Second primary colorectal cancers (SPCRCs): experiences from a large Australian Cancer Registry

A Rare Case of Triple Primary Malignant Neoplasms (RCC and Colon Cancer) Detected by 18F-FDG PET/CT

Multiple primary malignancies are not uncommon in daily oncology practice, even though their frequency in the same or different organ systems varies. Regardless, early detection and proper planning of therapeutic approaches are essential for successful management. Here, we present a 73-years-old male with adenocarcinoma of the sigmoid who was referred for initial staging with 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT). 18F-FDG PET/CT revealed two metabolically active formations in the sigmoid and ascending colon and a large, heterogeneous tumor lesion in the middle and lower third of the left kidney, with increased 18F-FDG uptake in soft tissue components, suggesting the presence of synchronous neoplasms. The scan also showed 18F-FDG-positive multiple metabolically active lytic bone lesions with soft tissue components, small pulmonary nodules, and mediastinal/hilar lymph nodes with mildly elevated metabolic activity, suggesting secondary foci. Considering these findings, the patient was referred for histological evaluation.

Associations between pathological features and risk of metachronous colorectal cancer

Survivors of colorectal cancer (CRC) are at risk of developing another primary colorectal cancer - metachronous CRC. Understanding which pathological features of the first tumour are associated with risk of metachronous CRC might help tailor existing surveillance guidelines. Population-based CRC cases were recruited from the United States, Canada and Australia between 1997 and 2012 and followed prospectively until 2022 by the Colon Cancer Family Registry. Metachronous CRC was defined as a new primary CRC diagnosed at least 1 year after the initial CRC. Those with the genetic cancer predisposition Lynch syndrome or MUTYH mutation carriers were excluded. Cox regression models were fitted to estimate hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) for the associations. Of 6085 CRC cases, 138 (2.3%) were diagnosed with a metachronous CRC over a median follow-up time of 12 years (incidence: 2.0 per 1000 person-years). CRC cases with a synchronous CRC were 3.4-fold more likely to develop a metachronous CRC (adjusted HR: 3.36, 95% CI: 1.89-5.98) than those without a synchronous tumour. CRC cases with MMR-deficient tumours had a 72% increased risk of metachronous CRC (adjusted HR: 1.72, 95% CI: 1.11-2.64) compared to those with MMR-proficient tumours. Compared to cases who had an adenocarcinoma histologic type, those with an undifferentiated histologic type were 77% less likely to develop a metachronous CRC (adjusted HR: 0.23, 95% CI: 0.06-0.94). Existing surveillance guidelines for CRC survivors could be updated to include increased surveillance for those whose first CRC was diagnosed with a synchronous CRC or was MMR-deficient.

Second primary cancer among 217702 colorectal cancer survivors: An analysis of national German cancer registry data

With improvements in survival after colorectal cancer (CRC), more survivors are at risk of developing a second cancer, particularly in younger populations where CRC incidence is increasing. We estimated the incidence of second primary cancer (SPC) in CRC survivors and its potential risk factors. We identified CRC cases diagnosed between 1990 and 2011 and SPCs until 2013 from nine German cancer registries. Standardized incidence ratios (SIR) and absolute excess risk (AER) per 10 000 person-years were calculated and were stratified by index site: colon cancer (CC) and rectal cancer (RC), age and sex. Cox regression assessed potential SPC risk factors, including primary tumor-related therapy considering death as a competing risk. We included 217 202 primary CRC cases. SPC occurred in 18 751 CRC survivors (8.6%; median age: 69 years). Risk of cancer was significantly higher in CRC survivors than in the general population (SIR males 1.14, 95% confidence interval [CI] 1.12-1.17, AER = 24.7; SIR females 1.20, 95% CI 1.17-1.23, AER = 22.8). Increased risks of SPCs were observed for the digestive system, urinary system and female and male reproductive organs. CRC incidence increased in younger persons (<50 years) and SPC incidence was 4-fold in this group (SIR males 4.51, 95% CI 4.04-5.01, AER = 64.2; SIR females 4.03, 95% CI 3.62-4.48, AER = 77.0). Primary tumor-related factors associated with SPC risk were right-sided cancer and smaller primary tumor size. Treatment and risk of SPC differed for CC (no effect) and RC (lower risk after chemotherapy). CRC survivors have excess risk of developing SPC, with particular characteristics that could guide targeted surveillance.

Surgery for synchronous and metachronous colorectal cancer: segmental or extensive colectomy?

PURPOSE

To assess the impact of surgical approach on morbidity, mortality, and the oncological outcomes of synchronous (SC) and metachronous (MC) colorectal cancer (CRC).

METHODS

All patients undergoing resection for double location CRC (SC or MC) between 2006 and 2020 were included. The exclusion criteria were polyposis or SC located on the same side.

RESULTS

Sixty-seven patients (age, 64.8 years; male, 78%) with SC (n = 41; 61%) or MC (n = 26; 39%) were included. SC was treated with segmental colectomy (right and left colectomy/proctectomy; n = 19) or extensive colectomy (subtotal/total colectomy or restorative proctocolectomy with pouch; n = 22). Segmental colectomy was associated with a higher incidence of anastomotic leakage (47.4 vs. 13.6%; p = 0.04) and a higher rate of medical morbidity (47.4 vs. 16.6%; p = 0.04). The mean number of lymph nodes harvested was similar. For MC, the second cancer was treated by iterative colectomy (n = 12) or extensive colectomy (n = 14) and there was no significant difference in postoperative outcomes between the two surgical approaches. The median follow-up period was 42.4 ± 29.1 months. The 5-year overall and disease-free survival of the SC and MC groups did not differ to a statistically significant extent.

CONCLUSIONS

Extensive colectomy should be preferred for SC to reduce morbidity and improve the prognosis. In contrast, iterative colectomy can be performed safely for patients with MC.

