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Donnelly C, Or M, Toh J, Thevaraja M, Janssen A, Shaw T, Pathma-Nathan N, Harnett P, Chiew KL, Vinod S, Sundaresan P. Measurement that matters: A systematic review and modified Delphi of multidisciplinary colorectal cancer quality indicators. Asia Pac J Clin Oncol 2024; 20:259-274. [PMID: 36726222 DOI: 10.1111/ajco.13917] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 12/19/2022] [Accepted: 12/26/2022] [Indexed: 02/03/2023]
Abstract
AIM To develop a priority set of quality indicators (QIs) for use by colorectal cancer (CRC) multidisciplinary teams (MDTs). METHODS The review search strategy was executed in four databases from 2009-August 2019. Two reviewers screened abstracts/manuscripts. Candidate QIs and characteristics were extracted using a tailored abstraction tool and assessed for scientific soundness. To prioritize candidate indicators, a modified Delphi consensus process was conducted. Consensus was sought over two rounds; (1) multidisciplinary expert workshops to identify relevance to Australian CRC MDTs, and (2) an online survey to prioritize QIs by clinical importance. RESULTS A total of 93 unique QIs were extracted from 118 studies and categorized into domains of care within the CRC patient pathway. Approximately half the QIs involved more than one discipline (52.7%). One-third of QIs related to surgery of primary CRC (31.2%). QIs on supportive care (6%) and neoadjuvant therapy (6%) were limited. In the Delphi Round 1, workshop participants (n = 12) assessed 93 QIs and produced consensus on retaining 49 QIs including six new QIs. In Round 2, survey participants (n = 44) rated QIs and prioritized a final 26 QIs across all domains of care and disciplines with a concordance level > 80%. Participants represented all MDT disciplines, predominantly surgical (32%), radiation (23%) and medical (20%) oncology, and nursing (18%), across six Australian states, with an even spread of experience level. CONCLUSION This study identified a large number of existing CRC QIs and prioritized the most clinically relevant QIs for use by Australian MDTs to measure and monitor their performance.
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Affiliation(s)
- Candice Donnelly
- Faculty of Medicine and Health, University of Sydney, Camperdown, Australia
| | - Michelle Or
- Radiation Oncology Network, Western Sydney Local Health District, Westmead, Australia
| | - James Toh
- Department of Surgery, Westmead Hospital, Westmead, Australia
- Westmead Clinical School, University of Sydney, Sydney, Australia
| | | | - Anna Janssen
- Faculty of Medicine and Health, University of Sydney, Camperdown, Australia
| | - Tim Shaw
- Faculty of Medicine and Health, University of Sydney, Camperdown, Australia
| | | | - Paul Harnett
- Westmead Clinical School, University of Sydney, Sydney, Australia
- Crown Princess Mary Cancer Centre, Western Sydney Local Health District, Westmead, Australia
| | - Kim-Lin Chiew
- Ingham Institute for Applied Medical Research, Liverpool, Australia
- Liverpool Cancer Therapy Centre, South Western Sydney Local Health District, Liverpool, Australia
- South Western Clinical School, University of New South Wales, Randwick, Australia
- Princess Alexandra Hospital, Division of Cancer Services, Brisbane, Australia
| | - Shalini Vinod
- Liverpool Cancer Therapy Centre, South Western Sydney Local Health District, Liverpool, Australia
- South Western Clinical School, University of New South Wales, Randwick, Australia
| | - Puma Sundaresan
- Radiation Oncology Network, Western Sydney Local Health District, Westmead, Australia
- Westmead Clinical School, University of Sydney, Sydney, Australia
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Guan X, Jiao S, Wen R, Yu G, Liu J, Miao D, Wei R, Zhang W, Hao L, Zhou L, Lou Z, Liu S, Zhao E, Wang G, Zhang W, Wang X. Optimal examined lymph node number for accurate staging and long-term survival in rectal cancer: a population-based study. Int J Surg 2023; 109:2241-2248. [PMID: 37428195 PMCID: PMC10442141 DOI: 10.1097/js9.0000000000000320] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 02/20/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Although the recommended minimal examined lymph node (ELN) number in rectal cancer (RC) is 12, this standard remains controversial because of insufficient evidence. We aimed to refine this definition by quantifying the relationship between ELN number, stage migration and long-term survival in RC. METHODS Data from a Chinese multi-institutional registry (2009-2018) and the Surveillance, Epidemiology, and End Results (SEER) database (2008-2017) on stages I-III resected RC were analysed to determine the relationship between ELN count, stage migration, and overall survival (OS) using multivariable models. The series of odds ratios (ORs) for negative-to-positive node stage migration and hazard ratios (HRs) for survival with more ELNs were fitted using a Locally Weighted Scatterplot Smoothing (LOWESS) smoother, and structural breakpoints were determined using the Chow test. The relationship between ELN and survival was evaluated on a continuous scale using restricted cubic splines (RCS). RESULTS The distribution of ELN count between the Chinese registry ( n =7694) and SEER database ( n =21 332) was similar. With increasing ELN count, both cohorts exhibited significant proportional increases from node-negative to node-positive disease (SEER, OR, 1.012, P <0.001; Chinese registry, OR, 1.016, P =0.014) and serial improvements in OS (SEER: HR, 0.982; Chinese registry: HR, 0.975; both P <0.001) after controlling for confounders. Cut-point analysis showed an optimal threshold ELN count of 15, which was validated in the two cohorts, with the ability to properly discriminate probabilities of survival. CONCLUSIONS A higher ELN count is associated with more precise nodal staging and better survival. Our results robustly conclude that 15 ELNs are the optimal cut-off point for evaluating the quality of lymph node examination and stratification of prognosis.
