Colorectal cancer incidence and mortality trends by sex and population group in South Africa: 2002-2014

Risk Model for Predicting Gaps in Surgical Oncology Care Among Patients With Stage I-III Rectal Cancer From KwaZulu-Natal, South Africa

PURPOSE

Gaps in surgical oncology care (GISOC), including delayed or nonreceipt of surgery, are detrimental to cancer control. This research sought to develop a risk model for predicting GISOC in South African rectal cancer (RC) patients with localized disease.

METHODS

This retrospective cohort study analyzed data from an existing colorectal cancer patient registry. GISOC was defined as surgery received >62 days after diagnosis with stage I-III RC or nonreceipt of surgery for stage I-III RC. Patient demographics, comorbidity, disease staging, and neoadjuvant therapy receipt were included as covariates in the analysis. A supervised logistic regression machine learning algorithm was used to train and test an appropriate risk model, which was translated into a nomogram. Receiver operating characteristic curve analyses and AUC assessments were used to establish the nomogram's performance.

RESULTS

The analysis included 490 patients (training data set = 245, testing data set = 245). Overall, there were 242 patients who experienced GISOC (49.4%), of whom 33 (13.6%) did not receive surgery and 209 (86.4%) had a delay in receiving surgery. The trained risk model consisted of patient race (Indian, odds ratio [OR] = 0.24; White, OR = 0.23; v Black), comorbidity (OR = 2.29 v no comorbidity), and neoadjuvant therapy receipt (OR = 18.40 v nonreceipt). AUCs for the risk model were >0.800.

CONCLUSION

An accurate, setting-specific risk model and nomogram was developed for predicting GISOC in patients with RC. The nomogram can be implemented without the use of technology to identify patients at high risk for GISOC, who can then be targeted with risk-reduction interventions. The impact of the nomogram on existing surgical unit workflows requires further investigation.

Prognostic value of the preoperative prognostic nutritional and systemic immunoinflammatory indexes in patients with colorectal cancer

INTRODUCTION

Colorectal cancer (CRC) is a common malignant tumor of the digestive tract. Although many prognostic indicators are currently available, it remains unclear which indicators are the most beneficial for patients with CRC. Therefore, there is a critical need to identify a simple, convenient and accurate prognostic indicator.

PURPOSE

To investigate the clinical significance of the systemic immune-inflammation index (SII) and prognostic nutritional index (PNI) as prognostic indicators for the survival of patients with CRC.

METHODS

The clinical data of CRC patients admitted to the general surgery ward of Taizhou People's Hospital affiliated to Nanjing Medical University from January 2015 to January 2018 were retrospectively analyzed. Two prognostic indicators (SII and PNI) were compared to evaluate their prognostic value in CRC patients.

RESULTS

Based on these variables, we constructed a LASSO prediction model. The AUC (Area Under the Curve) value and 95% CI of the training group were 0.917 (0.858-0.976) compared to 0.932 (0.846-1.000) in the validation group. We found that CEA > 5 ng/mL, tumor stage, pathological type, postoperative complications, and PNI were associated with the five-year survival rate of CRC patients. Receiver Operating Characteristic Curves (ROC) were drawn to assess the prediction accuracy of the model. The AUC and 95% CI of the training group were 0.913 (0.854-0.972), while the AUC and 95% CI of the validation group were 0.954 (0.899-1.000).

CONCLUSIONS

PNI is an independent risk factor for postoperative complications associated with CRC and a powerful tool for predicting survival outcomes in CRC patients.

Comparing the trend of colorectal cancer before and after the implementation of the Population-Based National Cancer Registry in Iran

Introduction

Colorectal cancer is the third most common malignancy and the second leading cause of cancer deaths worldwide. This disease is the fourth most common malignancy in Iran. Since knowing the trend of this cancer is necessary for planning; this study aimed to compare the trend of colorectal cancer before and after implementing the Population-Based National Cancer Registry.

