Predicting Functional Recovery and Quality of Life in Older Patients Undergoing Colorectal Cancer Surgery: Real-World Data From the International GOSAFE Study

Psychological distress in newly diagnosed patients with gastrointestinal cancer: A scoping review

Objective

A cancer diagnosis often triggers significant emotional and psychological challenges, underscoring the importance of addressing psychological distress. While psychological distress in patients with gastrointestinal (GI) cancer has been widely studied, less attention has been focused on those who are newly diagnosed. This scoping review aims to map the existing literature on psychological distress in newly diagnosed patients with GI cancer.

Methods

A scoping review was conducted following the framework outlined by Arksey and O'Malley. The last search was carried out on September 23, 2024, across PubMed, CINAHL, EMBASE, Scopus, and PsychINFO for literature published between January 2013 and September 2024. The search terms included "newly diagnosed," "distress," "patients," and "gastrointestinal cancer." A meta-analysis was conducted using the R package to synthesize the prevalence of psychological distress across studies, with a random-effects model applied to account for heterogeneity.

Results

Fifteen studies were included in the analysis, revealing an average prevalence of psychological distress of 28.1% (99% CI: 181.84, 433.39). Psychological distress was most prevalent during the diagnostic phase and gradually decreased over time. Factors such as older age, advanced cancer stage, poor performance status, and a lack of social support contributed to increased psychological distress. Additionally, only 20% of the studies were intervention-based.

Conclusions

Approximately one-third of newly diagnosed patients with GI cancer may experience psychological distress. Early identification and intervention to address this distress before treatment initiation are crucial for improving patient outcomes.

Systematic review registration

osf.io/n2796.

Management of older adults with severe aortic stenosis and indication of non-cardiac surgery for colorectal neoplasm: What do we treat first?

Severe aortic stenosis may increase risks and pose limitations in non-cardiac surgeries, sometimes requiring prior treatment. Surgery for colorectal neoplasms is frequently the priority indicated treatment as its delay can increase the risk of developing complications (e.g. bowel obstruction). The coexistence of both conditions in older comorbid patients may be challenging during the decision-making process. In this case series, four cases of older adults with severe aortic stenosis and colorectal neoplasms with surgical indication are presented. A description of the management of each case, with a revision of the current cardiovascular risk assessment guidelines, is done.

Environmental pollutants and rectal cancer: The impact of water contamination

BACKGROUND

Water is a fundamental resource for life, and exposure to water contamination has far-reaching implications for an increased risk of tumor diseases.

METHODS

Studies of rectal and colorectal cancer related to water contamination were identified from the published literature in the PUBMED databases from 2010 to 2024.

RESULTS

This review provides a critical analysis of the current evidence, summarizing the association of water contamination, including industrial waste, pesticides, heavy metals, with rectal and colorectal cancer. It highlights their impact on rectal and colorectal cancer progression by underlying processes of DNA damage, chronic inflammation, and microbial contamination.

CONCLUSION

Rectal cancer is a significant global health concern with a strong association between environmental pollutants in water sources and increased incidence of rectal cancer. It is vital to identify how waster pollutants influence the development and progression of rectal cancer and formulate targeted preventive approaches and social interventions to decrease the disease's impact.

Colonoscopy-Assisted Laparoscopic Wedge Resection for Colonic Lesions and Its Impact on Quality of Life: Results From the LIMERIC Study

BACKGROUND

The LIMERIC study has proven that colonoscopy-assisted laparoscopic wedge resection effectively and safely removes benign colonic lesions unsuitable for endoscopic removal, thereby avoiding the need for major surgery.

OBJECTIVE

To evaluate the impact of colonoscopy-assisted laparoscopic wedge on health-related quality of life of patients who participated in the LIMERIC study.

DESIGN

Prospective multicenter study.

SETTINGS

The LIMERIC study was performed between 2016 and 2020 in 13 Dutch hospitals. Five-level EuroQoL 5-dimension questionnaires were administered at baseline and 3 months after the procedure.

PATIENTS

Patients with incomplete pre- or postoperative questionnaires or those undergoing combined interventions were excluded from the intention-to-treat analysis. Those for whom CAL-WR was not feasible or who underwent completion surgery were excluded from the per-protocol analysis.

