Magnitude of the Age-Advancement Effect of Comorbidities in Colorectal Cancer Prognosis

Practice Patterns and Trends in the Surgical Management of Mismatch Repair Deficient Colon Cancer

INTRODUCTION

Defects in the DNA mismatch repair (MMR) pathway can predispose individuals to colorectal cancer (CRC), with germline mutations in this pathway leading to Lynch syndrome. Consequently, universal MMR testing is recommended for all newly diagnosed CRC patients to detect mismatch repair deficient (MMR-D) tumors, enabling informed treatment decisions. Given the increased potential for metachronous disease in patients with Lynch syndrome, the current guidelines for surgical management of Lynch-associated colon cancer recommend extended resection in patients under age 60.

METHODS

A retrospective analysis of nonmetastatic CRC was performed from the National Cancer Database to evaluate the current trends and practice patterns in the surgical management of MMR-D colon cancer, as well as assess the factors influencing choice of surgical procedure.

RESULTS

From 2018 to 2020, 98,112 nonmetastatic CRC patients were identified, with 19.93% being MMR-D. MMR-D colon cancer patients were more likely to undergo extended resection than those with mismatch repair proficient tumors (9.4% versus 4.2%, P < 0.001). When accounting for approximately one-fourth of MMR-D colon cancers being attributable to Lynch syndrome, the frequency of extended resection was less than expected (9.4% versus 25%, P < 0.001). MMR-D patients under age 60 were more likely to undergo extended resection than those over age 60 (9% versus 3%) (odds ratio [OR] 3.57, 95% confidence interval [CI] 3.06-4.15). Several factors were associated with decreased rate of extended resection: uninsured (OR 0.42, 95% CI 0.21-0.84), Black race (OR 0.54, 95% CI 0.35-0.82), treatment at nonacademic centers (OR 0.74, 95% CI 0.56-0.97), and crowfly distance >25 miles (OR 1.98, 95% CI 1.14-3.45).

CONCLUSIONS

These findings provide valuable insight into the current surgical practice patterns in the management of MMR-D colon cancers and possibly colon cancers associated with Lynch syndrome.

In-hospital outcomes of older patients with gastric cancer and their risk factors: large comprehensive institution-based study

PURPOSE

Gastric cancer (GC) is mostly a disease of aging, and older patients with GC are generally frailer. This study aimed to describe the characteristics and in-hospital outcomes, both overall and stratified by gender and resection, and to explore factors associated with outcomes of first hospitalization, in older GC patients.

METHODS

Data on GC patients ≥ 65 years hospitalized from January 2016 until December 2020 were retrieved from the electronic medical records of a large tertiary hospital. Patient and tumor characteristics, duration and fee of hospitalization, and in-hospital mortality were described for overall patients and compared by gender and resection. Factors associated with outcomes of first hospitalization were explored using multivariable-adjusted logistic regression.

RESULTS

3238 eligible patients were analyzed, with a mean age of 71 years and a male proportion of 74%. The median duration and fee of first hospitalization were 13 days and 40,000 RMB, respectively, with a median fee of 17,000 RMB not covered by insurance. 16 (< 1%) and 32 (1%) deaths occurred during first and any hospitalization, respectively, with only 4 (< 1%) perioperative deaths. Compared to male patients, female cases had more often signet-ring-cell carcinoma, reduced food intake, resection, and history of major abdominal surgery. Compared to unresected cases, resected patients had higher body-mass-index and Barthel index, less often reduced food intake, weight loss, and risk of malnutrition, and more often common diet, longer hospital stay, and higher fee. Through multivariable-adjusted analysis, longer first hospital-stay was associated with earlier year of diagnosis, older ages, emergency admission, signet-ring-cell carcinoma, resection, history of anticoagulant intake, larger body-mass-index, non-common diet, and non-low-salt and non-diabetes diets; higher fee of first hospitalization was associated with later year of diagnosis, male gender, older ages, emergency admission, signet-ring-cell carcinoma, and resection.

CONCLUSIONS

In this large institution-based study, older GC patients had low in-hospital mortality rates; the insurance coverage needs to be improved. Several characteristics and in-hospital outcomes significantly differed by gender and resection status, and various factors associated with duration and fee of first hospitalization were identified, providing important hints for individualized and stratified geriatric GC care.

Prevalence of cancer-related fatigue syndrome and its association with sociodemographic and clinical characteristics in adult patients with colorectal cancer: a cross-sectional study

PURPOSE

To describe the prevalence of fatigue in adults with colorectal cancer (CRC). Additionally, to explore the associations and correlations between fatigue and sociodemographic and clinical characteristics.

METHODS

Patients with CRC at various phases of the disease were evaluated for fatigue using the Brief Fatigue Inventory (BFI), independence in activities of daily living using the Barthel index, perception of pain using the Visual Analogue Scale (VAS), and performance status using the Eastern Cooperative Oncology Group criteria in a Chilean public hospital. Descriptive analyses were used to describe the variables. Chi-square and Spearman tests were utilized to evaluate associations between fatigue and other variables.

RESULTS

Among 241 patients participate (mean age 68.9 ± 12.2 years) and colon cancer was most common (66.4%). Fatigue was present in all disease phases, with moderate fatigue most prevalent (49.3%), followed by mild (24.2%) and severe (13.6%). Newly diagnosed patients had a higher proportion of severe fatigue (p = 0.04). Women experienced more moderate fatigue than men (p < 0.05). Patients with over three comorbidities and severe pain had higher severe fatigue (p < 0.05). Mood disorders were linked to more severe fatigue, while their absence was related to milder fatigue (p = 0.02). Musculoskeletal disorders correlated with moderate fatigue, while their absence correlated with mild fatigue (p < 0.01). Small positive correlations existed between fatigue and age (Rho = 0.15) and pain (Rho = 0.23) (p < 0.05).

