[Deficits in management of patients with colorectal carcinoma in Germany. Results of multicenter documentation of therapy algorithms]

Desmoplasia influenced recurrence of disease and mortality in stage III colorectal cancer within five years after surgery and adjuvant therapy

BACKGROUND/AIMS

In patients with colon cancer who undergo resection for potential cure, 40-60% have advanced locoregional disease (stage III). Those who are suitable for adjuvant treatment had a definite disease-free-survival benefit. The aim of the present study was to demonstrate whether the presence of desmoplasia influenced the mortality rate of stage III colorectal cancer (CRC) within 5 years from the surgery and adjuvant therapy.

PATIENTS AND METHODS

Sixty-five patients with stage III CRC underwent resection and adjuvant therapy. Qualitative categorization of desmoplasia was obtained using Ueno's stromal CRC classification. Desmoplasia was related to mortality using Spearman correlation and stratified with other histological variables (inflammation, grading) that concurred to the major determinant of malignancy (venous invasion and lymph nodes) using the Chi-square test.

RESULT

The 5-year survival rate was 65% and the relapse rate was 37%. The mortality rate in patients with immature desmoplasia was 86%, 27% in intermediate desmoplasia, and 0% in mature desmoplasia (Spearman correlation coefficient: -0.572,P= 0.05).

CONCLUSION

Immature desmoplasia appears to be associated with disease recurrence and mortality in stage III CRC patients.

Clinical competence in the surgery of rectal cancer: the Italian Consensus Conference

BACKGROUND AND AIM

The literature continues to emphasize the advantages of treating patients in "high volume" units by "expert" surgeons, but there is no agreed definition of what is meant by either term. In September 2012, a Consensus Conference on Clinical Competence was organized in Rome as part of the meeting of the National Congress of Italian Surgery (I Congresso Nazionale della Chirurgia Italiana: Unità e valore della chirurgia italiana). The aims were to provide a definition of "expert surgeon" and "high-volume facility" in rectal cancer surgery and to assess their influence on patient outcome.

METHOD

An Organizing Committee (OC), a Scientific Committee (SC), a Group of Experts (E) and a Panel/Jury (P) were set up for the conduct of the Consensus Conference. Review of the literature focused on three main questions including training, "measuring" of quality and to what extent hospital and surgeon volume affects sphincter-preserving procedures, local recurrence, 30-day morbidity and mortality, survival, function, choice of laparoscopic approach and the choice of transanal endoscopic microsurgery (TEM).

RESULTS AND CONCLUSION

The difficulties encountered in defining competence in rectal surgery arise from the great heterogeneity of the parameters described in the literature to quantify it. Acquisition of data is difficult as many articles were published many years ago. Even with a focus on surgeon and hospital volume, it is difficult to define their role owing to the variability and the quality of the relevant studies.

XELOX versus FOLFOX6 as an adjuvant treatment in colorectal cancer: an economic analysis

OBJECTIVES

An economic analysis (based on interim data from a long-term, randomised, multi-centre, controlled, clinical trial) to evaluate chemotherapy with XELOX (capecitabine/oxaliplatin) versus FOLFOX6 (5Fluorouracil/leucovorin/oxaliplatin) as an adjuvant treatment for high risk colorectal cancer patients in Greece.

METHODS

As survival rate was the same in the two arms, a cost-minimisation analysis was carried out, from the perspectives of the National Health Service (NHS), Social Insurance Funds (SIF) and patients in Greece. Patient data were combined with 2008 unit prices to estimate the total cost of patient care, the patients' travelling expenditure and their productivity losses. Raw data were bootstrapped 5000 times in order to allow statistical testing.

RESULTS

From an NHS perspective, the mean chemotherapy cost was 8762 euro with FOLFOX6 and 9713 euro with XELOX; costs of administration and hospitalisations were 5154 euro and 1050 euro, respectively. Total treatment cost with FOLFOX6 reached 17,480 euro and with XELOX 12 525 euro, a difference of 4955 euro (p < 0.001) in favour of the latter therapy. From an SIF perspective, the total cost of treatment was 16,240 euro with FOLFOX6 and 12,617 euro with XELOX, a reduction of 3623 euro (p < 0.001) with the latter therapy. Mean patient travelling cost was 184 euro with FOLFOX6 and 80 euro with XELOX, a difference of 104 euro (p < 0.001). Mean productivity loss was 100 euro with FOLFOX6 and 31 euro with XELOX, a difference of 69 euro (p < 0.001).

