Survival of colorectal cancer patients in the presence of competing-risk

Post-diagnosis adiposity and colorectal cancer prognosis: A Global Cancer Update Programme (CUP Global) systematic literature review and meta-analysis

The adiposity influence on colorectal cancer prognosis remains poorly characterised. We performed a systematic review and meta-analysis on post-diagnosis adiposity measures (body mass index [BMI], waist circumference, waist-to-hip ratio, weight) or their changes and colorectal cancer outcomes. PubMed and Embase were searched through 28 February 2022. Random-effects meta-analyses were conducted when at least three studies had sufficient information. The quality of evidence was interpreted and graded by the Global Cancer Update Programme (CUP Global) independent Expert Committee on Cancer Survivorship and Expert Panel. We reviewed 124 observational studies (85 publications). Meta-analyses were possible for BMI and all-cause mortality, colorectal cancer-specific mortality, and cancer recurrence/disease-free survival. Non-linear meta-analysis indicated a reverse J-shaped association between BMI and colorectal cancer outcomes (nadir at BMI 28 kg/m2). The highest risk, relative to the nadir, was observed at both ends of the BMI distribution (18 and 38 kg/m2), namely 60% and 23% higher risk for all-cause mortality; 95% and 26% for colorectal cancer-specific mortality; and 37% and 24% for cancer recurrence/disease-free survival, respectively. The higher risk with low BMI was attenuated in secondary analyses of RCTs (compared to cohort studies), among studies with longer follow-up, and in women suggesting potential methodological limitations and/or altered physiological state. Descriptively synthesised studies on other adiposity-outcome associations of interest were limited in number and methodological quality. All the associations were graded as limited (likelihood of causality: no conclusion) due to potential methodological limitations (reverse causation, confounding, selection bias). Additional well-designed observational studies and interventional trials are needed to provide further clarification.

Exploring the impact of stage and tumor site on colorectal cancer survival: Bayesian survival modeling

Colorectal cancer is a prevalent malignancy with global significance. This retrospective study aimed to investigate the influence of stage and tumor site on survival outcomes in 284 colorectal cancer patients diagnosed between 2001 and 2017. Patients were categorized into four groups based on tumor site (colon and rectum) and disease stage (early stage and advanced stage). Demographic characteristics, treatment modalities, and survival outcomes were recorded. Bayesian survival modeling was performed using semi-competing risks illness-death models with an accelerated failure time (AFT) approach, utilizing R 4.1 software. Results demonstrated significantly higher time ratios for disease recurrence (TR = 1.712, 95% CI 1.489-2.197), mortality without recurrence (TR = 1.933, 1.480-2.510), and mortality after recurrence (TR = 1.847, 1.147-2.178) in early-stage colon cancer compared to early-stage rectal cancer. Furthermore, patients with advanced-stage rectal cancer exhibited shorter survival times for disease recurrence than patients with early-stage colon cancer. The interaction effect between the disease site and cancer stage was not significant. These findings, derived from the optimal Bayesian log-normal model for terminal and non-terminal events, highlight the importance of early detection and effective management strategies for colon cancer. Early-stage colon cancer demonstrated improved survival rates for disease recurrence, mortality without recurrence, and mortality after recurrence compared to other stages. Early intervention and comprehensive care are crucial to enhance prognosis and minimize adverse events in colon cancer patients.

Personalized targeted therapy prescription in colorectal cancer using algorithmic analysis of RNA sequencing data

BACKGROUND

Overall survival of advanced colorectal cancer (CRC) patients remains poor, and gene expression analysis could potentially complement detection of clinically relevant mutations to personalize CRC treatments.