CONCLUSION

Cancer-related fatigue (CRF) is highly prevalent in individuals with CRC and can be present throughout all phases of the disease. Early screening and management are recommended, prior to surgical treatment.

eHealth interventions to support colorectal cancer patients' self-management after discharge from surgery-an integrative literature review

INTRODUCTION

Colorectal cancer (CRC) creates elevated self-management demands and unmet support needs post-discharge. Follow-up care through eHealth post-primary surgery may be an effective means of supporting patients' needs. This integrative review describes the evidence regarding eHealth interventions post-hospital discharge focusing on delivery mode, user-interface and content, patient intervention adherence, impact on patient-reported outcomes and experiences of eHealth.

METHODS

A university librarian performed literature searches in 2021 using four databases. After screening 1149 records, the authors read 30 full-text papers and included and extracted data from 26 papers. Two authors analysed the extracted data using the 'framework synthesis approach'.

RESULTS

The 26 papers were published between 2012 and 2022. The eHealth interventions were mainly delivered by telephone with the assistance of healthcare professionals, combined with text messages or video conferencing. The user interfaces included websites, applications and physical activity (PA) trackers. The interventions comprised the monitoring of symptoms or health behaviours, patient information, education and counselling. Evidence showed a better psychological state and improved PA. Patients reported high satisfaction with eHealth. However, patient adherence was inadequately reported.

CONCLUSIONS

eHealth interventions may positively impact CRC patients' anxiety and PA regardless of the user interface. Patients prefer technology combined with a human element.

Prognostic value of primary tumor location in colorectal cancer: an updated meta-analysis

The clinical, histological, and molecular differences between right-sided colon cancer (RCC) and left-sided colon cancer (RCC) have received considerable attention. Over the past decade, many articles have been published concerning the association between primary tumor location (PTL) of colorectal cancer and survival outcomes. Therefore, there is a growing need for an updated meta-analysis integrating the outcomes of recent studies to determine the prognostic role of right vs left-sidedness of PTL in patients with colorectal cancer. We conducted a comprehensive database review using PubMed, SCOPUS, and Cochrane library databases from February 2016 to March 2023 for prospective or retrospective studies reporting data on overall survival (OS) and cancer-specific survival (CSS) of RCC compared with LCC. A total of 60 cohort studies comprising 1,494,445 patients were included in the meta-analysis. We demonstrated that RCC is associated with a significantly increased risk of death compared with LCC by 25% (hazard ratio (HR), 1.25; 95% confidence interval (CI), 1.19-1.31; I2 = 78.4%; Z = 43.68). Results showed that patients with RCC have a worse OS compared with LCC only in advanced stages (Stage III: HR, 1.275; 95% CI 1.16-1.4; P = 0.0002; I2 = 85.8%; Stage IV: HR, 1.34; 95% CI 1.25-1.44; P < 0.0001; I2 = 69.2%) but not in primary stages (Stage I/II: HR, 1.275; 95% CI 1.16-1.4; P = 0.0002; I2 = 85.8%). Moreover, a meta-analysis of 13 studies including 812,644 patients revealed that there is no significant difference in CSS between RCC and LCC (HR, 1.121; 95% CI 0.97-1.3; P = 0.112). Findings from the present meta-analysis highlight the importance of PTL in clinical decision-making for patients with CRC, especially in advanced stages. We provide further evidence supporting the hypothesis that RCC and LCC are distinct disease entities that should be managed differently.

Aging characteristics of colorectal cancer based on gut microbiota

BACKGROUND

Aging is one of the factors leading to cancer. Gut microbiota is related to aging and colorectal cancer (CRC).

METHODS

A total of 11 metagenomic data sets related to CRC were collected from the R package curated Metagenomic Data. After batch effect correction, healthy individuals and CRC samples were divided into three age groups. Ggplot2 and Microbiota Process packages were used for visual description of species composition and PCA in healthy individuals and CRC samples. LEfSe analysis was performed for species relative abundance data in healthy/CRC groups according to age. Spearman correlation coefficient of age-differentiated bacteria in healthy individuals and CRC samples was calculated separately. Finally, the age prediction model and CRC risk prediction model were constructed based on the age-differentiated bacteria.

RESULTS

The structure and composition of the gut microbiota were significantly different among the three groups. For example, the abundance of Bacteroides vulgatus in the old group was lower than that in the other two groups, the abundance of Bacteroides fragilis increased with aging. In addition, seven species of bacteria whose abundance increases with aging were screened out. Furthermore, the abundance of pathogenic bacteria (Escherichia_coli, Butyricimonas_virosa, Ruminococcus_bicirculans, Bacteroides_fragilis and Streptococcus_vestibularis) increased with aging in CRCs. The abundance of probiotics (Eubacterium_eligens) decreased with aging in CRCs. The age prediction model for healthy individuals based on the 80 age-related differential bacteria and model of CRC patients based on the 58 age-related differential bacteria performed well, with AUC of 0.79 and 0.71, respectively. The AUC of CRC risk prediction model based on 45 disease differential bacteria was 0.83. After removing the intersection between the disease-differentiated bacteria and the age-differentiated bacteria from the healthy samples, the AUC of CRC risk prediction model based on remaining 31 bacteria was 0.8. CRC risk prediction models for each of the three age groups showed no significant difference in accuracy (young: AUC=0.82, middle: AUC=0.83, old: AUC=0.85).

