Improved survival of patients with rectal cancer since 1980: a population-based study

Trends in Staging, Treatment, and Survival in Colorectal Cancer Between 1990 and 2014 in the Rotterdam Study

Background

This study aims to assess trends in patient-related factors and treatment strategies in Dutch colorectal cancer (CRC) patients and their effect on survival.

Methods

Data were obtained from the Rotterdam study, an ongoing population-based study of individuals aged ≥45 years. Between 1990 and 2014, incident, pathology-confirmed CRC cases were divided into two groups based on date of diagnosis (either before or after January 1, 2003). Patient characteristics, initial treatment, and date of mortality were collected. Analyses were performed using Kaplan–Meier and Cox proportional hazard models.

Results

Of 14,928 individuals, 272 developed colon cancer and 124 rectal cancer. Median follow-up was 13.2 years. Patients diagnosed after January 1, 2003 were treated chemotherapeutically more often than those diagnosed prior to this date in colon cancer (28.6% vs. 9.1%, p = 0.02) and treated more often with chemotherapy (38.6% vs. 12.3%, p = 0.02) and radiotherapy (41.3% vs. 10.2%, p = 0.001) in rectal cancer. Overall survival, adjusted for patient, tumor characteristics, and treatment, improved in rectal cancer (HR, 0.31; 95% CI, 0.13–0.74) but remained stable in colon cancer (HR, 1.28; 95% CI, 0.84–1.95).

Conclusion

Chemotherapeutic agents and radiotherapy are increasingly used in CRC patients. Survival in rectal cancer improved, whereas in colon cancer this was not observed.

Are there sex differences among colorectal cancer patients in treatment and survival? A Swiss cohort study

BACKGROUND

Colorectal cancer (CRC) is among the three most common incident cancers and causes of cancer death in Switzerland for both men and women. To promote aspects of gender medicine, we examined differences in treatment decision and survival by sex in CRC patients diagnosed 2000 and 2001 in the canton of Zurich, Switzerland.

METHODS

Characteristics assessed of 1076 CRC patients were sex, tumor subsite, age at diagnosis, tumor stage, primary treatment option and comorbidity rated by the Charlson Comorbidity Index (CCI). Missing data for stage and comorbidities were completed using multivariate imputation by chained equations. We estimated the probability of receiving surgery versus another primary treatment using multivariable binomial logistic regression models. Univariable and multivariable Cox proportional hazards regression models were used for survival analysis.

RESULTS

Females were older at diagnosis and had less comorbidities than men. There was no difference with respect to treatment decisions between men and women. The probability of receiving a primary treatment other than surgery was nearly twice as high in patients with the highest comorbidity index, CCI 2+, compared with patients without comorbidities. This effect was significantly stronger in women than in men (p-interaction = 0.010). Survival decreased with higher CCI, tumor stage and age in all CRC patients. Sex had no impact on survival.

CONCLUSION

The probability of receiving any primary treatment and survival were independent of sex. However, female CRC patients with the highest CCI appeared more likely to receive other therapy than surgery compared to their male counterparts.

Net survival of patients with colorectal cancer: a comparison of two periods

BACKGROUND

The purpose of our analysis was to compare the results of treatment in patients who underwent resection for colorectal carcinoma.

METHODS

In the period from 1/1/1991 to 31/12/2000 1478 patients with colorectal carcinoma underwent potentially curative resection. We divided them into two 5-year period groups according to different treatment regimes. The 5-year net survival rate was estimated, where the net survival is the probability of survival derived solely from the cancer-specific hazard.

RESULTS

In a 10-year period, we resected 1478 patients. The 5-year net survival rate for R0-resected patients with colon cancer increased from 76.3 to 85.2% between the periods 1991-1995 and 1995-2000. The 5-year net survival rate for R0-resected patients with rectal cancer also increased from 67.5 to 73% in the same period.

CONCLUSION

A comparison of the 5-year net survival rate for R0-resected patients with colorectal cancer increased in the last period from 1995 to 2000 compared with the period from 1991 to 1995. In multivariate analysis, early stage at diagnosis and adjuvant chemotherapy was both associated with better net survival after surgery with curative intent. The improvement of net survival is potentially the result of combination of better surgical and adjuvant therapy.

A 25 year experience of perineal hernia repair

PURPOSE

Though perineal hernias remain rare, the incidence is reportedly rising. Secondary to the historical rarity, optimal method of repair and outcomes after repair remain poorly understood. Therefore, we reviewed the past 25 years of our institutional experience with perineal hernia repair.

METHODS

A retrospective review of an institution-maintained database was conducted from January 1, 1994 to January 31, 2018 for patients undergoing perineal hernia repair. Data were collected on patient characteristics, operative technique, and post-operative outcomes.

RESULTS

Twenty-one patients (n = 12 male) underwent perineal hernia repair in the study period with two-thirds of the operations occurring in the most recent 7 years (since January 1, 2011). The median time to repair was 13 months (range 2-127) after index operation. The approach was transabdominal in nine, perineal in nine, and combined in three. Mesh, a tissue flap, or a combination of these was used in 19 of the cases and 6 additional abdominal wall hernias were repaired concurrently. Post-operative complications consisted of superficial surgical-site infection (n = 2), infected seroma (n = 1), and a missed enterotomy (n = 1). Follow-up ranged from 0 to 112 months (median 2 months) and only one recurrence was noted.

CONCLUSION

Presentation for repair of perineal hernia has increased at our instituion over the past 2 decades. Outcomes did not differ between the three repair approaches and the choice of mesh or tissue-based repair. Surgeons should base these decisions on hernia complexity and local tissue conditions.

Population-based study of effectiveness of neoadjuvant radiotherapy on survival in US rectal cancer patients according to age

Recent cancer researches pay more attention to younger patients due to the variable treatment response among different age groups. Here we investigated the effectiveness of neoadjuvant radiation on the survival of younger and older patients in stage II/III rectal cancer. Data was obtained from Surveillance, Epidemiology, and End Results (SEER) database (n = 12801). Propensity score matching was used to balance baseline covariates according to the status of neoadjuvant radiation. Our results showed that neoadjuvant radiation had better survival benefit (Log-rank P = 3.25e-06) and improved cancer-specific 3-year (87.6%; 95% CI: 86.4-88.7% vs. 84.1%; 95% CI: 82.8-85.3%) and 5-year survival rates (78.1%; 95% CI: 76.2-80.1% vs. 77%; 95% CI: 75.3-78.8%). In older groups (>50), neoadjuvant radiation was associated with survival benefits in stage II (HR: 0.741; 95% CI: 0.599-0.916; P = 5.80e-3) and stage III (HR: 0.656; 95% CI 0.564-0.764; P = 5.26e-08). Interestingly, neoadjuvant radiation did not increase survival rate in younger patients (< = 50) both in stage II (HR: 2.014; 95% CI: 0.9032-4.490; P = 0.087) and stage III (HR: 1.168; 95% CI: 0.829-1.646; P = 0.372). Additionally, neoadjuvant radiation significantly decreased the cancer-specific mortality in older patients, but increased mortality in younger patients. Our results provided new insights on the neoadjuvant radiation in rectal cancer, especially for the younger patients.

Survival among clinical stage I-III rectal cancer patients treated with different preoperative treatments: A population-based comparison

BACKGROUND

Radical resection is regarded as the cornerstone of rectal cancer treatment. Preoperative (chemo)radiotherapy and adjuvant chemotherapy are often administered. This population-based study compares the survival in clinical stage I-III rectal cancer patients who received either preoperative radiotherapy, preoperative chemoradiotherapy or no preoperative therapy. As secondary research questions, the association of type of radical resection and adjuvant chemotherapy on survival is also investigated.

METHODS

Patients diagnosed between January 2006 and December 2011 with stage I-III rectal adenocarcinoma were retrieved from the Belgian Cancer Registry database. Multivariable Cox proportional hazards regression models were applied to evaluate the association of preoperative treatment, type of radical resection and use of adjuvant chemotherapy with survival, adjusting for the baseline characteristics age, gender, WHO performance status and clinical stage.