INTERVENTION

Colonoscopy-assisted laparoscopic wedge for either 1) colon polyp unsuitable for endoscopic resection; 2) nonlifting residual or recurrent polyp within scar tissue after previous polypectomy; or (3) Rx/R1 endoscopic removal of a low-risk pT1 colon carcinoma.

MAIN OUTCOME MEASURES

Three-month health-related quality of life.

RESULTS

Colonoscopy-assisted laparoscopic wedge did not affect health-related quality of life in the per-protocol analysis (n = 56) or in the intention-to-treat analysis (n = 67). The majority of patients reported no change in health status (57%). No significant differences were observed in the distribution of responses across all 5 dimensions before and after colonoscopy-assisted laparoscopic wedge. Patients'EuroQoL self-rated visual analog scale scores were also unaffected by a colonoscopy-assisted laparoscopic wedge, with a median score of 82.5 at baseline and 80 after surgery in the per-protocol analysis ( p = 0.63).

LIMITATIONS

Solely a patient-reported outcome measure evaluating global health-related quality of life was used, rather than one specifically assessing disease-related quality of life, such as the quality of life questionnaire colorectal cancer module 29.

CONCLUSIONS

Colonoscopy-assisted laparoscopic wedge has no significant impact on the health-related quality of life in patients with benign colonic lesions and should therefore be considered before major surgery is performed. See Video Abstract.

RESECCIN LAPAROSCPICA EN CUA ASISTIDA POR COLONOSCOPIA PARA LESIONES COLNICAS IMPACTO EN LA CALIDAD DE VIDA RESULTADOS DEL ESTUDIO LIMERIC

ANTECEDENTES:El estudio LIMERIC ha demostrado que la resección laparoscópica en cuña asistida por colonoscopia elimina de forma eficaz y segura las lesiones colónicas benignas inadecuadas para la extirpación endoscópica, evitando así la necesidad de cirugía mayor.OBJETIVO:Evaluar el impacto de la cuña laparoscópica asistida por colonoscopia en la calidad de vida relacionada con la salud de los pacientes que participaron en el estudio LIMERIC.DISEÑO:Estudio multicéntrico prospectivo.ENTORNO:El estudio LIMERIC se realizó entre 2016 y 2020 en 13 hospitales holandeses. Se administraron cuestionarios EQ-5D-5L al inicio y 3 meses después del procedimiento.PACIENTES:Los pacientes con cuestionarios pre o postoperatorios incompletos o aquellos sometidos a intervenciones combinadas fueron excluidos del análisis por intención de tratar. Aquellos en los que la CAL-WR no era factible o que se sometieron a cirugía de finalización fueron excluidos del análisis por protocolo.INTERVENCIÓN:Cuña laparoscópica asistida por colonoscopia para (1) pólipo de colon no apto para resección endoscópica; (2) pólipo residual o recidivante no elevable dentro de tejido cicatricial tras polipectomía previa; o (3) extirpación endoscópica Rx/R1 de un carcinoma de colon pT1 de bajo riesgo.MEDIDAS DE RESULTADO PRINCIPALES:Calidad de vida relacionada con la salud a los tres meses.RESULTADOS:La cuña laparoscópica asistida por colonoscopia no afectó a la calidad de vida relacionada con la salud en el análisis por protocolo (n = 56), ni en el análisis por intención de tratar (n = 67). La mayoría de los pacientes no informaron ningún cambio en su estado de salud (57%). No se observaron diferencias significativas en la distribución de las respuestas en las 5 dimensiones antes y después de la cuña laparoscópica asistida por colonoscopia. La EQ-VAS autoevaluada de los pacientes tampoco se vio afectada por la cuña laparoscópica asistida por colonoscopia, con una puntuación media de la VAS de 82,5 al inicio y 80 después de la cirugía en el análisis por protocolo (p = 0,63).LIMITACIONES:Se utilizó únicamente una medida de resultados comunicada por el paciente que evaluaba la calidad de vida global relacionada con la salud, en lugar de una que evaluara específicamente la calidad de vida relacionada con la enfermedad, como el QLQ-CR29.CONCLUSIONES:La cuña laparoscópica asistida por colonoscopia no tiene un impacto significativo en la calidad de vida relacionada con la salud en pacientes con lesiones colónicas benignas y, por lo tanto, debe considerarse antes de realizar una cirugía mayor. (Traducción-Dr. Aurian Garcia Gonzalez ).