CONCLUSION

Age as a factor affecting microbial composition should be considered in the application of gut microbiota to predict the risk of CRC.

Primary Tumor Resection Plus Chemotherapy versus Chemotherapy Alone for Colorectal Cancer Patients with Synchronous Bone Metastasis

Background and Objective: Colorectal cancer (CRC) bone metastasis (BM), particularly synchronous metastasis, is infrequent and has a poor prognosis. Radical surgery for CRC with BM is challenging, and chemotherapy is the standard treatment. However, it is unclear whether combining chemotherapy with primary tumor resection (PTR) yields greater survival benefits than chemotherapy alone, as no relevant reports exist. Material and Methods: The Surveillance, Epidemiology, and End Results (SEER) database provided data on 1662 CRC patients with bone metastasis between 2010 and 2018, who were divided into two groups: chemotherapy combined with PTR and chemotherapy alone. Survival distributions were compared using the log-rank test, and survival estimates were obtained using the Kaplan-Meier method. A Cox proportional multivariate regression analysis was conducted to estimate the survival benefit of chemotherapy combined with PTR while controlling for additional prognostic factors. Results: The chemotherapy only group consisted of 1277 patients (76.8%), while the chemotherapy combined with PTR group contained 385 patients (23.2%). Patients who received chemotherapy combined with PTR had a significantly higher 1-year survival rate (60.7%) and 2-year survival rate (32.7%) compared to those who only received chemotherapy (43.8% and 18.4%, respectively; p < 0.0001). Independent prognostic factors identified by Cox proportional analysis were age, location of the primary tumor, type of tumor, M stage, metastasectomy and PTR. Patients who received chemotherapy combined with PTR had a significantly improved prognosis (HR 0.586, 95% CI 0.497-0.691, p < 0.0001). All subgroups demonstrated a survival advantage for patients who received chemotherapy in combination with PTR. Conclusions: Our findings suggest that patients with BM from CRC may benefit from chemotherapy combined with PTR. Our analysis also identified age, location of the primary tumor, type of tumor, M stage, metastasectomy, and PTR as independent prognostic risk factors for CRC patients with synchronous BM.

Associations of advanced age with comorbidity, stage and primary subsite as contributors to mortality from colorectal cancer

Background

Although survival from colorectal cancer (CRC) has improved substantially in recent decades, people with advanced age still have a high likelihood of mortality from this disease. Nonetheless, few studies have investigated how cancer stage, subsite and comorbidities contribute collectively to poor prognosis of older people with CRC. Here, we decided to explore the association of age with mortality measures and how other variables influenced this association.

Methods

Using linkage of several administrative datasets, we investigated the risk of death among CRC cases during 2003–2014. Different models were used to explore the association of age with mortality measures and how other variables influenced this association.

Results

Our results indicated that people diagnosed at a young age and with lower comorbidity had a lower likelihood of all-cause and CRC-specific mortality. Aging had a greater association with mortality in early-stage CRC, and in rectal cancer, compared that seen with advanced-stage CRC and right colon cancer, respectively. Meanwhile, people with different levels of comorbidity were not significantly different in terms of their increased likelihood of mortality with advanced age. We also found that while most comorbidities were associated with all-cause mortality, only dementia [SHR = 1.43 (1.24–1.64)], Peptic ulcer disease [SHR = 1.12 (1.02–1.24)], kidney disease [SHR = 1.11 (1.04–1.20)] and liver disease [SHR = 1.65 (1.38–1.98)] were risk factors for CRC-specific mortality.

Conclusion

This study showed that the positive association of advanced age with mortality in CRC depended on stage and subsite of the disease. We also found only a limited number of comorbidities to be associated with CRC-specific mortality. These novel findings implicate the need for more attention on factors that cause poor prognosis in older people.

Establishment and validation of a prognostic nomogram for patients with early-onset stage I–II colon cancer

Background

The aims of this study were to establish and validate a nomogram model for predicting the survival of patients with early-onset stage I–II colon cancer (CC).

Methods

Data of eligible patients enrolled from 2012 to 2015 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Patients were randomly allocated to training and validation groups in a 7:3 ratio. Significant prognostic factors were identified by univariate and multivariate analysis and a nomogram model constructed. The predictive performance of the nomogram was evaluated by the concordance index (C-index), calibration plots, and decision curve analysis.

Results

Our study cohort comprised 3528 early-onset CC patients with stage I–II disease, 2469 of whom were allocated to the training cohort and 1059 to the validation cohort. Race, age, marital status, tumor grade, tumor size, tumor stage (T stage), and chemotherapy were considered the significant predictor by univariate analysis. Race, marital status, and T stage were found to be independent prognostic factors by multivariate analysis. The C-indexes of the nomogram were 0.724 and 0.692 in the training and validation cohorts, respectively. Likewise, the calibration plots showed good agreement regarding the probability of 3- and 5-year observed and nomogram-predicted overall survival in the training group. Decision curve analysis showed that the nomogram model was clinically practical and effective. Moreover, applying the nomogram enabled dividing of the patients into two cohorts with different risk scores. The low-risk group thus created had a better survival than the high-risk group.

Conclusions

We developed and validated a meaningful prognostic nomogram model for patients with early-onset stage I–II CC that clinicians can use to make better decisions for individual patients.

