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Aggarwal A, Simcock R, Price P, Rachet B, Lyratzopoulos G, Walker K, Spencer K, Roques T, Sullivan R. NHS cancer services and systems-ten pressure points a UK cancer control plan needs to address. Lancet Oncol 2024; 25:e363-e373. [PMID: 38991599 DOI: 10.1016/s1470-2045(24)00345-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 06/12/2024] [Accepted: 06/13/2024] [Indexed: 07/13/2024]
Abstract
In this Policy Review we discuss ten key pressure points in the NHS in the delivery of cancer care services that need to be urgently addressed by a comprehensive national cancer control plan. These pressure points cover areas such as increasing workforce capacity and its productivity, delivering effective cancer survivorship services, addressing variation in quality, fixing the reimbursement system for cancer care, and balancing of the cancer research agenda. These areas have been selected based on their relative importance to ensuring sustainable cancer services, persistence as key issues in the NHS, and their impact on delivering better and more equitable and affordable patient outcomes. Many of these pressure points are not acknowledged explicitly in any current discourse. The evidence we provide points to their impact on the ability to deliver world class cancer care, but also to their amenability to affordable solutions if given the relevant prioritisation and investment. The current narrative needs to move away from a technocentric approach to improving care, to one focused on understanding the complexity of cancer services and the wider health system to drive improvements in survival, quality of life, and experience for patients.
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Affiliation(s)
- Ajay Aggarwal
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK; Department of Oncology, Guy's & St Thomas' NHS Trust, London, UK.
| | - Richard Simcock
- Department of Oncology, University Hospitals Sussex NHS Trust, Brighton, UK
| | - Pat Price
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Bernard Rachet
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Kate Walker
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Katie Spencer
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK; Department of Oncology, Leeds Teaching Hospitals NHS Trust, Leeds
| | - Tom Roques
- Department of Oncology, Norfolk and Norwich NHS Foundation Trust, Norwich, UK
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Sullivan J, Donohue A, Brown S. Colorectal Oncologic Emergencies: Recognition, Management, and Outcomes. Surg Clin North Am 2024; 104:631-646. [PMID: 38677826 DOI: 10.1016/j.suc.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2024]
Abstract
Colorectal cancer is the third most frequent type of malignancy in the United States, and the age at diagnosis is decreasing. Although the goal of screening is focused on prevention and early detection, a subset of patients inevitably presents as oncologic emergencies. Approximately 15% of patients with colorectal cancer will present as surgical emergencies, with the majority being due to either colonic perforation or obstruction. Patients presenting with colorectal emergencies are a challenging cohort, as they often present at an advanced stage with an increase in T stage, lymphovascular invasion, and metachronous liver disease.
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Affiliation(s)
- Joshua Sullivan
- Department of General Surgery, Womack Army Medical Center, 2817 Reilly Road, Fort Liberty, NC 28310, USA
| | - Alec Donohue
- Department of General Surgery, Womack Army Medical Center, 2817 Reilly Road, Fort Liberty, NC 28310, USA
| | - Shaun Brown
- Department of General Surgery, Womack Army Medical Center, 2817 Reilly Road, Fort Liberty, NC 28310, USA.
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Cunningham R, Stanley J, Imlach F, Haitana T, Lockett H, Every-Palmer S, Clark MTR, Lacey C, Telfer K, Peterson D. Cancer diagnosis after emergency presentations in people with mental health and substance use conditions: a national cohort study. BMC Cancer 2024; 24:546. [PMID: 38689242 PMCID: PMC11062004 DOI: 10.1186/s12885-024-12292-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 04/19/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Cancer survival and mortality outcomes for people with mental health and substance use conditions (MHSUC) are worse than for people without MHSUC, which may be partly explained by poorer access to timely and appropriate healthcare, from screening and diagnosis through to treatment and follow-up. Access and quality of healthcare can be evaluated by comparing the proportion of people who receive a cancer diagnosis following an acute or emergency hospital admission (emergency presentation) across different population groups: those diagnosed with cancer following an emergency presentation have lower survival. METHODS National mental health service use datasets (2002-2018) were linked to national cancer registry and hospitalisation data (2006-2018), to create a study population of people aged 15 years and older with one of four cancer diagnoses: lung, prostate, breast and colorectal. The exposure group included people with a history of mental health/addiction service contact within the five years before cancer diagnosis, with a subgroup of people with a diagnosis of bipolar disorder, schizophrenia or psychotic disorders. Marginal standardised rates were used to compare emergency presentations (hospital admission within 30 days of cancer diagnosis) in the exposure and comparison groups, adjusted for age, gender (for lung and colorectal cancers), ethnicity, area deprivation and stage at diagnosis. RESULTS For all four cancers, the rates of emergency presentation in the fully adjusted models were significantly higher in people with a history of mental health/addiction service use than people without (lung cancer, RR 1.19, 95% CI 1.13, 1.24; prostate cancer RR 1.69, 95% CI 1.44, 1.93; breast cancer RR 1.42, 95% CI 1.14, 1.69; colorectal cancer 1.31, 95% CI 1.22, 1.39). Rates were substantially higher in those with a diagnosis of schizophrenia, bipolar disorder or psychotic disorders. CONCLUSIONS Implementing pathways for earlier detection and diagnosis of cancers in people with MHSUC could reduce the rates of emergency presentation, with improved cancer survival outcomes. All health services, including cancer screening programmes, primary and secondary care, have a responsibility to ensure equitable access to healthcare for people with MHSUC.
