3-month versus 6-month adjuvant chemotherapy for patients with high-risk stage II and III colorectal cancer: 3-year follow-up of the SCOT non-inferiority RCT

Does adjuvant chemotherapy result in poorer health-related quality of life among colorectal cancer patients? A longitudinal multisite observational study in Singapore

BACKGROUND

Research on health-related quality of life (HRQOL) using minimally important differences for cancer care in Asian settings are sparse. This study aimed to describe functional HRQOL trajectories among Colorectal Cancer (CRC) patients undergoing adjuvant chemotherapy (AC) compared to those who did not (No AC), evaluate if AC was associated with change in HRQOL prospectively, and examine QOL differences between elderly and non-elderly CRC patients requiring AC.

METHODS

CRC patients diagnosed between February 2018 to August 2021 were recruited from three Singapore public hospitals. Participants completed the EORTC QLQ-C30 over seven timepoints (diagnosis, predischarge, 1-, 3-, 6-, 9-, 12-months post-surgery). Clinical characteristics were collected from electronic medical records.

RESULTS

The sample comprised 251 participants (102 in AC group; 40.64%). Clinically relevant deteriorations in functional HRQOL were observed in both groups between baseline and predischarge. These returned to baseline by 12-month. AC was associated with poorer physical (β = -35.34, p < 0.05) and role functioning (β = -71.17, p < 0.05) over time. Being elderly was associated with poorer physical functioning (β = -0.44, p < 0.05) over time. However, the non-elderly AC subgroup tended to experience poorer HRQOL in general compared to elderly.

CONCLUSIONS

Functional recovery remains a challenge for CRC patients in general. However, non-elderly AC patients may experience more severe impacts to role and social functioning.

Inulin and hyaluronic acid-based oral liposome for enhanced photo-chemotherapy against orthotopic colon cancer and its reversal effects on tumor hypoxia and intestinal microbiota

Colon cancer has a complex microenvironment and course, and conventional chemotherapy is hindered by low permeability and immunosuppression at the cancer site, leading to poor efficacy. Integrating intestinal environment regulation and molecularly targeted drugs are more attractive strategies. This study aimed to developed an oral colonic targeted delivery system (5-Flu/MET@MSNs/Ce6@HIL) using hyaluronic acid (HA) and inulin (IN) as key components. IN is a polymer with colon-specific targeting capabilities, while HA targets CD44 on the surface of colon cancer cells. We used IN and HA-modified liposomes to co-encapsulate three therapeutic agents, chemotherapy drug 5-Fluorouracil (5-Flu), photosensitizer chlorin e6 (Ce6), and hypoxia reliever metformin (MET). 5-Flu and Ce6 effectively induced cell apoptosis, whereas MET downregulated Hypoxia-Inducible Factor 1-α (HIF-1α) and alleviate the hypoxic microenvironment. In orthotopic colon-tumor-bearing-mice, the final product of 5-Flu@MET@MSNs/Ce6@HIL effectively hindered growth of tumors, which was inhibited by 3.31, 14.31, and 7.88 times when compared to 5-Flu, MET, or Ce6 single-loaded formulations, respectively. Furthermore, after oral administration, the multifunctional liposomes showed good in vivo safety and compliance. In conclusion, this study proposes a novel orthotopic colon-targeted cancer treatment strategy with accurate tumor targeting capabilities, which has certain potential and development value in future clinical applications.

Chinese herbal medicine (JianPi-BuShen) and completion rate of adjuvant chemotherapy for patients with stage II and III colon cancer: A randomized clinical trial

PURPOSE

Many cancer patients express interest in using herbal medicine during chemotherapy, but little is known about its benefits and risks. This study aimed to evaluate the effects of the Chinese herbal medicine JianPi-BuShen formula (JPBS) on adjuvant chemotherapy completion in colon cancer patients.

PATIENTS AND METHODS

This multi-center, phase III, randomized, placebo-controlled trial included patients with stage II (high risk for recurrence) and stage III colon cancer following surgery, planning to receive CAPOX (capecitabine and oxaliplatin) chemotherapy. Patients were randomized 1:1 to receive either JPBS or a placebo. The primary outcome was the completion rate of planned chemotherapy cycles. Secondary outcomes included relative dose intensity (RDI), chemotherapy-induced toxicities, quality of life (measured by the Edmonton Symptom Assessment System - ESAS), adverse events (AEs), and serious AEs (SAEs). Predefined subgroup analyses were performed by age (>65/≤65) and TNM stage (II/III).

RESULTS

A total of 376 participants were analyzed, with a median age of 60.3 years; 56.9 % were male, and 67.6 % had stage III disease. Chemotherapy completion was significantly higher in the JPBS group than in the placebo group (63.0 % vs. 47.6 %, P = 0.003). Oxaliplatin RDI was also higher in the JPBS group (P = 0.049). Subgroup analyses showed JPBS significantly improved completion rates for stage II patients (73.0 % vs. 42.4 %, P = 0.001) and younger patients (66.9 % vs. 48.8 %, P = 0.004). JPBS reduced grade ≥ 2 vomiting (3.8 % vs. 6.4 %, P = 0.007) but increased grade ≥ 2 thrombocytopenia (16.2 % vs. 12.4 %, P = 0.012). Quality of life improved in stage II and younger patients.

CONCLUSION

JPBS improved chemotherapy completion rates in stage II and younger colon cancer patients without compromising tolerability. Further research is needed to explore its mechanisms and long-term effects.

