Anemia in patients with colorectal cancer

Goblet cell adenocarcinoma of the ascending colon: An underrecognized diagnostic pitfall

Goblet cell adenocarcinomas (GCA) are infrequent neoplasms of the digestive system that exhibit both mucinous and neuroendocrine differentiation. They predominate in the appendix and rarely involve the colon. Herein, the authors report a case of GCA involving the ascending colon in a 60-year-old woman who presented with severe anemia.

Absolute and Functional Iron Deficiency in Colon Cancer: A Cohort Study

Background and Objectives: Iron is an essential micronutrient for many biological functions and has been found to be intimately linked to cancer biology. Although the effects of increased dietary iron consumption in the development of CRC have been previously investigated in several cohort studies, the available evidence on the involvement of iron deficiency in this process is relatively scarce. Previously published papers did not analyze specific outcomes, such as the presence of biologically aggressive histopathological characteristics, that are associated with the subtypes of iron deficiency. The purpose of this study was to investigate the connection between the development of colorectal cancer and the presence of functional iron deficiency (FID), which is defined as insufficient biological availability of iron in the presence of adequate storage reserves, or absolute iron deficiency (AID), which is defined as severely depleted iron storage levels. Materials and Methods: Our paper represents a single center registry-based cohort study. Iron levels were routinely evaluated upon diagnosis of CRC and the collected data were coupled with patient- and tumor-specific data (2018–2022). Spearman’s correlation coefficient and the chi-squared test were used to analyze the association. Results: Out of 129 patients, 75 (58.13%) were anemic. AID was identified in 26.35% of cases and FID was encountered in 51.16% of cases. A statistically significant association between FID and lymphatic invasion was encountered. An analysis of the correlation demonstrated a significant association between anemia and right-sided tumor location. Conclusions: Functional iron deficiency seems to be independently associated with lymphatic invasion. Although a statistically significant correlation with the T or N stage was not demonstrated, the analysis suggested a potential positive relationship between the presence of FID and more aggressive tumor characteristics.

Diagnosis of Peritoneal Carcinomatosis of Colorectal Origin Based on an Innovative Fuzzy Logic Approach

Colorectal cancer represents one of the most important causes worldwide of cancer related morbidity and mortality. One of the complications which can occur during cancer progression, is peritoneal carcinomatosis. In the majority of cases, it is diagnosed in late stages due to the lack of diagnostic tools capable of revealing the early-stage peritoneal burden. Therefore, still associates with poor prognosis and quality of life, despite recent therapeutic advances. The aim of the study was to develop a fuzzy logic approach to assess the probability of peritoneal carcinomatosis presence using routine blood test parameters as input data. The patient data was acquired retrospective from patients diagnosed between 2010-2021. The developed model focuses on the specific quantitative alteration of these parameters in the presence of peritoneal carcinomatosis, which is an innovative approach as regards the literature in the field and validates the feasibility of using a fuzzy logic approach in the noninvasive diagnosis of peritoneal carcinomatosis.

The impact of preoperative anemia on pancreatic resection outcomes

BACKGROUND

Preoperative anemia is a risk factor for blood transfusions and delayed postoperative recovery, but few data are available for pancreatic surgery. Aim of the study was to analyze the impact of preoperative anemia on outcomes after pancreatic resection.

METHODS

Retrospective review of 1107 patients resected at San Raffaele Hospital (2015-2018). Preoperative anemia was defined as hemoglobin lower than 130 g/L for men and 120 g/L for women. Primary outcome was 90-day comprehensive complication index (CCI). Analysis was stratified according to type of surgery; proximal resections (pancreaticoduodenectomy and total pancreatectomy) versus distal pancreatectomy.

RESULTS

In 776 proximal resection patients, preoperative anemia was associated with increased CCI (24 ± 25 vs. 19 ± 23, p = 0.018) and perioperative allogenic blood transfusions (n = 124, 46% vs. n = 129, 26%; p < 0.001). Multivariate analysis showed that anemia was associated with a 7% (95%CI 0.02-0.57 p = 0.047) increase in CCI, and was an independent factor associated with perioperative blood transfusion (OR 2.762, 95%CI 1.72-4.49, p < 0.001). In 331 distal pancreatectomies, anemia was not associated to increased morbidity but only to an increased risk of perioperative blood transfusion.

CONCLUSION

Preoperative anemia is an independent risk factor for increased complication severity and blood transfusion in patients undergoing major pancreatic resection.

An Applicable Inflammation-Joined and Nutrition-Related Prognostic Indicator in Patients With Colorectal Cancer

Purpose

This study aimed to elucidate the prognostic significance of a novel inflammation-joined and nutrition-related clinicopathological marker for colorectal cancer (CRC).

Methods

Various factors from preoperative fasting blood samples from 2471 patients with CRC were retrospectively analyzed. Factors related to prognosis were evaluated using univariate and multivariate analyses. The Kaplan–Meier method was used to generate survival curves, while the log-rank test was used to measure survival differences between groups.