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Affiliation(s)
- Xu Guan
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing
- Department of Colorectal Surgery, Shanxi Province Cancer Hospital/Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences/Cancer Hospital Affiliated to Shanxi Medical University, Taiyuan
| | - Shuai Jiao
- Department of Colorectal Surgery, Shanxi Province Cancer Hospital/Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences/Cancer Hospital Affiliated to Shanxi Medical University, Taiyuan
- Department of Colorectal Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin
| | - Rongbo Wen
- Department of Colorectal Surgery, Changhai Hospital, Naval Medical University, Shanghai
| | - Guanyu Yu
- Department of Colorectal Surgery, Changhai Hospital, Naval Medical University, Shanghai
| | - Jungang Liu
- Department of Gastrointestinal Surgery, Guangxi Medical University Cancer Hospital, Nanning, Guangxi Zhuang Autonomous Region
- Guangxi Clinical Research Center for Colorectal Cancer, Nanning, Guangxi Zhuang Autonomous Region
| | - Dazhuang Miao
- Department of Colorectal Surgery, Harbin Medical University Cancer Hospital, Harbin
| | - Ran Wei
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing
| | - Weiyuan Zhang
- Department of Colorectal Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin
| | - Liqiang Hao
- Department of Colorectal Surgery, Changhai Hospital, Naval Medical University, Shanghai
| | - Leqi Zhou
- Department of Colorectal Surgery, Changhai Hospital, Naval Medical University, Shanghai
| | - Zheng Lou
- Department of Colorectal Surgery, Changhai Hospital, Naval Medical University, Shanghai
| | - Shucheng Liu
- Colorectal Surgery Department, Chifeng Municipal Hospital, Chifeng
| | - Enliang Zhao
- Surgical Oncology Department, The Second Affiliated Hospital of Qiqihar Medical University, Qiqihar, China
| | - Guiyu Wang
- Department of Colorectal Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin
| | - Wei Zhang
- Department of Colorectal Surgery, Changhai Hospital, Naval Medical University, Shanghai
| | - Xishan Wang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing
- Department of Colorectal Surgery, Shanxi Province Cancer Hospital/Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences/Cancer Hospital Affiliated to Shanxi Medical University, Taiyuan
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Liu Y, Qi H, Deng C, Zhang Z, Guo Z, Li X. Advantages of ligating the rectum with gauze pad band in laparoscopic anterior resection of rectal cancer: a propensity score matched analysis. BMC Surg 2022; 22:368. [DOI: 10.1186/s12893-022-01822-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 10/17/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Purpose
It is difficult to maintain sufficient tension throughout laparoscopic anterior resection with total mesorectal excision, which causes a decline in surgical quality. We used a soft, inexpensive gauze pad band pulling the rectal tube to analyze the effect of surgery.
Methods
A gauze pad band was positioned at the proximal of the tumor, followed by fastening the rectal tube and ligating the rectum. 233 patients undergoing laparoscopic anterior resection for mid to low rectal cancer were enrolled between January 2018 and December 2020. After propensity score matching, 63 cases were selected in gauze pad band group and 126 cases were selected in traditional group. The two groups were compared in preoperative, intraoperative, and pathological characteristics.