Correlation between hypoxia and HGF/c-MET expression in the management of pancreatic cancer

Pancreatic cancer (PC) is very deadly and difficult to treat. The presence of hypoxia has been shown to increase the probability of cancer developing and spreading. Pancreatic ductal adenocarcinoma (PDAC/PC) has traditionally viewed a highly lethal form of cancer due to its high occurrence of early metastases. Desmoplasia/stroma is often thick and collagenous, with pancreatic stellate cells as the primary source (PSCs). Cancer cells and other stromal cells interact with PSCs, promoting disease development. The hepatocyte growth factor (HGF)/c-MET pathway have been proposed as a growth factor mechanism mediating this interaction. Human growth factor (HGF) is secreted by pancreatic stellate cells (PSCs), and its receptor, c-MET, is generated by pancreatic cancer cells and endothelial cells. Hypoxia is frequent in malignant tumors, particularly pancreatic (PC). Hypoxia results from limitless tumor development and promotes survival, progression, and invasion. Hypoxic is becoming a critical driver and therapeutic target of pancreatic cancer as its hypoxia microenvironment is defined. Recent breakthroughs in cancer biology show that hypoxia promotes tumor proliferation, aggressiveness, and therapeutic resistance. Hypoxia-inducible factors (HIFs) stabilize hypoxia signaling. Hypoxia cMet is a key component of pancreatic tumor microenvironments, which also have a fibrotic response, that hypoxia, promotes and modulates. c-Met is a tyrosine-protein kinase. As describe it simply, the MET gene in humans' codes for a protein called hepatocyte growth factor receptor (HGFR). Most cancerous tumors and pancreatic cancer in particular, suffer from a lack of oxygen (PC). Due to unrestrained tumor development, hypoxia develops, actively contributing to tumor survival, progression, and invasion. As the processes by which hypoxia signaling promotes invasion and metastasis become clear, c-MET has emerged as an important determinant of pancreatic cancer malignancy and a potential pharmacological target. This manuscript provides the most current findings on the role of hypoxia and HGF/c-MET expression in the treatment of pancreatic cancer.

Effect of comorbidity assessed by the Charlson Comorbidity Index on the length of stay, costs, and mortality among colorectal cancer patients undergoing colorectal surgery

OBJECTIVE

Charlson Comorbidity Index (CCI) is a good predictor for hospitalization cost and mortality among patients with chronic disease. However, the impact of CCI on patients after colorectal cancer surgery is unclear. This study aims to investigate the influence of comorbidity assessed by CCI on length of stay, hospitalization costs, and in-hospital mortality in patients with colorectal cancer (CRC) who underwent surgical resection.

METHODS

This historical cohort study collected 10,271 adult inpatients for CRC undergoing resection surgery in 33 tertiary hospitals between January 2018 and December 2019. All patients were categorized by the CCI score into four classes: 0, 1,2, and ≥3. Linear regression was used for outcome indicators as continuous variables and logical regression for categorical variables. EmpowerStats software and R were used for data analysis.

RESULTS

Of all 10,271 CRC patients, 51.72% had at least one comorbidity. Prevalence of metastatic solid tumor (19.68%, except colorectal cancer) and diabetes without complication (15.01%) were the major comorbidities. The highest average cost of hospitalization (86,761.88 CNY), length of stay (18.13 days), and in-hospital mortality (0.89%) were observed in patients with CCI score ≥3 compared to lower CCI scores (p < .001). Multivariate regression analysis showed that the CCI score was associated with hospitalization costs (β, 7340.46 [95% confidence interval (CI) (5710.06-8970.86)], p < .001), length of stay (β, 1.91[95%CI (1.52-2.30)], p < .001), and in-hospital mortality(odds ratio (OR),16.83[95%CI (2.23-126.88)], p = .0062) after adjusted basic clinical characteristics, especially when CCI score ≥3. Notably, the most specific complication associated with hospitalization costs and length of stay was metastatic solid tumor, while the most notable mortality-specific comorbidity was moderate or severe renal disease.

CONCLUSION

The research work has discovered a strong link between CCI and clinical plus economic outcomes in patients with CRC who underwent surgical resection.

Establishment and validation of a postoperative predictive model for patients with colorectal mucinous adenocarcinoma

BACKGROUND

The aim of this study was to develop comprehensive and effective nomograms for predicting overall survival (OS) and cancer-specific survival (CSS) rates in patients with colorectal mucinous adenocarcinoma (CRMA).

METHODS

A total of 4711 CRMA patients who underwent radical surgery between 2010 and 2018 from the Surveillance, Epidemiology, and End Results (SEER) database were collected and randomized into development (n=3299) and validation (n=1412) cohorts at a ratio of 7:3 for model development and validation. OS and CSS nomograms were developed using the prognostic factors from the development cohort after multivariable Cox regression analysis. The performance of the nomograms was evaluated using Harrell's concordance index (C-index), calibration diagrams, receiver operating characteristic (ROC) curves, and decision curve analysis (DCA).

RESULTS

The study included 4711 patients. Multivariate Cox regression analysis demonstrated that age, tumor size, grade, pT stage, pN stage, M stage, carcinoembryonic antigen, perineural invasion, tumor deposits, regional nodes examined, and chemotherapy were correlated with OS and CSS. Marital status was independently related to OS. In the development and validation cohorts, the C-index of OS was 0.766 and 0.744, respectively, and the C-index of CSS was 0.826 and 0.809, respectively. Calibration curves and ROC curves showed predictive accuracy. DCA showed that the nomograms had excellent potency over the 8th edition of the TNM staging system with higher clinical net benefits. Significant differences in OS and CSS were observed among low-, medium-, and high-risk groups.