METHODS

We performed RNA sequencing of formalin-fixed, paraffin-embedded (FFPE) cancer tissue samples of 23 CRC patients and interpreted the data obtained using bioinformatic method Oncobox for expression-based rating of targeted therapeutics. Oncobox ranks cancer drugs according to the efficiency score calculated using target genes expression and molecular pathway activation data. The patients had primary and metastatic CRC with metastases in liver, peritoneum, brain, adrenal gland, lymph nodes and ovary. Two patients had mutations in NRAS, seven others had mutated KRAS gene. Patients were treated by aflibercept, bevacizumab, bortezomib, cabozantinib, cetuximab, crizotinib, denosumab, panitumumab and regorafenib as monotherapy or in combination with chemotherapy, and information on the success of totally 39 lines of therapy was collected.

RESULTS

Oncobox drug efficiency score was effective biomarker that could predict treatment outcomes in the experimental cohort (AUC 0.77 for all lines of therapy and 0.91 for the first line after tumor sampling). Separately for bevacizumab, it was effective in the experimental cohort (AUC 0.87) and in 3 independent literature CRC datasets, n = 107 (AUC 0.84-0.94). It also predicted progression-free survival in univariate (Hazard ratio 0.14) and multivariate (Hazard ratio 0.066) analyses. Difference in AUC scores evidences importance of using recent biosamples for the prediction quality.

CONCLUSION

Our results suggest that RNA sequencing analysis of tumor FFPE materials may be helpful for personalizing prescriptions of targeted therapeutics in CRC.

A bayesian approach to model the underlying predictors of early recurrence and postoperative death in patients with colorectal Cancer

Objective

This study aimed at utilizing a Bayesian approach semi-competing risks technique to model the underlying predictors of early recurrence and postoperative Death in patients with colorectal cancer (CRC).

Methods

In this prospective cohort study, 284 patients with colorectal cancer, who underwent surgery, referred to Imam Khomeini clinic in Hamadan from 2001 to 2017. The primary outcomes were the probability of recurrence, the probability of Mortality without recurrence, and the probability of Mortality after recurrence. The patients ‘recurrence status was determined from patients’ records. The Bayesian survival modeling was carried out by semi-competing risks illness-death models, with accelerated failure time (AFT) approach, in R 4.1 software. The best model was chosen according to the lowest deviance information criterion (DIC) and highest logarithm of the pseudo marginal likelihood (LPML).

Results

The log-normal model (DIC = 1633, LPML = -811), was the optimal model. The results showed that gender(Time Ratio = 0.764: 95% Confidence Interval = 0.456–0.855), age at diagnosis (0.764: 0.538–0.935 ), T₃ stage (0601: 0.530–0.713), N₂ stage (0.714: 0.577–0.935 ), tumor size (0.709: 0.610–0.929), grade of differentiation at poor (0.856: 0.733–0.988), and moderate (0.648: 0.503–0.955) levels, and the number of chemotherapies (1.583: 1.367–1.863) were significantly related to recurrence. Also, age at diagnosis (0.396: 0.313–0.532), metastasis to other sites (0.566: 0.490–0.835), T₃ stage (0.363: 0.592 − 0.301), T₄ stage (0.434: 0.347–0.545), grade of differentiation at moderate level (0.527: 0.387–0.674), tumor size (0.595: 0.500–0.679), and the number of chemotherapies (1.541: 1.332–2.243) were the significantly predicted the death. Also, age at diagnosis (0.659: 0.559–0.803), and the number of chemotherapies (2.029: 1.792–2.191) were significantly related to mortality after recurrence.

Conclusion

According to specific results obtained from the optimal Bayesian log-normal model for terminal and non-terminal events, appropriate screening strategies and the earlier detection of CRC leads to substantial improvements in the survival of patients.

Improving the Lung Cancer Clinical Trial Development by Incorporating Competing Risk Factors

Introduction

Distinct from other diseases, as cancer progresses, both the symptoms and treatments evolve, resulting in a complex, time-dependent relationship. Many competing risk factors influence the outcome of cancer. An improved method was used to evaluate the data from 6 non-small-cell lung cancer (NSCLC) clinical trials combined in our center since 2016 to deal with the bias caused by competing risk factors. Material and Methods. Data of 118 lung cancer patients were collected from 2016 to 2020. Fine and Gray's model for competing risk was used to evaluate survival of different treatment group compares with the classic survival analysis model.