Results
Compared to traditional group, the median operation duration (203 min vs. 233 min, p < 0.001) and the median intraoperative bleeding (48 ml vs. 67 ml, p < 0.001) were lesser in gauze pad band group. A higher percentage of one cartridge transection of rectum (36/63 vs. 51/126, p = 0.030), shorter length of cartridges used (6.88 ± 1.27 cm vs. 7.28 ± 1.25 cm, p = 0.040), and longer distal resection margin (2.74 ± 0.76 cm vs. 2.16 + 0.68 cm, p < 0.001) were found in the gauze pad band group. The completeness of total mesorectal excision (61/63 vs. 109/126, p = 0.022), harvested lymph nodes (19 vs. 17, p < 0.001) and positive lymph nodes (1 vs. 0, p = 0.046) were higher in gauze pad band group.
Conclusion
Ligation of the rectum with a gauze pad band allows for a reduction in operative time and intraoperative bleeding while increasing the rate of one cartridge transection. It also protected the quality of total mesorectal excision and membrane anatomy.
Trial registration: Not applicable.
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Cardoso R, Zhu A, Guo F, Heisser T, Hoffmeister M, Brenner H. Incidence and Mortality of Proximal and Distal Colorectal Cancer in Germany. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:281-287. [PMID: 34180790 DOI: 10.3238/arztebl.m2021.0111] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 07/31/2020] [Accepted: 12/15/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND The use of colonoscopy has increased and colorectal cancer (CRC) incidence has decreased after the introduction of screening colonoscopy in Germany. However, it remains unknown to what extent progress has been achieved in the prevention of cancer in the proximal colon, distal colon, and rectum. METHODS We analyzed trends in CRC incidence (2000-2016) and mortality (2000-2018) in Germany by sex, age, and tumor location. RESULTS The age-standardized incidence of CRC declined by 22.4% (from 65.3 to 50.7 per 100 000) in men and by 25.5% (from 42.7 to 31.8 per 100 000) in women. CRC mortality declined by 35.8% (from 29.6 to 19.0 per 100 000) in men and by 40.5% (19.0 to 11.3 per 100 000) in women. Despite demographic changes, the annual numbers of CRC cases and deaths still decreased from about 60 400 to 58 300 and from around 28 700 to 24 200, respectively. The decline in incidence was greatest in groups aged ≥ 55 years. While the incidence of cancer in the distal colon and rectum decreased by 34.5% and 26.2%, respectively, in men and by 41.0% and 27.9% in women, the incidence of proximal colon cancer remained stable in men and decreased by only 7.0% in women. However, a major shift towards earlier stages was observed for the proximal cancers. CONCLUSION The results support the assumption that the increased use of colo - noscopy has contributed to substantial reductions in the incidence of distal CRC incidence and the mortality from cancers in the entire colon and rectum.
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Affiliation(s)
- Rafael Cardoso
- Division of Preventive Oncology, German Cancer Research Center and National Center for Tumor Diseases, Heidelberg; Faculty of Medicine Heidelberg, University of Heidelberg; Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg; German Cancer Consortium, German Cancer Research Center, Heidelberg
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Cardoso R, Guo F, Heisser T, Hackl M, Ihle P, De Schutter H, Van Damme N, Valerianova Z, Atanasov T, Májek O, Mužík J, Nilbert MC, Tybjerg AJ, Innos K, Mägi M, Malila N, Bouvier AM, Bouvier V, Launoy G, Woronoff AS, Cariou M, Robaszkiewicz M, Delafosse P, Poncet F, Katalinic A, Walsh PM, Senore C, Rosso S, Vincerževskienė I, Lemmens VEPP, Elferink MAG, Johannesen TB, Kørner H, Pfeffer F, Bento MJ, Rodrigues J, Alves da Costa F, Miranda A, Zadnik V, Žagar T, Lopez de Munain Marques A, Marcos-Gragera R, Puigdemont M, Galceran J, Carulla M, Chirlaque MD, Ballesta M, Sundquist K, Sundquist J, Weber M, Jordan A, Herrmann C, Mousavi M, Ryzhov A, Hoffmeister M, Brenner H. Colorectal cancer incidence, mortality, and stage distribution in European countries in the colorectal cancer screening era: an international population-based study. Lancet Oncol 2021; 22:1002-1013. [PMID: 34048685 DOI: 10.1016/s1470-2045(21)00199-6] [Citation(s) in RCA: 189] [Impact Index Per Article: 63.