Conflicting Guidelines: A Systematic Review on the Proper Interval for Colorectal Cancer Treatment

Treatment interval in curative treatment of colon cancer, does it impact (cancer free) survival? A non-inferiority analysis

BACKGROUND

In treatment of colon cancer, strict waiting-time targets are enforced, leaving professionals no room to lengthen treatment intervals when advisable, for instance to optimise a patient's health status by means of prehabilitation. Good quality studies supporting these targets are lacking. With this study we aim to establish whether a prolonged treatment interval is associated with a clinically relevant deterioration in overall and cancer free survival.

METHODS

This retrospective multicenter non-inferiority study includes all consecutive patients who underwent elective oncological resection of a biopsy-proven primary non-metastatic colon carcinoma between 2010 and 2016 in six hospitals in the Southern Netherlands. Treatment interval was defined as time between diagnosis and surgical treatment. Cut-off points for treatment interval were ≤35 days and ≤49 days.

FINDINGS

3376 patients were included. Cancer recurred in 505 patients (15.0%) For cancer free survival, a treatment interval >35 days and >49 days was non-inferior to a treatment interval ≤35 days. Results for overall survival were inconclusive, but no association was found.

CONCLUSION

For cancer free survival, a prolonged treatment interval, even over 49 days, is non-inferior to the currently set waiting-time target of ≤35 days. Therefore, the waiting-time targets set as fundamental objective in current treatment guidelines should become directional instead of strict targets.

Effect of multidisciplinary team care on patient survival in chronic hepatitis B or C hepatocellular carcinoma

Introduction

Multidisciplinary team care coordinates with medical teams to improve the quality of cancer care. This study explored multidisciplinary team care in hepatitis B or hepatitis C virus-related hepatocellular carcinoma patients from the time of diagnosis to the first-time treatment interval and investigated treatment outcomes and prognosis.

Methods

This retrospective cohort study included data from a nationwide population from 2007 to 2016. Data were collected from the Taiwan Cancer Registry Database, linked to the Taiwan National Health Insurance Research Database. Propensity score matching was applied at a ratio of 1:2 to reduce the selection bias. A multiple regression model with generalized estimating equations was used to analyze whether multidisciplinary team care affected the diagnosis-to-treatment interval. The stratified Cox proportional hazards model examined whether involvement in multidisciplinary team care influenced survival status.

Results

A total of 10,928 and 21,856 patients with hepatocellular carcinoma received multidisciplinary and non-multidisciplinary care, respectively. Participants with multidisciplinary care had a longer diagnosis-to-treatment interval but a lower risk of cumulative cancer death (HR=0.88, 95% CI:0.84-0.92). In patients with intermediate- to advanced-stage hepatocellular carcinoma, multidisciplinary team care has obvious benefits for improving survival.

Conclusion

Patients with hepatocellular carcinoma who participated in multidisciplinary team care had a longer diagnosis-to-treatment interval but a lower risk of cancer death. Patients with intermediate- to advanced-stage hepatocellular carcinoma who received multidisciplinary team care significantly benefited from this outcome. Hospitals should provide HCC patients with multidisciplinary team care to improve cancer care.

Colorectal cancer treatment guidelines and shared decision making quality and reporting assessment: Systematic review

INTRODUCTION

Physicians must share decisions and choose personalised treatments regarding patients´ beliefs and values.

OBJECTIVE

To analyse the quality of the recommendations about shared decision making (SDM) in colorectal (CRC) and anal cancer treatment clinical practice guidelines (CPGs) and consensus statements (CSs).

METHODS

Guidelines were systematically reviewed following prospective registration (Prospero: CRD42021286146) without language restrictions searching 15 databases and 59 professional society websites from January 2010 to November 2021. A validated 31-item SDM quality assessment tool was employed to extract data in duplicate.

RESULTS

We identified 134 guidelines. Only 46/134 (34.3 %) mentioned SDM. Fifteen (11.1 %) made clear, precise and actionable recommendations, while 9/134 (6.7 %) indicated the strength of the SDM-related recommendations. CPGs underpinned by systematic reviews reported SDM more often than those based on consensus or reviews (35.9 % vs 32.0 %; p = 0.031). Guidelines that reported following quality tools (i.e., AGREE II) more commonly commented about SDM than when it was not reported (75.0 % vs 32.0 %; p = 0.003).

