Comparison of treatment and outcome information between a clinical trial and the National Cancer Data Repository

Sodium channel-inhibiting drugs and cancer-specific survival: a population-based study of electronic primary care data

OBJECTIVES

Antiepileptic and antiarrhythmic drugs inhibit voltage-gated sodium (Na+) channels (VGSCs), and preclinical studies show that these medications reduce tumour growth, invasion and metastasis. We investigated the association between VGSC inhibitor use and survival in patients with breast, bowel and prostate cancer.

DESIGN

Retrospective cohort study.

SETTING

Individual electronic primary healthcare records extracted from the Clinical Practice Research Datalink.

PARTICIPANTS

Records for 132 996 patients with a diagnosis of breast, bowel or prostate cancer.

OUTCOME MEASURES

Adjusted Cox proportional hazards regression was used to analyse cancer-specific survival associated with exposure to VGSC inhibitors. Exposure to non-VGSC-inhibiting antiepileptic medication and other non-VGSC blockers were also considered. Drug exposure was treated as a time-varying covariate to account for immortal time bias.

RESULTS

During 1 002 225 person-years of follow-up, there were 42 037 cancer-specific deaths. 53 724 (40.4%) patients with cancer had at least one prescription for a VGSC inhibitor of interest. Increased risk of cancer-specific mortality was associated with exposure to this group of drugs (HR 1.59, 95% CI 1.56 to 1.63, p<0.001). This applied to VGSC-inhibiting tricyclic antidepressants (HR 1.61, 95% CI 1.50 to 1.65, p<0.001), local anaesthetics (HR 1.49, 95% CI 1.43 to 1.55, p<0.001) and anticonvulsants (HR 1.40, 95% CI 1.34 to 1.48, p<0.001) and persisted in sensitivity analyses. In contrast, exposure to VGSC-inhibiting class 1c and 1d antiarrhythmics was associated with significantly improved cancer-specific survival (HR 0.75, 95% CI 0.64 to 0.88, p<0.001 and HR 0.54, 95% CI 0.33 to 0.88, p=0.01, respectively).

CONCLUSIONS

Association between VGSC inhibitor use and mortality in patients with cancer varies according to indication. Exposure to VGSC-inhibiting antiarrhythmics, but not anticonvulsants, supports findings from preclinical data, with improved survival. However, additional confounding factors may underlie these associations, highlighting the need for further study.

ACPS: An accurate bioinformatics tool for precision-based anti-cancer peptide generation via omics data

The anti-cancer targets play a crucial role in the signaling processes of cells, and therefore, it becomes nearly impossible to engage these targets without affecting the native cellular function. Thus, an approach has been taken to develop an anti-cancer Scanner (ACPS) tool aimed toward the recognition of anti-cancer marks in the form of peptides. The proposed ACPS tool allows fast fingerprinting of the anti-cancer targets having extreme significance in the current bioinformatics research. There already exist some tools that offer these features on a single platform; however, the performance of ACPS was compared with the preexisting online tools and was observed that ACPS offers greater than 95% accuracy that is comparatively much higher. The anti-cancer marked sequences of proteins supplied by the operators are scanned against the anti-cancer target datasets via ACPS and provide precision-based anti-cancer peptides. The proposed tool has been contrived in PERL programming language, and this tool is the extended version of A-CaMP codes, which are highly scalable having an extensible application in cancer biology with robust coding architecture. The availability of tools like ACPS will greatly benefit researchers in the field of oncology and structure-based drug design.

Superior pathologic and clinical outcomes after minimally invasive rectal cancer resection, compared to open resection

BACKGROUND

While the ACOSOG and ALaCaRT trials found that laparoscopic resections for rectal cancer failed to demonstrate non-inferiority of pathologic outcomes when compared with open resections, the COLOR II and COREAN studies demonstrated non-inferiority of clinical outcomes, leading to uncertainty regarding the value of minimally invasive (MIS) techniques in rectal cancer surgery. We analyzed differences in pathologic and clinical outcomes between open versus MIS resections for rectal cancer.

METHODS

We identified patients who underwent resection for stage II or III rectal adenocarcinoma from the National Cancer Database (2010-2015). Surgical approach was categorized as open or MIS (laparoscopic or robotic). Logistic regression and Cox proportional hazard analysis were used to assess differences in outcomes and survival. Analysis was performed in an intention-to-treat fashion.

