Inequity in colorectal cancer treatment and outcomes: a population-based study

The association between marital status and treatment initiation in lung cancer: A systematic review and meta-analysis of observational studies

Lung cancer is associated with high mortality, and significant health burden. Marital status has been associated with lung cancer survival. This systematic review and meta-analysis set out to investigate the association between marital status and treatment receipt in lung cancer. The search was conducted across three databases: Medline (OVID), Embase and CINAHL, from inception to June 2022. Retrospective or prospective observational studies that quantified treatment receipt by marital status were eligible for inclusion. Study quality was assessed via a modified checklist for retrospective databased-based studies. Meta-analysis using a random effects model was undertaken by chemotherapy, radiotherapy, surgery, and any treatment relative to married or not married. Pooled unadjusted odds ratios (ORs) and 95 % confidence intervals (CIs) were calculated for each type of treatment. 837 papers were screened and 18 met the inclusion criteria with eight being eligible for inclusion in the meta-analysis. Studies were excluded from meta-analysis due to overlap in the data reported in papers; the mean quality score of the 18 included papers was 12/17. Being married was associated with increased odds of overall treatment OR 1.43 (95 % CI 1.14-1.79; I2 = 82 %; Tau2 = 0.07; six studies) and also increased receipt of: chemotherapy 1.40 (95 % CI 1.35-1.44; I2 = 82 %; Tau2 = 0.00); radiotherapy 1.29 (95 % CI 0.96-1.75; I2 = 100 %; Tau2= 0.09; four studies) and surgery (95 % CI 1.31-1.52; I2 = 86 %; Tau2 = 0.00; five studies). The results indicate that those who are married are more likely to receive treatment for lung cancer compared to those who are not married. This requires further investigation to better understand the explanations behind this finding and how we can work to combat this inequality.

Rectal cancer surgery: does low volume imply worse outcome-a single surgeon experience

BACKGROUND

The centralisation of rectal cancer management to high-volume oncology centres has translated to improved oncological and survival outcomes. We hypothesise that individual surgeon caseload, specialisation, and experience may be as significant in determining oncologic and postoperative outcomes in rectal cancer surgery.

METHODS

A prospectively maintained colorectal surgery database was reviewed for patients undergoing rectal cancer surgery between January 2004 and June 2020. Data studied included demographics, Dukes' and TNM staging, neoadjuvant treatment, preoperative risk assessment scores, postoperative complications, 30-day readmission rates, length of stay (LOS), and long-term survival. Primary outcome measures were 30-day mortality and long-term survival compared to national and international standards and best practice guidelines.

RESULTS

In total, 87 patients were included (mean age: 66 years [range: 36-88]). The mean length of stay (LOS) was 16.5 days (SD 6.0). The median ICU LOS was 3 days (range 2-17). Overall, 30-day readmission rate was 16.4%. Twenty-four patients (26.4%) experienced ≥ 1 postoperative complication. The 30-day operative mortality rate was 3.45%. Overall 5-year survival rate was 66.6%. A significant correlation was observed between P-POSSUM scores and postoperative complications (p = 0.041), and all four variants of POSSUM, CR-POSSUM, and P-POSSUM scores and 30-day mortality.

CONCLUSION

Despite improved outcomes seen with centralisation of rectal cancer services at an institutional level, surgeon caseload, experience, and specialisation is of similar importance in obtaining optimal outcomes within institutions.

Direct mail from primary care and targeted recruitment strategies achieved a representative uptake of prostate cancer screening

OBJECTIVES

Prostate cancer screening studies has previously not been able to reflect a diverse group of participants. We evaluated a range of recruitment strategies and their ability to recruit from the Black population and areas of deprivation.

STUDY DESIGN AND SETTINGS

IP1-PROSTAGRAM was a prospective, population-based, paired screening study of 408 participants conducted at seven UK primary care practices and two imaging centres. All participants underwent screening with a PSA test, MRI and transrectal ultrasound. A number of recruitment strategies were embedded including direct mail, media campaigns and a targeted recruitment strategy to increase participation among harder-to-reach groups.