Second Cancer After Additive Chemotherapy in Patients With Colon Cancer

BACKGROUND

Additive chemotherapeutic treatment of UICC-stage -III / IV colon cancer with fluorouracil, leucovorin and oxaliplatin is widely accepted as current standard of treatment after R0-resection. However, as patients.. survival is increasing, long-term side effects of chemotherapeutic agents such as second cancer development are becoming increasingly important.

PATIENTS

We therefore investigated a total of 2 856 Patients with UICC-stage III / IV colon cancer, 223 of whom (7.8%) had developed a subsequent second cancer.

RESULTS

Median follow-up was 73.2 months (range 209.9 months, 95%-CI 69.8-76.9). Most frequent second cancers were prostate cancer (18.4%), colon cancer (16.1%), breast cancers (8.1%), lung cancer (8.1%), rectal cancer (4.9%) and uterine cancer (4.9%). However, in comparison to non-treated patients this did not represent a significantly increased risk for subsequent second cancer in patients after treatment with additive chemotherapy. Of interest, our data suggest a significantly decreased second cancer rate in patients treated with FOLFOX compared to FUFOL for additive treatment.

CONCLUSIONS

Second cancer development was not increased after additive chemotherapy for colon cancer, which is a novel aspect in the ongoing discussions on reduction of adjuvant treatment to 3 months or treatment of lymph node negative patients. Novelty and Impact Statement To our knowledge, this is the first population-based study analyzing second cancer development after additive chemotherapy in patients with UICC III-IV colon cancer. The results have an important impact on the surveillance and long-term follow-up of cancer patients.

The risk of developing second primary malignancies among colorectal cancer patients

Background: The increasing number of young colorectal cancer (CRC) survivors has led to ongoing concerns about the risk of secondary primary malignancies (SPMs). Here, we intended to comprehensively explore the pooled standardized incidence rates (SIRs) for total and site-specific SPMs in CRC survivors with different restriction to lag period.

Methods: Pubmed, Embase, Cochrane Library, and Web of science databases were searched to identify any studies reporting the SIRs of SPM following CRC until August 2021. Total and site-specific SIRs with different restriction to lag period were pooled using fixed/random effect models.

Results: A total of 42 full-text publications with more than 1, 524, 236 CRC survivors and 166, 210 SPM patients were included in the meta-analysis. Pooled data showed an increased SIRs for all SPMs in CRC survivors with different restriction to lag period (no restriction to lag period, SIR = 1.15, 95% CI = [1.08–1.23]; 1-year lag, 1.16 [1.10–1.23]; 5-year lag, 1.18 [1.09–1.28]; 10-year lag, 1.24 [1.11–1.39]). The conclusions were consistent for neoplasms of colorectum, corpus uteri, and small intestine with different restriction to lag period. However, limited evidence was presented for associations between CRC survivors and SPM for prostate, breast (female), ovarian, stomach, urinary bladder, kidney, thyroid, bone and soft tissue.

Conclusion: CRC survivors are associated with an increased risk of SPMs, especially neoplasms of colorectum, corpus uteri, and small intestine. Further studies should explore the risks for these neoplasms in CRC survivors, thus providing the reference for future follow-up care.

Risk of extracolonic second primary cancers following a primary colorectal cancer: a systematic review and meta-analysis

PURPOSE

The purpose of the study is to assess the global risk of extracolonic secondary primary cancers (SPCs) in patients with colorectal cancer (CRC).

METHODS

Studies of SPC in patients with CRC were included if they reported the standardised incidence ratio (SIR) for extracolonic SPCs in patients with CRC compared with the general population. Pooled summary estimates were calculated using a random-effects model.

RESULTS

A total of 7,716,750 patients with CRC from 13 retrospective cohort studies that reported extracolonic SPC incidence were included. The overall risk of several SPCs was significantly higher in patients with CRC compared with the general population, including cancers of the urinary bladder (pooled SIR 1.19, 95% confidence interval (CI) 1.06-1.33; p = 0.003), female genital tract (1.88, 1.07-3.31; p = 0.03), kidney (1.50, 1.19-1.89; p = 0.0007), thorax (lung, bronchus and mediastinum) (1.16, 1.01-1.32; p = 0.03), small intestine (4.26, 2.58-7.01; p < 0.0001), stomach (1.22, 1.07-1.39; p = 0.003), and thyroid (1.40, 1.28-1.53; p < 0.0001), as well as melanoma (1.28, 1.01-1.62; p = 0.04). There was also a decreased risk of developing cancer of the gall bladder (0.75, 0.60-0.94; p = 0.01).

CONCLUSION

Patients with CRC had a significantly increased risk of extracolonic SPCs compared with the general population. These findings highlight the need to develop research strategies for the management of second primary cancer in patients with CRC.

Circulating Folate and Folic Acid Concentrations: Associations With Colorectal Cancer Recurrence and Survival

BACKGROUND

Folates, including folic acid, may play a dual role in colorectal cancer development. Folate is suggested to be protective in early carcinogenesis but could accelerate growth of premalignant lesions or micrometastases. Whether circulating concentrations of folate and folic acid, measured around time of diagnosis, are associated with recurrence and survival in colorectal cancer patients is largely unknown.

METHODS

Circulating concentrations of folate, folic acid, and folate catabolites p-aminobenzoylglutamate and p-acetamidobenzoylglutamate were measured by liquid chromatography-tandem mass spectrometry at diagnosis in 2024 stage I-III colorectal cancer patients from European and US patient cohort studies. Multivariable-adjusted Cox proportional hazard models were used to assess associations between folate, folic acid, and folate catabolites concentrations with recurrence, overall survival, and disease-free survival.