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Aboelezz AF, Othman MO. Endoscopic Management of Colonic Obstruction. Gastrointest Endosc Clin N Am 2024; 34:141-153. [PMID: 37973225 DOI: 10.1016/j.giec.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Large bowel obstruction is a serious event that occurs in approximately 25% of all intestinal obstructions. It is attributed to either benign, malignant, functional (pseudo-obstruction), or mechanical conditions. Benign etiologies of colonic obstructions include colon volvulus, anastomotic strictures, radiation injury, ischemia, inflammatory processes such as Crohn's disease, diverticulitis, bezoars, and intussusception.
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Affiliation(s)
- Ahmad F Aboelezz
- Department of Internal Medicine, Gastroenterology and Hepatology Section, Faculty of Medicine, Tanta University, El Bahr Street, Tanta Qism 2, Tanta 1, Gharbia Governorate 31111, Egypt
| | - Mohamed O Othman
- Department of Internal Medicine, Gastroenterology and Hepatology Section, Baylor College of Medicine, Gastroenterology Section at Baylor St Luke's Medical Center, 7200 Cambridge Street. Suite 8A, Houston, TX 77030, USA.
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Proctor DW, Goodall R, Borsky K, Salciccioli JD, Marshall DC, Mohamed A, Shanmugarajah K, Shalhoub J. Trends in the mortality, incidence, and disability-adjusted life-years of intestinal obstruction and paralytic ileus: observational study of the Global Burden of Disease database. Br J Surg 2023; 110:1650-1654. [PMID: 37531553 DOI: 10.1093/bjs/znad232] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 06/12/2023] [Accepted: 07/06/2023] [Indexed: 08/04/2023]
Affiliation(s)
- Dominic W Proctor
- Department of Major Trauma, Imperial College Healthcare NHS Trust, London, UK
| | - Richard Goodall
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Kim Borsky
- Department of Plastic Surgery, Salisbury Hospital, Salisbury, UK
| | - Justin D Salciccioli
- Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Cambridge, Massachusetts, USA
| | - Dominic C Marshall
- Department of Major Trauma, Imperial College Healthcare NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Abdulla Mohamed
- Department of Major Trauma, Imperial College Healthcare NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | | | - Joseph Shalhoub
- Department of Major Trauma, Imperial College Healthcare NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
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Li M, Xu G, Cui Y, Wang M, Wang H, Xu X, Duan S, Shi J, Feng F. CT-based radiomics nomogram for the preoperative prediction of microsatellite instability and clinical outcomes in colorectal cancer: a multicentre study. Clin Radiol 2023; 78:e741-e751. [PMID: 37487841 DOI: 10.1016/j.crad.2023.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 06/15/2023] [Accepted: 06/29/2023] [Indexed: 07/26/2023]
Abstract
AIM To develop and validate a computed tomography (CT)-based radiomics nomogram for preoperative prediction of microsatellite instability (MSI) status and clinical outcomes in colorectal cancer (CRC) patients. MATERIALS AND METHODS This retrospective study enrolled 497 CRC patients from three centres. Least absolute shrinkage and selection operator regression was utilised for feature selection and constructing the radiomics signature. Univariate and multivariate logistic regression analyses were employed to identify significant clinical variables. The radiomics nomogram was constructed by integrating the radiomics signature and the identified clinical variables. The performance of the nomogram was evaluated through receiver operating characteristic curves, calibration curves, and decision curve analysis. Kaplan-Meier analysis was performed to investigate the prognostic value of the nomogram. RESULTS The radiomics signature comprised 10 radiomics features associated with MSI status. The nomogram, integrating the radiomics signature and independent predictors (age, location, and thickness), demonstrated favourable calibration and discrimination, achieving areas under the receiver operating characteristic (ROC) curves (AUCs) of 0.89 (95% confidence interval [CI]: 0.83-0.95), 0.87 (95% CI: 0.79-0.95), 0.88 (95% CI: 0.81-0.96), and 0.86 (95% CI: 0.78-0.93) in the training cohort, internal validation cohort, and two external validation cohorts, respectively. The nomogram exhibited superior performance compared to the clinical model (p<0.05). Additionally, survival analysis demonstrated that the nomogram successfully stratified stage II CRC patients based on prognosis (hazard ratio [HR]: 0.357, p=0.022). CONCLUSION The radiomics nomogram demonstrated promising performance in predicting MSI status and stratifying the prognosis of patients with CRC.
