The concept of Tenju-gann, or "natural-end cancer"

The Impact of Aging on Symptom Prevalence and Management in Terminally ill Patients With Cancer

CONTEXT

With global population aging, the number of older patients with cancer is increasing. However, few data are available on palliative care for these patients.

OBJECTIVES

To evaluate differences in symptom prevalence and the need for medical interventions among patients of different ages in a palliative care unit.

METHODS

In this retrospective analysis, a consecutive sample of 1032 terminally ill patients with cancer were categorized into the following age ranges: <70, 70-79, 80-89, and ≥90 years. We evaluated symptom prevalence, the need for palliative medicines, opioid dose on the day before death, and the need for palliative sedation. Trend tests were used to examine whether the prevalence of findings increased or decreased with age.

RESULTS

As age increased, significant decreasing trends were observed in the prevalence of pain, dyspnea, fatigue, constipation, nausea, drowsiness, difficulty sleeping, anxiety, and dysuria but not in appetite loss, edema, sputum production, or delirium. As age increased, significant decreasing trends were also observed in the need for opioids, benzodiazepines, antiemetics, and anticholinergics. The median opioid doses in the <70, 70-79, 80-89, and ≥90 years age groups were 118, 72, 48, and 48 mg oral morphine equivalents/day, respectively (P < 0.0001). The need for palliative sedation showed a significant decreasing trend as age increased (P < 0.0001).

CONCLUSION

We found age to be inversely related to symptom prevalence and medical interventions among terminally ill patients with cancer, contributing to the understanding of the experience of older patients with cancer.

Outcomes of colorectal cancer surgery in nonagenarian patients: a multicenter retrospective study

Background

The use of surgery in patients with colorectal cancer (CRC) aged ≥90 years remains controversial. This study aimed to evaluate the short-term postoperative and long-term oncologic outcomes of CRC surgery in patients within this age group.

Methods

A total of 151 consecutive nonagenarian patients who underwent CRC surgery were included from 3 different hospitals. The Comprehensive Complication Index (CCI) was used to grade postoperative complications. Univariate and multivariate analyses were conducted to identify factors associated with CCI and overall survival (OS).

Results

The patients had a mean age of 92.8 years (standard deviation ±1.9 years). Forty-six patients (30.5%) underwent emergency surgery, and 105 patients (69.5%) underwent elective surgery. The postoperative complications rate was 66.2% (100/151), and the mean CCI was 26.3 (±30.8). Twenty-three patients (15.2%) died postoperatively, and the perioperative mortality rates for elective surgery and emergency surgery were 7.6% (8/105) and 32.6% (15/46), respectively (P<0.001). The 1-, 3-, and 5-year survival rates were 77.5%, 53.9%, and 38.6%, respectively. Multivariate analysis revealed emergency surgery and American Society of Anesthesiologists (ASA) score to be predictors of postoperative complications. Advanced tumor stage, palliative surgery, ASA score ≥4, and CCI >17 were associated with poor OS.

Conclusions

CRC surgery should not be denied to nonagenarian patients. Surgical treatment can be performed with acceptable morbidity and mortality, and achieves long-term survival in a select group.

Prognostic significance of skeletal muscle decrease in unresectable pancreatic cancer: Survival analysis using the Weibull exponential distribution model

BACKGROUND/OBJECTIVES

Decrease in skeletal muscle mass and function is associated with a poor prognosis following surgical resection of pancreatic ductal adenocarcinomas (PDAs). This study evaluated whether skeletal muscle mass decrease affects PDA outcomes.

METHODS

Data of 112 patients with advanced and unresectable PDA who underwent chemotherapy in a single institution were retrospectively analyzed. Information on age, sex, hematological investigations, including systemic inflammation-based markers and nutritional assessment biomarkers, and imaging parameters of skeletal muscle mass and visceral adipose tissue were retrieved from the patients' medical records. The efficiency of the Cox, Weibull, and standardized exponential models were compared using hazard ratios and the Akaike Information Criterion (AIC).