Methods

In this time series analysis using secondary data, the autoregressive integrated moving average (ARIMA) was used to predict the future trend. An Interrupted Time Series (ITS) regression model was also used to compare the incidence and mortality of colorectal cancer before and after the setting up of the Iranian National Population-Based Cancer Registry (INPCR).

Results

Among Iranian men, an increasing trend in the incidence (from 16.8 in 2019 to 19.5 per 100,000 in 2027) and deaths of colorectal cancer for the coming years was predicted (from 10.2 in 2019 to 11.2 per 100,000 in 2027). A similar pattern was also observed for the incidence of this cancer among females (from 11 in 2019 to 12.3 per 100,000 in 2027), but a reverse pattern was predicted for the trend of deaths among women (from 2.06 in 2019 to 1.93 per 100,000 in 2027). During the years after the implementation of the INPCR, the trend of cases (β: 0.33, p < 0.001) as well as deaths due to colorectal cancer was significantly increasing (β: 0.08, p < 0.001) among the Iranian population.

Conclusions

Probably, part of the increase in the incidence and mortality of colorectal cancer could be due to the improvement of the registration and reporting system of new cancer cases.

Incidence and risk factors for colorectal cancer in Africa: a systematic review and meta-analysis

INTRODUCTION

Colorectal cancer (CRC) is the second leading cause of cancer-related death worldwide. There is a significant burden of mortality from colorectal cancer in Africa. Due to the heterogeneity of dietary and lifestyle practices throughout Africa, our work sought to define risk factors for the development of CRC in the African continent.

METHODS

We systematically searched PubMed, Embase, Global Health, CINAHL, Cochrane CENTRAL, and African Index Medicus for studies written in English, examining the incidence and risk factors of CRC in Africa. A systematic analysis was done to compare different risk factors in constituent studies. A meta-analysis random effects model was fitted to estimate the pooled incidence of CRC.

RESULTS

Of 2471 studies screened, 26 were included for the quantitative analysis; 20 in the incidence analysis, and six in the risk factor analysis. The overall ASIR per 100,000 person-years of CRC for males and females was 7.51 and 6.22, respectively. The highest incidence rates were observed between 2012 and 2021. Risk factors for CRC in Africa include tobacco smoking, and consumption of red meat, butter, and alcohol. Protective factors included, regular consumption of fruits and regular physical activity.

CONCLUSION

The incidence of CRC in Africa is higher than that suggested by previous studies. Our study shows that nonmodifiable and modifiable factors contribute to CRC in Africa. High-quality studies conducted on generalizable populations that examine risk factors in a comprehensive fashion are required to inform primary and secondary prevention initiatives for CRC in Africa.

Trends in the incidence of colorectal cancer in sub-Saharan Africa: A population-based registry study

In sub-Saharan Africa, colorectal cancer (CRC) has historically been considered a rare disease, although some previous studies have suggested that the incidence is increasing. We examine time trends in the incidence of CRC using data from 12 population-based cancer registries in 11 countries of sub-Saharan Africa that were able to provide time series data for periods of 12 or more years, or with earlier data with which recent rates may be compared. Age-standardized incidence rates were highest in the higher-income countries, and were increasing in all of the populations studied, and these increases were statistically significant in all but three. Current evidence has suggested a link between the increased adoption of western lifestyle habits with colorectal cancer, and along with increasing urbanization of African populations, there is an increase in body weight, as well as evidence of increasing consumption of meat, sugars, and alcohol.

Colorectal cancer spatial pattern in the northeast region of São Paulo, Brazil

Background

This study examined the spatial pattern of the colorectal cancer (CRC) in the 18 municipalities that compose the Regional Health Department of Barretos (RHD-V), which is in the northeast of the state of São Paulo, Brazil.

Methods

All incident cases and deaths from CRC between 2002 and 2016 were included. Age-standardized rates (ASR) for incidence and mortality per 100,000 person-years were used to evaluate the spatial distribution for the total and five-year periods. The lethality rates were also assessed. Excess risk maps compared the observed and expected events. Age-standardized net survival was used to evaluate CRC survival.