RESULTS

A total of 5173 rectal cancer patients were identified. Preoperative treatment was as follows: none in 1354 (26.2%), radiotherapy in 797 (15.4%) and chemoradiotherapy in 3022 (58.4%) patients. The patient group who did not receive preoperative therapy or radiotherapy followed by radical resection had a lower observed survival compared to the patient group receiving preoperative chemoradiotherapy. The patient groups who underwent abdominoperineal excision and those receiving adjuvant chemotherapy had a worse observed survival compared to the patient group treated with sphincter-sparing surgery and no adjuvant therapy respectively. These effects were age-dependent. Multivariable analysis demonstrated similar findings for the observed survival conditional on surviving the first year since surgery.

CONCLUSION

In this population-based study among clinical stage I-III rectal cancer patients treated with radical resection, a superior observed survival was noticed in the patient group receiving preoperative chemoradiotherapy compared to the patients groups receiving no or preoperative radiotherapy only, adjusting for case mix, type of radical resection and adjuvant chemotherapy. Additionally, higher adjusted observed survival was also detected for the patient groups with sphincter-sparing surgery or no adjuvant chemotherapy.

Differential effects of patient-related factors on the outcome of radiation therapy for rectal cancer

OBJECTIVE

The objective of this study was to investigate whether cancer specific survival in rectal cancer patients is affected by patient-related factors, conditional on radiation treatment.

METHODS

359 invasive rectal cancer patients who consented and provided questionnaire data for a population-based case-control study of colorectal cancer in Metropolitan Detroit were included in this study. Their vital status was ascertained through to the population-based cancer registry. Hazard ratios (HR) for cancer specific and other deaths and 95% confidence intervals (CIs) were calculated according to selected patients' characteristics, stratified by radiation status, using joint Cox proportional hazards models.

RESULTS

A total of 159 patients were found to be deceased after the median follow-up of 9.2 years, and 70% of them were considered to be cancer specific. Smoking and a history of diabetes were associated with an increased probability of deaths from other causes (HR 3.20, 95% CI 1.72-5.97 and HR 2.02, 95% CI 0.98-4.16, respectively), while regular use of non-steroidal anti-inflammatory drugs (NSAIDs) was inversely correlated with cancer-specific mortality (HR 0.50, 95% CI 0.30-0.81). Furthermore, the associations of smoking and NSAIDs with the two different types of deaths (cancer vs others) significantly varied with radiation status (P-values for the interactions= 0.014 for both). In addition, we observed a marginally significantly reduced risk of cancer specific deaths in the patients who had the relative ketogenic diet overall (HR=0.49, 95% 0.23-1.02).

CONCLUSION

Further research is warranted to confirm these results in order to develop new interventions to improve outcome from radiation treatment.

Gender aspects of survival after surgical treatment for rectal cancer

AIM

Longer survival in women than men after rectal cancer surgery has been reported. Our hypothesis was that after correction for their longer life expectancy a survival benefit for women would still remain.

METHOD

We studied 2792 patients diagnosed with rectal cancer in the southern part of Sweden between 1996 and 2006. The following parameters were included in a prespecified multivariable Cox regression analysis: age at diagnosis, gender, preoperative radiotherapy, stage, year and type of surgery. In addition to overall survival, relative survival was calculated using the Hakulinen approach utilizing an age-, gender- and calendar year-matched Swedish control cohort.

RESULTS

Female patients were significantly older, received neoadjuvant treatment less often and were more often operated on by local excision. Overall survival was significantly longer in women. In the multivariable analysis of relative survival, controlling for neoadjuvant treatment, Dukes stage and year and type of surgery, no significant effect of gender [hazard ratio (HR) 1.10 for men, P = 0.114] was found, whereas an improved relative survival with increased age (HR 0.96 per year, P < 0.001) was seen. In contrast, using the same multivariable model with no correction for underlying mortality in the population, male gender (HR 1.38, P < 0.001) and greater age (HR 1.05 per year, P < 0.001) increased the risk of death.

CONCLUSION

The results show that after correction for the underlying longer survival in women and some known confounders, survival after surgical treatment for rectal cancer appears to be gender neutral.

Insulin-like growth factor receptor-1 overexpression is associated with poor response of rectal cancers to radiotherapy

AIM: To explore the potential correlation between insulin-like growth factor receptor-1 (IGF-1R) expression and rectal cancer radiosensitivity.

METHODS: Eighty-seven rectal cancer patients (cTNM I-III) treated in our department between January 2011 and December 2012 were enrolled. All subjects were treated with preoperative radiotherapy and radical resection of rectal carcinoma. Immunohistochemistry and reverse transcription polymerase chain reaction (RT-PCR) were performed to detect IGF-1R expression in pre-treatment and postoperative colorectal cancer specimens. Radiosensitivity for rectal cancer specimens was evaluated by observing rectal carcinoma mass regression combined with fibrosis on HE staining, degree of necrosis and quantity of remaining tumor cells. The relative IGF-1R expression was evaluated for association with tumor radiosensitivity.

RESULTS: Immunohistochemistry showed diffuse IGF-1R staining on rectal cancer cells with various degrees of signal density. IGF-1R expression was significantly correlated with cTNM staging (P = 0.012) while no significant association was observed with age, sex, tumor size and degree of differentiation (P = 0.424, 0.969, 0.604, 0.642). According to the Rectal Cancer Regression Grades (RCRG), there were 31 cases of RCRG1 (radiation sensitive), 28 cases of RCRG2 and 28 cases of RCRG3 (radiation resistance) in 87 rectal cancer subjects. IGF-1R protein hyper-expression was significantly correlated with a poor response to radiotherapy (P < 0.001, r = 0.401). RT-PCR results from pre-radiation biopsy specimens also showed that IGF-1R mRNA negative group exhibited a higher radiation sensitivity (P < 0.001, r = 0.497). Compared with the pre-radiation biopsy specimens, the paired post-operative specimens showed a significantly increased IGF-1R protein and mRNA expression in the residual cancer cells (P < 0.001, respectively).

CONCLUSION: IGF-1R expression level may serve as a predictive biomarker for radiosensitivity of rectal cancer before preoperative radiotherapy.

Oncological superiority of extralevator abdominoperineal resection over conventional abdominoperineal resection: a meta-analysis

PURPOSE

The oncological superiority, i.e., lower circumferential resection margin (CRM) involvement, lower intraoperative perforation (IOP), and local recurrence (LR) rates, of extralevator abdominoperineal resection (EAPR) over conventional abdominoperineal resection (APR) for rectal cancer is inconclusive. This meta-analysis systematically compared the rates of CRM involvement, IOP, and LR of rectal cancer patients treated by EAPR and APR, respectively.

METHODS

An electronic literature search of MEDLINE, EMBASE, and Cochrane Library through May 2013 was performed by two investigators independently to identify studies evaluating the CRM involvement, IOP, and LR rates of EAPR and APR, and search results were cross-checked to reach a consensus. Data was extracted accordingly. A Mantel-Haenszel random effects model was used to calculate the odds ratio (OR) with 95 % confidence intervals (95 % CI).

RESULTS

Six studies with a total of 881 patients were included. Meta-analysis of CRM involvement and IOP data from all six studies demonstrated significant lower CRM involvement (OR, 0.36; 95%CI, 0.23-0.58; P < 0.0001) and IOP (OR, 0.31; 95%CI, 0.12-0.80; P = 0.02) rates of EAPR. Data from four studies also showed that EAPR was associated with a lower LR rate than APR (OR, 0.27; 95%CI, 0.08-0.95; P = 0.04). No differences of between-study heterogeneity or publication bias were seen in any of the meta-analyses.

CONCLUSIONS

Extralevator abdominoperineal resection could achieve better CRM involvement outcome and lower IOP and LR rates, demonstrating an oncological superiority over conventional abdominoperineal resection.