Long‐term prognostic outcomes in high‐risk T1 colorectal cancer: A multicentre retrospective comparison of surgery versus observation postendoscopic treatment

Aim

The risk of lymph node metastasis after endoscopic resection of high‐risk T1 colorectal cancer prompts additional resection. However, age and comorbidities are considered in decision‐making and some surgeons opt for observation. We compared the long‐term outcomes of these approaches with the aim of clarifying the need for additional resection.

Method

This multicentre retrospective study included high‐risk T1 colorectal cancer patients treated with endoscopic submucosal dissection (ESD) between January 2013 and April 2021. Patients who met one or more of the following criteria were eligible for inclusion: submucosal invasion depth ≥1000 μm, vessel invasion, poor differentiation, budding grade 2/3 or a positive vertical margin. Patients were divided into resection (R) and observation (O) groups. Outcomes were evaluated based on overall survival (OS) and 5‐year cancer‐specific survival (CSS), with an additional stratified analysis using the age‐adjusted Charlson comorbidity index (ACCI).

Results

The study included 178 patients (group R, n = 131; group O, n = 47). Patients in group O were significantly older and had more comorbidities. Group R showed better 5‐year OS and CSS (OS 87.0% vs. 58.9%, p = 0.001; CSS 98.8% vs. 78.4%, p = 0.002). Stratification by ACCI revealed that benefits of additional resection remained for patients with ACCI ≤ 6 (OS 91.2% vs. 58.3%, p = 0.013; CSS 98.4% vs. 61.7%, p < 0.001) but not for those with ACCI ≥7 (OS 75.9% vs. 59.8%, p = 0.289; CSS 100% vs. 100%, p = 0.617).

Conclusions

Significant survival benefits were demonstrated in group R patients with high‐risk T1 cancer. However, the survival benefit of additional surgical resection was unconfirmed in patients with ACCI ≥ 7.

Predictors of perioperative morbidity in elderly patients undergoing colorectal cancer resection

AIM

Colorectal cancer resection in the elderly may be associated with significant morbidity. This study aimed to assess perioperative morbidity in elderly patients undergoing colorectal cancer resection and to investigate risk factors for postoperative complications.

MATERIALS AND METHODS

Consecutive patients aged ≥ 75 years undergoing colorectal cancer resection with curative intent between January 2014 and December 2021 at our institution were included. We evaluated risk factors for postoperative complications, length of hospital stays (LOS), 30-day readmission, and 90-day mortality rates.

RESULTS

A total of 843 patients underwent colorectal cancer resection during the study period, of whom 202 patients were 75 years or older. Advanced age was associated with postoperative complications (Clavien-Dindo score > 3b, p = 0.001). Sarcopenia, preoperative plasma albumin < 3.5 g/dL, and open and urgent surgery were significantly correlated with major complications (p = 0.015, p = 0.022, p = 0.003, and p < 0.001, respectively). LOS was longer in elderly patients with a modified 5-item Frailty Index (5-mFI) ≥ 2 and low preoperative serum albumin levels, as well as following open surgery (p = 0.006, p = 0.001 and p < 0.001, respectively). Sarcopenia and preoperative plasma albumin < 3.5 g/dL were predictors for 90-day mortality (p = 0.004 and p > 0.001).

CONCLUSION

Advanced age, sarcopenia, preoperative hypoalbuminemia, 5-mFI ≥ 2, and open or urgent surgery may serve as predictors for postoperative morbidity in the elderly population.

Total neoadjuvant therapy followed by total mesorectal excision for rectal cancer in older patients real world data and proof of concept

Background

Rectal cancer (RC) commonly affects older patients. Total Neoadjuvant Therapy (TNT) has been introduced to improve local and systemic control of RC. The aim was to present real-world data of older patients receiving TNT followed by surgery after a frailty assessment and verify feasibility and safety of this approach.