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Affiliation(s)
- M Li
- Department of Radiology, Affiliated Tumour Hospital of Nantong University, Nantong 226001, Jiangsu Province, China; Department of Radiology, Yancheng No. 1 People's Hospital, Yancheng 224006, Jiangsu Province, China
| | - G Xu
- Department of Radiology, Yancheng No. 1 People's Hospital, Yancheng 224006, Jiangsu Province, China; Department of Radiology, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, China
| | - Y Cui
- Department of Radiology, Shanxi Cancer Hospital, Shanxi 030013, Shanxi Province, China
| | - M Wang
- Department of Radiology, Yancheng No. 1 People's Hospital, Yancheng 224006, Jiangsu Province, China
| | - H Wang
- Department of Radiology, Affiliated Tumour Hospital of Nantong University, Nantong 226001, Jiangsu Province, China
| | - X Xu
- Department of Radiotherapy, Affiliated Tumour Hospital of Nantong University, Nantong 226001, Jiangsu Province, China
| | - S Duan
- GE Healthcare China, Shanghai 210000, China
| | - J Shi
- Department of Radiology, Affiliated Tumour Hospital of Nantong University, Nantong 226001, Jiangsu Province, China.
| | - F Feng
- Department of Radiology, Affiliated Tumour Hospital of Nantong University, Nantong 226001, Jiangsu Province, China.
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Bosch X, Montori-Palacin E, Calvo J, Carbonell I, Naval-Álvarez J, Moreno P, López-Soto A. Time intervals and previous primary care consultations in the pathway to emergency cancer diagnosis. Cancer Epidemiol 2023; 86:102445. [PMID: 37651939 DOI: 10.1016/j.canep.2023.102445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 08/04/2023] [Accepted: 08/10/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Time intervals and number of prior consultations in primary care (PC) are recognised metrics of diagnostic timeliness of cancer and are interrelated. However, whether and how the two measures correlate with each other in the emergency diagnostic pathway is unknown. We investigated the association between the number of prereferral consultations and the length of intervals from PC presentation to cancer diagnosis following emergency referral to hospital. METHODS Patients were eligible if they first consulted in PC and were diagnosed with cancer following emergency or nonemergency referral to hospital. We analysed for differences in PC and diagnostic intervals and number of consultations between emergency and nonemergency presenters and determined their associations by cancer type. Differences in presenting symptoms and stage at diagnosis between populations and according to number of consultations were also examined. RESULTS There were 796 emergency and 865 nonemergency presenters with comparable sociodemographic and comorbidity data. Correlation analysis in emergency presenters revealed a strong positive association between number of consultations and intervals for seven of 13 different cancers, including cancers characterised by high proportions of > 3 consultations and long intervals (pancreatic, lung, and colorectal cancer) and vice versa for others (e.g., endometrial, cervical, or oesophageal cancer). Additionally, emergency presenters with > 3 consultations were more likely than those with 1-2 to report nonspecific symptoms (60 vs. 40%, respectively) and to be diagnosed at a later stage. CONCLUSION System level interventions are needed to reduce unnecessary delays in the emergency diagnostic pathway, particularly in cancer patients with multiple prereferral consultations. The findings also suggest opportunities to reduce the proportion of emergency diagnoses by targeting symptomatic individuals pre-presentation.
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Affiliation(s)
- Xavier Bosch
- Department of Internal Medicine, Hospital Clínic, August Pi i Sunyer Biomedical Research Institute (IDIBAPS) and Clínic Foundation for Biomedical Research (FCRB), University of Barcelona, Villarroel 170, 08036 Barcelona, Spain.
| | - Elisabet Montori-Palacin
- Department of Internal Medicine, Hospital Clínic, August Pi i Sunyer Biomedical Research Institute (IDIBAPS) and Clínic Foundation for Biomedical Research (FCRB), University of Barcelona, Villarroel 170, 08036 Barcelona, Spain
| | - Julia Calvo
- Department of Internal Medicine, Hospital Clínic, August Pi i Sunyer Biomedical Research Institute (IDIBAPS) and Clínic Foundation for Biomedical Research (FCRB), University of Barcelona, Villarroel 170, 08036 Barcelona, Spain
| | - Irene Carbonell
- Department of Internal Medicine, Hospital Clínic, August Pi i Sunyer Biomedical Research Institute (IDIBAPS) and Clínic Foundation for Biomedical Research (FCRB), University of Barcelona, Villarroel 170, 08036 Barcelona, Spain
| | - José Naval-Álvarez
- Department of Internal Medicine, Hospital Clínic, August Pi i Sunyer Biomedical Research Institute (IDIBAPS) and Clínic Foundation for Biomedical Research (FCRB), University of Barcelona, Villarroel 170, 08036 Barcelona, Spain
| | - Pedro Moreno
- Department of Internal Medicine, Hospital Clínic, August Pi i Sunyer Biomedical Research Institute (IDIBAPS) and Clínic Foundation for Biomedical Research (FCRB), University of Barcelona, Villarroel 170, 08036 Barcelona, Spain
| | - Alfonso López-Soto
- Department of Internal Medicine, Hospital Clínic, August Pi i Sunyer Biomedical Research Institute (IDIBAPS) and Clínic Foundation for Biomedical Research (FCRB), University of Barcelona, Villarroel 170, 08036 Barcelona, Spain
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Nantais J, Baxter NN, Saskin R, Logsetty S, Gomez D. Population-level trends in emergency general surgery presentations and mortality over time. Br J Surg 2023; 110:1057-1062. [PMID: 36869820 PMCID: PMC10416690 DOI: 10.1093/bjs/znad041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/05/2023] [Accepted: 02/01/2023] [Indexed: 03/05/2023]
Affiliation(s)
- Jordan Nantais
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Section of General Surgery, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nancy N Baxter
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Management and Evaluation, Dalla Lana School of Public Health, Institute of Health Policy, University of Toronto, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | | | - Sarvesh Logsetty