Patterns of colorectal cancer care in Europe, Australia, and New Zealand

Colorectal cancer is the second most common cancer in women and the third most common in men worldwide. In this study, we used MEDLINE to conduct a systematic review of existing literature published in English between 2000 and 2010 on patterns of colorectal cancer care. Specifically, this review examined 66 studies conducted in Europe, Australia, and New Zealand to assess patterns of initial care, post-diagnostic surveillance, and end-of-life care for colorectal cancer. The majority of studies in this review reported rates of initial care, and limited research examined either post-diagnostic surveillance or end-of-life care for colorectal cancer. Older colorectal cancer patients and individuals with comorbidities generally received less surgery, chemotherapy, or radiotherapy. Patients with lower socioeconomic status were less likely to receive treatment, and variations in patterns of care were observed by patient demographic and clinical characteristics, geographical location, and hospital setting. However, there was wide variability in data collection and measures, health-care systems, patient populations, and population representativeness, making direct comparisons challenging. Future research and policy efforts should emphasize increased comparability of data systems, promote data standardization, and encourage collaboration between and within European cancer registries and administrative databases.

Chronological improvement in survival following rectal cancer surgery: a large-scale, single-center study

BACKGROUND

Total mesorectal excision (TME) and preoperative chemoradiation therapy (PCRT) for rectal cancer are used sequentially in our center. The aim of this study was to evaluate survival of patients with stage II/III rectal cancer chronologically and to determine whether therapeutic advances associated with TME and PCRT have improved patient survival.

METHODS

A retrospective review of 2,197 patients from July 1989 to December 2006 was conducted. The time period (P) for this study was divided into three groups: P1 (1989-1995), P2 (1996-2001) for TME, P3 (2002-2006) for PCRT. Cancer-specific survival (CSS), disease-free survival (DFS), and recurrences among the three periods were investigated.

RESULTS

A total of 293 patients in P1, 836 patients in P2, and 1,068 patients in P3 were enrolled. The 5-year CSS in stages II and III was statistically different between P1/P2 and P3 (stage II, p = 0.008; stage III, p < 0.001). The 5-year DFS was significantly different between P1/P2 and P3 for stage III (p = 0.001). The local recurrence and systemic recurrence rates decreased during P3, but there was no significant difference between the three periods for stage II. For stage III, local recurrence was significantly different between the three periods (P1 vs. P2, p = 0.002; P1 vs. P3, p < 0.001; P2 vs. P3, p = 0.008).

CONCLUSIONS

We identified an improvement in survival for stage II/III rectal cancer and a decrease in local recurrence for stage III rectal cancer during P3, the most recent period. This may be due to frequent application of PCRT based on the TME.

Benefits and drawbacks of short-course preoperative radiotherapy in rectal cancer patients aged 75 years and older

PURPOSE

To study incidence of local recurrences, postoperative complications and survival, in patients with rectal carcinoma aged 75 years and older, treated with either surgery and pre-operative 5 × 5 Gy radiotherapy or surgery alone.

PATIENTS AND METHODS

A random sample of patients aged over 75 years with pT2-T3, N0-2, M0 rectal carcinoma diagnosed between 2002 and 2004 in the Netherlands was included, treated with surgery alone (N = 296) or surgery in combination with pre-operative radiotherapy (N = 346). Information on local recurrent disease, postoperative complications, ECOG-performance score and comorbidity was gathered from the medical files.

RESULTS

Local recurrences developed less frequently in patients treated with pre-operative radiotherapy compared to surgery alone (2% vs 6%, p = 0.002). Postoperative complications developed more frequently in irradiated patients (58% vs 42%, p < 0.0001). Especially deep infections (anastomotic leakage, pelvic abscess) were significantly increased in this group (16% vs 10%, p = 0.02). 30-day mortality was equal in both groups (8%). A significant increase in postoperative complication rate and 30-day mortality was only seen in those with "severe comorbidity" compared to patients without comorbidity (respectively 58% and 10% vs 43% and 3%), COPD (59% and 12%), diabetes (60% and 11%) and cerebrovascular disease (62% and 14%). In multivariable analysis, postoperative complications predicted 5-year survival.

CONCLUSION

Elderly patients receiving pre-operative radiotherapy show a lower local recurrence rate. However, as incidence rates of local recurrent disease are low and incidence of postoperative complications is increased in irradiated patients, omitting preoperative RT may be suitable in elderly patients with additional risks for complications or early death.

Predictors of Colorectal Cancer Survival in Golestan, Iran: A Population-based Study

OBJECTIVES

We aimed to investigate factors associated with colorectal cancer survival in Golestan, Iran.

METHODS

We used a population based cancer registry to recruit study subjects. All patients registered since 2004 were contacted and data were collected using structured questionnaires and trained interviewers. All the existing evidences to determine the stage of the cancer were also collected. The time from first diagnosis to death was compared in patients according to their stage of cancer using the Kaplan-Meir method. A Cox proportional hazard model was built to examine their survival experience by taking into account other covariates.

RESULTS

Out of a total of 345 subjects, 227 were traced. Median age of the subjects was 54 and more than 42% were under 50 years old. We found 132 deaths among these patients, 5 of which were non-colorectal related deaths. The median survival time for the entire cohort was 3.56 years. A borderline significant difference in survival experience was detected for ethnicity (log rank test, p=0.053). Using Cox proportional hazard modeling, only cancer stage remained significantly associated with time of death in the final model.

CONCLUSIONS

Colorectal cancer occurs at a younger age among people living in Golestan province. A very young age at presentation and what appears to be a high proportion of patients presenting with late stage in this area suggest this population might benefit substantially from early diagnoses by introducing age adapted screening programs.

Use of adjuvant chemotherapy in stage C (III) rectal cancer: comparison of data from matched patients in a teaching hospital's clinico-pathological database

AIMS

Controversy continues regarding the treatment of patients with resectable rectal cancer, particularly in regard to the effects of adjuvant therapies on long-term survival. The benefits of adjuvant chemotherapy alone in patients with stage III rectal cancer after curative resection remain unclear. The aim of this study was to compare the overall survival of patients who had received adjuvant chemotherapy after resection of a stage III rectal cancer (111 patients) with the survival of a historical control group who had surgery alone before chemotherapy was introduced (129 patients).

METHODS

Treatment and outcomes data were drawn from a prospective hospital registry of consecutive patients who had a resection for stage III rectal cancer.

RESULTS

The estimated Kaplan-Meier overall 5-year survival rate in patients who received chemotherapy (68.7%, 95% CI 58.3-77.1%, log-rank P < 0.001) was improved compared with the historical controls (40.5%, 95% CI 31.4-49.5%, log-rank P < 0.001). No systematic differences between the treated and control group were found.

CONCLUSION

This study has shown improved survival after adjuvant chemotherapy in patients with stage III rectal cancer as compared with historical controls treated by surgery alone. Hence, there could be subsets of patients whom when treated with surgery in a specialized surgical unit, may benefit from chemotherapy and spared the toxicities of adjuvant radiotherapy. This should be explored further in a cooperative trial group setting.

Extended abdominoperineal excision vs. standard abdominoperineal excision in rectal cancer--a systematic overview

BACKGROUND

After introduction of total mesorectal excision (TME) as the gold standard for rectal cancer surgery, oncologic results appeared to be inferior for abdominoperineal excision (APE) as compared to anterior resection. This has been attributed to the technique of standard APE creating a waist at the level of the tumor-bearing segment. This systematic review investigates outcome of both standard and extended techniques of APE regarding inadvertent bowel perforation, circumferential margin (CRM) involvement, and local recurrence.

METHODS

A literature search was performed to identify all articles reporting on APE after the introduction of TME using Medline, Ovid, and Embase. Extended APE was defined as operations that resected the levator ani muscle close to its origin. All other techniques were taken to be standard. Studies so identified were evaluated using a validated instrument for assessing nonrandomized studies. Rates for perforation, CRM involvement, and local recurrence were compared using chi-square statistics.

