What's the magic number? Impact of time to initiation of treatment for rectal cancer

The effect of time before diagnosis and treatment on colorectal cancer outcomes: systematic review and dose-response meta-analysis

BACKGROUND

This systematic review and meta-analysis aimed to evaluate existing evidence on the relationship between diagnostic and treatment intervals and outcomes for colorectal cancer.

METHODS

Four databases were searched for English language articles assessing the role of time before initial treatment in colorectal cancer on any outcome, including stage and survival. Two reviewers independently screened articles for inclusion and data were synthesised narratively. A dose-response meta-analysis was performed to examine the association between treatment interval and survival.

RESULTS

One hundred and thirty papers were included in the systematic review, eight were included in the meta-analysis. Forty-five different intervals were considered in the time from first symptom to treatment. The most common finding was of no association between the length of intervals on any outcome. The dose-response meta-analysis showed a U-shaped association between the treatment interval and overall survival with the nadir at 45 days.

CONCLUSION

The review found inconsistent, but mostly a lack of, association between interval length and colorectal cancer outcomes, but study design and quality were heterogeneous. Meta-analysis suggests survival becomes increasingly poorer for those commencing treatment more than 45 days after diagnosis.

REGISTRATION

This review was registered, and the protocol is available, in PROSPERO, the international database of systematic reviews, with the registration ID CRD42021255864.

Hepatopancreatobiliary malignancies: time to treatment matters

Background

Initiation of oncologic care is often delayed, yet little is known about delays in hepatopancreatobiliary (HPB) cancers or their impact. This retrospective cohort study describes trends in time to treatment initiation (TTI), assesses the association between TTI and survival, and identifies predictors of TTI in HPB cancers.

Methods

The National Cancer Database was queried for patients with cancers of the pancreas, liver, and bile ducts between 2004 and 2017. Kaplan-Meier survival analysis and Cox regression were used to investigate the association between TTI and overall survival for each cancer type and stage. Multivariable regression identified factors associated with longer TTI.

Results

Of 318,931 patients with HPB cancers, median TTI was 31 days. Longer TTI was associated with increased mortality in patients with stages I-III extrahepatic bile duct (EHBD) cancer and stages I-II pancreatic adenocarcinoma. Patients treated within 3-30, 31-60, and 61-90 days had median survivals of 51.5, 34.9, and 25.4 months (log-rank P<0.001), respectively, for stage I EHBD cancer, and 18.8, 16.6, and 15.2 months for stage I pancreatic cancer, respectively (P<0.001). Factors associated with increased TTI included stage I disease (+13.7 days vs. stage IV, P<0.001), treatment with radiation only (β=+13.9 days, P<0.001), Black race (+4.6 days, P<0.001) and Hispanic ethnicity (+4.3 days, P<0.001).

Conclusions

Some HPB cancer patients with longer time to definitive care experienced higher mortality than patients treated expeditiously, particularly in non-metastatic EHBD cancer. Black and Hispanic patients are at risk for delayed treatment. Further research into these associations is needed.

A systematic review of methodological considerations in time to diagnosis and treatment in colorectal cancer research

Research focusing on timely diagnosis and treatment of colorectal cancer is necessary to improve outcomes for people with cancer. Previous attempts to consolidate research on time to diagnosis and treatment have noted varied methodological approaches and quality, limiting the comparability of findings. This systematic review was conducted to comprehensively assess the scope of methodological issues in this field and provide recommendations for future research. Eligible articles had to assess the role of any interval up to treatment, on any outcome in colorectal cancer, in English, with no limits on publication time. Four databases were searched (Ovid Medline, EMBASE, EMCARE and PsycInfo). Papers were screened by two independent reviewers using a two-stage process of title and abstract followed by full text review. In total, 130 papers were included and had data extracted on specific methodological and statistical features. Several methodological problems were identified across the evidence base. Common issues included arbitrary categorisation of intervals (n = 107, 83%), no adjustment for potential confounders (n = 65, 50%), and lack of justification for included covariates where there was adjustment (n = 40 of 65 papers that performed an adjusted analysis, 62%). Many articles introduced epidemiological biases such as immortal time bias (n = 37 of 80 papers that used survival as an outcome, 46%) and confounding by indication (n = 73, 56%), as well as other biases arising from inclusion of factors outside of their temporal sequence. However, determination of the full extent of these problems was hampered by insufficient reporting. Recommendations include avoiding artificial categorisation of intervals, ensuring bias has not been introduced due to out-of-sequence use of key events and increased use of theoretical frameworks to detect and reduce bias. The development of reporting guidelines and domain-specific risk of bias tools may aid in ensuring future research can reliably contribute to recommendations regarding optimal timing and strengthen the evidence base.

