Rectal cancer in old age -is it appropriately managed? Evidence from population-based analysis of routine data across the English national health service

Registry-based study comparing health-related quality of life between patients with primary rectal cancer and locally recurrent rectal cancer

AIM

National clinical registries offer the benefits of a comprehensive dataset, particularly when linked with patient-reported outcome (PRO) data. This aim of this study was to utilise UK registry data to assess cross-sectional differences in health-related quality of life (HrQoL) in patients with primary rectal (PRC) and locally recurrent rectal cancer (LRRC).

MATERIALS AND METHODS

Data were extracted from the COloRECTal cancer Repository (CORECT-R) and the Locally Recurrent Rectal Cancer - Quality of Life (LRRC-QoL) datasets. Propensity score matching was undertaken in a 1:1 ratio using two covariates: age and sex. The primary outcome was the FACT-C Colorectal Cancer Subscale (CCS). Statistical significance was determined using p < 0.05 and clinical significance using effect size (ES) and minimally important clinical difference (MCID).

RESULTS

A matched cohort with 72 patients in each group was identified. Overall FACT-C CCS scores were worse in patients with LRRC from a statistical (11.80 vs 18.03, p < 0.001) and clinically meaningful perspective (ES 1.63, MCID 6.23). Patients with PRC reported better digestion (p < 0.001, ES 0.85), better control over their bowels (p < 0.001, ES 1.03) and increased appetite (p < 0.001, ES 1.74, MCID 2.08). Patients with LRRC reported worse stomach swelling (p < 0,001, ES 0.97) and more diarrhoea (p < 0.001, ES 0.92), however they reported better body image (p < 0.001, ES 0.80).

CONCLUSION

Patients with LRRC reported significantly worse overall scores in the FACT-C CCS from both a statistical and clinical perspective, demonstrating the ability of the FACT-C to distinguish between these patient groups and the benefits of the inclusion of PROs within colorectal cancer registries, specifically including patients with advanced/recurrent disease.

Postoperative morbidity following Hartmann's procedure in comparison to anterior resection and abdominoperineal resection for rectal cancer-a population-based study

AIM

There is ongoing controversy regarding the extent to which Hartmann's procedure (HP) should be used in rectal cancer treatment. This study was designed to investigate 30-day postoperative morbidity and mortality following HP, anterior resection (AR) and abdominoperineal resection (APR) for rectal cancer using a national registry.

METHODS

All patients operated for rectal cancer, tumour height 5-15 cm, between the years 2010 and 2017, were identified through the Swedish colorectal cancer registry.

RESULTS

A total of 8476 patients were included: 1210 (14%) undergoing HP, 5406 (64%) AR and 1860 (22%) APR. HP was associated with an increased risk of intra-abdominal infection (OR 1.7, CI 1.26-2.28, P = 0.0004) compared to AR and APR, while APR was related to an increased risk of overall complications (OR 1.18, CI 1.01-1.40, P = 0.040). No significant difference was observed in the rate of reoperations and readmissions between HP, AR and APR, and type of surgical procedure was not a risk factor for 30-day mortality. Findings from a subgroup analysis of patients with a tumour 5-7 cm from the anal verge revealed that HP was not associated with increased risk for complications or 30-day mortality.

CONCLUSIONS

For patients where AR is not appropriate HP is a valid alternative with a favourable outcome. APR was associated with the highest overall 30-day complication rate.

A comparison of frailty measures in population-based data for patients with colorectal cancer

BACKGROUND

Numerous studies have revealed age-related inequalities in colorectal cancer care. Increasing levels of frailty in an ageing population may be contributing to this, but quantifying frailty in population-based studies is challenging.

OBJECTIVE

To assess the feasibility, validity and reliability of the Hospital Frailty Risk Score (HFRS), the Secondary Care Administrative Records Frailty (SCARF) index and the frailty syndromes (FS) measures in a national colorectal cancer cohort.