CONCLUSIONS

Nomograms were developed for the first time to predict personalized 1-, 3-, and 5-year OS and CSS in CRMA postoperative patients. External and internal validation confirmed the excellent discrimination and calibration ability of the nomograms. The nomograms can help clinicians design personalized treatment strategies and assist with clinical decisions.

Characteristics and in-hospital outcomes of elderly patients with cancer in a top-ranked hospital in China, 2016-2020: Real-world study

BACKGROUND

Cancer is mostly a disease of aging, and older patients with cancer are generally frailer. This study aimed to describe the characteristics and in-hospital outcomes and explore factors associated with duration, cost, and mortality during first hospitalization, in older patients with cancer admitted to a top-ranked hospital in China.

METHODS

Data on patients with solid cancer ≥65 years consecutively hospitalized in 2016-2020 were retrieved from the electronic medical records of Ruijin Hospital in Shanghai, China. Baseline characteristics, duration, cost, and mortality during hospitalization were described. Factors associated with duration, cost, and mortality during first hospitalization were explored using multivariable-adjusted logistic regression.

RESULTS

20,650 eligible patients with male proportion of 59% and median age of 70 years were analyzed. 45% of the patients underwent resection in our hospital. Upon first admission, 49% of patients had hypertension, 19% diabetes, 22% weight loss, and 28% risks of malnutrition. The median duration and cost of first hospitalization were 9 days and 32,000 RMB, respectively. 118 (0.6%) and 228 (1.1%) deaths occurred during first and any hospitalization, respectively. For first hospitalization, longer duration and higher cost were positively associated with older ages, male gender, emergency admission, certain tumor locations and histology, histories of diabetes, cirrhosis, and anticoagulant intake, higher body mass index, weight loss, reduced food intake, risk of falling, and worse self-care ability; in-hospital mortality was positively associated with age ≥85 years, emergency admission, certain cancer types, histories of hypertension and psychotropic intake, reduced food intake, and worse self-care ability.

CONCLUSIONS

This study identified certain baseline patient and tumor characteristics, medical and medication histories, changes of weight and food intake, diet, and self-care ability which were independently associated with in-hospital outcomes among older patients with cancer admitted to our hospital and which should be paid special attention to. While the factors might not be easily modifiable, our study can help identify patients at higher risks of inferior in-hospital outcomes.

An assessment of left-digit bias in the treatment of older patients with potentially curable rectal cancer

BACKGROUND

Patient age is associated with poorer rectal cancer treatment compliance. However, it is unknown whether left-digit bias (disproportionate influence of leftmost age digit) influences this association.

METHODS

The patients diagnosed with stage I-III rectal cancer between 2006 to 2017 in the National Cancer Database were identified. The association between age and receipt of guideline-adherent care was assessed using mixed-effects multivariable analyses.

RESULTS

Among 97,960 patients, 46.2% received guideline-adherent overall treatment and 73.3% underwent guideline-adherent surgical resection. Of those who underwent guideline-adherent surgery, 86.4% received guideline-adherent radiotherapy and 56.6% received guideline-adherent chemotherapy. After risk-adjustment, each decade increase in age was associated with 36% decreased odds of guideline-adherent therapy (odds ratio = 0.64, 95% confidence interval = 0.63-0.65). Patients aged 58 to 59 (odds ratio = 1.15, 95% confidence interval = 1.02-1.27) and 78 to 79 (odds ratio = 1.28, 95% confidence interval = 1.08-1.51) had higher odds of guideline-adherent overall treatment compared with patients aged 60 and 80, respectively. However, there were no significant differences in the receipt of guideline-adherent treatment between patients aged 60 vs 61-62 and 80 vs 81-82.

CONCLUSION

Older patients with rectal cancer are less likely to receive guideline-adherent care, and a left-digit bias is present. Geriatric assessment-guided treatment decisions could help mitigate this bias.

Effect of comorbidities on long-term outcomes of colorectal cancer patients

OBJECTIVE

The objective of this work is to evaluate the association of comorbidities with various outcomes in patients diagnosed with colon or rectal cancer.

METHODS

We conducted a prospective cohort study of patients diagnosed with colon or rectal cancer who underwent surgery. Data were gathered on sociodemographic, clinical characteristics, disease course, and the EuroQol EQ-5D and EORTC QLQ-C30 scores, up to 5 years after surgery. The main outcomes of the study were mortality, complications, readmissions, reoperations, and changes in PROMs up to 5 years. Multivariable multilevel logistic regression models were used in the analyses.

RESULTS

Mortality at some point during the 5-year follow-up was related to cardiocerebrovascular, hemiplegia and/or stroke, chronic obstructive pulmonary disease (COPD), diabetes, cancer, and dementia. Similarly, complications were related to cardiovascular disease, COPD, diabetes, hepatitis, hepatic or renal pathologies, and dementia; readmissions to cardiovascular disease, COPD, and hepatic pathologies; and reoperations to cerebrovascular and diabetes. Finally, changes in EQ-5D scores at some point during follow-up were related to cardiocerebrovascular disease, COPD, diabetes, pre-existing cancer, hepatic and gastrointestinal pathologies, and changes in EORTC QLQ-C30 scores to cardiovascular disease, COPD, diabetes, and hepatic and gastrointestinal pathologies.

CONCLUSIONS

Optimising the management of the comorbidities most strongly related to adverse outcomes may help to reduce those events in these patients.

