Does comorbidity interact with colorectal cancer to increase mortality? A nationwide population-based cohort study

Preoperative anemia in older individuals undergoing major abdominal surgery is associated with early postoperative morbidity: a prospective observational study

PURPOSE

Preoperative anemia is associated with poor postoperative outcomes. Older patients have limited physiologic reserves, which renders them vulnerable to the stress of major abdominal surgery. We aimed to determine if the severity of preoperative anemia is associated with early postoperative morbidity among older patients undergoing major abdominal surgery.

METHODS

Ethics approval was obtained from SingHealth Centralized Institutional Review Board. This is a prospective observational study conducted in the preoperative anesthesia clinic of a tertiary Singapore hospital from 2017 to 2021. Patient demographic data, comorbidities, and intraoperative details were collected. Outcome measures included blood transfusions, complications according to the Postoperative Morbidity Survey, days alive and out of hospital (DaOH), length of hospital stay, and mortality.

RESULTS

A total of 469 patients were analyzed, 37.5% of whom had preoperative anemia (serum hemoglobin of < 13 g·dL-1 in males and < 12 g·dL-1 in females). Anemia was significantly associated with older age, a higher age-adjusted Comprehensive Complication Index score, a higher incidence of diabetes mellitus, and a higher proportion of patients with an American Society of Anesthesiologists Physical Status of III or IV. The severity of anemia was associated with the presence of early postoperative morbidity at day 5, increased blood transfusions, longer length of hospital stay, and fewer DaOH at 30 days and six months.

CONCLUSION

Anemia is significantly associated with poorer postoperative outcomes in the older population. The impact of anemia on postoperative outcomes could be further evaluated with quality of life indicators, patient-reported outcome measures, and health economic tools.

The mortality risk in patients with early onset colorectal cancer: the role of comorbidities

The global incidence of early-onset colorectal cancer (EO-CRC) is increasing. Although the mortality rate is relatively stable, some comorbidities have been associated with a higher mortality rate. This study estimated the mortality risk in patients with EO-CRC with various comorbidities using real-world data to identify the high-risk group using Cox proportional regression for overall and cancer-specific mortality. The incidence rate of EO-CRC significantly increased from 6.04 per 100,000 population in 2007 to 12.97 per 100,000 population in 2017. The five-year overall mortality rate was 101.50 per 1000 person year and the cancer-specific mortality rate was 94.12 per 1000 person year. Patients with cerebrovascular disease (CVD) had a higher mortality risk (hazard ratio (HR): 1.68; 95% confidence interval (CI): 1.25-2.28; p=0.0007). After subgroup analyses based on age, sex, clinical stage, and treatment type, patients with CVD had a higher overall mortality risk compared to non-CVD patients, except for patients undergoing surgery and chemotherapy. Patients with chronic kidney disease had a higher mortality risk in the early clinical stages (HR: 2.31; 95% CI: 1.08-4.96; p=0.0138). Patients who underwent radiotherapy had a higher overall mortality risk (HR: 1.38; 95% CI: 1.04-1.85; p=0.0285) than those without liver disease. Identifying specific comorbidity mortality risks in patients with EO-CRC allows for risk stratification when screening target groups and may lower disease mortality.

Patient-Reported Symptom Burden and Supportive Care Needs of Patients With Stage II-III Colorectal Cancer During and After Adjuvant Systemic Treatment: A Real-World Evidence Study

PURPOSE

Patients with colorectal cancer (CRC) experience a range of physical and psychologic symptoms, and supportive care needs throughout the illness trajectory. We used patient-reported outcomes and administrative health data to describe symptom burden and supportive care needs during and after adjuvant treatment and determine factors associated with changes to symptom burden.

METHODS

A retrospective population-based cohort study of patients who were newly diagnosed with stage II-III CRC in Alberta, Canada, between January 1, 2016, and January 31, 2019. Adults age 18 years or older who completed a patient-reported outcomes survey (Edmonton Symptom Assessment System) and supportive care needs (Canadian Problem Checklist) within 3 months after starting adjuvant treatment (during treatment) and > 7 months after starting treatment (after treatment) were included. Changes to symptom severity were stratified as stable, improved, or deteriorated. Multivariable logistic regression was used to evaluate factors associated with these changes.

RESULTS

We included 303 patients (median age 60 years, 62% male, 84.5% stage III, 51.2% rectal v colon). Prevalent symptoms included tiredness (80.5%), pain (50.8%), and poor well-being (50%) during treatment, and tiredness (71.3%), pain (44.2%), and poor well-being (62.1%) after treatment. The results were heterogeneous with respect to improvements, stability, or deterioration. Pain worsened for 25% of the cohort, tiredness for 28%, and depression, anxiety, and well-being for 21%, 22%, and 31%, respectively. Deterioration of some symptoms was associated with older age, stage II, comorbidities, rural setting, and higher income.

CONCLUSION

We demonstrated symptom severity was generally low and most symptoms remained stable or improved after treatment. Particular groups of patients were at greater risk for more severe and/or more persistent symptoms. Ongoing assessments and interventions to address physical and psychologic symptoms, and supportive care needs in patients with CRC during and after treatment are needed.

Frailty affects prognosis in patients with colorectal cancer: A systematic review and meta-analysis

Background

The prevalence of colorectal cancer has remained high. Most patients have already developed into the middle and advanced stage when they are diagnosed with colorectal cancer, and a small number of them are accompanied by metastasis. In recent years, frailty has been recognized as an important factor affecting the prognosis of colorectal cancer. The aim of this study was to assess the value of frailty on prognosis in patients with colorectal cancer after treatment.

Method

We systematically searched PubMed, Embase, Web Of Science databases up until March2022. A total of 18 studies were retrieved that met the inclusion criteria, including 9 prospective studies and 9 retrospective studies. Frailty screening tools, proportion of frail patients, and outcomes of colorectal cancer patients after treatment were recorded.

Result

18 studies were included with a total of 352,535 participants. Regardless of differences in frailty screening and treatment approaches, outcomes for frailty patients were less favorable in all studies. Compared with the non-frail group, the frail group had higher mortality, more serious complications, more postoperative blood transfusions and delirium, and more support outside the home.

Conclusion

Although there is no uniform standard for frailty screening, assessing the frailty of colorectal cancer patients is of great significance for predicting prognosis of patients after treatment.

The association between short-term exposure to ambient carbon monoxide and hospitalization costs for bronchitis patients: A hospital-based study

Ambient carbon monoxide (CO) is associated with bronchitis morbidity, but there is no evidence concerning its correlation with hospitalization costs for bronchitis patients. This study aimed to investigate the relationship between short-term ambient CO exposure and hospitalization costs for bronchitis patients in Chongqing, China. Baseline data for 3162 hospitalized bronchitis patients from November 2013 to December 2019 were collected. Multiple linear regression analysis was used to determine the association, delayed and cumulative, between short-term CO exposure and hospitalization costs. Additionally, subgroup analyses were performed by gender, age, season, and comorbidity. Positive association between CO and hospitalization costs for bronchitis patients was observed. The strongest association was observed at lag 015 days, with per 1 mg/m³ increase of CO concentrations corresponded to 5834.40 Chinese Yuan (CNY) (95% CI: 2318.71, 9350.08; P < 0.001) (845.97 US dollars) increment in hospitalization costs. Stratified analysis results showed that the association was more obvious among those males, elderly, with comorbidities, and in warm seasons. More importantly, there was strongest correlation between CO and bronchitis patients with coronary heart disease. In summary, short-term exposure to ambient CO, even lower than Chinese and WHO standards, can be associated with increased hospitalization costs for bronchitis. Controlling CO exposure can be helpful to reduce medical burden associated with bronchitis patients. The results also suggest that when setting air quality standards and formulating preventive measures, susceptible subpopulations ought to be considered.

Effect of comorbidities on long-term outcomes of colorectal cancer patients

OBJECTIVE

The objective of this work is to evaluate the association of comorbidities with various outcomes in patients diagnosed with colon or rectal cancer.

METHODS

We conducted a prospective cohort study of patients diagnosed with colon or rectal cancer who underwent surgery. Data were gathered on sociodemographic, clinical characteristics, disease course, and the EuroQol EQ-5D and EORTC QLQ-C30 scores, up to 5 years after surgery. The main outcomes of the study were mortality, complications, readmissions, reoperations, and changes in PROMs up to 5 years. Multivariable multilevel logistic regression models were used in the analyses.

RESULTS

Mortality at some point during the 5-year follow-up was related to cardiocerebrovascular, hemiplegia and/or stroke, chronic obstructive pulmonary disease (COPD), diabetes, cancer, and dementia. Similarly, complications were related to cardiovascular disease, COPD, diabetes, hepatitis, hepatic or renal pathologies, and dementia; readmissions to cardiovascular disease, COPD, and hepatic pathologies; and reoperations to cerebrovascular and diabetes. Finally, changes in EQ-5D scores at some point during follow-up were related to cardiocerebrovascular disease, COPD, diabetes, pre-existing cancer, hepatic and gastrointestinal pathologies, and changes in EORTC QLQ-C30 scores to cardiovascular disease, COPD, diabetes, and hepatic and gastrointestinal pathologies.

CONCLUSIONS

Optimising the management of the comorbidities most strongly related to adverse outcomes may help to reduce those events in these patients.