Pressurized Intraperitoneal Aerosol Chemotherapy for Peritoneal Carcinomatosis in Colorectal Cancer Patients: A Systematic Review of the Evidence

INTRODUCTION

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) consists of the administration of aerosolized chemotherapy into the abdominal cavity of patients suffering from peritoneal carcinomatosis. Our aim was to review the evidence supporting PIPAC in patients with peritoneal carcinomatosis from colorectal cancer.

METHODS

A systematic review was performed in accordance with the 2020 PRISMA guideline. MEDLINE and CENTRAL were searched using combinations of terms including "Peritoneal carcinomatosis", "Peritoneal metastasis", "PIPAC", "Pressurized intraperitoneal aerosol chemotherapy" and "Colorectal cancer". Original studies, in English, including patients treated with PIPAC for colorectal peritoneal carcinomatosis, were considered eligible. Case reports, non-English or French language articles and secondary analyses were excluded.

RESULTS

A total of 385 articles were screened and 374 articles were excluded, leaving 11 publications for inclusion in the qualitative analysis. The included studies totalized 949 patients who received PIPAC for peritoneal carcinomatosis due to colorectal cancer. The median peritoneal carcinomatosis index (PCI) ranged from 10 to 31. In all studies, the complete PIPAC protocol was achieved with an average of two to three 3 PIPAC sessions per patient. Oxaliplatin (OX) was used as a chemotherapeutic agent in all studies and could be associated with intravenous 5-FU and leucovorin. Most post-operative adverse events were recorded as mild to moderate with no intraoperative complications. Only four studies reported a decrease in the average PCI score for 50% of the patients. Median overall survival ranged from 8 to 37.8 months. Quality of life indicators were stable between PIPAC-OX cycles with a small but not statistically significant trend of improvement of most functional scales.

CONCLUSIONS

PIPAC for peritoneal carcinomatosis from colorectal origin is feasible, safe and tolerable. Its impact on survival outcomes or quality of life remains to be demonstrated by randomized trials.

Principles of risk assessment in colon cancer: immunity is key

In clinical practice, the administration of adjuvant chemotherapy (ACT) following tumor surgical resection raises a critical dilemma for stage II colon cancer (CC) patients. The prognostic features used to identify high-risk CC patients rely on the pathological assessment of tumor cells. Currently, these factors are considered for stratifying patients who may benefit from ACT at early CC stages. However, the extent to which these factors predict clinical outcomes (i.e. recurrence, survival) remains highly controversial, also uncertainty persists regarding patients' response to treatment, necessitating further investigation. Therefore, an imperious need is to explore novel biomarkers that can reliably stratify patients at risk, to optimize adjuvant treatment decisions. Recently, we evaluated the prognostic and predictive value of Immunoscore (IS), an immune digital-pathology assay, in stage II CC patients. IS emerged as the sole significant parameter for predicting disease-free survival (DFS) in high-risk patients. Moreover, IS effectively stratified patients who would benefit most from ACT based on their risk of recurrence, thus predicting their outcomes. Notably, our findings revealed that digital IS outperformed the visual quantitative assessment of the immune response conducted by expert pathologists. The latest edition of the WHO classification for digestive tumor has introduced the evaluation of the immune response, as assessed by IS, as desirable and essential diagnostic criterion. This supports the revision of current cancer guidelines and strongly recommends the implementation of IS into clinical practice as a patient stratification tool, to guide CC treatment decisions. This approach may provide appropriate personalized therapeutic decisions that could critically impact early-stage CC patient care.

Chemotherapy reduces long-term quality of life in recurrence-free colon cancer survivors (LaTE study)-a nationwide inverse probability of treatment-weighted registry-based cohort study and survey

AIM

Stage III colon cancer is routinely treated with adjuvant chemotherapy, which causes significant short-term morbidity. Its effect on long-term quality of life (QoL) is poorly investigated. The aim of this study was to investigate long-term QoL after curative treatment for colon cancer and explore the impact of chemotherapy on general and disease-specific QoL.

METHOD

All patients aged under 75 years operated on for colon cancer between 30 September 2007 and 1 October 2019 were identified by the Cancer Registry of Norway. Exclusion criteria were distant metastasis, recurrence, dementia and rectal/rectosigmoid cancer operation. The primary outcome measure was Gastrointestinal Quality of Life Index (GIQLI). Secondary outcome measures included the Short Form Health Survey (SF-36). To achieve balanced groups when assessing differences in outcome measures the analyses were weighted by inverse probability weights based on a multiple logistic regression model with prechosen confounders.

RESULTS

A total of 8627 patients were invited and 3109 responded (36% response rate). After exclusions 3025 patients were included, of whom 1148 (38%) had received adjuvant chemotherapy and 1877 (62%) had surgery alone, with mean follow-up of 75.5 versus 74.5 months, respectively. The GIQLI differed significantly between the groups [mean 111.0 (SD 18.4) vs. 115.6 (SD 17.8), respectively; mean difference: -4.6 (95% CI -5.9; -3.2); p < 0.001]. Those with the highest neurotoxicity exhibited the lowest GIQLI. The adjuvant chemotherapy group scored significantly lower in six of eight SF-36 domains compared with the surgery alone group. The main differences were found in social, physical and emotional function.

CONCLUSION

Long-term QoL was significantly lower in patients who received adjuvant chemotherapy than in patients who did not. Neurotoxicity was closely related to reduced QoL in these patients. The low response rate limits the generalizability of the results.