- Section of General Surgery, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Plastic Surgery, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David Gomez
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Management and Evaluation, Dalla Lana School of Public Health, Institute of Health Policy, University of Toronto, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
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Arnarson Ö, Axmarker T, Syk I. Short- and long-term outcomes following bridge to surgery and emergency resection in acute malignant large bowel obstruction. Colorectal Dis 2022; 25:669-678. [PMID: 36567604 DOI: 10.1111/codi.16458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 11/07/2022] [Accepted: 11/29/2022] [Indexed: 12/27/2022]
Abstract
AIM Bridge to surgery (BtS) aims to decrease perioperative morbidity and mortality in emergency resection (ER) of the colon. Previous results are inconsistent, and long-term comparisons are scarce. The aim of this study was to compare the short- and long-term outcomes of BtS and ER. METHOD This retrospective study examined data from the Swedish Colorectal Cancer Registry for patients treated for acute malignant large bowel obstruction from 2007 to 2009. Patients were grouped by treatment strategy: BtS (using a self-expanding metallic stent or diverting stoma) or ER. Medical records were scrutinized for all patients in the BtS group. The primary endpoints were 5-year overall survival (OS) and 3-year recurrence-free survival (RFS). The secondary endpoints were postoperative mortality and morbidity rates and stoma permanence. RESULTS Overall, 143 patients were treated using BtS versus 1302 patients treated with ER. The 5-year OS was higher in the BtS group than in the ER group (53.8% vs. 37.4%; p < 0.05). No difference was noted in the 3-year RFS (75.7% vs. 75.0%; p = 0.38). The postoperative mortality rate was lower in the BtS group than in the ER group (0.7% vs. 7.3%; p < 0.05). Complications occurred in 46.9% of patients in the BtS group (both procedures) versus 35.9% of patients in the ER group (p < 0.05); the rate of severe complications was 23.1% and 16.9%, respectively (p = 0.07). CONCLUSION This retrospective population-based registry study showed higher long-term survival and lower postoperative mortality rates among patients treated with BtS versus ER for acute malignant large bowel obstruction.
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Affiliation(s)
- Örvar Arnarson
- Department of Surgery, Skane University Hospital Malmo, Lund University, Lund, Sweden
| | - Tobias Axmarker
- Department of Surgery, Skane University Hospital Malmo, Lund University, Lund, Sweden
| | - Ingvar Syk
- Lund University, Lund, Sweden.,Department of Surgery, Skane University Hospital, Malmo, Sweden
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Survival Outcomes after Elective or Emergency Surgery for Synchronous Stage IV Colorectal Cancer. Biomedicines 2022; 10:biomedicines10123114. [PMID: 36551870 PMCID: PMC9775222 DOI: 10.3390/biomedicines10123114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/29/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022] Open
Abstract
Patients with stage IV colorectal cancer (CRC) who have not undergone primary tumor resection (PTR) are at risk of sudden medical emergencies. Despite the ongoing controversy over the necessity and timing of PTR in patients with stage IV CRC, studies comparing the survival outcomes of elective and emergency surgery in this population are scarce. This is a retrospective study conducted at a single institute. The patients were divided into two groups: the elective surgery (ELS) group (n = 46) and the emergency surgery (EMS) group (n = 26). The primary outcome was 2-year overall survival (OS). During a median follow-up period of 27.0 months, the 2-year OS was significantly better in the ELS group (80% vs. 42.9%, p = 0.002). No significant differences were observed in the 2-year relapse-free survival and 30-day postoperative complication rates. Planning and performing elective surgery could help increase the survival rate of patients with synchronous stage IV CRC, especially those that undergo simultaneous or staged metastasectomy.
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Inflammation promotes resistance to immune checkpoint inhibitors in high microsatellite instability colorectal cancer. Nat Commun 2022; 13:7316. [PMID: 36443332 PMCID: PMC9705377 DOI: 10.1038/s41467-022-35096-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 11/17/2022] [Indexed: 11/29/2022] Open
Abstract
Inflammation is a common medical complication in colorectal cancer (CRC) patients, which plays significant roles in tumor progression and immunosuppression. However, the influence of inflammatory conditions on the tumor response to immune checkpoint inhibitors (ICI) is incompletely understood. Here we show that in a patient with high microsatellite instability (MSI-H) CRC and a local inflammatory condition, the primary tumor progresses but its liver metastasis regresses upon Pembrolizumab treatment. In silico investigation prompted by this observation confirms correlation between inflammatory conditions and poor tumor response to PD-1 blockade in MSI-H CRCs, which is further validated in a cohort of 62 patients retrospectively enrolled to our study. Inhibition of local but not systemic immune response is verified in cultures of paired T cells and organoid cells from patients. Single-cell RNA sequencing suggests involvement of neutrophil leukocytes via CD80/CD86-CTLA4 signaling in the suppressive immune microenvironment. In concordance with this finding, elevated neutrophil-to-lymphocyte ratio indicates inhibited immune status and poor tumor response to ICIs. Receiver operating characteristic curve further demonstrates that both inflammatory conditions and a high NLR could predict a poor response to ICIs in MSI- CRCs, and the predictive value could be further increased when these two predictors are combined. Our study thus suggests that inflammatory conditions in MSI-H CRCs correlate with resistance to ICIs through neutrophil leukocyte associated immunosuppression and proposes both inflammatory conditions and high neutrophil-to-lymphocyte ratio as clinical features for poor ICI response.