RESULTS

No statistically significant associations were observed between folate, p-aminobenzoylglutamate, and p-acetamidobenzoylglutamate concentrations and recurrence, overall survival, and disease-free survival, with hazard ratios ranging from 0.92 to 1.16. The detection of folic acid in the circulation (yes or no) was not associated with any outcome. However, among patients with detectable folic acid concentrations (n = 296), a higher risk of recurrence was observed for each twofold increase in folic acid (hazard ratio = 1.31, 95% confidence interval = 1.02 to 1.58). No statistically significant associations were found between folic acid concentrations and overall and disease-free survival.

CONCLUSIONS

Circulating folate and folate catabolite concentrations at colorectal cancer diagnosis were not associated with recurrence and survival. However, caution is warranted for high blood concentrations of folic acid because they may increase the risk of colorectal cancer recurrence.

Rapid health data repository allocation using predictive machine learning

Health-related data is stored in a number of repositories that are managed and controlled by different entities. For instance, Electronic Health Records are usually administered by governments. Electronic Medical Records are typically controlled by health care providers, whereas Personal Health Records are managed directly by patients. Recently, Blockchain-based health record systems largely regulated by technology have emerged as another type of repository. Repositories for storing health data differ from one another based on cost, level of security and quality of performance. Not only has the type of repositories increased in recent years, but the quantum of health data to be stored has increased. For instance, the advent of wearable sensors that capture physiological signs has resulted in an exponential growth in digital health data. The increase in the types of repository and amount of data has driven a need for intelligent processes to select appropriate repositories as data is collected. However, the storage allocation decision is complex and nuanced. The challenges are exacerbated when health data are continuously streamed, as is the case with wearable sensors. Although patients are not always solely responsible for determining which repository should be used, they typically have some input into this decision. Patients can be expected to have idiosyncratic preferences regarding storage decisions depending on their unique contexts. In this paper, we propose a predictive model for the storage of health data that can meet patient needs and make storage decisions rapidly, in real-time, even with data streaming from wearable sensors. The model is built with a machine learning classifier that learns the mapping between characteristics of health data and features of storage repositories from a training set generated synthetically from correlations evident from small samples of experts. Results from the evaluation demonstrate the viability of the machine learning technique used.

Developing a Novel Machine Learning-Based Classification Scheme for Predicting SPCs in Colorectal Cancer Survivors

Colorectal cancer is ranked third and fourth in terms of mortality and cancer incidence in the world. While advances in treatment strategies have provided cancer patients with longer survival, potentially harmful second primary cancers can occur. Therefore, second primary colorectal cancer analysis is an important issue with regard to clinical management. In this study, a novel predictive scheme was developed for predicting the risk factors associated with second colorectal cancer in patients with colorectal cancer by integrating five machine learning classification techniques, including support vector machine, random forest, multivariate adaptive regression splines, extreme learning machine, and extreme gradient boosting. A total of 4287 patients in the datasets provided by three hospital tumor registries were used. Our empirical results revealed that this proposed predictive scheme provided promising classification results and the identification of important risk factors for predicting second colorectal cancer based on accuracy, sensitivity, specificity, and area under the curve metrics. Collectively, our clinical findings suggested that the most important risk factors were the combined stage, age at diagnosis, BMI, surgical margins of the primary site, tumor size, sex, regional lymph nodes positive, grade/differentiation, primary site, and drinking behavior. Accordingly, these risk factors should be monitored for the early detection of second primary tumors in order to improve treatment and intervention strategies.

The ability of positron emission tomography/computed tomography to detect synchronous colonic cancers in patients with obstructive colorectal cancer

Positron emission tomography/computed tomography (PET/CT) is frequently used to detect colorectal cancer. The present retrospective study assessed the ability of PET/CT to identify synchronous colonic lesions in 72 patients with obstructive colorectal cancer. All patients had undergone surgical resection without undergoing preoperative total colonoscopy (TCS) at the Digestive Disease Center (April 2007 to September 2016), and subsequently underwent TCS of the proximal colon within 2 years post-surgery. A total of 11 patients exhibited 18F-fluorodeoxyglucose uptake during PET/CT of the proximal colon (4 invasive cancers, 3 advanced adenomas and 4 false-positive results), and 61 patients had no uptake in the proximal colon. Among these 61 patients, postoperative TCS revealed 2 invasive cancers and 4 advanced adenomas. The sensitivity of PET/CT for detecting synchronous invasive cancers was 66.6% (4/6), with a specificity of 89.4% (59/66), a positive predictive value of 36.4% (4/11), a negative predictive value of 96.7% (59/61), and an accuracy of 87.5% (63/72). Negative PET/CT results indicated a low probability of synchronous lesions in the proximal colon. Thus, PET/CT may be a useful tool for detecting synchronous colonic cancers in patients with obstructive colon cancer.

Rates of metachronous adenoma after curative resection for left-sided or right-sided colon cancer

Background/Aims

We determined the rates of metachronous colorectal neoplasm in colorectal cancer (CRC) patients after resection for right (R)-sided or left (L)-sided cancer.

Methods

Consecutive CRC patients who had undergone surgical resection for curative intent in our hospital between 2001 and 2004 were identified. R-sided colonic cancers refer to cancer proximal to splenic flexure whereas L-sided cancers include rectal cancers. Patients were included only if they had a clearing colonoscopy performed either before or within 6 months after the operation. Findings of surveillance colonoscopy performed up to 5 years after colonic resection were included in the analysis.

Results

Eight hundred and sixty-three CRC patients underwent curative surgical resection during the study period. Three hundred and twenty-seven patients (107 R-sided and 220 L-sided) fulfilled the inclusion criteria and had at least 1 postoperative surveillance colonoscopy performed. The proportion of patients who had polyp and adenoma on surveillance colonoscopy was significantly higher among patients with L-sided than R-sided cancers (polyps: 30.9% vs. 19.6%, P=0.03; adenomas: 25.5% vs. 13.1%, P=0.01). The mean number of adenoma per patient on surveillance colonoscopy was also higher for patients with L-sided than R-sided tumors (0.52; 95% confidence interval [CI], 0.37–0.68 vs. 0.22; 95% CI, 0.08–0.35; P<0.01). Multivariate analysis showed that L-sided cancers, age, male gender and longer follow-up were independent predictors of adenoma detection on surveillance colonoscopy.