Factors Associated With Adjuvant Chemotherapy Noncompliance and Survival in Older Adults With Stage III Colon Cancer

BACKGROUND

Standard management of stage III colon cancer includes surgical resection and adjuvant chemotherapy. Despite improved overall survival with adjuvant chemotherapy in stage III colon cancer, it is reportedly underused in older adults. To date, no contemporary national analysis of adjuvant chemotherapy use and its impact on older adults with stage III colon cancer exists.

OBJECTIVE

This study aimed to assess the current use of adjuvant chemotherapy in older adults with stage III colon cancer and determine factors associated with noncompliance.

DESIGN

Retrospective cohort study.

SETTINGS

Conducted using the National Cancer Database.

PATIENTS

This study included patients aged 65 years and older undergoing curative resection for stage III colon adenocarcinomas, 2010-2017.

MAIN OUTCOME MEASURES

Adjuvant chemotherapy use, factors associated with adjuvant chemotherapy use, and overall survival with and without adjuvant chemotherapy in older adults with pathologic stage III disease.

RESULTS

Of 64,608 patients included, 64.3% received adjuvant chemotherapy. Adjuvant chemotherapy was significantly independently associated with improved 1-, 3-, and 5-year overall survival vs no adjuvant chemotherapy (92.8%, 75.3%, 62.4% vs 70.8%, 46.6%, 32.7%; HR 0.475; 95% CI, 0.459-0.492; p <0.001). Compared with the no adjuvant chemotherapy cohort, patients who received adjuvant chemotherapy were younger, female, and less comorbid ( p < 0.001). Factors associated with adjuvant chemotherapy noncompliance included advancing age, lower annual income, open approach, longer length of stay, pathologic stage IIIA, and fewer than 12 lymph nodes.

LIMITATIONS

Administrative data source with inherent risks of bias, coding errors, and limitations in the fields available for analysis.

CONCLUSIONS

Adjuvant chemotherapy significantly improved overall survival but was only used in 64.3% of older adults with stage III colon cancer. Adjuvant chemotherapy noncompliance was seen in the most vulnerable and highest-risk patients, including those with greater comorbidity, lower income, and patients who received open surgery. See Video Abstract at http://links.lww.com/DCR/C125 .

FACTORES ASOCIADOS CON EL INCUMPLIMIENTO DE LA QUIMIOTERAPIA ADYUVANTE Y LA SUPERVIVENCIA EN ADULTOS MAYORES CON CNCER DE COLON EN ESTADIO III

ANTECEDENTES: El tratamiento estándar de oro del cáncer de colon en estadio III incluye la resección quirúrgica y la quimioterapia adyuvante. A pesar de la mejora de la supervivencia general con la quimioterapia adyuvante en el cáncer de colon en estadio III, se reporta que se utiliza poco en los adultos mayores. Hasta la fecha, no existe ningún análisis nacional actual, sobre el uso de quimioterapia adyuvante y su impacto en adultos mayores con cáncer de colon en etapa III.OBJETIVO: Evaluar el uso actual de quimioterapia adyuvante en adultos mayores con cáncer de colon en estadio III y determinar los factores asociados con el incumplimiento.DISEÑO: Estudio de cohorte retrospectivo.AJUSTES: Realizado y utilizando la Base de Datos Nacional de Cáncer.PACIENTES: Pacientes de 65 años o más sometidos a resección curativa por adenocarcinomas de colon en estadio III de 2010-2017.PRINCIPALES MEDIDAS DE RESULTADO: Uso de quimioterapia adyuvante, factores asociados con el uso de quimioterapia adyuvante y supervivencia general con y sin quimioterapia adyuvante en adultos mayores con enfermedad en estadio patológico III.RESULTADOS: De 64.608 pacientes incluidos, el 64,3% recibió quimioterapia adyuvante. La quimioterapia adyuvante se asoció de forma significativa e independiente con una mejor supervivencia general a 1, 3 y 5 años frente a ninguna quimioterapia adyuvante (92,8 %, 75,3 %, 62,4 % frente a 70,8 %, 46,6 %, 32,7 %; respectivamente, HR 0,475, 95 % IC 0,459-0,492, p < 0,001). En comparación con la cohorte sin quimioterapia adyuvante, los pacientes que recibieron quimioterapia adyuvante eran más jóvenes, mujeres y con menos comorbilidad. (p < 0,001). Los factores asociados con el incumplimiento de la quimioterapia adyuvante incluyeron edad avanzada (OR 0,857, IC del 95 % 0,854-0,861), ingresos anuales más bajos (OR 0,891, IC del 95 % 0,844-0,940), abordaje abierto (0,730, IC del 95 % 0,633-0,842), mayor duración de la estancia (OR 0,949, IC 95% 0,949-0,954) y estadio patológico IIIA (0,547, IC 95% 0,458-0,652) y <12.LIMITACIONES: Fuente de datos administrativos con riesgos inherentes de sesgo, errores de codificación y limitaciones en los campos disponibles para el análisis.CONCLUSIONES: La quimioterapia adyuvante mejoró significativamente la supervivencia general, pero solo se utilizó en el 64,3 % de los adultos mayores con cáncer de colon en estadio III. El incumplimiento de la quimioterapia adyuvante se observó en los pacientes más vulnerables y de mayor riesgo, incluidos aquellos con mayor comorbilidad, menores ingresos y pacientes que recibieron cirugía abierta. Consulte Video Resumen en http://links.lww.com/DCR/C125 . (Traducción-Dr. Fidel Ruiz Healy ).

