The dynamics of colorectal cancer management in 17 countries

The Impact of Hematologic Parameters on Histopathologic Features of Colorectal Cancer

Background

Colorectal cancers (CRC) are one of the most common tumors that are being researched for new biomarkers worldwide. In this context, studies are being carried out to estimate whether various hematological parameters can be used for predicting prognosis. In this study, our aim was to evaluate the relation between platelet (PLT) levels as well as neutrophil-to-lymphocyte ratio (NLR), platelet (PLT)-to-lymphocyte ratio (PLR), and Lymphocyte-to-CRP ratio (LCR) which are easily accessible inflammatory response indicators.

Methods

In this retrospective cross-sectional study, 111 patients diagnosed as colorectal adenocarcinoma were included. Patients with clinical evidence of an infection, recurrent colorectal cancer, previous history of a hematological disease, and a neoadjuvant chemo/radiotherapy were excluded. Demographic features such as age, gender, and histopathologic parameters such as tumor size, surgical margin status (proximal, distal, and radial), the presence of serosal inflammation, lymphovascular invasion (LVI), perineural invasion (PNI), lymph node metastasis (LNM) and distant metastasis, preoperative blood sample analysis, and CRP levels were noted. Statistical analysis for the association between hematologic parameters platelet (PLT) levels as well as neutrophil-to-lymphocyte ratio (NLR), platelet (PLT)-to-lymphocyte ratio (PLR), and Lymphocyte-to-CRP ratio (LCR) and histopathological features were done.

Results

Among 111 patients, the mean age was 65.37, and the mean tumor size was 5.41 cm. Lymphovascular invasion, perineural invasion, radial surgical margin positivity, lymph node metastasis, localization, and stage were statistically significantly related to the number of platelets. For NLR, PNI (p=0.001), LNM (p=0.048), and stage (early/advanced) (p=0.045) were significantly related. None of the parameters were related to PLR and LCR.

Conclusion

Perineural invasion, lymph node metastasis, and the stage of the tumor could be the major histopathological features that could be related to hematologic parameters; however, this should be researched by larger studies as if they can be used as prognostic markers.

Educational interventions to improve bowel cancer awareness and screening in Organisation for Economic Co-operation and Development countries: A scoping review

Objectives

Summarise theory informed educational interventions for improving bowel cancer awareness and screening.

Methods

A search was conducted in PubMed, EMBASE, Web of Science and CINAHL. English studies from 2016 to 2022 which implemented community-based bowel cancer awareness and/or screening education interventions for adults in Organisation for Economic Co-operation and Development countries were included.

Results

Sixty-two studies were included, 32 measured both screening and awareness (24 measured screening only, 6 measured awareness only). Education interventions were grouped and summarised in five education types: lay community health education/counselling (n = 28), education material (n = 5), health professional education/counselling (n = 10), mass media (n = 5) and other (n = 19). Other included education interventions which did not fit into the four types previously mentioned. Six studies tested more than one education type. Each type within these studies were reported/summarised separately within the appropriate education type. Lay educators resulted in improved awareness and screening. Brochures were effective education materials for screening and combined with lay educators resulted in increased awareness. State-wide mass media campaigns significantly improved screening uptake for up to 2-months post-campaign. Fear and loss-framed messaging improved screening intentions compared to humour or gain-based messaging. Decision aids had limited improvements in awareness. Facebook campaign and telephone counselling had limited improvements in screening.

Conclusions

Lay community health educators, brochures, and mass media campaigns occurring multiple times a year may be effective interventions in improving screening and/or awareness. Such approaches should be considered when developing community education. Education interventions should include multiple components suggested above to maximise improvements of awareness and screening.

Making colonoscopy-based screening more efficient: A "gateopener" approach

Screening colonoscopy for early detection and prevention of colorectal cancer (CRC) is mostly used inefficiently. Here, we assessed the potential of an innovative approach to colonoscopy-based screening, by use of a single, low threshold fecal immunochemical test (FIT) as a "gateopener" for screening colonoscopy. Using COSIMO, a validated simulation model, we modeled scenarios including either direct invitation to screening colonoscopy or an alternative approach involving mailing a single ("gateopener") FIT along with an invitation to colonoscopy contingent on a FIT value above a low threshold yielding a 50% positivity rate (ie, every other pretest will be positive). Under plausible assumptions on screening offer adherence, we found that such "gateopener screening" (use of screening colonoscopy contingent on a positive, low threshold gateopener FIT) approximately doubled cancer detection rates vs conventional screening. In those spared from screening colonoscopy due to a negative gateopener FIT pretest, numbers needed to screen were 10-times higher vs those for individuals with a positive FIT, peaking in >2000 and >3800 (hypothetically) needed colonoscopies to detect one case of cancer in men and women, respectively. Gateopener screening resulted in 42%-51% and 59%-65% more prevented CRC cases and deaths, respectively. In summary, by directing colonoscopy capacities to those most likely to benefit, offering screening colonoscopy contingent on a "gateopener" low-threshold FIT would substantially enhance efficiency of colonoscopy screening.

How Can the EU Beating Cancer Plan Help in Tackling Lung Cancer, Colorectal Cancer, Breast Cancer and Melanoma?

Cancer is the second leading cause of mortality in EU countries, and the needs to tackle cancer are obvious. New scientific understanding, techniques and methodologies are opening up horizons for significant improvements in diagnosis and care. However, take-up is uneven, research needs and potential outstrip currently available resources, manifestly beneficial practices—such as population-level screening for lung cancer—are still not generalised, and the quality of life of patients and survivors is only beginning to be given attention it merits. This paper, mainly based on a series of multistakeholder expert workshops organised by the European Alliance for Personalised Medicine (EAPM), looks at some of those specifics in the interest of planning a way forward. Part of this exercise also involves taking account of the specific nature of Europe and its constituent countries, where the complexities of planning a way forward are redoubled by the wide variations in national and regional approaches to cancer, local epidemiology and the wide disparities in health systems. Despite all the differences between cancers and national and regional resources and approaches to cancer care, there is a common objective in pursuing broader and more equal access to the best available care for all European citizens.

Out-of-pocket costs in gastrointestinal cancer patients: Lack of a perfectly framed problem contributing to financial toxicity

Fighting cancer is an economically expensive challenge for both health care payers, and the patients and their families and the median costs for cancer care are rapidly increasing in the last decade. Although both direct and indirect costs of medical assistance have been a frequent source of distress and contention, however analysis of the non-medical expenses incurred directly by cancer patients has not received adequate attention. Developing a deeper understanding of so-called "out-of-pocket" costs may be necessary. Out-of-pocket costs for medical care range from 7 % to 11 % of medical costs for all payers. However, the range of out-of-pocket costs shows considerable variability in different studies. In this review, we reviewed available data concerning direct and indirect medical costs, including psychosocial ones.

Associations of P Score With Real-World Survival Improvement Offered by Adjuvant Chemotherapy in Stage II Colon Cancer: A Large Population-Based Longitudinal Cohort Study

Background

Based on a prognostic scoring system (P score) proposed by us recently, this retrospective large population-based and propensity score-matched (PSM) study focused on predicting the survival benefit of adjuvant CT in stage II disease.

Methods

Patients diagnosed with stage II colon cancer (N = 73397) were identified from the Surveillance, Epidemiology, and End Results database between January 1, 1988 and December 31, 2005 and divided into the CT and non-CT groups. PSM balanced the patient characteristics between the CT and non-CT groups.

Results

The magnitude of CSS improvement among patients treated with adjuvant CT was significantly associated with the P score, score 8 [hazard ratio (HR) = 0.580, 95% confidence interval (CI) = 0.323–1.040, P = 0.067] was associated with a much higher increased CSS benefit among patients treated with adjuvant CT as compared to score 2* (*, including scores 0, 1, and 2; HR = 1.338, 95% CI = 1.089–1.644, P = 0.006).