Methods

This was a single-center retrospective study which enrolled all patients ≥70 years of age with RC who underwent TNT followed by surgery between November 2017 and April 2022. Data regarding cancer characteristics, neoadjuvant chemoradiotherapy (CRT), and toxicity were recorded. All patients underwent surgery 12-16 weeks after the end of therapy. Intra- and postoperative outcomes were recorded. Pre- and postoperative functional evaluation was carried out.

Results

Fifteen patients were enrolled. Mean age was 74 (70-81) years. Mean distance of the tumor from the anal verge was 5.2 cm. Fourteen patients had positive nodes (93.3%), 11 (73.3%) showed involvement of the circumferential margin (CRM+) and 10 (66.6%) had extramural vascular invasion (EMVI+). Ten patients (66.6%) received mFOLFOX-6 and 5 CAPOX (33.3%) followed by CRT. After CRT, positive nodes were reported in 4 cases (26.6%), CRM+ in 4 (26.6%), and EMVI+ in 1 (6.6%). Transanal total mesorectal excision (taTME) was performed in all cases. Median operative time was 280 min (110-420). Median length of stay was 4 days (3-29). One Clavien-Dindo grade 4 complication, no readmissions, and no variations in pre- and postoperative functional status within 30 days from surgery were reported. No positive distal or CRMs were detected. Three pathologic complete responses were reported (20%).

Conclusions

TNT followed by TME is feasible and safe in older patients, with good clinical and oncologic outcomes. Patient evaluation is crucial for maximizing cancer care in fit older patients.

Pre-emptive Laparoscopic Colostomy Creation in Obstructing Locally Advanced Rectal and Anal Cancer Does Not Delay the Starting of Oncological Treatments

BACKGROUND

Managing patients with obstructing rectal cancer is challenging due to the risks of gastrointestinal obstruction and perforation. This study evaluates the outcomes of pre-emptive laparoscopic colostomy creation in patients with locally advanced rectal and anal cancer to prevent symptoms and facilitate therapy initiation.

METHODS

This retrospective cohort study includes patients with locally advanced rectal or anal cancer assessed by our Colorectal Multidisciplinary Team from January 2017 to February 2024. Patients who underwent pre-emptive laparoscopic colostomy were compared to a control group of non-obstructing rectal cancer patients who started direct oncological treatment. The primary endpoint was the time from diagnosis to the initiation of oncological treatments. The secondary endpoints were the rate and timing of subsequent radical resection, surgical morbidity and hospital stay. A Weibull regression was used to evaluate the time differences between the groups.

RESULTS

There were 37 patients who received pre-emptive laparoscopic colostomy, compared to 207 control patients. The mean time from diagnosis to the start of neoadjuvant therapy was 38.3 ± 2.3 days. Despite higher rates of malnutrition and more advanced stages in the colostomy group, no significant differences were observed in the time to start therapy (p = 0.083) or time to radical resection (p = 0.187) between the groups. The laparoscopic procedure showed low rates of postoperative complications and acceptable lengths of stay.

DISCUSSION AND CONCLUSIONS

Pre-emptive laparoscopic colostomy is a feasible approach for managing obstructing rectal or anal cancer. Treatment timelines were not extended compared to timelines for non-obstructing cases, despite differences in nutritional status and staging. Further prospective studies with larger cohorts are needed to validate these findings and refine treatment protocols for obstructing gastrointestinal malignancies.

Supportive care interventions in metastatic bone disease: scoping review

BACKGROUND

Patients with secondary metastatic involvement of the musculoskeletal system due to primary cancers are a rapidly growing population with significant risks for health-related end-of-life morbidities. In particular, bone metastases or metastatic bone disease (MBD) imparts significant adversity to remaining quality of life. No rigorous review of clinical trials on the use of supportive care interventions for MBD has been conducted. The objective of this review was to examine the characteristics of supportive care interventions for MBD and critically appraise study designs, key findings, and quality of evidence of the research.

METHODS

We searched for published clinical trials, systematic reviews and meta-analyses in PubMED, CINAHL and Google Scholar for articles published between September 2017 and September 2022. Some examples of Medical Subject Headings terms were: 'secondary neoplasm', 'metastatic bone disease', 'palliative care' and 'supportive care intervention'. Quality of published evidence was evaluated based on treatment types and study design.