RESULTS

Results from the Weibull, Cox, and standardized exponential model analyses indicated that low skeletal muscle mass, Eastern Cooperative Oncology Group performance status (PS), and the requirement of biliary drainage were associated with the highest risk of death, followed by carcinoembryonic antigen (CEA) levels and the presence of ascites. The AIC value from the four significant parameters was lowest for the Weibull-exponential distribution (222.3) than that of the Cox (653.7) and standardized exponential models (265.7). We developed a model for estimating the 1-year survival probability using the Weibull-exponential distribution.

CONCLUSIONS

Low-skeletal muscle index, PS, requirement of biliary drainage, CEA levels, and presence of ascites are independent factors for predicting poor patient survival after chemotherapy. Improved survival modeling using a parametric approach may accurately predict the outcome of patients with advanced-stage PDA.

Colorectal cancer surgery in selected nonagenarians is relatively safe and it is associated with a good long-term survival: an observational study

Background

Advanced age is a risk factor for colorectal cancer, and very elderly patients often need to be surgically treated. This study aimed to analyze the outcomes of a cohort of nonagenarian patients operated on for colorectal cancer.

Methods

Observational study conducted on a cohort of 40 nonagenarian patients, who were treated surgically for colorectal cancer between 2000 and 2018 in our institution. Clinical data, ASA score, Charlson Comorbidity Index, Surgical Mortality Probability Model, tumor characteristics, and nature and technical features of the surgical procedure, were recorded. The Comprehensive Complication Index (CCI) and survival time after the procedure were recorded as outcome variables. Univariate and multivariate analyses were performed in order to define risk factors for postoperative complications and long-term survival.

Results

Out of the 40 patients, 13 (32.5%) were men, 27 (67.5%) women, and mean age 91.6 years (SD ± 1.5). In 24 patients (60%), surgery was elective, and in 16 patients (40%), surgery was emergent. Curative surgery with intestinal resection was performed in 34 patients (85%). In 22 patients (55%), intestinal continuity was restored by performing an anastomosis. The median CCI was 22.6 (IRQ 0.0–42.6). Operative mortality was 10% (4 patients). Cumulative survival at 1, 3, and 5 years was 70%, 47%, and 29%, respectively. In multivariate analysis, only the need for transfusion remained as an independent prognostic factor for complications (p = 0.021) and TNM tumor stage as a significant predictor of survival (HR 3.0, CI95% 1.3–7.2).

Conclusions

Colorectal cancer surgery is relatively safe in selected nonagenarian patients and may achieve long-term survival.

Should Surgical Treatment Be Provided to Patients with Colorectal Cancer Who Are Aged 90 Years or Older?

PURPOSE

The number of patients aged ≥ 90 years is increasing worldwide; however, the treatment guidelines for colorectal cancer in elderly patients remain unclear. This study aimed to investigate the clinical outcomes of patients with primary colorectal cancer aged ≥ 90 years.

METHODS

We retrospectively reviewed the medical records of 100 patients (aged ≥ 90 years) with primary colorectal adenocarcinoma. Their demographic and clinical characteristics and surgical outcomes were assessed.

RESULTS

The patients who underwent tumor resections (n = 71) showed longer overall and cancer-specific survival than those who underwent non-operative treatments (n = 29) (median overall survival time: 23.92 months vs. 2.99 months, P < 0.0001). Age, body mass index, performance status, advanced cancer stage (stages 3 and 4), and treatment strategy were identified as risk factors, prognostic factors, and predictors of overall survival. No significant differences in the postoperative morbidity rate, in-hospital mortality rate, and survival time were found between the elective laparoscopic (n = 27) and elective open (n = 37) surgery subgroups. However, the in-hospital mortality rate was 6.25% (4/64) in the patients who underwent elective open surgeries and 42.9% (3/7) in those who underwent emergent open surgeries (p = 0.0179).

CONCLUSIONS

In clinical practice, surgical treatment should not be denied to patients with primary colorectal cancer aged ≥ 90 years. However, the high complication and mortality rates for emergency surgeries act as a deterrent. Further studies to eliminate the bias between operative and non-operative groups may be needed to validate our results.