Conclusions

Patients with Lsided cancer had a higher rate of metachronous polyps and adenoma than those with R-sided cancer on surveillance colonoscopy.

Risk of Synchronous and Metachronous Colorectal Cancer: Population-Based Estimates in Denmark with Focus on Non-Hereditary Cases Diagnosed After Age 50

BACKGROUND AND AIMS

The risk of synchronous and metachronous colorectal cancer is influenced by heritable and environmental factors. As a basis for comparative studies, we provide population-based estimates of synchronous and metachronous colorectal cancer with a focus on non-heritable cases.

MATERIAL AND METHODS

Based on data from national Danish cancer registers, we estimated the proportion of synchronous colorectal cancer and the incidence rates and risks for metachronous colorectal cancer in 28,504 individuals, who developed 577 metachronous colorectal cancer above age 50.

RESULTS

Synchronous colorectal cancer was diagnosed in 1.3% of the cases. The risk of metachronous colorectal cancer was associated with sex, tumor location, and age with the strongest influence from the latter. The incidence rate ratios for metachronous colorectal cancer ranged from above 6 in patients below age 65 to <1-3.2 in patients above age 65. The absolute risk of metachronous colorectal cancer was ⩾10% in patients below age 65 and 1.0%-8.0% in patients above age 65.

CONCLUSION

Individuals who develop sporadic, non-inherited colorectal cancer above age 50 are at a significantly increased risk of metachronous colorectal cancer with risk estimates that are strongly affected by age. This observation underscores the need for development of targeted surveillance in the most common clinical subset of colorectal cancer.

Various clinicopathological features of patients with metachronous colorectal cancer in relation to different diagnostic intervals

BACKGROUNDS

Clinicopathologic factors relating to developing metachronous colorectal cancer (CRC) have been reported. However, the effects of different diagnostic intervals on these risk factors required further analysis.

PATIENTS AND METHODS

This retrospective study comprised 14,481 patients diagnosed from January 1995 to December 2012. Metachronous CRC was defined as the occurrence of a second colorectal cancer at least 1 year post-operatively.

RESULTS

A total of 153 (1.06%) patients developed metachronous CRCs during the follow-up. Significantly higher rates of developing metachronous cancer occurred in male patients (1.2 vs 0.9%), patients with synchronous CRC (2.0 vs 1.0%), and patients with a positive family history of CRC (1.4 vs 0.9%). Pertaining to diagnostic intervals related to clinicopathological features, more severe staging was significant in the diagnostic interval between 2 and 3 years (35 vs 7.7%, 20.6%, 17.5%, P = .01) compared with other intervals. Male patients were more frequently detected to have CRC within 3 years compared with females (53.1 vs 29.1%, P = .005). For a diagnostic interval ≧ 5 years, a significantly higher rate of metachronous CRC located at the right colon was observed than that located at the left colon (36.6 vs 19.7%, p = 0.03).

CONCLUSIONS

We evinced that a diagnostic interval between 2 and 3 years was a key time for metachronous CRC diagnosis with worse staging distribution. Based on current findings, we recommend the stratification of metachronous CRCs into diagnostic intervals of 1-2, 2-3, and ≧ 3 years, as they exhibit significantly different characteristics.

Do Patients with Second Primary Colorectal Cancer Hold the Similar Prognosis and Therapeutic Benefits as Those with Initial Primary Colorectal Cancer?

Aim

The objective is to compare the differences on prognosis and the therapeutic benefits between initial and second primary colorectal cancer (pCRC).

Methods

A dataset containing 377,271 initial pCRC cases and 18,617 second pCRC cases from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) 1988-2015 was evaluated. Survival comparisons were made using the log-rank test. Cox proportional hazards models were used to assess the survival benefits.

Results

The cancer-specific survival rate of patients with initial pCRC was significantly higher than that of patients with second pCRC (5-years survival rate: 64.85% vs. 60.22%, P<0.001). The Chi-square of stratified log rank for age at diagnosis was lower than that for primary site, pTNM stage, sex, race, histology, and grade (Chi-square=86.73). There were almost no differences on therapeutic benefits between patients with initial and second pCRC except that treatments with chemotherapy were significantly associated with longer survival rate compared with treatments without chemotherapy among stage III surgical initial and second primary left-sided colon cancers patients (HR=0.764 vs. 0.581; P for interaction =0.008).

Conclusion

Patients with second pCRC have worse prognosis than those with initial pCRC primarily because of older age in the former group. The results evidenced that the therapeutic benefits on the prognosis for colorectal cancer were generally similar between patients with initial and second pCRC.

Subsite heterogeneity in the profiles of circulating cytokines in colorectal cancer

Colorectal cancers (CRCs) are treated as one entity but are in fact a heterogeneous group of diseases. If not addressed, subsite-associated variability may interfere with mechanism-targeted therapies and accuracy of potential CRC biomarkers. Little is known about the contribution of systemic inflammatory and immune mediators to subsite heterogeneity in CRC. Our purpose was to compare the profiles of key cytokines between right and left colonic and rectal CRCs. Using Luminex xMAP® technology, serum concentrations of eotaxin, IL-1β, IL-1ra, IL-2, IL-4, IL-5, IL-6, IL-7, IL-8, IL-9, IL-10, IL-12(p70), IL-13, IL-15, IL-17, IFNγ, IP-10, FGF-2, G-CSF, GM-CSF, MCP-1, MIP-1α and β, PDGF-BB, RANTES, TNFα, and VEGF-A were determined in 104 CRC patients. We found the concentrations of IL-12(p70), IL-10, IL-1ra, IL-4, IL-6, IL-7, IL-8, G-CSF and TNFα to be significantly higher in right-sided and GM-CSF in left-sided than rectal CRCs. The concentrations of IFNγ and MIP-1α were significantly higher in right-sided CRCs as compared to cancers of other locations combined. In turn, MIP-1β was higher in rectal CRCs as compared to colon cancers. Taken together, our results show subsite heterogeneity of CRC cancers in terms of systemic inflammatory and immune responses that ought to be taken into account when attempting immunotherapy or developing biomarkers. Additionally, more pronounced T_H2 response accompanied by T_H1 immunity and more prominent tumor-promoting inflammation in CRC patients with primary tumors originating from right-sided colon may constitute a molecular background of unfavorable prognosis associated with this location.