The relation of blood cell division control protein 42 level with disease risk, comorbidity, tumor features/markers, and prognosis in colorectal cancer patients

BACKGROUND

Cell division control protein 42 (CDC42) is involved in colorectal cancer (CRC) progression by modulating CD8⁺ T cell activation, immune escape, and direct oncogenetic biological processes. This study aimed to explore the correlation of blood CDC42 with disease risk, comorbidities, disease features, tumor markers, and prognosis among CRC patients.

METHODS

CDC42 in peripheral blood mononuclear cells was detected by reverse transcription-quantitative polymerase chain reaction from 250 resectable CRC patients and 50 healthy controls (HCs). CDC42 was divided by quartiles, as well as high and low expressions in CRC patients for correlation and survival analysis.

RESULTS

CDC42 was elevated in CRC patients vs. HCs (p < 0.001), which had a good ability to distinguish CRC patients from HCs with the area under the curve (95% confidence interval) of 0.889 (0.841-0.937). In CRC patients, CDC42 was not associated with demographics or comorbidities (all p > 0.05), while its higher quartile was linked to increased T stage (p < 0.001), N stage (p = 0.009), TNM stage (p < 0.001), abnormal carcinoembryonic antigen (p = 0.043), and adjuvant chemotherapy administration (p = 0.002). Higher CDC42 quartile (p = 0.002) and CDC42 high (vs. low) (p < 0.001) were related to worse disease-free survival (DFS); meanwhile, elevated CDC42 quartile (p = 0.002) and CDC42 high (vs. low) (p = 0.001) were also linked to poor overall survival (OS). Multivariate Cox's regression analysis presented that CDC42 quartile 3 and 4 (vs. quartile 1) independently predicted declined DFS and OS (all p < 0.05).

CONCLUSION

Circulating CDC42 relates to higher disease risk, T, N, and TNM stage, abnormal tumor marker, and poor prognosis among CRC patients.

The effect of the first year of the COVID-19 pandemic on sphincter preserving surgery for rectal cancer: A single referral center experience

Background

COVID-19 has significantly impacted healthcare worldwide. Lack of screening and limited access to healthcare has delayed diagnosis and treatment of various malignancies. The purpose of this study was to determine the effect of the first year of the COVID-19 pandemic on sphincter-preserving surgery in patients with rectal cancer.

Methods

This was a single-center retrospective study of patients undergoing surgery for newly diagnosed rectal cancer. Patients operated on during the first year of the COVID-19 pandemic (March 2020–February 2021) comprised the study group (COVID-19 era), while patients operated on prior to the pandemic (March 2016–February 2020) served as the control group (pre–COVID-19).

Results

This study included 234 patients diagnosed with rectal cancer; 180 (77%) patients in the pre–COVID-19 group and 54 patients (23%) in the COVID-19–era group. There were no differences between the groups in terms of mean patient age, sex, or body mass index. The COVID-19–era group presented with a significantly higher rate of locally advanced disease (stage T3/T4 79% vs 58%; P = .02) and metastatic disease (9% vs 3%; P = .05). The COVID-19–era group also had a much higher percentage of patients treated with total neoadjuvant therapy (52% vs 15%; P = .001) and showed a significantly lower rate of sphincter-preserving surgery (73% vs 86%; P = .028). Time from diagnosis to surgery in this group was also significantly longer (median 272 vs 146 days; P < .0001).

Conclusion

Patients undergoing surgery for rectal cancer during the first year of the COVID-19 pandemic presented later and at a more advanced stage. They were more likely to be treated with total neoadjuvant therapy and were less likely candidates for sphincter-preserving surgery.