RESULTS

A total of 31,190 patients who underwent rectal adenocarcinoma resection were identified, of whom 52.8% underwent open resection and 47.2% underwent MIS resection (31.0% laparoscopic, 16.2% robotic). After adjustment for patient, tumor, and institutional characteristics, MIS approaches were associated with significantly decreased risk of positive circumferential resection margins (OR 0.82, 95% CI 0.72-0.94), increased likelihood of harvesting ≥ 12 lymph nodes (OR 1.12, 95% CI 1.04-1.21), shorter length of stay (OR 0.57, 95% CI 0.53-0.62), and improved overall survival (HR 0.90, 95% CI 0.83-0.98).

CONCLUSIONS

MIS approaches to rectal cancer resection were associated with improved pathologic and clinical outcomes when compared to the open approach. In this nationwide, facility-based sample of cancer cases in the United States, our data suggest superiority of MIS techniques for rectal cancer treatment.

Combining Nonclinical Determinants of Health and Clinical Data for Research and Evaluation: Rapid Review

Background

Nonclinical determinants of health are of increasing importance to health care delivery and health policy. Concurrent with growing interest in better addressing patients’ nonmedical issues is the exponential growth in availability of data sources that provide insight into these nonclinical determinants of health.

Objective

This review aimed to characterize the state of the existing literature on the use of nonclinical health indicators in conjunction with clinical data sources.

Methods

We conducted a rapid review of articles and relevant agency publications published in English. Eligible studies described the effect of, the methods for, or the need for combining nonclinical data with clinical data and were published in the United States between January 2010 and April 2018. Additional reports were obtained by manual searching. Records were screened for inclusion in 2 rounds by 4 trained reviewers with interrater reliability checks. From each article, we abstracted the measures, data sources, and level of measurement (individual or aggregate) for each nonclinical determinant of health reported.

Results

A total of 178 articles were included in the review. The articles collectively reported on 744 different nonclinical determinants of health measures. Measures related to socioeconomic status and material conditions were most prevalent (included in 90% of articles), followed by the closely related domain of social circumstances (included in 25% of articles), reflecting the widespread availability and use of standard demographic measures such as household income, marital status, education, race, and ethnicity in public health surveillance. Measures related to health-related behaviors (eg, smoking, diet, tobacco, and substance abuse), the built environment (eg, transportation, sidewalks, and buildings), natural environment (eg, air quality and pollution), and health services and conditions (eg, provider of care supply, utilization, and disease prevalence) were less common, whereas measures related to public policies were rare. When combining nonclinical and clinical data, a majority of studies associated aggregate, area-level nonclinical measures with individual-level clinical data by matching geographical location.

Conclusions

A variety of nonclinical determinants of health measures have been widely but unevenly used in conjunction with clinical data to support population health research.

High hospital research participation and improved colorectal cancer survival outcomes: a population-based study

OBJECTIVE

In 2001, the National Institute for Health Research Cancer Research Network (NCRN) was established, leading to a rapid increase in clinical research activity across the English NHS. Using colorectal cancer (CRC) as an example, we test the hypothesis that high, sustained hospital-level participation in interventional clinical trials improves outcomes for all patients with CRC managed in those research-intensive hospitals.

DESIGN

Data for patients diagnosed with CRC in England in 2001-2008 (n=209 968) were linked with data on accrual to NCRN CRC studies (n=30 998). Hospital Trusts were categorised by the proportion of patients accrued to interventional studies annually. Multivariable models investigated the relationship between 30-day postoperative mortality and 5-year survival and the level and duration of study participation.

RESULTS

Most of the Trusts achieving high participation were district general hospitals and the effects were not limited to cancer 'centres of excellence', although such centres do make substantial contributions. Patients treated in Trusts with high research participation (≥16%) in their year of diagnosis had lower postoperative mortality (p<0.001) and improved survival (p<0.001) after adjustment for casemix and hospital-level variables. The effects increased with sustained research participation, with a reduction in postoperative mortality of 1.5% (6.5%-5%, p<2.2×10^-6) and an improvement in survival (p<10^-19; 5-year difference: 3.8% (41.0%-44.8%)) comparing high participation for ≥4 years with 0 years.