Adherence to colonoscopy at 1 year following resection of localized colon cancer: a retrospective cohort study

BACKGROUND

For patients with stages I-III colon cancer who have undergone surgical resection, guidelines recommend surveillance colonoscopy at 1 year. However, limited data exist on adherence and associated factors. We aimed to determine the rate of adherence to surveillance colonoscopy at 1 year among nonmetastatic colon cancer patients who underwent resection and factors associated with adherence.

METHODS

In this population-based retrospective cohort study, the Surveillance, Epidemiology, and End Results (SEER)-Medicare database was used. We identified patients with stages I-III colon cancer who underwent surgical resection and survived >3 years without recurrence (no chemotherapy after 8 months) from 2002-2011. Our primary outcome was a colonoscopy claim 10-15 months after resection. We used multivariable regression analysis to assess associations between sociodemographic and clinical factors and receipt of timely colonoscopy.

RESULTS

Among 28,732 patients who survived >3 years without recurrence, 7967 (28%) did not undergo colonoscopy; 12,033 (42%) had it at one year, with 3159 (11%) before 10 months and 5573 (19%) after 15 months. Decreased adherence was associated with older age; being male versus female; being black or Hispanic versus white; higher tumor stage; left-sided tumors versus right sided; and increased comorbidities. Chemotherapy receipt was associated with increased adherence (odds ratio 2.06; 95% confidence interval 1.88-2.24).

CONCLUSIONS

In a large population-based sample of individuals aged ⩾ 65 years, only 42% of colon cancer survivors underwent 1-year surveillance colonoscopy. Demographic and clinical factors were associated with adherence.

The Experience of Extended Bowel Resection in Individuals With a High Metachronous Colorectal Cancer Risk: A Qualitative Study

PURPOSE/OBJECTIVES

To ascertain individual experiences of extended bowel resection as treatment for colorectal cancer (CRC) in those with a high metachronous CRC risk, including the self-reported adequacy of information received at different time points of treatment and recovery.
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RESEARCH APPROACH

Qualitative.
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SETTING

Participants were recruited through the Australasian Colorectal Cancer Family Registry and two hospitals in Melbourne, Australia.
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PARTICIPANTS

18 individuals with a high metachronous CRC risk who had an extended bowel resection from 6-12 months ago.
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METHODOLOGIC APPROACH

Semistructured interviews. Data were analyzed thematically.
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FINDINGS

In most cases, the treating surgeon decided on the best option regarding surgical treatment. Participants felt well informed about the surgical procedure. Information related to surgical outcomes, recovery, and lifestyle adjustment from surgery was not always adequate. Many participants described ongoing worry about developing another cancer. 
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CONCLUSIONS

Patients undergoing an extended resection to reduce metachronous CRC risk require detailed information delivered at more than one time point and relating to several different aspects of the surgical procedure and its outcomes.
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INTERPRETATION

An increased emphasis should be given to the provision of patient information on surgical outcomes, recovery, and lifestyle adjustment. Colorectal nurses could provide support for some of the reported unmet needs.

Surgical treatment of multiple sporadic colorectal carcinoma

Aim: Many aspects of the surgical management of multiple sporadic colorectal cancer syndrome, either synchronous and metachronous, remain to be cleared, in particular the prognostic influence of the extent of surgical resection. Method: A retrospective review was performed of patients diagnosed with multiple colorectal cancer from 1982 to May 2010. Clinical and pathologic data were collected and reviewed. Survival analysis was performed. Results: We identified 23 patients with multiple sporadic colorectal cancers, of which 8 had synchronous (SC) and 15 metachronous cancers (MC). Of the MC patients, 2 (13%) had the second cancer within 2 years, 4 (27%) in the time period of 2-5 years and 9 (60%) after 5 years. Twenty-one patients underwent multiple segmental resections; 2 patients underwent subtotal colectomy. The 5-year overall survival rate of SC and MC patients was 100% and 87% (p<0.001) respectively. The 5-year overall survival rate of multiple segmental resection patients and subtotal colectomy was 94% and 75% (p=0.655) respectively. Conclusion: Either synchronous and metachronous MSCRC patients showed good prognosis independently from to the extent of resection. Our results support a less aggressive biological behaviour allowing a more conservative management. Multiple segmental colorectal resections seem appropriate from an oncologic point of view in MSCRC patients. (www.actabiomedica.it)

Risk factors for metachronous colorectal cancer or polyp: A systematic review and meta-analysis

BACKGROUND AND AIM

We conducted a systematic review and meta-analysis to identify personal, lifestyle, and tumor-related risk factors for metachronous colorectal cancer (CRC) and polyp.

METHODS

Relevant studies were identified by searching MEDLINE, Web of Science and Cochrane Central Register through 15 May 2016. Estimates for associations were summarized using random effects models.