Conclusions

High P scores were demonstrated to be associated with superior survival benefit of adjuvant CT. Therapy decisions of adjuvant CT in stage II colon cancer could be tailored on the basis of tumor biology, patient characteristics and the P score.

The prognosis of radiofrequency ablation versus hepatic resection for patients with colorectal liver metastases: A systematic review and meta-analysis based on 22 studies

BACKGROUND

Though hepatic resection (HR) is the standard local therapy for patients with colorectal cancer liver metastases (CRLMs), currently, radiofrequency ablation (RFA) may play an alternative role for elderly and vulnerable patients with various organ dysfunctions. This study aims to compare the prognosis of RFA and HR in treatment of CRLMs.

METHODS

A systematic search of PubMed, Embase, Cochrane Library and Web of Science up to October 1, 2020 was conducted for relevant studies that compared the prognosis of RFA with HR in the treatment of CRLMs. The primary outcomes were 30-day mortality, long-term recurrence, overall survival (OS) and disease-free survival (DFS). The secondary outcomes were various factors of OS, recurrence-free survival (RFS), survival, recurrence and complication.

RESULTS

A total of 22 studies including 4385 CRLM patients were identified. There was no significant difference between RFA and HR in 30-day mortality, with a pooled OR of 0.88 (95% CI 0.34-2.29; P = 0.80). CRLM patients undergoing RFA experienced significantly higher incidences of marginal and intrahepatic recurrence than HR, with pooled ORs of 7.09 (95% CI 4.56-11.2; 1251 pts) and 2.02 (95% CI 1.24-3.28; 1038 pts). In addition, RFA showed lower 1-, 3- and 5-yr OS rate than HR with pooled ORs of 0.39, 0.40 and 0.60 respectively. A lower 5-yr DFS rate was also found in RFA than HR group, with a pooled OR of 0.74 (95% CI 0.56-0.97; P = 0.03; 1231 pts). Multivariable analysis showed that tumor size, multiple tumors, age, primary node positive and metachronous metastasis were independent factors of OS, and multiple tumors was also an independent factor of RFS.

CONCLUSIONS

Though the 30-day mortality of RFA was equal to HR, RFA showed a higher recurrence rate and poor long-term survival outcomes for CRLM patients. Tumor size, multiple tumors, age, primary node positive and metachronous metastasis were independent factors of survival. However, the results were limited because of the inequality baseline characteristics between the comparative groups. Randomized or propensity score matching studies should be performed to clarify the effectiveness of RFA and to determine target populations that benefit most from RFA in the future.

Fecal MicroRNA-Based Algorithm Increases Effectiveness of Fecal Immunochemical Test-Based Screening for Colorectal Cancer

BACKGROUND & AIMS

An algorithm based on fecal levels of 2 microRNAs (miR-421 and miR-27a-3p), fecal hemoglobin concentration, and patient age and sex can identify patients with advanced colorectal neoplasia. We investigated whether this algorithm, called miRFec, could increase effectiveness and efficiency of fecal immunochemical test (FIT)-based colorectal cancer (CRC) screening programs.

METHODS

We obtained data and fecal samples from 767 persons with a positive result from the FIT who then underwent colonoscopy examination while participating a population-based CRC screening program, from March 2011 through May 2017 in Barcelona, Spain. Fecal miRNAs were isolated from the buffer contained in the original FIT collection device and analyzed by quantitative reverse transcription PCR. Aims were to evaluate the usefulness of the miRFec algorithm in identifying persons at greatest risk for CRC who should be prioritized for colonoscopy examination and individuals at low risk for whom colonoscopy could be avoided.

RESULTS

Of the 767 study subjects, 414 (54.0%) were found by colonoscopy to have advanced colorectal neoplasia (67 with CRC and 347 with advanced adenomas) and 353 (46.0%) were found to have either non-advanced adenomas (n = 136) or a normal examination (n = 217). MiRFec algorithm scores (1-4) were independently associated with the presence of advanced colorectal neoplasia (P < .001). The miRFec algorithm differentiated patients with CRC from those with non-advanced adenomas or normal colonoscopy with an area under the receiver operating characteristic curve of 90% (95% CI, 86-94). Subjects with miRFec scores in the 4th quartile (above 3.09, high-risk group) were 8-fold more likely to have advanced colorectal neoplasia than subjects with miRFec scores in the 1st quartile (below 2.14, low-risk group). Subjects in the low-risk group had a positive predictive value below 30% for detection of advanced colorectal neoplasia. When we used a 50% specificity cut-off value, the miRFec algorithm identified 97% of patients with CRC and would allow 264 subjects (34.4%) to avoid colonoscopy examination.

CONCLUSIONS

An algorithm based on fecal levels of 2 miRNAs and hemoglobin, patient age and sex (miRFec) differentiated patients with CRC from those with non-advanced adenomas or normal colonoscopy with an area under the receiver operating characteristic curve value of 90% and avoided 34% of colonoscopies. Inclusion of this algorithm in FIT-based CRC screening programs could increase their effectiveness and efficiency.

International evaluation of circumferential resection margins after rectal cancer resection: insights from the Swedish and Dutch audits

AIM

This study aimed to determine predictive factors for the circumferential resection margin (CRM) within two northern European countries with supposed similarity in providing rectal cancer care.

METHOD

Data for all patients undergoing rectal resection for clinical tumour node metastasis (TNM) stage I-III rectal cancer were extracted from the Swedish ColoRectal Cancer Registry and the Dutch ColoRectal Audit (2011-2015). Separate analyses were performed for cT1-3 and cT4 stage. Predictive factors for the CRM were determined using univariable and multivariable logistic regression analyses.

RESULTS

A total of 6444 Swedish and 12 089 Dutch patients were analysed. Over time the number of hospitals treating rectal cancer decreased from 52 to 42 in Sweden, and 82 to 79 in the Netherlands. In the Swedish population, proportions of cT4 stage (17% vs 8%), multivisceral resection (14% vs 7%) and abdominoperineal excision (APR) (37% vs 31%) were higher. The overall proportion of patients with a positive CRM (CRM+) was 7.8% in Sweden and 5.4% in the Netherlands. In both populations with cT1-3 stage disease, common independent risk factors for CRM+ were cT3, APR and multivisceral resection. No common risk factors for CRM+ in cT4 stage disease were found. An independent impact of hospital volume on CRM+ could be demonstrated for the cT1-3 Dutch population.

CONCLUSION

Within two northern European countries with implemented clinical auditing, rectal cancer care might potentially be improved by further optimizing the treatment of distal and locally advanced rectal cancer.

Provider Costs of Treating Colorectal Cancer in Government Hospital of Malaysia

Background

The incidence of colorectal cancer (CRC) is rapidly rising in several Asian countries, including Malaysia, but there is little data on health care provider costs in this region. The aim of this study was to estimate the cost of CRC management from the perspective of the health care provider, based on standard operating procedures.

Methods

A combination of top-down approach and activity-based costing was applied. The standard operating procedure (SOP) for CRC was developed for each stage according to national data and guidelines at the University of Malaya Medical Centre (UMMC). The unit cost was calculated and incorporated into the treatment pathway in order to obtain the total cost of managing a single CRC patient according to the stage of illness. The cost data were represented by means and standard deviation and the results were demonstrated by tabulation. All cost data are presented in Malaysian Ringgit (RM). The cost difference between early stage (Stage I) and late stage (Stage II–IV) was analysed using independent t-test.

Results

The cost per patient increased with stage of CRC, from RM13,672 (USD4,410.30) for stage I, to RM27,972 (USD9,023.20) for Stage IV. The early stage had statistically significant lower cost compared to late stage t(2) = −4.729, P = 0.042. The highest fraction of the cost was related to surgery for Stage I, but was superseded by oncology day care treatment for Stages II–IV. CRC is a costly illness. From a provider perspective, the highest cost was found in Stages III and IV. The early stages conserved more resources than did the advanced stages of cancer.