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Benitez Majano S, Lyratzopoulos G, de Wit NJ, White B, Rachet B, Helsper C, Usher-Smith J, Renzi C. Mental Health Morbidities and Time to Cancer Diagnosis Among Adults With Colon Cancer in England. JAMA Netw Open 2022; 5:e2238569. [PMID: 36315146 PMCID: PMC9623442 DOI: 10.1001/jamanetworkopen.2022.38569] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/29/2022] [Indexed: 11/29/2022] Open
Abstract
Importance Mental health morbidity (MHM) in patients presenting with possible cancer symptoms may be associated with prediagnostic care and time to cancer diagnosis. Objective To compare the length of intervals to cancer diagnosis by preexisting MHM status in patients who presented with symptoms of as-yet-undiagnosed colon cancer and evaluate their risk of emergency cancer diagnosis. Design, Setting, and Participants This cohort study was conducted using linked primary care data obtained from the population-based Clinical Practice Research Datalink, which includes primary care practices in England, linked to cancer registry and hospital data. Included participants were 3766 patients diagnosed with colon cancer between 2011 and 2015 presenting with cancer-relevant symptoms up to 24 months before their diagnosis. Data analysis was performed in January 2021 to April 2022. Exposures Mental health conditions recorded in primary care before cancer diagnosis, including anxiety, depression, schizophrenia, bipolar disorder, alcohol addiction, anorexia, and bulimia. Main Outcomes and Measures Fast-track (also termed 2-week wait) specialist referral for investigations, time to colonoscopy and cancer diagnosis, and risk of emergency cancer diagnosis. Results Among 3766 patients with colon cancer (median [IQR] age, 75 [65-82] years; 1911 [50.7%] women ), 623 patients [16.5%] had preexisting MHM recorded in primary care the year before cancer diagnosis, including 562 patients (14.9%) with preexisting anxiety or depression (accounting for 90.2% of patients with preexisting MHM) and 61 patients (1.6%) with other MHM; 3143 patients (83.5%) did not have MHM. Patients with MHM had records of red-flag symptoms or signs (ie, rectal bleeding, change in bowel habit, or anemia) in the 24 months before cancer diagnosis in a smaller proportion compared with patients without MHM (308 patients [49.4%] vs 1807 patients [57.5%]; P < .001). Even when red-flag symptoms were recorded, patients with MHM had lower odds of fast-track specialist referral (adjusted odds ratio [OR] = 0.72; 95% CI, 0.55-0.94; P = .01). Among 2115 patients with red-flag symptoms or signs, 308 patients with MHM experienced a more than 2-fold longer median (IQR) time to cancer diagnosis (326 [75-552] days vs 133 [47-422] days) and higher odds of emergency diagnosis (90 patients [29.2%] vs 327 patients [18.1%]; adjusted OR = 1.63; 95% CI, 1.23-2.24; P < .001) compared with 1807 patients without MHM. Conclusions and Relevance This study found that patients with MHM experienced large and prognostically consequential disparities in diagnostic care before a colon cancer diagnosis. These findings suggest that appropriate pathways and follow-up strategies after symptomatic presentation are needed for earlier cancer diagnoses and improved health outcomes in this large patient group.