RESULTS

Fifty-five studies were included in the review. For individuals who had a CRC resection, having a synchronous polyp was a risk factor for metachronous CRC or polyp (relative risk [RR], 2.04; 95% confidence interval [CI], 1.48-2.82) and having a synchronous CRC (RR, 1.90; 95% CI, 1.25-2.91) and proximally located CRC (RR, 2.12; 95% CI, 1.24-3.64) were risk factors for metachronous CRC. For individuals who had a polypectomy, larger size (RR, 4.26; 95% CI, 2.11-8.57) or severe dysplasia of the initial polyp (RR, 5.15; 95% CI, 2.02-13.14), and having a synchronous polyp (RR, 2.52; 95% CI, 1.35-4.73) were risk factors for metachronous CRC; and a family history of CRC (RR, 1.90; 95% CI, 1.26-2.87), having a synchronous polyp (RR, 2.47; 95% CI, 1.74-3.50) and a larger size (RR, 1.49; 95% CI, 1.03-2.15) and proximal location of the initial polyp (RR, 1.20; 95% CI, 1.02-1.40) were risk factors for metachronous polyp. Meta-regression showed duration of follow-up was not a source of heterogeneity for most associations. There was no evidence that lifestyle factors were associated with metachronous CRC or polyp risk.

CONCLUSION

A comprehensive list of risk factors identified for metachronous CRC or polyp may have important clinical implications.

The Incidence Characteristics of Second Primary Malignancy after Diagnosis of Primary Colon and Rectal Cancer: A Population Based Study

BACKGROUND

With the expanding population of colorectal cancer (CRC) survivors in the United States, one concerning issue is the risk of developing second primary malignancies (SPMs) for these CRC survivors. The present study attempts to identify the incidence characteristics of SPMs after diagnosis of first primary colon cancer (CC) and rectal cancer (RC).

METHODS

189,890 CC and 83,802 RC cases were identified from Surveillance, Epidemiology and End Results Program (SEER) database. We performed rate analysis on incidence trend of SPMs in both CC and RC. Expected incidence rates were stratified by age, race and stage, calendar year of first CRC diagnosis and latency period since first CRC diagnosis. The standardized incidence ratios (SIRs), measure for estimating risk of SPMs, were calculated for CC and RC respectively.

RESULTS

The trends of incidence of SPMs in both CC and RC were decreasing from 1992 to 2012. Both CC and RC survivors had higher risk of developing SPMs (SIRCC = 1.13; SIRRC = 1.05). For CC patients, the highest risks of SPM were cancers of small intestine (SIR = 4.03), colon (SIR = 1.87) and rectum (SIR = 1.80). For RC patients, the highest risks of SPMs were cancers of rectum (SIR = 2.88), small intestine (SIR = 2.16) and thyroid (SIR = 1.46). According to stratified analyses, we also identified incidence characteristics which were contributed to higher risk of developing SPMs, including the age between 20 and 40, American Indian/Alaska Native, localized stage, diagnosed at calendar year from 2002 to 2012 and the latency between 12 and 59 months.

CONCLUSIONS

Both CC and RC survivors remain at higher risk of developing SPMs. The identification of incidence characteristics of SPMs is extremely essential for continuous cancer surveillance among CRC survivors.

No increase in colorectal cancer in patients under 50 years of age: a Victorian experience from the last decade

AIM

The study aimed to assess whether there has been an increase in the incidence of colorectal cancer (CRC) among young patients in Victoria and whether such cancers are more advanced at presentation.

METHOD

The Victorian Cancer registry database was searched for patients, 18-50 years of age, diagnosed with CRC [young colorectal cancer (YCRC)] between 2000 and 2010. Average annual percentage changes and incidence rate ratios (IRRs) were calculated to characterize trends in CRC rates over time and to make comparisons with patients over 50 years of age with CRC [late colorectal cancer (LCRC)].

RESULTS

Of 37432 CRCs registered during the study period, 2635 (7%) were in YCRC patients (annual increase in incidence = 1.7%; 95% CI: 0.5-2.9), compared with 34797 (93%) in LCRC patients (annual increase in incidence = 1.3%; 95% CI: 0.9-1.6). A small, nonsignificant increase in the incidence of YCRC over time was observed [IRR = 1.004 (95% CI: 0.992-1.016) for YCRC vs. 0.989 (95% CI: 0.986-0.992) for LCRC]. Rectal cancer was more common in YCRC patients than in LCRC patients (42% vs. 34%, respectively; P < 0.0001). The cancer would have been seen on flexible sigmoidoscopy in 63% of YCRC patients compared with 53.6% of LCRC patients (P < 0.0001). YCRC patients were more likely to have node-positive disease (49.3% YCRC patients vs. 40% LCRC patients; P < 0.0001), especially those with colonic cancer (52.7% YCRC patients vs. 41.2% LCRC patients; P < 0.0001).

CONCLUSION

There has been an increase in incident cases of YCRC. A small, nonsignificant increase in the incidence of YCRC over time was observed. Young patients are more likely to have rectal cancer and to be node positive.

Clinical characteristics of second primary cancer in colorectal cancer patients: the impact of colorectal cancer or other second cancer occurring first

BACKGROUND

Due to improvements in early detection, treatment, and supportive care, the number of colorectal cancer (CRC) survivors is increasing; therefore, careful attention should always be paid to the second primary cancer (SPC) in treating these CRC patients. The present study attempts to determine the correlation and clinical aspects of CRC to other cancers in patients suffering from SPC involving CRC.

METHODS

From January 2002 and June 2010, 1,679 cancer cases, CRC was accompanied by SPC in 89 patients (5.3%), including 16 (18%) synchronous and 73 (82%) metachronous SPC patients. These patients were subsequently classified into two groups: the first group had CRC diagnosed first as CRC first (CRCF); and the second group had another type of cancer diagnosed before the diagnosis of CRC as other cancer first (OCF). Of these 73 patients, 22 (30.1%) were in the group of CRCF, whereas 51 (69.9%) were in the group of OCF. Patients' clinicopathological characteristics and clinical outcomes were analyzed and compared between the two groups.