CONCLUSIONS

Chemotherapy combining oral capecitabine and oxaliplatin reduces total treatment cost for the Greek National Health Service and Social Insurance Funds, mainly through a reduction in the cost of administration. From patients' perspective, it reduces travelling expenditure and productivity losses. Therefore, this combination may be a cost-effective approach for the management of colorectal cancer patients who have had surgery in Greece. This is an analysis alongside a clinical trial, and should be interpreted in this specific context in which it was undertaken.

[Health services research and geriatrics: deficits and research approaches using the example of colorectal carcinoma and anaemia]

The number of elderly people with cancer will increase within the next decades. Cancer will surpass cardiovascular diseases as the leading cause of death. In comparison to younger patients elderly patients with cancer are less often treated within the scope of clinical trials. Data from health care research demonstrate that the treatment of elderly patients is less often guideline-directed than that of younger patients. This will be demonstrated in more detail for patients with colorectal carcinoma and for patients with anaemia. Older people are reluctant to participate in programs for the early detection of colorectal carcinoma and its precursors. They less often receive adjuvant chemotherapy in stage III disease, despite the fact that adjuvant chemotherapy is no more toxic than in younger patients and equally effective and therefore recommended in the guidelines. Compared to younger patients, elderly patients less often receive palliative chemotherapy in stage IV disease. Anaemia has a prevalence of about 10% in people aged 65 and more; the reported values are highly variable. There is a lack of data on the grade of evaluation. Also, there are no diagnostic and therapeutic guidelines in Germany. Health services research will play an important role in assessing deficits in the diagnosis and therapy of cancer diseases in the elderly and in determining the goals for future efforts in health care and research.

The quality of chemotherapy and its quality assurance

AIMS

Assessment of the quality of chemotherapy care and its quality assurance in clinical trials and daily practice.

METHODS

Using Medline, literature was searched combining the following words: quality assurance or quality of care, combined with anti-neoplastic agents. The bibliography of each article was reviewed for additional literature. Those reports in English, French, German or Dutch focusing quality assurance or quality of care and chemotherapy were selected.

RESULTS

One hundred and five articles were selected by Medline and after review and adding of additional literature 53 articles remained. In clinical trials information on quality of chemotherapy is sparse. Different cooperative groups reported on suboptimal dosing, suboptimal registration of chemotherapy and several trials indicated that suboptimal dosing led to impaired outcome. Most quality assurance activities in clinical trials are concerned with audit and feedback and on-site visits. In daily practice the quality of chemotherapy is mostly impaired by the fact that it is not given although indicated and if it is given non-evidence based chemotherapy or administration schedules and reduced dose intensity decrease the quality of care. Especially, age, comorbidity and socio-economic status reduce the chance of receiving good quality of care regarding chemotherapy. Activities mostly used for quality assurance are generation of guidelines, specialisation and multidisciplinary care.

CONCLUSIONS

Most quality assurance activities in clinical trials and daily practice are directed to structure and process parameters. More evidence that quality of care is related to outcome should be sought. Quality assurance in daily practice should aim at guideline implementation, specialisation and multidisciplinary care and should pay attention especially to the older patients, patients with comorbidity and patients from lower socio-economic classes.

Capecitabine as adjuvant treatment for stage III colon cancer

BACKGROUND

Intravenous bolus fluorouracil plus leucovorin is the standard adjuvant treatment for colon cancer. The oral fluoropyrimidine capecitabine is an established alternative to bolus fluorouracil plus leucovorin as first-line treatment for metastatic colorectal cancer. We evaluated capecitabine in the adjuvant setting.

METHODS

We randomly assigned a total of 1987 patients with resected stage III colon cancer to receive either oral capecitabine (1004 patients) or bolus fluorouracil plus leucovorin (Mayo Clinic regimen; 983 patients) over a period of 24 weeks. The primary efficacy end point was at least equivalence in disease-free survival; the primary safety end point was the incidence of grade 3 or 4 toxic effects due to fluoropyrimidines.

RESULTS

Disease-free survival in the capecitabine group was at least equivalent to that in the fluorouracil-plus-leucovorin group (in the intention-to-treat analysis, P<0.001 for the comparison of the upper limit of the hazard ratio with the noninferiority margin of 1.20). Capecitabine improved relapse-free survival (hazard ratio, 0.86; 95 percent confidence interval, 0.74 to 0.99; P=0.04) and was associated with significantly fewer adverse events than fluorouracil plus leucovorin (P<0.001).

CONCLUSIONS

Oral capecitabine is an effective alternative to intravenous fluorouracil plus leucovorin in the adjuvant treatment of colon cancer.

