Nonadherence to Standard of Care for Locally Advanced Colon Cancer as a Contributory Factor for High Mortality Rates in Kentucky

Accuracy and consistency of publicly available Large Language Models as clinical decision support tools for the management of colon cancer

BACKGROUND

Large Language Models (LLM; e.g., ChatGPT) may be used to assist clinicians and form the basis of future clinical decision support (CDS) for colon cancer. The objectives of this study were to (1) evaluate the response accuracy of two LLM-powered interfaces in identifying guideline-based care in simulated clinical scenarios and (2) define response variation between and within LLMs.

METHODS

Clinical scenarios with "next steps in management" queries were developed based on National Comprehensive Cancer Network guidelines. Prompts were entered into OpenAI ChatGPT and Microsoft Copilot in independent sessions, yielding four responses per scenario. Responses were compared to clinician-developed responses and assessed for accuracy, consistency, and verbosity.

RESULTS

Across 108 responses to 27 prompts, both platforms yielded completely correct responses to 36% of scenarios (n = 39). For ChatGPT, 39% (n = 21) were missing information and 24% (n = 14) contained inaccurate/misleading information. Copilot performed similarly, with 37% (n = 20) having missing information and 28% (n = 15) containing inaccurate/misleading information (p = 0.96). Clinician responses were significantly shorter (34 ± 15.5 words) than both ChatGPT (251 ± 86 words) and Copilot (271 ± 67 words; both p < 0.01).

CONCLUSIONS

Publicly available LLM applications often provide verbose responses with vague or inaccurate information regarding colon cancer management. Significant optimization is required before use in formal CDS.

Real-life experiences and barriers to adjuvant chemotherapy in Saudi patients with advanced stage II and stage III colon cancer

BACKGROUND

Colorectal cancer is the most common malignancy in Saudi males and third most common in females. Patients with locally advanced colon cancer may eventually develop metastatic disease if not treated promptly and according to guidelines. The recent National Comprehensive Cancer Network guideline recommends tumor resection followed by adjuvant chemotherapy for stage III and high-risk stage II tumors. Therefore, the objective of this study was to characterize patients with locally advanced colon cancer and identify factors associated with the use of adjuvant chemotherapy and the addition of oxaliplatin in locally advanced colon cancer patients.

METHODS

All patients diagnosed with locally advanced colon cancer at National Guard Health Affairs (NGHA) during 2016-2021 were investigated. Patients' characteristics were compared using Chi-square and Fisher exact test, whereas predictors of adjuvant chemotherapy/Oxaliplatin use were identified using univariate and multivariate logistic regression.

RESULTS

Out of 222 patients diagnosed with locally advanced colon cancer, 133 received adjuvant chemotherapy. Factors associated with adjuvant chemotherapy administration were age and smoking status. In the multivariable analysis, older patients were less likely to receive oxaliplatin than younger patients. Stage III patients diagnosed during 2019-2021 had 5.61 times higher odds of receiving oxaliplatin.

CONCLUSION

The findings of this study show that older patients and smokers are less likely to be treated with adjuvant chemotherapy. Moreover, age as well as diagnosis year were important determinants of oxaliplatin administration in stage III locally advanced colon cancer patients.

Immune function status of postoperative patients with colon cancer for predicting liver metastasis

BACKGROUND

Colon cancer (CC) has a high incidence rate. Radical resection is the main treatment method for CC; however, liver metastasis (LM) often occurs post-surgery. The liver contains both innate and adaptive immune cells that monitor and remove abnormal cells and pathogens. Before LM, tumor cells secrete cytokines and exosomes to adjust the immune microenvironment of the liver, thus forming an inhibitory immune microenvironment for colonization by circulating tumor cells. This indicates that the immune state of patients with CC plays a crucial role in the occurrence and progression of LM.

AIM

To observe and analyze the relationship between immune status and expression of tumor factors in patients with LM of CC, and to provide a scientific intervention method for promoting the patient prognosis.

METHODS

A retrospective analysis was performed. The baseline data of 100 patients with CC and 100 patients with CC who suffered from postoperative LM and were admitted to our hospital from May 2021 to May 2023 were included in the non-occurrence and occurrence groups, respectively. The immune status of the patients and the expression of tumor factor-related indicators in the two groups were compared, and the predictive value of the indicators for postoperative LM in patients with CC was analyzed.