RESULTS

After reviewing 572 publications, 13 articles were included in the final review and evaluation including seven clinical trials, two trial protocols and four systematic reviews. Feasible interventions included enhanced palliative care consultation, palliative radiotherapy and alternative medicines. Interventions addressed primary endpoints of fatigue (N=4, 31%), pain (N=3, 23%) or cancer-related symptoms (N=3, 23%) with patient-reported outcome instruments. No interventions reported on fracture complications or endpoints, specifically. The quality of most studies was moderate to strong.

CONCLUSION

Supportive care interventions for MBD are feasible and the impact is measurable via patient-reported outcome measures. While the evidence for interventions was moderate to strong, there are very few specific controlled trials for skeletal-related events and impacts of social determinants of health. Further clinical trials are needed to define supportive care interventions for MBD that demonstrate reduced risk of fracture and that mitigate the reduced quality of life when negative musculoskeletal outcomes arise.

The Old: Is There Any Role for Screening Colonoscopy after the Age of 75? The Surgeon's Perspective

Guidelines recommend individualized decision making for screening colonoscopy for colorectal cancer (CRC) in patients after the age of 75 years due to low additional benefits. That should be taken with a grain of salt, as these recommendations are based on expert opinion and simulation models which do not consider (1) the differences in pathogenesis and cancer biology of CRC in elderly; (2) the risks of colonoscopy in this patient population; (3) and the impact of new surgical and nonsurgical therapies for CRC. In this review, our goal is to bring a surgeon's perspective to understand the role of screening colonoscopy in patients older than 75 years.

Functional Outcomes after Abdominal Surgery in Older Adults - How concerned are we about this?

Amidst trends of a rapidly ageing population with better surgical outcomes for geriatric patients, it is imperative to consider outcome measures beyond mortality and morbidity rates. In fact, the preservation of one's postoperative function has been cited as a key priority for older adults and is a crucial determinant of postoperative independence and survival. This review aims to examine the prevalence of perioperative function reporting amongst older surgical patients undergoing elective major abdominal surgery for cancer. We systematically reviewed studies from inception to December 2023 for studies which focused on the outcomes of older surgical patients undergoing elective major abdominal surgery for cancer. Relevant citations were screened (title, abstract and full article review) based on the inclusion and exclusion criteria. 103 studies were included, of which only 31 studies consisting of 20885 participants reported perioperative function. While the nominal number of studies which report perioperative function has been on a steady rise since 2018, the proportion of studies which do so remains low. Postoperative function is three times less likely to be reported than preoperative function, suggesting that functional recovery is not sufficiently assessed. This suggests that there is still a poor uptake of functional recovery as an outcome measure amongst surgeons, and any increase in perioperative function reporting is likely due to the increased administration of frailty assessments. These findings should urge greater efforts in quantifying and enabling functional recovery to improve the clinical outcomes and quality of care for older surgical patients.

Updates on the Management of Colorectal Cancer in Older Adults

Colorectal cancer (CRC) poses a significant global health challenge. Notably, the risk of CRC escalates with age, with the majority of cases occurring in those over the age of 65. Despite recent progress in tailoring treatments for early and advanced CRC, there is a lack of prospective data to guide the management of older patients, who are frequently underrepresented in clinical trials. This article reviews the contemporary landscape of managing older individuals with CRC, highlighting recent advancements and persisting challenges. The role of comprehensive geriatric assessment is explored. Opportunities for treatment escalation/de-escalation, with consideration of the older adult's fitness level. are reviewed in the neoadjuvant, surgical, adjuvant, and metastatic settings of colon and rectal cancers. Immunotherapy is shown to be an effective treatment option in older adults who have CRC with microsatellite instability. Promising new technologies such as circulating tumor DNA and recent phase III trials adding later-line systemic therapy options are discussed. Clinical recommendations based on the data available are summarized. We conclude that deliberate efforts to include older individuals in future colorectal cancer trials are essential to better guide the management of these patients in this rapidly evolving field.

Predictive performance of different measures of frailty (CFS, mFI-11, mFI-5) on postoperative adverse outcomes among colorectal cancer patients: a diagnostic meta-analysis

PURPOSE

To clarify the predictive performance of different measures of frailty, including Clinical Frailty Scale (CFS), 11-factor modified Frailty Index (mFI-11), and 5-factor modified Frailty Index (mFI-5), on adverse outcomes.