Results

Immunotherapy had better progression-free survival than chemotherapy. (HR: 0.62, 95% CI: 0.41-0.95, p = 0.0260). However, there were no significant differences in patients who withdrew due to treatment-related adverse events from different groups. (Z = 0.0508, p = 0.8217). The PD-1/PD-L1 inhibitors in our study did not significantly improve overall survival compared with chemotherapy (HR:0.77, 95% CI:0.48-1.24, p = 0.2812), estimated 1-year overall survival rates were 55% and 46%, and 3-year overall survival rates were 17% and 10%, respectively.

Conclusion

When the outcome caused by competing risk exists, the corresponding competing risk model method should be adopted to eliminate the bias caused by the classic survival analysis.

Recurrence, death risk, and related factors in patients with stage 0 colorectal cancer: A nationwide population-based study

In this study, the National Health Insurance Research Database of Taiwan was used to examine the recurrence and death risk for stage 0 colorectal cancer patients. We examined stage 0 colorectal cancer patients to identify factors causing recurrence and death.This is a retrospective study, and stage 0 colorectal cancer patients that are registered in the Taiwan Cancer Registry of the Health Promotion Administration in 2007 to 2012 were included. The database was linked to the National Health Insurance Research Database, and subjects were followed up until the end of 2016. The mean follow-up period was 69 months. Bivariate analysis methods (log-rank test) and Cox proportional hazards model were used to evaluate the risk of recurrence and death and demographic characteristics, economic factors, environmental factors, health factors, treatment and hospitals, and absence/presence of postoperative tests were used to examine related risk factors.Our study showed that the 5-year recurrence rate and 5-year mortality rate for stage 0 colorectal cancer are 1.68% and 0.6%, respectively. For stage 0 colorectal cancer, age (61-74 years) is the only factor affecting recurrence in patients (hazard ratio (HR) = 2.44; 95% CI: 1.41-4.22), while age >75 years (HR = 4.35; 95% CI: 1.14-16.68) and Charlson Comorbidity Index >4 points (HR = 7.20, 95% CI: 2.60-19.94) can increase the risk of death. In contrast, patients who underwent one (HR = 0.27, 95% CI: 0.10-0.71) and two or more colonoscopies (HR = 0.26, 95% CI: 0.10-0.70) within 2 years after surgery can reduce the risk of death from stage 0 colorectal cancer. In addition, the risk of recurrence is higher in patients who underwent colonoscopic polypectomy (HR = 2.07, 95% CI: 0.98-4.33) and patients with rectal cancer (HR = 2.74, 95% CI: 0.96-7.83), but these differences are not statistically significant (P > .05).From this study, we can see that age and comorbidity index increase the risk of recurrence and death for stage 0 colorectal cancer, while postoperative colonoscopy can decrease the risk of death.

The incidence, associated factors, and predictive nomogram for early death in stage IV colorectal cancer

PURPOSE

The purpose of the present study was to investigate the incidence and associated factors for early death in stage IV colorectal cancer (CRC) and to construct the predictive nomogram.

METHODS

Patients with stage IV CRC, who had been diagnosed between 2010 and 2014 in the Surveillance, Epidemiology, and End Results datasets, were eligible for this retrospective cohort study. The univariable and multivariable logistic regression models were conducted to determine the associated factors for early death (survival time ≤ 3 months). The predictive nomogram was constructed and the internal validation was performed.

RESULTS

Ten thousand two hundred sixty-three out of 36,461 (28.1%) eligible patients resulted in all causes of early death (25.8% for cancer-specific early death and 2.3% for non-cancer early death). Advanced age, marital status, right colon, poor differentiation, higher N stage, and bone metastasis were positively associated with all causes of early death, cancer-specific early death, and non-cancer early death, while higher T stage, positive carcinoembryonic antigen, and distant metastases (bone, lung, liver, and brain) were only positively associated with all causes of early death and cancer-specific early death. The calibration curve for all causes of early death, cancer-specific early death, and non-cancer early death showed the prediction curve closely approximated at the 45° line and the areas under the curve were 75.7% (95% CI, 74.9-76.4%), 75.9% (95% CI, 75.1-76.6%), and 76.9% (95% CI, 76.3-77.6%), respectively.