RESULTS

Compared with the non-occurrence group, the expression of serum carcinoembryonic antigen (CEA), CA19-9, CA242, CA72-4 and CA50 in patients in the occurrence group were significantly higher, while the expression of CD3+, CD4+, CD8+, natural killer (NK) and CD4+/CD25 in patients in the occurrence group were significantly lower (P < 0.05). No significant difference was observed in other baseline data between groups (P > 0.05). Multivariate logistic regression model analysis revealed that the expressions of CEA, CA19-9, CA242, CA72-4, CA50, CD3+, CD4+, CD8+, NK, and CD4+/CD25 were associated with the LM in patients with CC. High expressions of serum CEA, CA19-9, CA242, CA72-4 and CA50, and low expressions of CD3+, CD4+, CD8+, NK, and CD4+/CD25 in patients with CC were risk factors for LM (OR > 1, P < 0.05). The receiver operating characteristic curve showed that the area under curve for CEA, CA19-9, CA242, CA72-4, CA50, CD3+, CD4+, CD8+, NK, and CD4+/CD25 in the prediction of LM in patients with CC were all > 0.80, with a high predictive value.

CONCLUSION

The expression of tumor factors and immune state-related indices in patients with CC is closely associated with the occurrence of LM.

Phase I Safety and Feasibility Pilot of Hepatic Artery Infusion Chemotherapy in a Rural Catchment Area Using The Codman Vascular Catheter with The Medtronic SynchroMed II Pump for Intrahepatic Cancers

BACKGROUND

Discontinuation of the Codman 3000 pump in 2018 left no Food and Drug Administration (FDA)-approved hepatic artery infusion (HAI) device for unresectable colorectal liver metastases (uCLM) and intrahepatic cholangiocarcinoma (uIHC). Historically, HAI has been performed at academic medical centers in large metropolitan areas, which are often inaccessible to rural patients. Consequently, feasibility of dissemination of HAI to rural populations is unknown.

PATIENTS AND METHODS

Under an FDA investigational device exemption, we opened the only HAI program in Kentucky and enrolled patients with uCLM and uIHC in a phase I clinical trial. The trial examined the safety of the hybrid Codman catheter/Medtronic SynchroMed II pump (hCMP) combination, defined as successful completion of one cycle of HAI chemotherapy. Rural feasibility was assessed by number of missed pump fills appointments.

RESULTS

A total of 21 patients (n = 17 uCLM, n = 4 uIHC) underwent hCMP implantation before accrual was stopped early owing to FDA approval of the Intera 3000 pump. 20/21 (95%) patients met the primary safety endpoint. Serious adverse events (AEs) included a grade 5 coronavirus disease 2019 (COVID-19) infection (n = 1) and a grade 3 catheter erosion into the bowel (n = 1). Biliary sclerosis developed in two patients (9.5%). Median distance to infusion center was 47.6 miles (2-138 miles), and 62% were from Appalachia, yet there were no missed pump fill appointments. The 2-year overall survival was 82.4% (uCLM) and 50% (uIHC).

CONCLUSIONS

The hCMP device had an acceptable safety profile. Despite the complexity of starting a new HAI program, early results showed feasibility for HAI delivery in a rural catchment area and comparable outcomes to larger urban-based HAI centers.

Cloud platform to improve efficiency and coverage of asynchronous multidisciplinary team meetings for patients with digestive tract cancer

Background

Multidisciplinary team (MDT) meetings are the gold standard of cancer treatment. However, the limited participation of multiple medical experts and the low frequency of MDT meetings reduce the efficiency and coverage rate of MDTs. Herein, we retrospectively report the results of an asynchronous MDT based on a cloud platform (cMDT) to improve the efficiency and coverage rate of MDT meetings for digestive tract cancer.

Methods

The participants and cMDT processes associated with digestive tract cancer were discussed using a cloud platform. Software programming and cMDT test runs were subsequently conducted to further improve the software and processing. cMDT for digestive tract cancer was officially launched in June 2019. The doctor response duration, cMDT time, MDT coverage rate, National Comprehensive Cancer Network guidelines compliance rate for patients with stage III rectal cancer, and uniformity rate of medical experts' opinions were collected.

Results

The final cMDT software and processes used were determined. Among the 7462 digestive tract cancer patients, 3143 (control group) were diagnosed between March 2016 and February 2019, and 4319 (cMDT group) were diagnosed between June 2019 and May 2022. The average number of doctors participating in each cMDT was 3.26 ± 0.88. The average doctor response time was 27.21 ± 20.40 hours, and the average duration of cMDT was 7.68 ± 1.47 min. The coverage rates were 47.85% (1504/3143) and 79.99% (3455/4319) in the control and cMDT groups, respectively. The National Comprehensive Cancer Network guidelines compliance rates for stage III rectal cancer patients were 68.42% and 90.55% in the control and cMDT groups, respectively. The uniformity rate of medical experts' opinions was 89.75% (3101/3455), and 8.97% (310/3455) of patients needed online discussion through WeChat; only 1.28% (44/3455) of patients needed face-to-face discussion with the cMDT group members.