RESULTS

In the extended group, 1,097 patients, and in the standard group, 4,147 patients could be pooled for statistical analysis. The rate of inadvertent bowel perforation and the rate of CRM involvement for extended vs. standard APE was 4.1% vs. 10.4% (relative risk reduction 60.6%, p = 0.004) and 9.6% vs. 15.4% (relative risk reduction 37.7%, p = 0.022), respectively. The local recurrence rate was 6.6% vs. 11.9% (relative risk reduction 44.5%, p < 0.001) for the two groups.

CONCLUSION

This systematic review suggests that extended techniques of APE result in superior oncologic outcome as compared to standard techniques.

Assessing the effectiveness of a guideline recommendation for pre-operative radiochemotherapy in rectal cancer

AIM

To ascertain the degree of adherence to the guideline recommendation on pre-operative RT/ChT for stage-II and -III patients in Catalonian public hospitals, and its impact on local recurrence among rectal cancer patients.

METHODS

Data were derived from a multicentre retrospective cohort study of patients who underwent curative-intent surgery for primary rectal cancer at Catalonian public hospitals in 2005 and 2007.

RESULTS

The study covered 1229 patients with TNM stage-II or -III primary rectal cancer. Of these patients, 54.5% underwent pre-operative RT/ChT; 14.9% underwent post-operative RT (± chemotherapy); and 30.6% did not undergo any RT. The crude local recurrence rate at 2years was 4.1% and the crude distant recurrence rate at 2years was 6.5%. The results of the univariate analyses showed a local-recurrence hazard ratio of 1.84 for the group of patients that received no RT versus the group that received pre-operative RT/ChT (p<0.01).

CONCLUSIONS

This is the first population-based study in Catalonia to support the use of pre-operative RT/ChT in rectal cancer patients because, in line with the results of population-based studies reported from other countries, its application, compared to non-application of RT, was found to lead to a clear reduction in the probability of local recurrence.

Chemotherapy in rectal cancer: variation in utilization and development of an evidence-based benchmark rate of optimal chemotherapy utilization

BACKGROUND

Published chemotherapy utilization rates for rectal cancer show considerable variation. Optimal chemotherapy utilization rates can serve as benchmarks to assess the quality of cancer care. The purpose of this study was to determine the optimal proportion of patients with rectal cancer who should receive chemotherapy at least once.

PATIENTS AND METHODS

An optimal chemotherapy utilization tree was constructed using indications for chemotherapy identified from evidence-based treatment guidelines. Epidemiologic data were merged with treatment indications to calculate an optimal chemotherapy utilization rate; this rate was compared with reported actual rates of chemotherapy utilization.

RESULTS

Chemotherapy is indicated at least once in 64% of patients with rectal cancer. Although the actual (Australian and United States data) and optimal utilization rates are comparable for patients presenting in stages II or III rectal cancer, actual utilization rates are higher than the optimal for stage I and lower than optimal for patients presenting in stage IV rectal cancer.

CONCLUSION

Chemotherapy may be under-utilized in the initial management of patients presenting with metastatic rectal cancer.

Risk factors of rectal cancer local recurrence: population-based survey and validation of the Swedish rectal cancer registry

AIM

Despite advances in rectal cancer treatment, local recurrence (LR) remains a significant problem. To select high-risk patients for different treatment options aimed at reducing LR, it is essential to identify LR risk factors.

METHOD

Local recurrence and survival rates of 4153 patients registered 1995-1997 in the Swedish Rectal Cancer Registry were analysed. LR risk factors were analysed by multivariate methods. For LR patients the registry was validated and additional data retrieved.

RESULTS

The 5-year overall and cancer-specific survival rates were 45% and 62% respectively. LR was registered in 326 (8%) patients. After R0-resections for tumours in TNM stages I-III, LR developed in 10% of tumours at 0-5 cm, 8% at 6-10 cm and 6% at 11-15 cm above the anal verge. Preoperative radiotherapy (RT) reduced the LR rate irrespective of height [0-5 cm: OR 0.50 (0.30-0.83), 6-10 cm: OR 0.42 (0.25-0.71), and 11-15 cm: OR 0.29 (0.13-0.64)]. Patients without preoperative RT had significantly higher LR risk after rectal perforation [OR 2.50 (1.48-4.24)], and almost significantly decreased LR risk when rectal washout was performed [OR 0.65 (0.43-1.00)]. Preoperative RT prolonged time to LR but did not significantly influence the survival among LR patients. LR was an isolated tumour manifestation in 103 (39%) patients with validated LR.

CONCLUSION

Preoperative RT should be considered for rectal cancer also in the upper third of the rectum. Intraoperative perforation should be avoided, and rectal washout is indicated as valuable. Follow-up for the detection of isolated LR is important. Extended follow up should be considered for patients treated with RT.

Trends in colorectal cancer in the south of the Netherlands 1975-2007: rectal cancer survival levels with colon cancer survival

OBJECTIVE

In the Netherlands over 11 200 patients are yearly diagnosed with colorectal cancer (CRC), of who about 4 700 are expected to die of the disease ultimately. Investigating long-term trends is useful for clinicians and policy makers to evaluate the impact of changes in practice and will help predict future developments.

PATIENTS

The 26 826 cases of primary CRC (C18.0-C20.9) diagnosed between 1975 and 2007 in the Dutch population-based Eindhoven Cancer Registry area were included. We analysed trends in incidence, prevalence, stage distribution, treatment, survival, and mortality.

RESULTS

The age-standardised incidence of colon carcinoma kept increasing, most markedly in males (up to 39 patients per 100 000 inhabitants) and for tumours of the colon ascendens (subsite-specific incidence doubled). The incidence of rectal carcinoma remained stable. The share of patients aged 80 or older rose from 12 to 19% (p<0.0001). The proportion of patients diagnosed with distant metastases increased up to 25% for colon carcinoma (p<0.0001). Resection rates of the primary tumour remained high except for patients with metastasised disease, showing a decrease since 2000. Recently, the use of adjuvant chemotherapy seemed to level off among patients with stage III colon carcinoma, but the use of neo-adjuvant chemoradiation clearly increased among patients with stage II/III rectal cancer (p<0.0001). Five-year relative survival of colon cancer improved from 51% in 1975-1984 to 58% in 2000-2004, for rectal cancer it improved from 44 to 59%. Two-year relative survival of colon cancer in 2005-2006 was 69%, and 77% for rectal cancer.

CONCLUSIONS

The changes in management of rectal cancer led to a superior increase in survival of these patients compared to patients with colon cancer, even surpassing the latter.

Variation in treatment and outcome of patients with rectal cancer by region, hospital type and volume in the Netherlands

BACKGROUND

Aim of this study was to describe treatment patterns and outcome according to region and hospital type and volume among patients with rectal cancer in the Netherlands.

METHODS

All patients with rectal carcinoma diagnosed in the period 2001-2006 were selected from the Netherlands Cancer Registry. Logistic regression analyses were performed to examine the influence of relevant factors on the odds of receiving preoperative radiotherapy and on the odds of postoperative mortality. Relative survival analysis was used to estimate relative excess risk of dying according to hospital type and volume.

RESULTS

In total, 16 039 patients were selected. Patients diagnosed in a teaching or university hospital had a lower odds (OR 0.85; 95% CI 0.73-0.99 and OR 0.70; 95% CI 0.52-0.92) and patients diagnosed in a hospital performing >50 resections per year had a higher odds (OR 1.95; 95% CI 1.09-1.76) of receiving preoperative radiotherapy. A large variation between individual hospitals in rates of preoperative radiotherapy and between Comprehensive Cancer Centre-regions in the administration of preoperative chemoradiation was revealed. Postoperative mortality was not correlated to hospital type or volume. Patients with T1-M0 tumours diagnosed in a hospital with >50 resections per year had a better survival compared to patients diagnosed in a hospital with <25 resections per year (RER 0.11; 95% CI 0.02-0.78).