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Affiliation(s)
- Sara Benitez Majano
- Inequalities in Cancer Outcomes Network Group, Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes Research Group, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
| | - Niek J. de Wit
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, the Netherlands
| | - Becky White
- Epidemiology of Cancer Healthcare and Outcomes Research Group, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
| | - Bernard Rachet
- Inequalities in Cancer Outcomes Network Group, Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Charles Helsper
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, the Netherlands
| | - Juliet Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Cristina Renzi
- Epidemiology of Cancer Healthcare and Outcomes Research Group, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
- Faculty of Medicine, University Vita-Salute San Raffaele, Milan, Italy
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Use of a New Prevention Model in Acute Care Surgery. ANNALS OF SURGERY OPEN 2022; 3. [PMID: 35990734 PMCID: PMC9390954 DOI: 10.1097/as9.0000000000000188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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McPhail S, Swann R, Johnson SA, Barclay ME, Abd Elkader H, Alvi R, Barisic A, Bucher O, Clark GRC, Creighton N, Danckert B, Denny CA, Donnelly DW, Dowden JJ, Finn N, Fox CR, Fung S, Gavin AT, Gomez Navas E, Habbous S, Han J, Huws DW, Jackson CGCA, Jensen H, Kaposhi B, Kumar SE, Little AL, Lu S, McClure CA, Møller B, Musto G, Nilssen Y, Saint-Jacques N, Sarker S, Te Marvelde L, Thomas RS, Thomas RJS, Thomson CS, Woods RR, Zhang B, Lyratzopoulos G. Risk factors and prognostic implications of diagnosis of cancer within 30 days after an emergency hospital admission (emergency presentation): an International Cancer Benchmarking Partnership (ICBP) population-based study. Lancet Oncol 2022; 23:587-600. [PMID: 35397210 PMCID: PMC9046095 DOI: 10.1016/s1470-2045(22)00127-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 02/20/2022] [Accepted: 02/22/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Greater understanding of international cancer survival differences is needed. We aimed to identify predictors and consequences of cancer diagnosis through emergency presentation in different international jurisdictions in six high-income countries. METHODS Using a federated analysis model, in this cross-sectional population-based study, we analysed cancer registration and linked hospital admissions data from 14 jurisdictions in six countries (Australia, Canada, Denmark, New Zealand, Norway, and the UK), including patients with primary diagnosis of invasive oesophageal, stomach, colon, rectal, liver, pancreatic, lung, or ovarian cancer during study periods from Jan 1, 2012, to Dec 31, 2017. Data were collected on cancer site, age group, sex, year of diagnosis, and stage at diagnosis. Emergency presentation was defined as diagnosis of cancer within 30 days after an emergency hospital admission. Using logistic regression, we examined variables associated with emergency presentation and associations between emergency presentation and short-term mortality. We meta-analysed estimates across jurisdictions and explored jurisdiction-level associations between cancer survival and the percentage of patients diagnosed as emergencies. FINDINGS In 857 068 patients across 14 jurisdictions, considering all of the eight cancer sites together, the percentage of diagnoses through emergency presentation ranged from 24·0% (9165 of 38 212 patients) to 42·5% (12 238 of 28 794 patients). There was consistently large variation in the percentage of emergency presentations by cancer site across jurisdictions. Pancreatic cancer diagnoses had the highest percentage of emergency presentations on average overall (46·1% [30 972 of 67 173 patients]), with the jurisdictional range being 34·1% (1083 of 3172 patients) to 60·4% (1317 of 2182 patients). Rectal cancer had the lowest percentage of emergency presentations on average overall (12·1% [10 051 of 83 325 patients]), with a jurisdictional range of 9·1% (403 of 4438 patients) to 19·8% (643 of 3247 patients). Across the jurisdictions, older age (ie, 75-84 years and 85 years or older, compared with younger patients) and advanced stage at diagnosis compared with non-advanced stage were consistently associated with increased emergency presentation risk, with the percentage of emergency presentations being highest in the oldest age group (85 years or older) for 110 (98%) of 112 jurisdiction-cancer site strata, and in the most advanced (distant spread) stage category for 98 (97%) of 101 jurisdiction-cancer site strata with available information. Across the jurisdictions, and despite heterogeneity in association size (I2=93%), emergency presenters consistently had substantially greater risk of 12-month mortality than non-emergency presenters (odds ratio >1·9 for 112 [100%] of 112 jurisdiction-cancer site strata, with the minimum lower bound of the related 95% CIs being 1·26). There were negative associations between jurisdiction-level percentage of emergency presentations and jurisdiction-level 1-year survival for colon, stomach, lung, liver, pancreatic, and ovarian cancer, with a 10% increase in percentage of emergency presentations in a jurisdiction being associated with a decrease in 1-year net survival of between 2·5% (95% CI 0·28-4·7) and 7·0% (1·2-13·0). INTERPRETATION Internationally, notable proportions of patients with cancer are diagnosed through emergency presentation. Specific types of cancer, older age, and advanced stage at diagnosis are consistently associated with an increased risk of emergency presentation, which strongly predicts worse prognosis and probably contributes to international differences in cancer survival. Monitoring emergency presentations, and identifying and acting on contributing behavioural and health-care factors, is a global priority for cancer control. FUNDING Canadian Partnership Against Cancer; Cancer Council Victoria; Cancer Institute New South Wales; Cancer Research UK; Danish Cancer Society; National Cancer Registry Ireland; The Cancer Society of New Zealand; National Health Service England; Norwegian Cancer Society; Public Health Agency Northern Ireland, on behalf of the Northern Ireland Cancer Registry; the Scottish Government; Western Australia Department of Health; and Wales Cancer Network.