Comorbidities, Rather Than Older Age, Are Strongly Associated With Higher Utilization of Healthcare in Colorectal Cancer Survivors

BACKGROUND

Colorectal cancer (CRC) survivors generally have a higher healthcare utilization (HCU) than the general population due to cancer burden. However, it is unclear which factors are associated with this increased uptake. Our study aimed to (1) compare CRC-related and non-CRC visits to general practitioners (GPs) and medical specialists (MSs) by comorbidities, and (2) assess whether HCU differs by demographic, clinical, and psychological factors.

METHODS

We used data from a German population-based cohort of 1,718 survivors of stage I-III CRC diagnosed in 2003 through 2010 who provided information on HCU at 5-year follow-up. Multivariable linear regression was used to calculate least-square means of CRC-related and non-CRC HCU according to the Charlson comorbidity index and comorbidity cluster, adjusting for relevant demographic, clinical, and psychological characteristics.

RESULTS

A higher comorbidity level was associated with more CRC-related MS visits and non-CRC GP visits. In addition to being strongly associated with non-CRC GP visits, comorbidity clusters were associated with CRC-related GP and MS visits, but their association varied by specific cardiometabolic comorbidities. HCU was less dependent on prognostic factors for CRC, such as age and tumor stage, but was strongly associated with disease recurrence, depression, and emotional functioning.

CONCLUSIONS

Comorbidities, rather than age or tumor stage, were related to HCU, suggesting that CRC survivors use healthcare mainly for reasons other than cancer 5 years postdiagnosis. Improved communication between primary and tertiary healthcare providers could enhance the medical care of cancer survivors with complex health needs and thereby also reduce healthcare costs.

Association of Polypharmacy with Colorectal Cancer Survival Among Older Patients

Background

In geriatric oncology, polypharmacy is often assessed during a comprehensive geriatric assessment. Previous studies about its association with survival among patients with colorectal cancer (CRC) were inconclusive and had high risk for indication bias.

Patients and Methods

A cohort study was conducted with 3,239 patients with CRC, aged ≥65 years, who were recruited in Germany between 2003 and 2016, while being hospitalized for CRC surgery. We defined polypharmacy as the concurrent use of five or more drugs, and excessive polypharmacy (EPP) as concurrent use of eight or more drugs. Cox proportional hazards regression models were performed to assess the associations of polypharmacy with 5‐year overall (OS), CRC‐specific (CSS), and non‐cancer‐specific survival (NCS) with rigorous adjustment for morbidity to minimize indication bias (e.g., for cancer stage, functional status, and 13 common diseases/conditions).

Results

The prevalence of polypharmacy was 54.7% and that of EPP was 24.2%. During up to 5 years of follow‐up, 1,070 participants died, among whom 615 died of CRC and 296 died of other causes than cancer. EPP was statistically significantly associated with poorer up‐to‐5‐year OS (hazard ratio [HR], 1.23; 95% confidence interval [CI], 1.02–1.47) and CSS (HR, 1.31; 95% CI, 1.03–1.68). HR point estimate for NCS was higher than 1 (1.22) but not statistically significant.

Conclusion

Polypharmacy was very common and EPP was a weak risk factor for mortality in this large cohort of older patients with CRC. Clinical trials are needed to address the causality of this relationship because older patients with CRC might benefit from deprescribing drugs without an indication.

Implications for Practice

The results of this study support the hypothesis that excessive polypharmacy, defined as use of eight or more concurrently used active substances, has a negative impact on the prognosis of older patients with colorectal cancer (CRC). This study suggests to oncologists that performing a medication review for older patients with CRC with eight drugs or more is indicated (especially when a broader comprehensive geriatric assessment is being performed). Such a medication review should not only focus on reducing the number of medications (by deprescribing drugs without an indication) but also check the appropriateness of indicated drugs for older patients with cancer.

Excessive polypharmacy, defined as the concurrent use of eight or more drugs, is becoming more common, especially in the older population. This article evaluates the association of polypharmacy with overall survival in large cohort patients with colorectal cancer.

Association of co-medication quality with chemotherapy-related adverse drug reactions and survival in older colorectal cancer patients

BACKGROUND

Evidence about the clinical relevance of appropriate co-medication among older colorectal cancer (CRC) patients is sparse.

METHODS

A cohort study was conducted with 3,239 CRC patients aged 65 years and older. To assess co-medication quality, we calculated the total Fit fOR The Aged (FORTA) score and its sub-scores for medication overuse, underuse, and potentially inappropriate medication use. Multivariable Cox proportional hazards or logistic regression models were performed to evaluate the association of co-medication quality with up to 5-year overall survival, CRC-specific survival, and chemotherapy-related adverse drug reactions (ADRs).

RESULTS

Overall, 3,239 and 1,209 participants were included in analyses on survival and ADRs, respectively. The hazard ratios [95%-confidence intervals] for the total FORTA score ≥ 7 vs. 0-1 points were 1.83 [1.40-2.40] and 1.76 [1.22-2.52] for up to 5-year overall and CRC-specific survival, respectively. Worse up to 5-year OS and CSS was also evident for FORTA sub-scores for PIM use and overuse whereas no association was observed for underuse. Although results for the total FORTA and potentially inappropriate medication score were much stronger among patients receiving chemotherapy, no significant associations with chemotherapy-related ADRs were observed. Moreover, associations were particularly strong among men and rectal cancer patients as compared to women and colon cancer patients.