RESULTS

There was a significant difference in the sites of cancers between the two groups: 14 (27.5%) patients in the OCF group had gastric cancer, compared to one (4.5%) patient in the CRCF group (P = 0.026). Although there was no difference of hepatitis B virus (HBV) or hepatitis C virus (HCV) carriers between the OCF and CRCF groups (P = 0.165), there were six (27.3%) CRC patients with hepatocellular carcinoma (HCC) in the CRCF group, which was significantly higher than the two (3.9%) patients in the OCF group (P = 0.003). Furthermore, the cancer-specific survival rate of the CRCF patient group was significantly higher than that of the OCF patient group (P = 0.036).

CONCLUSIONS

In this retrospective analysis, gastric cancer patients compared to other secondary cancers were at a higher risk of developing subsequent CRC as SPC; alternatively, patients with CRC were at a higher risk of developing HCC as SPC subsequently, no matter whether patients were HBV or HCV carriers. Therefore, careful attention should always be paid to the possibility of secondary CRC to construct effective surveillance when treating cancer patients.

Current and emerging surveillance strategies to expand the window of opportunity for curative treatment after surgery in colorectal cancer

Colorectal cancer is the third most common cancer globally. At diagnosis, more than 70% of patients have nonmetastatic disease. Cure rates for early-stage colorectal cancer have improved with primary screening, improvements in surgical techniques and advances in adjuvant chemotherapy. Despite optimal primary treatment, 30-50% of these patients will still relapse. While death will result from widespread metastatic disease, patients with small volume oligometastatic disease are still considered curable with aggressive multimodality therapy. Hence, early detection of relapsed cancer when it is still amenable to resection expands the window of opportunity for cure. Here, the authors review the modalities currently employed in clinical practice and the evidence supporting intensive surveillance strategies. The authors also discuss ongoing clinical trials examining specific surveillance programs and emerging modalities that may be deployed in the future for early detection of metastatic disease.

Results from an American Society of Colon and Rectal Surgeons survey on the management of young-onset colorectal cancer

BACKGROUND

Young patients with colorectal cancer (CRC) present a diagnostic and clinical challenge. The aim of our study was to survey the approaches to preoperative evaluation and clinical management of young patients with CRC by colorectal surgeons in North America.

METHODS

A standard electronic survey was sent to the members of the American Society of Colon and Rectal Surgeons. The survey polled management decisions in various clinical scenarios for CRC patients less than 50 years old. Survey responses were collated and analyzed.

RESULTS

One hundred ninety surgeons responded and 140 completed the entire survey (response rate 10%). Eighty percent of surgeons would offer preoperative genetic testing if the patient's family met the Amsterdam criteria compared to only 67% if the criteria were not met. Of those offering preoperative tumor testing, 48% test microsatellite instability, 19% mismatch repair protein expression by immunohistochemistry, and 24% offer both. Decisions regarding the extent of the resection for cancer were dependent on family history: Most members (86%) would perform a segmental colectomy for CRC in a patient without family history. Eighty-four percent of respondents would offer a total abdominal colectomy if preoperative tests indicated Lynch syndrome. When questioned about MYH-associated polyposis, only 27% recognized the appropriate diagnosis.

CONCLUSIONS

Among the American Society of Colon and Rectal Surgeons, family history influences preoperative testing and surgical management decisions. A significant portion of surgeons do not offer preoperative genetic testing, despite implications on operative management, postoperative surveillance, and screening of family members.

Anatomic subsite of primary colorectal cancer and subsequent risk and distribution of second cancers

BACKGROUND

Individuals with a history of colorectal cancer (CRC) have an increased risk of subsequent cancer. In this study, the authors used cancer registry data to evaluate whether this increased risk of cancer after CRC differed by anatomic subsite of a first CRC.

METHODS

Individuals diagnosed with a first primary CRC between 1992 and 2009 were identified from 12 Surveillance, Epidemiology, and End Results (SEER) cancer registries. Standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) were calculated by comparing the incidence of subsequent cancers in these patients who had an index CRC versus the cancer incidence rates in the general population. SIRs were calculated for cancers at anatomic sites within and outside the colorectum in analyses stratified by subsite of the index CRC.

RESULTS

Cancer incidence rates were significantly higher in individuals who had a previous CRC than in the general population (SIR, 1.15; 95% CI, 1.13-1.16). Individuals with an index CRC located between the transverse and descending colon experienced the greatest increased risk both overall (SIR, 1.29-1.33) and particularly with respect to the risk of a second CRC (SIR, 2.53-3.35). The incidence of small intestinal cancer was elevated significantly regardless of the index CRC subsite (SIR, 4.31; 95% CI, 3.70-4.77), and the incidence of endometrial cancer was elevated in those who had an index CRC in the proximal colon (SIR, 1.37-1.79).

CONCLUSIONS

The risk of second cancer after CRC differs by anatomic site of the first tumor and is particularly pronounced for those with prior CRC located in the transverse to descending colon. The mechanisms underlying this pattern of second cancer risk remain unknown.

High constant incidence of second primary colorectal cancer

Patients who had a colorectal cancer have a 1.5- to 2-fold excess risk of a second colorectal cancer as compared to the general population, the excess being higher at younger age at diagnosis. To further investigate the risk and the age-relation of the incidence of second primary colorectal cancer, we considered 9,389 first colon and rectal cancers registered in the Vaud Cancer Registry, Switzerland, between 1974 and 2008, and followed-up to the end of 2008 for a total of 44,113 person-years. There were 136 second colorectal cancers versus 90.5 expected, corresponding to a standardized incidence ratio (SIR) of 1.5 (95% confidence interval, CI, 1.3-1.8). The SIRs were not heterogeneous between men and women, and in strata of calendar year at diagnosis, duration of follow-up, and subsite. However, the SIR was 7.5 (95% CI 4.2-12.4) for subjects diagnosed below age 50 and declined thereafter to reach 1.0 (95% CI 0.6-1.6) at age 80 or over. Consequently, the incidence of second primary colorectal cancer was stable, and exceedingly high, around 300-400/100,000 between age 30-39 and 70 or over. This age pattern is consistent with the existence of a single mutational event in a population of highly susceptible individuals.