Conclusion

Early diagnosis and management of CRC, therefore, not only affects oncologic prognosis, but has implications for health care costs. This adds further justification to develop and implement CRC screening programmes in Malaysia.

Barriers for Access to New Medicines: Searching for the Balance Between Rising Costs and Limited Budgets

Introduction: There is continued unmet medical need for new medicines across countries especially for cancer, immunological diseases, and orphan diseases. However, there are growing challenges with funding new medicines at ever increasing prices along with funding increased medicine volumes with the growth in both infectious diseases and non-communicable diseases across countries. This has resulted in the development of new models to better manage the entry of new medicines, new financial models being postulated to finance new medicines as well as strategies to improve prescribing efficiency. However, more needs to be done. Consequently, the primary aim of this paper is to consider potential ways to optimize the use of new medicines balancing rising costs with increasing budgetary pressures to stimulate debate especially from a payer perspective. Methods: A narrative review of pharmaceutical policies and implications, as well as possible developments, based on key publications and initiatives known to the co-authors principally from a health authority perspective. Results: A number of initiatives and approaches have been identified including new models to better manage the entry of new medicines based on three pillars (pre-, peri-, and post-launch activities). Within this, we see the growing role of horizon scanning activities starting up to 36 months before launch, managed entry agreements and post launch follow-up. It is also likely there will be greater scrutiny over the effectiveness and value of new cancer medicines given ever increasing prices. This could include establishing minimum effectiveness targets for premium pricing along with re-evaluating prices as more medicines for cancer lose their patent. There will also be a greater involvement of patients especially with orphan diseases. New initiatives could include a greater role of multicriteria decision analysis, as well as looking at the potential for de-linking research and development from commercial activities to enhance affordability. Conclusion: There are a number of ongoing activities across countries to try and fund new valued medicines whilst attaining or maintaining universal healthcare. Such activities will grow with increasing resource pressures and continued unmet need.

Administration of adjuvant chemotherapy for stage II-III colon cancer patients: An European population-based study

The advantage of adjuvant chemotherapy (ACT) for treating Stage III colon cancer patients is well established and widely accepted. However, many patients with Stage III colon cancer do not receive ACT. Moreover, there are controversies around the effectiveness of ACT for Stage II patients. We investigated the administration of ACT and its association with overall survival in resected Stage II (overall and stratified by low-/high-risk) and Stage III colon cancer patients in three European countries including The Netherlands (2009-2014), Belgium (2009-2013) and Sweden (2009-2014). Hazard ratios (HR) for death were obtained by Cox regression models adjusted for potential confounders. A total of 60244 resected colon cancer patients with pathological Stages II and III were analyzed. A small proportion (range 9-24%) of Stage II and over half (range 55-68%) of Stage III patients received ACT. Administration of ACT in Stages II and III tumors decreased with higher age of patients. Administration of ACT was significantly associated with higher overall survival in high-risk Stage II patients (in The Netherlands (HR; 95%CI = 0.82 (0.67-0.99), Belgium (0.73; 0.59-0.90) and Sweden (0.58; 0.44-0.75)), and in Stage III patients (in The Netherlands (0.47; 0.43-0.50), Belgium (0.46; 0.41-0.50) and Sweden (0.48; 0.43-0.54)). In Stage III, results were consistent across subgroups including elderly patients. Our results show an association of ACT with higher survival among Stage III and high-risk Stage II colon cancer patients. Further investigations are needed on the selection criteria of Stages II and III colon cancer patients for ACT.

Sustaining Cancer Care Through Collaborative Stewardship

Cancer care has undergone rapid changes in recent years, providing dramatically improved outcomes for many patients. However, these changes have resulted in substantial increases in the costs of care in some situations. This symposium brought together a multidisciplinary faculty of experts in oncology, patient advocacy, hospital pharmacy, and health economics to discuss current issues of affordability and improving patient access to oncology medicines. The aim of the symposium was to understand what value truly means with regard to cancer care, consider what could happen when the cost of cancer care becomes unsustainable, and propose solutions to ensure optimal cancer care now and in the future. In healthcare, it is no longer sufficient to demonstrate the effectiveness and cost-effectiveness of treatment. Now, issues of value, evidence-based decision-making, and quality must also be considered. The emerging paradigm of population and personalised healthcare was discussed by Prof Sir Gray, who highlighted the basic concepts of value-based healthcare and the need for improvement through collaborative systems and networks. The right of all patients to have equitable access to the best treatments and care was discussed by Geoffrey Henning. Among the potential solutions available, patient knowledge and empowerment will be of utmost importance, and co-ordinated campaigns by, and on behalf of, patients have the potential to change legislation for the benefit of patients. Prof Aapro considered how cost savings from the increased use of biosimilar medicines might be re-invested to improve access to other medications, and Jatinder Harchowal provided examples of how pharmacists can improve system-wide efficiencies, thus establishing and embedding value at a fundamental level. Finally, Prof Jönsson provided an overview of the burden, cost, and cost-effectiveness of cancer management, highlighting the growing importance of appropriate economic evaluations in the new paradigm of value-based healthcare. The session demonstrated that through the actions of patients and healthcare professionals as equal partners, a shift towards value-based healthcare and a culture of stewardship can be achieved. Importantly, these changes are necessary to safeguard the future sustainability of cancer care.

Association Between Concentrations of Hemoglobin Determined by Fecal Immunochemical Tests and Long-term Development of Advanced Colorectal Neoplasia

BACKGROUND & AIMS

Colorectal cancer (CRC) screening using quantitative fecal immunochemical tests (FITs) is rapidly gaining ground worldwide. FITs are invariably used in a dichotomous manner using pre-specified cut-off values. To optimize FIT-based screening programs, we investigated the association between fecal hemoglobin (_fHb) concentrations below the FIT cut-off value and later development of colorectal advanced neoplasia (AN).

METHODS

We analyzed data collected from a population-based study of 9561 average-risk subjects (50-74 years old) in the Netherlands who were offered 4 rounds of FIT screening for CRC from November 2006 through December 2014. We analyzed data from 7663 participants screened at least once and found to have a negative FIT result at baseline (below the cut-off value of 10 μg Hb/ g feces). Participants were followed for a median of 4.7 years (interquartile range, 2.0-6.1 years); CRCs diagnosed outside the screening program were identified from the Dutch Comprehensive Cancer Centre database. Hazard ratios for AN were determined using Cox proportional hazard regression analyses. Logistic regression techniques were used to calculate risks of AN after consecutive fHb concentrations below the cut-off value.

RESULTS

After 8 years of follow-up, participants with baseline concentrations of 8-10 μg fHb/g had a higher cumulative incidence of AN (33%) than participants with 0 μg fHb/g (5%) (P < .001). Multi-variate hazard ratios increased from 1.2 for subjects with concentrations of 0-2 μg fHb/g to 8.2 for subjects with concentrations of 8-10 μg fHb/g (P < .001). Participants with 2 consecutive fHb concentrations of 8 μg Hb/g had a 14-fold increase in risk of AN compared with participants with 2 consecutive fHb concentrations of 0 μg Hb/g (P < .001).

CONCLUSIONS

In a population-based study of average-risk individuals with a FIT result below the cut-off value, we associated baseline concentrations of 8-10 μg fHb/g with an increased risk of AN compared with baseline concentrations of 0 μg fHb/g. Baseline and consecutive fHb concentrations are independent predictors for incident AN. This information might be used in designing personalized strategies for population-based CRC screening and reduce unnecessary repeat tests. Trialregister.nl no: first round, NTR1096; second round and additional invitees, NTR1512.