CONCLUSIONS

There is a strong independent association between survival and participation in interventional clinical studies for all patients with CRC treated in the hospital study participants. Improvement precedes and increases with the level and years of sustained participation.

Systematic review of laparoscopic vs open surgery for colorectal cancer in elderly patients

AIM: To verify the safety and validity of laparoscopic surgery for the treatment of colorectal cancer in elderly patients.

METHODS: A meta-analysis was performed of a systematic search of studies on an electronic database. Studies that compared laparoscopic colectomy (LAC) in elderly colorectal cancer patients with open colectomy (OC) were retrieved, and their short and long-term outcomes compared. Elderly people were defined as 65 years old or more. Inclusion criteria were set at: Resection of colorectal cancer, comparison between laparoscopic and OC and no significant difference in backgrounds between groups.

RESULTS: Fifteen studies were identified for analysis. LAC was performed on 1436 patients, and OC performed on 1810 patients. In analyses of short-term outcomes, operation time for LAC was longer than for OC (mean difference = 34.4162, 95%CI: 17.8473-50.9851, P < 0.0001). The following clinical parameters were lower in LAC than in OC: Amount of estimated blood loss (mean difference = -93.3738, 95%CI: -132.3437 to -54.4039, P < 0.0001), overall morbidity (OR = 0.5427, 95%CI: 0.4425-0.6655, P < 0.0001), incisional surgical site infection (OR = 0.6262, 95%CI: 0.4310-0.9097, P = 0.0140), bowel obstruction and ileus (OR = 0.6248, 95%CI: 0.4519-0.8638, P = 0.0044) and cardiovascular complications (OR = 0.4767, 95%CI: 0.2805-0.8101, P = 0.0062). In analyses of long-term outcomes (median follow-up period: 36.4 mo in LAC, 34.3 mo in OC), there was no significant difference in overall survival (mean difference = 0.8321, 95%CI: 0.5331-1.2990, P = 0.4187) and disease specific survival (mean difference = 1.0254, 95%CI: 0.6707-1.5675, P = 0.9209). There was also no significant difference in the number of dissected lymph nodes (mean difference = -0.1360, 95%CI: -4.0553-3.7833, P = 0.9458).

CONCLUSION: LAC in elderly colorectal cancer patients had benefits in short-term outcomes compared with OC except operation time. The long-term outcomes and oncological clearance of LAC were similar to that of OC. These results support the assertion that LAC is an effective procedure for elderly patients with colorectal cancer.

Designing and incorporating a real world data approach to international drug development and use: what the UK offers

Assessments of the safety, efficacy and appropriate use of new medicines lie at the heart of treatment development and subsequent adoption in clinical practice. Highly controlled randomised clinical trials routinely inform decisions on the approval, coverage and use of a medicine. Researchers and decision makers have become increasingly aware that these experimental data alone are insufficient to address those decisions fully. Real world data recorded from routine healthcare delivery by healthcare professionals and patients help provide a more complete picture of care. The UK, with its connectivity and rich longitudinal patient records, accumulated research and informatics experience and National Health Service, provides an exemplar of how real world data address a wide range of challenges across drug development.

Post-colonoscopy colorectal cancer (PCCRC) rates vary considerably depending on the method used to calculate them: a retrospective observational population-based study of PCCRC in the English National Health Service

OBJECTIVE

Post-colonoscopy colorectal cancer (PCCRC) is a key quality indicator of colonoscopy. This study compares methods for defining PCCRC rates, proposes a new method of calculating them and quantifies them across the English National Health Service (NHS).

DESIGN

This retrospective observational population-based study involved all individuals with a first primary diagnosis of colorectal cancer made between 2001 and 2010 and treated in the English NHS. Previously published methods for deriving PCCRC rates were applied to the linked routine health data for this population to investigate the effect on the rate. A new method, based on the year of the colonoscopy rather than colorectal cancer diagnosis, was then used to calculate PCCRC rates.

RESULTS

Of 297,956 individuals diagnosed with colorectal cancer, a total of 94,648 underwent a colonoscopy in the 3 years prior to their diagnosis. The application of the published methods and exclusion criteria to the dataset produced significantly different PCCRC rates from 2.5% to 7.7%. The new method demonstrates that PCCRC rates within 3 years of colonoscopy (without exclusions) decreased in the English NHS over 8 years, falling from 10.6% to 7.3% for colonoscopies performed in 2001 and 2007 respectively.

