Australasian ACPGBI risk prediction model for 30-day mortality after colorectal cancer surgery

BACKGROUND

Postoperative mortality after colorectal cancer surgery varies across hospitals and countries. The aim of this study was to test the Association of Coloproctologists of Great Britain and Ireland (ACPGBI) models as predictors of 30-day mortality in an Australian cohort.

METHODS

Data from patients who underwent surgery in six hospitals between 1996 and 2015 (CRC data set) were reviewed to test ACPGBI models, and patients from 79 hospitals in the Bi-National Colorectal Cancer Audit between 2007 and 2016 (BCCA data set) were analysed to validate model performance. Recalibrated models based on ACPGBI risk models were developed, tested and validated on a data set of Australasian patients.

RESULTS

Of 18 752 patients observed during the study, 6727 (CRC data set) and 3814 (BCCA data set) were analysed. The 30-day mortality rate was 1·1 and 3·5 per cent in the CRC and BCCA data sets respectively. Both the original and revised ACPGBI models overestimated 30-day mortality for the CRC data set (observed to expected (O/E) ratio 0·17 and 0·21 respectively). Their ability to correctly predict mortality risk was poor (P < 0·001, Hosmer-Lemeshow test); however, the area under the curve for both models was 0·88 (95 per cent c.i. 0·85 to 0·92) showing good discriminatory power to classify 30-day mortality. The recalibrated original model performed well for calibration and discrimination, whereas the recalibrated revised model performed well for discrimination but not for calibration. Risk prediction was good for both recalibrated models. On external validation using the BCCA data set, the recalibrated models underestimated mortality risk (O/E ratio 3·06 and 2·98 respectively), whereas both original and revised ACPGBI models overestimated the risk (O/E ratio 0·48 and 0·69). All models showed similar good discrimination.

CONCLUSION

The original and revised ACPGBI models overpredicted risk of 30-day mortality. The new Australasian calibrated ACPGBI model needs to be tested further in clinical practice.

Is experience as a prisoner of war a risk factor for accelerated age-related illness and disability?

OBJECTIVE

To determine whether the experience of internment as a Prisoner of War (POW) during World War II was associated with a higher prevalence of chronic disease and diminished functional performance in later life.

DESIGN

A retrospective and prospective cohort design.

SETTING

Concord Repatriation General Hospital, Sydney, Australia.

PARTICIPANTS

A random sample of 101 Australian, male, ex-prisoners of the Japanese and a comparison group of 107 non-POW combatants from the same theatre of war.

MEASUREMENTS

Outcome variables were self-perceived health status, hospital admissions and length of stay, number of prescription medications used, number of somatic symptoms reported, number and types of medical diagnoses, a neurology of aging clinical examination, and the Instrumental Activities of Daily Living (IADL) and Physical Self Maintenance Scales (PSMS).

RESULTS

Prisoners of War reported more somatic symptoms (mean 7.2 vs 5.4, P = .002) than non-POWs, had more diagnoses (mean 9.4 vs 7.7 P < .001), and used a greater number of different medications (mean 4.5 vs 3.4, P = .001). There were no differences in hospital admissions or length of stay. Among 15 broad categories of diagnosis, differences were confined to gastrointestinal disorders (POWs 63% vs non-POWs 49%, P = .032), musculoskeletal disorders (POWs 76% vs non-POWs 60%, P = .011), and cognitive disorders (excluding head injury, dementia, and stroke) (POWs 31% vs non-POWs 15%, P = .006). Of the 36 signs in the neurology of aging examination, POWs had a significantly higher proportion of seven extrapyramidal signs and six signs relating to ataxia. POWs were more likely to be impaired on the IADL scale than were non-POWs (33% vs 17%, P = .012) but not significantly more likely to be impaired on the PSMS.

CONCLUSIONS

There were few differences between POWs and controls, and those differences were relatively small. Our findings do not support a major role for a catastrophic life stress in the development of chronic illness and disability in later life. However it is possible that the POW experience played a part in premature, abnormal, or unsuccessful aging in some individuals.