The prognostic significance of high/positive expression of cyclin B1 in patients with three common digestive cancers: a systematic review and meta-analysis

Recently, several studies have reported that the expression of cyclin B1 may be associated with the prognosis of cancer. Nevertheless, their conclusions were still controversial. The present was designed to analyze and evaluate the prognostic role of cyclin B1 expression in patients with digestive cancer. PubMed, Embase, Cochrane Library and Web of Science were searched to January, 2017. Pooled odds ratio (OR) with 95% confidence intervals (CIs) were estimated. For the pooled OR estimates of OS, we performed subgroup analysis. Besides, sensitivity analysis was performed to examine the stability of the combined results. All statistical analyses were performed using standard statistical procedures provided in RevMan 5.2. A total of 12 studies (N = 2080 participants) were included for this meta-analysis. The positive/high expression of cyclin B1 had an obvious association with both 3-year overall survival (OR 0.21, 95% CI 0.12-0.37; P < 0.00001) and 5-year overall survival (OR 0.20, 95% CI 0.12-0.34; P < 0.00001) in esophageal cancer, and 5-year overall survival of colorectal cancer (OR 2.01, 95% CI 1.32-3.08; P = 0.001). This meta-analysis indicated that positive/high expression of cyclin B1 may have a close association with worse survival in patients with esophageal cancer, but better prognosis in patients with colorectal cancer.

The elevated NLR, PLR and PLT may predict the prognosis of patients with colorectal cancer: a systematic review and meta-analysis

Recently, several studies have reported that inflammatory response and elevated platelet counts may be associated with the poor prognosis of colorectal cancer. This meta-analysis was designed to analyze and evaluate the prognostic role of elevated preoperative or pretreatment neutrophils-to-lymphocytes ratio, platelet-to-lymphocytes ratio or platelet counts in patients with colorectal cancer. We searched PubMed, EMBASE, Cochrane Library and Web of Science to April, 2016. A total of 23 studies (N = 11762 participants) were included for this meta-analysis. Elevated neutrophils-to-lymphocytes ratio have a close relationship with the poor Overall Survival of colorectal cancer with the pooled HR being 1.92 [95% CI 1.57–2.34; P < 0.00001]. This meta-analysis indicated that elevated neutrophils-to-lymphocytes ratio, platelet-to-lymphocytes ratio or platelet counts may be a cost-effective and noninvasive serum biomarker for poor prognosis for patients with colorectal cancer.

The pretreatment thrombocytosis may predict prognosis of patients with colorectal cancer: a systematic review and meta-analysis

AIM

Recently, several studies have reported that thrombocytosis may be associated with the poor prognosis of colorectal cancer (CRC). Nevertheless, their conclusions were still controversial. Results & methodology: We searched PubMed, Embase, Cochrane Library and Web of Science up to April 2016. A total of 30 studies including 9129 patients were included in this meta-analysis. Thrombocytosis had a close relationship with the poor overall survival of CRC compared with normal platelet counts, with the pooled hazard ratios being 1.89 (95% CI: 1.45-2.47; p < 0.00001) and 1.83 (95% CI: 1.33-2.53; p = 0.0002), with univariate and multivariate analyses, respectively.

DISCUSSION & CONCLUSION

This meta-analysis indicated that thrombocytosis may be a cost-effective and noninvasive indicator for poor prognosis of patients with CRC, especially for overall survival.

The prognostic role of pretreatment platelet-to-lymphocyte ratio as predictors in patients with colorectal cancer: a meta-analysis

AIM

This meta-analysis was designed to analyze and evaluate the prognostic role of preoperative or pretreatment platelet-to-lymphocyte ratio (PLR) in patients with colorectal cancer (CRC).

METHOD

We searched PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure, Chinese Biomedical Literature Database and WanFang Database up to April 2016.

RESULTS

A total of 16 studies (n = 5068 participants) were included for this meta-analysis. Elevated PLR has a close relationship with the poor overall survival of CRC, with the pooled hazard ratio being 1.88 (95% CI: 1.50, 2.36; p < 0.00001).

CONCLUSION

This meta-analysis indicated that pretreatment PLR may be a cost-effective and noninvasive serum biomarker for poor prognosis for patients with CRC.

Trends in colorectal cancer mortality in Europe: retrospective analysis of the WHO mortality database

OBJECTIVE

To examine changes in colorectal cancer mortality in 34 European countries between 1970 and 2011.

DESIGN

Retrospective trend analysis.

DATA SOURCE

World Health Organization mortality database.

POPULATION

Deaths from colorectal cancer between 1970 and 2011. Profound changes in screening and treatment efficiency took place after 1988; therefore, particular attention was paid to the evolution of colorectal cancer mortality in the subsequent period.

MAIN OUTCOMES MEASURES

Time trends in rates of colorectal cancer mortality, using joinpoint regression analysis. Rates were age adjusted using the standard European population.

RESULTS

From 1989 to 2011, colorectal cancer mortality increased by a median of 6.0% for men and decreased by a median of 14.7% for women in the 34 European countries. Reductions in colorectal cancer mortality of more than 25% in men and 30% in women occurred in Austria, Switzerland, Germany, the United Kingdom, Belgium, the Czech Republic, Luxembourg, and Ireland. By contrast, mortality rates fell by less than 17% in the Netherlands and Sweden for both sexes. Over the same period, smaller or no declines occurred in most central European countries. Substantial mortality increases occurred in Croatia, the former Yugoslav republic of Macedonia, and Romania for both sexes and in most eastern European countries for men. In countries with decreasing mortality, reductions were more important for women of all ages and men younger than 65 years. In the 27 European Union member states, colorectal cancer mortality fell by 13.0% in men and 27.0% in women, compared with corresponding reductions of 39.8% and 38.8% in the United States.

CONCLUSION

Over the past 40 years, there has been considerable disparity in the level of colorectal cancer mortality between European countries, as well as between men and women and age categories. Countries with the largest reductions in colorectal cancer mortality are characterised by better accessibility to screening services, especially endoscopic screening, and specialised care.

Relationship of postoperative thrombocytosis and survival of patients with colorectal cancer

INTRODUCTION

Thrombocytosis accompanying solid tumors and predicting the prognosis of malignant tumors has been the subject of intensive research lately. Reports so far have evaluated the role of preoperative platelet count. In our present study we looked at the effect of tumor removal on platelet count and the predictive power of postoperative thrombocytosis on the survival of patients with colorectal cancer (CRC).

METHODS

We retrospectively evaluated the clinical and histopathological data of 336 patients operated due to CRC between 2001 and 2011. Thrombocytosis was defined as a platelet count exceeding 400 × 10(3)/μL. Preoperative platelet count was compared with the value measured 1 month postoperatively.

RESULTS

The platelet count significantly decreased after the removal of the primary tumor (paired Wilcoxon test p < 0.001). In univariate analysis preoperative thrombocytosis was a significant marker of overall survival (OS) with HR 2.2, p < 0.001 while the postoperative thrombocytosis was nearly significant with HR = 1.59, p = 0.087. In multivariate setting, when corrected for location, stage, tumor size and controlling for gender and age (> 65 years vs. ≤ 65 years), both pre- and postoperative thrombocytosis were significant independent prognostic markers with HR 1.80, p = 0.20 and HR = 1.98, p = 0.018, respectively.

DISCUSSION AND CONCLUSION

Although the pathomechanism of thrombocytosis related to solid tumors is not known the decrease of platelet count after the removal of the primary tumor raises the possibility that the tumor may play an active role in the development of thrombocytosis. Furthermore, the observation of postoperative thrombocytosis with significant worse outcome underlines the predictive power of elevated platelet count.

Thrombocytosis of Liver Metastasis from Colorectal Cancer as Predictive Factor

There is increasing evidence that thrombocytosis is associated with tumor invasion and metastasis formation. It was shown in several solid tumor types that thrombocytosis prognosticates cancer progression. The aim of this study was to evaluate preoperative thrombocytosis as a potential prognostic biomarker in isolated metastases, in patients with liver metastasis of colorectal cancer (mCRC). Clinicopathological data of 166 patients with mCRC who had surgical resection between 2001 and 2011 were collected retrospectively. All primary tumors have been already resected. The platelet count was evaluated based on the standard preoperative blood profile. The patients were followed-up on average for 28 months. Overall survival (OS) of patients with thrombocytosis was significantly worse both in univariate (HR = 3.00, p = 0.03) and in multivariate analysis (HR = 4.68, p = 0.056) when adjusted for gender, age, tumor size and surgical margin. Thrombocytosis was also a good prognosticator of disease-free survival (DFS) with HR = 2.7, p = 0.018 and nearly significant in multivariate setting (HR = 2.26, p = 0.073). The platelet count is a valuable prognostic marker for the survival in patients with mCRC.