CONCLUSIONS

The method used to determine PCCRC rates significantly affects findings with potential to substantially underestimate rates. To enable international benchmarking there needs to be a standardised method for defining PCCRC. This study proposes a new methodology using colonoscopy as a denominator and between 2001 and 2007 this method indicated an 8.6% PCCRC rate across the English NHS. It also demonstrated PCCRC rates have fallen over time.

Short-term results of a randomized study between laparoscopic and open surgery in elderly colorectal cancer patients

BACKGROUND

In surgical treatment of elderly patients, securing the safety of surgery and radical cure must be balanced. Our purpose was to verify the safety and validity of laparoscopic surgery for the treatment of colorectal cancer in elderly patients.

METHODS

Patients with cTis–T4a colorectal cancer who were 75 years or older were randomized to receive open or laparoscopic surgery. Exclusion criteria were patients who had a bulky tumor, rectal cancer that required pelvic side wall lymphadenectomy, and history of colon resection. Patients were divided according to tumor location (right colon, left colon, and rectum). The short-term outcomes were compared between the two groups.

RESULTS

One hundred patients (right 43, left 28, and rectum 29) were registered in each group from August 2008 to August 2012. There were no differences in patient characteristics between the two groups. Three patients were converted from laparoscopic to open, because of bleeding, excision of peritoneum metastasis, and patient’s desire, respectively. In the short-term results (open:laparoscopic), there were significant differences in the rates of complications (36:23 %) and ileus (12:4 %), amount of blood loss (157:63 mL), and duration of surgery (150:172 min). There were no significant differences in the pathological margins, and the number of dissected lymph nodes. In the subgroup analysis according to the tumor location, there were significant differences in the rate of complications (39.4:22.5 %), amount of blood loss (135:42 mL), duration of surgery (139:160 min), and length of postoperative stay (13.0:10.0 days) in the colon cancer. There were no significant differences in short-term results in the rectal cancer.

CONCLUSIONS

Laparoscopic surgery in elderly colorectal cancer patients did not result in a difference in radical cure compared with open surgery, and the short-term results except the duration of surgery were excellent. It is an effective procedure for elderly patients with colorectal cancer, especially colon cancer.

The challenges of long-term follow-up data collection in non-commercial, academically-led breast cancer clinical trials: the UK perspective

BACKGROUND

Improved survival rates in early breast cancer and the chronic nature of disease relapse result in a large cohort of patients being available for long-term follow-up (LTFUP) in randomised controlled trials. Whilst of recognised scientific value to assess long-term treatment-related sequelae, the volume of this activity can be challenging for trialists and participating sites, and comes at a considerable cost to research funders and the National Health Service (NHS). A National Cancer Research Institute Breast Clinical Studies Group supported project aimed to characterise UK LTFUP data collection procedures in order to propose improvements.

METHODS

Protocols and case report forms for UK non-commercial National Institute for Health Research portfolio early breast cancer randomised controlled trials were reviewed and a questionnaire sent to associated participating NHS sites. Responders were asked to give opinions on issues with follow-up and LTFUP data collection procedures and to suggest potential improvements to practice. Results were used to inform design of a proposed standard LTFUP case report form.

RESULTS

Thirty-four trials, involving eight Clinical Trials Units were eligible for inclusion in the review. All trials requested follow-up at least annually up to 5 years, with two-thirds requesting LTFUP after that time point. Information relating to efficacy endpoints was captured for all trials via case report forms; however, precise detail on recording of recurrence, second malignancies and death varied. Separately, questionnaires were returned from 66 NHS sites. Main concerns identified included difficulties in identifying all adverse events from hospital notes, volume of work, bureaucratic data management practices in Clinical Trials Units and perceptions of prioritisation of recruitment over follow-up.

CONCLUSION

Variation has existed with respect to detail of LTFUP information requested for UK trials. Improved communication, simplification and standardisation of data and associated collection methods are possible without compromising data requirements for efficient and effective trial reporting. Future use of routinely collected data, captured via electronic means, could transform practices and alleviate resource usage.

Impact of bowel cancer screening on the management of colorectal cancer

AIM

The National Bowel Cancer Screening Programme (NBCSP) was introduced in the West Midlands in 2006. Studies, including the UK Bowel Cancer Screening Pilot, have reported an 18% reduction in mortality. This regional study assesses the impact of screening on elective and emergency colorectal cancer (CRC) surgery.