K-ras mutation and loss of heterozygosity of chromosome 17p and survival in colorectal cancer

BACKGROUND

The development of colorectal cancer (CRC) is thought to be a multistage process involving alterations to several types of genes, including oncogenes and tumour suppressor genes. This study examined the associations between allelic deletions of chromosome 17p in the region of the p53 gene and K-ras gene mutation and survival among CRC patients.

METHODS

Resected specimens from 233 patients were examined. Point mutation of codon 12 of K-ras was assessed using a modified polymerase chain reaction method. Allelic deletion of 17p was demonstrated by loss of heterozygosity (LOH) with the marker Mfd144.

RESULTS

Fifty-seven tumours (24%) showed somatic point mutation of codon 12 of K-ras and 86 tumours (37%) showed LOH of Mfd144. There were 107 tumours (46%) with either K-ras mutation or LOH and 18 tumours (8%) with both. Compared with patients with neither alteration, significantly poorer survival was experienced only by those with both alterations (P = 0.015). However, when this variable was introduced into a multivariate analysis controlling for the patient's age and tumour stage, it failed to show a statistically significant independent effect on survival.

CONCLUSIONS

Point mutation of K-ras and LOH of Mfd144 in CRC does not add to the prognostic information already available from clinicopathological staging.

The development of a treatment protocol for patients with chronic radiation-induced rectal bleeding

BACKGROUNDS AND METHODS: This study reviews the clinical features and reports the preliminary results of treatment of 34 consecutive patients with clinically significant bleeding from chronic, radiation-induced proctitis, using a combination of endoscopic YAG Laser and the application of topical formalin dressings to the rectal mucosa.

RESULTS

Bleeding ceased in 25 patients (74%); bleeding continued but occurred only slightly and occasionally in five patients (15%); and three patients required operation to control the bleeding (9%). One patient relapsed after treatment and died while receiving a further transfusion.

CONCLUSIONS

This experience has been used to develop a management protocol for patients with this serious complication.

Inflammatory bowel disease: a retrospective review of a specialist-based cohort

OBJECTIVE

To study the morbidity and mortality of inflammatory bowel disease in Australia and whether it decreases life expectancy.

DESIGN

A retrospective review of patient case notes from two Sydney teaching hospitals and the consulting rooms of the 17 gastroenterologists appointed to these hospitals, examining all presentations with a diagnosis of inflammatory bowel disease from January 1977 to September 1992.

RESULTS

997 cases were identified: 533 with ulcerative colitis, 417 with Crohn's disease, and 47 with indeterminate colitis. In patients diagnosed from 1977 onwards (n = 730), no difference in survival was demonstrated for inflammatory bowel disease overall, or any subgroup, or in males or females, as compared with an age- and sex-matched control population. Gastrointestinal malignancies occurred in 19 cases (18 colorectal carcinoma and one cholangiocarcinoma). The most commonly encountered problems were the use of immunosuppressants and the need for surgery. Inflammatory bowel disease, particularly Crohn's disease, entails appreciable morbidity.

CONCLUSION

Since 1977, despite a significant requirement for medical and surgical treatment in patients with inflammatory bowel disease, there has been no adverse effect on survival in a specialist-referred cohort as compared with the general population.