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/29/2021] [Accepted: 03/30/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Colorectal cancer screening programmes and uptake vary substantially across Europe. We aimed to compare changes over time in colorectal cancer incidence, mortality, and stage distribution in relation to colorectal cancer screening implementation in European countries. METHODS Data from nearly 3·1 million patients with colorectal cancer diagnosed from 2000 onwards (up to 2016 for most countries) were obtained from 21 European countries, and were used to analyse changes over time in age-standardised colorectal cancer incidence and stage distribution. The WHO mortality database was used to analyse changes over time in age-standardised colorectal cancer mortality over the same period for the 16 countries with nationwide data. Incidence rates were calculated for all sites of the colon and rectum combined, as well as the subsites proximal colon, distal colon, and rectum. Average annual percentage changes (AAPCs) in incidence and mortality were estimated and relevant patterns were descriptively analysed. FINDINGS In countries with long-standing programmes of screening colonoscopy and faecal tests (ie, Austria, the Czech Republic, and Germany), colorectal cancer incidence decreased substantially over time, with AAPCs ranging from -2·5% (95% CI -2·8 to -2·2) to -1·6% (-2·0 to -1·2) in men and from -2·4% (-2·7 to -2·1) to -1·3% (-1·7 to -0·9) in women. In countries where screening programmes were implemented during the study period, age-standardised colorectal cancer incidence either remained stable or increased up to the year screening was implemented. AAPCs for these countries ranged from -0·2% (95% CI -1·4 to 1·0) to 1·5% (1·1 to 1·8) in men and from -0·5% (-1·7 to 0·6) to 1·2% (0·8 to 1·5) in women. Where high screening coverage and uptake were rapidly achieved (ie, Denmark, the Netherlands, and Slovenia), age-standardised incidence rates initially increased but then subsequently decreased. Conversely, colorectal cancer incidence increased in most countries where no large-scale screening programmes were available (eg, Bulgaria, Estonia, Norway, and Ukraine), with AAPCs ranging from 0·3% (95% CI 0·1 to 0·5) to 1·9% (1·2 to 2·6) in men and from 0·6% (0·4 to 0·8) to 1·1% (0·8 to 1·4) in women. The largest decreases in colorectal cancer mortality were seen in countries with long-standing screening programmes. INTERPRETATION We observed divergent trends in colorectal cancer incidence, mortality, and stage distribution across European countries, which appear to be largely explained by different levels of colorectal cancer screening implementation. FUNDING German Cancer Aid (Deutsche Krebshilfe) and the German Federal Ministry of Education and Research.
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Affiliation(s)
- Rafael Cardoso
- Division of Preventive Oncology, German Cancer Research Center and National Center for Tumor Diseases, Heidelberg, Germany; Medical Faculty Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Feng Guo
- Medical Faculty Heidelberg, University of Heidelberg, Heidelberg, Germany; Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
| | - Thomas Heisser
- Medical Faculty Heidelberg, University of Heidelberg, Heidelberg, Germany; Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
| | - Monika Hackl
- Austrian National Cancer Registry, Statistics Austria, Vienna, Austria
| | - Petra Ihle
- Austrian National Cancer Registry, Statistics Austria, Vienna, Austria
| | | | | | - Zdravka Valerianova
- Bulgarian National Cancer Registry, University Hospital of Oncology, Sofia, Bulgaria
| | - Trajan Atanasov
- Bulgarian National Cancer Registry, University Hospital of Oncology, Sofia, Bulgaria
| | - Ondřej Májek
- Institute of Health Information and Statistics of the Czech Republic, Prague, Czech Republic; Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jan Mužík
- Institute of Health Information and Statistics of the Czech Republic, Prague, Czech Republic; Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Mef Christina Nilbert
- Danish Cancer Society Research Center, Copenhagen, Denmark; Department of Clinical Medicine, Hvidovre University Hospital, University of Copenhagen, Copenhagen, Denmark
| | | | - Kaire Innos
- Department of Epidemiology and Biostatistics, National Institute for Health Development, Tallinn, Estonia
| | - Margit Mägi
- Estonian Cancer Registry, National Institute for Health Development, Tallinn, Estonia
| | - Nea Malila
- Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, Helsinki, Finland
| | - Anne-Marie Bouvier
- Digestive Cancer Registry of Burgundy, University Hospital of Dijon, INSERM U1231, French Network of Cancer Registries (FRANCIM), Dijon, France
| | - Véronique Bouvier
- Digestive Tumors Registry of Calvados, University Hospital of Caen, U1086 INSERM UCN-ANTICIPE, French Network of Cancer Registries (FRANCIM), Caen, France
| | - Guy Launoy
- Interdisciplinary Research Unit for the Prevention and Treatment of Cancer, Normandy University, University of Caen Normandy, INSERM-ANTICIPE, Caen, France; Department of Research, University Hospital of Caen, Caen, France
| | - Anne-Sophie Woronoff
- Cancer Registry of Doubs, Centre Hospitalier Régional Universitaire Besançon, Besançon, France
| | - Mélanie Cariou
- Digestive Tumors Registry of Finistère, Centre Hospitalier Régional Universitaire Morvan, French Network of Cancer Registries (FRANCIM), Brest, France
| | - Michel Robaszkiewicz
- Digestive Tumors Registry of Finistère, Centre Hospitalier Régional Universitaire Morvan, French Network of Cancer Registries (FRANCIM), Brest, France
| | - Patricia Delafosse