DESIGN

Retrospective population-based study using 136,008 patients with colorectal cancer treated within the English National Health Service.

METHODS

Each measure was generated in the dataset to assess their feasibility. The diagnostic codes used in each measure were compared with those in the Charlson Comorbidity Index (CCI). Validity was assessed using the prevalence of frailty and relationship with 1-year survival. The Brier score and the c-statistic were used to assess performance and discriminative ability of models with included each measure.

RESULTS

All measures demonstrated feasibility, validity and reliability. Diagnostic codes used in SCARF and CCI have considerable overlap. Prevalence of frailty determined by each differed; SCARF allocating 55.4% of the population to the lowest risk group compared with 85.1% (HFRS) and 81.2% (FS). HFRS and FS demonstrated the greatest difference in 1-year overall survival between those with the lowest and highest measured levels of frailty. Differences in model performance were marginal.

CONCLUSIONS

HFRS, SCARF and FS all have value in quantifying frailty in routine administrative health care datasets. The most suitable measure will depend on the context and requirements of each individual epidemiological study.

Hartmann's procedure in rectal cancer surgery is often an intraoperative decision: a retrospective multicenter study

PURPOSE

This study aimed to investigate patient-related factors predicting the selection of rectal cancer patients to Hartmann's procedure as well as to investigate how often, and on what grounds, anterior resection is intraoperatively changed to Hartmann's procedure.

METHODS

Prospectively collected data from the Swedish Colorectal Cancer Registry regarding patients with rectal cancer operated upon from January 1 2007 to June 30 2017 in the county of Skåne were retrospectively reviewed. Data were expanded with further details from medical charts. A univariable analysis was performed to investigate variables associated with unplanned HP and significant variables included in a multivariable logistic regression analysis.

RESULTS

Altogether, 1141 patients who underwent Hartmann's procedure (275 patients, 24%), anterior resection (491 patients, 43%), or abdominoperineal resection (375 patients, 33%) were included. Patients undergoing Hartmann's procedure were significantly older and had more frequently comorbidity. The decision to perform Hartmann's procedure was made preoperatively in 209 (76%) patients, most commonly because of a comorbidity (27%) or oncological reasons (25%). Patient preference was noted in 8% of cases. In 64 cases (23%), the decision was made intraoperatively, most often due to anastomotic difficulties (60%) and oncological reasons (22%). Anastomotic difficulties were most often reported due to technical difficulties, a low tumor or neoadjuvant radiotherapy. Male gender was a significant risk factor for undergoing unplanned Hartmann's procedure.

CONCLUSIONS

The decision to perform Hartmann's procedure was frequently made intraoperatively. Hartmann's procedure should be considered and discussed preoperatively in old and frail patients, especially in the presence of mid-rectal cancer and/or male gender, since these factors increase the risk of intraoperative anastomotic difficulties.

Association of age with outcomes in locally advanced rectal cancer treated with neoadjuvant therapy followed by surgery

INTRODUCTION

We aimed to assess the association of age with outcomes in patients with Locally Advanced Rectal Cancer (LARC) who received neoadjuvant therapy followed by major surgery.

METHODS

Retrospective review of 328 patients with LARC, N = 99 < 70 years (younger) versus N = 229 ≥ 70 years (elderly) from 2004 to 2018.

RESULTS

Elderly patients had a higher American Society of Anesthesiologists (ASA) score, Charlson Comorbidity Index (CCI), length of stay and 30-day readmissions (p < 0.05). They also had worse overall survival (OS) & disease-free survival (DFS) (p < 0.001), but similar disease-specific survival (DSS) compared to younger group. Age was not associated with hazard of death (HR 1.01, 0.98-1.03). Rather, CCI (HR 1.29, 1.01-1.5), extramural vascular invasion (HR 4.98, 2.84-8.74), and adjuvant therapy (0.37, 0.21-0.64) were significantly associated with the hazard of death; when controlled for stage, tumor distance from anal verge, and neoadjuvant completion.