Clinicopathological staging for colorectal cancer: an International Documentation System (IDS) and an International Comprehensive Anatomical Terminology (ICAT)

The purpose of tumour staging for colorectal cancer (CRC) is to help define clinical management, facilitate communication between physicians, provide a basis for stratification and analysis of treatment results in prospective studies, and provide some prognostic information for patients and their families. The World Congresses of Gastroenterology, Digestive Endoscopy, and Coloproctology, Working Party on staging for CRC studied six commonly used systems to review their strengths and weaknesses. Although it was concluded that defining a new staging system was unnecessary, it was recognized that there is a need to define a terminology to describe the full anatomic extent of spread of CRC. Furthermore, we note that there are several additional features, derived from both clinical and pathology information, which have had prognostic significance shown by appropriately constructed multivariate analyses and which can be used to formulate a more accurate prognostic index than that provided by a description of anatomical tumour spread. Thus the Working Party came to two principal conclusions. First, a standard format should be adopted for the collection of the essential data required for prospective studies, and we recommend the 'International Documentation System (IDS) for CRC' for this purpose. Second, a nomenclature which describes the full anatomical extent of tumour spread and residual tumour status in CRC has been defined and should be adopted, from which all currently used staging systems can be derived. We have called this nomenclature the 'International Comprehensive Anatomical Terminology (ICAT) for CRC'. In the event that these recommendations are adopted, we envision that there will be improved clarity in the documentation of treatment outcome for patients with CRC and improved communication of results derived from prospective studies. Furthermore, an acceptance of IDS and ICAT would set the scene to develop a prognostic index for individual patients with CRC by the expansion of anatomical clinicopathology staging information to include additional factors which have independent prognostic significance.

How useful is pre-operative computerized tomography scanning in staging rectal cancer?

This study evaluates prospectively the reliability of computerized tomography (CT) in the pre-operative staging of 80 patients with rectal cancer. The scans were performed and reviewed by one radiologist without knowledge of either the operative findings or the final clinicopathological stage of the tumours. Fourteen of 60 patients (23%) who had a potentially curative resection were correctly staged by CT. The tumour was understaged in 28 patients (47%) and was overstaged in 18 patients (30%). CT did not identify the one patient with histological demonstration of invasion of an adjacent organ was equivocal or incorrect in 10 others on the question of adjacent organ invasion. CT failed to define accurately local tumour spread confined to the rectal was (positive predictive value (PPV) 23%), identify venous invasion (PPV 35%) or involved regional lymph nodes (PPV 42%). However, the negative predictive value for excluding synchronous liver metastases was 90%, and 11 patients who subsequently developed histologically confirmed local recurrence were all correctly diagnosed on CT. These findings suggest that pre-operative examination of patients with rectal cancer by CT is not routinely justified specifically for purposes of staging the disease.

A basic audit: knowledge and attitudes of teaching and nonteaching surgeons towards colorectal cancer

In order to determine surgeons' knowledge of colorectal cancer in New Zealand and to see whether this knowledge was related to clinical practice a questionnaire was sent to all general surgeons on the New Zealand Medical Register. One hundred and twenty-three responses were received and analysed. Surgeons involved in student teaching had a better knowledge of this cancer than their nonteaching colleagus. There was a significant association between knowledge and attitudes towards screening, polyp removal and occult blood testing.

Clinical psychiatric illness in prisoners of war of the Japanese: forty years after release

Clinical psychiatric and medical assessments were carried out on a randomly selected sample of Australian prisoners of war captured by the Japanese in 1942 and a sample of combatants from Pacific theatres of war who were not captured. Prisoners of war had significantly more anxiety and depressive 'neuroses' and more major affective illness, although the latter finding was not statistically significant. The two groups did not differ in the risk of alcohol abuse and dependence.

Australian prisoners of war of the Japanese: post-war psychiatric hospitalisation and psychological morbidity

Evidence of chronic psychiatric and psychosomatic morbidity was found in a randomly selected sample of Australian prisoners of war (POWs) of the Japanese over the 40-year period following the Second World War. A clinical interview revealed more contemporary depressive and anxiety disorders and more post-war psychiatric illness overall than in a comparison group of randomly selected combatant veterans of the Pacific and South East Asian campaign. The POWs were no more likely to have had psychiatric admissions than non-POWs and fewer of them had had multiple psychiatric admissions. POWs had more duodenal ulcers than controls but otherwise their physical health was similar, as was their age-adjusted mortality in the post-war years. Finally, POWs were more likely to have Totally and Permanently Incapacitated Service Pensions than controls.