Results

For CRC incidence, the ASR value for the general population over the entire period (2002-2016) was 17.7 (95% CI: 16.7, 18.6), ranging from 16.7 (95% CI: 14.9, 18.4) (2002-2006) to 20.0 (95% CI: 18.3, 21.7) (2012-2016) per 100,000. When males and females were compared, the ASR was 20.1 (95% CI: 18.6, 21.6) and 15.7 (95% CI: 14.5, 17.0) per 100,000, respectively. For CRC mortality (2002-2016), the ASR was 8.2 (95% CI: 7.6, 8.9), ranging from 9.0 (95% CI: 7.8, 10.3) (2002-2006) to 8.2 (95% CI: 7.2, 9.3) (2012-2016) per 100,000. Overall, the excess risk up to 2.0 was more frequent. In terms of survival, municipalities with large port populations had lower survival in comparison with medium port.

Conclusions

This study showed a variation in CRC incidence and mortality, with differences considering five-year periods and gender, being the incidence higher in males than females in the entire period, with mortality equivalent to half the incidence. The survival was lower in municipalities with large port populations in comparison with medium port. Knowing spatial patterns of incidence, mortality, lethality, and survival can be necessary to support policymakers to advance or implement effective cancer control programs.

Genetic insights: High germline variant rate in an indigenous African cohort with early-onset colorectal cancer

Introduction

The increase in incidence of colorectal cancer in young patients of African ancestry coupled with increased aggressiveness has warranted investigation of the heritable nature of these cancers. Only a limited number of published reports of hereditary colorectal cancer in indigenous African populations have been reported and no systematic screening of these groups has been performed previously. We aimed to investigate causative germline variants and to establish the incidence of pathogenic/likely pathogenic germline variants in the known colorectal cancer genes in indigenous African colorectal cancer patients using a next-generation sequencing (NGS) multigene panel.

Materials and methods

Patients were selected from two hospitals in Cape Town and Johannesburg, South Africa. Patients with unresolved molecular diagnosis with an age of onset below or at 60 years were selected. Germline DNA samples were analyzed using a 14-gene NGS panel on the Ion Torrent platform. Variant calling and annotation were performed, and variants were classified according to the American College of Medical Genetics and Genomics guidelines. Observed variants were verified by Sanger sequencing and/or long-range PCR.

Results

Out of 107 patients, 25 (23.4%) presented with a pathogenic/likely pathogenic germline variant (PGV). Fourteen PGVs in at least one mismatch repair (MMR) gene were identified and verified in 12 patients (11.2%). Of these MMR gene variants, five were novel. The remaining 10 PGVs were in the APC, BMPR1A, MUTYH, POLD1, and TP53 genes.

Conclusion

The high incidence of PGVs associated with early-onset colorectal cancer in indigenous African patients has important implications for hereditary colorectal cancer risk management. These findings pave the way for personalized genetic screening programs and cascade testing in South Africa. The next step would involve further screening of the unresolved cases using tools to detect copy number variation, methylation, and whole exome sequencing.

Self-adherence to post-colonoscopy consults in patients undergoing diagnostic colonoscopy: Findings from a cross-sectional, quantitative survey at a South African quaternary hospital