The underlying regulatory mechanisms of colorectal carcinoma by combining Vitexin and Aspirin: based on systems biology, molecular docking, molecular dynamics simulation, and in vitro study

Introduction

Colorectal cancer (CRC) is a highly prevalent digestive system malignancy. Aspirin is currently one of the most promising chemopreventive agents for CRC, and the combination of aspirin and natural compounds helps to enhance the anticancer activity of aspirin. Natural flavonoids like vitexin have an anticancer activity focusing on colorectal carcinoma.

Methods

This study investigated the potential mechanism of action of the novel combination of vitexin and aspirin against colorectal cancer through network pharmacology, molecular docking, molecular dynamics simulation, and in vitro experiments.

Results

The results of network pharmacology suggested that vitexin and aspirin regulate multiple signaling pathways through various target proteins such as NFKB1, PTGS2 (COX-2), MAPK1, MAPK3, and TP53. Cellular experiments revealed that the combined effect of vitexin and aspirin significantly inhibited HT-29 cell growth. Vitexin dose-dependently inhibited COX-2 expression in cells and enhanced the down-regulation of COX-2 and NF-κB expression in colorectal cancer cells by aspirin.

Discussion

This study provides a pharmacodynamic material and theoretical basis for applying agents against colorectal cancer to delay the development of drug resistance and improve the prognosis of cancer patients.

The content and effectiveness of physical activity for cancer-related fatigue among colorectal cancer survivors: Systematic review and meta-analysis

AIMS

To review the content and efficacy of physical activity (PA) for cancer-related fatigue (CRF) among colorectal cancer survivors.

DESIGN

Systematic review.

METHODS

A comprehensive search for randomized controlled trials from inception to April 1, 2022, of the following database was performed: EMBASE, PubMed, Web of Science, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang Data and China Biology Medicine (CBM). RevMan5.4 software was used for performing meta-analysis.

RESULTS

A total of eight qualified randomized controlled trials that included 542 survivors were included. PA interventions significantly reduced the CRF (SMD = -0.46; 95% CI: [-0.76, -0.15], Z = 2.67, p = 0.003); Subgroup analysis showed that fatigue was significantly improved when the length of interventions was at least 6 months and the weekly duration of PA was less than 150 min/week (SMD = -0.54; 95% CI: [-0.81, -0.27], Z = 3.87 and p = 0.0001; SMD = -0.67; 95% CI: [-1.15, -0.19], Z = 2.74 and p = 0.006); PA intervention with the length of <6 months and the volume of ≥150 min/week did not reduce fatigue (p > 0.05).

Efficacy and influencing factors of Insect Compound Particle combined with chemotherapy for mismatch repair-related locally advanced stage III CRC who had undergone surgery and achieved R0 resection: a multicenter, double-blind, randomized, placebo-controlled clinical trial protocol

Background

Colorectal cancer (CRC) is an insidious malignancy and the occurrence of chemotherapy resistance and toxicity seriously limits its clinical efficacy. Insect Compound Particle [Chong Yao Fu Fang (CYFF)] is a traditional Chinese medicine (TCM) compound based on the concepts of "invigorating spleen for strengthening vital qi" and "collateral disease theory". In long-term clinical application, it can reduce the toxicity of CRC chemotherapy and improve the anti-tumor effect. However, there is currently a lack of high-quality clinical evidence to prove the clinical efficacy and safety of CYFF in the treatment of CRC.

Methods

We plan to include 262 patients with locally advanced stage III CRC who had undergone surgery and achieved R0 resection. These patients will be randomized into a CYFF group (treated with CYFF combined with chemotherapy) and a control group (treated with placebo plus chemotherapy) at a 1:1 ratio. The patients were routinely followed-up every 2 weeks within 2 months and every 4 weeks after 2 months after the treatment, every 3 months within 1 year, and every 6 months after 1 year. The primary endpoint is disease-free survival (DFS), defined as the time from random assignment to recurrence of primary CRC or death from any cause. The secondary endpoints include overall survival (OS) (defined as the time from randomization to death from any cause), safety [any adverse events (AEs)], and the Colorectal Cancer-Specific Quality of Life Questionnaire (QLQ-CR38) score.

Conclusions

Compared with previous studies, our current study applies CYFF plus basic adjuvant chemotherapy, which is expected to achieve better efficacy and longer survival than standard chemotherapy, and reduce the toxic and side effects of chemotherapy, improve the safety of clinical treatment. In addition, our present study is the first clinical study to evaluate the safety and efficacy of CYFF in combination with chemotherapy in the treatment of stage III CRC after R0 resection.

Trial Registration

This clinical trial has been registered in the Chinese Clinical Trial Registry (ChiCTR) (registration No. ChiCTR2000037568; August 28, 2020).

Health economic evidence for adjuvant chemotherapy in stage II and III colon cancer: a systematic review

OBJECTIVE

The aims of this study was to appraise the health economic evidence for adjuvant chemotherapy (AC) strategies in stage II and III colon cancer (CC) and identify gaps in the available evidence that might inform further research.

METHOD

A systematic review of published economic evaluations was undertaken. Four databases were searched and full-text publications in English were screened for inclusion. A narrative synthesis was performed to summarise the evidence.

RESULTS

Thirty-eight studies were identified and stratified by cancer stage and AC strategy. The majority (89%) were full economic evaluations considering both health outcomes, usually measured as quality-adjusted life years (QALYs), and costs. AC was found to be cost-effective compared to no AC for both stage II and III CC. Oral and oxaliplatin-based AC was cost-effective for stage III. Three months of CAPOX was cost-effective compared to 6-month in high-risk stage II and stage III CC. Preliminary evidence suggests that biomarker approaches to AC selection in stage II can reduce costs and improve health outcomes. Notably, assessment of QALYs were predominantly reliant on a small number of non-contemporary health-utility studies. Only 32% of studies considered societal costs such as travel and time off work.