Long-term conditions, multimorbidity and colorectal cancer risk in the UK Biobank cohort

PURPOSE

Early identification of colorectal cancer (CRC) is an international priority. Multimorbidity (presence of ≥2 long-term conditions (LTCs)) is increasing and the relationship between CRC and LTCs is little-understood. This study explores the relationship between individual LTCs, multimorbidity and CRC incidence and mortality.

METHODS

Longitudinal analysis of the UK Biobank cohort, participants recruited 2006-2010; N = 500,195; excluding previous CRC at baseline. Baseline data was linked with cancer/mortality registers. Demographic characteristics, lifestyle factors, 43 LTCs, CRC family history, non-CRC cancers, and multimorbidity count were recorded. Variable selection models identified candidate LTCs potentially predictive of CRC outcomes and Cox regression models tested for significance of associations between selected LTCs and outcomes.

RESULTS

Participants' age range: 37-73 (mean age 56.5; 54.5% female). CRC was diagnosed in 3669 (0.73%) participants, and 916 (0.18%) died from CRC during follow-up (median follow-up 7 years). CRC incidence was higher in the presence of heart failure (Hazard Ratio (HR) 1.96, 95% Confidence Interval (CI) 1.13-3.40), diabetes (HR 1.15, CI 1.01-1.32), glaucoma (HR 1.36, CI 1.06-1.74), male cancers (HR 1.44, CI 1.01-2.08). CRC mortality was higher in presence of epilepsy (HR 1.83, CI 1.03-3.26), diabetes (HR 1.32, CI 1.02-1.72), osteoporosis (HR 1.67, CI 1.12-2.58). No significant association was found between multimorbidity (≥2 LTCs) and CRC outcomes.

CONCLUSIONS

The associations of certain LTCs with CRC incidence and mortality has implications for clinical practice: presence of certain LTCs in patients presenting with CRC symptoms could trigger early investigation and diagnosis. Future research should explore causative mechanisms and patient perspectives.

High World Heath Organization Performance Status Is Associated With Short- and Long-term Outcomes After Colorectal Cancer Surgery: A Nationwide Population-Based Study

BACKGROUND

The value of performance status is widely used in medical oncology, but the association with surgical outcomes in colorectal cancer has not been described.

OBJECTIVE

The aim of this study was to investigate the association between World Heath Organization performance status and 90-day mortality, 30-day mortality, complications, and overall survival after elective colorectal cancer surgery.

DESIGN

The study was conducted as a nationwide population-based cohort study with prospectively collected data.

SETTING

Data from 2014 through 2016 were provided by the Danish nationwide colorectal cancer database (Danish Colorectal Cancer Group).

PATIENTS

All patients aged ≥18, who had elective surgery for colorectal cancer were included.

MAIN OUTCOME MEASURES

Multiple logistic regressions were performed to investigate 90-day mortality, 30-day mortality, and complications. One-year mortality was determined by Cox regression, and overall survival was illustrated by Kaplan-Meier curves.

RESULTS

A total of 10,279 patients had elective colorectal cancer surgery during the study period (6892 colonic and 3387 rectal). Thirty-four percent of the patients with colorectal cancer had a World Heath Organization performance status ≥1. The odds ratios of postoperative 90-day mortality in colon cancer for performance status 1, 2, and 3/4 compared with performance status 0 were 2.50 (95% CI, 1.67-3.73), 5.00 (95% CI, 3.19-7.86), and 17.34 (95% CI, 10.18-29.55). The odds ratios of postoperative 90-day mortality in rectal cancer for performance status 1, 2, and 3/4 were 3.90 (95% CI, 2.23-6.85), 9.25 (95% CI, 4.75-18.02), and 10.56 (95% CI, 4.07-27.41). Performance status was also associated with 30-day mortality, overall survival, and medical complications.

LIMITATIONS

Only 1 year of follow-up was possible for all patients, and cancer-specific survival was not available.

CONCLUSION

One of three patients has a performance status >0 and is associated with an increased risk of death, complications, and overall survival for both colonic and rectal cancers. See Video Abstract at http://links.lww.com/DCR/B540.

EL ALTO NIVEL DE DESEMPEO DE LA ORGANIZACIN MUNDIAL DE LA SALUD SE ASOCIA CON RESULTADOS A CORTO Y LARGO PLAZO DESPUS DE LA CIRUGA DEL CNCER COLORRECTAL UN ESTUDIO POBLACIONAL A NIVEL NACIONAL

ANTECEDENTES:El valor del estado funcional se usa ampliamente en oncología médica, pero no se ha descrito la asociación con los resultados quirúrgicos en el cáncer colorrectal.OBJETIVO:El objetivo fue investigar la asociación entre el estado funcional de la Organización Mundial de la Salud y la mortalidad a 90 días, la mortalidad a 30 días, las complicaciones y la supervivencia general después de la cirugía electiva del cáncer colorrectal.DISEÑO:El estudio se realizó como un estudio de cohorte poblacional a nivel nacional con datos recolectados prospectivamente.ENTORNO CLINICO:Los datos fueron proporcionados por la base de datos de cáncer colorrectal a nivel nacional danés (DCCG.dk) en un período de estudio de 2014-2016.PACIENTES:Se incluyeron todos los pacientes de ≥18 años que se sometieron a cirugía electiva por cáncer colorrectal.PRINCIPALES MEDIDAS DE VALORACION:Para investigar la mortalidad a los 90 días, la mortalidad a los 30 días y las complicaciones se realizaron regresiones logísticas múltiples. La mortalidad a un año se determinó mediante regresión de Cox y la supervivencia general se ilustra mediante curvas de Kaplan-Meier.RESULTADOS:Un total de 10 279 pacientes se sometieron a cirugía electiva de cáncer colorrectal en el período de estudio (6892 colónico y 3387 rectal). Treinta y cuatro por ciento de los pacientes con cáncer colorrectal tenían un estado funcional de la Organización Mundial de la Salud ≥1. Los ratios de probabilidades (odds ratios) de mortalidad postoperatoria a los 90 días en cáncer de colon para el estado funcional 1, 2 y 3/4 en comparación con el estado funcional 0 fueron 2,50 (IC del 95%: 1,67-3,73), 5,00 (IC del 95%: 3,19-7,86) y 17,34 (IC del 95%: 10,18-29,55), respectivamente. Los ratios de probabilidades de mortalidad postoperatoria de 90 días en cáncer de recto para el estado funcional 1, 2 y 3/4 fueron 3,90 (IC del 95%: 2,23-6,85), 9,25 (IC del 95%: 4,75-18,02) y 10,56 (IC del 95%: 2,23-6,85) % CI: 4,07-27,41). El estado funcional también se asoció con la mortalidad a los 30 días, la supervivencia general y las complicaciones médicas.LIMITACIONES:Solo fue posible un año de seguimiento para todos los pacientes y la supervivencia específica del cáncer no estaba disponible.CONCLUSIÓN:Uno de cada tres pacientes tiene un estado funcional> 0 y se asocia con un mayor riesgo de muerte, complicaciones y supervivencia general para los cánceres de colon y recto. Consulte Video Resumen en http://links.lww.com/DCR/B540.

Ostomy prevalence and survival in elderly patients with stage III and IV rectal cancer

AIM

Oncological strategies in the elderly population are often debated. The objective of this study was to investigate the survival rates and prevalence of ostomy in elderly patients operated on for stage III and IV rectal cancers.

METHODS

This retrospective multicentric population-based study included 151 patients aged ≥75 years with stage III and IV rectal adenocarcinoma who underwent surgery between 2007 and 2014. Multivariable logistic regression was used to assess the impact of different prognostic factors.

RESULTS

The median age of the patients was 81 years (range: 75-97 years) with 40 patients >85 years of age. Age was significantly correlated with overall survival (OS) in both stage III and IV cancers (P < 0.001). For patients ≥80 years the presence of comorbid conditions was associated with a lower chance of survival (P = 0.02). A digestive stoma was created in 67 (76.1%) patients with stage III cancer and 26 (29.54%) had a stoma reversal. A palliative derivative stoma was performed in half of patients with stage IV cancer. Adjuvant chemotherapy was independently associated with improved 5-year OS (P < 0.001).

CONCLUSIONS

Age, comorbidities and adjuvant chemotherapy were independent predictors for OS. Resection of rectal tumors in fit elderly patients should be promoted; however, patients should be aware of the high risk of stoma. Geriatr Gerontol Int 2021; 21: 670-675.

Prescribed drugs in 27 000 individuals after diagnosis of colorectal cancer: A population-based cohort study

BACKGROUND

The prevalence of prescribed drugs in survivors of colorectal cancer (CRC) was evaluated.

METHODS

Data from the Cancer Registry of Norway were linked to the Norwegian Prescription Database for a study population of 3.52 million individuals. Prevalence ratios (PRs) with 95% confidence intervals (CIs) of prescribed drugs in CRC-survivors compared to the cancer-free population, were estimated by log-binomial regression, adjusting for age and education.