Post-colonoscopy consults empower patients to make informed decisions around their subsequent treatment, and non-compliance with these consults ("no-shows") hinders disease management. There is a paucity in the literature regarding self-adherence to post-colonoscopy consults in resource-limited settings such as South Africa. An understanding of self-adherence to post-colonoscopy consults in this setting is required to establish whether improved interventions are needed, and what specific elements of self-adherence should be addressed with these interventions. The objective of this hypothesis-generating, cross-sectional, quantitative survey was to conduct a baseline assessment of cognitive, motivational, social, and behavioural variables related to self-adherence to post-colonoscopy consults in patients who underwent diagnostic colonoscopy at a South African quaternary hospital. The Adherence Determinants Questionnaire (ADQ) was administered in 47 patients to establish a baseline assessment of elements related to self-adherence to post-colonoscopy consults, including interpersonal aspects of care, perceived utility, severity, susceptibility, subjective norms, intentions, and supports/barriers. ADQ scores were transformed to a percentage of the maximum score for each element (100.0%). The overall mean transformed ADQ score was 57.8%. The mean transformed scores for specific ADQ components were as follows: subjective norms (40.8%), perceived severity (55.4%), perceived utility (56.6%), intentions (59.4%), supports/barriers (59.9%), interpersonal aspects (62.2%), and perceived susceptibility (65.9%). There were no statistically significant differences in overall mean transformed ADQ scores and individual ADQ elements across categories of participant age (p-values ranging between 0.180 and 0.949 when compared between participants ≤40 years and >40 years old), gender (p-values ranging between 0.071 and 0.946 when compared between males and females), and race (p-values ranging between 0.119 and 0.774 when compared between Black Africans and non-Black Africans). Our findings suggest a general need for appropriate interventions to improve self-adherence to post-colonoscopy consults in our setting.

Cost-effectiveness of adjuvant chemotherapy for high-risk stage II and stage III colon cancer in South Africa

BACKGROUND

Colon cancer incidence is rising in low- and middle-income countries (LMICs), where resource limitations and cost often dictate treatment decisions. In this study, we evaluate the cost-effectiveness of adjuvant chemotherapy for high-risk stage II and stage III colon cancer treatment in South Africa (ZA) and illustrate how such analyses can inform cancer treatment recommendations in a LMIC.

METHODS

We created a decision-analytic Markov model to compare lifetime costs and outcomes for patients with high-risk stage II and stage III colon cancer treated with three adjuvant chemotherapy regimens in a public hospital in ZA: capecitabine and oxaliplatin (CAPOX) for 3 and 6 months, and capecitabine for 6 months, compared to no adjuvant treatment. The primary outcome was the incremental cost-effectiveness ratio (ICER) in international dollars (I$) per disability-adjusted life-year (DALY) averted, at a willingness-to-pay (WTP) threshold equal to the 2021 ZA gross domestic product per capita (I$13,764/DALY averted).

RESULTS

CAPOX for 3 months was cost-effective for both patients with high-risk stage II and patients with stage III colon cancer (ICER = I$250/DALY averted and I$1042/DALY averted, respectively), compared to no adjuvant chemotherapy. In subgroup analyses of patients by tumor stage and number of positive lymph nodes, for patients with high-risk stage II colon cancer and T4 tumors, and patients with stage III colon cancer with T4 or N2 disease. CAPOX for 6 months was cost-effective and the optimal strategy. The optimal strategy in other settings will vary by local WTP thresholds. Decision analytic tools can be used to identify cost-effective cancer treatment strategies in resource-constrained settings.

CONCLUSION

Colon cancer incidence is increasing in low- and middle-income countries, including South Africa, where resource constraints can impact treatment decisions. This cost-effectiveness study evaluates three systemic adjuvant chemotherapy options, compared to surgery alone, for patients in South African public hospitals after surgical resection for high-risk stage II and stage III colon cancer. Doublet adjuvant chemotherapy (capecitabine and oxaliplatin) for 3 months is the cost-effective strategy and should be recommended in South Africa.

Patient's attitudes and perceptions around attending oncology consultations following surgery for colorectal cancer: A qualitative study