METHOD

Data were extracted from the West Midlands cancer registration database for CRC diagnosed in residents of the West Midlands between 1998 and 2010. Screen-detected cancers were identified by matching to the NBCSP database. Mode of admission and intervention was obtained by matching to Hospital Episode Statistics and the classification of Interventions and Procedures code.

RESULTS

Of 42,082 patients diagnosed with CRC, 30,309 received surgical treatment. From 1998 to 2005, the number of patients who underwent emergency surgery increased from 4362 to 18,357, with the proportion each year remaining constant (23.85 ± 0.95% each year). In the screening age group (60-69 years) over the same period, emergency surgery was performed in 918 of 4831 patients (19.15 ± 1.65% each year). Following the introduction of screening, the emergency surgery rate decreased each year, reaching 16% (406/2520) in all patients and 12% (101/829) in the screening age group in 2010 (P < 0.001). These changes in emergency surgery were mirrored by increases in elective surgery.

CONCLUSION

The NBCSP has had a positive impact on elective and emergency surgery for CRC in the West Midlands.

Laparoscopic versus open total mesorectal excision for rectal cancer

BACKGROUND

Colorectal cancer including rectal cancer is the third most common cause of cancer deaths in the western world. For colon carcinoma, laparoscopic surgery is proven to result in faster postoperative recovery, fewer complications and better cosmetic results with equal oncologic results. These short-term benefits are expected to be similar for laparoscopic rectal cancer surgery. However, the oncological safety of laparoscopic surgery for rectal cancer remained controversial due to the lack of definitive long-term results. Thus, the expected short-term benefits can only be of interest when oncological results are at least equal.

OBJECTIVES

To evaluate the differences in short- and long-term results after elective laparoscopic total mesorectal excision (LTME) for the resection of rectal cancer compared with open total mesorectal excision (OTME).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2013, Issue 2), MEDLINE (January 1990 to February 2013), EMBASE (January 1990 to February 2013), ClinicalTrials.gov (February 2013) and Current Controlled Trials (February 2013). We handsearched the reference lists of the included articles for missed studies.

SELECTION CRITERIA

Only randomised controlled trials (RCTs) comparing LTME and OTME, reporting at least one of our outcome measures, was considered for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study quality according to the CONSORT statement, and resolved disagreements by discussion. We rated the quality of the evidence using GRADE methods.

MAIN RESULTS

We identified 45 references out of 953 search results, of which 14 studies met the inclusion criteria involving 3528 rectal cancer patients. We did not consider the risk of bias of the included studies to have impacted on the quality of the evidence. Data were analysed according to an intention-to-treat principle with a mean conversion rate of 14.5% (range 0% to 35%) in the laparoscopic group.There was moderate quality evidence that laparoscopic and open TME had similar effects on five-year disease-free survival (OR 1.02; 95% CI 0.76 to1.38, 4 studies, N = 943). The estimated effects of laparoscopic and open TME on local recurrence and overall survival were similar, although confidence intervals were wide, both with moderate quality evidence (local recurrence: OR 0.89; 95% CI 0.57 to1.39 and overall survival rate: OR 1.15; 95% CI 0.87 to1.52). There was moderate to high quality evidence that the number of resected lymph nodes and surgical margins were similar between the two groups.For the short-term results, length of hospital stay was reduced by two days (95% CI -3.22 to -1.10), moderate quality evidence), and the time to first defecation was shorter in the LTME group (-0.86 days; 95% CI -1.17 to -0.54). There was moderate quality evidence that 30 days morbidity were similar in both groups (OR 0.94; 95% CI 0.8 to 1.1). There were fewer wound infections (OR 0.68; 95% CI 0.50 to 0.93) and fewer bleeding complications (OR 0.30; 95% CI 0.10 to 0.93) in the LTME group.There was no clear evidence of any differences in quality of life after LTME or OTME regarding functional recovery, bladder and sexual function. The costs were higher for LTME with differences up to GBP 2000 for direct costs only.