CONCLUSIONS

Poor total co-medication quality was significantly associated with worse up to 5-year overall and CRC-specific survival. Randomized controlled trials are needed to test whether improved cancer co-medication management in older CRC patients prolongs survival.

The association of vitamin D with survival in colorectal cancer patients depends on antioxidant capacity

BACKGROUND

Vitamin D plays a role in detoxifying free radicals, which might explain the previously reported lower mortality in colorectal cancer (CRC) patients with higher vitamin D concentrations.

OBJECTIVES

We aimed to assess whether the associations of 25-hydroxyvitamin D [25(OH)D] with prognosis in CRC patients differ by total thiol concentration (TTC), a biomarker of antioxidant capacity.

METHODS

CRC patients who were diagnosed from 2003 to 2010 and recruited into a population-based study in southern Germany (n = 2,592) were followed over a period of 6 y. 25(OH)D and TTC were evaluated from blood samples collected shortly after CRC diagnosis. Associations of 25(OH)D with all-cause and CRC mortality according to TTC were estimated using multivariable Cox proportional hazards regression.

RESULTS

There was a weak positive correlation between 25(OH)D and TTC (r = 0.26, P < 0.001). 25(OH)D was inversely associated with mortality among patients in the lowest and middle TTC tertiles, but no associations were found among patients in the highest TTC tertile (P-interaction = 0.01). Among patients in the lowest/middle TTC tertiles, those in the middle and highest (compared with lowest) 25(OH)D tertiles had 31% and 44% lower all-cause mortality (P < 0.001) and 25% and 45% lower CRC mortality (P < 0.001), respectively. However, in the highest TTC tertile, 25(OH)D was not associated with all-cause (P = 0.638) or CRC mortality (P = 0.395).

CONCLUSIONS

The survival advantages in CRC patients with adequate vitamin D strongly depend on antioxidant capacity and are most pronounced in cases of low antioxidant capacity. These findings suggest that TTC and other biomarkers of antioxidant status may be useful as the basis for enhanced selection criteria of patients for vitamin D supplementation, in addition to the conventional judgment based on blood 25(OH)D concentrations, and also for refining selection of patients for clinical trials aiming to estimate the effect of vitamin D supplementation.

Impact of comorbidities at diagnosis on the 10-year colorectal cancer net survival: A population-based study

BACKGROUND

It is established that comorbidities negatively influence colorectal cancer (CRC)-specific survival. Only few studies have used the relative survival (RS) setting to estimate this association, although RS has been proven particularly useful considering the inaccuracy in death certification. This study aimed to investigate the impact of non-cancer comorbidities at CRC diagnosis on net survival, using cancer registry data.

METHODS

We included 1076 CRC patients diagnosed between 2000 and 2001 in the canton of Zurich. The number and severity of comorbidities was expressed using the Charlson Comorbidity Index (CCI). Multiple imputation was performed to account for missing information and 10-year net survival was estimated by modeling the excess hazards of death due to CRC, using flexible parametric models.

RESULTS

After imputation, approximately 35 % of the patients were affected by comorbidities. These appeared to decrease the 10-year net survival; the estimated excess hazard ratio for patients with one mild comorbidity was 2.14 (95 % CI 1.60-2.86), and for patients with one more severe or more than one comorbidity was 2.43 (95 % CI 1.77-3.34), compared to patients without comorbidities.

CONCLUSIONS

Our analysis suggested that non-cancer comorbidities at CRC diagnosis significantly decrease the 10-year net survival. Future studies should estimate net survival of CRC including comorbidities as prognostic factor and use a RS framework to overcome the uncertainty in death certification.

Clinical Effectiveness of Oncological Treatment in Metastatic Colorectal Cancer Is Independent of Comorbidities and Age

Simple Summary

Colorectal cancer (CRC) is the third most common cancer worldwide. As with many other cancers, the risk for CRC increases with age. This is also true for comorbidities, which may hamper sufficient treatment of the cancer. Due to restrictive inclusion criteria, older patients and patients with comorbidities are underrepresented in clinical trials. Comprehensive knowledge about modern effectiveness of oncological treatments in older and/or comorbid patients is sparse. Due to the lack of clinical trials, this issue is investigated in real-life settings predominantly. In our retrospective study we show that patients benefit from oncological treatments irrespective of comorbidities, measured by the age-adjusted Charlson Comorbity (aaCCI) index, and age. Differences found in treatment outcomes are marginal and are likely due to less intense treatment of comorbid or elderly patients. Balancing risk and benefit for treatment decisions should take potential under-treatment of comorbid and older patients into account.

Abstract

We aimed to investigate the effectiveness of oncological treatments in metastatic CRC related to comorbidities and age. This retrospective study included 1105 patients from three oncological centers. aaCCI and CCI was available from 577 patients. An aaCCI > 3 was of the highest predictive value compared to other aaCCI-levels, CCI or age (p < 0.001 for all). Treatment (best supportive care (BSC), systemic treatment only (STO) and resection of metastases (ROM)) significantly prolonged survival in patients with aaCCI > 3 (STO: HR 0.39, CI 0.29–0.51; ROM: HR 0.16, CI 0.10–0.24) and patients older than 70 years (STO: HR 0.56, CI 0.47–0.66; ROM: HR 0.23, 0.18–0.30). Median overall survival was shorter in patients with aaCCI or age > 70 years and interaction for treatment type not significant for aaCCI, but significant for age older or younger than 70 years (STO: p = 0.01; ROM p = 0.02). BSC is more often considered as optimal care for patients with an aaCCI > 3 (37.6% vs. 12.4%; p < 0.001) or age > 70 years (35.7% vs. 11.2%; p < 0.001). Older patients or patients with comorbidities benefit from cancer-specific therapy independently of their age and comorbidities.

