer, and to compare these results with an historical control group. Patients and methods At a community based teaching hospital, a prospective audit of outcomes and survival of patients with colorectal cancer was compared with a historical control. The study included all patients referred to a colorectal service with colorectal cancer from 1996 to 2000 (5‐year period). The control group was a retrospective review of patients presenting to the same hospital with colorectal cancer from 1989 to 1994 (6‐year period). A Kaplan‐Meier survival analysis compared the overall survival (all‐cause mortality) between the two groups. Results When comparing the study periods 1989–95 (n = 477) to 1996–2000 (n = 323), there has been a significant reduction in postoperative stay (16.2 vs 8.0 days, P < 0.05), and a reduction in postoperative mortality (4.5%vs 2.7%, n.s.). There was a significant increase in the overall 2 years survival for patients with colorectal cancer (62% to 71%, P < 0.01). There was also a significant increase in the overall 2 years survival of patients with rectal cancer (66% to 74%, P < 0.01), patients with ACPS C colon cancers (64% to 83%, P < 0.05), and ACPS C rectal cancers (74% to 85%, P < 0.01). Conclusions There have been significant gains in the survival of patients presenting to a community based teaching hospital with colorectal cancer. These improvements have been most notable in patients with nodal metastases at the time of diagnosis.     

Long-term survival following radiofrequency ablation of colorectal liver metastases: A retrospective study

AIM: To retrospectively evaluate the long-term survivalof patients that received radiofrequency ablation(RFA) therapies of colorectal liver metastases. METHODS: In 2005 to 2008, RFA of 105 colorectal liver metastases(CRLM) were performed on 49 patients in our institution. The liver metastases were evaluated, both before and after ablation therapies, with contrast enhanced computerised tomography and contrast enhanced ultrasonography. Histological evidence of malignant liver metastases was obtained in the few instances where contrast enhanced ultrasonography gave equivocal results. Accesses to the CRLM were guided ultrasonically in all patients. The data obtained from records of these ablations were retrospectively analysed and survival data were compared with existing studies in the literature.RESULTS: 1-, 2-, 3-, 4- and 5-year survival rates, when no stringent selection criteria were applied, were 92%, 65%, 51%, 41% and 29% respectively. To explore the impact of the number and size of CRLM on patients' survival, an exclusion of 13 patients(26.5%) with number of CRLM ≥ 5 and tumour size ≥ 40 mm resulted in 1-, 2-, 3-, 4- and 5-year survival rates improving to 94%, 69%, 53%, 42% and 31% respectively. It is of note that 9 of 49 patients developed extra-hepatic metastases, not visible or seen on pretreatment scans, just after RFA treatment. These patients had poorer survival. The development of extra-hepatic metastases in nearly 20% of the patients included in our study can partly account for modestly lower survival rates as compared with earlier studies in the literature.CONCLUSION: Our study underscores the fact that optimum patients' selection before embarking on RFA treatment is vitally important to achieving a superior outcome.     

Trends in colorectal cancer survival in northern Denmark: 1985–2004

Objective The prognosis for colorectal cancer (CRC) is less favourable in Denmark than in neighbouring countries. To improve cancer treatment in Denmark, a National Cancer Plan was proposed in 2000. We conducted this population‐based study to monitor recent trends in CRC survival and mortality in four Danish counties. Method We used hospital discharge registry data for the period January 1985–March 2004 in the counties of north Jutland, Ringkjøbing, Viborg and Aarhus. We computed crude survival and used Cox proportional hazards regression analysis to compare mortality over time, adjusted for age and gender. A total of 19 515 CRC patients were identified and linked with the Central Office of Civil Registration to ascertain survival through January 2005. Results From 1985 to 2004, 1‐year and 5‐year survival improved both for patients with colon and rectal cancer. From 1995–1999 to 2000–2004, overall 1‐year survival of 65% for colon cancer did not improve, and some age groups experienced a decreasing 1‐year survival probability. For rectal cancer, overall 1‐year survival increased from 71% in 1995–1999 to 74% in 2000–2004. Using 1985–1989 as reference period, 30‐day mortality did not decrease after implementation of the National Cancer Plan in 2000, neither for patients with colon nor rectal cancer. However, 1‐year mortality for patients with rectal cancer did decline after its implementation. Conclusion Survival and mortality from colon and rectal cancer improved before the National Cancer Plan was proposed; after its implementation, however, improvement has been observed for rectal cancer only.     

Development and validation of a nomogram for predicting the overall survival of prostate cancer patients: a large population-based cohort study

BackgroundProstate cancer (PC) is the second most common malignant tumor, and its survival is of great concern. However, the assessment of survival risk in current studies is limited. This study is to develop and validate a nomogram for the prediction of survival in PC patients using data from the Surveillance, Epidemiology, and End Results (SEER) database.MethodsA total of 153,796 PC patients were included in this cohort study. Patients were divided into a training set (n=107,657) and a testing set (n=46,139). The 3-, 5- and 10-year survival of the PC patients were regarded as the outcomes. Predictors based on the demographic and pathological data for survival were identified by multivariate Cox regression analysis to develop the predictive nomogram. Internal and subgroup validations were performed to assess the predictive performance of the nomogram. The C-index, time-dependent receiver operating characteristic (ROC) curves, and corresponding areas under the ROC curves (AUCs) were used to estimate the predictive performance of the nomogram.ResultsAge at diagnosis, race, marital status, tumor node metastasis (TNM) stage, prostate specific antigen (PSA) status, Gleason score, and pathological stage were identified as significantly associated with the survival of PC patients (P<0.05). The C-index of the nomogram indicated a moderate predictive ability [training set: C-index =0.782, 95% confidence interval (CI): 0.779–0.785; testing set: C-index =0.782, 95% CI: 0.777–0.787]. The AUCs of this nomogram for the 3-, 5-, and 10-year survival were 0.757 (95% CI: 0.756–0.758), 0.741 (95% CI: 0.740–0.742), and 0.716 (95% CI: 0.715–0.717), respectively. The results of subgroup validation showed that all the AUCs for the nomogram at 3, 5, and 10 years were more than 0.70, regardless of marital status and race.ConclusionsWe developed a nomogram with the moderate predictive ability for the long-term survival (3-, 5-, and 10-year survival) of patients with PC.