CONCLUSION AND PRACTICE IMPLICATIONS

Most of the CRC and anal treatment guidelines did not mention SDM and it was superficial. Guidelines based on systematic reviews and those using quality tools demonstrated better reporting of SDM. Recommendations about SDM in these guidelines merit urgent improvement.

Effect of Multimodal Prehabilitation on Reducing Postoperative Complications and Enhancing Functional Capacity Following Colorectal Cancer Surgery: The PREHAB Randomized Clinical Trial

Importance

Colorectal surgery is associated with substantial morbidity rates and a lowered functional capacity. Optimization of the patient's condition in the weeks prior to surgery may attenuate these unfavorable sequelae.

Objective

To determine whether multimodal prehabilitation before colorectal cancer surgery can reduce postoperative complications and enhance functional recovery.

Design, Setting, and Participants

The PREHAB randomized clinical trial was an international, multicenter trial conducted in teaching hospitals with implemented enhanced recovery after surgery programs. Adult patients with nonmetastasized colorectal cancer were assessed for eligibility and randomized to either prehabilitation or standard care. Both arms received standard perioperative care. Patients were enrolled from June 2017 to December 2020, and follow-up was completed in December 2021. However, this trial was prematurely stopped due to the COVID-19 pandemic.

Interventions

The 4-week in-hospital supervised multimodal prehabilitation program consisted of a high-intensity exercise program 3 times per week, a nutritional intervention, psychological support, and a smoking cessation program when needed.

Main Outcomes and Measures

Comprehensive Complication Index (CCI) score, number of patients with CCI score more than 20, and improved walking capacity expressed as the 6-minute walking distance 4 weeks postoperatively.

Results

In the intention-to-treat population of 251 participants (median [IQR] age, 69 [60-76] years; 138 [55%] male), 206 (82%) had tumors located in the colon and 234 (93%) underwent laparoscopic- or robotic-assisted surgery. The number of severe complications (CCI score >20) was significantly lower favoring prehabilitation compared with standard care (21 of 123 [17.1%] vs 38 of 128 [29.7%]; odds ratio, 0.47 [95% CI, 0.26-0.87]; P = .02). Participants in prehabilitation encountered fewer medical complications (eg, respiratory) compared with participants receiving standard care (19 of 123 [15.4%] vs 35 of 128 [27.3%]; odds ratio, 0.48 [95% CI, 0.26-0.89]; P = .02). Four weeks after surgery, 6-minute walking distance did not differ significantly between groups when compared with baseline (mean difference prehabilitation vs standard care 15.6 m [95% CI, -1.4 to 32.6]; P = .07). Secondary parameters of functional capacity in the postoperative period generally favored prehabilitation compared with standard care.

Conclusions and Relevance

This PREHAB trial demonstrates the benefit of a multimodal prehabilitation program before colorectal cancer surgery as reflected by fewer severe and medical complications postoperatively and an optimized postoperative recovery compared with standard care.

Trial Registration

trialregister.nl Identifier: NTR5947.

Prehabilitation for patients with colorectal cancer: a snapshot of current daily practice in Dutch hospitals

BACKGROUND

Multimodal prehabilitation programmes are increasingly being imbedded in colorectal cancer (CRC) pathways to enhance the patient's recovery after surgery. However, there is no (inter)national consensus on the content or design of such a programme. This study aimed to evaluate the current practice and opinion regarding preoperative screening and prehabilitation for patients undergoing surgery for CRC throughout the Netherlands.

METHODS

All regular Dutch hospitals offering colorectal cancer surgery were included. An online survey was sent to one representative colorectal surgeon per hospital. Descriptive statistics were used for analyses.

RESULTS

Response rate was 100% (n = 69). Routine preoperative screening of patients with CRC for frailty, diminished nutritional status and anaemia was the standard of care in nearly all Dutch hospitals (97%, 93% and 94%, respectively). Some form of prehabilitation was provided in 46 hospitals (67%) of which more than 80% addressed nutritional status, frailty, physical status and anaemia. All but two of the remaining hospitals were willing to adopt prehabilitation. The majority of the hospitals offered prehabilitation to specific subgroups of patients with CRC, such as the elderly (41%), the frail (71%) or high-risk patients (57%). There was high variability in the setting, design and content of the prehabilitation programmes.

CONCLUSIONS

Whereas preoperative screening is sufficiently incorporated in Dutch hospitals, standardised enhancement of the patient's condition in the context of multimodal prehabilitation seems to be challenging. This study presents an overview of current clinical practice in the Netherlands. Uniform clinical prehabilitation guidelines are vital to diminish heterogeneity in programmes and to produce useful data to enable a nationwide implementation of an evidence-based prehabilitation programme.