RESULTS

Almost 27 000 individuals, aged 20 to 84, were diagnosed with CRC during 2005 to 2014. The first year after diagnosis, the prevalence of prescribed drugs was higher in CRC-survivors compared with the cancer-free population, especially drugs for anxiety and tension, and steroid-responsive conditions. PRs for several drugs, especially drugs used for mental and behavioural disorders, decreased with time since diagnosis. The prevalence of drugs used for anxiety and tension was elevated 10 years after diagnosis; PRs the first year after diagnosis were 20 (95% CI: 18-22) in males and 17 (16-18) in females. Ten years after diagnosis PRs were 5.0 (3.1-7.9) and 2.0 (1.0-3.8), respectively. In absolute numbers, the largest increase, compared to the cancer-free population, was in drugs used for gastric acid disorders and pain. The prevalence of neuromodulatory drugs was higher in CRC-survivors.

CONCLUSIONS

The prevalence of several drugs was higher in CRC-survivors than in the cancer-free population 10 years after diagnosis. The largest absolute excess in prevalence was for gastric acid disorder and pain medications, while the relative prevalence of drugs used for anxiety and tension was high in CRC-survivors. Long persisting neuropathia was indicated.

Association of Comorbid Diabetes With Clinical Outcomes and Healthcare Utilization in Colorectal Cancer Survivors

OBJECTIVES

To compare clinical outcomes and healthcare utilization in colorectal cancer (CRC) survivors with and without diabetes.

SAMPLE & SETTING

CRC survivors (N = 3,287) were identified from a statewide electronic health record database using International Classification of Diseases (ICD) codes. Data were extracted on adults aged 21 years or older with an initial diagnosis of stage II or III CRC with diabetes present before CRC diagnosis or no diagnosis of diabetes (control).

METHODS & VARIABLES

ICD codes were used to extract diabetes diagnosis and clinical outcome variables. Healthcare utilization was determined by encounter type. Data were analyzed using descriptive statistics, multivariable logistic, and Cox regression.

RESULTS

CRC survivors with diabetes were more likely to develop anemia and infection than CRC survivors without diabetes. In addition, CRC survivors with diabetes were more likely to utilize emergency resources sooner than CRC survivors without diabetes.

IMPLICATIONS FOR NURSING

Oncology nurses can facilitate the early identification of high-risk survivor groups, reducing negative clinical outcomes and unnecessarily high healthcare resource utilization in CRC survivors with diabetes.

Magnitude of the Age-Advancement Effect of Comorbidities in Colorectal Cancer Prognosis

BACKGROUND

Comorbidities and old age independently compromise prognosis of patients with colorectal cancer (CRC). The impact of comorbidities could thus be considered as conveying worse prognosis already at younger ages, but evidence is lacking on how much worsening of prognosis with age is advanced to younger ages in comorbid versus noncomorbid patients. We aimed to quantify, for the first time, the impact of comorbidities on CRC prognosis in "age advancement" of worse prognosis.

METHODS

A total of 4,602 patients aged ≥30 years who were diagnosed with CRC in 2003 through 2014 were recruited into a population-based study in the Rhine-Neckar region of Germany and observed over a median period of 5.1 years. Overall comorbidity was quantified using the Charlson comorbidity index (CCI). Hazard ratios and age advancement periods (AAPs) for comorbidities were calculated from multivariable Cox proportional hazards models for relevant survival outcomes.

RESULTS

Hazard ratios for CCI scores 1, 2, and ≥3 compared with CCI 0 were 1.25, 1.53, and 2.30 (P<.001) for overall survival and 1.20, 1.48, and 2.03 (P<.001) for disease-free survival, respectively. Corresponding AAP estimates for CCI scores 1, 2, and ≥3 were 5.0 (95% CI, 1.9-8.1), 9.7 (95% CI, 6.1-13.3), and 18.9 years (95% CI, 14.4-23.3) for overall survival and 5.5 (95% CI, 1.5-9.5), 11.7 (95% CI, 7.0-16.4), and 21.0 years (95% CI, 15.1-26.9) for disease-free survival. Particularly pronounced effects of comorbidity on CRC prognosis were observed in patients with stage I-III CRC.

CONCLUSIONS

Comorbidities advance the commonly observed deterioration of prognosis with age by many years, meaning that at substantially younger ages, comorbid patients with CRC experience survival rates comparable to those of older patients without comorbidity. This first derivation of AAPs may enhance the empirical basis for treatment decisions in patients with comorbidities and highlight the need to incorporate comorbidities into prognostic nomograms for CRC.

Recurrence, death risk, and related factors in patients with stage 0 colorectal cancer: A nationwide population-based study

In this study, the National Health Insurance Research Database of Taiwan was used to examine the recurrence and death risk for stage 0 colorectal cancer patients. We examined stage 0 colorectal cancer patients to identify factors causing recurrence and death.This is a retrospective study, and stage 0 colorectal cancer patients that are registered in the Taiwan Cancer Registry of the Health Promotion Administration in 2007 to 2012 were included. The database was linked to the National Health Insurance Research Database, and subjects were followed up until the end of 2016. The mean follow-up period was 69 months. Bivariate analysis methods (log-rank test) and Cox proportional hazards model were used to evaluate the risk of recurrence and death and demographic characteristics, economic factors, environmental factors, health factors, treatment and hospitals, and absence/presence of postoperative tests were used to examine related risk factors.Our study showed that the 5-year recurrence rate and 5-year mortality rate for stage 0 colorectal cancer are 1.68% and 0.6%, respectively. For stage 0 colorectal cancer, age (61-74 years) is the only factor affecting recurrence in patients (hazard ratio (HR) = 2.44; 95% CI: 1.41-4.22), while age >75 years (HR = 4.35; 95% CI: 1.14-16.68) and Charlson Comorbidity Index >4 points (HR = 7.20, 95% CI: 2.60-19.94) can increase the risk of death. In contrast, patients who underwent one (HR = 0.27, 95% CI: 0.10-0.71) and two or more colonoscopies (HR = 0.26, 95% CI: 0.10-0.70) within 2 years after surgery can reduce the risk of death from stage 0 colorectal cancer. In addition, the risk of recurrence is higher in patients who underwent colonoscopic polypectomy (HR = 2.07, 95% CI: 0.98-4.33) and patients with rectal cancer (HR = 2.74, 95% CI: 0.96-7.83), but these differences are not statistically significant (P > .05).From this study, we can see that age and comorbidity index increase the risk of recurrence and death for stage 0 colorectal cancer, while postoperative colonoscopy can decrease the risk of death.

Short-term effects of air pollution on daily single- and co-morbidity cardiorespiratory outpatient visits

Several studies have noted that the existence of comorbidities lead to an increase in the risk of premature mortality and morbidity. Most of the studies examining the effects of air pollution on comorbidity visits were from Northern American countries, with scarce literature from Asia. This study contributes to existing, yet limited understanding of air pollution-comorbidity by examining the effects of daily air pollutants on outpatient single morbidity and comorbid cardiorespiratory visits in Japan. A total of 1,452,505 outpatient cardiorespiratory visits were recorded among the 21 Japanese cities from 2013 to 2016. Daily outpatient cardiorespiratory visit data were obtained from a health insurance claims database managed by the Japan Medical Data Center Co., Ltd. (JMDC). A time-stratified case crossover analysis coupled with Generalized Additive Mixed Model was used to analyze the association of daily air pollutants (particulate matter 2.5 μm or less in diameter, ozone and nitrogen dioxide) on daily single (respiratory and cardiovascular) and comorbidity health outcomes. We further examined single and cumulative effects for 0-3 and 0-14 lag periods. Ozone, NO₂, and PM_2.5 were positively associated with cardiorespiratory visits in either shorter or longer lags, with more apparent comorbidity associations with NO₂ exposure. A 10-unit increase in NO₂, after adjusting for ozone, was associated with a 2.24% (95% CI: 1.34-3.15) and 6.49% (95% CI: 5.00-8.01) increase in comorbidity visit at Lag 0 (of Lag 0-3) and cumulative lag 0-3, respectively. Our results contribute to existing evidence suggesting that short-term and extended exposure to air pollution elicit health risks on cardiovascular, respiratory and comorbid clinic visits. Exposure to NO₂, in particular, was associated with increase in the risk of single and comorbidity cardiorespiratory visits. Results can be potentially utilized for both individual health (e.g. risk population health management) and health facility management (e.g. health visit influx determination).

Factors associated with the initiation of chemotherapy within 90 days of death in metastatic colorectal cancer patients: a population-based study

INTRODUCTION

Initiation of chemotherapy in patients with cancer near end-of-life (EOL) has become more frequent due to an increasing number of treatment options. We aimed to analyze the proportion of metastatic colorectal cancer patients (mCRC) in Alberta, Canada, who were started on a new chemotherapy regimen within 90 days of death.

METHODS

This was a retrospective, population-based study using data from the cancer measurement outcomes and evaluation (C-MORE) database. All patients who received chemotherapy for mCRC in a large Canadian province from January 1, 2011, to December 31, 2016, were included in the current analysis. We identified the proportion of patients who initiated chemotherapy near EOL. Further, we analyzed the associations of baseline factors with initiation of chemotherapy near EOL.