The influence of waiting times on cost-effectiveness: a case study of colorectal cancer mass screening

When a cost-effectiveness analysis is implemented, the health-care system is usually assumed to adjust smoothly to the proposed new strategy. However, technological innovations in health care may often induce friction in the organization of care supply, implying the congestion of services and subsequent waiting times. Our objective here is to measure how these short run rigidities can challenge cost-effectiveness recommendations favorable to an innovative mass screening test for colorectal cancer. Using Markov modeling, we compare the standard Guaiac fecal occult blood test (gFOBT) with an innovative screening test for colorectal cancer, namely the immunological fecal occult blood test (iFOBT). Waiting time can occur between a positive screening test and the subsequent confirmation colonoscopy. Five scenarios are considered for iFOBT: no further waiting time compared with gFOBT, twice as much waiting time for a period of 5 or 10 years, and twice as much waiting time for a period of 5 or 10 years combined with a 25% decrease in participation to confirmation colonoscopies. According to our modeling, compared with gFOBT, iFOBT would approximately double colonoscopy demand. Probabilistic sensitivity analysis enables concluding that the waiting time significantly increases the uncertainty surrounding recommendations favorable to iFOBT if it induces a decrease in the adherence rate for confirmation colonoscopy.

Risk stratification for advanced colorectal neoplasia according to fecal hemoglobin concentration in a colorectal cancer screening program

BACKGROUND & AIMS

The latest generation of fecal immunochemical tests (FIT) allows for quantitation of hemoglobin in feces, allowing for selection of optimal cut-off concentrations. We investigated whether individuals with positive results from quantitative FITs, in combination with other factors, could be identified as being at greatest risk for advanced colorectal neoplasia.

METHODS

In a retrospective study, we analyzed data from a consecutive series of 3109 participants with positive results from FITs (≥20 μg/g of feces) included in the first round of the Barcelona colorectal cancer screening program, from December 2009 through February 2012. All participants underwent colonoscopy and were assigned to groups with any advanced colorectal neoplasia or with nonadvanced colorectal neoplasia (but with another diagnosis or normal examination findings).

RESULTS

Median fecal hemoglobin concentrations were significantly higher in participants with advanced colorectal neoplasia (105 μg/g; interquartile range, 38-288 μg/g) compared with participants with nonadvanced colorectal neoplasia (47 μg/g; interquartile range, 23-119 μg/g) (P < .001). Positive predictive values for advanced colorectal neoplasia, determined using arbitrary fecal hemoglobin concentrations, differed with sex and age. Multivariate logistic regression analysis identified sex (men: odds ratio [OR], 2.07; 95% confidence interval, 1.78-2.41), age (60-69 y: OR, 1.24; 95% confidence interval, 1.07-1.44), and fecal hemoglobin concentration (>177 μg/g: OR, 3.80; 95% confidence interval, 3.07-4.71) as independent predictive factors for advanced colorectal neoplasia. Combining these factors, we identified 16 risk categories associated with different probabilities of identifying advanced colorectal neoplasia. Risk for advanced colorectal neoplasia increased 11.46-fold among individuals in the highest category compared with the lowest category; positive predictive values ranged from 21.3% to 75.6%.

CONCLUSIONS

Fecal hemoglobin concentration, in addition to sex and age, in individuals with positive results from FITs can be used to stratify probability for the detection of advanced colorectal neoplasia. These factors should be used to prioritize individuals for colonoscopy examination.

SALL4 as a new biomarker for early colorectal cancers

PURPOSE

Colorectal cancer (CRC) is one of the most common causes of cancer-related death worldwide, and there is an urgent need to identify critical diagnostic and prognostic factors for early detection of the disease. Our aim in this study was to elucidate absolute copy number of SALL4 mRNA in the peripheral blood and serum of CRC patients to evaluate its probable prognostic or diagnostic value for CRC.

METHODS

Peripheral mononuclear cells from 111 cases were examined using absolute quantitative real-time RT-PCR to assess the exact copy number of SALL4 and CEA mRNA. Receiver operator characteristic (ROC) curves were also depicted to detect the sensitivity and specificity of SALL4 mRNA.

RESULTS

The blood copy number of SALL4 in recruited CRC patients was significantly higher than healthy controls (p = 0.0001). This high copy number was not only inversely associated with the depth of tumor invasion (p = 0.045), but also was significantly correlated with the high grade of tumor differentiation (p = 0.029) and sex (p = 0.027). Furthermore, the copy number of SALL4 was elevated in all examined serum samples (p = 0.0001) in significant association with high grade of tumor differentiation (p = 0.026) and patients' age (p = 0.012). ROC analysis indicated 96.1 and 95% sensitivity and specificity of SALL4 for CRC screening, respectively.

CONCLUSION

Early detection of CRC is directly correlated to improved outcomes, increased survival rates and reduced mortality. Our results can introduce SALL4 as a critical biomarker for efficient screening of patients to detect early stages of CRC.

How might healthcare systems influence speed of cancer diagnosis: a narrative review

Striking differences exist in outcomes for cancer between developed countries with comparable healthcare systems. We compare the healthcare systems of 3 countries (Denmark, Norway, Sweden), 3 UK jurisdictions (England, Wales and Northern Ireland), 3 Canadian provinces (British Columbia, Manitoba, Ontario) and 2 Australian states (New South Wales, Victoria) using a framework which assesses the possible contribution of primary care systems to a range of health outcomes, drawing on key characteristics influencing population health.

For many of the characteristics we investigated there are no significant differences between those countries with poorer cancer outcomes (England and Denmark) and the rest. In particular, regulation, financing, the existence of patient lists, the GP gatekeeping role, direct access to secondary care, the degree of comprehensiveness of primary care services, the level of cost sharing and the type of primary care providers within healthcare systems were not specifically and consistently associated with differences between countries. Factors that could have an influence on patient and professional behaviour, and consequently contribute to delays in cancer diagnosis and poorer cancer outcomes in some countries, include centralisation of services, free movement of patients between primary care providers, access to secondary care, and the existence of patient list systems.

It was not possible to establish a causal correlation between healthcare system characteristics and cancer outcomes. Further studies should explore in greater depth the associations between single health system factors and cancer outcomes, recognising that in complex systems where context is all-important, it will be difficult to establish causal relationships. Better understanding of the interaction between healthcare system variables and patient and professional behaviour may generate new hypotheses for further research.

•

We examined cancer outcomes in six developed countries with comparable healthcare systems.

•

Clear differences exist in cancer outcomes between countries with comparable healthcare systems.

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Centralisation, movement of patients between providers, access to secondary care, and list systems appear influential.

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Better understanding of interactions between system variables and patient and professional behaviour may improve outcomes.

Public stated preferences and predicted uptake for genome-based colorectal cancer screening

Background

Emerging developments in nanomedicine allow the development of genome-based technologies for non-invasive and individualised screening for diseases such as colorectal cancer. The main objective of this study was to measure user preferences for colorectal cancer screening using a nanopill.

Methods

A discrete choice experiment was used to estimate the preferences for five competing diagnostic techniques including the nanopill and iFOBT. Alternative screening scenarios were described using five attributes namely: preparation involved, sensitivity, specificity, complication rate and testing frequency. Fourteen random and two fixed choice tasks, each consisting of three alternatives, were offered to 2225 individuals. Data were analysed using the McFadden conditional logit model.