- Cancer Registry of Isère, French Network of Cancer Registries (FRANCIM), Grenoble, France
| | - Florence Poncet
- Cancer Registry of Isère, French Network of Cancer Registries (FRANCIM), Grenoble, France
| | | | | | - Carlo Senore
- University Hospital 'Città della Salute e della Scienza', SSD Epidemiologia Screening-CPO Piemonte, Turin, Italy
| | | | | | - Valery E P P Lemmens
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, Netherlands; Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Marloes A G Elferink
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, Netherlands
| | | | - Hartwig Kørner
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Frank Pfeffer
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Department of Surgery, Haukeland University Hospital, Bergen, Norway
| | - Maria José Bento
- Department of Epidemiology, North Region Cancer Registry of Portugal, Portuguese Oncology Institute of Porto, Porto, Portugal; IPO Porto Research Center, Portuguese Oncology Institute of Porto, Porto, Portugal; Department of Population Studies, Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
| | - Jessica Rodrigues
- Department of Epidemiology, North Region Cancer Registry of Portugal, Portuguese Oncology Institute of Porto, Porto, Portugal; IPO Porto Research Center, Portuguese Oncology Institute of Porto, Porto, Portugal
| | - Filipa Alves da Costa
- Portuguese National Cancer Registry, Portuguese Oncology Institute of Lisbon, Lisbon, Portugal
| | - Ana Miranda
- Portuguese National Cancer Registry, Portuguese Oncology Institute of Lisbon, Lisbon, Portugal
| | - Vesna Zadnik
- Slovenian Cancer Registry, Institute of Oncology, Ljubljana, Slovenia
| | - Tina Žagar
- Slovenian Cancer Registry, Institute of Oncology, Ljubljana, Slovenia
| | | | - Rafael Marcos-Gragera
- Epidemiology Unit and Girona Cancer Registry, Oncology Coordination Plan, Department of Health Government of Catalonia, Catalan Institute of Oncology, Girona, Spain; Descriptive Epidemiology, Genetics and Cancer Prevention Group, Biomedical Research Institute, Salt, Spain; Consortium for Biomedical Research in Epidemiology and Public Health, Madrid, Spain
| | - Montse Puigdemont
- Epidemiology Unit and Girona Cancer Registry, Oncology Coordination Plan, Department of Health Government of Catalonia, Catalan Institute of Oncology, Girona, Spain; Descriptive Epidemiology, Genetics and Cancer Prevention Group, Biomedical Research Institute, Salt, Spain
| | - Jaume Galceran
- Tarragona Cancer Registry, Epidemiology and Prevention Cancer Service, Hospital Universitari Sant Joan de Reus, Pere Virgili Health Research Institute, Reus, Spain
| | - Marià Carulla
- Tarragona Cancer Registry, Epidemiology and Prevention Cancer Service, Hospital Universitari Sant Joan de Reus, Pere Virgili Health Research Institute, Reus, Spain
| | - María-Dolores Chirlaque
- Consortium for Biomedical Research in Epidemiology and Public Health, Madrid, Spain; Tarragona Cancer Registry, Epidemiology and Prevention Cancer Service, Hospital Universitari Sant Joan de Reus, Pere Virgili Health Research Institute, Reus, Spain
| | - Monica Ballesta
- Consortium for Biomedical Research in Epidemiology and Public Health, Madrid, Spain; Department of Epidemiology, Regional Health Council, IMIB-Arrixaca, Murcia University, Murcia, Spain
| | - Kristina Sundquist
- Department of Clinical Sciences, Center for Primary Health Care Research, Lund University, Malmö, Sweden; Department of Family Medicine and Community Health, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Center for Community-based Healthcare Research and Education, Department of Functional Pathology, School of Medicine, Shimane University, Shimane, Japan
| | - Jan Sundquist
- Department of Clinical Sciences, Center for Primary Health Care Research, Lund University, Malmö, Sweden; Department of Family Medicine and Community Health, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Center for Community-based Healthcare Research and Education, Department of Functional Pathology, School of Medicine, Shimane University, Shimane, Japan
| | - Marco Weber
- Cancer Registry Bern-Solothurn, Bern, Switzerland
| | | | - Christian Herrmann
- Cancer Registry of Eastern Switzerland and Liechtenstein, St Gallen, Switzerland; Graubünden and Glarus Cancer Registry, Chur, Switzerland
| | - Mohsen Mousavi
- Cancer Registry of Eastern Switzerland and Liechtenstein, St Gallen, Switzerland; Graubünden and Glarus Cancer Registry, Chur, Switzerland
| | - Anton Ryzhov
- National Cancer Registry of Ukraine, National Institute of Cancer, Kyiv, Ukraine; Taras Shevchenko National University of Kyiv, Kyiv, Ukraine
| | - Michael Hoffmeister
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
| | - Hermann Brenner
- Division of Preventive Oncology, German Cancer Research Center and National Center for Tumor Diseases, Heidelberg, Germany; Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany; German Cancer Consortium, German Cancer Research Center, Heidelberg, Germany.