Early discontinuation and dose reduction of adjuvant chemotherapy in stage III colon cancer patients

BACKGROUND

The benefit of chemotherapy in colon cancer patients is well documented but depends largely on whether patients complete the planned treatment regimen. We evaluated predictors of early discontinuation (EDChemo) and dose reduction of chemotherapy, especially the role of adverse treatment effects, in stage III patients who received adjuvant chemotherapy.

METHODS

Stage III colon cancer patients who were diagnosed in 2003-2014 and recruited into a population-based study in Germany and received FOLFOX [5-fluorouracil (5-FU), leucovorin (LV), and oxaliplatin], capecitabine monotherapy (CapMono), or 5-FU/LV were included. We assessed determinants of EDChemo and dose reduction using multivariable logistic regression. Also, we estimated proportions of EDChemo and dose reduction that are attributable to adverse effects using attributable fractions.

RESULTS

EDChemo and dose reduction rates were 52% and 17% for FOLFOX, 28% and 9% for CapMono, and 45% and 6% for 5-FU/LV, respectively. Predictors of EDChemo were low-grade tumor and treatment in a medium-volume hospital (for FOLFOX), obesity (for CapMono), and increasing age, T4 stage, and treatment in a medium-volume hospital (for 5-FU/LV). Adverse effects were particularly strongly associated with EDChemo and contributed to about 63%, 51%, and 32% of EDChemo of FOLFOX, CapMono, and 5-FU/LV, respectively. Of the various adverse effects, gastrointestinal events showed the strongest associations with EDChemo and accounted for about 7%, 26%, and 20% of EDChemo of FOLFOX, CapMono, and 5-FU/LV, respectively. Adverse effects were, moreover, a strong determinant of dose reduction and accounted for about 82% of all cases.

CONCLUSIONS

EDChemo is common in stage III colon cancer patients receiving chemotherapy and more than half of the cases of EDChemo and dose reduction are due to adverse treatment effects. Further research should address the potential for reducing EDChemo and dose reduction rates by close monitoring of patients for early signs and enhanced management of adverse effects, especially gastrointestinal events.

Blood markers of oxidative stress are strongly associated with poorer prognosis in colorectal cancer patients

Oxidative stress has been implicated in the initiation of several cancers, including colorectal cancer (CRC). Whether it also plays a role in CRC prognosis is unclear. We assessed the associations of two oxidative stress biomarkers (Diacron's reactive oxygen metabolites [d-ROMs] and total thiol level [TTL]) with CRC prognosis. CRC patients who were diagnosed in 2003 to 2012 and recruited into a population-based study in Germany (n = 3361) were followed for up to 6 years. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) for the associations of d-ROMs and TTL (measured from blood samples collected shortly after CRC diagnosis) with overall survival (OS) and disease-specific survival (DSS) were estimated using multivariable Cox regression. Particularly pronounced associations of higher d-ROMs with lower survival were observed in stage IV patients, with patients in the highest (vs lowest) tertile having much lower OS (HR = 1.52, 95% CI = 1.14-2.04) and DSS (HR = 1.61, 95% CI = 1.20-2.17). For TTL, strong inverse associations of TTL with mortality were observed within all stages. In patients of all stages, those in the highest (vs lowest) quintile had substantially higher OS (HR = 0.48, 95% CI = 0.38-0.62) and DSS (HR = 0.52, 95% CI = 0.39-0.69). The addition of these biomarkers to models that included age, sex, tumor stage and subsite significantly improved the prediction of CRC prognosis. The observed strong associations of higher d-ROMs and lower TTL levels with poorer prognosis even in stage IV patients suggest that oxidative stress contributes significantly to premature mortality in CRC patients and demonstrate a large potential of these biomarkers in enhancing the prediction of CRC prognosis beyond tumor stage.

Age-adjusted Charlson Comorbidity Index predicts survival in intrahepatic cholangiocarcinoma patients after curative resection

Background

Comorbidity among cancer patients is prevalent and influential to prognosis after operation. Limited data are available on comorbidity evaluations in patients with intrahepatic cholangiocarcinoma (ICC). This study aimed to assess the comorbidity distribution in ICC patients and to adapt the Charlson Comorbidity Index (CCI) or the age-adjusted CCI (ACCI) for survival prediction.

Methods

The study cohort included 268 ICC patients treated with curative surgery from January 2000 to December 2007 at the Department of Liver Surgery, Zhongshan Hospital. The association between the comorbidity index and overall survival (OS) or disease-free survival (DFS). was analyzed by the Kaplan-Meier method. Multivariable analysis was established to select the determinant parameters.

Results

Major comorbid conditions of ICC patients included liver disease, hypertension, diabetes and ulcer. The median follow-up time was 25.5 months in the whole data set. Among the entire cohort, the 1-, 3- and 5-year OS rates were 55.3%, 26.0% and 15.6%, respectively. In multivariate analysis, the ACCI correlated with OS, and higher scores were associated with poorer prognosis (hazard ratio =1.134, 95% confidence interval: 1.015–1.267 and P value =0.026). CCI was not an independent predictive factor for OS or DFS.

Conclusions

In contrast to CCI, ACCI was a more promising model to accurately predict OS in ICC patients who underwent liver resection. Further research should be focused on the impact of comorbidity therapies.