CONCLUSIONS

Published economic evaluations consistently supported the use of AC in stage II and III colon cancer. Biomarker-driven approaches to patient selection have great potential to be cost-effective, but more robust clinical and economic evidence is warranted. Patient surveys embedded into clinical trials may address critical knowledge gaps regarding accurate assessment of QALYs and societal costs in the modern era.

De-escalating adjuvant durvalumab treatment duration in stage III non-small cell lung cancer

BACKGROUND

One year of adjuvant durvalumab following concurrent chemoradiotherapy significantly improves progression-free survival (PFS) and overall survival (OS) for patients with stage III non-small cell lung cancer (NSCLC). However, the optimal length of adjuvant therapy has not been determined.

METHODS

We identified patients with stage III NSCLC treated with definitive chemoradiation and adjuvant durvalumab from November 2017 to April 2021 from the United States Veterans Affairs system. Predictors of early durvalumab discontinuation were evaluated with Cox proportional hazards regression. The effect of differing durations of durvalumab treatment (up to 6, 9, and 12 months) on PFS and OS were compared with a marginal structural model and time-dependent Cox modelling.

RESULTS

We included 1006 patients with stage III non-small cell lung cancer who received concurrent chemoradiotherapy and at least one dose of adjuvant durvalumab. The median duration of durvalumab treatment was 7 months (interquartile range 2.8-11.5) and 31% completed the intended durvalumab course. The most common reasons for early discontinuation were tumour progression (22%), immune-related adverse events (15%), and non-immune-related toxicity (6.0%), Marginal structural models suggested similar PFS for 9 months versus 12 months of durvalumab treatment and inferior PFS for 6 months versus 12 months.

CONCLUSIONS

A substantial proportion of patients undergoing adjuvant durvalumab discontinue therapy early due to toxicity, and shorter durvalumab treatment durations may provide similar disease control to 12 months of therapy. Prospective randomised controlled studies are needed to characterise the optimal durvalumab treatment duration in locally advanced NSCLC patients.

Long-term obesity prevalence and linear growth in children with idiopathic nephrotic syndrome: is normal growth and weight control possible with steroid-sparing drugs and low-dose steroids for relapses?

BACKGROUND

Long-term steroid treatment in children is known to cause obesity and negatively affect growth. The objective of this study was to determine the prevalence of obesity and overweight and analyze linear growth in children with nephrotic syndrome.

METHODS

The study involved 265 children treated with glucocorticoids for nephrotic syndrome for a mean duration of 43 months (range: 6-167, IQR: 17, 63.3). Height, weight, and BMI SDS were recorded at each visit. Rate of change between the final and initial height, weight, and BMI was calculated (Δ score). The cumulative steroid dose (mg/kg/day) during follow-up was calculated. Relapses without significant edema were treated with low-dose steroids and steroid-sparing drugs were used in children with steroid dependency/frequent relapses.

RESULTS

Mean first BMI SDS was + 1.40 ± 1.30 and final + 0.79 ± 1.30. At initial assessment, 41.4% of the patients were obese (BMI ≥ 95^th percentile) and 19.5% were overweight (BMI 85^th-95^th percentile). At the last clinical visit, 24% were obese and 17% overweight. The children had lower BMI SDS at last clinical visit compared to initial assessment. Mean first height SDS of the cohort was - 0.11 ± 1.22 and final score 0.078 ± 1.14 (p < 0.0001). Almost 85% of patients were treated with steroid-sparing drugs.

CONCLUSIONS

Our results indicate that children with nephrotic syndrome, despite a need for steroid treatment for active disease, can improve their obesity and overweight and also improve their linear growth from their first to last visit with us.

Whether Patients With Stage Ⅱ/Ⅲ Colorectal Cancer Benefit From Adjuvant Chemotherapy: A Modeling Analysis of Literature Aggregate Data

Objective: This study used model analysis to clarify the benefits and risks of postoperative adjuvant chemotherapy compared with surgery alone in patients with stage II/III colorectal cancer.

Methods: Clinical trials involving patients with stage II/III colorectal cancer who underwent surgery alone or those who received post-surgical adjuvant chemotherapy were searched in the PubMed and embase databases. By establishing a survival model, the overall survival (OS) and disease-free survival (DFS) of patients who underwent surgery alone or postoperative adjuvant chemotherapy were quantitatively analyzed to compare the differences between the two. In addition, the incidence of grade 3/4 adverse reactions in the adjuvant chemotherapy group was analyzed using the random effects model in the single-arm meta-analysis.

Results: A total of 34 studies containing 33,069 patients were included in the analysis. This study found that postoperative adjuvant chemotherapy can effectively improve the OS and DFS of patients with colorectal cancer. The median OS of the adjuvant chemotherapy group and the surgery-only group was 118.8 months (95% CI: 96.6, 146.6) and 74.6 months (95% CI: 57.8, 96.1) respectively; and median DFS was 86.3 months (95% CI: 67.6, 110.6) and 40.8 months (95% CI: 23.7, 69.6) in the adjuvant chemotherapy and surgery-only groups, respectively. Common grade 3/4 adverse reactions in the adjuvant chemotherapy group include diarrhea, stomatitis, leukopenia, and nausea or vomiting, with an incidence of approximately 3%–6%.