Background: The oncology consultation following surgery for colorectal cancer (CRC) is usually the first step in the receipt of chemotherapy. Non-compliance with this consultation results in non-receipt of recommended chemotherapy, when appropriate, and worse clinical outcomes. This study sought to explore South African patients' attitudes and perceptions around attending scheduled oncology consultations following their CRC surgery. Methods: Semi-structured qualitative interviews were conducted with patients who had surgery for CRC at a quaternary South African hospital and who had to decide whether they would return for an oncology consultation. The "Model of health services use" informed the design of the interview guide, which included questions on factors that impact health seeking behavior. Demographics of participants, CRC disease stage, and compliance with scheduled oncology consultations were also collected. Descriptive statistics were used to analyse the quantitative data, while deductive thematic analysis was used to analyse the qualitative data. Results: Seven participants were interviewed. The median age was 60.0 years and four participants (57.1%) were female. Black African, White, and Asian participants accounted for 85.7% of the study sample. Most participants had stage III CRC (71.4%). The oncology consultation no-show rate was 14.3%. Participant's knowledge and beliefs around CRC proved to be an important predisposing factor that influenced follow-up decisions. Family support and religion were cited as important enabling factors. Travel costs to the hospital and frustrations related to the clinic appointment booking/scheduling process were cited as important disabling factors. Lastly, the participant's self-perceived need for additional oncology care also appeared to influence their decision to return for ongoing oncology consultation after the initial surgery. Conclusion: Several contextual factors can potentially influence a patient's compliance with a scheduled oncology consultation following CRC surgery. A multipronged approach which addresses these factors is required to improve compliance with oncology consultations.

Comparative Analyses of Fucoidans from South African Brown Seaweeds That Inhibit Adhesion, Migration, and Long-Term Survival of Colorectal Cancer Cells

Human colorectal cancer (CRC) is a recurrent, deadly malignant tumour with a high incidence. The incidence of CRC is of increasing alarm in highly developed countries, as well as in middle to low-income countries, posing a significant global health challenge. Therefore, novel management and prevention strategies are vital in reducing the morbidity and mortality of CRC. Fucoidans from South African seaweeds were hot water extracted and structurally characterised using FTIR, NMR and TGA. The fucoidans were chemically characterised to analyse their composition. In addition, the anti-cancer properties of the fucoidans on human HCT116 colorectal cells were investigated. The effect of fucoidans on HCT116 cell viability was explored using the resazurin assay. Thereafter, the anti-colony formation potential of fucoidans was explored. The potency of fucoidans on the 2D and 3D migration of HCT116 cells was investigated by wound healing assay and spheroid migration assays, respectively. Lastly, the anti-cell adhesion potential of fucoidans on HCT116 cells was also investigated. Our study found that Ecklonia sp. Fucoidans had a higher carbohydrate content and lower sulphate content than Sargassum elegans and commercial Fucus vesiculosus fucoidans. The fucoidans prevented 2D and 3D migration of HCT116 colorectal cancer cells to 80% at a fucoidan concentration of 100 µg/mL. This concentration of fucoidans also significantly inhibited HCT116 cell adhesion by 40%. Moreover, some fucoidan extracts hindered long-term colony formation by HCT116 cancer cells. In summary, the characterised fucoidan extracts demonstrated promising anti-cancer activities in vitro, and this warrants their further analyses in pre-clinical and clinical studies.

Rectum adenocarcinoma metabolic subtypes analysis and a risk prognostic model construction based on fatty acid metabolism genes