Dietary terpenoids and prostate cancer chemoprevention

Cancer chemoprevention by phytochemicals may be one of the most feasible approaches for cancer control. Phytochemicals obtained from vegetables, fruits, spices, teas, herbs and medicinal plants, such as terpenoids and other phenolic compounds, have been proven to suppress experimental carcinogenesis in various organs in pre-clinical models. Recent studies have indicated that mechanisms underlying chemopreventive potential may be a combination of antioxidant, anti-inflammatory, immune-enhancing, and hormone modulation effects, with modification of drug metabolizing enzymes, influence on cell cycle and cell differentiation, induction of apoptosis, suppression of proliferation and angiogenesis playing roles in the initiation and secondary modification stages of neoplastic development. Specific features of prostate cancer, such as high prevalence and long latency period provides ample opportunities for chemopreventive agents to work at various stages of disease progression. Finally, suitable populations with appropriate risk factors, including the presence of pre-malignant lesions and genetic predispositions, need to be well characterized for future chemopreventive interventions. Here we review naturally occurring dietary terpenoids as useful agents for prostate cancer chemoprevention with reference to their classes and sources.

Prevention of carcinogenesis and cancer metastasis by bovine lactoferrin

Increasing attention is being paid to chemopreventive agents for individuals at high risk of cancer. We have concentrated on bovine lactoferrin (bLF), an 80 kDa iron-binding glycoprotein known to have anti-microbial and immunoprotective effects. Lactoferrin is particularly abundant in colostrum, and is also present in tears, saliva and seminal and uterine secretions. However, only little is known regarding its influence on carcinogenesis. We have shown preventive effects of bLF and its fragment peptide, lactoferricin (bLFcin), consisting of a 25 amino acid sequence without iron binding capacity, on chemically-induced colon carcinogenesis in the rat and transplanted carcinoma cell metastasis in the mouse. The mechanisms are wide-spectrum, including elevation of caspase-1 and IL-18 in the small intestine, enhancement of the cell killing activity of cytotoxic T and natural killer (NK) cells, and anti-inflammatory and anti-angiogenic effects. It also inhibits the induction of liver CYP1A2, a carcinogen activating enzyme, and induces apoptosis in the colon epithelium of carcinogen treated rats. Thus, bLF possesses multi-functional potential to suppress carcinogenesis and is a good candidate for practical application in humans.

Cancer prevention by natural compounds

Increasing attention is being paid to the possibility of applying cancer chemopreventive agents for individuals at high risk of neoplastic development. For this purpose by natural compounds have practical advantages with regard to availability, suitability for oral application, regulatory approval and mechanisms of action. Candidate substances such as phytochemicals present in foods and their derivatives have been identified by a combination of epidemiological and experimental studies. Plant constituents include vitamin derivatives, phenolic and flavonoid agents, organic sulfur compounds, isothiocyanates, curcumins, fatty acids and d-limonene. Examples of compounds from animals are unsaturated fatty acids and lactoferrin. Recent studies have indicated that mechanisms underlying chemopreventive potential may be combinations of anti-oxidant, anti-inflammatory, immune-enhancing, and anti-hormone effects, with modification of drug-metabolizing enzymes, influence on the cell cycle and cell differentiation, induction of apoptosis and suppression of proliferation and angiogenesis playing roles in the initiation and secondary modification stages of neoplastic development. Accordingly, natural agents are advantageous for application to humans because of their combined mild mechanism. Here we review naturally occurring compounds useful for cancer chemprevention based on in vivo studies with reference to their structures, sources and mechanisms of action.