Results

Univariate analysis revealed that C-reactive protein (CRP)/mean corpuscular volume (MCV) ratio, TNM stage, differentiation, right-sided tumor, age, carcinoembryonic antigen (CEA) level, and CRP level were significantly associated with poor prognosis in CRC. In contrast, adjuvant chemotherapy is regarded as a protective factor. Elevation of CRP/MCV ratio (odds ratio [OR]: 1.535, 95% confidence interval [CI]: 1.121–2.104, P = 0.008), TNM stage (OR: 2.747, 95% CI: 2.175–3.469, P < 0.001), and differentiation (OR, 1.384; 95% CI, 1.150–1.666; P = 0.001) were prognostic risk factors in the multivariate analyses. Subgroup analysis showed that CRP/MCV, TNM staging system, and differentiation also independently affected survival in patients with lymph node-positive CRC. The nomogram based on these three indicators showed that CRP/MCV had a greater prognostic value and clinical significance for lymph node-positive patients with poorly differentiated tumors at the late stage.

Conclusion

A novel nomogram using the clinicopathologic index of inflammation and nutrition was constructed to predict the prognosis of CRC. Early interventions should be emphasized for advanced-stage patients with severe inflammation and poor nutritional status.

Anaemia and its impact on colorectal cancer patients: how can we better optimize surgical outcomes?

BACKGROUND

Anaemia is a common manifestation of colorectal cancer (CRC). However, appropriate workup prior to surgery and the effect of anaemia on outcomes have not been well defined. This study aimed to describe preoperative anaemia incidence, investigations performed, treatment and associated complications in a CRC surgical population at a single large tertiary institution in Australia.

METHODS

Patients who received surgery with curative intent for CRC between 2012 and 2017 were identified from a prospectively maintained database. Demographic and clinical outcome data were analysed.

RESULTS

In total, 754 patients with CRC were included. Anaemia was found in 350 (46.4%) patients, of which 124 (35.4%) were microcytic, 20 (5.7%) were macrocytic and 206 (58.9%) were normocytic. Older patients were more likely to have anaemia (mean age 70.28 years, standard deviation (SD) 12.98 versus 64.74 years, SD 11.74). Only 89 patients (25.4%) were tested for iron deficiency, and of these, 76 (85.4%) were found to be iron deficient and 42 (47.7%) had low ferritin. Preoperative anaemia was associated with a higher incidence of postoperative complications (adjusted odds ratio (OR) 1.46, 95%, CI 1.04-2.05; P = 0.03) and a longer length of stay (LOS; average 1.8 days; 95% CI 0.3-3.3 days).

CONCLUSION

A significant proportion of CRC patients had anaemia and the majority were normocytic. Only a small number of anaemic patients were tested for iron deficiency. Preoperative anaemia had an adverse effect on LOS and postoperative complications. The evaluation of anaemic patients is essential in CRC patients undergoing surgery.

Iron deficiency in colorectal cancer patients: a cohort study on prevalence and associations

AIM

The aim of this work was to estimate the prevalence of iron deficiency in patients diagnosed with colorectal cancer (CRC) and to clarify its association with patient- and tumour-related characteristics.

METHOD

This was a single-centre registry-based cohort study. Iron status was routinely evaluated upon diagnosis of CRC, and these data were coupled with patient- and tumour-specific data from the Danish CRC Group Registry (2013-2018). Data were analysed using multivariate logistic regression.

RESULTS

Out of 846 patients, 543 (64%) were iron deficient. There was an association between increasing depth of invasion and iron deficiency, with odds ratios (ORs) of iron deficiency being 2.8 (p = 0.001, CI 1.5-5.1), 4.22 (p < 0.001, CI 2.48-7.18) and 4.63 (p < 0.001, CI 2.30-9.34) for T-stages 2, 3 and 4, respectively. Right-sided tumours had an OR of 3.54 (p < 0.001, CI 2.22-5.67) of iron deficiency compared with left-sided tumours. Tumours diagnosed through the national CRC screening programme were less likely to be associated with iron deficiency (OR 0.34, CI 0.22-0.52), while female gender was associated with an increase in the odds for iron deficiency (OR 1.91, CI 1.33-2.76). Iron deficiency was prevalent in 88% of anaemic patients and 43% of nonanaemic patients.

CONCLUSION

Iron deficiency was highly prevalent in patients diagnosed with CRC. Increased depth of tumour invasion, right-sided location and female gender were all associated with higher odds for iron deficiency, while patients diagnosed through the national screening programme were associated with lower odds for iron deficiency. A large proportion of patients with a normal haemoglobin were also iron deficient.

Colorectal cancer is associated with increased circulating lipopolysaccharide, inflammation and hypercoagulability

Gut dysbiosis contributes to the development of a dysfunctional gut barrier, facilitating the translocation of bacteria and inflammagens, and is implicated in colorectal cancer (CRC) pathogenesis. Such 'leaky gut' conditions result in systemic inflammation, of which a hallmark is increased hypercoagulability. Fluorescence antibody confocal microscopy was used to determine circulating levels of lipopolysaccharide (LPS) in control and CRC populations. Here we showed that circulating levels of LPS are significantly elevated in the CRC population. We also showed that markers of inflammation and hypercoagulability are increased in this population. Furthermore, anomalous blood clotting and structural changes in blood components are presented. Importantly, the association between LPS levels, inflammation, and hematological dysfunction was analysed. Statistical regression models were applied to identify markers with strong association with CRC, and to investigate the correlation between markers. A core aim is enhanced biomarker discovery for CRC. We conclude that circulating LPS can promote systemic inflammation and contribute to the development of a pathological coagulation system, with resulting chronic inflammation and an activated coagulation system implicated in tumorigenesis. Blood-based screening tools are an emerging research area of interest for CRC screening. We propose the use of additional (novel) biomarkers to effectively screen for CRC.