CONCLUSIONS

The nomogram was calibrated to predict all causes of early death development, cancer-specific early death development, and non-cancer early death development. These findings can be utilized in early screening and to tailor targeted treatment regimens for stage IV CRC patients.

Is Brain-Derived Neurotrophic Factor: A Common Link Between Neurodegenerative Disorders and Cancer?

BACKGROUND

Cancer is a common disease caused by the excessive proliferation of cells, and neurodegenerative diseases are the disorders caused due to the degeneration of neurons. Both can be considered as diseases caused by the dysregulation of cell cycle events. A recent data suggests that there is a strong inverse association between cancer and neurodegenerative disorders. There is indirect evidence to postulate Brain-derived Neurotrophic Factor (BDNF) as a potential molecular link in this association.

DISCUSSION

The BDNF levels are found to be downregulated in many neurodegenerative disorders and are found to be upregulated in various kinds of cancers. The lower level of BDNF in Alzheimer's and Parkinson's disease has been found to be related to cognitive and other neuropsychological impairments, whereas, its higher levels are associated with the tumour growth and metastasis and poor survival rate in the cancer patients.

CONCLUSION

In this review, we propose that variance in BDNF levels is critical in determining the course of cellular pathophysiology and the development of cancer or neurodegenerative disorder. We further propose that an alternative therapeutic strategy that can modulate BDNF expression, can rescue or prevent above said pathophysiological course. Larger studies that examine this link through animal studies are imperative to understand the putative biochemical and molecular link to wellness and disease.

Relationships of colorectal cancer with dietary factors and public health indicators: an ecological study

BACKGROUND

Colorectal cancer (CRC) is the third most common cancer in Iranian women and fifth in men. The aims of this study were to investigate the relation of dietary factors and public health indicators to its development.

MATERIALS AND METHODS

The required information (2001-2006) about risk factors was obtained from the Non- Communicable Disease Surveillance Centre (NCDSC) of Iran. Risk factor data (RFD) from 89,404 individuals (15-64 years old) were gathered by questionnaire and laboratory examinations through a cross sectional study in all provinces by systematic clustering sampling method. CRC incidence segregated by age and gender was obtained from Cancer Registry Ministry of Health (CRMH) of Iran. First, correlation coefficients were used for data analysis and then multiple regression analysis was performed to control for confounding factors.

RESULTS

Colorectal cancer incidence showed a positive relationship with diabetes mellitus, hypertension, lacking or low physical activity, high education, high intake of dairy products, and non-consumption of vegetables and fruits.

CONCLUSIONS

We concluded that many dietary factors and public health indicators have positive relationships with CRC and might therefore be targets of preliminary prevention. However, since this is an ecological study limited by potential ecological fallacy the results must be interpreted with caution.

Survival of Colorectal Cancer in the Presence of Competing- Risks - Modeling by Weibull Distribution

BACKGROUND

Colorectal cancer (CRC) is the commonest malignancy in the lower gastrointestinal tract in both men and women. It is the third leading cause of cancer-dependent death in the world. In Iran the incidence of colorectal cancer has increased during the last 25 years.

MATERIALS AND METHODS

In this article we analyzed the survival of 447 colorectal patients of Taleghani hospital in Tehran using parametric competing-risks models. The cancers of these patients were diagnosed during 1985 - 2012 and followed up to 2013. The purpose was to assess the association between survival of patients with colorectal cancer in the presence of competing-risks and prognostic factors using parametric models. The analysis was carried out using R software version 3.0.2.