Chemopreventive effect of Lactobacillus rhamnosus on growth of a subcutaneously implanted bladder cancer cell line in the mouse

Lactic acid bacteria are known to have beneficial effects on the host, such as preventing carcinogenesis. The present study was designed to evaluate the chemopreventive effects of Lactobacillus rhamnosus strain GG (LGG) in suppressing bladder cancer formation in a murine subcutaneous model of bladder cancer involving the inoculation of MB49 cells in C57B / L6 mice. After tumor implantation, one group of mice (n = 8) was fed LGG immediately. The remaining mice that had tumors between 0.03 - 0.1 cm(3) were divided into two groups: those fed LGG after 7 days (n = 7) and those fed saline (n = 7). A second group of mice without any inoculation of MB49 cells was fed either LGG (n = 10) or saline (n = 10) and served as non-tumor-bearing controls. LGG was administered orally at 1.6 x 10(8) colony-forming units daily. Mice fed LGG immediately after tumor cell implantation formed smaller tumors and some did not develop tumors (2 out of 8 mice), when the tumor burden was small. The level of spleen CD3, CD4 and CD8a T lymphocytes, as well as natural killer cells in mice fed immediately with LGG was also higher than that in control tumor-bearing mice. There was an increase in lymphocytes and granulocytes in tumor sections, especially from the immediately fed group as compared to the controls. Our results suggest that oral consumption of LGG may prevent tumor growth via modulation of the immune system. The potential of LGG as an adjunct therapy in the treatment of bladder cancer could be further explored.

Enhancement of natural killer cytotoxicity delayed murine carcinogenesis by a probiotic microorganism

Regulation of innate immunity may be an effective means of cancer control. Delaying cancer onset is regarded as an important mode of action in cancer prevention. We have been investigating the chemopreventive mechanisms of Lactobacillus casei Shirota (LcS), a probiotic strain. In this study, we evaluated the effect of LcS on tumor onset and the involvement of natural killer (NK) cells using a 3-methylcholanthrene-induced carcinogenesis model. C3H/HeN mice were divided into three groups, according to treatment: vehicle-treated, treated with vehicle only; control, 3-methylcholanthrene treated; LcS, 3-methylcholanthrene and LcS treated. 3-Methylcholanthrene was injected intradermally at 7 weeks of age. LcS was mixed into the diet (0.05%, w/w), which the mice were fed from the day of 3-methylcholanthrene injection onward. Tumor incidence was observed weekly. Profiles of splenic NK cells, in vitro cytotoxicity and the proportion, in the early stage of carcinogenesis were analyzed at 5 weeks after the injection. The tumor suppressive effect of LcS was also evaluated in a beige mouse model that is genetically deficient in NK cells. LcS delayed tumor onset and reduced tumor incidence in the results with C3H/HeN mice (P< 0.05). More specifically, tumor incidence in the control group was 33% at 6 weeks after the injection and 83% at 11 weeks as opposed to 0 and 42%, respectively, in the LcS group. NK cell cytotoxicity was significantly higher than in the control group, and the number of NK cells also increased in the LcS group of C3H/HeN mice. However, LcS failed to suppress tumorigenesis in the beige mouse. These findings suggest that enhancement of the cytotoxicity of NK cells by LcS delays tumor onset.

Nutrition and dietary carcinogens

Three major factors for human carcinogenesis are (i) cigarette smoking, (ii) infection and inflammation and (iii) nutrition and dietary factors. Nutrition and dietary factors include two categories, namely genotoxic agents and constituents including tumor promotion-associated phenomena. This article first describes the genotoxic agents as microcomponents. These are mutagens/carcinogens in cooked food, fungal products, plant and mushroom substance, and nitrite-related materials, polycyclic aromatic hydrocarbons and oxidative agents. Emphasis has been given to heterocyclic amines (HCAs) to which humans are continuously exposed in an ordinary lifestyle. HCAs in food are mainly produced from creatin(in)e, sugar and from amino acids in meat (upon heating). They are imidazoquinoline and imidazoquinoxaline derivatives and phenylimidazopyridine. HCAs are pluripotent in producing cancers in various organs including breast, colon and prostate. Discussion is also given to plant flavonoids which are mutagenic but not carcinogenic. As a macrocomponent, overintake of total calories, fat and sodium chloride is discussed from the viewpoint of the increase of genetic alterations in tissues and of tumor promotion-associated issues. Studies of nutrition and dietary condition will eventually lead us to cancer prevention, namely delay of onset of cancer to the late phase of human life, which is called 'natural-end cancer' (Tenju-gann).