Conclusion

A cMDT can increase the coverage rate of MDTs and the compliance rate with National Comprehensive Cancer Network guidelines for stage III rectal cancer. The uniformity rate of the medical experts' opinions was high in the cMDT group, and it reduced contact between medical experts during the COVID-19 pandemic.

Surgical treatment of locally advanced right colon cancer invading neighboring organs

Purpose

Invasion of the pancreas and/or duodenum with/without neighboring organs by locally advanced right colon cancer (LARCC) is a very rare clinical phenomenon that is difficult to manage. The purpose of this review is to suggest the most reasonable surgical approach for primary right colon cancer invading neighboring organs such as the pancreas and/or duodenum.

Methods

An extensive systematic research was conducted in PubMed, Medline, Embase, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL) using the MeSH terms and keywords. Data were extracted from the patients who underwent en bloc resection and local resection with right hemicolectomy (RHC), the analysis was performed with the survival rate as the outcome parameters.

Results

As a result of the analysis of 117 patient data with locally advanced colon cancer (LACC) (73 for males, 39 for females) aged 25-85 years old from 11 articles between 2008 and 2021, the survival rate of en bloc resection was 72% with invasion of the duodenum, 71.43% with invasion of the pancreas, 55.56% with simultaneous invasion of the duodenum and pancreas, and 57.9% with invasion of neighboring organs with/without invasion of duodenum and/or pancreas. These survival results were higher than with local resection of the affected organ plus RHC.

Conclusion

When the LARCC has invaded neighboring organs, particularly when duodenum or pancreas are invaded simultaneously or individually, en bloc resection is a reasonable option to increase patient survival after surgery.

Neoadjuvant Therapy in Stage II/III Rectal Cancer: A Retrospective Study in a Disparate Population and the Effect on Survival

BACKGROUND

Kentucky has one of the highest rectal cancer incidences in the United States. High poverty rates have led to poor insurance coverage and inadequate access to care. The treatment of locally advanced rectal cancer utilizes a multimodal regimen requiring regular access to expert care. The rate of receipt of neoadjuvant therapy in Kentucky is unknown.

OBJECTIVE

This study aimed to evaluate the rate and factors associated with the receipt of neoadjuvant therapy for localized advanced rectal cancer in Kentucky and the effect on overall survival.

DESIGN

This is a retrospective database review.

SETTINGS

This study was conducted by utilizing the Kentucky Cancer Registry at an academic center.

PATIENTS

All patients diagnosed with stage II/III rectal adenocarcinoma from 2005 to 2015 in the Commonwealth of Kentucky were included.

MAIN OUTCOME MEASURES

The primary outcomes measured were the factors associated with nonreceipt of neoadjuvant therapy and overall survival.

RESULTS

Of 1896 patients, only 46.8% received neoadjuvant therapy. Factors associated with not receiving neoadjuvant therapy included older age, female sex, low education level, high poverty level, and treatment at nonacademic centers. Survival analysis demonstrated significantly improved survival in patients receiving neoadjuvant therapy compared with other treatment regimens.

LIMITATIONS

This study was limited by the retrospective nature of the review and by unmeasured confounders.

CONCLUSIONS

Our study was the first to evaluate the factors behind the low rates of neoadjuvant therapy for locally advanced rectal cancer in Kentucky. Neoadjuvant therapy in this population is beneficial for survival; efforts should be made in policy and education with focus on older patients, female patients, and treatment at nonacademic centers. Centralization of rectal cancer care improves outcomes, but we must be aware of the effect it may have on disparate populations with poor access. See Video Abstract at http://links.lww.com/DCR/B596.

TERAPIA NEOADYUVANTE EN EL MANEJO DEL CNCER DE RECTO EN ESTADIO II / III UN ESTUDIO RETROSPECTIVO EN UNA POBLACIN DISPAR Y EL EFECTO EN LA SUPERVIVENCIA