RESULTS

We identified 511 patients with mCRC who received chemotherapy. Of these, 132 (25.8%) initiated chemotherapy near EOL. Charlson's comorbidity index (CCI) score (score 1: OR, 0.524; 95% CI, 0.279-0.985; P = 0.045; CCI score > 1: OR, 0.366; 95% CI, 0.180-0.746; P = 0.006) and Eastern cooperative oncology group performance status (ECOG PS) (ECOG PS 2: OR, 4.457; 95% CI 2.518-7.890; P < 0.0001; ECOG PS > 2: OR 7.725; 95% CI 3.465-17.222; P < 0.0001) were predictive of initiation of chemotherapy near EOL. The most frequent chemotherapy regimens initiated were FOLFIRI (17%), capecitabine (15%), and panitumumab (15%), respectively.

CONCLUSIONS

Chemotherapy is frequently initiated near EOL in patients with mCRC. Routine clinical assessments including ECOG PS and comorbid medical conditions can help select patients with mCRC who are unlikely to benefit from palliative chemotherapy and prevent the adverse events and healthcare costs associated with such interventions near EOL.

Real-world evidence on adjuvant chemotherapy in older adults with stage II/III colon cancer

Colon cancer represents one of the most common cancers diagnosed in older adults worldwide. The standard of care in resected stage II and stage III colon cancer continues to evolve. While there is unequivocal evidence to suggest both disease free and overall survival benefits with the use of combination chemotherapy in patients with stage III colon cancer, data regarding its use in patients with stage II colon cancer are less clear. Further, although colon cancer is a disease that affects older adults, there is considerable debate on the value of adjuvant chemotherapy in the aging population. In particular, many older patients are undertreated when compared to their younger counterparts. In this review, we will describe the clinical trials that contributed to the current adjuvant chemotherapy approach in colon cancer, discuss representation of older adults in trials and the specific challenges associated with the management of this sub-population, and highlight the role of comprehensive geriatric assessments. We will also review how real-world evidence complements the data gaps from clinical trials of early stage colon cancer.

Patient-reported symptom burden and supportive care needs at cancer diagnosis: a retrospective cohort study

PURPOSE

Patient-reported outcomes (PROs) are used to assess patients' symptoms and supportive care needs. While PROs are increasingly employed in clinical practice, research utilizing these data remains limited. Our goal was to evaluate PROs from a provincial cancer program.

METHODS

A retrospective, population-based cohort study using administrative health data of patients in Alberta, Canada, diagnosed with cancer between January 1, 2016, and October 23, 2017. Adults who completed PROs (Edmonton Symptom Assessment System, ESAS) and supportive care needs inventory (Canadian Problem Checklist)) within ± 60 days of diagnosis were included. Patients were stratified by tumor types (breast, colorectal, lung, prostate, hematological, or other). Descriptive statistics were used to characterize symptom burden and supportive care needs. Multivariate logistic regression was used to evaluate factors associated with higher symptom severity.

RESULTS

We included 1310 patients (mean age 64 years; 51% female), the majority of whom had breast (19%), lung (25%), or other cancers (26%). For the cohort, severity of symptoms based on ESAS was low, but prevalence of specific symptoms was high including tiredness (84%), anxiety (60%), pain (60%), and low well-being (80%). Seventy percent of the cohort reported at least one supportive care need. The highest-ranking problems were fears and worries and needing information about illness/treatment. There were differences across tumor types with respect to symptoms and supportive care needs. Comorbidity and having a high number of supportive care needs were associated with higher symptom severity.

DISCUSSION

Our results underscore the need to develop and implement tumor-specific supportive care interventions.

When and how should surgery be performed in senior colorectal cancer patients?

Older studies reported high rates of postoperative morbidity and mortality in the senior population, which lead to a tendency to withhold curative surgery in the older population. However, more recent studies showed impressing developments in postoperative outcomes in seniors. Probably, these improvements are due to enhancements in both surgical and non-surgical aspects in the pre-, peri- and postoperative period, such as minimally invasive techniques and anesthesiological insights. The postoperative survival gap seen earlier between younger and older patients is fading. For optimal treatment in the older population, special awareness and care on several aspects is needed. As only a minority of the seniors are frail, a quick frailty assessment is crucial to distinguish the fit from the frail in the decision-making process. In addition, it could be valuable to improve the lacks in physical condition in the preoperative period with the use of prehabilitation programs. Furthermore, it is important to evolve an emergency to an elective setting by postponing emergency surgery to prevent any high-risk situation. In conclusion, based on modern insights, surgery is a valid option in the curative treatment of colorectal cancer in seniors, however individual attention and care is required.

Patient-level factors associated with chronic opioid use in cancer: a population-based cohort study

PURPOSE

Concerns around chronic opioid use (COU), misuse, and harms have led to increased scrutiny of opioid prescribing in oncology. There is lack of research examining patient-level factors associated with COU. Our aim was to examine patient-level factors associated with COU in newly diagnosed cancer patients.

METHODS

Population-based retrospective cohort study using administrative health data of patients in Alberta, Canada, diagnosed between February 2016 and October 2017. Adult cancer patients who completed a symptom survey within ± 60 days of diagnosis were included. Patients were divided into two groups: COU (defined as continuous opioid prescriptions for at least 90 days post-diagnosis) and non-chronic opioid use (NCOU). Logistic regression was used to evaluate factors associated with COU.

RESULTS

We included 694 patients (mean age 65 years; 51% female). Most had breast (20%), colorectal (13%), and lung (33%) cancers. Of the 14% with COU, 79% were opioid naïve at diagnosis. Those in the COU group were more often diagnosed with advanced cancer (66% versus 40%), had lung cancer (47%), and were opioid tolerant (> 90 days of continuous opioids within one-year pre-diagnosis). A total of 64% of COU versus 27% of NCOU had moderate to severe pain at diagnosis (p < 0.001). Irrespective of treatment type or stage, those with moderate to severe pain, were opioid tolerant at diagnosis, or had multiple prescribers were at greater risk for COU.

CONCLUSIONS

Specific patient groups were at increased risk of COU and should be the focus of adaptive prescribing approaches to ensure that opioid use is appropriate.

Comorbid chronic diseases and cancer diagnosis: disease-specific effects and underlying mechanisms

An earlier diagnosis is a key strategy for improving the outcomes of patients with cancer. However, achieving this goal can be challenging, particularly for the growing number of people with one or more chronic conditions (comorbidity/multimorbidity) at the time of diagnosis. Pre-existing chronic diseases might affect patient participation in cancer screening, help-seeking for new and/or changing symptoms and clinicians' decision-making on the use of diagnostic investigations. Evidence suggests, for example, that pre-existing pulmonary, cardiovascular, neurological and psychiatric conditions are all associated with a more advanced stage of cancer at diagnosis. By contrast, hypertension and certain gastrointestinal and musculoskeletal conditions might be associated with a more timely diagnosis. In this Review, we propose a comprehensive framework that encompasses the effects of disease-specific, patient-related and health-care-related factors on the diagnosis of cancer in individuals with pre-existing chronic illnesses. Several previously postulated aetiological mechanisms (including alternative explanations, competing demands and surveillance effects) are integrated with newly identified mechanisms, such as false reassurances, or patient concerns about appearing to be a hypochondriac. By considering specific effects of chronic diseases on diagnostic processes and outcomes, tailored early diagnosis initiatives can be developed to improve the outcomes of the large proportion of patients with cancer who have pre-existing chronic conditions.

Failure-to-rescue in Patients Undergoing Pancreatectomy: Is Hospital Volume a Standard for Quality Improvement Programs? Nationwide Analysis of 12,333 Patients

OBJECTIVE

To evaluate the influence of hospital volume on failure-to-rescue (FTR) after pancreatectomy in France.

BACKGROUND

There are growing evidences that FTR is an important source of postoperative mortality (POM) after pancreatectomy. However, few studies have analyzed the volume-FTR relationship following pancreatic surgery.

METHODS

All patients undergoing pancreatectomy between 2012 and 2015 were included. FTR is defined as the 90-day POM rate among patients with major complications. According to the spline model, the critical cutoff was 20 resections per year and hospitals were divided into low (<10 resections/an), intermediate (11-19 resections/yr), and high volume centers (≥20 resections/yr).

RESULTS

Overall, 12,333 patients who underwent pancreatectomy were identified. The POM was 6.9% and decreased significantly with increased hospital volume. The rate of FTR was 14.5% and varied significantly with hospital volume (18.3% in low hospital volume vs 11.9% in high hospital volume, P < 0.001), age (P < 0.001) and ChCl (CCl0-2: 11.5%, ChCl3: 13%, CCl ≥4:18.6%; P < 0.001). FTR for renal failure was the highest of all complications (40.2%), followed by postoperative shock (36.4%) and cardiac complications (35.1%). The FTR was significantly higher in low and intermediate compared with high volume hospitals for shock, digestive, and thromboembolic complications and reoperation. In multivariable analysis, intermediate (OR = 1.265, CI95%[1.103-1.701], P = 0.045) and low volume centers (OR = 1.536, CI95%[1.165-2.025], P = 0.002) were independently associated with increased FTR rates.

CONCLUSION

FTR after pancreatectomy is high and directly correlated to hospital volume, highlighting variability in the management of postoperative complications. Measurement of the FTR rate should become a standard for quality improvement programs.

