Contributing factors and short-term surgical outcomes of patients with early-onset rectal cancer

Risk factors, histopathological landscape, biomarkers, treatment patterns and survival of early-onset colorectal cancer: A narrative review

Early-onset colorectal cancer (EOCRC) incidence has increased in most Western countries over the last decade, with Australia at the forefront. Recent literature has thus focused on characterizing EOCRC from later-onset colorectal cancer (LOCRC). Earlier exposure to modifiable risk factors resulting in gut dysbiosis has been linked with EOCRC development. EOCRCs have more aggressive histopathological features with somatic mutations resulting in pro-inflammatory tumor microenvironments. There is a tendency to treat EOCRCs with multimodal chemotherapeutic regimens and more extensive surgery than LOCRCs with conflicting postoperative outcomes and survival data. Current research is limited by a lack of Australasian studies, retrospective study designs, and heterogeneous definitions of EOCRC. Future research should address these and focus on investigating the role of immunotherapies, establishing minimally invasive diagnostic biomarkers and nomograms, and evaluating the survival and functional outcomes of EOCRC.

Surgical and survival outcomes of early-onset colorectal cancer patients: a single-centre descriptive Australian study

BACKGROUND

Early-onset colorectal cancer (EOCRC) incidence is increasing in Australia. However, no Australian studies have reported on EOCRC patients' surgical management and survival patterns.

METHODS

A retrospective study of 111 EOCRC patients treated at the Royal Prince Alfred Hospital (RPAH), Sydney, Australia between January 2013 and December 2021 was performed. RPAH is a quaternary referral centre for pelvic exenteration (PE) and cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC).

RESULTS

Most patients had left-sided tumours (76.58%) and stage IV disease at the time of presentation (37.85%). 27.93% of patients underwent either CRS/HIPEC and PE and 72.07% of patients underwent other colorectal resections of which the most common was low anterior resection (19.82%). A stoma was fashioned in 50.54% of patients. Complications occurred in 54.95% of patients of which most were Clavien-Dindo grade II (47.54%). Absolute 1-, 3- and 5-year time intervals were 93.69%, 87.39% and 85.48%. Disease-free and overall survival were poorer in stage IV patients who had PE, followed by CRS/HIPEC then other colorectal resections (P < 0.001 and P = 0.003).

CONCLUSIONS

Stoma formation, PE and CRS/HIPEC and minor postoperative complications were common in our EOCRC cohort. Despite this, the 5-year absolute survival rate was acceptable. Thus, an aggressive surgical approach in EOCRC patients at a quaternary referral centre may be feasible at the cost of greater postoperative morbidity. This information is imperative in the surgical consent and preoperative counselling of EOCRC patients and highlights the need for further research to assess the postoperative functional outcomes and quality of life of EOCRC patients.

Young adults with colon cancer: clinical features and surgical outcomes

BACKGROUND

The clinicopathological features, surgical outcomes, and long-term survival of patients with young-onset colon cancer (≤ 40 years old) remain controversial.

METHODS

The clinicopathologic and follow-up data of patients aged < 40 years with colon cancer between January 2014 and January 2022 were reviewed. The primary objectives were clinical features and surgical outcomes. Long-term survival was investigated as a secondary objective.

RESULTS

Seventy patients were included in the study, and no significant rising trend (Z=0, P=1) of these patients was observed over the 8-year study period. Stage IV disease was accompanied by more ulcerative or infiltrating type (84.2% vs. 52.9%, P=0.017) and lymphovascular or perineural invasion (64.7% vs. 25.5%, P=0.003) than stage I-III disease. After a median follow-up time of 41 months (range 8-99 months), the 1-, 3-, and 5-year estimated overall survival (OS) rates were 92.6%, 79.5%, and 76.4%, respectively. The 1-, 3-, and 5-year progression-free survival (PFS) rates were 79.6%, 71.7%, and 71.7%, respectively. Multivariate Cox regression showed that M+ stage (hazard ratio [HR], 3.942; 95% confidence interval [CI], 1.176-13.220, P=0.026) was the only independent risk factor affecting OS. Meanwhile, tumor deposits (HR, 4.807; 95% CI, 1.942-15.488, P=0.009), poor differentiation (HR, 2.925; 95% CI, 1.012-8.454, P=0.047), and M+ stage (HR, 3.540; 95% CI, 1.118-11.202, P=0.032) independently affected PFS.

CONCLUSIONS

The differences in the clinical features, surgical outcomes, and long-term survival between young adults and elderly colon cancer patients need further investigation.