Colorectal cancer: knowledge and attitude of surgeons in New Zealand

In order to determine surgeons' knowledge of colorectal cancer (CRC) in New Zealand, a questionnaire was sent to all general surgeons on the New Zealand Medical register. One hundred and thirty-three responses were received and 123 were analysed. In general, respondents seemed to have a better detailed knowledge of CRC than Australian physicians and surgeons, although trends were similar and knowledge was patchy and in some areas poor. The value of rectal examination and sigmoidoscopy in relation to the detection of colorectal neoplasia was overestimated. Knowledge of faecal occult blood testing was such as to preclude useful evaluation of test results. The findings have serious implications for medical education.

A clinical approach to improving survival in colorectal cancer

The majority of large bowel cancers arise from benign adenomatous polyps. The identification of groups at high risk, the effective investigation and surveillance of these groups, together with a more discerning clinical approach to patients with bowel symptoms provides the best hope of cure.

Geographic distribution and demographic correlates of colorectal cancer mortality in Sydney, New South Wales

Colorectal cancer (CC) has the highest incidence of any internal malignancy in Australia and is a major cause of death. A knowledge of the geographic distribution of CC will aid in the identification of high risk groups for whom diagnostic and treatment facilities should be provided and may give clues to aetiological factors. Total CC deaths and age-standardized mortality ratios for Local Government Areas in Sydney, Australia were mapped and the relationships between mortality and selected demographic measures were examined. Several statistically significant zero-order correlation coefficients were found but multiple regression analysis showed a dominant independent negative effect of distance from the centre of the city on CC mortality. No substantial independent effects of demographic variables were observed. The existence of presently unmeasured environmental aetiological factors is postulated.

Leucocyte adherence inhibition and carcinoembryonic antigen in combination for diagnosis of colorectal cancer

A combination of leucocyte adherence (LAI) and carcinoembryonic antigen (CEA) diagnosed colorectal carcinoma with 91% sensitivity and 68% specificity. Relative operating characteristic (ROC) analysis was used to calculate the cutoff points for optimum detectability in a group of 159 patients with bowel symptoms who were investigated by endoscopy and radiology. Combining LAI and CEA would be likely to reduce the chance of missed diagnosis of colorectal carcinoma when x-ray and colonoscopic findings are equivocal.

Community attitudes to cancer

The success of screening programmes for cancer will depend greatly on public attitudes if sufficiently high levels of participation are tobe attained. The aimof this study was to identify major independent dimensions of public attitudes to cancer through factor analysis of responses to interview questions using a representative population sample. Data were collected by questioning a random sample of 500 persons aged 18 or over in Canberra on their attitudes to and knowledge of cancer and experience of the disease in others knownpersonally to them. Subjects with the disease were excluded. Factor analysis showed four relatively independent attitude dimensions: anxiety about cancer, denial of the threat of cancer, fatalism about prevention and fatalism about control. Item analysis and inter-scale correlations confirmed the internal coherence and relative independence of these dimensions, except that the latter two showed a moderate positive correlation. It is suggested that cancer education and promotion of screening should deal separately yet concurrently with these four attitudes toachieve best effect.

Colorectal cancer: knowledge and attitudes of doctors in Victoria

Successful introduction of screening for early colorectal cancer will depend, at least in part, on doctors' knowledge and attitudes. A 34-item questionnaire was sent to a random sample of one in five doctors in Victoria, with a final completion rate of 65%. The survey revealed gaps of knowledge, particularly about recognition of high-risk groups. Only 12% were aware of the degree of increased risk faced by first-degree relatives of patients with colorectal cancer and only 10% recognised the similar increase in risk for people with a history of resected colorectal cancer. While 73% of doctors order faecal occult blood tests, only 9% were aware that the more reliable quaiac method was used for their patients. Overall, 38% considered that faecal occult blood testing was a practical method for screening for colorectal cancer. Most of the doctors who accepted occult blood screening would follow up a positive test with digital rectal examination (80%) and barium enema (75%), but only 58% would want sigmoidoscopy performed and 34% colonoscopy. The diagnostic potential of digital rectal examination and sigmoidoscopy was over-estimated by half of the doctors surveyed. Recognition of subjects at high risk for colorectal cancer, and knowledge about the proper use, follow-up, and potential for screening of faecal occult blood tests need emphasis in medical educational programmes.