The potential impact of chronic obstructive pulmonary disease in lung cancer screening: implications for the screening clinic

Introduction: Following the findings of the National Lung Screening Trial (NLST), lung cancer screening is now recommended in the United States. However, post-hoc analyses of the NLST suggest that reducing lung cancer mortality through screening is highly dependent on the underlying characteristics of the screening participants, in particular, the presence of chronic obstructive pulmonary disease (COPD). Areas covered: In this review, we outline how outcomes in lung cancer screening are significantly affected by the presence of airflow limitation, as caused by COPD, and how this might impact the assessment of eligible smokers in a lung cancer screening clinic. Expert opinion: There is growing evidence showing that CT-based screening for lung cancer reduces lung cancer mortality. The benefits of screening exceed those seen in the NLST when screening is carried out in lower risk populations, for a longer duration, and when outcomes are compared with usual care control cohorts. In this article, we review data from a post-hoc analysis of the NLST. We suggest that whilst worsened airflow limitation is associated with greater lung cancer risk, there is also more aggressive lung cancer, reduced lung cancer operability, and for advanced COPD, reduced benefits from screening. We advocate an 'outcomes-based' approach to screening over a 'risk-based' approach.

Association Between Drug Exposure and Occurrence of Parkinsonism in Korea: A Population-Based Case-Control Study

Background: Although drug-induced parkinsonism is reversible in most cases, some patients can suffer from persistent/recurrent symptoms. Therefore, prevention is the most efficient way to manage drug-induced parkinsonism. However, there is a paucity of studies exploring the relationship between parkinsonism and drug exposure. Objective: To examine the association between drug exposure and the risk of parkinsonism using Korean population-based data. Methods: We conducted a matched case-control study using the National Health Insurance Service-National Sample Cohort database. Cases and controls were defined as individuals with and without parkinsonism, respectively, between 2007 and 2013. Cases and controls were matched for sex, age group, income, type of insurance, and Charlson comorbidity index. Drug exposures, including propulsives, antipsychotics, and flunarizine, were identified at 1 year before the first date of parkinsonism and stratified by recency and cumulative dose. Conditional logistic regression was used to estimate odds ratios (ORs) and 95% CIs. Results: We identified 5496 cases and 5496 controls. ORs for current use group of propulsives, antipsychotics, and flunarizine compared with those of the never use group were 2.812 (95% CI = 2.466-3.206), 3.009 (95% CI = 1.667-5.431), and 4.950 (95% CI = 2.711-9.037), respectively. ORs were greater in those more recently exposed and those exposed to higher cumulative doses. Conclusion and Relevance: At the population level, use of propulsives, antipsychotics, and flunarizine had a significant association with the increased risk of parkinsonism, depending on recency and cumulative dose. Drugs associated with parkinsonism should be used with careful monitoring to prevent drug-induced parkinsonism.

Association of multidimensional comorbidities with survival, toxicity, and unplanned hospitalizations in older adults with metastatic colorectal cancer treated with chemotherapy

BACKGROUND

Studies of older patients with colorectal cancer(CRC) have found inconsistent results about the correlation of various comorbidities with overall survival(OS) and treatment tolerance. To refine our understanding, we evaluated this correlation using the Cumulative Illness Rating Scale-Geriatric(CIRS-G) and heat maps to identify subgroups with the highest impact.

METHODS

We retrospectively reviewed 153 patients aged 65 years and older with stage IV CRC undergoing chemotherapy. We calculated CIRS-G scores, and a Total Risk Score(TRS) derived from a previous heat map study. The association between CIRS-G scores/TRS and OS, unplanned hospitalizations, and chemotoxicity was examined by the Cox proportional hazards model.

RESULTS

Median age was 71 years. Median MAX2 score of chemotherapies was 0.134(0.025-0.231). The most common comorbidities were vascular(79.8%), eye/ear/nose/throat(68%), and respiratory disease(52.4%). Median OS was 25.1 months(95% confidence interval: 21.2-27.6). In univariate analysis, ECOG PS ≥ 2(HR 1.86(1.1-3.17), p = 0.019), poorly differentiated histology(HR 2.03(1.27-3.25), p = 0.003), primary site(rectum vs colon)(HR 0.58 (0.34-0.98), p = 0.04), age at diagnosis(HR per 5y 1.20 (1.04-1.39), p = 0.012), and number of CIRS-G grade 4 comorbidities(HR 1.86 (1.1-3.17), p = 0.019) were associated with OS. In multivariate analysis, the number of CIRS-G grade 4 comorbidities lost significance, although it retained it in the subgroup of patients with colon cancer. Conversely, the TRS was associated with OS in patients with rectal cancer. No association of comorbidity with unplanned hospitalization or chemotoxicity was observed.

CONCLUSIONS

In older adults with metastatic CRC, the number of CIRS-G grade 4 comorbidities was associated with worse OS but no specific CIRS-G category was independently associated with OS, unplanned hospitalization, or toxicities.

The Role of Comorbidity in Mortality After Hip Fracture: A Nationwide Norwegian Study of 38,126 Women With Hip Fracture Matched to a General-Population Comparison Cohort

Hip fracture patients often have comorbid conditions. We investigated whether the combination of comorbidity and hip fracture could explain the previously observed excess mortality among hip fracture patients as compared with the general population. Using a population-based matched study design with 38,126 Norwegian women who suffered a hip fracture during the period 2009–2015 and the same number of women in a matched comparison cohort, we matched participants on prefracture comorbidity, age, and education. We estimated relative survival and additive and multiplicative comorbidity–hip fracture interactions. An additive comorbidity–hip fracture interaction of 4 or 9 additional deaths per 100 patients, depending on Charlson Comorbidity Index (CCI) score, was observed 1 year after hip fracture. Among women with a CCI score of ≥3, 15 additional deaths per 100 patients were observed; of these, 9 deaths could be attributed to the interaction and 6 to the hip fracture per se. On the relative scale, we observed increasing heterogeneity in survival by comorbidity over time; survival was reduced by 39% after 6 years among patients with a CCI score of ≥3, while among women with no comorbidity, survival was reduced by 17% (hip fracture vs. no hip fracture). In summary, prefracture comorbidity was associated with short-term absolute excess mortality and long-term relative excess mortality.

Role, Extent, and Impact of Comorbidity on Prognosis and Survival in Advanced Metastatic Melanoma: A Review

Increased incidence of comorbidity in advanced metastatic melanoma (AMM) is emerging as an important factor in patient prognosis, treatment, and survival. This paper reviews the impact of comorbidities on the prognosis and survival outcomes of patients diagnosed with AMM. Our search initially yielded limited results. We then broadened our search to include breast, colorectal, and prostate cancer and covered malignancies in which screening (like melanoma) is associated with the detection of early-stage disease. Most studies showed that a higher prevalence of comorbidity was associated with more advanced cancer stage. Both treatment and survival of patients were influenced by age and the extent of comorbidity. Racial differences in survival were greatest for patients with no comorbidities and less evident at higher levels of comorbidity. Comorbid conditions showed differential effects for prognosis, treatment, and survival. Limited Information in the literature demonstrates that more research is warranted with respect to comorbidities and AMM.

Clinicopathological, genomic and immunological factors in colorectal cancer prognosis

BACKGROUND

Numerous factors affect the prognosis of colorectal cancer (CRC), many of which have long been identified, such as patient demographics and the multidisciplinary team. In more recent years, molecular and immunological biomarkers have been shown to have a significant influence on patient outcomes. Whilst some of these biomarkers still require ongoing validation, if proven to be worthwhile they may change our understanding and future management of CRC. The aim of this review was to identify the key prognosticators of CRC, including new molecular and immunological biomarkers, and outline how these might fit into the whole wider context for patients.

METHODS

Relevant references were identified through keyword searches of PubMed and Embase Ovid SP databases.

RESULTS

In recent years there have been numerous studies outlining molecular markers of prognosis in CRC. In particular, the Immunoscore® has been shown to hold strong prognostic value. Other molecular biomarkers are useful in guiding treatment decisions, such as mutation testing of genes in the epidermal growth factor receptor pathway. However, epidemiological studies continue to show that patient demographics are fundamental in predicting outcomes.

CONCLUSION

Current strategies for managing CRC are strongly dependent on clinicopathological staging, although molecular testing is increasingly being implemented into routine clinical practice. As immunological biomarkers are further validated, their testing may also become routine. To obtain clinically useful information from new biomarkers, it is important to implement them into a model that includes all underlying fundamental factors, as this will enable the best possible outcomes and deliver true precision medicine.

The age-adjusted Charlson comorbidity index as a predictor of survival in surgically treated vulvar cancer patients

Objective

To evaluate the impact of age-adjusted Charlson comorbidity index (ACCI) in predicting disease-free survival (DFS), overall survival (OS), and cancer-specific survival (CSS) among surgically treated patients with vulvar carcinoma. The secondary aim is to evaluate its impact as a predictor of the pattern of recurrence.

Methods

We retrospectively evaluated data of patients that underwent surgical treatment for vulvar cancer from 1998 to 2016. ACCI at the time of primary surgery was evaluated and patients were classified as low (ACCI 0–1), intermediate (ACCI 2–3), and high risk (>3). DFS, OS and CSS were analyzed using the Kaplan-Meir and the Cox proportional hazard models. Logistic regression model was used to assess predictors of distant and local recurrence.