Impact of anaemia at discharge following colorectal cancer surgery

OBJECTIVES

Preoperative anaemia is common in patients with colorectal cancer and increasingly optimised prior to surgery. Comparably little attention is given to the prevalence and consequences of postoperative anaemia. We aimed to investigate the frequency and short- or long-term impact of anaemia at discharge following colorectal cancer resection.

METHODS

A dedicated, prospectively populated database of elective laparoscopic colorectal cancer procedures undertaken with curative intent within a fully implemented ERAS protocol was utilised. The primary endpoint was anaemia at time of discharge (haemoglobin (Hb) < 120 g/L for women and < 135 g/L for men). Patient demographics, tumour characteristics, operative details and postoperative outcomes were captured. Median follow-up was 61 months with overall survival calculated with the Kaplan-Meier log rank method and Cox proportional hazard regression based on anaemia at time of hospital discharge.

RESULTS

A total of 532 patients with median 61-month follow-up were included. 46.4% were anaemic preoperatively (cohort mean Hb 129.4 g/L ± 18.7). Median surgical blood loss was 100 mL (IQR 0-200 mL). Upon discharge, most patients were anaemic (76.6%, Hb 116.3 g/L ± 14, mean 19 g/L ± 11 below lower limit of normal, p < 0.001). 16.7% experienced postoperative complications which were associated with lower discharge Hb (112 g/L ± 12 vs. 117 g/L ± 14, p = 0.001). Patients discharged anaemic had longer hospital stays (7 [5-11] vs. 6 [5-8], p = 0.037). Anaemia at discharge was independently associated with reduced overall survival (82% vs. 70%, p = 0.018; HR 1.6 (95% CI 1.04-2.5), p = 0.034).

CONCLUSION

Anaemia at time of discharge following elective laparoscopic colorectal cancer surgery and ERAS care is common with associated negative impacts upon short-term clinical outcomes and long-term overall survival.

Deceitful red-flag: angina secondary to iron deficiency anaemia as a presenting complaint for underlying malignancy

A 73-year-old man with an 8-week history of angina underwent an exercise tolerance test at the rapid access clinic, which indicated inducible ischaemia and he was subsequently referred for angiogram. His angiogram demonstrated no coronary pathology. It was later discovered that bloods taken on the day of the procedure showed a haemoglobin of 54 g/L (130-180 g/L). His haemoglobin used to book the angiogram 3 months before was 143 g/L. Following angiogram, a mass was identified in the right iliac fossa and CT scan confirmed a caecal tumour. The patient ultimately underwent a curative right hemicolectomy as an outpatient. The case is a reminder of the importance of basic preangiogram investigations, in particularly a full blood count, to rule-out angina secondary to anaemia through a low haemoglobin. Most importantly, it also questions when the appropriate time is for these investigations to be carried out, prior to coronary angiography.

Association of preoperative anemia and perioperative allogenic red blood cell transfusion with oncologic outcomes in patients with nonmetastatic colorectal cancer

Background

We investigated whether preoperative anemia and perioperative blood transfusion (pbt) are associated with overall survival and recurrence-free survival in patients with nonmetastatic colorectal cancer.

Methods

From 1 January 2009 to 31 December 2014, 1003 patients with primary colorectal cancer were enrolled in the study. Perioperative clinical and oncologic outcomes were analyzed based on the presence of preoperative anemia and pbt.

Results

Preoperative anemia was found in 468 patients (46.7%). In the anemia and no-anemia groups, pbt was performed in 44% and 15% of patients respectively. Independent predictors for pbt were preoperative anemia, higher American Society of Anesthesiologists score, laparotomy, lengthy operative time, advanced TNM stage, T4 stage, and 30-day morbidity. The use of pbt, but not preoperative anemia, was found to be an independent adverse prognostic factor for overall survival. In terms of recurrence-free survival, the presence of preoperative anemia was similarly not a significant prognostic factor, but the use of pbt was an independent factor for an unfavourable prognosis.

Conclusions

The use of pbt, but not preoperative anemia, was independently associated with worse overall and recurrence-free survival in nonmetastatic colorectal cancer. For better oncologic outcomes, our findings indicate a need to reduce the use of blood transfusion during the perioperative period.