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Safari M, Mahjub H, Esmaeili H, Abbasi M, Roshanaei G. Determining the Risk Factors Affecting on Death Due to Colorectal Cancer Progression: Survival Analysis in the Presence of Competing Risks. J Gastrointest Cancer 2021; 53:348-355. [PMID: 33656691 DOI: 10.1007/s12029-021-00609-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE In survival analysis, some patients may be at risk of more than one event, for example cancer-related death and cancer-unrelated death. In this case, if the aim of study becomes to assess the impact of risk factors on different causes of death, the competing risk model should be used rather than classical survival model. The aim of the present study is to determine the risk factors for related and unrelated mortality in patients with colorectal cancer using competing risk regression models. METHODS The present retrospective cohort study was carried out on 310 CRC patients. Death due to cancer progression was considered as the interest event, and death due to unrelated cancer was considered as a competing event. Two most popular methods, cause-specific and subdistribution hazard regression model, were used to determine the effect of covariates on incidence and cause-specific hazard. Data analysis was performed using R3.6.2 software and cmprsk and survival packages. RESULTS The mean (SD) of patients' age was 55.84 ± 13.2 years and 53.9% of them were male. BMI, T and N stage had a significant effect on both incidence and cause specific hazard of cancer-related death. CONCLUSION The results of this study showed that cancer-related death is strongly correlated with under-weight (BMI < 18.5) and advanced clinical stage of the disease in patients with colorectal cancer. So, in the presence of competing events, both types of regression hazard models should be applied to permit a full understanding of the impact of covariates on the incidence and the rate of occurrence of each outcome.
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Affiliation(s)
- Malihe Safari
- Department of Biostatistics, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Hossein Mahjub
- Research Center for Health Sciences, Department of Biostatistics, Faculty of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Habib Esmaeili
- PhD in Mathematics, Principal Statistician and Project Lead, Staburo GmbH, Munich, Germany
| | - Mohammad Abbasi
- Department of Internal Medicine, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Ghodratollah Roshanaei
- Associate Professor in Biostatistics, Department of Biostatistics, School of Public Health, Modeling of Noncommunicable Diseases Research Center, Hamadan University of Medical Sciences, Hamadan, Iran.
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7
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Lee CHA, Wilkins S, Oliva K, Staples MP, McMurrick PJ. Role of lymph node yield and lymph node ratio in predicting outcomes in non-metastatic colorectal cancer. BJS Open 2018; 3:95-105. [PMID: 30734020 PMCID: PMC6354193 DOI: 10.1002/bjs5.96] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 07/02/2018] [Indexed: 02/06/2023] Open
Abstract
Background Lymph node yield (LNY) of 12 or more in resection of colorectal cancer is recommended in current international guidelines. Although a low LNY (less than 12) is associated with poorer outcome in some studies, its prognostic value is unclear in patients with early‐stage colorectal or rectal cancer with a complete pathological response following neoadjuvant therapy. Lymph node ratio (LNR), which reflects the proportion of positive to total nodes obtained, may be more accurate in predicting outcome in stage III colorectal cancer. This study aimed to identify factors correlating with LNY and evaluate the prognostic role of LNY and LNR in colorectal cancer. Methods An observational study was performed on patients with colorectal cancer treated at three hospitals in Melbourne, Australia, from January 2010 to March 2016. Association of LNY and LNR with clinical variables was analysed using linear regression. Disease‐free (DFS) and overall (OS) survival were investigated with Cox regression and Kaplan–Meier survival analyses. Results Some 1585 resections were analysed. Median follow‐up was 27·1 (range 0·1–71) months. Median LNY was 16 (range 0–86), and was lower for rectal cancers, decreased with increasing age, and increased with increasing stage. High LNY (12 or more) was associated with better DFS in colorectal cancer. Subgroup analysis indicated that low LNY was associated with poorer DFS and OS in stage III colonic cancer, but had no effect on DFS and OS in rectal cancer (stages I–III). Higher LNR was predictive of poorer DFS and OS. Conclusion Low LNY (less than 12) was predictive of poor DFS in stage III colonic cancer, but was not a factor for stage I or II colonic disease or any rectal cancer. LNR was a predictive factor in DFS and OS in stage III colonic cancer, but influenced DFS only in rectal cancer.