Results

Thirteen hundred and fifty-six respondents completed the questionnaire. The most important attributes (and preferred levels) were the screening technique (nanopill), sensitivity (100%) and preparation (no preparation). Stated screening uptake for the nanopill was 79%, compared to 76% for iFOBT. In the case of screening with the nanopill, the percentage of people preferring not to be screened would be reduced from 19.2% (iFOBT) to 16.7%.

Conclusions

Although the expected benefits of nanotechnology based colorectal cancer screening are improved screening uptake, assuming more accurate test results and less preparation involved, the relative preference of the nanopill is only slightly higher than the iFOBT. Estimating user preferences during the development of diagnostic technologies could be used to identify relative performance, including perceived benefits and harms compared to competitors allowing for significant changes to be made throughout the process of development.

Estimating colorectal cancer treatment costs: a pragmatic approach exemplified by health insurance data from Germany

BACKGROUND

The cost of colorectal cancer (CRC) treatment is a crucial parameter to inform cost-effectiveness analyses on CRC screening but it is not readily available and therefore often lacking. We aimed to elaborate and exemplify a pragmatic approach to estimate CRC treatment cost based on health insurance data from Germany.

METHODS

We included two groups of persons who were continuously health-insured between 2005-2010: A) Cases: Persons with a hospital discharge diagnosis of CRC (ICD C18-C20) between 2007-2010 and no such a diagnosis between 2005-2006 (to focus on incident CRC cases); B) Controls: Persons without a diagnosis of CRC during the observation period, matched to CRC cases by age and sex (matching factor: 1∶5). We considered in-patient, out-patient and drug costs and calculated incremental costs as the difference in means between cases and controls. We divided costs into three phases of care (initial, intermediate and end-of-life phase).

RESULTS

The initial, the intermediate and the end-of-life phase included 12,792, 5,280, and 3,779 CRC cases, respectively, and 63,960, 26,400, and 18,895 controls. The mean incremental costs--annualized for each phase--were €26,000, €2,300, and €51,700, respectively. The costs of the initial phase of care were higher for rectal than for colon cancer. Annualized stage-specific cost estimates ranged from €15,000 to €21,300 for early stages and from €29,800 to €35,000 for late stages.

CONCLUSION

This pragmatic and feasible approach provided plausible estimates of CRC treatment costs in Germany; being transferable to other settings, it may thus facilitate to weigh up potential savings in treatment costs against the resources required for CRC control programs in various countries.

miR-429 identified by dynamic transcriptome analysis is a new candidate biomarker for colorectal cancer prognosis

Colorectal cancer (CRC) is a common malignant gastrointestinal cancer. Efforts for preventive and personalized medicine have intensified in the last decade with attention to novel forms of biomarkers. In the present study, microRNA and genetic analyses were performed in tandem for differential transcriptome profiling between primary tumors with or without nodes or distant metastases. Serial Test Cluster (STC) analysis demonstrated that 20 genes and two microRNAs showed distinctive expression patterns associated with the tumor, node, and metastasis (TNM) stage. The selected target genes were characterized by GO and Pathway analysis. A microRNA-target gene network analysis showed that miR-429 resided in the center of the network, indicating that miR-429 might serve important roles in the development of CRC. Real-time PCR and tissue microarrays showed that miR-429 had a dynamic expression pattern during the CRC progression stage, and was significantly downregulated in stage II and stage III clinical progression. The low expression of miR-429 was correlated with poor prognosis for CRC. Taken together, miR-429 warrant further clinical translation research as a candidate biomarker for CRC prognosis. Additional downstream targets and attendant gene function also need to be discerned to design a sound critical path to personalized medicine for persons susceptible to, or diagnosed with CRC.

Cost effectiveness of fecal DNA screening for colorectal cancer: a systematic review and quality appraisal of the literature

BACKGROUND

Fecal DNA (fDNA) testing is a noninvasive potential alternative to current colorectal cancer screening tests.

OBJECTIVE

We conducted a systematic review and quality assessment of studies of cost-effectiveness of fDNA as a colorectal cancer screening tool (compared with no screening and other screening modalities), and identified key variables that impinged on cost-effectiveness.

DATA SOURCES

We searched MEDLINE, Embase, and the Centre for Reviews and Dissemination for cost-effectiveness studies of fDNA-based screening, published in English by September 2011.

STUDY SELECTION

Studies that undertook an economic evaluation of fDNA, using either a cost-effectiveness or cost-utility analysis, compared with other relevant screening modalities and/or no screening were included. Additional inclusion criteria related to the presentation of data pertaining to model variables including time horizon, costs, fDNA performance characteristics, screening uptake, and comparators. A total of 369 articles were initially identified for review. After removing duplicates and applying inclusion and exclusion criteria, seven articles were included in the final review.

STUDY APPRAISAL

Data was abstracted on key descriptor variables including screening scenarios, time horizon, costs, test performance characteristics, screening uptake, comparators, and incremental cost-effectiveness ratios. Quality assessment was undertaken using a standard checklist for economic evaluations. Studies cited by cost-effectiveness articles as the source of data on fDNA test performance characteristics were also reviewed.

RESULTS

Seven cost-effectiveness studies were included, from the USA (4), Canada (1), Israel (1), and Taiwan (1). Markov models (5), a partially observable Markov decision process model (1) and MISCAN and SimCRC (1) microsimulation models were used. All studies took a third-party payer perspective and one included, in addition, a societal perspective. Comparator screening tests, screening intervals, and specific fDNA tests varied between studies. fDNA sensitivity and specificity parameters were derived from 12 research studies and one meta-analysis. Outcomes assessed were life-years gained and quality-adjusted life-years gained. fDNA was cost-effective when compared with no screening in six studies. Compared with other screening modalities, fDNA was not considered cost-effective in any of the base-case analyses: in five studies it was dominated by all alternatives considered. Sensitivity analyses identified cost, compliance, and test parameters as key influential parameters. In general, poor presentation of "study design" and "data collection" details lowered the quality of included articles.

LIMITATIONS

Although the literature searches were designed for high sensitivity, the possibility cannot be excluded that some eligible studies may have been missed. Reports (such as Health Technology Assessments produced by government agencies) and other forms of grey literature were excluded because they are difficult to identify systematically and/or may not report methods and results in sufficient detail for assessment.

CONCLUSION

On the basis of the available (albeit limited) evidence, while fDNA is cost-effective when compared with no screening, it is currently dominated by most of the other available screening options. Cost and test performance appear to be the main influences on cost-effectiveness.

How much does it cost to care for survivors of colorectal cancer? Caregiver's time, travel and out-of-pocket costs

Purpose

Cancer treatment is increasingly delivered in an outpatient setting. This may entail a considerable economic burden for family members and friends who support patients/survivors. We estimated financial and time costs associated with informal care for colorectal cancer.

Methods

Two hundred twenty-eight carers of colorectal cancer survivors diagnosed on October 2007–September 2009 were sent a questionnaire. Informal care costs included hospital- and domestic-based foregone caregiver time, travel expenses and out-of-pocket (OOP) costs during two phases: diagnosis and treatment and ongoing care (previous 30 days). Multiple regression was used to determine cost predictors.

Results

One hundred fifty-four completed questionnaires were received (response rate = 68 %). In the diagnosis and treatment phase, weekly informal care costs per person were: hospital-based costs, incurred by 99 % of carers, mean = €393 (interquartile range (IQR), €131–€541); domestic-based time costs, incurred by 85 %, mean = €609 (IQR, €170–€976); and domestic-based OOP costs, incurred by 68 %, mean = €69 (IQR, €0–€110). Ongoing costs included domestic-based time costs incurred by 66 % (mean = €66; IQR, €0–€594) and domestic-based OOP costs incurred by 52 % (mean = €52; IQR, €0–€64). The approximate average first year informal care cost was €29,842, of which 85 % was time costs, 13 % OOP costs and 2 % travel costs. Significant cost predictors included carer age, disease stage, and survivor age.

