Gender aspects of survival after surgical treatment for rectal cancer

Sex Disparities in Rectal Cancer Surgery: An In-Depth Analysis of Surgical Approaches and Outcomes

Anatomical and physiological differences exist between sex, leading to variations in how diseases, such as rectal cancer, are prevalence and treatment outcomes of diseases including rectal cancer. In particular, in the case of rectal cancer, anatomical differences may be associated with surgical challenges, and these factors are believed to be important contributors to potential disparities in postoperative recovery, associated complications, and oncological outcomes between male and female patients. However, there is still ongoing debate regarding this matter. Significantly, the male pelvic anatomy is distinguished by its narrower dimensions, which can present surgical challenges and impede visual access during operative procedures, rendering it more complex than surgical interventions in the female pelvis. As a result, this anatomical difference leads to a greater occurrence of postoperative complications, such as anastomotic leakage. Moreover, the pelvis houses nerves that are vital for urinary and genital functions, underscoring the need to assess the potential risks of sexual and urinary dysfunction in rectal cancer surgery. These postoperative complications can significantly impact the quality of life; therefore, it is imperative to perform surgery with an understanding of the structural differences between sexes. Therefore, to address the limitations imposed by anatomical structures, new approaches such as robotic surgery, trans-anal total mesorectal excision, and intraoperative neuromonitoring are being introduced. Furthermore, it is essential to conduct research into fundamental mechanisms that may give rise to differences in surgical outcomes and oncological results between sexes. By comprehending the disparities between males and females, we can advance toward personalized treatments. Consequently, this review outlines variations in surgical approaches, complications, and treatments for rectal cancer in male and female patients.

Five-year follow-up study of stage I-IV rectal cancer including EGFR immunoexpression and p21 immunoactivity

Introduction

Both environmental and genetic factors increase the likelihood of developing rectal cancer.

Aim

To assess the EGFR and p21 immunoreactivity in rectal cancer and to assess its relationship with the clinical outcome.

Material and methods

Applying exclusion criteria, 102 patients with stage I–IV rectal cancer, who had undergone scheduled surgery during the period 2005–2011, were included in the study. There was a follow-up study with a span of 5 years from the date of the surgery. Immunohistochemistry using epidermal growth factor receptor (EGFR Ab10, Clone111.6) and antibodies against p21 (p21^WAF1 (Clone H252)) was performed to detect overexpression of the targeted receptor. Digital analysis of positive reactions of membranes and nuclei was performed utilizing Visiopharm.

Results

The degree of EGFR intensity (log OR = 0.854, OR = 2.35, 95% CI: 1.14–4.85, p = 0.021) is a significant factor in the prognosis of death within 2 years after surgery. The OS curve showed a significant decrease after 40 months from the date of surgery in the cases where EGFR had high expression. The ROC curve for cancer stage, according to the UICC classification and EGFR expression, in order to predict 2-year RFS, reached a high specificity value (ROC = 0.81, p = 0.0408). The analysis showed no statistically significant differences in the survival curves of patients in groups with immunoreactivity of p21 protein at 0, 1, 2, 3 (p = 0.6453 in the log-rank test). Also, it is not a significant risk factor for death (HR = 0.915, p = 0.7842) or for tumor dissemination (HR = 0.94, p = 0.9426).

Conclusions

The determination of EGFR immunoreactivity is important in the monitoring and treatment of patients with rectal cancer, as opposed to p21.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Gender aspects of survival after abdominoperineal resection for low rectal cancer: a retrospective study

PURPOSE

The difference in prognosis between genders after abdominoperineal resection (APR) for low rectal cancer (LRC) is unclear. This study aimed to compare survival outcomes between genders in patients with LRC who underwent curative APR.

METHODS

This retrospective cohort study used a database of consecutive colorectal resections. Patients who received curative APR with LRC were grouped according to their gender. Female patients were frequency-matched 1:1 on American Joint Committee on Cancer (AJCC) stage to male patients. Overall survival (OS), disease-free survival (DFS), and their independent risk factors were examined.

RESULTS

A total of 140 patients with APR for LRC were included after matching: 70 (50.0%) males and 70 (50.0%) females. No significant differences were found between the groups in terms of age, operation methods, AJCC stage, and adjuvant therapy (all P > 0.05). Median follow-up was 39 (range: 3-128) months. Male gender was independently associated with worse OS (adjusted hazard ratio [HR] = 2.755, 95% CI: 1.507-5.038, P = 0.001) and worse DFS (adjusted HR = 2.440, 95% CI: 1.254-4.746, P = 0.009). Subgroup analysis revealed that female patients with stage III disease had better OS (P = 0.001) and DFS (P < 0.001) than male patients.

CONCLUSION

Gender affects survival after a curative APR for LRC. Compared with females, male patients with LRC after curative APR had worse prognosis, especially for stage III disease.

Gender differences in stage at diagnosis and preoperative radiotherapy in patients with rectal cancer

Background

Few studies have examined gender differences in the clinical management of rectal cancer. We examine differences in stage at diagnosis and preoperative radiotherapy in rectal cancer patients.