Racial Disparities in Colorectal Cancer Care for Black Patients: Barriers and Solutions

Racial disparities in colorectal cancer for Black patients have led to a significant mortality difference when compared to White patients, a gap which has remained to this day. These differences have been linked to poorer quality insurance and socioeconomic status in addition to lower access to high-quality health care resources, which are emblematic of systemic racial inequities. Disparities impact nearly every point along the colorectal cancer care continuum and include barriers to screening, surgical care, oncologic care, and surveillance. These critical faults are the driving forces behind the mortality difference Black patients face. Health care systems should strive to correct these disparities through both cultural competency at the provider level and public policy change at the national level.

Early-onset colorectal cancer: why it should be high on our list of differentials

Background

Early‐onset colorectal cancer (EOCRC) (<50 years) incidence has increased in Australia and worldwide. However, the diagnosis of EOCRC is often delayed. Recent research has discovered some differences from later‐onset colorectal cancer (LOCRC) (>50 years). An awareness of the unique features of EOCRC is crucial to reduce time from symptom onset to diagnosis.

Methods

A literature search was conducted on electronic databases (MEDLINE, EMBASE and Cochrane Library) using the search terms “early onset colorectal cancer” or “young onset colorectal cancer.”

Results

The American Cancer Society has reduced the colorectal cancer screening initiation age to 45 for average‐risk adults whilst screening programmes in the United Kingdom and Australia remain unchanged with initiation at 60 and 50, respectively. Exposures resulting in dysbiosis (obesity, westernised diet, alcohol, antibiotic and sugar‐sweetened beverage consumption) have been linked with increased EOCRC risk. EOCRC is often left‐sided presenting with rectal bleeding, altered bowel habit and constitutional symptoms. EOCRC is more commonly sporadic than hereditary, harbouring different genetic mutations than LOCRC. Comparative survival outcomes of EOCRC and LOCRC are conflicting with studies suggesting either better or poorer survival. Young patients better tolerate treatment‐related toxicities, which may account for their improved survival despite comparatively advanced stages and poorer histopathological features at diagnosis.

Conclusion

Current EOCRC literature is limited by American‐focused datasets and heterogenous EOCRC definitions and study designs (the greatest strength of evidence exists for EOCRC risk factor studies comprised of large retrospective cohorts). There is minimal research into the quality of life and surgical outcomes of EOCRC patients, and this area warrants further investigation.

Racial Disparities in the Management of Locoregional Colorectal Cancer

Racial disparities pervade nearly all aspects of management of locoregional colorectal cancer, including time to treatment, receipt of resection, adequacy of resection, postoperative complications, and receipt of neoadjuvant and adjuvant multimodality therapies. Disparate gaps in treatment translate into enduring effects on survivorship, recurrence, and mortality. Efforts to reduce these gaps in care must be undertaken on a multilevel basis and focus on modifiable factors that underlie racial disparity.

Pathologic complete response is associated with decreased morbidity following rectal cancer resection

BACKGROUND

There are conflicting data regarding the relationship between pathologic complete response (pCR) and post-operative complications following rectal cancer resection. The objective of this study was to compare the rates of morbidity among pCR patients and non-pCR patients and to identify factors that predict pCR morbidity in a large national database.

METHODS

This is a retrospective study using American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) targeted proctectomy data (2016-18). Patients with neoadjuvant chemoradiation therapy followed by proctectomy were included, and divided into pCR and non-pCR groups according to final stage. The groups were compared with Student's t-test, Chi-squared or Fisher's exact test. Multivariate logistic regression models were constructed to estimate the association between pCR status and post-operative morbidity while adjusting for key covariates.

RESULTS

244 pCR and 1656 non-pCR patients were included. pCR patients had higher body mass index (28.1 ± 6.2 vs. 29.1 ± 5.9 kg/m²; p = 0.01) and lower pre-operative stage (T stage, p = 0.03; N stage, p < 0.001). The groups were equivalent with respect to surgical approach, type of surgery, and operative time (p > 0.05). Post-operative complications in pCR patients were less frequent than in non-pCR patients (23.0% vs. 29.3%; p = 0.04). This association was robust to adjustment for confounders in logistic regression, as patients with pCR had decreased odds of post-operative morbidity (OR 0.66, CI [0.43, 0.96], p = 0.04).

CONCLUSION

pCR is associated with fewer post-operative complications compared to non-pCR, suggesting that pCR is not a marker of severe pelvic fibrosis. This difference may be due to underlying tumor biology, and associated increased technical challenges resecting larger, non-responsive tumors.