Elevation of n-3/n-6 PUFAs ratio suppresses mTORC1 and prevents colorectal carcinogenesis associated with APC mutation

Although epidemiological and preclinical studies have shown the preventative effect of n-3 polyunsaturated fatty acids (PUFAs) on colorectal cancer (CRC), the underlying molecular mechanisms are not clear. In this study, we revealed that elevation of n-3/n-6 PUFAs ratio suppress the mechanistic target of rapamycin complex 1 (mTORC1) and prevent colorectal tumorigenesis. The transgenic expression of fat-1, a desaturase that catalyzes the conversion of n-6 to n-3 PUFAs and produces n-3 PUFAs endogenously, repressed colorectal tumor cell growth and remarkably reduced tumor burden, and alleviated anemia as well as hyperlipidemia in APCMin/+ (adenomatous polyposis coli) mice, a classic CRC model that best simulates most clinical cases. In contrast to arachidonic acid (AA, C20:4 n-6), either Docosahexaenoic acid (DHA, C22:6 n-3), eicosapentaenoic acid (EPA, C20:5 n-3), or a combination of DHA and AA, efficiently inhibited the proliferation of CRC cell lines and promoted apoptosis in these cells. The ectopic expression of fat-1 had similar effects in colon epithelial cells with APC depletion. Mechanistically, elevation of n-3/n-6 ratio suppressed mTORC1 activity in tumors of APCMin/+ mice, CRC cell lines with APC mutation, and in normal colon epithelial cells with APC depletion. In addition, elevation of n-3/n-6 ratio repressed mTORC1 activity and inhibited adipogenic differentiation in preadipocytes with APC knockdown, as well as alleviated hyperlipidemia in APCMin/+ mice. Taken together, our findings have provided novel insights into the potential mechanism by which increase in n-3/n-6 PUFAs ratio represses CRC development, and also a new rationale for utilizing n-3 PUFAs in CRC prevention and treatment.

Serum Ferritin in Colorectal Cancer Patients and its Prognostic Evaluation

The aim of this study was to investigate the relationship between preoperative serum ferritin levels, clinicopathological parameters and survival analysis of patients with colorectal cancer. Ninety-four patients (57 males) with a mean age of 65 years (39–87 years) underwent 63 curative and 31 palliative operations. Follow-up was at least 5 years. Patients were categorized with normal (30-215 ng/mL in men and 11-148 ng/mL in women), low, or high serum ferritin levels. Prognostic evaluation was undertaken with stratified survival analysis and Cox's regression model. Twenty-nine of the patients (30.9%) had raised ferritin levels and 14 (14.9%) had low values. Comparisons of the survival curves showed significant differences in stage C disease; specifically, patients with either low or high ferritin levels had a shorter survival than patients with normal levels. Patients who underwent palliative surgery and had high ferritin serum values also had a shorter survival. In multivariate analysis, the variables with a negative effect on survival were stage, serum ferritin levels and age. Our data suggest that patients with advanced colorectal cancer having normal preoperative serum ferritin levels may have a better prognosis, although the prognostic value related to this association requires further investigation.

Preoperative anemia in colorectal cancer: relationships with tumor characteristics, systemic inflammation, and survival

Anemia is common in colorectal cancer (CRC) but its relationships with tumor characteristics, systemic inflammation, and survival have not been well characterized. In this study, blood hemoglobin levels and erythrocyte mean corpuscular volume (MCV) levels were measured in two independent cohorts of 148 CRC patients and 208 CRC patients, and their correlation with patient and tumor characteristics, systemic inflammatory markers (modified Glasgow Prognostic Score: mGPS; serum levels of thirteen cytokines, C-reactive protein, albumin), and survival were analyzed. We found that anemia, most frequently normocytic, followed by microcytic, was present in 43% of the patients. Microcytic anemia was most commonly associated with proximal colon tumor location. Average MCV and blood hemoglobin levels were lower in tumors with high T-class. Low blood hemoglobin associated with systemic inflammation, including high mGPS and high serum levels of C-reactive protein and IL-8. Particularly, normocytic anemia associated with higher mGPS. Normocytic anemia associated with a tendency towards worse overall survival (multivariate hazard ratio 1.61, 95% confidence interval 1.07–2.42, p = 0.023; borderline statistical significance considering multiple hypothesis testing). In conclusion, anemia in CRC patients is most frequently normocytic. Proximal tumor location is associated with predominantly microcytic anemia and systemic inflammation is associated with normocytic anemia.

Is whole-colon investigation by colonoscopy, computerised tomography colonography or barium enema necessary for all patients with colorectal cancer symptoms, and for which patients would flexible sigmoidoscopy suffice? A retrospective cohort study

BACKGROUND

For patients referred to hospital with suspected colorectal cancer (CRC), it is current standard clinical practice to conduct an examination of the whole colon and rectum. However, studies have shown that an examination of the distal colorectum using flexible sigmoidoscopy (FS) can be a safe and clinically effective investigation for some patients. These findings require validation in a multicentre study.

OBJECTIVES

To investigate the links between patient symptoms at presentation and CRC risk by subsite, and to provide evidence of whether or not FS is an effective alternative to whole-colon investigation (WCI) in patients whose symptoms do not suggest proximal or obstructive disease.

DESIGN

A multicentre retrospective study using data collected prospectively from two randomised controlled trials. Additional data were collected from trial diagnostic procedure reports and hospital records. CRC diagnoses within 3 years of referral were sourced from hospital records and national cancer registries via the Health and Social Care Information Centre.

SETTING

Participants were recruited to the two randomised controlled trials from 21 NHS hospitals in England between 2004 and 2007.

PARTICIPANTS

Men and women aged ≥ 55 years referred to secondary care for the investigation of symptoms suggestive of CRC.