CONCLUSION

Comorbidities and lower rates of adjuvant therapy, and not chronologic age, are associated with poor OS of elderly patients with LARC treated with neoadjuvant therapy and major surgery.

Assessment of Quality of Life in Rectal Cancer with Organ-Preservation Treatment: Are We There yet?

Rectal cancer is a common cancer and shows an increased incidence with older age. Although the gold standard treatment is surgical excision, minimally invasive approaches are increasingly used and organ preservation is becoming a reasonable approach. The conservative treatment approach includes local excision, external beam radiotherapy and brachytherapy. However, these all carry a risk of side-effects. It is crucial to provide patients with information to quantify the improvement or detriment in quality of life with their cancer treatment. This can only be done with patient-reported outcome measures (PROMs) as tools within current and future trials. Colorectal cancer has numerous publications with specific PROMs. However, PROMs reporting in rectal cancer is more sparse; PROMs are generally extrapolated from colorectal cancer. Rectal PROMs trials hold small population samples and PROMs as an end point is scarce. We present a review of recent literature based on the PROMs reporting of quality of life for rectal cancer patients and introduce the CITRuS trial as an innovative feasibility study related to electronic PROMs data collection.

Exploring Determinants of Interdisciplinary Collaboration within a Geriatric Oncology Setting: A Mixed-Method Study

Simple Summary

Collaboration between oncologists and geriatricians has been shown to improve the quality of elderly cancer patient care. However, previous research has revealed how interpersonal factors might hinder this interdisciplinary work. This study aims to assess sprocessual and contextual determinants of the collaboration between these two disciplines, including shared time and routines, medical decision criteria and perceptions of age and needs of elderly patients. These aspects are important to develop a more efficient patient-centered approach in oncogeriatric care and improve collaboration between the different disciplines involved.

Abstract

Therapeutic challenges regarding the population of elderly cancer patients and their heterogeneity lead to the need to implement person-centered approaches in order to optimize care strategies and adapt oncology treatments to each pattern of aging. The International Society of Geriatric Oncology recommends a multidisciplinary evaluation of these patients and the use of screening tools prior to the initiation of treatments. However, previous research shows a poor implementation of these recommendations in geriatric oncology. Although some studies have identified how different perceptions of geriatric oncology might hinder routine teamwork, little is known about the impact of other factors on promoting the collaboration between the two specialties. This mixed-method exploratory study used an online questionnaire to assess the perception of a group of 22 geriatricians and oncology physicians on different determinants of oncology care and teamwork. In this sample, older oncology patients benefited from geriatric care. However, there was a variability regarding age criteria and a limited use of screening tools. The multidimensional framework for interprofessional teamwork by Reeves has been used to analyze some of the determinants of the collaboration between oncology physicians and geriatricians. This study has identified systematic issues to consider when promoting communication and common values between the two disciplines, including available resources in terms of shared time, space and routine actions.

Challenges in Geriatric Oncology-A Surgeon's Perspective

As our global population ages, we will see more cancer diagnoses in older adults. Surgery is an important treatment modality for solid tumours, forming the majority of all cancers. However, the management of older adults with cancer can be more complex compared to their younger counterparts. This narrative review will outline the current challenges facing older adults with cancer and potential solutions. The challenges facing older adults with cancer are complex and include lack of high-level clinical trials targeting older adults and selection of the right patient for surgery. This may be standard surgical treatment, minimally invasive surgery or alternative therapies (no surgery) which can be local or systemic. The next challenge is to identify the individual patient's vulnerabilities to allow them to be maximally optimised for treatment. Prehabilitation has been shown to be of benefit in some cancer settings but uniform guidance across all surgical specialties is required. Greater awareness of geriatric conditions amongst surgical oncologists and integration of geriatric assessment into a surgical clinic are potential solutions. Enhanced recovery programmes tailored to older adults could reduce postoperative functional decline. Ultimately, the greatest challenge an older adult with cancer may face is the mindset of their treating clinicians-a shared care approach between surgical oncologists and geriatricians is required.