Conclusion

Informal caregiving associated with colorectal cancer entails considerable time and OOP costs. This burden is largely unrecognised by policymakers, service providers and society in general. These types of studies may facilitate health decision-makers in better assessing the consequences of changes in cancer care organisation and delivery.

Electronic supplementary material

The online version of this article (doi:10.1007/s00520-013-1834-3) contains supplementary material, which is available to authorized users.

Using resource modelling to inform decision making and service planning: the case of colorectal cancer screening in Ireland

Background

Organised colorectal cancer screening is likely to be cost-effective, but cost-effectiveness results alone may not help policy makers to make decisions about programme feasibility or service providers to plan programme delivery. For these purposes, estimates of the impact on the health services of actually introducing screening in the target population would be helpful. However, these types of analyses are rarely reported. As an illustration of such an approach, we estimated annual health service resource requirements and health outcomes over the first decade of a population-based colorectal cancer screening programme in Ireland.

Methods

A Markov state-transition model of colorectal neoplasia natural history was used. Three core screening scenarios were considered: (a) flexible sigmoidoscopy (FSIG) once at age 60, (b) biennial guaiac-based faecal occult blood tests (gFOBT) at 55–74 years, and (c) biennial faecal immunochemical tests (FIT) at 55–74 years. Three alternative FIT roll-out scenarios were also investigated relating to age-restricted screening (55–64 years) and staggered age-based roll-out across the 55–74 age group. Parameter estimates were derived from literature review, existing screening programmes, and expert opinion. Results were expressed in relation to the 2008 population (4.4 million people, of whom 700,800 were aged 55–74).

Results

FIT-based screening would deliver the greatest health benefits, averting 164 colorectal cancer cases and 272 deaths in year 10 of the programme. Capacity would be required for 11,095-14,820 diagnostic and surveillance colonoscopies annually, compared to 381–1,053 with FSIG-based, and 967–1,300 with gFOBT-based, screening. With FIT, in year 10, these colonoscopies would result in 62 hospital admissions for abdominal bleeding, 27 bowel perforations and one death. Resource requirements for pathology, diagnostic radiology, radiotherapy and colorectal resection were highest for FIT. Estimates depended on screening uptake. Alternative FIT roll-out scenarios had lower resource requirements.

Conclusions

While FIT-based screening would quite quickly generate attractive health outcomes, it has heavy resource requirements. These could impact on the feasibility of a programme based on this screening modality. Staggered age-based roll-out would allow time to increase endoscopy capacity to meet programme requirements. Resource modelling of this type complements conventional cost-effectiveness analyses and can help inform policy making and service planning.

Screening for colorectal cancer: how can we maximize uptake?

SUMMARY Screening for colorectal cancer is being introduced in a number of countries, yet uptake remains low. The rationalistic model of screening participation explains low uptake in terms of deficient knowledge and high cost. There is evidence to support this view and remedial actions produce anticipated effects up to a point. However, differential uptake among specific groups suggests that the individual decision to participate in screening is idiosyncratic, and understanding decisions requires interpretation in terms of message framing, reference points, the use of simplifying heuristics and affective or emotional reaction. As these aspects of decisions originate from fundamental personal characteristics, they may be difficult to combat. When decision determinants, such as fear and herding, are manipulated, consequences for uptake can be contradictory.

Levels and variation in overuse of fecal occult blood testing in the Veterans Health Administration

BACKGROUND

Policy-makers have called for efforts to reduce overuse of cancer screening tests, including colorectal cancer screening (CRCS). Overuse of CRCS tests other than colonoscopy has not been well documented.

OBJECTIVE

To estimate levels and correlates of fecal occult blood test (FOBT) overuse in a national Veterans Health Administration (VHA) sample.

DESIGN

Observational

PARTICIPANTS

Participants included 1,844 CRCS-eligible patients who responded to a 2007 CRCS survey conducted in 24 VHA facilities and had one or more FOBTs between 2003 and 2009.

MAIN MEASURES

We combined survey data on race, education, and income with administrative data on region, age, gender, CRCS procedures, and outpatient visits to estimate overuse levels and variation. We coded FOBTs as overused if they were conducted <10 months after prior FOBT, <9.5 years after prior colonoscopy, or <4.5 years after prior barium enema. We used multinomial logistic regression models to examine variation in overuse by reason (sooner than recommended after prior FOBT; sooner than recommended after colonoscopy, barium enema, or a combination of procedures), adjusting for clustering of procedures within patients, and patients within facilities.

KEY RESULTS

Of 4,236 FOBTs received by participants, 885 (21 %) met overuse criteria, with 323 (8 %) sooner than recommended after FOBT, and 562 (13 %) sooner than recommended after other procedures. FOBT overuse varied across facilities (9-32 %, p<0.0001) and region (12-23 %, p< .0012). FOBT overuse after prior FOBT declined between 2003 and 2009 (8 %-5 %, p= .0492), but overuse after other procedures increased (11-19 %, p= .0002). FOBT overuse of both types increased with number of outpatient visits (OR 1.15, p<0.001), but did not vary by patient demographics. More than 11 % of overused FOBTs were followed by colonoscopy within 12 months.

CONCLUSIONS

Many FOBTs are performed sooner than recommended in the VHA. Variation in overuse by facility, region, and outpatient visits suggests addressing FOBT overuse will require system-level solutions.

Cost-effectiveness of computed tomography colonography in colorectal cancer screening: a systematic review

OBJECTIVES

The European Code Against Cancer recommends individuals aged ≥ 50 should participate in colorectal cancer screening. CT-colonography (CTC) is one of several screening tests available. We systematically reviewed evidence on, and identified key factors influencing, cost-effectiveness of CTC screening.

METHODS

PubMed, Medline, and the Cochrane library were searched for cost-effectiveness or cost-utility analyses of CTC-based screening, published in English, January 1999 to July 2010. Data was abstracted on setting, model type and horizon, screening scenario(s), comparator(s), participants, uptake, CTC performance and cost, effectiveness, ICERs, and whether extra-colonic findings and medical complications were considered.

RESULTS

Sixteen studies were identified from the United States (n = 11), Canada (n = 2), and France, Italy, and the United Kingdom (1 each). Markov state-transition (n = 14) or microsimulation (n = 2) models were used. Eleven considered direct medical costs only; five included indirect costs. Fourteen compared CTC with no screening; fourteen compared CTC with colonoscopy-based screening; fewer compared CTC with sigmoidoscopy (8) or fecal tests (4). Outcomes assessed were life-years gained/saved (13), QALYs (2), or both (1). Three considered extra-colonic findings; seven considered complications. CTC appeared cost-effective versus no screening and, in general, flexible sigmoidoscopy and fecal occult blood testing. Results were mixed comparing CTC to colonoscopy. Parameters most influencing cost-effectiveness included: CTC costs, screening uptake, threshold for polyp referral, and extra-colonic findings.

CONCLUSION

Evidence on cost-effectiveness of CTC screening is heterogeneous, due largely to between-study differences in comparators and parameter values. Future studies should: compare CTC with currently favored tests, especially fecal immunochemical tests; consider extra-colonic findings; and conduct comprehensive sensitivity analyses.

Cost of care for colorectal cancer in Ireland: a health care payer perspective

OBJECTIVE

Management options for colorectal cancer have expanded in recent years. We estimated average lifetime cost of care for colorectal cancer in Ireland in 2008, from the health care payer perspective.

METHOD

A decision tree model was developed in Microsoft EXCEL. Site and stage-specific treatment pathways were constructed from guidelines and validated by expert clinical opinion. Health care resource use associated with diagnosis, treatment and follow-up were obtained from the National Cancer Registry Ireland (n=1,498 cancers diagnosed during 2004-2005) and three local hospital databases (n=155, 142 and 46 cases diagnosed in 2007). Unit costs for hospitalisation, procedures, laboratory tests and radiotherapy were derived from DRG costs, hospital finance departments, clinical opinion and literature review. Chemotherapy costs were estimated from local hospital protocols, pharmacy departments and clinical opinion. Uncertainty was explored using one-way and probabilistic sensitivity analysis.