Oral capecitabine: Bridging the Atlantic divide in colon cancer treatment

5-Fluorouracil (5-FU) plus leucovorin (LV) has been the mainstay of treatment for colorectal cancer (CRC), with infused schedules more widely adopted in Europe and bolus schedules preferred in North America. However, the effective, oral fluoropyrimidine capecitabine is increasingly replacing intravenous (IV) 5-FU/LV on both sides of the Atlantic. Capecitabine generates 5-FU preferentially in tumor and is a well-established, first-line treatment for metastatic CRC. In this setting, capecitabine achieves a superior response rate, at least equivalent time to disease progression (TTP) and overall survival, and favorable safety compared with bolus 5-FU/LV. The benefits of capecitabine have been transfered into the adjuvant setting. Recent data from a large, international, randomized trial (Xeloda Adjuvant Chemotherapy Trial [X-ACT]) confirm that capecitabine (Xeloda, Roche Laboratories, Nutley, NJ) achieves favorable safety versus 5-FU/LV (Mayo Clinic regimen) and is at least as effective as IV 5-FU/LV in the adjuvant treatment of patients with resected stage III colon cancer. Capecitabine is also an effective and well-tolerated combination partner for oxaliplatin (XELOX) and irinotecan (XELIRI), achieving high efficacy with a good safety profile. An extensive phase III clinical trial program is further establishing the potential of the simplified capecitabine combinations to improve outcomes and unify treatment practices in the metastatic and adjuvant settings. New combinations with novel agents such as capecitabine/oxaliplatin plus erlotinib or bevacizumab are currently under investigation. Capecitabine has also shown promising activity and good tolerability in combination with radiotherapy in rectal cancer.

Application of adjuvant chemotherapy in colorectal cancer -- a survey in the region of Essen, Germany

BACKGROUND

The value of adjuvant chemotherapy (AC) in colorectal carcinoma (CRC) is definitely proven and its application is clearly recommended by the German Cancer Society (GCS). The goal of this study was to investigate whether these findings and recommendations have been introduced in daily practice and whether this might depend on the specialization of the treating physicians.

PATIENTS AND METHODS

Patients presenting with CRC in the department of oncology of the Kliniken Essen-Mitte between 1997 and 2002 who had started AC until the end of 2001 were evaluated. Data on AC were collected retrospectively from patients' records and prospectively by patient interviews. We investigated whether the guidelines of the GCS were followed and whether 5-fluorouracil (5-FU) was applied properly and we correlated the results with the treating institution.

RESULTS

133 patients were analyzed for correlation of their treatment with the guidelines of the GCS. In 81% the AC met these guidelines. This was significantly more frequent in oncologic institutions than in non-specialized ones (96 vs. 9%, p < 0.001). Regarding dose and infusion time chemotherapy was properly administered to 83% of the patients (109/132) treated with 5-FU. Again, correct treatment was significantly correlated with specialization of the physicians (98 vs. 9%, medical oncology vs. other, p < 0.001).

CONCLUSIONS

The results of our random search in the region of Essen, Germany, lead to the hypothesis that a quality-assured chemotherapy is best provided by specialized oncologic institutions, even if the treatment has been established for years. This should be proven by a large epidemiologic study.

Costs of treatment of colorectal cancer in different settings in Germany

The objective of this study was to evaluate the cost implications of different settings (inpatient, outpatient/day clinic, or office-based oncologists) for the administration of standard fluoropyrimidine therapies, i.e., Mayo Clinic and Arbeitsgemeinschaft Internistische Onkologie (AIO)/Ardalan regimen, and to compare the results with the cost of oral capecitabine in Germany. In total, 89 quarterly fee-listings from 26 patients provided by 5 office-based oncologists were analyzed. Physician's services, drug costs, pharmacy costs, and costs for implantable venous port systems and single-use pumps were considered. Findings were transferred to the hospital setting. A third-party payer perspective was applied. Quarterly treatment costs for the Mayo Clinic regimen varied between <euro> 2,036 and <euro> 10,569, and between <euro> 1,294 and <euro> 10,179 for the AIO/Ardalan regimen depending on the treatment setting. Projected costs for capecitabine were <euro> 2,338. No hospitalization was considered to be necessary for capecitabine due to its oral administration route. The most expensive treatment options were the AIO/Ardalan protocol in the office-based setting and the Mayo Clinic protocol in the hospital setting. Capecitabine emerged as the cheapest option in the office-based setting. Overall, the cheapest option was the AIO/Ardalan protocol in municipal hospitals. However, municipal hospitals are unlikely to cover their costs in this situation. Substantial cost savings without incurring losses to providers may be realized if patients are transferred from the hospital setting to the office-based setting and treated with capecitabine.