Multiple primary cancers among colorectal cancer survivors in Queensland, Australia, 1996-2007

PURPOSE

To quantify the demographic and clinical factors associated with an increased risk of multiple primary cancers (MPCs) among colorectal cancer survivors.

METHODS

Standardized incidence ratios for MPCs were calculated for residents of Queensland, Australia, who were diagnosed with a first primary colorectal cancer between 1996 and 2005 and survived for at least 2 months. Relative risk ratios were calculated for all MPCs combined and selected individual sites using multivariate Poisson models.

RESULTS

A total of 1,615 MPCs were observed among 15,755 study patients. The cohort had a significant excess risk of developing subsequent colorectal (SIR = 1.47, 95 % CI 1.30-1.66) or non-colorectal (SIR = 1.24, 95 % CI 1.18-1.31) cancers relative to the incidence of cancer in the general population. Age at initial diagnosis, follow-up time, initial colorectal subsite, and surgical treatment were independently associated (p < 0.01) with the overall risk of developing MPCs after adjustment. The relative risk ratio was 1.23 (95 % CI 1.07-1.41) for those aged 20-59 years compared with the 70-79 age group and 0.82 (95 % CI 0.72-0.92) for 1-5-year follow-up relative to the first year. The likelihood of being diagnosed with a MPC was 33 % higher (95 % CI 1.12-1.56) for surgically treated patients and 45 % higher (95 % CI 1.29-1.64) after proximal colon cancers relative to rectal cancer.

CONCLUSIONS

While these population-based results do not incorporate all possible risk factors, they form an important foundation from which to further investigate the etiological causes that result in the development of MPCs among colorectal cancer survivors.

The incidence and risk factors of metachronous colorectal cancer: an indication for follow-up

BACKGROUND

Patients with colorectal cancer are at risk for developing metachronous colorectal cancer. The purpose of posttreatment surveillance is to detect and remove premalignant lesions to prevent metachronous colorectal cancer.

OBJECTIVE

The aim of this study was to investigate the incidence of and predictive factors for metachronous colorectal cancer in patients with newly diagnosed colorectal cancer.

DESIGN AND PATIENTS

The data on all patients with newly diagnosed colorectal cancer between 1995 and 2006 were obtained from the Rotterdam Cancer Registry in The Netherlands and studied for metachronous colorectal cancer.

MAIN OUTCOME MEASURES

The annual incidence rate and the standardized incidence ratios were calculated.

RESULTS

In total, colorectal cancer was diagnosed in 10,283 patients; there were 39,974 person-years of follow-up. The mean annual incidence rate of metachronous colorectal cancer was 314/100,000 person-years at risk during 10 years of follow-up, corresponding with a mean annual incidence of 0.3% and a cumulative incidence of 1.1% at 3 years, 2.0% at 6 years, and 3.1% at 10 years. The incidence of metachronous colorectal cancer after resection of a first colorectal cancer is significantly higher than the incidence of colorectal cancer in an age- and sex-matched general population (standardized incidence ratio 1.3, 95% CI 1.1-1.5). This difference is especially seen during the first 3 years after first colorectal cancer diagnosis (standardized incidence ratio 1.4, 95% CI 1.1-1.8). The presence of synchronous colorectal cancer was the only significant risk factor for developing metachronous colorectal cancer (relative risk 13.9, 95% CI 4.7-41.0).

CONCLUSIONS

Despite the availability of colonoscopy, metachronous colorectal cancer is still seen during follow-up in patients with colorectal cancer; the highest risk is during the first 3 years after initial diagnosis. For this reason, a follow-up colonoscopy is useful at a short-term interval after colorectal cancer diagnosis. The presence of synchronous colorectal cancer at the time of first colorectal cancer diagnosis is the only predictive risk factor for developing metachronous colorectal cancer. Tailored surveillance programs may be considered in patients with a diagnosis of synchronous tumors.

Risk-adjusted colon and rectal cancer incidence rates in the United States

BACKGROUND

Population-based cancer incidence rates that adjust for multiple cancer primaries and for prevalent cases of the disease provide a better approximation of risk.

DESIGN

This study is based on a retrospective cohort.

SETTING/PATIENTS

Included in the study were 9 original Surveillance, Epidemiology and End Results registries focusing on white and black males and females from 2000 through 2007.

MAIN OUTCOME MEASURE

The main outcome measured was malignant colorectal cancer.

RESULTS

Conventional colorectal cancer incidence rates overestimate population risk by 3.6% for white males, 4.0% for black males, 3.4% for white females, and 3.3% for black females. The level of overestimation bias remained similar across the age span for white and black males. However, for white females, rates were overestimated by 2.1% for ages 30 to 39 and increased to 3.8% for ages 80 years and older. Corresponding values for black females were 1.5% and 3.8%. The trends in conventional rates were generally similar to the trends in risk-adjusted incidence rates, increasing or stable before age 50, but decreasing thereafter. The number of colorectal cancer cases in the United States is estimated from conventional incidence rates. In 2007, the number of colorectal cases was 59,599 for white males, 7,670 for black males, 58,972 for white females, and 8,786 for black females. The number of colorectal cancer cases based on prevalence-corrected incidence rates increased by 2.2% for white males, 1.5% for black males, 2.1% for white females, and 1.5% for black females.

CONCLUSION

Colorectal cancer incidence rates that include second and later colorectal cancer primaries and adjust for prevalence better reflect cancer burden, whereas colorectal cancer incidence rates that only include the first diagnosed case and adjust for prevalence better reflect cancer risk.