Methods

A prospective cohort study was conducted in 22 hospitals in Spain including 770 patients undergoing surgery for rectal cancer. Study outcomes were disseminated disease at diagnosis and receiving preoperative radiotherapy. Age, comorbidity, referral from a screening program, diagnostic delay, distance from the anal verge, and tumor depth were considered as factors that might explain gender differences in these outcomes.

Results

Women were more likely to be diagnosed with disseminated disease among those referred from screening (odds ratio, confidence interval 95% (OR, CI = 7.2, 0.9–55.8) and among those with a diagnostic delay greater than 3 months (OR, CI = 5.1, 1.2–21.6). Women were less likely to receive preoperative radiotherapy if they were younger than 65 years of age (OR, CI = 0.6, 0.3–1.0) and if their tumors were cT3 or cT4 (OR, CI = 0.5, 0.4–0.7).

Conclusions

The gender-specific sensitivity of rectal cancer screening tests, gender differences in referrals and clinical reasons for not prescribing preoperative radiotherapy in women should be further examined. If these gender differences are not clinically justifiable, their elimination might enhance survival.

Population-based analysis of outcomes with early-age colorectal cancer

BACKGROUND

The aim was to evaluate differences in stage, treatment and prognosis in patients aged less than 50 years with colorectal cancer compared with older age groups.

METHODS

This population-based study included all patients diagnosed with colorectal cancer in Sweden, 2010-2015. Disease stage, treatment, 5-year disease-free survival (DFS) and relative survival were analysed in relation to age groups: less than 50, 50-74 and at least 75 years.

RESULTS

Of 34 434 patients included, 24·1, 19·7 and 14·0 per cent of patients aged less than 50, 50-74 and at least 75 years respectively were diagnosed with stage IV disease (P < 0·001). Adverse histopathological features were more common in young patients. Among patients aged less than 50 years, adjuvant chemotherapy was given to 18·9, 42·0 and 93·9 per cent of those with stage I, III and III disease respectively, compared with 0·7, 4·4 and 29·6 per cent of those aged 75 years or older (P < 0·001). Stage-adjusted DFS at 5 years for patients under 50 years old was 0·96, 0·90 and 0·77 in stage I, II and III respectively. Corresponding proportions were 0·88, 0·82 and 0·68 among patients aged 50-74 years, and 0·69, 0·62 and 0·49 for those aged 75 years or older. Relative survival was better for young patients only among those with stage III disease.

CONCLUSION

Patients younger than 50 years with colorectal cancer had a poorer stage at diagnosis and received more intensive oncological treatment. DFS was better than that among older patients in early-stage disease.

Prognostic Value of Clinical vs Pathologic Stage in Rectal Cancer Patients Receiving Neoadjuvant Therapy

Background

Neoadjuvant chemoradiation is currently standard of care in stage II-III rectal cancer, resulting in tumor downstaging for patients with treatment-responsive disease. However, the prognosis of the downstaged patient remains controversial. This work critically analyzes the relative contribution of pre- and post-therapy staging to the anticipated survival of downstaged patients.

Methods

The National Cancer Database (NCDB) was queried for patients with rectal cancer treated with transabdominal resection between 2004 and 2014. Stage II-III patients downstaged with neoadjuvant radiation were compared with stage I patients treated with definitive resection alone. Patients with positive surgical margins were excluded. Overall survival was evaluated using both Kaplan-Meier analyses and Cox proportional hazards models. All statistical tests were two-sided.

Results

A total of 44 320 patients were eligible for analysis. Survival was equivalent for patients presenting with cT1N0 disease undergoing resection (mean survival = 113.0 months, 95% confidence interval [CI] = 110.8 to 115.3 months) compared with those downstaged to pT1N0 from both cT3N0 (mean survival = 114.9 months, 95% CI = 110.4 to 119.3 months, P = .12) and cT3N1 disease (mean survival = 115.4 months, 95% CI = 110.1 to 120.7 months, P = .22). Survival statistically significantly improved in patients downstaged to pT2N0 from cT3N0 disease (mean survival = 109.0 months, 95% CI = 106.7 to 111.2 months, P < .001) and cT3N1 (mean survival = 112.8 months, 95% CI = 110.0 to 115.7 months, P < .001), compared with cT2N0 patients undergoing resection alone (mean survival = 100.0 months, 95% CI = 97.5 to 102.5 months). Multiple survival analysis confirmed that final pathologic stage dictated long-term outcomes in patients undergoing neoadjuvant radiation (hazard ratio [HR] of pT2 = 1.24, 95% CI = 1.10 to 1.41; HR of pT3 = 1.81, 95% CI = 1.61 to 2.05; HR of pT4 = 2.72, 95% CI = 2.28 to 3.25, all P ≤ .001 vs pT1; HR of pN1 = 1.50, 95% CI = 1.41 to 1.59; HR of pN2 = 2.17, 95% CI = 2.00 to 2.35, both P < .001 vs pN0); while clinical stage at presentation had little to no predictive value (HR of cT2 = 0.81, 95% CI = 0.69 to 0.95, P = .008; HR of cT3 = 0.83, 95% CI = 0.72 to 0.96, P = .009; HR of cT4 = 1.02, 95% CI = 0.85 to 1.21, P = .87 vs cT1; HR of cN1 = 0.96, 95% CI = 0.91 to 1.02, P = .19; HR of cN2 = 0.96, 95% CI = 0.86 to 1.08, P = .48 vs cN0).