AUTHORS' CONCLUSIONS

We have found moderate quality evidence that laparoscopic total mesorectal excision (TME) has similar effects to open TME on long term survival outcomes for the treatment of rectal cancer. The quality of the evidence was downgraded due to imprecision and further research could impact on our confidence in this result. There is moderate quality evidence that it leads to better short-term post-surgical outcomes in terms of recovery for non-locally advanced rectal cancer. Currently results are consistent in showing a similar disease-free survival and overall survival, and for recurrences after at least three years and up to 10 years, although due to imprecision we cannot rule out superiority of either approach. We await long-term data from a number of ongoing and recently completed studies to contribute to a more robust analysis of long-term disease free, overall survival and local recurrence.

Outcome following laparoscopic and open total mesorectal excision for rectal cancer

BACKGROUND

There are few reports on the oncological quality of resection and outcome after laparoscopic versus open total mesorectal excision (TME) for rectal cancer in everyday surgical practice.

METHODS

Between January 2006 and October 2011, data for patients with mid or low rectal adenocarcinoma who underwent elective TME were recorded in the PROCARE database. A multivariable model and the propensity score as a co-variable in Cox or logistic regression models were used for adjustment of differences in patient mix and non-random assignment of surgical approach.

RESULTS

Data for 2660 patients from 82 hospitals were recorded. Implementation of laparoscopic TME was highly variable. The oncological quality of resection was similar in the laparoscopic and the open group: incomplete mesorectal excision in 13·2 and 11·4 per cent respectively, circumferential resection margin positivity in 18·1 per cent, and a median of 11 lymph nodes examined per specimen in both groups. The hazard ratio for survival after laparoscopic versus open TME was 1·05 (95 per cent confidence interval 0·88 to 1·24) after correction for differences in patient mix, and 1·06 (0·89 to 1·25) after correction for the propensity score. The definitive colostomy rate was similar in the two groups: 31·0 per cent after open and 31·4 per cent after laparoscopic TME. Postoperative morbidity was lower and length of stay was shorter after laparoscopic TME compared with open TME. Survival was not negatively affected by converted laparoscopic resection, whereas postoperative morbidity, mortality and length of stay after converted laparoscopy were comparable with those after open TME.

CONCLUSION

Oncological outcome is comparable after laparoscopic and open TME in everyday surgical practice.

Population-based study of laparoscopic colorectal cancer surgery 2006-2008

Background

Clinical guidelines recommend that, where clinically appropriate, laparoscopic tumour resections should be available for patients with colorectal cancer. This study aimed to examine the introduction of laparoscopic surgery in the English National Health Service.

Methods

Data were extracted from the National Cancer Data Repository on all patients who underwent major resection for a primary colorectal cancer diagnosed between 2006 and 2008. Laparoscopic procedures were identified from codes in the Hospital Episode Statistics and National Bowel Cancer Audit Project data in the resource. Trends in the use of laparoscopic surgery and its influence on outcomes were examined.

Results

Of 58 135 resections undertaken over the study period, 10 955 (18·8 per cent) were attempted laparoscopically. This increased from 10·0 (95 per cent confidence interval (c.i.) 8·1 to 12·0) per cent in 2006 to 28·4 (25·4 to 31·4) per cent in 2008. Laparoscopic surgery was used less in patients with advanced disease (modified Dukes' stage ‘D’ versus A: odds ratio (OR) 0·45, 95 per cent c.i. 0·40 to 0·50), rectal tumours (OR 0·71, 0·67 to 0·75), those with more co-morbidity (Charlson score 3 or more versus 0: OR 0·69, 0·58 to 0·82) or presenting as an emergency (OR 0·15, 0·13 to 0·17). A total of 1652 laparoscopic procedures (15·1 per cent) were converted to open surgery. Conversion was more likely in advanced disease (modified Dukes' stage ‘D’ versus A: OR 1·56, 1·20 to 2·03), rectal tumours (OR 1·29, 1·14 to 1·46) and emergencies (OR 2·06, 1·54 to 2·76). Length of hospital stay (OR 0·65, 0·64 to 0·66), 30-day postoperative mortality (OR 0·55, 0·48 to 0·64) and risk of death within 1 year (hazard ratio 0·60, 0·55 to 0·65) were reduced in the laparoscopic group.

Conclusion

Laparoscopic surgery was used more frequently in low-risk patients. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Long-term follow-up of the Medical Research Council CLASICC trial of conventional versus laparoscopically assisted resection in colorectal cancer

BACKGROUND

Laparoscopic resection is used widely in the management of colorectal cancer; however, the data on long-term outcomes, particularly those related to rectal cancer, are limited. The results of long-term follow-up of the UK Medical Research Council trial of laparoscopically assisted versus open surgery for colorectal cancer are presented.