CONCLUSION

This study demonstrated variation in treatment and outcome of patients with rectal cancer in the Netherlands, with differences related to hospital volume and hospitals teaching or academic status. However, variation in treatment patterns between individual hospitals proved to be much larger than could be explained by the investigated characteristics. Future studies should focus on the reasons behind these differences, which could lead to a higher proportion of patients receiving optimal treatment for their stage of the disease.

Was there shortening of the interval between diagnosis and treatment of colorectal cancer in southern Netherlands between 2005 and 2008?

BACKGROUND

The Dutch Cancer Society proposed that the interval between diagnosis and start of treatment should be less than 15 working days. The purpose of this study was to determine whether the interval from diagnosis to treatment for patients with colorectal cancer (CRC) shortened between 2005 and 2008 in hospitals in southern Netherlands.

METHODS

Patients with CRC diagnosed in six hospitals in southern Netherlands during January to December in 2005 (n = 445) and January to July in 2008 (n = 353) were included. The time between diagnosis and start of treatment was assessed, and the proportion of patients treated within the recommended time (<15 working days) was calculated.

RESULTS

The time to treatment for colon cancer patients was 13 working days in 2005 and 17 working days in 2008. For rectal cancer patients, the median time to preoperative radiotherapy was 28 working days in 2005 and 30 working days in 2008, and the median time to surgical treatment for rectal cancer patients was 26 working days in 2005 and 18 working days in 2008. Time to treatment did not shorten between 2005 and 2008 for colon and rectal cancer patients, except for rectal cancer patients who underwent surgery as initial treatment in patients aged >70 years and those with stage I disease. Substantial variation was seen among hospitals.

CONCLUSIONS

Time to treatment for patients with CRC in southern Netherlands did not shorten between 2005 and 2008. The time to treatment should be reduced to meet the advice of the Dutch Cancer Society.

Adjuvant chemotherapy in elderly patients with colorectal cancer. A retrospective analysis of the implementation of tumor board recommendations in a single institution

BACKGROUND

A number of studies have shown that elderly cancer patients were denied optimal anticancer treatment because of age. Colorectal cancer is among the most frequent cancers in Western countries, and adjuvant chemotherapy has proven efficacy and tolerance in this condition. This study was undertaken to explore the current approaches to adjuvant chemotherapy in elderly cancer patients in a single institution.

PATIENTS AND METHODS

We retrospectively analyzed all patients' files that were discussed in the gastro-intestinal tumor board of the Hôpitaux Universitaires de Strasbourg during 3 years (2004-2006). The recorded variables included sex, age, tumor stage, cancer location colon vs rectum, number of comorbidities, occurrence of an oncogeriatric assessment, type and tolerance of chemotherapy. We investigated the reason to not administer adjuvant therapy in patients whom should have received this treatment if guidelines had to be applied.

RESULTS

A total of 193 consecutive patients' files were extracted from colorectal cancer patients that had been discussed in the gastro-intestinal tumor board. Among these, we isolated patients over 70 years old who were proposed with either adjuvant chemotherapy (group A, n=65) or follow up (group B, n=128). The median age in group A was 75.3 years old. Tumor board recommendations were in accordance with guidelines in 91% of cases. Chemotherapy was delivered in 44 pts (76%) and completed in 42 (95%). The median age in group B was 78.6 years old, and in this group tumor board proposal met the guidelines in 83% of cases. In the logistic regression model, disease stage was the major variable leading to adjuvant treatment recommendation, age and comorbidities being of lesser importance.

CONCLUSIONS

In our series, elderly colorectal cancer patients are not undertreated. Efforts should be maintained to educate physicians with regard to feasibility of adjuvant chemotherapy in elderly patients.

Improvable quality of diagnostic assessment of colorectal cancer in southern Netherlands

OBJECTIVE

To determine the extent of guideline implementation of the diagnostic approach in patients with colorectal cancer (CRC) in southern Netherlands in 2005, with special focus on colonoscopy.

METHODS

Data were extracted from the medical records for a random sample of 257 colon and 251 rectal cancer patients newly diagnosed in 2005 and recorded from the Eindhoven Cancer Registry. Adherence to guidelines was determined for diagnostic assessment. Multivariable logistic regression analysis was conducted to assess determinants of complete colonoscopy.

RESULTS

Diagnostic assessment was carried out mainly by internists (50%) and gastroenterologists (36%). Colonoscopy was performed in 83% of patients with proximal/transverse colon cancer, 55% of those with distal colon cancer, and 65% of those with rectal cancer. A tumour biopsy was taken for 84% of colon and 93% of rectal tumours. Colonoscopy completeness was lower for patients with comorbidity, obstructing tumours, and patients with poor bowel preparation. Abdominal ultrasound was performed for 72% of colon and 52% of rectal cancer patients and a thoracic radiography of over 80% of CRC patients. Computed tomography (CT) of the abdomen was performed in over half of the colon cancer patients and a pelvic CT scan or magnetic resonance imaging in 36% of rectal cancer patients.

CONCLUSION

Improvements in adherence to diagnostic guidelines for CRC appear possible, especially in the performance of imaging procedures. Among patients where complete visualization of the colon was not feasible with colonoscopy, imaging techniques such as virtual CT might be of added value in the near future.

Comparison of colorectal and gastric cancer: survival and prognostic factors

BACKGROUND/AIMS

Gastric and colorectal cancers are the most common gastrointestinal malignancies in Iran. We aim to compare the survival rates and prognostic factors between these two cancers.

METHODS

We studied 1873 patients with either gastric or colorectal cancer who were registered in one referral cancer registry center in Tehran, Iran. All patients were followed from their time of diagnosis until December 2006 (as failure time). Survival curves were calculated according to the Kaplan-Meier Method and compared by the Log-rank test. Multivariate analysis of prognostic factors was carried out using the Cox proportional hazard model.

RESULTS

Of 1873 patients, there were 746 with gastric cancer and 1138 with colorectal cancer. According to the Kaplan-Meier method 1, 3, 5, and 7-year survival rates were 71.2, 37.8, 25.3, and 19.5%, respectively, in gastric cancer patients and 91.1, 73.1, 61, and 54.9%, respectively, in patients with colorectal cancer. Also, univariate analysis showed that age at diagnosis, sex, grade of tumor, and distant metastasis were of prognostic significance in both cancers (P < 0.0001). However, in multivariate analysis, only distant metastasis in colorectal cancer and age at diagnosis, grade of tumor, and distant metastasis in colorectal cancer were identified as independent prognostic factors influencing survival.

CONCLUSIONS

According to our findings, survival is significantly related to histological differentiation of tumor and distant metastasis in colorectal cancer patients and only to distant metastasis in gastric cancer patients.

Inequity in colorectal cancer treatment and outcomes: a population-based study

Several uncertainties surround optimal management of colorectal cancer. We investigated treatment patterns and factors influencing treatment receipt and mortality in routine clinical practice. We included 15 249 individuals, recorded by the National Cancer Registry (Ireland), with primary invasive colon or rectal tumours, diagnosed during 1994–2002. Logistic regression and Cox proportional hazards were used to determine factors associated with treatment receipt within 1 year of diagnosis and with mortality, respectively. A total of 78% had colorectal resection, 31% chemotherapy, and 13% radiotherapy (4% colon; 28% rectum). Half of stage IV patients underwent resection. Chemotherapy and radiotherapy use increased by at least 10% per annum. There was a notable increase in pre-operative radiotherapy from 2000 onwards. Patient-related factors were significantly associated with treatment receipt. Patients who were male, older, not married, or smokers had significantly higher risks of death. Chemotherapy was significantly associated with lower mortality for stage III, but not stage II, colon cancer. For rectal cancer, pre-operative radiotherapy was associated with reduced mortality. Surgery and chemotherapy were associated with longer survival for stage IV patients. The observed inequities in treatment and outcomes suggest that there is potential for further dissemination of therapies in routine practice. Improving treatment availability overall, and equity, has the potential to reduce mortality.