MAIN OUTCOME MEASURE

Diagnostic yield of CRC at distal (to the splenic flexure) and proximal subsites by symptoms/clinical signs at presentation.

RESULTS

The data set for analysis comprised 7380 patients, of whom 59% were women (median age 69 years, interquartile range 62-76 years). Change in bowel habit (CIBH) was the most frequently presenting symptom (73%), followed by rectal bleeding (38%) and abdominal pain (29%); 26% of patients had anaemia. CRC was diagnosed in 551 patients (7.5%): 424 (77%) patients with distal CRC, 122 (22%) patients with cancer proximal to the descending colon and five patients with both proximal and distal CRC. Proximal cancer was diagnosed in 96 out of 2021 (4.8%) patients with anaemia and/or an abdominal mass. The yield of proximal cancer in patients without anaemia or an abdominal mass who presented with rectal bleeding with or without a CIBH or with a CIBH to looser and/or more frequent stools as a single symptom was low (0.5%). These low-risk groups for proximal cancer accounted for 41% (3032/7380) of the cohort; only three proximal cancers were diagnosed in 814 low-risk patients examined by FS (diagnostic yield 0.4%).

LIMITATIONS

A limitation to this study is that changes to practice since the trial ended, such as new referral guidelines and improvements in endoscopy quality, potentially weaken the generalisability of our findings.

CONCLUSIONS

Symptom profiles can be used to determine whether or not WCI is necessary. Most proximal cancers were diagnosed in patients who presented with anaemia and/or an abdominal mass. In patients without anaemia or an abdominal mass, proximal cancer diagnoses were rare in those with rectal bleeding with or without a CIBH or with a CIBH to looser and/or more frequent stools as a single symptom. FS alone should be a safe and clinically effective investigation in these patients. A cost-effectiveness analysis of symptom-based tailoring of diagnostic investigations for CRC is recommended.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN95152621.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 66. See the NIHR Journals Library website for further project information.

Preoperative anaemia and perioperative red blood cell transfusion as prognostic factors for recurrence and mortality in colorectal cancer-a Swedish cohort study

PURPOSE

The hypothesis in this study was that anaemia prior to surgery and perioperative red blood cell transfusion increases the risk for recurrence and overall mortality in patients with stages I-III colorectal cancer after abdominal resection with curative intent.

METHODS

This is a Swedish single centre retrospective cohort study. Data on 496 consecutive radical abdominal resections stages I-III colorectal cancer performed at the Karolinska University Hospital 2007-2010 were extracted from the Swedish Colorectal Cancer Registry. Data were linked to local laboratory and transfusion databases to identify preoperative anaemia and perioperative transfusion. Disease recurrence was validated by scrutiny of patient records. A total of 496 stages I-III colorectal cancer patients were included in the analysis. Multivariate Cox regression analysis adjusted for tumour and patient characteristics were performed to assess risk for recurrence and overall mortality.

RESULTS

Anaemia prior to surgery was associated with increased risk for overall mortality (HR 2.1, 95% CI 1.4-3.2). There was no association between anaemia and risk for recurrence (HR 1.6, 95% CI 0.97-2.6). Transfusion was not associated with increased risk of recurrence (HR 0.7, 95% CI 0.4-1.3) or overall mortality (HR 1.04, 95% CI 0.7-1.6).

CONCLUSIONS

Anaemia prior to colorectal cancer surgery was associated with increased risk for overall mortality while a no increased risk was seen for recurrence. Previous findings indicating an association between blood transfusion and increased risk for recurrence could not be confirmed.

Iron, microbiota and colorectal cancer

Iron deficiency and anaemia are common in colorectal cancer. Replacement with oral or intravenous iron effectively treats this deficiency. However, mechanistic and population studies suggest that excess iron promotes colorectal carcinogenesis. Growing research into gut microbiota and dysbiosis suggests one explanation for this association. Iron is growth limiting for many pathogenic bacteria and may promote a shift in the ratio of pathogenic to protective bacteria. This may increase the toxic bacterial metabolites, promoting inflammation and carcinogenesis. This has important implications as we seek to correct anaemia in our patients.

The yield of colorectal cancer among fast track patients with normocytic and microcytic anaemia

INTRODUCTION

We receive fast track referrals on the basis of iron deficiency anaemia (IDA) for patients with normocytic anaemia or for patients with no iron studies. This study examined the yield of colorectal cancer (CRC) among fast track patients to ascertain whether awaiting confirmation of IDA is necessary prior to performing bowel investigations.

METHODS

A review was undertaken of 321 and 930 consecutive fast track referrals from Centre A and Centre B respectively. Contingency tables were analysed using Fisher's exact test. Logistic regression analyses were performed to investigate significant predictors of CRC.

RESULTS

Overall, 229 patients were included from Centre A and 689 from Centre B. The odds ratio for microcytic anaemia versus normocytic anaemia in the outcome of CRC was 1.3 (95% confidence interval [CI]: 0.5-3.9) for Centre A and 1.6 (95% CI: 0.8-3.3) for Centre B. In a logistic regression analysis (Centre B only), no significant difference in CRC rates was seen between microcytic and normocytic anaemia (adjusted odds ratio: 1.9, 95% CI: 0.9-3.9). There was no statistically significant difference in the yield of CRC between microcytic and normocytic anaemia (p=0.515, Fisher's exact test) in patients with anaemia only and no colorectal symptoms. Finally, CRC cases were seen in both microcytic and normocytic groups with or without low ferritin.