Multimodal Prehabilitation in Patients Undergoing Complex Colorectal Surgery, Liver Resection, and Hyperthermic Intraperitoneal Chemotherapy (HIPEC): A Pilot Study on Feasibility and Potential Efficacy

BACKGROUND

Surgery for complex primary and metastatic colorectal cancer (CRC), such as liver resection and hyperthermic intraperitoneal chemotherapy (HIPEC), in academic settings has led to improved survival but is associated with complications up to 75%. Prehabilitation has been shown to prevent complications in non-academic hospitals. This pilot study aimed to determine the feasibility and potential efficacy of a multimodal prehabilitation program in patients undergoing surgery in an academic hospital for complex primary and metastatic CRC.

METHODS

All patients awaiting complex colorectal surgery, liver resection, or HIPEC from July 2019 until January 2020 were considered potentially eligible. Feasibility was measured by accrual rate, completion rate, adherence to the program, satisfaction, and safety. To determine potential efficacy, postoperative outcomes were compared with a historical control group.

RESULTS

Sixteen out of twenty-five eligible patients (64%) commenced prehabilitation, and fourteen patients fully completed the intervention (88%). The adherence rate was 69%, as 11 patients completed >80% of prescribed supervised trainings. No adverse events occurred, and all patients expressed satisfaction with the program. The complication rate was significantly lower in the prehabilitation group (37.5%) than the control group (70.2%, p = 0.020). There was no difference in the type of complications.

CONCLUSION

This pilot study illustrates that multimodal prehabilitation is feasible in the majority of patients undergoing complex colorectal cancer, liver resection, and HIPEC in an academic setting.

Guidance documents for colorectal and anal cancer treatment: A systematic quality and reporting assessment

AIM

Evidence-based medicine is essential for clinical practice. Clinical practice guidelines (CPGs) and consensus statements (CSs) ought to follow a consistent methodology to underpin high-quality healthcare. We systematically analysed the quality and reporting of colorectal (CRC) and anal cancer CPGs and CSs.

METHODS

Embase, MEDLINE, Scopus, Web of Science, the Cochrane Database of Systematic Reviews and online sources (59 professional society websites and eight guideline databases) were systematically searched following prospective registration (PROSPERO no. CRD42021286146) by two reviewers independently, without language restrictions. CPGs and CSs about CRC and anal cancer treatment were included from January 2018 to November 2021 and were assessed using the AGREE II tool (per cent of maximum score) and the RIGHT tool (per cent of total 35 items) for quality and reporting respectively.

RESULTS

The median overall quality and reporting of the 59 guidelines analysed were 55.0% (interquartile range 47.0-62.0) and 58% (interquartile range 50.0-67.9), respectively, with a proportion scoring less than half (<50%) for quality (20/59, 33.9%) and reporting (15/59, 25.4%). Guidance reported that following AGREE II methodology scored better on average than that without (AGREE II 77.7% vs. 47.6%, P = 0.001; RIGHT 50.0% vs. 33.9%, P = 0.001). Guidelines based on systematic reviews had better quality and reporting on average than those based on consensus (AGREE II 56.5% vs. 46.6%, P = 0.001; RIGHT 36.9% vs. 35.4%, P = 0.019).

CONCLUSION

The quality and reporting of colorectal and anal cancer treatment CPGs and CSs were poor. Despite AGREE II and RIGHT inherent methodological limitations, few high-quality guidelines were found. Despite wide variability in scoring different domains, they merit urgent improvement in all areas. It has also been demonstrated that CPGs and CSs should be underpinned by systematic reviews collecting the best available clinical research findings.

Perceived Provision of Perioperative Information and Care by Patients Who Have Undergone Surgery for Colorectal Cancer: A Cross-Sectional Study

BACKGROUND

Active patient participation in preparation and recovery from colorectal cancer surgery can be facilitated by timely information and care and may improve patient wellbeing and reduce hospitalizations; Methods: We aimed to identify gaps in perioperative information and care by asking colorectal cancer surgical patients to retrospectively report on their perceptions of care via a cross-sectional survey; Results: Overall, 179 (64% consent rate) patients completed one of two 64-item surveys exploring their views of 'optimal care' or their experiences of 'actual care'. In total, 41 (64%) aspects of care were endorsed as optimal. Of these, almost three-quarters (73%) were received by most patients (80% or more). Gaps in care were identified from discrepancies in the endorsement of optimal versus actual survey items. Of the 41 items identified as representing 'optimal care', 11 items were received by fewer than 80% of patients, including the provision of information about the impact of surgical wait-times on cancer cure (69%); pre-habilitation behaviors to improve health (75%); the type of questions to ask the health care team (74%); impact of pain medications on bowel movements (73%); how to obtain medical supplies for self-care at home (67%); dietary or exercise advice after discharge (25-31%); and emotional advice after discharge (44%).