Changes in rectal cancer treatment after the introduction of a national screening program; Increasing use of less invasive strategies within a national cohort

AIM

Organ preserving treatment strategies and the introduction of a colorectal cancer-screening program have likely influenced the resection rates of rectal cancer. The aim of this study is to assess the influence of these developments on rectal cancer treatment and resection rates in the Netherlands.

METHODS

Patients diagnosed with non-metastatic rectal cancer between 2013 and 2018, were selected from the Netherlands Cancer Registry. The distribution of surgical and neo-adjuvant treatment and resection rates were analyzed and compared over time.

RESULTS

Between 2013 and 2018 22640 patients were diagnosed with non-metastatic rectal cancer. The incidence of early stage (cT1) disease increased from 141 (4%) in 2013 to 448 (12%) in 2018. The use of neoadjuvant radiotherapy and chemo-radiotherapy dropped from 39% to 21% and 34%-25%, respectively. A decrease in surgical resection rates (including TEM) was observed from 85% to 73%. The proportion of patients who underwent endoscopic resections increased from 3% to 10%. The decrease in surgical resection rates was larger in patients treated with neo-adjuvant chemo-radiotherapy.

CONCLUSION

An increase in stage I disease is noted after the introduction of the screening program. Surgical resection rates for rectal cancer have fallen over time. Endoscopic resections due to more early-stage disease probably accounts for a large part of this decline. Furthermore, a watch and wait approach after neo-adjuvant chemo-radiotherapy may play an important role as well.

Influence of age on surgical treatment and postoperative outcomes of patients with colorectal cancer in Denmark and Yorkshire, England

AIM

Denmark and Yorkshire are demographically similar and both have undergone changes in their management of colorectal cancer to improve outcomes. The differential provision of surgical treatment, especially in the older age groups, may contribute to the magnitude of improved survival rates. This study aimed to identify differences in the management of colorectal cancer surgery and postoperative outcomes according to patient age between Denmark and Yorkshire.

METHOD

This was a retrospective population-based study of colorectal cancer patients diagnosed in Denmark and Yorkshire between 2005 and 2016. Proportions of patients undergoing major surgical resection, postoperative mortality and relative survival were compared between Denmark and Yorkshire across several age groups (18-59, 60-69, 70-79 and ≥80 years) and over time.

RESULTS

The use of major surgical resection was higher in Denmark than in Yorkshire, especially for patients aged ≥80 years (70.5% versus 50.5% for colon cancer, 49.3% versus 38.1% for rectal cancer). Thirty-day postoperative mortality for Danish patients aged ≥80 years was significantly higher than that for Yorkshire patients with colonic cancer [OR (95% CI) = 1.22 (1.07, 1.38)] but not for rectal cancer or for 1-year postoperative mortality. Relative survival significantly increased in all patients aged ≥80 years except for Yorkshire patients with colonic cancer.

CONCLUSION

This study suggests that there are major differences between the management of elderly patients with colorectal cancer between the two populations. Improved selection for surgery and better peri- and postoperative care in these patients appears to improve long-term outcomes, but may come at the cost of a higher 30-day mortality.

Surgery for rectal cancer: Differences in resection rates among hospitals in the Netherlands

AIM

Numerous quality improvement initiatives for rectal cancer surgery have focused on textbook outcome parameters. In these studies, resection rate and patients who did not undergo surgery are not included, but these parameters might help to evaluate the surgical care for rectal cancer. The aim of this study is to assess the variation of non-metastatic rectal cancer resection rates among hospitals and its effect on patient outcomes.