Results

Seventy-eight patients were included in the study. Twelve were classified as low, 36 as intermediate, and 30 as high risk according to their ACCI. Using multivariate analysis, ACCI class was an independent predictor of worse DFS (hazard ratio [HR]=3.04; 95% confidence interval [CI]=1.54–5.99; p<0.001), OS (HR=5.25; 95% CI=1.63–16.89; p=0.005) and CSS (HR=3.79; 95% CI=1.13–12.78; p=0.03). Positive nodal status (odds ratio=8.46; 95% CI=2.13–33.58; p=0.002) was the only parameter correlated with distant recurrence at logistic regression.

Conclusion

ACCI could be a useful tool in predicting prognosis in surgically treated vulvar cancer patients. Prospective multicenter trials assessing the role of ACCI in vulvar cancer patients are warranted.

A systematic review of the prevalence of comorbid cancer and dementia and its implications for cancer-related care

OBJECTIVES

A comorbid diagnosis of cancer and dementia (cancer-dementia) may have unique implications for patient cancer-related experience. The objectives were to estimate prevalence of cancer-dementia and related experiences of people with dementia, their carers and cancer clinicians including cancer screening, diagnosis, treatment and palliative care.

METHOD

Databases were searched (CINAHL, Psychinfo, Medline, Embase, BNI) using key terms such as dementia, cancer and experience. Inclusion criteria were as follows: (a) English language, (b) published any time until early 2016, (c) diagnosis of cancer-dementia and (d) original articles that assessed prevalence and/or cancer-related experiences including screening, cancer treatment and survival. Due to variations in study design and outcomes, study data were synthesised narratively.

RESULTS

Forty-seven studies were included in the review with a mix of quantitative (n = 44) and qualitative (n = 3) methodologies. Thirty-four studies reported varied cancer-dementia prevalence rates (range 0.2%-45.6%); the others reported reduced likelihood of receiving: cancer screening, cancer staging information, cancer treatment with curative intent and pain management, compared to those with cancer only. The findings indicate poorer cancer-related clinical outcomes including late diagnosis and higher mortality rates in those with cancer-dementia despite greater health service use.

CONCLUSIONS

There is a dearth of good-quality evidence investigating the cancer-dementia prevalence and its implications for successful cancer treatment. Findings suggest that dementia is associated with poorer cancer outcomes although the reasons for this are not yet clear. Further research is needed to better understand the impact of cancer-dementia and enable patients, carers and clinicians to make informed cancer-related decisions.

Pre-emptive skin treatments to prevent skin toxicity caused by anti-EGFR antibody: the real-world evidence in Japan

AIM

Clinically managing skin toxicity associated with anti-EGFR antibody usage to treat colorectal cancer improves quality of life for colorectal cancer patients. This study assesses trends of pre-emptive skin treatments and their impact on subsequent dermatologist visits in Japanese colorectal cancer patients.

PATIENTS & METHODS

Pre-emptive treatment status and dermatologist visit data were investigated for 9461 colorectal cancer patients who experienced anti-EGFR antibody treatment. Data were collected from an electronic hospital-based claims database.

RESULTS

Pre-emptive treatments increased around 2013. Furthermore, subsequent dermatologist visits decreased significantly among the pre-emptive treatment group (p < 0.05).

CONCLUSION

Pre-emptive skin treatments seem to be related to reducing subsequent dermatologist visits by severe skin toxicity prevention and gained popularity in Japan.

The effect of comorbidities on outcomes in colorectal cancer survivors: a population-based cohort study

PURPOSE

To examine the prevalence of comorbidities and the association of these comorbidities with demographics, tumor characteristics, treatments received, overall survival, and causes of death in a population-based cohort of colorectal cancer (CRC) patients.

METHODS

Adult patients with stage I-III CRC diagnosed between 2004 and 2015 were included. Comorbidities were captured using Charlson comorbidity index. Causes of death were categorized using International Classification of Diseases, tenth revision codes. Patients were categorized into five mutually exclusive comorbid groups (cardiovascular disease alone, diabetes alone, cardiovascular disease plus diabetes, other comorbidities, or no comorbidities). Data were analyzed using descriptive statistics, Kaplan-Meier survival analyses, and Cox proportional hazards models.

RESULTS

There were 12,265 patients. Mean follow-up was 3.8 years. Approximately one third of patients had a least one comorbidity, with cardiovascular disease and diabetes being most common. There were statistically significant differences across comorbid groups on treatments received and overall survival. Those with comorbidity had lower odds of treatment and greater risk of death than those with no comorbidity. Those with cardiovascular disease plus diabetes fared the worst for prognosis (median overall survival 3.3 [2.8-3.7] years; adjusted HR for death, 2.27, 95% CI 2.0-2.6, p < .001). Cardiovascular disease was the most common cause of non-CRC death.

CONCLUSIONS

CRC patients with comorbidity received curative intent treatment less frequently and experienced worse outcomes than patients with no comorbidity. Cardiovascular disease was the most common cause of non-cancer death.

IMPLICATIONS FOR CANCER SURVIVORS

Management of comorbidities, including healthy lifestyle coaching, at diagnosis and into survivorship is an important component of cancer care.

Chronic obstructive pulmonary disease (COPD) and lung cancer screening

The primary aim of lung cancer screening is to improve survival from lung cancer by identifying early stage non-small cell lung cancers and prolong survival through their surgical removal. In a post-hoc analysis of 10,054 screening participants from the National Lung Screening Trial (NLST) we show that the risk of lung cancer, according to the PLCOm2012 model, is closely related to the likelihood of having chronic obstructive pulmonary disease (COPD). Those at greatest risk for lung cancer have the highest prevalence of COPD and greater likelihood of dying of a non-lung cancer cause. This "competing cause of death" effect occurs because smokers eligible for lung cancer screening have a high prevalence of comorbid disease and greater likelihood of dying from cardiovascular disease, respiratory disease or other cancers. This means high risk smokers at greatest risk of lung cancer may not necessarily benefit from screening due to greater inoperability and premature death. In this analysis we show that the benefit of annual computed tomography (CT) screening is greatest in those with normal lung function or only mild-to-moderate COPD. We found no mortality benefit in those with severe or very severe COPD (GOLD 3-4). We also show that the efficiency of screening, based on optimizing the number of lung cancer deaths averted per 1,000 persons screened, is best achieved by screening those at intermediate risk. By combining clinical risk variables with a gene-based risk score, even greater reductions in lung cancer mortality can be achieved with CT. We suggest a biomarker-led outcomes-based approach may help to better define which eligible smokers might defer screening (low risk of lung cancer), discontinue screening (high risk of overtreatment with little benefit) or continue screening to achieve the greatest reduction in lung cancer mortality.

Preoperative ANemiA among the elderly undergoing major abdominal surgery (PANAMA) study: Protocol for a single-center observational cohort study of preoperative anemia management and the impact on healthcare outcomes

INTRODUCTION

Preoperative anemia and old age are independent risk factors for perioperative morbidity and mortality. However, despite the high prevalence of anemia in elderly surgical patients, there is limited understanding of the impact of anemia on postoperative complications and postdischarge quality of life in the elderly. This study aims to investigate how anemia impacts elderly patients undergoing major abdominal surgery in terms of perioperative morbidity, mortality and quality of life for 6 months postoperatively.

METHODS AND ANALYSIS

We will conduct a prospective observational study over 12 months of 382 consecutive patients above 65 years old, who are undergoing elective major abdominal surgery in Singapore General Hospital (SGH), a tertiary public hospital. Baseline clinical assessment including full blood count and iron studies will be done within 1 month before surgery. Our primary outcome is presence of morbidity at fifth postoperative day (POD) as defined by the postoperative morbidity survey (POMS). Secondary outcomes will include 30-day trend of POMS complications, morbidity defined by Clavien Dindo Classification system (CDC) and Comprehensive Complication Index (CCI), 6-month mortality, blood transfusion requirements, days alive out of hospital (DaOH), length of index hospital stay, 6-month readmission rates and Health Related Quality of Life (HRQoL). HRQoL will be assessed using EuroQol five-dimensional instrument (EQ-5D) scores at preoperative consult and at 1, 3, and 6 months.

ETHICS AND DISSEMINATION

The SingHealth Centralised Institutional Review Board (CIRB Ref: 2017/2640) approved this study and consent will be obtained from all participants. This study is funded by the National Medical Research Council, Singapore (HNIG16Dec003) and the findings will be published in peer-reviewed journals and presented at academic conferences. Deidentified data will be made available from Dryad Repository upon publication of the results.

Trends in the contemporary incidence of colorectal cancer and patient characteristics in the United Kingdom: a population-based cohort study using The Health Improvement Network

Background

Cancer registry data show that survival of colorectal cancer (CRC) in the United Kingdom is poor compared with other European countries and the United States, yet these data sources lack information on patient comorbidities and medication use, which could help explain these differences.

Methods

Among individuals aged 40–89 years in The Health Improvement Network (2000–2014), we identified first ever cases of CRC and calculated incidence rates with 95% confidence intervals (CIs). For CRC cases and non-cases in two separate calendar years (2002 and 2014), we evaluated patient demographics, lifestyle factors, comorbidities and medication use and bowel screening.