Prognostic factors in 1,138 Iranian colorectal cancer patients

BACKGROUND AND AIM

The incidence of colorectal cancer is increased in Iran in recent years and colorectal cancer is the fourth most common cancer in both sexes. The aim of this study is to define the prognostic factors in Iranian colorectal cancer patients using univariate and multivariate methods.

MATERIALS AND METHODS

All patients with colorectal cancer diagnosis according to the pathology report that registered in our cancer registry center in the period between Jan 2002 until Jan 2007 were eligible for this study. These patients were followed up by telephone contact. The probability curves for survival were calculated according to the Kaplan-Meier method and compared by the Log-rank test. Multivariate analysis was carried out using the Cox proportional hazard model.

RESULTS

Of 1,138 cases, a survival information was available on 1,127 patients, 690 males (61.2%) and 437 females (38.8%). Mean survival time was 105.1 (CI: 95.1-115.1) months. The Kaplan-Meier method indicated that the 1, 3, 5, 7, 10, and 15 years of survival rates are 91.1%, 73.1%, 61.0%, 54.9%, 47.9%, and 25.9%, respectively. According to the univariate analysis, the factors influencing overall survival rate were the following: type of first treatment, body mass index, marital status, tumor grade, extent of wall penetration, distant metastasis, regional lymph nodes metastasis, and pathologic stage of tumor. The following five variables were independent prognostic factors for survival as determined by multivariate analysis: tumor size, metastasis of tumor, body mass index, marital status, and grade of tumor.

CONCLUSION

Our results showed that stage of tumor, distant metastasis, grade of tumor, and tumor size should be considered as the most important prognostic factors in colorectal cancer patients.

Improved overall survival for patients with rectal cancer since 1990: the effects of TME surgery and pre-operative radiotherapy

AIM

The aim was to study the effects of the introduction of TME surgery and pre-operative radiotherapy on overall survival (OS) by comparing patients treated in the period before (1990-1995), during (1996-1999) and after (2000-2002) the TME trial.

PATIENTS AND METHODS

Patients diagnosed with rectal carcinoma in the region of Comprehensive Cancer Centres South and West were used (n=3179).

RESULTS

Five-year OS was, respectively, 56%, 62% and 65% in the pre-trial, trial and post-trial periods (p<0.001). Pre-operative RT was increasingly used over time and significantly related to OS in the post-trial period (p=0.002), but not in the pre-trial and trial periods.

CONCLUSIONS

Population-based OS improved markedly since the introduction of TME surgery. With standardised TME surgery, pre-operative RT improved OS, whereas withholding pre-operative RT was associated with a poorer prognosis. The present study supports that pre-operative RT was correctly introduced as a standard treatment before TME surgery in our national guideline.

Controversies of total mesorectal excision for rectal cancer in elderly patients

The cornerstone of treatment for rectal cancer is resectional treatment according to the principles of total mesorectal excision (TME). However, population-based registries show that improvements in outcome after resectional treatment occur mainly in younger patients. Furthermore, 6-month postoperative mortality is significantly increased in elderly patients (> or = 75 years of age) compared with younger patients (< 75 years of age). Several confounding factors, such as treatment-related complications and comorbidity, are thought to be responsible for these disappointing findings. Thus, major resectional treatment is not advantageous for all older patients with rectal cancer. However, the Dutch TME trial showed a good response to a short course of neoadjuvant radiotherapy in elderly patients. Biological responses to cancer treatment seem to change with age, and, therefore, individualised cancer treatments should be used that take into account the heterogeneity of ageing. For elderly patients who retain a good physical and mental condition, treatment that is given to younger patients is deemed appropriate, whereas for those with diminished physiological reserves and comorbid conditions, alternative treatments that keep surgical trauma to a minimum and optimise the use of radiotherapy might be more suitable.

Survival and treatment trends of rectal cancer patients in a population with suboptimal local control

AIM

To explore trends in rectal cancer survival in Manitoba, particularly in patients where local control was an issue.

METHOD

Patients diagnosed with rectal or rectosigmoid adenocarcinoma from 1985 to 1999 were included. Demographic, treatment and mortality information were abstracted from the registry. Relative survival was examined for all patients for the periods 1985-1989, 1990-1994 and 1995-1999, and subsequently limited to those who underwent major surgery (Hartmann's, anterior, and abdominal perineal resection).

RESULTS

Of the 2925 patients identified, 2163 (74%) had undergone a major surgery. Five-year relative survival was 46%, 54% and 53% for all patients for the three periods, respectively; major surgery results were 53%, 59% and 60%. Radiotherapy was used in 32% of cases in 1985-1989 and in 40% of cases in 1995-1999. Chemotherapy was used in 13% of cases in 1985-1989 and in 37% of cases in 1995-1999.

CONCLUSION

Consistent with other studies, overall rectal cancer survival in Manitoba has improved since 1985. Better local control, as suggested in other studies, does not appear to be a major factor in that improvement. Future work should include review of the local control strategy in Manitoba and factors to explain the improved survival.

A population-based study of radiotherapy in a cohort of patients with rectal cancer diagnosed between 1996 and 2000

AIMS

To study, in a population-based setting, the use of delayed radiotherapy (RT) in a cohort of 2008 unselected rectal cancer patients diagnosed between 1996 and 2000.

PATIENTS AND METHODS

Radiation within 6 months of diagnosis was considered part of the primary treatment (PRT). RT given 6 months or later after diagnosis or after PRT was considered as delayed or secondary RT (SRT). Number, percentage and cumulative proportion of patients receiving SRT were calculated. The odds for receiving SRT (total and for recurrent rectal cancer only) were studied by logistic regression analysis, taking into account age, gender, co-morbidity, socio-economic status, stage, prior PRT and RT department (2 departments, each serving general hospitals only).

RESULTS

Forty-six percent of all newly diagnosed patients received RT. Ten percent (n=203) received at least once SRT, either after PRT or as first RT, of which 96 patients for a relapsed rectal tumour (31 after PRT on the rectal tumour, 65 as a first radiation treatment). In a multivariate analysis of patients with rectal recurrence secondary pelvic irradiation was less often given after primary irradiation (OR: 0.7, 95% CI: 0.4-1.1). Patients with a stage III significantly more often received SRT on a recurrence (OR=2.5, 95% CI=1.4-4.5). Generally, patients in the eastern department received more often PRT and less often SRT for recurrence (OR: 0.5, 95% CI: 0.3-0.8).

CONCLUSIONS

Five percent of all patients with rectal cancer received SRT on a recurrent tumour, with a large variation between the two RT departments in the region.

Management and survival of colorectal cancer in the elderly in population-based studies

Colorectal cancer is a major problem in elderly patients. Most data on the management and survival of colorectal cancer has been provided by specialised hospital units and as such cannot be used as reference because of unavoidable selection bias. Cancer registries recording data on treatment and survival at a population level represent the best valuable resource to assess the management of patients. However, there is a paucity of reports published in the literature due to the difficulty to routinely collect such data. Relative survival rates in the elderly were lower than in younger patients. However, the gap that has separated younger from elderly patients is closing. Stage at diagnosis remains the major determinant of prognosis. There is also large variation in survival within countries: survival rates being dramatically lower in Eastern European countries, compared to Western European countries. Comorbidity, which is particularly frequent in the elderly, increases the complexity of cancer management and affects survival. Substantial improvement in the care of colorectal cancer in the elderly has been achieved (increase in the proportion of patients resected for cure, decrease in operative mortality, improvement in stage at diagnosis). Surgery should not be restricted on the basis of age alone. Further improvements can be made, in particular with respect to adjuvant therapy.

Survival of elderly rectal cancer patients not improved: analysis of population based data on the impact of TME surgery

INTRODUCTION

The incidence of rectal cancer is highest in elderly patients. However, these patients are often underrepresented in randomised studies. Therefore, it is not clear whether results of rectal cancer studies are equally applicable to both elderly and younger patients. In this paper, the Dutch Total Mesorectal Excision (TME) study is revisited, focused on patients aged 75 years and above. The rectal cancer databases of the Comprehensive Cancer Centres (CCC) South and West were combined to analyse the effect of the TME-study in three different periods: before (1990-1995), during (1996-1999) and after (2000-2002) the trial.