Fatty acid metabolism is an essential part of cancer research due to its role in cancer initiation and progression. However, its characteristics and prognostic value in rectum adenocarcinoma have not been systematically evaluated. We collected fatty acid metabolism gene expression profiles and clinical information from the cancer genome atlas and gene expression omnibus databases. After excluding individuals lacking clinical information and the presence of genetic mutations, we performed consistent clustering of the remaining patients and selected stable clustering results to group patients. Differentially expressed genes and gene set enrichment analysis were compared between subgroups, while metabolic signature identification and decoding the tumor microenvironment were performed. In addition, we explored the survival status of patients among different subgroups and identified signature genes affecting survival by least absolute shrinkage and selection operator regression. Finally, we selected signature genes to construct a risk prognostic model by multivariate Cox regression and evaluated model efficacy by univariate Cox regression and the receiver operating characteristic curve. By consensus clustering, patients were distinguished into 2 stable subpopulations, gene set enrichment analysis and metabolic signature identification effectively defined 2 completely different subtypes of fatty acid metabolism: fatty acid catabolic subtype and fatty acid anabolic subtype. Among them, patients with the fatty acid catabolic subtype had a poorer prognosis, with a significantly lower proportion of myeloid dendritic cells infiltration within the tumor microenvironment. Aquaporin 7 (hazard ratio, HR = 2.064 (1.4408-4.5038); P < .01), X inactive specific transcript (HR = (0.3758-0.7564), P = .045) and interleukin 4 induced 1 (HR = 1.34 (1.13-1.59); P = .034), were selected by multivariate Cox regression, which constructed a risk prognostic model. The independent hazard ratio of the model was 2.72 and the area under curve was higher than age, gender and tumor stage, showing better predictive efficacy. Our study revealed the heterogeneity of fatty acid metabolism in rectum adenocarcinoma, defined 2 completely distinct subtypes of fatty acid metabolism, and finally established a novel fatty acid metabolism-related risk prognostic model. The study contributes to the early risk assessment and monitoring of individual prognosis and provides data to support individualized patient treatment.

Epidemiology and genetics of early onset colorectal cancer—African overview with a focus on Ethiopia

Colorectal cancer (CRC) is a common cause of cancer-related death worldwide, with high rates of late diagnosis and increased mortality in sub-Saharan Africa. Furthermore, there is an alarming uptrend in the incidence of early onset colorectal cancer (EOCRC) across the globe, thus necessitating the need for early screening in general and special populations. There is, however, limited data available on the incidence and genetic characteristics of EOCRC from resource-poor countries, particularly Africa. Moreover, there is lack of clarity if recommendations and mechanisms proposed based on data from resource-rich countries applies to other regions of the world. In this review, we appraise the literature on EOCRC, its overall incidence, and genetic components as it pertains to sub-Saharan Africa. In addition, we highlight epidemiologic and epigenetic findings of our EOCRC cohort in Ethiopia.

The global, regional, and national burden of colorectal cancer in 204 countries and territories from 1990 to 2019

Background

We aimed to estimate the global burden of colorectal cancer (CRC) between 1990 and 2019.

Methods

Data were extracted from the Global Burden of Disease study 2019. Estimated annual percentage changes (EAPCs) were calculated to quantify temporal trends in the age-standardized rates of CRC incidence, deaths, and disability-adjusted life-years (DALYs) by age, sex, region, and country. The correlations of EAPCs in the age-standardized rates with sociodemographic index (SDI) were also analyzed.

Results

From 1990 to 2019, the CRC incidence, deaths, and DALYs increased worldwide by 157%, 110%, and 96%, respectively. The global age-standardized incidence rate increased (EAPC, 0.58; 95% confidence interval [CI], 0.51–0.66), whereas both the age-standardized death rate (EAPC, −0.21; 95% CI, −0.28 to −0.14) and age-standardized DALY rate (EAPC, −0.21; 95% CI, −0.26 to −0.15) presented downward trends. As for regions, the largest increases in the age-standardized incidence rate, age-standardized death rate, and age-standardized DALY rate were observed in East Asia. In terms of countries, the largest increase in CRC incidence was found in Equatorial Guinea (3.98), followed by Vietnam (3.79) and China (3.66). The age-standardized incidence rate was higher in men than in women. Negative correlations were found between the EAPC in the age-standardized incidence rate of CRC and the SDI.

Conclusions

Future CRC preventive strategies should focus on the male population and older adults, especially in East Asia, Qatar, United Arab Emirates, Saudi Arabia, and other high-risk regions.