Results

The incidence of CRC remained relatively constant across the study period; incidence rates per 10,000 person-years (95% CIs) were 9.27 (8.59–1.01) in 2000, 10.65 (10.15–11.18) in 2007 and 8.37 (7.93–8.83) in 2014. Incidence rates per 10,000 person-years were higher in men than women at 11.44 (95% CI: 10.35-12.66) vs. 7.40 (95% CI: 6.59–8.32) in 2000, and 9.39 (95% CI: 8.74–10.10) vs. 7.38 (95% CI: 6.81–8.00) in 2014. An increase was seen in the proportion of CRC cases diagnosed at age < 60 years. In 2002, 3.5% of CRC cases were diagnosed at age 40–49 compared with 5.1% in 2014 (p = 0.064). Similarly, in 2002, 12.5% were diagnosed at age 50–59 years compared with 16.2% in 2014 (p = 0.002). Between 2002 and 2014, previous bowel screening increased in both CRC cases (+ 10.6%) and non-cases (+ 9.7%)(p < 0.001 for both groups). Greater rises in the following were seen among CRC cases compared with non-cases: diabetes (+ 9.3% vs. + 3.3%; p < 0.001 for both), obesity (+ 14.5% vs. + 10.1%; p < 0.001 for both), hypertension (+ 8.3% vs. + 3.6%; p < 0.001 for both), atrial fibrillation (+ 2.6% [p < 0.01] vs. + 0.3% [p < 0.001]), and use of proton pump inhibitors (+ 11.5% vs. + 9.0%), anti-hypertensives (+ 9.9% vs. + 1.4%) and warfarin (+ 3.2% vs. + 0.4%); p < 0.001 for CRC cases and non-cases with respect to each medication.

Conclusions

CRC incidence has remained relatively stable in the UK over the last decade. The increased prevalence of some comorbidities and medications among CRC cases should be considered when evaluating patterns in CRC survival.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4265-1) contains supplementary material, which is available to authorized users.

Socioeconomic and demographic inequalities in stage at diagnosis and survival among colorectal cancer patients: evidence from a Swiss population-based study

Socioeconomic inequalities in cancer stage at diagnosis and survival are important public health issues. This study investigates the association between socioeconomic position (SEP) and colorectal cancer (CRC) stage at diagnosis and survival in Switzerland, a European country with highest level of medical facilities and life expectancy. We used population-based CRC data from seven Swiss cantonal cancer registries 2001-2008 (N = 10,088) linked to the Swiss National Cohort (SNC). Follow-up information was available until the end of 2013. SEP was estimated based on education. The association between cancer stage and SEP was assessed using logistic regression models including cancer localization (colon/rectum), sex, age, civil status, urbanity of residence, language region, and nationality (Swiss/non-Swiss). Survival was analyzed using competing risk regressions reporting subhazard ratios (SHRs) for the risk of dying due to CRC. We observed a social gradient for later stage CRC with adjusted odds ratios (ORs) of 1.11 (95% CI: 0.97-1.19) and 1.28 (95% CI: 1.08-1.50) for middle and low SEP compared to high SEP. Further, single compared to married people had elevated odds of being diagnosed at later stages. Survival was lower in patients with CRC with low SEP in the unadjusted model (SHR: 1.18, 95% CI: 1.07-1.30). After adjustment for stage at diagnosis and further sociodemographic characteristics, significant survival inequalities by SEP disappeared but remained for non-Swiss compared to Swiss citizens and for patients living in nonurban areas compared to their urban counterparts. Swiss public health strategies should facilitate equal access to CRC screening and optimal CRC care for all social groups and in all regions of Switzerland.

Descriptive characteristics of colon and rectal cancer recurrence in a Danish population-based study

BACKGROUND

Recurrence is a common outcome among patients that have undergone an intended curative resection for colorectal cancer. However, data on factors that influence colorectal cancer recurrence are sparse. We report descriptive characteristics of both colon and rectal cancer recurrence in an unselected population.

MATERIAL AND METHODS

We identified 21,152 patients with colorectal cancer diagnosed between May 2001 and December 2011 and registered with the Danish Colorectal Cancer Group. Recurrences were identified in 3198 colon and 1838 rectal cancer patients during follow-up. We calculated the frequency, proportion, and incidence rates of colon and rectal cancer recurrence within descriptive categories, and the cumulative five- and ten-year incidences of recurrence, treating death as a competing risk. We used a Cox proportional hazard model to calculate hazard ratios (HR) and 95% confidence intervals (CI).

RESULTS

Recurrence risk was highest in the first three years of follow-up. Patients <55 years old at initial diagnosis (incidence rate for colon: 7.2 per 100 person-years; 95% CI: 6.5-7.9; rectum: 8.1 per 100 person-years; 95% CI: 7.2-9.0) and patients diagnosed with stage III cancer (colon HR: 5.70; 95% CI: 4.61-7.06; rectal HR: 7.02; 95% CI: 5.58-8.82) had increased risk of recurrence. Patients diagnosed with stage III cancer from 2009 to 2011 had a lower incidence of recurrence than those diagnosed with stage III cancer in the years before. Cumulative incidences of colon and rectal cancer recurrence were similar for both cancer types among each descriptive category.

CONCLUSIONS

In this population, increases in colorectal cancer recurrence risk were associated with younger age and increasing stage at diagnosis. Cumulative incidence of recurrence did not differ by cancer type. Descriptive characteristics of colon and rectal cancer recurrence may help to inform patient-physician decision-making, and could be used to determine adjuvant therapies or tailor surveillance strategies so that recurrence may be identified early, particularly within the first 3 years of follow-up.

The mortality reducing effect of aspirin in colorectal cancer patients: Interpreting the evidence

In 1971 the first study appeared that suggested a relationship between aspirin and cancer. Currently publications on the subject of aspirin and cancer are numerous, with both a beneficial effect of aspirin on cancer incidence and a beneficial effect on cancer survival. This review focusses on the relation between the use of aspirin and improved survival in colorectal cancer patients. Various study designs have been used, with the main part being observational studies and post hoc meta-analyses of cancer outcomes in cardiovascular prevention trials. The results of these studies are unambiguously pointing towards an effect of aspirin on colorectal cancer survival, and several randomised controlled trials are currently ongoing. Some clinicians feel that the current evidence is conclusive and that the time has come for aspirin to be prescribed as adjuvant therapy. However, until this review, not much attention has been paid to the specific types of bias associated with these studies. One of these biases is confounding by indication, because aspirin is indicated for patients as secondary prevention for cardiovascular disease. This review aims to provide perspective on these biases and provide tools for the interpretation of the current evidence. Albeit promising, the current evidence is not sufficient to already prescribe aspirin as adjuvant therapy for colorectal cancer.

The Charlson age comorbidity index predicts prognosis in patients with resected pancreatic cancer

BACKGROUND

The Charlson age comorbidity index (CACI) is a useful measure of comorbidity to standardize the evaluation of surgical patients and has been reported to predict postoperative mortality in various cancers.

METHOD

A total of 379 patients who underwent R0/R1 resection for pancreatic cancer between 2003 and 2014 were enrolled in this study. According to the CACI, the age-adjusted comorbidity index was calculated by weighting individual comorbidities; CACI<4 was considered the low-CACI group, whereas CACI≥4 was considered the high-CACI group. The correlations between the CACI and clinicopathologic features and survival outcomes were statistically analyzed.

RESULTS

The patients with a high CACI were more likely to be old and had higher CA19-9 levels and lower incidences of portal vein resection and blood transfusion. The rate of patients who received chemotherapy was significantly higher in the low-CACI group than in the high-CACI group (87% vs. 69%, P < 0.0001). The overall survival (OS) rate was significantly higher in the low-CACI group than in the high-CACI group (P = 0.047). Multivariable analysis showed that a high CACI was a predictor of poor survival (P = 0.024). In the high-CACI group, patients with high relative dose intensity (RDI) for postoperative adjuvant chemotherapy had significantly better relapse-free survival (RFS) and OS than those with low RDI (both P < 0.0001).

CONCLUSIONS

The CACI was a significant independent predictor of prognosis and compliance for postoperative adjuvant chemotherapy in the resected pancreatic cancer.

Initiation of adjuvant chemotherapy within 8 weeks of elective colorectal resection improves overall survival regardless of reoperation

AIM

Reoperation after elective colorectal resection may delay the start of adjuvant chemotherapy (AC). The study investigated the dual impact of a reoperation and AC delay on overall survival (OS).

METHOD

The Hospital Episode Statistics database was analysed between 1997 and 2012. Patients were divided into colon and rectal cancer cohorts and data were analysed based on whether there was delay in receiving AC beyond 8 weeks and whether a patient suffered reoperation within 30 days. Multivariate regression analysis was undertaken to investigate the relationship between delay in giving AC and reoperation and their combined effect on OS.

RESULTS

Logistic regression showed reoperation, amongst other things, to be an independent predictor of AC delay, in both colon and rectal cancer (colon, odds ratio 2.31, P < 0.001; rectal, odds ratio 2.19, P < 0.001). There was no significant difference in OS between patients who had no AC delay but suffered a reoperation and patients who had no AC delay and no reoperation. Patients who had AC delay but no reoperation, however, had significantly worse OS compared to those who had no AC delay and no reoperation [colon, hazard ratio (HR) 1.16, P < 0.001; rectal, HR 1.17, P < 0.001]. Individuals who had both AC delay and a reoperation also had worse OS compared with patients who had neither (colon, HR 1.33, P = 0.037; rectal, HR 1.38, P < 0.001).