RESULTS

Implementation of preoperative radiotherapy, as investigated in the TME trial, and the introduction of TME surgery resulted in improved 5 year survival during the subsequent periods, in patients younger than 75 years, of 60% (1990-1995) to 67% (1996-1999) and 70% (2000-2002) (log rank p<0.0001). The older patients did not improve and remained at 41%, 40% and 43% at 5 years in the respective periods. Furthermore, mortality during the first 6-month period after treatment is significantly raised compared to younger patients: 14% in the elderly, compared to 3.9% in the younger TME-study patient (p<0.0001 X2). In the CCC database these figures were confirmed at 16% and 3.9% (p<0.0001 X2).

CONCLUSION

Overall survival was not improved in the elderly rectal cancer patient after introduction of preoperative radiotherapy and TME-surgery. Non-cancer related mortality is a significant problem in the first 6 months after surgery.

Patterns of care for adjuvant therapy in a random population-based sample of patients diagnosed with colorectal cancer

OBJECTIVES

Over the past decade, clinical trials have proved the efficacy of treatments for colorectal cancer (CRC). This study tracks dissemination of these treatments for patients diagnosed with stage II and III disease and compares risk of death for those who received guideline therapy to those who did not.

METHODS

We conducted a stratified randomly sampled, population-based study of CRC treatment trends in the United States. Multivariate models were used to explore patient characteristics associated with receipt of treatments. We pooled data with a previous study-patients diagnosed in 1987-1991 and 1995. Cox proportional hazards models were used to assess observed cause-specific and all-cause mortality.

RESULTS

In 2000, guideline therapy receipt decreased among stage III rectal cancer patients, but increased for stage III colon and stage II rectal cancer patients. As age increased, likelihood of receiving guideline treatment decreased (p < 0.0001). Overall, race/ethnicity was significantly associated with guideline therapy (p = 0.04). Rectal patients were less likely to have received guideline treatment. Consistent with randomized clinical trial findings, all-cause mortality was lower in patients who received guideline therapy, regardless of Charlson comorbidity score.

CONCLUSIONS

Mortality was decreased in patients receiving guideline therapy. Although, rates of guideline-concordant therapy are low in community clinical practice, they are apparently increasing. Newer treatment (oxaliplatin, capecitabine) started to disseminate in 2000. Racial disparities, present in 1995, were not detected in 2000. Age disparities remain despite no evidence of greater chemotherapy-induced toxicity in the elderly. More equitable receipt of cancer treatment to all segments of the community will help to reduce mortality.

Trends in survival and excess risk of death after diagnosis of cancer in 1980-1996 in New South Wales, Australia

Survival from almost all cancers has improved during the last 30 years. There is debate over the reasons for the improvement. We examined trends in survival for 28 cancers from 1980 to 1996 in New South Wales (NSW), Australia, with adjustment for disease spread at diagnosis. NSW Central Cancer Registry data were used to estimate 5-year relative survival and relative excess risk of death for patients diagnosed in 1980-84, 1985-88, 1989-92 and 1993-96. Statistical significance of variation in excess deaths between periods of diagnosis was assessed using Poisson regression, with adjustment for age, sex, duration of follow-up, histology and spread of disease at diagnosis. There were statistically significant falls in excess deaths for 20 of the cancers with a 25% fall for all cancers combined. Cancers of the prostate, liver, thyroid, breast, gallbladder, body of uterus, rectum, cervix and ovary had falls of >30%. The falls varied by spread of disease; the largest being in localised and regionally spread tumours. Overall survival, when unadjusted for spread of cancer, generally fell in parallel with that in the specific categories of spread, which implies that stage migration did not contribute importantly to survival trends. While acknowledging the limitations of incomplete data on stage of cancer at diagnosis, we conclude that falls in excess deaths in NSW from 1980 to 1996 are unlikely, for many cancers, to be attributed to earlier diagnosis or stage migration; thus advances in cancer treatment have almost certainly contributed to them.

Survival from rectal and anal cancers in England and Wales, 1986–2001

The aim of this study was to investigate the effects of tumour and patient characteristics on trends in the survival of patients with cancer of the anus or rectum in England and Wales. A total of 132,542 adults (15-99 years) who were diagnosed during the 14 years 1986-1999 were followed up to 2001 through the National Health Service Central Register. Relative survival up to 5 years after diagnosis was estimated, using deprivation-specific life tables. Generalised linear models were used to estimate relative excess risks of death, adjusted for patient and tumour characteristics. The results showed that 5-year relative survival was higher in women, younger patients and more affluent patients, and higher for anal cancer than rectal cancer. Survival improved by more than 10% from the late 1980s (around 38%) to the late 1990s (49%). This trend was not explained by changes in the distribution of age, anatomical site, morphology or deprivation. The trend was more marked in younger and more affluent patients, and for adenocarcinoma and epidermoid carcinoma than for tumours with other morphology. The inequality in survival between affluent and deprived patients widened. It is concluded that improvements in survival may reflect improvements in disease stage, diagnostic technique or treatment. Which of these factors contribute to the widening socioeconomic inequalities in survival remains to be elucidated.

Elderly patients with rectal cancer have a higher risk of treatment-related complications and a poorer prognosis than younger patients: a population-based study

It is likely that the shift from post- to pre-operative radiotherapy and the introduction of total mesorectal excision (TME) surgery have contributed to the observed improved survival of rectal cancer in the south of the Netherlands. However, no improvement was seen for patients aged 70 or older. To investigate possible causes of this lack of improvement, we examined the risk of treatment-related complications and overall survival. Therefore, a random sample of 455 patients with rectal cancer aged 60 years or older, diagnosed between 1995 and 2001 was extracted from in the Eindhoven Cancer Registry database. Fifty-one percent of patients aged 60-69 years-old had any complication within one year of diagnosis compared to 65% of patients aged 70 or older (p=0.007). Older patients were at higher risk of developing treatment-related complications (odds ratio (OR) 1.8; p=0.01), as were patients with comorbidity (OR 1.7; p=0.07), and those who received pre-operative radiotherapy (OR 1.8; p=0.02). In a multivariable analysis, age older than 70 (hazard ratio (HR) 2.2; p<0.0001), comorbidity (HR 1.7; p=0.03), and having two or more complications (HR=2.2; p=0.0002) had a negative effect on survival. The lack of improvement in the prognosis of elderly patients with rectal cancer after a shift from post- to preoperative radiotherapy might partially be explained by a higher risk of treatment-related complications. In order to optimise the risk/benefit ratio of elderly patients, individualisation of treatment by means of a comprehensive geriatric assessment will be of critical importance.

Growth hormone receptor overexpression predicts response of rectal cancers to pre-operative radiotherapy

In this study, we evaluated the possible role of Growth Hormone Receptor (GHR) expression pattern in determining rectal cancer radiosensitivity. We examined GHR expression in pre-treatment biopsy materials and post-operative specimens from 98 patients by immunohistochemistry (IHC) and reverse transcription-polymerase chain reaction (RT-PCR). GHR expression was evaluated for association with tumour radiosensitivity, which was defined according to Rectal Cancer Regression Grade (RCRG). IHC results demonstrated that GHR overexpression was significantly associated with a poor response to radiotherapy (P < 0.001, r(s) = 0.399); RT-PCR detection of GHR expression on pre-radiation biopsy specimens also showed that GHR mRNA negative group had a higher radiation sensitivity (P < 0.001, r(s) = 0.398). Compared with the pre-radiation biopsy specimens, the paired post-operative specimens showed a significantly up-regulated GHR expression in the reliquus cancer cells (P < 0.001). In conclusion, GHR expression levels may be an indicator for rectal cancer radiosensitivity before pre-operative irradiation. The administration of GHR antagonist may have the potential to increase rectal cancer radiosensitivity.