Conclusion: Patients with mid-stage colorectal cancer can benefit significantly from postoperative adjuvant chemotherapy. This study provides the necessary quantitative information for decision-making regarding the benefits and risks of receiving adjuvant chemotherapy after resection in patients with colorectal cancer.

Women are predisposed to early dose-limiting toxicities during adjuvant CAPOX for colorectal cancer

AIM

Oxaliplatin-based adjuvant chemotherapy was demonstrated to be beneficial for stage III or high-risk stage II colorectal cancer (CRC). Moreover, a recent international collaborative trial suggested 3-months CAPOX as an alternative regimen for low-risk stage III colorectal cancer (CRC) patients. Thus, it is important to clarify the frequency and predictive markers of dose-limiting toxicities (DLTs) developed within the short-course CAPOX cycles.

METHODS

We investigated CRC patients who underwent radical surgery and adjuvant CAPOX therapy at our hospital between December 2010 and February 2021. Patients who received initially reduced doses of CAPOX and those who had early recurrence were excluded. We reviewed the age, sex, comorbidities, physical, laboratory and oncological data and other perioperative factors. The associations between these variables and early DLTs within four cycles of CAPOX were examined by multivariate analyses using logistic regression models.

RESULTS

Among 168 patients (96 men, mean age: 58.3 years), 120 (71%) developed early DLTs. Patients with early DLTs were predominantly women and sarcopenic and habitual alcohol consumers. On multivariate analyses, only the female sex was an independent predictive factor for early DLTs (odds ratio: 2.61, P = .027).

CONCLUSION

Women were prone to early DLTs during adjuvant CAPOX in the current study. Doctors should be aware of the sex difference in the incidence of early DLTs, adjust the CAPOX dosage and provide supportive care for female CRC patients.

Standardized Astragalus Mongholicus Bunge-Curcuma Aromatica Salisb. Extract Efficiently Suppresses Colon Cancer Progression Through Gut Microbiota Modification in CT26-Bearing Mice

Altered gut microbiota and a damaged colon mucosal barrier have been implicated in the development of colon cancer. Astragalus mongholicus Bunge-Curcuma aromatica Salisb. (ACE) is a common herbal drug pair that widely used clinically to treat cancer. However, whether the anti-cancer effect of ACE is related to gut microbiota remains unclear yet. We standardized ACE and investigated the effects of ACE on tumour suppression and analyze the related mechanisms on gut microbiota in CT26 colon cancer-bearing mice in the present study. Firstly, four flavonoids (calycosin-7-glucoside, ononin, calycosin, formononetin) and three astragalosides (astragaloside A, astragaloside II, astragaloside I) riched in Astragalus mongholicus Bunge, three curcumins (bisdemethoxycurcumin, demethoxycurcumin, curcumin) and four essential oils (curdione, curzerene, germacrone and β-elemene) from Curcuma aromatica Salisb., in concentrations from 0.08 to 2.07 mg/g, were examined in ACE. Then the results in vivo studies indicated that ACE inhibited solid tumours, liver and spleen metastases of colon cancer while simultaneously reducing pathological tissue damage. Additionally, ACE regulated gut microbiota dysbiosis and the short chain fatty acid content in the gut, repaired intestinal barrier damage. ACE treatment suppressed the overgrowth of conditional pathogenic gut bacteria, including Escherichia-Shigella, Streptococcus and Enterococcus, while the probiotic gut microbiota like Lactobacillus, Roseburia, Prevotellaceae_UCG-001 and Mucispirillum were increased. More interestingly, the content level of SCFAs such as propionic acid and butyric acid was increased after ACE administration, which further mediates intestinal SDF-1/CXCR4 signalling pathway to repair the integrity of the intestinal barrier, decrease Cyclin D1 and C-myc expressions, eventually suppress the tumor the growth and metastasis of colon cancer. To sum up, the present study demonstrated that ACE could efficiently suppress colon cancer progression through gut microbiota modification, which may provide a new explanation of the mechanism of ACE against colon cancer.

Identification of a Novel Immune-Related CpG Methylation Signature to Predict Prognosis in Stage II/III Colorectal Cancer

With the increasing incidence of colorectal cancer (CRC) and continued difficulty in treating it using immunotherapy, there is an urgent need to identify an effective immune-related biomarker associated with the survival and prognosis of patients with this disease. DNA methylation plays an essential role in maintaining cellular function, and changes in methylation patterns may contribute to the development of autoimmunity, aging, and cancer. In this study, we aimed to identify a novel immune-related methylated signature to aid in predicting the prognosis of patients with CRC. We investigated DNA methylation patterns in patients with stage II/III CRC using datasets from The cancer genome atlas (TCGA). Overall, 182 patients were randomly divided into training (n = 127) and test groups (n = 55). In the training group, five immune-related methylated CG sites (cg11621464, cg13565656, cg18976437, cg20505223, and cg20528583) were identified, and CG site-based risk scores were calculated using univariate Cox proportional hazards regression in patients with stage II/III CRC. Multivariate Cox regression analysis indicated that methylated signature was independent of other clinical parameters. The Kaplan-Meier analysis results showed that CG site-based risk scores could significantly help distinguish between high- and low-risk patients in both the training (P = 0.000296) and test groups (P = 0.022). The area under the receiver operating characteristic curve in the training and test groups were estimated to be 0.771 and 0.724, respectively, for prognosis prediction. Finally, stratified analysis results suggested the remarkable prognostic value of CG site-based risk scores in CRC subtypes. We identified five methylated CG sites that could be used as an efficient overall survival (OS)-related biomarker for stage II/III CRC patients.