CONCLUSION

Delayed receipt of AC beyond 8 weeks after surgery is associated with significantly reduced OS regardless of reoperation status in both colon and rectal cancer patients.

The impact of cardiopulmonary exercise testing on patients over the age of 80 undergoing elective colorectal cancer surgery

AIM

Advanced age and occult cardiorespiratory disease are associated with increased morbidity and mortality following surgery. Cardiopulmonary exercise testing (CPET) may allow the identification of high-risk patients and facilitate planned postoperative critical care support. The aim of this study was to determine whether preoperative CPET in patients aged over 80 undergoing elective colorectal cancer resection was associated with improved outcome.

METHOD

All patients aged 80 years and above undergoing elective colorectal cancer resection between 1 March 2011 and 1 September 2013 were retrospectively analysed. Referral for CPET testing was at the discretion of the operating surgeon. Postoperative critical care unit (CCU) admission was based upon the CPET results.

RESULTS

Ninety-four patients were identified, of whom 48 underwent CPET testing. The CPET group were significantly older than the non-CPET group (85 vs 83 years, P = 0.04) and were more likely to have a planned admission to CCU postoperatively (P < 0.0001). Despite the increased use of CCU resources, the overall CCU length of stay (LOS) in the CPET group did not differ from the non-CPET group, but the non-CPET group had a higher proportion of Level-3 care. There were no differences in the incidence of unplanned CCU admission between the CPET and the non-CPET group (P = 0.23). There were no differences in overall LOS between the two groups (P = 0.42). There was no difference in mortality (P = 0.11), overall complications (P = 0.53) or severe complications (P = 0.3).

CONCLUSION

Preoperative CPET testing in patients aged over 80 undergoing elective colorectal cancer resection allows identification of higher-risk patients and mitigation of risk by preemptive admission to a CCU. This stratification allows equivalent results to be achieved in high- and low-risk elderly patients undergoing colorectal surgery.

Does comorbidity interact with prostate cancer to increase mortality? A Danish cohort study of 45 326 prostate cancer patients diagnosed during 1995-2011

BACKGROUND

Many prostate cancer patients die of other causes, but it remains unknown whether comorbidity interacts synergistically with prostate cancer to increase the mortality rate beyond that explained by the individual risks of comorbidity and prostate cancer.

METHODS

A nationwide cohort study of 45 326 Danish prostate cancer patients diagnosed during 1995-2011, each matched to approximately five men from the general population on age and individual comorbidities in the Charlson Comorbidity Index (CCI). We calculated five-year mortality rates and interaction contrasts as a measure of the excess mortality rate explained by synergy between prostate cancer and comorbidity.

RESULTS

Five-year mortality was 46.8% in prostate cancer patients and 25.8% in matched men from the general population. For prostate cancer patients with a CCI score of 2-3, the mortality rate was 250 per 1000 person-years [95% confidence interval (CI): 236, 263], and interaction between comorbidity and prostate cancer accounted for 20% of the total mortality rate (50 deaths per 1000 person-years, 95% CI 35, 65) in the first year following cancer diagnosis. The interaction was mainly present for patients with metastatic disease and those not treated with prostatectomy.

CONCLUSION

Up to 20% of all deaths among men who had both prostate cancer and comorbidities could be explained by the comorbidity-prostate cancer interaction. The mortality attributable to comorbidity itself and the mortality attributable to the interaction may be reduced by successful treatment of the comorbidity.

Relationships of colorectal cancer with dietary factors and public health indicators: an ecological study

BACKGROUND

Colorectal cancer (CRC) is the third most common cancer in Iranian women and fifth in men. The aims of this study were to investigate the relation of dietary factors and public health indicators to its development.

MATERIALS AND METHODS

The required information (2001-2006) about risk factors was obtained from the Non- Communicable Disease Surveillance Centre (NCDSC) of Iran. Risk factor data (RFD) from 89,404 individuals (15-64 years old) were gathered by questionnaire and laboratory examinations through a cross sectional study in all provinces by systematic clustering sampling method. CRC incidence segregated by age and gender was obtained from Cancer Registry Ministry of Health (CRMH) of Iran. First, correlation coefficients were used for data analysis and then multiple regression analysis was performed to control for confounding factors.

RESULTS

Colorectal cancer incidence showed a positive relationship with diabetes mellitus, hypertension, lacking or low physical activity, high education, high intake of dairy products, and non-consumption of vegetables and fruits.

CONCLUSIONS

We concluded that many dietary factors and public health indicators have positive relationships with CRC and might therefore be targets of preliminary prevention. However, since this is an ecological study limited by potential ecological fallacy the results must be interpreted with caution.

Adjusted Age-Adjusted Charlson Comorbidity Index Score as a Risk Measure of Perioperative Mortality before Cancer Surgery

Background

Identification of patients at risk of death from cancer surgery should aid in preoperative preparation. The purpose of this study is to assess and adjust the age-adjusted Charlson comorbidity index (ACCI) to identify cancer patients with increased risk of perioperative mortality.

Methods

We identified 156,151 patients undergoing surgery for one of the ten common cancers between 2007 and 2011 in the Taiwan National Health Insurance Research Database. Half of the patients were randomly selected, and a multivariate logistic regression analysis was used to develop an adjusted-ACCI score for estimating the risk of 90-day mortality by variables from the original ACCI. The score was validated. The association between the score and perioperative mortality was analyzed.

Results

The adjusted-ACCI score yield a better discrimination on mortality after cancer surgery than the original ACCI score, with c-statics of 0.75 versus 0.71. Over 80 years of age, 70–80 years, and renal disease had the strongest impact on mortality, hazard ratios 8.40, 3.63, and 3.09 (P < 0.001), respectively. The overall 90-day mortality rates in the entire cohort varied from 0.9%, 2.9%, 7.0%, and 13.2% in four risk groups stratifying by the adjusted-ACCI score; the adjusted hazard ratio for score 4–7, 8–11, and ≥ 12 was 2.84, 6.07, and 11.17 (P < 0.001), respectively, in 90-day mortality compared to score 0–3.

Conclusions

The adjusted-ACCI score helps to identify patients with a higher risk of 90-day mortality after cancer surgery. It might be particularly helpful for preoperative evaluation of patients over 80 years of age.

Impact of Comorbidity and Age on Determinants Therapeutic Strategies in Advanced Pancreatic Head Cancer Patients With Obstructive Jaundices

The current retrospective study aimed to investigate the relationship between prognostic factors and overall survival (OS) in patients with advanced pancreatic head cancers who initially presented with obstructive jaundice. Furthermore, the impact of age and comorbidities on therapeutic strategies in such patients was evaluated.A total of 79 advanced pancreatic head cancer patients who were treated at our institution between January 2006 and November 2013 were reviewed. We analyzed OS risk factors including sex, age, laboratory characteristics, Eastern Cooperative Oncology Group performance status, Charlson Comorbidity Index Scores (CCIS), and therapeutic strategies using Cox proportional hazards regression models.There was no difference in the OS of patients according to the type biliary drainage procedure they underwent. Other related factors, such as better performance status, lower CCIS, and receiving chemotherapy significantly correlated with survival in multivariate analyses. There was a significant survival benefit in systemic chemotherapy compared to best supportive care (BSC) or local radiotherapy. However, no survival benefit was found in elderly patients (age >70 years) undergoing systemic therapy compared to younger patients, except in those elderly patients with CCIS ≤ 1.In advanced pancreatic head cancer patients with obstructive jaundice, systemic therapy and adequate biliary drainage were still the most effective procedures for improving OS in the general population. However, in elderly patients with relatively higher CCIS, BSC with adequate biliary drainage was palliative and no less effective than systemic/local therapies.

Associations between cardiovascular disease severity, osteoarthritis co-morbidity and physical health: a population-based study

OBJECTIVE

The aim of this study was to investigate the interaction between cardiovascular disease severity and OA co-morbidity on physical health.

METHODS

A baseline questionnaire was mailed to 9676 patients aged ≥40 years from UK family practices. A priori exclusive morbidity groups were constructed as follows, based on records 3 years before baseline: (i) reference group--neither cardiovascular disease nor OA; (ii) cardiovascular disease severity index groups--with hypertension, ischaemic heart disease or heart failure without OA; (iii) OA index group without cardiovascular disease and (iv) co-morbid severity groups with hypertension, ischaemic heart disease or heart failure with OA. Adjusted associations between morbidity groups and physical health [mean physical component summary (PCS) score based on the 12-item Short Form Health Survey (SF-12)] compared with the reference group were assessed using linear regression methods.

RESULTS

A total of 5426 patients responded to the baseline questionnaire (56% response). The adjusted mean difference in PCS score between the reference group and the cardiovascular disease index were -2.4 (95% CI -3.4, -1.4) for hypertension, -5.3 (-6.3, -4.3) for ischaemic heart disease and -11.8 (-13.6, -9.9) for heart failure. The difference in the score for the index OA group was -5.6 (-6.5, -4.6). Estimates for co-morbid OA groups were -6.8 (-7.9, -5.7) for hypertension, -9.1 (-10.6, -7.6) for ischaemic heart disease and -12.8 (-16.0, -9.7) for heart failure.

CONCLUSION

In cardiovascular populations with differing severity, the co-morbid addition of OA was associated with incrementally poorer physical health, but such interactions were less than additive.