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Affiliation(s)
- C H A Lee
- Cabrini Monash University Department of Surgery Cabrini Hospital Malvern Victoria Australia
| | - S Wilkins
- Cabrini Monash University Department of Surgery Cabrini Hospital Malvern Victoria Australia.,Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine Monash University Melbourne Victoria Australia
| | - K Oliva
- Cabrini Monash University Department of Surgery Cabrini Hospital Malvern Victoria Australia
| | - M P Staples
- Cabrini Institute Cabrini Hospital Malvern Victoria Australia
| | - P J McMurrick
- Cabrini Monash University Department of Surgery Cabrini Hospital Malvern Victoria Australia
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Galata C, Merx K, Mai S, Gaiser T, Wenz F, Post S, Kienle P, Hofheinz RD, Horisberger K. Impact of adjuvant chemotherapy on patients with ypT0-2 ypN0 rectal cancer after neoadjuvant chemoradiation: a cohort study from a tertiary referral hospital. World J Surg Oncol 2018; 16:156. [PMID: 30071852 PMCID: PMC6091008 DOI: 10.1186/s12957-018-1455-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 07/19/2018] [Indexed: 02/07/2023] Open
Abstract
Background To investigate the importance of adjuvant chemotherapy in locally advanced rectal cancer (≥ cT3 or N+) staged ypT0–2 ypN0 on final histological work-up after neoadjuvant chemoradiation and radical resection. Methods The clinical course of patients with rectal cancer and ypT0–2 ypN0 stages after neoadjuvant chemoradiation and radical resection was analyzed from 1999 to 2012. Patients were divided into two groups depending on whether adjuvant chemotherapy was administered or not. Overall survival, distant metastases, and local recurrence were compared between both groups. Results Fifty-four patients with adjuvant (ACT) and 50 patients without adjuvant chemotherapy (NACT) after neoadjuvant chemoradiation followed by radical resection for rectal cancer were included in the analysis. Mean follow-up was 68 ± 33.7 months. One patient without adjuvant chemotherapy and none in the ACT group developed a local recurrence. Five patients in the NACT group and three patients in the ACT group had distant recurrences. Median disease-free survival for all patients was 65.5 ± 34.5 months. Multivariate analysis showed adjuvant chemotherapy to be the most relevant factor for disease-free and overall survival. Patients staged ypT2 ypN0 showed a significantly better disease-free survival after application of adjuvant chemotherapy. Disease-free survival in ypT0–1 ypN0 patients showed no correlation to the administration of adjuvant chemotherapy. Conclusion Administration of adjuvant chemotherapy after neoadjuvant chemoradiation and radical resection in rectal cancer improved disease-free and overall survival of patients with ypT0–2 ypN0 tumor stages in our study. In particular, ypT2 ypN0 patients seem to profit from adjuvant treatment.