METHODS

All patients diagnosed with non-metastatic rectal cancer between 2013 and 2018 were selected from the Netherlands Cancer Registry. Hospitals were categorized in quartiles according to resection rates. A multivariable logistic analysis was performed to determine variation in resection rate between these quartiles using a logistic regression analysis to correct for confounders. The association between resection rates and survival was analyzed using Kaplan-Meier method and Cox-regression analysis.

RESULTS

A total of 22,530 patients were included in the analysis. Resection rates varied from 68 to 89% between hospitals. After multivariable analysis, resection rate remained significantly different among the quartiles when correcting for several factors (odds ratio (95%Confidence-interval) 1.71 (1.56-1.88), 2.42 (2.19-2.67), and 4.04 (3.61-4.53) for increasing resection rate quartiles, in reference to the lowest quartile). A higher resection rate was associated with better overall survival, in multivariable analysis this survival benefit could no longer be identified.

CONCLUSION

There is a substantial variation in resection rates for rectal cancer among hospitals in the Netherlands with an impact on overall survival. This may be a relevant issue when analyzing the overall quality of rectal cancer care.

Current Treatment Approaches and Outcomes in the Management of Rectal Cancer Above the Age of 80

Background: The number of cases of rectal cancer in our older cohort is expected to rise with our ageing population. In this study, we analysed patterns in treatment and the long-term outcomes of patients older than 80 years with rectal cancer across a health district. Methods: All cases of rectal cancer managed at the Illawarra Cancer Care Centre, Australia between 2006 and 2018 were analysed from a prospectively maintained database. Patients were stratified into three age groups: ≤65 years, 66–79 years and ≥80 years of age. The clinicopathological characteristics, operative and non-operative treatment approach and survival outcomes of the three groups were compared. Results: Six hundred and ninety-nine patients with rectal cancer were managed, of which 118 (17%) were aged 80 and above. Patients above 80 were less likely to undergo surgery (71% vs. 90%, p < 0.001) or receive adjuvant/neoadjuvant chemoradiotherapy (p < 0.05). Of those that underwent surgical resection, their tumours were on average larger (36.5 vs. 31.5 mm, p = 0.019) and 18 mm closer the anal verge (p = 0.001). On Kaplan–Meier analysis, those above 80 had poorer cancer-specific survival when compared to their younger counterparts (p = 0.032), but this difference was no longer apparent after the first year (p = 0.381). Conclusion: Patients above the age of 80 with rectal cancer exhibit poorer cancer-specific survival, which is accounted for in the first year after diagnosis. Priority should be made to optimise care during this period. There is a need for further research to establish the role of chemoradiotherapy in this population, which appears to be underutilised.

Outcomes following major resection for colorectal cancer in patients aged 65+ years: a population-based study in Queensland, Australia

BACKGROUND

The risk of developing colorectal cancer (CRC) increases with increasing age. As surgery is the primary treatment for CRC, our aim was to examine outcomes following major resection for CRC in a cohort of individuals aged ≥65 years.

METHODS

This population-based retrospective study included 18 339 patients aged ≥65 years diagnosed with CRC from 2007 to 2016. Multivariate logistic regression was used to examine factors associated with the likelihood of having major resection, 30-day mortality and laparoscopic surgical procedure. Cox proportional hazards was used to examine factors associated with risk of death at 2 years post-surgery.

RESULTS

Overall, 77.8% (n = 14 274) of patients had a major resection. Males and patients ≥75 years were significantly less likely to have a major resection (P < 0.001 and P < 0.001, respectively). Thirty-day mortality was 3.1% and 2-year overall survival was 78.7%. After adjustment, factors such as increasing age (≥75 years), ≥2 comorbidities, emergency admission, open surgical procedure and treatment in a public hospital were all independently and significantly associated with poorer outcomes. The likelihood a patient had a laparoscopic procedure was significantly lower for those from a disadvantaged area (P < 0.001), emergency admission (P < 0.001) as well as for those treated in a public versus private hospital (P < 0.001).