METHODS

PubMed, Embase, Web of Science, and other databases were retrieved from the inception of each database to June 2023. The pooled sensitivity, specificity, and the area under the summary receiver operating curve (SROC) values were analyzed to determine the predictive power of CFS, mFI-11, and mFI-5 for adverse outcomes.

RESULTS

A total of 25 studies were included in quantitative synthesis. The pooled sensitivity values of CFS for predicting anastomotic leakage, total complications, and major complications were 0.39, 0.57, 0.45; pooled specificity values were 0.70, 0.58, 0.73; the area under SROC values were 0.58, 0.6, 0.66. The pooled sensitivity values of mFI-11 for predicting total complications and delirium were 0.38 and 0.64; pooled specificity values were 0.83 and 0.72; the area under SROC values were 0.64 and 0.74. The pooled sensitivity values of mFI-5 for predicting total complications, 30-day mortality, and major complications were 0.27, 0.54, 0.25; pooled specificity values were 0.82, 0.84, 0.81; the area under SROC values were 0.63, 0.82, 0.5.

CONCLUSION

The results showed that CFS could predict anastomotic leakage, total complications, and major complications; mFI-11 could predict total complications and delirium; mFI-5 could predict total complications and 30-day mortality. More high-quality research is needed to support the conclusions of this study further.

Colorectal cancer surgery in octogenarians: real-world long-term results

AIMS

Colon cancer is the most common intra-abdominal cancer in older people. In the elderly with cancer, clinical decision making is often complicated by the effects of aging. However, as life expectancy continues to rise, more people aged 80 and older will present with colorectal cancer and may need major surgery.

METHODS

Between 2000 and 2020 we operated on 352 patients aged 80 and older for colorectal cancer. We reviewed the case-notes of these patients and made a survival analysis for those patients who had a surgical resection of the tumor.

RESULTS

In 20 patients a palliative procedure was performed. Three hundred and thirty-two (332) patients had a colorectal cancer resected. Of these, 57 patients died within 90 days postoperatively. Survival analysis was done for 275 patients who were alive longer than 90 days postoperatively. The overall 5-year survival in this group is 41.5%. There was no significant difference in postoperative survival between patients over the age of 85 and patients aged 80-84 at the time of operation. The survival of patients with stage IV colorectal adenocarcinoma is significantly worse than survival in stage I-III patients (Cox-Mantel log-rank test p < 0.001).

CONCLUSIONS

After exclusion of the patients in the 90-day mortality group the overall 5-year survival in octogenarians who had a resection of a colorectal cancer was 41.5%. The most difficult problem is to choose the right treatment for the right patient. Optimal surgical and adjuvant treatment should not be denied to these older patients.

Preoperative evaluation of the elderly patient

Nowadays, the pre-operative evaluation of older patients is a critical step in the decision-making process. Clinical assessment and care planning should be considered a whole process rather than separate issues. Clinicians should use validated tools for pre-operative risk assessment of older patients to minimize surgery-related morbidity and mortality and enhance care quality. Traditional pre-operative consultation often fails to capture the pathophysiological and functional profiles of older patients. The elderly's pre-operative evaluation should be focused on determining the patient's functional reserve and reducing any possible peri-operative risk. Therefore, older adults may benefit from the Comprehensive Geriatric Assessment (CGA) that allows clinicians to evaluate several aspects of elderly life, such as depression and cognitive disorders, social status, multi-morbidity, frailty, geriatric syndromes, nutritional status, and polypharmacy. Despite the recognized challenges in applying the CGA, it may provide a realistic risk assessment for post-operative complications and suggest a tailored peri-operative treatment plan for older adults, including pre-operative optimization strategies. The older adults' pre-operative examination should not be considered a mere stand-alone, that is, an independent stage of the surgical pathway, but rather a vital step toward a personalized therapeutic approach that may involve professionals from different clinical fields. The aim of this review is to revise the evidence from the literature and highlight the most important items to be implemented in the pre-operative evaluation process in order to identify better all elderly patients' needs.