CONCLUSIONS

There is no significant difference in the yield of CRC between fast track patients with microcytic and normocytic anaemia. This study provides insufficient evidence to support awaiting confirmation of IDA in fast track patients with normocytic anaemia prior to requesting bowel investigations.

Pre-operative anaemia in colon cancer patients became normal after more than a year post-operatively but did not influence oncological outcome in the final analysis

BACKGROUND

Pre-operative anaemia has been related to adverse outcomes after surgical management of colorectal cancer. How various factors may contribute to anaemia and also its post-operative recovery has not been extensively investigated.

METHODS

Two hundred and thirty five colon cancer patients treated surgically in a community teaching hospital in Norway between 2007 and 2009 were prospectively examined.

RESULTS

Anaemia was detected in 53.8%, which was dependent on tumour location, albumin level and female gender. More than 60% of all patients were overweight or obese. Pre-operative BMI was negatively associated with age and positively associated with albumin level (p = 0.018 for both). Haemoglobin levels slowly returned to normal during the first year in significant incremental steps, coincidental with an increase in BMI. At 6 months post-operative, age, albumin, female gender and TNM stage (p = 0.010; p = 0.020; p < 0.001; p = 0.028, respectively) were significantly connected with anaemia, whereas only age and albumin (p = 0.016; p = 0.004, respectively) were associated with a reduced BMI. Pre-operative anaemia gave a significantly worse overall survival (p = 0.040) in the univariate analysis but was not significant in the multivariate analysis.

CONCLUSION

Beside the influence of tumour location, it appeared that pre-operative Hgb had some relation to a reduced nutritional state. The post-operative recovery of anaemia was more closely related to an improved nutritional state. The relation between anaemia and oncological outcome should undergo further studies.

Iron homeostasis and distal colorectal adenoma risk in the prostate, lung, colorectal, and ovarian cancer screening trial

Red meat consumption has been positively associated with colorectal cancer; however, the biological mechanism underlying this relationship is not understood. Red meat is a major source of iron, which may play a role in colorectal carcinogenesis via increased crypt cell proliferation, cytotoxicity, and endogenous N-nitrosation. In a nested case-control study within the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial, we prospectively evaluated multiple iron exposure parameters, including dietary intake and serum measures of iron, ferritin, transferrin, total iron binding capacity (TIBC), and unsaturated iron binding capacity (UIBC) in relation to incident colorectal adenoma in 356 cases and 396 matched polyp-free controls. We also investigated variation in eight key genes involved in iron homeostasis in relation to colorectal adenoma in an additional series totaling 1,126 cases and 1,173 matched controls. We observed a positive association between red meat intake and colorectal adenoma [OR comparing extreme quartiles (OR(q4-q1)) = 1.59, 95% CI = 1.02-2.49, P(trend) = 0.03]. Serum TIBC and UIBC were inversely associated with colorectal adenoma (OR(q4-q1) = 0.57, 95% CI = 0.37-0.88, P(trend) = 0.03; and OR(q4-q1) = 0.62, 95% CI = 0.40-0.95, P(trend) = 0.04, respectively). Colorectal adenoma was not associated with serum ferritin, iron, or transferrin saturation or with polymorphisms in genes involved in iron homeostasis. Serum TIBC and UIBC, parameters that have a reciprocal relationship with overall iron load, were inversely related to colorectal adenoma, suggesting that individuals with lower iron status have a reduced risk of developing colorectal adenoma.

Is anaemia relevant in the referral and diagnosis of colorectal cancer?

OBJECTIVE

Current efforts to improve the outcome from colorectal cancer aim to shorten the delay between referral and diagnosis. Investigation of iron-deficiency anaemia has a high yield for the diagnosis of gastrointestinal malignancy and its presence is included in current referral guidelines. We explored the relationship between anaemia and colorectal cancer.

METHOD

We reviewed hospital and laboratory database records of patients diagnosed with colorectal cancer between January 2003 and June 2004. The site of colorectal cancer was correlated with the presence of anaemia at the time of referral. Anaemia was defined according to local practice (Hb < 12.0 g/dl in females and <13.0 g/dl in males), compared with the threshold recommended in current national referral guidelines (Hb < 10 g/dl in females and <11 g/dl in males).

RESULTS

Over 18 months, 143 patients were diagnosed with colorectal cancer. Anaemia was present in 48% of males and 50% of females using local practice and 24% of males and 16% of females using national referral guidelines. Those with right-sided and non-rectal cancers were significantly more likely to be anaemic than those with left-sided and rectal cancers, respectively.

CONCLUSION

In approximately half of cases the diagnosis of colorectal cancer is not associated with anaemia. Anaemia is more common with proximal lesions but this is not a consistent finding. The current threshold for anaemia at which national guidelines suggest referral also appears to be insensitive.

What proportion of patients referred to secondary care with iron deficiency anemia have colon cancer?