Conclusions

Survival in patients with rectal cancer undergoing neoadjuvant radiation is driven by post-therapy pathologic stage, regardless of pretherapy clinical stage. These data will further inform prognostic discussions with patients.

Association of the oestrogen receptor beta with hormone status and prognosis in a cohort of female patients with colorectal cancer

BACKGROUND

The oestrogen receptor beta (ERβ) is the predominant oestrogen receptor in the normal colon mucosa and has been reported to exert anti-proliferative and pro-apoptotic effects. However, the role of ERβ in colorectal cancer (CRC) progression remains unclear.

AIM

To investigate the role of ERβ and its association with hormone status and lifestyle indicators in a female cohort of patients with CRC.

METHODS

Tissue microarrays of primary CRC tumour samples from 320 female patients were conducted with a monoclonal anti-ERβ antibody. The staining intensity was evaluated using immunohistochemistry. The association of ERβ expression with overall survival, disease-free survival, hormone status and lifestyle was evaluated, and effect estimators with 95% confidence intervals (CIs) were reported.

RESULTS

Among the 314 samples with successfully detected ERβ, 182 (58%) had low expression and 132 (42%) had high expression. The Cox multivariate analysis indicated that patients with high ERβ expression had a decreased risk of overall mortality by 50% (hazard ratio [HR], 0.50; CI, 0.30-0.83) and of cancer recurrence by 76% (HR, 0.24; CI, 0.11-0.52) after adjusting for age, tumour-node-metastasis stage and tumour intravascular invasion. Furthermore, high ERβ expression was significantly correlated with shorter breastfeeding time and longer use of hormone replacement therapy. No association was found between ERβ expression and lifestyle indicators.

CONCLUSION

Elevated ERβ expression is independently associated with a better prognosis and hormone status but not lifestyle indicators in female CRC patients.

Gender differences in colorectal cancer survival: A meta-analysis

A meta-analysis was conducted to determine the influence of gender on overall survival (OS) and cancer-specific survival (CSS) in colorectal cancer patients. Major databases were searched for clinical trials, which compare survival differences between male and female for colorectal cancer patients. A list of these studies and references, published in English and Chinese from 1960 to 2017, was obtained independently by two reviewers from databases such as PubMed, Medline, ScienceDirect, the China National Knowledge Infrastructure (CNKI) and Web of Science. Overall survival and cancer-specific survival were compared using Review Manager 5.3. Females had significantly better OS (hazard ratio [HR] = 0.87; 95% confidence interval [CI] = 0.85-0.89) and CSS (HR = 0.92; 95% CI = 0.89-0.95) than males after meta-analysis. These results suggest that gender seems to be a significant factor influencing survival results among colorectal cancer patients.

Secondary malignancies after rectal cancer resection with and without radiation therapy: A propensity-adjusted, population-based SEER analysis

BACKGROUND

The relationship between radiation therapy for rectal cancer and secondary malignancies is debated. The present study is the first population-based analysis using conventional multivariable analyses as well as propensity score matching to assess this relationship.

METHODS

Overall, 77,484 patients after resection of localized or locally advanced rectal adenocarcinoma diagnosed between 1973 and 2012 were identified in the Surveillance, Epidemiology, and End Results (SEER) registry. The occurrence of secondary malignancies diagnosed at least 1 (median follow up 5.8years [1-39.9years]) year after rectal cancer diagnosis was compared in patients who did and did not undergo radiation using stratified and propensity score matched Cox regression analysis.

RESULTS

Of 77,484 patients, 34,114 underwent radiation and 43,370 did not. Ignoring gender and entity, radiation therapy was not associated with secondary malignancies (hazard ratio [HR]=0.97 (95%CI: 0.92-1.02, P=0.269). The risk for prostate cancer was decreased and (HR=0.42, 95%CI: 0.36-0.48, P<0.001) and increased risk for endometrial cancer (HR=1.95, 95%CI: 1.49-2.56, P<0.001). Overall, patients undergoing radiation had higher risks for lung cancer (HR=1.18, 95%CI: 1.06-1.30, P<0.001), bladder cancer (HR=1.54, 95%CI: 1.31-1.80, P<0.001) and lymphomas (HR=1.27, 95%CI: 1.03-1.58, P=0.026).

CONCLUSIONS

The present analysis describes the occurence of secondary malignancies after pelvic radiation in patients undergoing rectal cancer surgery. Indeed, radiation for rectal cancer is associated with a significantly decreased risk of prostate cancer, however, an increased risk of endometrial, lung, and bladder cancer as well as lymphomas was observed. Overall, the risk of secondary malignancies was slightly decreased with radiation in patients undergoing rectal cancer resection, this was attributable to lower rates in prostate cancer.