CONCLUSIONS

Post-operative mortality increased, and 2-year survival decreased after age 75 years. The finding of significantly lower rates of laparoscopic surgery for patients from disadvantaged areas and those treated in a public hospital requires further investigation.

Surgical oncology in the elderly

Poor cancer-specific outcomes in the elderly group are primarily a surgical failure. Surgeons are insufficiently trained to draw a line between fit and frail patients; this results in over-treatment of the frail patient, as well as under-treatment of the fit one. Communication skills should be improved to better understand the patient's requests. The timing of the surgical procedure is crucially important; all efforts should be put in place to optimize the patient's conditions before the surgery takes place.

Minimally invasive surgery in elderly patients with rectal cancer: An analysis of the Bi-National Colorectal Cancer Audit (BCCA)

BACKGROUND

Advanced age is associated with worse outcomes after open rectal cancer surgery. However, not much is known about outcomes of minimally invasive surgery (MIS) in the elderly. The aim of this study was to evaluate safety and efficacy of MIS in elderly rectal cancer patients using the Bi-national Colorectal Cancer Audit (BCCA) data from Australia and New Zealand (ANZ).

METHODS

3451 patients were included, divided into three groups: <50 years (n = 364), 50-74 years (n = 2157) and ≥75 years (n = 930). Propensity-score matching was performed for the elderly group analysis to correct for differences in baseline characteristics.

RESULTS

MIS was performed in 52.9% of elderly patients, slightly lower than rates in <50 year and 50-74 year old groups (61% and 55.5%, respectively, p = 0.022). Elderly patients had more postoperative complications (p < 0.0001) and had a longer length of hospital stay (LOS; median 11 vs. 8 days for both other groups; p < 0.0001). Elderly patients had higher (y)pT-stages compared to both other groups (p < 0.0001) and were less likely to receive adjuvant therapy (p < 0.0001). Propensity-score matched analysis of the elderly group showed a higher rate of superficial wound dehiscence and a longer LOS after open surgery compared to MIS (10.3% vs. 2.6%, p = 0.030; 12 days vs. 9.5 days, p = 0.001, respectively), with comparable short-term oncological outcomes.

CONCLUSIONS

MIS is performed in just over half of elderly rectal cancer patients who are selected for elective rectal resection surgery in ANZ. When performed in the elderly, MIS appears safe and is associated with fewer wound complications and a shorter LOS.

m6 A RNA methylation regulators contribute to malignant progression in rectal cancer

N6,2'-O-dimethyladenosine (m⁶ A) RNA methylation, which is correlated with cancer initiation and progression, is dynamically regulated by m⁶ A RNA methylation regulators, including writers, erasers, and readers. Two subgroups of rectal cancer, including cluster1 and cluster2, were identified based on consensus clustering to m⁶ A RNA methylation regulators. A protein-protein interaction network was constructed and hub genes were identified. The results demonstrated that the expression of WTAP was significantly associated with YTHDC1 and YTHDF2. The principal component analysis was used to compare the transcriptional profile between cluster1 and cluster2 subgroups. By using two identified m⁶ A RNA methylation regulators, we constructed a risk signature to predict the survival outcomes of rectal cancer. The results revealed that YTHDC2 and YTHDF2 were protective genes with HR < 1. The coefficients obtained from the least absolute shrinkage and selection operator algorithm were used to calculate the risk score. Patients were then divided into low- and high-risk groups based on the median risk score. The survival analysis demonstrated that there were significant differences in overall survival between these two groups (p < .05). The results of the univariate analysis showed that the risk score, AJCC stage, M stage, and age were associated with overall survival. The results of the multivariate Cox regression analysis showed that the risk score and age were still significantly associated with the overall survival (p < .05). To conclude, m⁶ A RNA methylation regulators can be regarded as potentially useful biomarkers for predicting the prognosis and designing a treatment strategy in rectal cancer.