Longitudinal effects of adjuvant chemotherapy and related neuropathy on health utility in stage II and III colon cancer patients: A prospective cohort study

Patient's quality of life should be included in clinical decision making regarding the administration of adjuvant chemotherapy (ACT) in stage II/III colon cancer. Therefore, quality of life, summarized as health utility (HU), was evaluated for patients treated with and without ACT. Furthermore, the role of chemotherapy–induced peripheral neuropathy (CIPN) on HU was evaluated. Patients diagnosed with stage II/III colon cancer between 2011 and 2019 and participating in the Prospective Dutch ColoRectal Cancer cohort were included (n = 914). HU scores were assessed with the EQ‐5D‐5L at baseline, 3, 6, 12, 18, and 24 months. Patients treated with ACT received mainly capecitabine and oxaliplatin (57%) or capecitabine monotherapy (40%) (average duration: 3.5 months). HU 3 to 18 months after diagnosis (potential ACT period + 12 months follow‐up) was compared between patients treated with and without ACT using a mixed model adjusted for age, sex and education level. Subsequently, the CIPN sensory, motor and autonomy scales, measured using the EORTC QLQ‐CIPN20, were independently included in the model to evaluate the impact of neuropathy. Using a mixed model, a significant difference of −0.039 (95% confidence interval: −0.062; −0.015) in HU was found between patients treated with and without ACT. Including the CIPN sensory, motor and autonomy scales decreased the difference with 0.019, 0.015 and 0.02, respectively. HU 3 to 18 months after diagnosis is significantly lower in patients treated with ACT vs without ACT. This difference is on the boundary of clinical relevance and appears to be partly related to the sensory and motor neuropathy‐related side effects of ACT.

What's new?

Given its potentially serious side effects, patient quality of life should be included in clinical decision‐making regarding the administration of adjuvant chemotherapy in stage II/III colon cancer. Using a mixed model which was corrected for relevant covariates, here the authors found a statistically‐significant but small decrease in HU of −0.039 during chemotherapy and the following 12 months for patients treated with adjuvant chemotherapy compared to patients without adjuvant chemotherapy. The decrease in HU, which is on the boundary of clinical relevance, appears to be partly related to sensory and motor neuropathy side effects of adjuvant chemotherapy.

Randomised phase II trial of capecitabine plus oxaliplatin with continuous versus intermittent use of oxaliplatin as adjuvant chemotherapy for stage II/III colon cancer (CCOG-1302 study)

BACKGROUND

Peripheral sensory neuropathy (PSN) caused by oxaliplatin-based adjuvant chemotherapy adversely affects patients' quality of life. This study evaluated the efficacy and safety of capecitabine plus oxaliplatin (CAPOX) with intermittent oxaliplatin use compared with the standard CAPOX in adjuvant therapy for colon cancer.

PATIENTS AND METHODS

Patients with curative resection for stage II/III colon cancer were randomly assigned to receive either CAPOX with continuous oxaliplatin (eight cycles of CAPOX) or CAPOX with intermittent oxaliplatin (two cycles of CAPOX, four cycles of capecitabine and two cycles of CAPOX). The primary end-point was the 1-year PSN rate, and the key secondary end-point was disease-free survival (DFS).

RESULTS

Two hundred patients were enrolled in the intent-to-treat population. After 4 patients withdrew, 196 patients were included in the safety analysis. The overall treatment completion rate was 65% for continuous vs. 89% for intermittent treatment (p < 0.001). The 1-year PSN rate was 60% (95% confidence interval [CI], 50%-70%) for continuous and 16% (95% CI, 10%-25%) for intermittent treatment (p < 0.001). After a median follow-up of 52 months, 40 events (20%) were observed. The 3-year DFS was 81% (95% CI, 71%-87%) for continuous and 84% (95% CI, 75%-90%) for intermittent treatment (hazard ratio [HR], 0.87; 95% CI, 0.47-1.63). Among patients with high-risk disease (T4 or N2-3), the 3-year DFS was 57% for continuous vs. 74% for intermittent treatment (HR, 0.66).

CONCLUSION

CAPOX with planned intermittent oxaliplatin may be feasible as an adjuvant therapy for colon cancer and substantially reduce the duration of long-lasting PSN.

TRIAL IDENTIFIER

UMIN000012535.

Model-based evaluation of the cost effectiveness of 3 versus 6 months' adjuvant chemotherapy in high-risk stage II colon cancer patients

BACKGROUND

Our aim was to evaluate the cost effectiveness of 3 months' adjuvant chemotherapy versus 6 months in high-risk (T4 stage + microsatellite stable) stage II colon cancer (CC) patients.

METHODS

Using the validated PATTERN Markov cohort model, which simulates the disease progression of stage II CC patients from diagnosis to death, we first evaluated a reference strategy in which high-risk patients were treated with chemotherapy for 6 months. In the second strategy, treatment duration was shortened to 3 months. Both strategies were evaluated for CAPOX (capecitabine plus oxaliplatin) and FOLFOX (fluorouracil, leucovorin and oxaliplatin). Based on trial data, we assumed that shortened treatment duration compared with a 6-month regimen was equally effective for CAPOX and less effective for FOLFOX. Adverse events were highest in the 6-month strategy. Analyses were conducted from a societal perspective using a lifelong time horizon. Outcomes were number of CC deaths per 1000 patients and total discounted costs and quality-adjusted life-years (QALYs) per patient (pp). Incremental net monetary benefit (iNMB) was calculated using a willingness-to-pay value of €50,000/QALY.