CONCLUSIONS

These gaps represent patient-centered priorities and targets for supportive interventions.

Feasibility of a tele-prehabilitation program in high-risk patients with colon or rectal cancer undergoing elective surgery: a feasibility study

Background

Prehabilitation appears to be an effective strategy to reduce postoperative complications and enhance recovery after colorectal surgery. Although many patients prefer (unsupervised) home-based prehabilitation, adherence can be problematic. Combining home-based prehabilitation with tele-monitoring might demonstrate a higher adherence than unsupervised prehabilitation; however, evidence on its feasibility and effectiveness in patients with colorectal cancer scheduled for elective surgery who are at high risk for postoperative complications is lacking. The aim of this study was to assess the feasibility of a bimodal tele-prehabilitation program in patients with colorectal cancer at high risk for postoperative complications.

Methods

High-risk patients (oxygen uptake at the ventilatory anaerobic threshold ≤11 mL/kg/min or oxygen uptake at peak exercise ≤ 18 mL/kg/min) with colorectal cancer were included in a home-based bimodal tele-prehabilitation program. The program consisted of a personalized tele-monitored moderate to high-intensity interval training intervention and nutritional counseling. Feasibility was measured by participation rate, dropout rate, adherence to the physical exercise training session’s frequency, intensity, and time, and retention rate. Patient appreciation was measured by a patient appreciation questionnaire. Changes in preoperative physical fitness as secondary outcomes were quantified by time to exhaustion on a constant work rate (cycle) test, number of repetitions on the 30-s chair-stand test, and walking speed on the 4-m gait speed test.

Results

The participation rate was 81%, there were no adverse events, and all participants managed to complete the tele-prehabilitation program (retention rate of 100%). Adherence with regard to the exercise program’s frequency, intensity, and time was respectively 91%, 84%, and 100%. All participants appreciated the tele-prehabilitation program. Time to exhaustion on the constant work rate test improved (not statistically significant) from a pre-prehabilitation median score of 317 seconds to a post-prehabilitation median score of 412 seconds (p = 0.24). Median number of repetitions on the 30-s chair-stand test improved from 12 to 16 (p = 0.01).

Conclusions

Tele-prehabilitation seems feasible in high-risk patients with colorectal cancer, but efforts should be made to further improve adherence to physical exercise training intensity. More research is needed to establish the (cost-)effectiveness of tele-prehabilitation regarding preoperative improvements in preoperative aerobic fitness and postoperative reduction of complications.

Trial registration

ISRCTN, ISRCTN64482109. Registered 09 November 2021 - Retrospectively registered.

Feasibility and Efficiency of the BEFORE (Better Exercise and Food, Better Recovery) Prehabilitation Program

Prehabilitation has been postulated as an effective preventive intervention to reduce postoperative complications, particularly for elderly patients with a relatively high risk of complications. To date, it remains to be determined whether prehabilitation increases physical capacity and reduces postoperative complications. The aim of this study was to assess the feasibility of a 4-week multimodal prehabilitation program consisting of a personalized, supervised training program and nutritional intervention with daily fresh protein-rich food for colorectal cancer patients aged over 64 years prior to surgery. The primary outcome was the feasibility of this prehabilitation program defined as ≥80% compliance with the exercise training program and nutritional intervention. The secondary outcomes were the organizational feasibility and acceptability of the prehabilitation program. A compliance rate of ≥80% to both the exercise and nutritional intervention was accomplished by 6 patients (66.7%). Attendance of ≥80% at all 12 training sessions was achieved by 7 patients (77.8%); all patients (100%) attended ≥80% of the available training sessions. Overall, compliance with the training was 91.7%. Six patients (66.7%) accomplished compliance of ≥80% with the nutritional program. The median protein intake was 1.2 (g/kg/d). No adverse events occurred. This multimodal prehabilitation program was feasible for the majority of patients.