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Affiliation(s)
- Christian Galata
- Department of Surgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Kirsten Merx
- Interdisciplinary Tumor Centre, III. Department of Internal Medicine, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Sabine Mai
- Institute for Radiotherapy and Radiooncology, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Timo Gaiser
- Institute for Pathology, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Frederik Wenz
- Institute for Radiotherapy and Radiooncology, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Stefan Post
- Department of Surgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Peter Kienle
- Department of Surgery, Theresienkrankenhaus Mannheim, Mannheim, Germany
| | - Ralf-Dieter Hofheinz
- Interdisciplinary Tumor Centre, III. Department of Internal Medicine, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Karoline Horisberger
- Department of Surgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.,Department of Visceral and Transplant Surgery, Universitätsspital Zürich, Zürich, Switzerland
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Arnold A, Kloor M, Jansen L, Chang-Claude J, Brenner H, von Winterfeld M, Hoffmeister M, Bläker H. The association between microsatellite instability and lymph node count in colorectal cancer. Virchows Arch 2017; 471:57-64. [DOI: 10.1007/s00428-017-2150-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 04/26/2017] [Accepted: 05/12/2017] [Indexed: 12/12/2022]
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A nomogram improves AJCC stages for colorectal cancers by introducing CEA, modified lymph node ratio and negative lymph node count. Sci Rep 2016; 6:39028. [PMID: 27941905 PMCID: PMC5150581 DOI: 10.1038/srep39028] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 11/16/2016] [Indexed: 02/07/2023] Open
Abstract
Lymph node stages (pN stages) are primary contributors to survival heterogeneity of the 7th AJCC staging system for colorectal cancer (CRC), indicating spaces for modifications. To implement the modifications, we selected eligible CRC patients from the Surveillance Epidemiology and End Results (SEER) database as participants in a training (n = 6675) and a test cohort (n = 6760), and verified tumor deposits to be metastatic lymph nodes to derive modified lymph node count (mLNC), lymph node ratio (mLNR), and positive lymph node count (mPLNC). After multivariate Cox regression analyses with forward stepwise elimination of the mLNC and mPLNC for the training cohort, a nomogram was constructed to predict overall survival (OS) via incorporating preoperative carcinoembryonic antigen, pT stages, negative lymph node count, mLNR and metastasis. Internal validations of the nomogram showed concordance indexes (c-index) of 0.750 (95% CI, 0.736-0.764) and 0.749 before and after corrections for overfitting. Serial performance evaluations indicated that the nomogram outperformed the AJCC stages (c-index = 0.725) with increased accuracy, net benefits, risk assessment ability, but comparable complexity and clinical validity. All the results were reproducible in the test cohort. In summary, the proposed nomogram may serve as an alternative to the AJCC stages. However, validations with longer follow-up periods are required.
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Liu TP, Huang CC, Yeh KT, Ke TW, Wei PL, Yang JR, Cheng YW. Down-regulation of let-7a-5p predicts lymph node metastasis and prognosis in colorectal cancer: Implications for chemotherapy. Surg Oncol 2016; 25:429-434. [DOI: 10.1016/j.suronc.2016.05.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 03/15/2016] [Accepted: 05/19/2016] [Indexed: 02/06/2023]
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Märkl B, Schaller T, Kokot Y, Endhardt K, Kretsinger H, Hirschbühl K, Aumann G, Schenkirsch G. Lymph node size as a simple prognostic factor in node negative colon cancer and an alternative thesis to stage migration. Am J Surg 2016; 212:775-780. [DOI: 10.1016/j.amjsurg.2015.05.026] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 05/08/2015] [Accepted: 05/24/2015] [Indexed: 12/19/2022]
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Emmanuel A, Haji A. Complete mesocolic excision and extended (D3) lymphadenectomy for colonic cancer: is it worth that extra effort? A review of the literature. Int J Colorectal Dis 2016; 31:797-804. [PMID: 26833471 DOI: 10.1007/s00384-016-2502-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/05/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE Recent interest in complete mesocolic excision (CME) with central vascular ligation (CVL) or extended (D3) lymphadenectomy (EL) for curative resection of colon cancer has been driven by published series from experienced practitioners showing excellent survival outcomes and low recurrence rates. In this article, we attempt to clarify the role of CME or EL in modern colorectal surgery. METHODS A narrative review of the evidence for CME and EL in the curative treatment of colon cancer. RESULTS The principal of CME surgery, similar to total mesorectal excision (TME) for rectal cancer, is the removal of all lymphatic, vascular, and neural tissue in the drainage area of the tumour in a complete mesocolic envelope with intact mesentery, peritoneum and encasing fascia. Extended (D3) lymphadenectomy (EL) is based on similar principles. Sound anatomical and oncological arguments are made to support the principles of removing the tumor contained within an intact mesocolic facial envelope together with an extended lymph node harvest. Excellent oncological outcomes with minimal morbidity and mortality have been reported. This has led to calls for the standardisation of surgery for colon cancer using CME. However, there is conflicting evidence regarding the prognostic benefit of greater lymph node harvests and the evidence for an oncological benefit of CME is limited by methodology flaws and several potential confounding factors. CONCLUSIONS Although there is a reasonable anatomical and oncological basis for these techniques, there are no randomised controlled trials from which to draw confident conclusions and there is insufficient consistent high quality evidence to recommend widespread adoption of CME.
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Affiliation(s)
- Andrew Emmanuel
- Department of Colorectal Surgery, King's College Hospital, King's College Hospital NHS Foundation Trust, 2nd Floor Hambelden Wing, Denmark Hill, London, SE5 9RS, UK.
| | - Amyn Haji
- Department of Colorectal Surgery, King's College Hospital, King's College Hospital NHS Foundation Trust, 2nd Floor Hambelden Wing, Denmark Hill, London, SE5 9RS, UK
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