Participation and needs among members of the Royal Australian College of Ophthalmologists

A survey of Australian Ophthalmologists in relation to Continuing Education and related issues was carried out in 1979-80. 53% of College members responded. A small multi-choice question paper tested the level of competency of the group. Age, geographic distribution, and type of practice were recorded and related to presently available continuing education facilities. Future needs are assessed and questions raised regarding the direction of continuing education in the future. The level of ophthalmic knowledge appears to be satisfactory but decreases with age, along with attendance at education programmes. 25% of ophthalmologists consider themselves isolated. Future programmes should consider these factors. Views on undergraduate, general practitioner and community education are also summarised.

Knowledge of colorectal cancer and attitude to occult blood testing among recent medical graduates in New South Wales

The extent to which new information on colorectal cancer (C.C.) is being transmitted to medical undergraduates was assessed in a repeated survey of new interns' knowledge of and attitudes on C.C. A probability sample of 214 graduates of the two Sydney medical schools was drawn as they commenced their internships in 1978. A comparable sample of 186 was drawn in 1980. Interns in each sub-sample completed a questionnaire of 54 pre-coded items of knowledge of C.C. epidemiology, early diagnosis, and followup, and on their attitudes towards C.C. On most topics knowledge was not well developed, and 1980 graduates were not significantly better informed than those of 1978. Almost three-quarters of 1980 interns intend using faecal occult blood testing.

The distribution of colorectal carcinoma and the relationship of tumour site to the survival of patients following resection

A review of 532 patients undergoing elective resection for colorectal carcinoma between January 1971 and December 1978 showed no significant trend in the proportion of right colon carcinomas resected during this time. There was a higher proportion of advanced-stage tumours in the right colon than in the rectum. Patients with carcinoma of the right colon had a significantly poorer survival than did patients with rectal carcinoma.

Demographic and social background characteristics of members of the Royal College of Obstetricians and Gynaecologists in Australia

Demographic and social background characteristics of a random sample of 200 Australian members of the Royal College of Obstetricians and Gynaecologists were obtained in a questionnaire survey. Data are presented on age-sex distribution, marital status, period since graduation, length of College membership, type of practice, birthplace, education, religion, political orientation and social rank of family of origin.

Knowledge and attitudes of gastroenterologists in colorectal cancer

A group of 73 gastroenterological specialists (36 physicians, 25 surgeons, 12 trainees) completed a detailed questionnaire on their knowledge of and attitudes to colorectal cancer. A surprising unawareness of recent developments in colorectal cancer was apparent. Although responses to individual questions varied throughout the three groups, overall knowledge and attitudes on colorectal cancer were not related to age and years since graduation, and were not different in the three groups. This study suggests failure of traditional methods of continuing medical education, and has practical implications for any screening programme designed to detect early colorectal cancer.

Breast cancer following multiple chest fluoroscopy: the Ontario experience

The hypothesis, derived from experience in Nova Scotia, that artificial pneumothorax, requiring repeated fluoroscopy of the chest, is associated with an increased risk of subsequent breast cancer was tested in Ontario by means of a retrospective cancer patient/control study using record linkage. Sanatorium patients treated by artificial pneumothorax were estimated to have incurred a risk of breast cancer between two and three times as high as that of matched, contemporary sanatorium patients treated by other means. There was a tendency for the malignant disease to develop on the side of collapse, and there was evidence of a characteristic latent interval between exposure and onset.