METHODS

A total of 794 patients from 27 UK centres were randomized to laparoscopic or open surgery in a 2:1 ratio between 1996 and 2002. Long-term follow-up data were analysed to determine differences in survival outcomes and recurrences for intention-to-treat and actual treatment groups.

RESULTS

Median follow-up of all patients was 62·9 (interquartile range 22·9 - 92·8) months. There were no statistically significant differences between open and laparoscopic groups in overall survival (78·3 (95 per cent confidence interval (c.i.) 65·8 to 106·6) versus 82·7 (69·1 to 94·8) months respectively; P = 0·780) and disease-free survival (DFS) (89·5 (67·1 to 121·7) versus 77·0 (63·3 to 94·0) months; P = 0·589). In colonic cancer intraoperative conversions to open surgery were associated with worse overall survival (hazard ratio (HR) 2·28, 95 per cent c.i. 1·47 to 3·53; P < 0·001) and DFS (HR 2·20, 1·31 to 3·67; P = 0·007). In terms of recurrence, no significant differences were observed by randomized procedure. However, at 10 years, right colonic cancers showed an increased propensity for local recurrence compared with left colonic cancers: 14·7 versus 5·2 per cent (difference 9·5 (95 per cent c.i. 2·3 to 16·6) per cent; P = 0·019).

CONCLUSION

Long-term results continue to support the use of laparoscopic surgery for both colonic and rectal cancer.

Hospital morbidity data for determining spread of disease at diagnosis for colorectal cancer: a validation study

AIMS

There is currently no routine collection of cancer stages in population-based data in Australia. This study evaluates the accuracy of International classification of diseases (ICD) codes for secondary neoplasms recorded in hospital morbidity data to assign spread of disease at diagnosis for colorectal cancer.

METHODS

The reference (gold) standard was the Australian clinicopathological stage (ACPS) documented by a treating colorectal surgeon and derived from histopathology and clinical findings. To allow comparison with stages derived from the hospital morbidity data (HMD), ACPS was mapped to the spread of disease (local, regional and distant). Sensitivity, specificity and positive-predictive values were calculated to compare the accuracy of stage derived from HMD.

RESULTS

Data from both the reference standard and HMD were available for 499 patients. HMD slightly overestimated patients with local disease (62.3 vs 56.9%). There was a corresponding underestimation of regional and distant spread of disease. While sensitivity for regional and distant disease was moderate (66.4 and 71.4%, respectively), specificity was high (92.7 and 96.6%, respectively).

CONCLUSION

ICD codes for secondary neoplasms in HMD are limited in their utility for determining the spread of disease for colorectal cancer. Clinicians need to ensure that clinical coders are provided with enough information to accurately code for spread of disease. We recommend reporting histopathology in a synoptic format which includes background information on the presence or absence of distant metastasis and the tumor node metastasis stage.

Lymph nodes, tumor deposits, and TNM: are we getting better?

PURPOSE

New editions of the TNM staging system for colorectal cancer have been subject to extensive criticism. In the current study, we evaluate each edition of TNM and analyze stage migration caused by the different versions.

PATIENTS AND METHODS

Two independent test populations were used: participants derived from a randomized surgical trial from the United Kingdom (n = 455) and patients from a population-based series from Sweden (n = 505). All slides from these patient cases were reviewed with special attention for the presence of tumor deposits. Tumor deposits were classified according to the fifth, sixth, and seventh editions of TNM and correlated with prognosis.

RESULTS

Every change in edition of TNM led to a stage migration of between 33% and 64% in patients with tumor deposits. Reproducibility was best in the fifth edition of TNM. The prognostic value of the seventh edition was best only when all tumor deposits irrespective of size or contour were included as lymph nodes. The prognostic value of the fifth edition was better than that of the sixth.

CONCLUSION

We demonstrate there is a place for tumor deposits in the staging of patients with colorectal cancer. However, many questions remain about their definition and the reproducibility and use of this category in special situations, such as after neoadjuvant treatment. These should be the subject of additional research before use as a factor in TNM staging. This work demonstrates the necessity of testing modifications before their introduction.