Surgery and pre-operative irradiation for locally advanced or recurrent rectal cancer in patients over 75 years of age

OBJECTIVE

Reports of multimodal treatment regimens especially focusing on locally advanced or recurrent rectal cancer in the elderly, aged>75 years, are unavailable. We have tried to identify and evaluate pre- and peri-operative risk factors for morbidity and mortality and outcome after irradiation/surgery regimens in such patients.

PATIENTS AND METHODS

Prospective registration of 86 consecutive patients aged>75 years undergoing elective surgery after irradiation 46-50 Gy for either primary locally advanced rectal cancer (n=51) or recurrent rectal cancer (n=35) from January 1991 to August 2003, 51 men and 35 women, median age 78 years (range 75-85 years) in a national cancer hospital.

RESULTS

Multivisceral resections were needed in 63% of patients and 70% R0 resections were obtained in locally advanced cases and 46% in recurrent ones. Both in-hospital- and 30-day-mortality was 3.5%. Sixty-two postoperative complications occurred in 38 patients, three of them fatal. Both operation times over 5 h and transfusion of more than 3 SAG were prognostic factors regarding infections. Estimated five-year survival in R0 patients was 46%. Estimated five-year survival for patients with nonmetastatic tumours with locally advanced primary cancer was 29% and for locally recurrent rectal cancer 32%. Old males had a higher mortality rate the first year after surgery than females with only 65% relative survival compared to a matched normal population. The estimated five-year local recurrence rates were 24% for R0 resections and 54% for R1 resections (P=0.434 ns) and 24% and 45% for locally advanced and recurrent rectal cancer (P=0.248 ns), respectively.

CONCLUSION

Thorough pre-operative evaluation and preparation and judicious surgery are important for achieving potentially curative treatment with acceptable morbidity in locally advanced and recurrent rectal cancer in patients over 75 years of age. We suggest that these patients should be evaluated and considered for treatment by multidisciplinary teams as younger patients.

Mixed adherence to clinical practice guidelines for colorectal cancer in the Southern Netherlands in 2002

AIMS

Population-based cancer registries can provide excellent data for insight in disease management practice. This study examines the extent to which the consensus-based national clinical guidelines (version 2000-2001) for colorectal cancer (CRC) had been implemented in the diagnostic and treatment approach in the Southern Netherlands in 2002.

METHODS

Data were gathered from the medical records for a random sample from the Eindhoven Cancer Registry of 308 patients with colorectal cancer. Adherence to clinical guidelines was determined for diagnostic assessment, pathology, and treatment during the first year after diagnosis.

RESULTS

Surgical procedures and referral for pre-operative radiotherapy were carried out largely conform the recommendations. The number of performed colonoscopies among colon cancer patients amounted to 60%; contrast enemas after incomplete colonoscopy were performed in only 27% of patients. The median number of examined lymph nodes was only six for patients with colon and five for patients with rectal cancer; the administration of adjuvant chemotherapy for patients with stage III colon cancer decreased from 95% of patients younger than 70 years to 48% of patients over 70.

CONCLUSIONS

Adherence to clinical guidelines was not optimal. Feedback to surgeons and pathologists should improve adherence, especially with respect to nodal retrieval and assessment.

Higher long-term cancer survival rates in southeastern Netherlands using up-to-date period analysis

BACKGROUND

The aim was to compare long-term survival rates for different types of cancer estimated by means of up to date period analysis with those from more traditional cohort analysis.

PATIENTS AND METHODS

Data from the Eindhoven Cancer Registry were used. In total 140,137 newly diagnosed patients diagnosed between 1980 and 2002 and followed until 1 January 2005 were included. Five-, 10- and 20-year relative survival rates were calculated.

RESULTS

For total cancer in men and women, childhood cancer, rectal cancer, melanoma in women, breast cancer, prostate cancer and all leukaemias, much higher 10-year survival rates were found with period analyses (differences with cohort analyses were 5.1%, 3.6%, 7.4%, 5.6%, 6.5%, 4.0%, 5.1% and 10.5%, respectively). For laryngeal and bladder cancer the 10-year survival rates estimated with period analyses were about 7.5% lower compared with those estimated by means of cohort analyses.

CONCLUSIONS

Period analysis, based on the most recent period of diagnosis, enabled us to show higher survival rates for total cancer, childhood cancer, rectal cancer, melanoma, breast cancer, prostate cancer and acute leukaemia, but also lower rates for laryngeal and bladder cancer. Period analysis should be the preferred tool for showing up-to-date survival rates to cancer patients and their physicians.

How much can current interventions reduce colorectal cancer mortality in the U.S.?

BACKGROUND

Although colorectal cancer (CRC) is the second leading cause of cancer death in the U.S., available interventions to reduce CRC mortality are disseminated only partially throughout the population. This study assessed the potential reduction in CRC mortality that may be achieved through further dissemination of current interventions for risk-factor modification, screening, and treatment.

METHODS

The MISCAN-COLON microsimulation model was used to simulate the 2000 U.S. population with respect to CRC risk-factor prevalence, screening use, and treatment use. The model was used to project age-standardized CRC mortality from 2000 to 2020 for 3 intervention scenarios.

RESULTS

Without changes in risk-factor prevalence, screening use, and treatment use after 2000, CRC mortality would decrease by 17% by the Year 2020. If the 1995 to 2000 trends continue, then the projected reduction in mortality would be 36%. However, if trends in the prevalence of risk-factors could be improved above continued trends, if screening use increased to 70% of the target population, and if the use of chemotherapy increased among all age groups, then a 49% reduction would be possible. Screening drove most (23%) of the projected mortality reduction with these optimistic trends; however, decreasing risk-factors (16%) and increasing use of chemotherapy (10%) also contributed substantially. The contribution of risk-factors may have been overestimated, because effect estimates could not be obtained from randomized controlled trials.

CONCLUSIONS

Currently available interventions for risk-factor modification, screening, and treatment have the potential to reduce CRC mortality by almost 50% by the Year 2020. However, without action now to further increase the uptake of current effective interventions, the reduction in CRC mortality may be only 17%.

The impact of diagnosis and treatment of rectal cancer on paid and unpaid labor

PURPOSE

This study was designed to describe the consequences of diagnosis and treatment of rectal cancer for paid and unpaid labor over time and to identify sociodemographic-related factors, treatment-related factors, and quality of life-related factors associated with paid and unpaid labor.

METHODS

Data were assessed prospectively in two samples of patients with primary rectal cancer, participating in a multicenter clinical trial, who were randomized to receive surgery with or without 5 x 5-Gy preoperative radiotherapy. For paid labor, 292 patients who indicated paid labor before treatment filled out quality of life questionnaires, which included questions on paid labor at 3, 6, 12, 18, and 24 months after surgery. For unpaid labor, another sample of 92 patients also filled out the Health and Labor questionnaire, which included questions on unpaid labor, before treatment, and at 3 and 12 months after treatment.

RESULTS

From 3 to 18 months after surgery, paid labor resumption increased from 19 to 63 percent (P < 0.001). At 24 months after surgery, paid labor resumption was 61 percent. In a multivariate analysis, age older than 55 years (P <or= 0.001), lower education level (P <or= 0.003), shorter time since surgery (P < 0.001), preoperative radiotherapy (P = 0.02), lower valuation of overall health (P < 0.01), more physical symptom distress (P < 0.001), and more limitations in daily activities (P < 0.001) were all associated with less or later resumption of paid labor. The average amount of unpaid labor increased from 17.3 hours per week at 3 months to 21 hours per week at 12 months after surgery. In a multivariate analysis, only shorter time since surgery (P = 0.03) and male gender (P < 0.001) were related to less unpaid labor.

CONCLUSIONS

Diagnosis and treatment of rectal cancer affect paid and unpaid labor. The impact on paid labor is most pronounced. Multiple other sociodemographic and quality of life-related variables also were associated with paid labor. Patient information and decision making on preoperative radiotherapy should include the effects on paid labor, and interventions focused on promoting paid labor participation in patients with rectal cancer should be tailored to the specific characteristics and needs of those patients.