ANTECEDENTES:El estado de Kentucky tiene una de las mayores incidencias de cáncer de recto en los EE. UU. Debido a una alta tasa de pobreza, el porcentaje de la población que cuenta con seguro de salud, es muy limitado, y por lo tanto el acceso a una atención de alto nivel es muy bajo. El tratamiento del cáncer de recto localmente avanzado, es multidisciplinario, lo que exige acceso y disponibilidad a un grupo experto. Se desconoce la tasa de pacientes que reciben terapia neoadyuvante en Kentucky.OBJETIVO:Establecer la tasa y los factores asociados con el uso de terapia neoadyuvante en el tratamiento del cáncer de recto localmente avanzado en Kentucky, y su efecto en la supervivencia global.DISEÑO:Revisión retrospectiva de una base de datos.ESCENARIO:Este estudio se llevó a cabo utilizando el Registro de Cáncer de Kentucky en un centro académico.PACIENTES:Se incluyen todos los pacientes diagnosticados con adenocarcinoma de recto, de la Mancomunidad (Commonwealth) de Kentucky, en estadio II / III entre 2005 y 2015.PRINCIPALES MEDIDAS DE RESULTADO:Establecer los factores asociados con el hecho de no recibir terapia neoadyuvante; y establecer la supervivencia global.RESULTADOS:De 1896 pacientes evaluados, solo el 46,8% recibió terapia neoadyuvante. Los factores asociados, para no haber recibido terapia neoadyuvante fueron: la edad avanzada, sexo femenino, bajo nivel educativo, alto nivel de pobreza y tratamiento en centros no académicos. El análisis de la supervivencia mostró una supervivencia significativamente mejor en los pacientes que recibieron terapia neoadyuvante en comparación con otros esquemas de tratamiento.LIMITACIONES:Revisión retrospectiva, factores de confusión no medidos.CONCLUSIONES:Nuestro estudio ha sido el primero en evaluar los factores determinantes de las bajas tasas de terapia neoadyuvante para el tratamiento del cáncer de recto localmente avanzado en Kentucky. La terapia neoadyuvante mejora y favorece la supervivencia en esta población, por lo tanto se deben hacer esfuerzos en las políticas de salud, así como en educación, enfocados a los pacientes mayores, pacientes femeninas y tratamiento en centros no académicos. El centralizar la atención del cáncer de recto, mejora los resultados, pero debemos ser conscientes del efecto que puede tener en poblaciones desiguales económicamente, con acceso deficiente a la posibilidad de recibir atención de alto nivel. Consulte Video Resumen en http://links.lww.com/DCR/B596.

Practical Guide to Implementation Science for Surgical Oncologists: Case Study of Breast Cancer Short Stay Program

BACKGROUND

Long lags exist in adoption and uptake of evidence-based interventions into real-world clinical practice based on oncology clinical trial results. Implementation science (IS) is a distinct field of health services research that aims to understand the barriers related to adoption of evidence-based guidelines and research in clinical practice.

METHODS

Use of IS study design, methods, and outcomes can be elusive to surgical oncologists despite the tremendous need for the application of IS to bridge the evidence-to-practice gap. This report describes key components of high-quality IS.

RESULTS

Herein, we illustrate how IS can be used in surgical oncology practice. Examples from implementation of the breast cancer Short Stay Program (SSP) in Netherlands is used to illustrate IS methods. Specific funding and training opportunities in implementation science are described in detail.

CONCLUSION

Use of IS in surgical oncology can help improve the uptake of evidence based medicine.

Adjuvant chemotherapy for patients with stage II high-risk and III colon cancer: Hindering factors to adherence and impact on long-term survival

Purpose

Adjuvant chemotherapy is recommended after curative surgery in patients with colon cancer of high-risk stage II and stage III. However, a considerable number of patients cannot complete the scheduled adjuvant treatment for various reasons. This study investigates the hindering factors to the adherence to adjuvant chemotherapy and their impact on long-term survival.

Methods

A retrospective study was conducted for patients with colon cancer and had curative resection from 2009 to 2014. Among patients with pathologic stage II and III, stage II with low-risk features, double primary cancers, R2 resection cases were excluded. Patients were grouped into three groups: no-adjuvant therapy, adjuvant therapy for less than 3 months, and more than 3 months. Factors for withdrawal and the oncologic outcome were analyzed.

Results

Of 571 patients, adjuvant chemotherapy was recommended in 403. One hundred and sixteen patients (28.8%) did not receive adjuvant chemotherapy, 78 (19.4%) withdrew within 3 months, and 209 (51.9%) maintained for more than 3 months. Factors for not receiving adjuvant chemotherapy or withdrawing within 3 months were older than 70 and American Society of Anesthesiologists class 3 or higher. Main reasons for discontinuation before 3 months were chemotoxicity and patient's refusal. The long-term oncologic outcome of the patients who received adjuvant chemotherapy for more than 3 months was significantly better than others.

Conclusion

No-adjuvant therapy or receiving them for lesser than 3 months is significantly affected by the patient's performance status and social support, which coincides with a poor oncologic outcome. Social support and rehabilitation system may help to improve the survival outcome.