PURPOSE

Iron deficiency anemia can be the first presentation of right-sided colon cancer. There is an impression that because this presentation is nonspecific it may be associated with a longer delay from referral to diagnosis compared with those patients with symptoms of change in bowel habit and/or rectal bleeding caused by more distal colorectal cancer. This study was designed to determine the incidence of colon cancers in patients referred to the hospital with iron deficiency anemia and to determine what proportion of these patients were referred and diagnosed urgently in line with cancer waiting time targets.

METHODS

A retrospective study was performed, including all patients referred to one district general hospital in 2003 whose blood indices met the criteria for significant iron deficiency anemia as defined by the Referral Guidelines for Suspected Cancer issued by the Department of Health in 1999, which defined iron deficiency anemia in the "target wait" criterion as a low hemoglobin (<11 g/dl in males and < 10 g/dl in postmenopausal females) with a mean corpuscular volume < 78 fl and/or a serum ferritin < 12 ng/ml. Patients with hemoglobinopathy were excluded. The underlying diagnosis reached for each patient was determined by using ICD10 C18-21. Case note review confirmed the diagnoses and yielded information on urgency of referral and time to diagnosis.

RESULTS

Of 513 patients referred with iron deficiency anemia in 2003, 142 (28 percent) met the eligibility criteria. Nine (6.3 percent) of these had colon cancer, including one (1.2 percent) female and eight (14 percent) males. Eight of nine cancers were in the right colon. Other patients with iron deficiency anemia were found to have benign upper or lower gastrointestinal disease (n = 125) or upper gastrointestinal cancer (n = 1). In seven patients, no cause was found. Of the nine patients with iron deficiency anemia who were found to have colon cancer, five had been referred urgently and four as routine. The mean delay from referral to diagnosis for these was 31 days for those referred urgently but 60 days for those referred routinely.

CONCLUSIONS

Males referred with iron deficiency anemia have a significant risk of having colon cancer. The risk seems lower in females; this gender difference has been observed in other studies and further evidence should be sought before advising any change in referral practice.

Evaluation of the Danish national strategy for selective use of colonoscopy in symptomatic outpatients without known risk factors for colorectal cancer

OBJECTIVE

A diagnostic strategy implemented in Denmark in 2002 recommends selective use of colonoscopy in outpatients without known colorectal cancer (CRC) risk factors who are referred with symptoms consistent with possible CRC. Selection of patients for colonoscopy was based on the presenting symptom(s) and findings at the initial examination (flexible sigmoidoscopy/faecal occult blood test). The aim of this study was to evaluate the strategy by assessing the prevalence of patients with diagnosed CRC, the frequency of patients with missed CRC, the adherence to the strategy and the number of examinations performed.

MATERIAL AND METHODS

We prospectively studied patients aged 40 years and older without known risk factors for CRC, referred to two surgical outpatient clinics during a period of 15-16 months. Examinations, findings at the examinations, the final diagnoses and date of discharge were recorded. Missed CRCs were identified by follow-up in hospital discharge registries.

RESULTS

CRC was diagnosed in 126 (5.3%; 95% CI: 4.5-6.3%) of the 2361 patients included during the diagnostic work-up. Two additional cancers identified at follow-up were both missed during colonoscopy (1.5%; 95% CI: 0.2-5.4%). The adherence to the strategy was 75.7%, and 125 of the 126 patients with a CRC were examined in conformity with the recommended strategy. Almost 60% of the patients underwent colonoscopy and almost 50% underwent both flexible sigmoidoscopy and colonoscopy.

CONCLUSIONS

The diagnostic strategy is an acceptable alternative to initial colonoscopy, with a low probability of missing a CRC; however, a considerable proportion of the patients undergo colonoscopy and multiple examinations.

The prevalence of iron deficiency among patients presenting with colorectal cancer

OBJECTIVES

To examine prospectively the prevalence of iron deficiency among new patients presenting with colorectal cancer and to compare transferrin saturation and serum ferritin as markers of iron deficiency in this group of patients.

PATIENTS AND METHODS

Data were gathered on all patients presenting with a new diagnosis of colorectal cancer over a 12-month period. Iron status was estimated and, when possible, confirmed by measurement of serum ferritin concentration and transferrin saturation. Iron status was further examined in relation to tumour site and Dukes' stage.

RESULTS

During the study 157 patients presented with a new colorectal cancer. Of these, 130 could be evaluated and 78[60%] had evidence of iron deficiency. Transferrin saturation was below the reference range in 55 patients, but serum ferritin was below in only 18 patients. Among the 49 patients with right-sided cancers, 39[80%] were iron deficient. Iron deficiency was significantly more likely in patients with right sided cancers compared with those with cancers at or distal to the splenic flexure (chi2 = 13, P < 0.001).

CONCLUSION

The majority of patients with a new diagnosis of colorectal cancer are iron deficient at presentation. In such patients transferrin saturation measurement is a more sensitive marker of iron deficiency than serum ferritin. The potential role of measuring serum transferrin saturation as an adjunct to faecal occult blood screening should be explored further.

Iron-deficiency anaemia and delay in the diagnosis of colorectal cancer

AIMS

Iron-deficiency anaemia (IDA) is a recognized complication of colorectal cancer (CRC) especially with right-sided tumours, and failure to investigate the anaemia in older patients may lead to a delay in diagnosis. The aims of this study were to establish the proportion of patients with CRC shown to have an IDA for more than six months before diagnosis and to establish the proportion of patients with IDA who subsequently prove to have CRC.