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Affiliation(s)
- Sean McPhail
- National Disease Registration Service, NHS Digital, Leeds, UK
| | - Ruth Swann
- National Disease Registration Service, NHS Digital, Leeds, UK; Cancer Research UK, London, UK
| | | | - Matthew E Barclay
- Epidemiology of Cancer Healthcare and Outcomes, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care (IEHC), University College London, London, UK
| | | | - Riaz Alvi
- Department of Epidemiology and Performance Measurement, Saskatchewan Cancer Agency, Saskatoon, SK, Canada
| | | | - Oliver Bucher
- Department of Epidemiology and Cancer Registry, CancerCare Manitoba, Winnipeg, MB, Canada
| | | | | | - Bolette Danckert
- Danish Cancer Society Research Center, Danish Cancer Society, Copenhagen, Denmark
| | | | - David W Donnelly
- Northern Ireland Cancer Registry, Queen's University Belfast, Belfast, UK
| | - Jeff J Dowden
- Provincial Cancer Care Program, Eastern Health, St John's, NL, Canada
| | - Norah Finn
- Victorian Cancer Registry, Cancer Council Victoria, Melbourne, VIC, Australia; Cancer Support, Treatment and Research, Department of Health, Melbourne, VIC, Australia
| | - Colin R Fox
- Northern Ireland Cancer Registry, Queen's University Belfast, Belfast, UK
| | - Sharon Fung
- Canadian Partnership against Cancer, Toronto, ON, Canada
| | - Anna T Gavin
- Northern Ireland Cancer Registry, Queen's University Belfast, Belfast, UK
| | | | - Steven Habbous
- Ontario Health (Cancer Care Ontario), Toronto, ON, Canada
| | - Jihee Han
- Canadian Partnership against Cancer, Toronto, ON, Canada
| | - Dyfed W Huws
- Welsh Cancer Intelligence and Surveillance Unit, Public Health Data, Knowledge and Research Directorate, Public Health Wales, Cardiff, UK; Population Data Science, Swansea University Medical School, Swansea, UK
| | | | - Henry Jensen
- Research Unit for General Practice, Aarhus University, Aarhus, Denmark
| | - Bethany Kaposhi
- Surveillance and Reporting, Advanced Analytics, Cancer Care Alberta, Alberta Health Services, Edmonton
| | - S Eshwar Kumar
- New Brunswick Cancer Network, Department of Health, New Brunswick, Fredericton, NB, Canada
| | | | | | - Carol A McClure
- Prince Edward Island Cancer Registry, Queen Elizabeth Hospital, Charlottetown, PE, Canada
| | | | - Grace Musto
- Department of Epidemiology and Cancer Registry, CancerCare Manitoba, Winnipeg, MB, Canada
| | | | | | - Sabuj Sarker
- Department of Epidemiology and Performance Measurement, Saskatchewan Cancer Agency, Saskatoon, SK, Canada
| | - Luc Te Marvelde
- Victorian Cancer Registry, Cancer Council Victoria, Melbourne, VIC, Australia
| | - Rebecca S Thomas
- Welsh Cancer Intelligence and Surveillance Unit, Public Health Data, Knowledge and Research Directorate, Public Health Wales, Cardiff, UK; Department of the Dean, Medicine Dentistry and Health Sciences, University of Melbourne, Parkville, VIC, Australia
| | - Robert J S Thomas
- Welsh Cancer Intelligence and Surveillance Unit, Public Health Data, Knowledge and Research Directorate, Public Health Wales, Cardiff, UK; Department of the Dean, Medicine Dentistry and Health Sciences, University of Melbourne, Parkville, VIC, Australia
| | | | - Ryan R Woods
- Cancer Control Research, BC Cancer, Vancouver, BC, Canada
| | - Bin Zhang
- Health Analytics, Department of Health, Fredericton, NB, Canada
| | - Georgios Lyratzopoulos
- National Disease Registration Service, NHS Digital, Leeds, UK; Epidemiology of Cancer Healthcare and Outcomes, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care (IEHC), University College London, London, UK.
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Abdel-Rahman O, Tang PA, Ghosh S, Scarfe A. Patterns of emergency department visits preceding colorectal cancer diagnosis: a population-based study. J Comp Eff Res 2022; 11:311-318. [PMID: 35189709 DOI: 10.2217/cer-2021-0163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To assess the patterns of emergency department (ED) visits in the 3 months preceding a diagnosis of colorectal cancer (CRC) in a real-world, population-based context. Materials & methods: Linked provincial registries in Alberta, Canada, were accessed and patients with CRC diagnosed between 2004 and 2018 were identified. The National Ambulatory Care reporting system was used to identify patients who visited an ED within 3 months of a diagnosis of CRC. Multivariable logistic regression analysis was used to identify factors associated with any ED visits as well as frequent (≥3) ED visits. Results: A total of 25,310 patients with CRC were included in the current study. These include 10,126 patients (40%) who had at least one visit to the ED in the 3 months before a diagnosis of CRC diagnosis and 613 patients (2.4%) who visited the ED multiple (≥3) times. The following factors were associated with any visit to an ED: older age (odds ratio [OR]: 1.010; 95% CI: 1.008-1.012), female gender (OR: 1.23; 95% CI: 1.16-1.30), higher comorbidity index (OR: 1.38; 95% CI: 1.35-1.41), metastatic disease (OR: 2.37; 95% CI: 2.23-2.53), proximal tumors (OR: 1.59; 95% CI: 1.50-1.68) and North zone (OR vs south zone: 1.75; 95% CI: 1.55-1.98). Conclusion: It is not uncommon for CRC patients to visit the ED at least once in the 3 months prior to having such a diagnosis. Factors associated with frequent pre diagnosis emergency visits included female gender, higher burden of comorbid disease, advanced stage, proximal tumors and living in the North zone of Alberta (where there is limited access to specialist care).