Colorectal Surgery Practice, Training, and Research in Low-Resource Settings

Colorectal surgery (CRS) practice, training, and research differ between low- and middle-income countries (LMICs) and high-income countries due to disparity in resources. LMIC CRS is primarily done by general surgeons due to the paucity of fully trained colorectal surgeons. The majority of colon and rectal resections are done using open techniques, and laparoscopy and robotic platforms are only available in select private or academic centers. Multi-disciplinary teams are not available in most hospitals, so surgeons must have a broad knowledge base, and learn to adapt their practice. Formal CRS training opportunities through accredited post-residency fellowships and professional colorectal surgical associations are limited in LMICs. CRS is less established as an academic field, and less data are generated in LMICs. There are fewer staff and less dedicated funding for CRS research. However, LMIC colorectal surgeons and researchers can contribute valuable clinical findings especially on conditions of higher prevalence in their settings such as anal squamous cell carcinoma and obstetric fistulas. Effective surgical care for colorectal conditions requires significant investment in infrastructure, training, and governance in LMICs. This is critical to improve access to safe surgical care for all.

Incidence of Mortality and Associated Factors Among Colorectal Cancer Patients at Oncology Units of Northwest Ethiopia: A Retrospective Cohort Study

Background

Colorectal cancer is one of the commonest types of malignant neoplasm with an estimated 935,000 deaths in 2020 worldwide. In Ethiopia, colorectal cancer is the third most common cancer with an incidence of 8/100,000 person-years. Despite studies related to the burden of colorectal cancer, data of mortality related to colorectal cancer are limited and unknown in the study areas. Therefore, the aim of this study was to assess the incidence of mortality and associated factors among colorectal cancer patients who were followed-up at oncology units of Northwest Amhara hospitals, Ethiopia.

Methods and Materials

A retrospective cohort study was conducted among 367 study participants from January 1, 2017, to December 31, 2020 at oncology units of Northwest Amhara hospitals. Data were entered into EPi-data 4.2.0.0 and transferred to STATA version 14 statistical software for statistical analysis. The Cox regression model was used to identify factors associated with mortality. All variables with P-value < 0.2 during bi-variable analysis were considered for multivariable Cox regression model and level of statistical significance was declared at P value ≤ 0.05.

Results

The overall incidence of colorectal cancer mortality was 22.5 per 100 person-years (95% CI: 18.5, 27.38). Being male [AHR =1.60; 95% CI (1.03, 2.48)], having rural residence [AHR=1.68; 95% CI (1.11, 2.55)], carcinoembryonic antigen level ≥5ng/mL [AHR=1.84; 95% CI: (1.02, 3.30)], delay to first health care visit [AHR=1.97; 95% CI (1.19, 3.25)], delay to confirmed diagnosis [AHR=2.45; 95% CI (1.22, 4.90)], and patients who had recurrence after treatment [AHR=1.61;95% CI (1.05, 2.47)] were independently associated with mortality.

Conclusion

Incidence of colorectal cancer mortality was high. Sex, residency, carcinoembryonic antigen level, time to health care visit, time to confirmed diagnosis, and recurrence significantly increased incidence of mortality. Therefore, creating awareness of colorectal cancer and expanding cancer treatment centers could have paramount importance in reducing the burden of mortality.

Bile Acids, Gut Microbes, and the Neighborhood Food Environment-a Potential Driver of Colorectal Cancer Health Disparities

Bile acids (BAs) facilitate nutrient digestion and absorption and act as signaling molecules in a number of metabolic and inflammatory pathways. Expansion of the BA pool and increased exposure to microbial BA metabolites has been associated with increased colorectal cancer (CRC) risk. It is well established that diet influences systemic BA concentrations and microbial BA metabolism. Therefore, consumption of nutrients that reduce colonic exposure to BAs and microbial BA metabolites may be an effective method for reducing CRC risk, particularly in populations disproportionately burdened by CRC. Individuals who identify as Black/African American (AA/B) have the highest CRC incidence and death in the United States and are more likely to live in a food environment with an inequitable access to BA mitigating nutrients. Thus, this review discusses the current evidence supporting diet as a contributor to CRC disparities through BA-mediated mechanisms and relationships between these mechanisms and barriers to maintaining a low-risk diet.