RESULTS

In 2008, the average (stage weighted) lifetime cost of managing a case of colorectal cancer was €39,607. Average costs were 16% higher for rectal (€43,502) than colon cancer (€37,417). Stage I disease was the least costly (€23,688) and stage III most costly (€48,835). Diagnostic work-up and follow-up investigations accounted for 4 and 5% of total costs, respectively. Cost estimates were most sensitive to recurrence rates and prescribing of biological agents.

CONCLUSION

This study demonstrates the value of using existing data from national and local databases in contributing to estimating the cost of managing cancer. The findings illustrate the impact of biological agents on costs of cancer care and the potential of strategies promoting earlier diagnosis to reduce health care resource utilisation and care costs.

Quality indicators for colorectal cancer surgery and care according to patient-, tumor-, and hospital-related factors

Background

Colorectal cancer (CRC) care has improved considerably, particularly since the implementation of a quality of care program centered on national evidence-based guidelines. Formal quality assessment is however still needed. The aim of this research was to identify factors associated with practice variation in CRC patient care.

Methods

CRC patients identified from all cancer centers in South-West France were included. We investigated variations in practices (from diagnosis to surgery), and compliance with recommended guidelines for colon and rectal cancer. We identified factors associated with three colon cancer practice variations potentially linked to better survival: examination of ≥12 lymph nodes (LN), non-use and use of adjuvant chemotherapy for stage II and stage III patients, respectively.

Results

We included 1,206 patients, 825 (68%) with colon and 381 (32%) with rectal cancer, from 53 hospitals. Compliance was high for resection, pathology report, LN examination, and chemotherapy use for stage III patients. In colon cancer, 26% of stage II patients received adjuvant chemotherapy and 71% of stage III patients. 84% of stage US T3T4 rectal cancer patients received pre-operative radiotherapy. In colon cancer, factors associated with examination of ≥12 LNs were: lower ECOG score, advanced stage and larger hospital volume; factors negatively associated were: left sided tumor location and one hospital district. Use of chemotherapy in stage II patients was associated with younger age, advanced stage, emergency setting and care structure (private and location); whereas under-use in stage III patients was associated with advanced age, presence of comorbidities and private hospitals.

Conclusions

Although some changes in practices may have occurred since this observational study, these findings represent the most recent report on practices in CRC in this region, and offer a useful methodological approach for assessing quality of care. Guideline compliance was high, although some organizational factors such as hospital size or location influence practice variation. These factors should be the focus of any future guideline implementation.

[The Alliance for the Prevention of Colorectal Cancer in Spain. A civil commitment to society]

Colorectal cancer (CRC) is the most common malignant tumor in Spain, when men and women are considered together, and the second leading cause of cancer death. Every week in Spain over 500 cases of CRC are diagnosed, and nearly 260 people die from the disease. Epidemiologic estimations for the coming years show a significant increase in the number of annual cases. CRC is a perfectly preventable tumor and can be cured in 90% of cases if detected in the early stages. Population-based screening programs have been shown to reduce the incidence of CRC and mortality from the disease. Unless early detection programs are established in Spain, it is estimated that in the coming years, 1 out of 20 men and 1 out of 30 women will develop CRC before the age of 75. The Alliance for the Prevention of Colorectal Cancer in Spain is an independent and non-profit organization created in 2008 that integrates patients' associations, altruistic non-governmental organizations and scientific societies. Its main objective is to raise awareness and disseminate information on the social and healthcare importance of CRC in Spain and to promote screening measures, early detection and prevention programs. Health professionals, scientific societies, healthcare institutions and civil society should be sensitized to this highly important health problem that requires the participation of all sectors of society. The early detection of CRC is an issue that affects the whole of society and therefore it is imperative for all sectors to work together.

Patterns of treatment with chemotherapy and monoclonal antibodies for metastatic colorectal cancer in Western Europe

BACKGROUND AND OBJECTIVES

Treatment outcomes improved in metastatic colorectal cancer (mCRC) due to the introduction of new chemotherapies and monoclonal antibodies. This study describes current patterns of pharmacological treatment for mCRC in clinical practice in four European countries.

METHODS

This cohort study used physician-survey data from the LifeLink Oncology Analyzer Database for mCRC patients in France, Germany, Italy and Spain. All patients aged ≥21 years at mCRC diagnosis and with data collected during 2009 were included. Treatment patterns were examined descriptively by lines of therapy.

RESULTS

The study sample included 2682 mCRC patients. In first-line, more patients received FOLFOX (infusional 5-fluorouracil/leucovorin and oxaliplatin)- than FOLFIRI (infusional 5-fluorouracil/leucovorin and irinotecan)-, containing regimens in Germany (42 vs. 30%) and Spain (25 vs. 16%), while in Italy and France the reverse was true (Italy: 34% FOLFIRI vs.29% FOLFOX; France: 26 vs. 19%). In second-line, FOLFIRI-containing regimens were more commonly used than FOLFOX-containing regimens in Germany (36 vs. 18%), Italy (29 vs. 14%), and Spain (34 vs. 6%), while similar proportions of FOLFOX and FOLFIRI were used in France (18 vs. 15%). As part of first-line treatment, bevacizumab use ranged from 44% of patients in Italy to 30% in Spain, with slightly lower rates in second-line. Cetuximab first-line use ranged from 14% of patients in Spain to 7% in Italy, increasing in second-line to 30% in Spain, 26% in Italy, 20% in Germany, and 17% in France.

LIMITATIONS

This analysis focused on description of treatment patterns, however, the actual clinical benefits of these treatment regimens on survival or quality of life were not addressed due to lack of relevant information in the data source. Some country differences in treatment patterns were observed. These differences might be partly explained by differences in local treatment guidelines, physician prescribing behaviours, reimbursement policies, and response to various regimens due to genetic differences.

CONCLUSIONS

In clinical practice in four European countries, FOLFOX- and FOLFIRI-based regimens are common standard of care chemotherapies for mCRC (FOLFOX and bevacizumab + FOLFIRI are the most common regimens), and monoclonal antibodies are often combined with these chemotherapies.

Fecal occult blood testing when colonoscopy capacity is limited

BACKGROUND

Fecal occult blood testing (FOBT) can be adapted to a limited colonoscopy capacity by narrowing the age range or extending the screening interval, by using a more specific test or hemoglobin cutoff level for referral to colonoscopy, and by restricting surveillance colonoscopy. Which of these options is most clinically effective and cost-effective has yet to be established.

METHODS

We used the validated MISCAN-Colon microsimulation model to estimate the number of colonoscopies, costs, and health effects of different screening strategies using guaiac FOBT or fecal immunochemical test (FIT) at various hemoglobin cutoff levels between 50 and 200 ng hemoglobin per mL, different surveillance strategies, and various age ranges. We optimized the allocation of a limited number of colonoscopies on the basis of incremental cost-effectiveness.

RESULTS

When colonoscopy capacity was unlimited, the optimal screening strategy was to administer an annual FIT with a 50 ng/mL hemoglobin cutoff level in individuals aged 45-80 years and to offer colonoscopy surveillance to all individuals with adenomas. When colonoscopy capacity was decreasing, the optimal screening adaptation was to first increase the FIT hemoglobin cutoff value to 200 ng hemoglobin per mL and narrow the age range to 50-75 years, to restrict colonoscopy surveillance, and finally to further decrease the number of screening rounds. FIT screening was always more cost-effective compared with guaiac FOBT. Doubling colonoscopy capacity increased the benefits of FIT screening up to 100%.

CONCLUSIONS

FIT should be used at higher hemoglobin cutoff levels when colonoscopy capacity is limited compared with unlimited and is more effective in terms of health outcomes and cost compared with guaiac FOBT at all colonoscopy capacity levels. Increasing the colonoscopy capacity substantially increases the health benefits of FIT screening.