RESULTS

For CAPOX, the 6-month strategy resulted in 316 CC deaths per 1000 patients, 6.71 QALYs pp and total costs of €41,257 pp. The 3-month strategy resulted in an equal number of CC deaths, but higher QALYs (6.80 pp) and lower costs (€37,645 pp), leading to a iNMB of €8454 per person for 3 months versus 6 months. For FOLFOX, the 6-month strategy resulted in 316 CC deaths per 1000 patients, 6.71 QALYs pp and total costs of €47,135 pp. The 3-month strategy resulted in more CC deaths (393), lower QALYs (6.19 pp) and lower costs (€44,389 pp). An iNMB of -€23,189 was found for 3 months versus 6 months.

CONCLUSION

Our findings indicate that 3 months' adjuvant chemotherapy should be considered as standard of care in high-risk stage II CC patients for CAPOX, but not for FOLFOX.

Stratification of Stage III colon cancer may identify a patient group not requiring adjuvant chemotherapy

Purpose

Adjuvant chemotherapy for colon cancer with lymph node involvement (Stage III) has been the standard of care since the 1990s. Meanwhile, considerable evolvement of surgery combined with dedicated histopathological examinations may have led to stage migration. Furthermore, prognostic factors other than lymph node involvement have proven to affect overall survival. Thus, adjuvant chemotherapy in Stage III colon cancer should be reconsidered. The objective was to compare recurrence rates and survival in stage III colon cancer patients treated with or without adjuvant chemotherapy. Further, to assess the impact of extensive mesenterectomy, lymph node stage and vascular invasion on outcome.

Methods

Consecutive patients operated for Stage III colon carcinoma between 31 December 2005 and 31 December 2015 were identified in the pathological code register by matching colon (T67) and either adenocarcinoma (M81403) or mucinous adenocarcinoma (M84803), with lymph node (T08) and metastasis of adenocarcinoma (M81406 or M84806). Medical records of all identified patients were reviewed.

Results

Of 216 identified patients, 69 received no postoperative adjuvant chemotherapy (group NC), 69 insufficient adjuvant chemotherapy (FLV or < minimum recommended 6 cycles FLOX, group IC), and 78 sufficient adjuvant chemotherapy (≥ 6 cycles FLOX, group SC). When adjusted for age and comorbidity, 5-year overall survival did not differ statistically significant between groups (76% vs. 83% vs. 85%, respectively). Vascular invasion and a high lymph node ratio significantly reduced overall survival.

Conclusion

The findings imply that subgroups of Stage III colon cancer patients have good prognosis also without adjuvant chemotherapy. For definite conclusions about necessity of adjuvant chemotherapy, prospective trials are needed.

The Optimal Duration of Adjuvant Chemotherapy in Colon Cancer

Adjuvant chemotherapy for colon cancer (UICC stage II and III) has been under investigation over the last 30 years, regarding treatment duration and regimens. In this review, choice of regimen, its duration, possible limitations and future perspectives are discussed. Monotherapy with 5-fluorouracil was followed by addition of oxaliplatin, resulting in improved 3-yr disease free survival (DFS) and overall survival (OS) rates, but also increased peripheral sensory neurotoxicity (PSN). The International Duration Evaluation of Adjuvant therapy (IDEA) collaboration demonstrated less toxicity, especially PSN, when shortening treatment duration to 3 months. However, formally, the anticipated non-inferiority of 3 months with fluoropyrimidine (FP)/oxaliplatin over 6 months (at 3-yr DFS) was not met for all patients groups, although subgroup analyses showed non-inferiority with capecitabine/oxaliplatin (CAPOX) rather than with FOLFOX, and also in relation to the prognostic information (e.g., clinical low-risk group, pT1-3 N0). In addition, first data of newer parameters like Immunoscore® and ctDNA show promising results as stratification parameters. Further investigations to better define clinical risk groups and prognostic factors are mandatory. Besides this, individual decision-making of treatment intensity (FP or FP/oxaliplatin) and duration should always consider patient characteristics and preferences, also given the absolute relatively small differences and their clinical relevance.

Lipid-Based Drug Delivery Nanoplatforms for Colorectal Cancer Therapy

Colorectal cancer (CRC) is a prevalent disease worldwide, and patients at late stages of CRC often suffer from a high mortality rate after surgery. Adjuvant chemotherapeutics (ACs) have been extensively developed to improve the survival rate of such patients, but conventionally formulated ACs inevitably distribute toxic chemotherapeutic drugs to healthy organs and thus often trigger severe side effects. CRC cells may also develop drug resistance following repeat dosing of conventional ACs, limiting their effectiveness. Given these limitations, researchers have sought to use targeted drug delivery systems (DDSs), specifically the nanotechnology-based DDSs, to deliver the ACs. As lipid-based nanoplatforms have shown the potential to improve the efficacy and safety of various cytotoxic drugs (such as paclitaxel and vincristine) in the clinical treatment of gastric cancer and leukemia, the preclinical progress of lipid-based nanoplatforms has attracted increasing interest. The lipid-based nanoplatforms might be the most promising DDSs to succeed in entering a clinical trial for CRC treatment. This review will briefly examine the history of preclinical research on lipid-based nanoplatforms, summarize the current progress, and discuss the challenges and prospects of using such approaches in the treatment of CRC.

Impact of the COVID-19 outbreak on adjuvant chemotherapy for patients with stage II or III colon cancer: experiences from a multicentre clinical trial in China

Since January 2020, the outbreak of the novel coronavirus disease designated covid-19 by the World Health Organization, a human-to-human contagious viral pneumonia that began in 2019, has been extensively influencing daily life in China[...]