METHODS

All patients presenting with confirmed CRC in a health district (catchment population 280000) in the 4 years 1996-9 were identified from the pathology database after ethical approval. The criteria for IDA were haemoglobin (Hb) < 10.1 g/dl plus mean corpuscular volume < 78 fl and/or mean corpuscular Hb concentration < 32 g/dl. The haematology data-base serving the same population was searched for evidence of: 1. IDA at diagnosis of CRC; 2. IDA more than 6 months and more than one year before the diagnosis of CRC; 3. The number of haematology referrals per annum in women over 55 and men over 50 years of age meeting the criteria for IDA.

RESULTS

Of 440 patients with colorectal cancer, 166 (38%) had IDA at diagnosis and of the latter 54 (12%) were known to have IDA for more than six months before diagnosis and 26 (6%) had IDA more than one year before diagnosis. IDA was more common in right sided tumours (65%) than in those arising in the left side of the colon and rectum (26%). The annual incidence of IDA in the sampled population was 1366 in the stated age group.

CONCLUSION

The investigation of iron-deficiency anaemia in older patients is important but in order to detect 26 patients with colorectal cancer a year earlier, the investigation of approximately 5000 patients would be required--a detection rate of less than 1%.

Preoperative Anemia in Colon Cancer: Assessment of Risk Factors

Anemia is common in cancer patients and is associated with reduced survival. Recent studies document that treatment of anemia with blood transfusion in cancer patients is associated with increased infection risk, tumor recurrence, and mortality. We therefore investigated the incidence of preoperative anemia in colorectal cancer and assessed risk factors for anemia. Prospective data were collected on 311 patients diagnosed with colorectal cancer over a 6-year period from 1994 through 1999. Patients were stratified by age, gender, presenting complaint, preoperative hematocrit, American Joint Committee on Cancer (AJCC) stage, and TNM classification. Discrete variables were compared using Pearson's Chi-square analysis. Continuous variables were compared using Student's t test. Differences were considered significant when P < 0.05. The mean age of the study cohort was 67 ± 9.2 with 98 per cent of the study population being male. The mean AJCC stage was 2.2 ± 1.2 and the mean preoperative hematocrit was 35 ± 7.9 with an incidence of 46.1 per cent. The most common presenting complaints were hematochezia (n = 59), anemia (n = 51), heme-occult-positive stool (n = 33), bowel obstruction (n = 26), abdominal pain (n = 21), and palpable mass (n = 13). Preoperative anemia was most common in patients with right colon cancer with an incidence of 57.6 per cent followed by left colon cancer (42.2%) and rectal cancer (29.8%). Patients with right colon cancer had significantly lower preoperative hematocrits compared with left colon cancer (33 ± 8.5 vs 36 ± 7.4; P < 0.01) and rectal cancer (33 ± 8.5 vs 38 ± 6.0; P < 0.0001). Patients with right colon cancer also had significantly increased stage at presentation compared with left colon cancer (2.3 ± 1.3 vs 2.1 ± 1.2; P < 0.02). Age was not a significant risk factor for preoperative anemia in colorectal cancer. We conclude that there is a high incidence of anemia in patients with colon cancer. Patients with right colon cancer had significantly lower preoperative hematocrits and higher stage of cancer at diagnosis. Complete colon evaluation with colonoscopy is warranted in patients with anemia to improve earlier diagnosis of right colon cancer. A clinical trial of preoperative treatment of anemic colorectal cancer patients with recombinant human erythropoietin is warranted.

Mean corpuscular volume may be a useful index of risk for colorectal adenoma in middle-aged Japanese men

OBJECTIVE

It has been reported that alcohol intake and folate deficiency are associated with an increased risk of colorectal adenomas and carcinomas. Mean corpuscular volume (MCV) of red blood cells has been reported to be increased in these conditions. The purpose of this study was to assess the association between MCV and risk of colorectal adenoma.

METHODS

The subjects were 497 middle-aged (45-65 yr old) men who underwent both barium enema examination and total colonoscopy. The subjects answered a questionnaire regarding their alcohol consumption history, and their blood samples were analyzed. The subjects were divided into four groups three times: with or without alcoholism, and with or without adenoma according to alcohol intake, and according to the MCV value. Various variables were compared among the groups, and the odds ratios of adenoma were calculated.

RESULTS

The MCV was higher in the alcoholic group than in the nonalcoholic group (p < 0.01) and in patients with adenoma than in those without adenoma (p < 0.0001). When the subjects were stratified by alcohol intake, the MCV value had a higher significant difference than alcohol intake, between patients with adenoma and those without adenoma. As for the MCV value, the odds ratio (95% confidence interval) of adenoma was 1.00 (referent); (<92), 1.20 (0.71-1.69); (> or =92 but <95), 2.61 (2.07-3.15); (> or =95 but <98); and 3.62 (2.99-4.25); (> or =98).

CONCLUSION

A high MCV value may be used as a simple index of the risk of colorectal adenomas, regardless of alcohol consumption.