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Affiliation(s)
- Omar Abdel-Rahman
- Department of Oncology, University of Alberta, Cross Cancer Institute, Edmonton, AB, T6G1Z2, Canada
| | - Patricia A Tang
- Department of Oncology, University of Calgary, Tom Baker Cancer Centre, Calgary, AB, T2N 4N2, Canada
| | - Sunita Ghosh
- Department of Oncology, University of Alberta, Cross Cancer Institute, Edmonton, AB, T6G1Z2, Canada
| | - Andrew Scarfe
- Department of Oncology, University of Alberta, Cross Cancer Institute, Edmonton, AB, T6G1Z2, Canada
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Yoo RN, Cho HM, Kye BH. Management of obstructive colon cancer: Current status, obstacles, and future directions. World J Gastrointest Oncol 2021; 13:1850-1862. [PMID: 35070029 PMCID: PMC8713324 DOI: 10.4251/wjgo.v13.i12.1850] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 07/07/2021] [Accepted: 09/23/2021] [Indexed: 02/06/2023] Open
Abstract
Approximately 10%–18% of patients with colon cancer present with obstruction at the initial diagnosis. Despite active screening efforts, the incidence of obstructive colon cancer remains stable. Traditionally, emergency surgery has been indicated to treat patients with obstructive colon cancer. However, compared to patients undergoing elective surgery, the morbidity and mortality rates of patients requiring emergency surgery for obstructive colon cancer are high. With the advancement of colonoscopic techniques and equipment, a self-expandable metal stent (SEMS) was introduced to relieve obstructive symptoms, allowing the patient’s general condition to be restored and for them undergo elective surgery. As the use of SEMS placement is growing, controversies about its application in potentially curable diseases have been raised. In this review, the short- and long-term outcomes of different treatment strategies, particularly emergency surgery vs SEMS placement followed by elective surgery in resectable, locally advanced obstructive colon cancer, are described based on the location of the obstructive cancer lesion. Controversies regarding each treatment strategy are discussed. To overcome current obstacles, a potential diagnostic method using circulating tumor DNA and further research directions incorporating neoadjuvant chemotherapy are introduced.
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Affiliation(s)
- Ri-Na Yoo
- Division of Colorectal Surgery, Department of Surgery, St. Vincent’s Hospital, The Catholic University of Korea, Suwon 442-723, South Korea
| | - Hyeon-Min Cho
- Division of Colorectal Surgery, Department of Surgery, St. Vincent’s Hospital, The Catholic University of Korea, Suwon 442-723, South Korea
| | - Bong-Hyeon Kye
- Division of Colorectal Surgery, Department of Surgery, St. Vincent’s Hospital, The Catholic University of Korea, Suwon 442-723, South Korea
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Pilleron S, Maringe C, Charvat H, Atkinson J, Morris EJA, Sarfati D. The impact of timely cancer diagnosis on age disparities in colon cancer survival. J Geriatr Oncol 2021; 12:1044-1051. [PMID: 33863698 DOI: 10.1016/j.jgo.2021.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/01/2021] [Accepted: 04/07/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE We described the role of patient-related and clinical factors on age disparities in colon cancer survival among patients aged 50-99 using New Zealand population-based cancer registry data linked to hospitalisation data. METHOD We included 21,270 new colon cancer cases diagnosed between 1 January 2006 and 31 July 2017, followed up to end 2019. We modelled the effect of age at diagnosis, sex, ethnicity, deprivation, comorbidity, and emergency presentation on colon cancer survival by stage at diagnosis using flexible excess hazard regression models. RESULTS The excess mortality in older patients was minimal for localised cancers, maximal during the first six months for regional cancers, the first eighteen months for distant cancers, and over the three years for missing stages. The age pattern of the excess mortality hazard varied according to sex for distant cancers, emergency presentation for regional and distant cancers, and comorbidity for cancer with missing stages. Ethnicity and deprivation did not influence age disparities in colon cancer survival. CONCLUSION Factors reflecting timeliness of cancer diagnosis most affected age-related disparities in colon cancer survival, probably by impacting treatment strategy. Because of the high risk of poor outcomes related to treatment in older patients, efforts made to improve earlier diagnosis in older patients are likely to help reduce age disparities in colon cancer survival in New Zealand.
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Affiliation(s)
- Sophie Pilleron
- Dept of Public Health, School of medicine, University of Otago, Wellington, New Zealand; Nuffield Department of Population Health, University of Oxford, Big Data Institute, Old Road Campus, Oxford OX3 7LF, UK.
| | - Camille Maringe
- Inequalities in Cancer Outcomes Network, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Hadrien Charvat
- Epidemiology and Prevention Group, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan; Section of Cancer Surveillance, International Agency for Research on Cancer, Lyon, France
| | - June Atkinson
- Dept of Public Health, School of medicine, University of Otago, Wellington, New Zealand
| | - Eva J A Morris
- Nuffield Department of Population Health, University of Oxford, Big Data Institute, Old Road Campus, Oxford OX3 7LF, UK
| | - Diana Sarfati
- Dept of Public Health, School of medicine, University of Otago, Wellington, New Zealand
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