RESULTS

The prognostic variables included in the model were age at diagnosis, tumour site, body mass index and sex. The effect of age at diagnosis and body mass index on survival time was statistically significant. The median survival for Iranian patients with colorectal cancer is about 20 years.

CONCLUSIONS

Survival function based on Weibull model compared with Kaplan-Meier survival function is smooth. Iranian data suggest a younger age distribution compared to Western reports for CRC.

Demographic survey of four thousand patients with 10 common cancers in North Eastern Iran over the past three decades

BACKGROUND

Cancer is a major cause of mortality in developing countries and correct and valid information about the epidemiology of this disease is the first step in the planning of health care in each region. The aim of this study was to determine the relative frequency, mean age and sex ratio of the most 10 common non-skin cancers in the world and Iran, among patients referred to an oncology clinic.

MATERIALS AND METHODS

This descriptive study was conducted in Mashhad, north east of Iran. The data obtained from the records of patients referred to the private oncology center between the years of 1985-2012." According to the latest report of GLOBOCAN study commonest malignancies included were lung, breast, colorectal, prostate, stomach, liver, cervix, esophageal, bladder cancers and Non-Hodgkin lymphoma.

RESULTS

A total of 4,606 cases were analyzed. The mean age was 55.5±13.8years (male: 59.5±13.9, female: 52.6±12.9). Overall, breast cancer (1,264 cases, relative frequency of 27.4%) was the most prevalent cancer; however the mean ages of diagnosis were not significantly different between 5-year time period divisions (p=0.290). The most common cancer in men was esophageal cancer (26.3%).The lowest mean age was related to women diagnosed with breast cancer (48.5±11.8) and men with non-Hodgkins lymphoma (48.4±17.8). There were statistically significant differences between the mean age of men and women with gastric (p=0.003) and esophageal cancers (p<0.001). Male to female sex ratios in our study for bladder, lung and stomach cancers were 6.57, 2.60 and 2.50 respectively.

CONCLUSIONS

The results showed that breast cancer tends to be found in younger female patients and bladder cancer appears more often in men. Screening in target population in addition to early diagnosis may reduce death and disability.

Prevalence of colorectal polyps in a group of subjects at average-risk of colorectal cancer undergoing colonoscopic screening in Tehran, Iran between 2008 and 2013

BACKGROUND

Colorectal cancer (CRC) is one of the prime causes of mortality around the globe, with a significantly rising incidence in the Middle East region in recent decades. Since detection of CRC in the early stages is an important issue, and also since to date there are no comprehensive epidemiologic studies depicting the Middle East region with special attention to the average risk group, further investigation is of significant necessity in this regard.

AIM

Our aim was to investigate the prevalence of preneoplastic and neoplastic lesions of the colon in an average risk population.

MATERIALS AND METHODS

A total of 1,208 eligible asymptomatic, average- risk adults older than 40 years of age, referred to Firuzgar Hospotal in the years 2008-2012, were enrolled. They underwent colonoscopy screening and all polypoid lesions were removed and examined by an expert gastrointestinal pathologist. The lesions were classified by size, location, numbers and pathologic findings. Size of lesions was measured objectively by endoscopists.

RESULTS

The mean age of participants was 56.5±9.59 and 51.6% were male. The overall polyp detection rate was 199/1208 (16.5 %), 26 subjects having non-neoplastic polyps, including hyperplastic lesions, and 173/1208 (14.3%) having neoplastic polyps, of which 26 (2.15%) were advanced neoplasms .The prevalence of colorectal neoplasia was more common among the 50-59 age group. Advanced adenoma was more frequent among the 60-69 age group. The majority of adenomas were detected in the distal colon, but a quarter of advanced adenomas were found in the proximal colon; advance age and male gender was associated with the presence of adenoma.

CONCLUSIONS

It seems that CRC screening among average-risk population might be recommended in countries such as Iran. However, sigmioidoscopy alone would miss many colorectal adenomas. Furthermore, the 50-59 age group could be considered as an appropriate target population for this purpose in Iran.