Modeling the Cost-Effectiveness of Adjuvant Chemotherapy for Stage III Colon Cancer in South African Public Hospitals

PURPOSE

Cancer incidence is rising in low- and middle-income countries, where resource constraints often complicate therapeutic decisions. Here, we perform a cost-effectiveness analysis to identify the optimal adjuvant chemotherapy strategy for patients with stage III colon cancer treated in South African (ZA) public hospitals.

METHODS

A decision-analytic Markov model was developed to compare lifetime costs and outcomes for patients with stage III colon cancer treated with six adjuvant chemotherapy regimens in ZA public hospitals: fluorouracil, leucovorin, and oxaliplatin for 3 and 6 months; capecitabine and oxaliplatin (CAPOX) for 3 and 6 months; capecitabine for 6 months; and fluorouracil/leucovorin for 6 months. Transition probabilities were derived from clinical trials to estimate risks of toxicity, disease recurrence, and survival. Societal costs and utilities were obtained from literature. The primary outcome was the incremental cost-effectiveness ratio in international dollars (I$) per disability-adjusted life-year (DALY) averted, compared with no therapy, at a willingness-to-pay (WTP) threshold of I$13,006.56.

RESULTS

CAPOX for 3 months was cost-effective (I$5,381.17 and 5.74 DALYs averted) compared with no adjuvant chemotherapy. Fluorouracil, leucovorin, and oxaliplatin for 6 months was on the efficiency frontier with 5.91 DALYs averted but, with an incremental cost-effectiveness ratio of I$99,021.36/DALY averted, exceeded the WTP threshold.

CONCLUSION

In ZA public hospitals, CAPOX for 3 months is the cost-effective adjuvant treatment for stage III colon cancer. The optimal strategy in other settings may change according to local WTP thresholds. Decision analytic tools can play a vital role in selecting cost-effective cancer therapeutics in resource-constrained settings.

Colorectal Cancer in Uganda: A 10-Year, Facility-Based, Retrospective Study

Introduction

Colorectal cancer (CRC) is the most common type of gastrointestinal malignancies and the third leading cause of cancer-related deaths for both sexes worldwide. Although the burden of CRC is highest in developed countries, reports are indicating a rise in the incidence of early-onset CRC in developing countries. In this study, we aimed to determine the prevalence of CRC among patients hospitalized with lower gastrointestinal complaints at a tertiary health facility in Uganda.

Methods

We conducted a 10-year retrospective chart review of patients admitted to Mulago National Referral Hospital in Kampala, Uganda, between 1st January 2010 and 31st December 2020. We reviewed all charts of patients admitted to the lower gastrointestinal tract (GIT) ward. Charts with grossly missing data, pediatric patients, and those from other non-lower GIT specialties were excluded.

Results

Data of 1476 unique eligible patients were analyzed. Of these,138 had a diagnosis of CRC (prevalence: 9.3%, 95% confidence interval (95% CI): 6.5-11.7%). Among patients with CRC, the female:male ratio was 1:1. The most common site for CRC was the rectum (59.8%, n= 79). For the 138 participants with CRC, 44 had staging data with 72.8% (n=32) having advanced disease, that is, stage 3 or 4. Factors independently associated with CRC were age ≥50 years (adjusted odds ratio (aOR): 4.3, 95% CI: 2.6-7.1, p < 0.001), female sex (aOR: 1.8, 95% CI: 1.2 -2.8, p = 0.005), being widowed (aOR: 2.5, 95% CI: 1.3-5.0, p = 0.006), and presence of any risk factor for CRC (aOR: 5.3, 95% CI: 2.9-9.9, p < 0.001).

Conclusion

CRC is relatively common among patients hospitalized with lower GIT complaints, particularly among women and those with known risk factors for CRC. Awareness creation and screening programs should be instituted to allow early diagnosis of CRC in our setting.

The Looming Threat: Cancer in Sub-Saharan Africa

Recent trends in cancer epidemiology in low‐ and middle‐income countries show the need for urgent action. This article focuses on sub‐Saharan Africa, where populations are showing an increased risk for diseases associated with the Western lifestyle, including cancer.