RESULTS

1,316 expressions of interest in total were received (20^th September 2018 to 15th May 2019). The direct mail strategy generated 317 expressions of interest from 1707 invitation letters. 387 expressions of interest were received following the targeted strategy and 612 from media campaigns. The recruitment target was met 19 months ahead of schedule. Of 411 participants, ethnicity was White (38.0%), Black (32.4%), Asian (23.0%) and Other/Mixed (4.4%) ethnic groups. This higher recruitment of black men was driven by the targeted recruitment strategy. A comparison of recruitment methods showed marked differences between ethnicities recruited (p<0.001). The proportion of black participants recruited by direct mail (8%) was similar to the prevalence of black local population (9%) whereas targeted recruitment was 88% (115) and media recruitment 1.7% (1). The Index of Multiple Deprivation (IMD) distribution was similar to the local population with marginal higher recruitment from more deprived areas; proportion increasing from 26% to 40% from least to most deprived IMD quintiles (Quintiles 4/5 vs. 1/2). Direct mail recruited a close-to-normal distribution for deprivation with targeted recruitment trending towards recruiting from most deprived areas.

CONCLUSIONS

Direct mail and targeted strategies designed to engage a diverse population can achieve a representative uptake from black participants and those from a lower socioeconomic group.

Age-related and socioeconomic inequalities in timeliness of referral and start of treatment in colorectal cancer: a population-based analysis

BACKGROUND

Poorer colorectal cancer survival in the UK than in similar countries may be partly due to delays in the care pathway. To address this, cancer waiting time targets were established. We investigated if socio-demographic inequalities exist in meeting cancer waiting times for colorectal cancer.

METHODS

We identified primary colorectal cancers (International Classification of Diseases, Tenth Revision C18-C20; n=35 142) diagnosed in the period 2001-2010 in the Northern and Yorkshire Cancer Registry area. Using multivariable logistic regression, we calculated likelihood of referral and treatment within target by age group and deprivation quintile.

RESULTS

48% of the patients were referred to hospital within target (≤14 days from general practitioner (GP) referral to first hospital appointment); 52% started treatment within 31 days of diagnosis; and 44% started treatment within 62 days of GP referral. Individuals aged 60-69, 70-79 and 80+ years were significantly more likely to attend a first hospital appointment within 14 days than those aged <60 years (adjusted OR=1.23, 95% CI 1.12 to 1.34; adjusted OR=1.19, 95% CI 1.09 to 1.29; adjusted OR=1.30, 95% CI 1.18 to 1.42, respectively). Older age was significantly associated with lower likelihood of starting treatment within 31 days of diagnosis and 62 days of referral. Deprivation was not related to referral within target but was associated with lower likelihood of starting treatment within 31 days of diagnosis or 62 days of referral (most vs least: adjusted OR=0.82, 95% CI 0.74 to 0.91).

CONCLUSIONS

Older patients with colorectal cancer were less likely to experience referral delays but more likely to experience treatment delays. More deprived patients were more likely to experience treatment delays. Investigation of patient pathways, treatment decision-making and treatment planning would improve understanding of these inequalities.

Gender differences in stage at diagnosis and preoperative radiotherapy in patients with rectal cancer

Background

Few studies have examined gender differences in the clinical management of rectal cancer. We examine differences in stage at diagnosis and preoperative radiotherapy in rectal cancer patients.

Methods

A prospective cohort study was conducted in 22 hospitals in Spain including 770 patients undergoing surgery for rectal cancer. Study outcomes were disseminated disease at diagnosis and receiving preoperative radiotherapy. Age, comorbidity, referral from a screening program, diagnostic delay, distance from the anal verge, and tumor depth were considered as factors that might explain gender differences in these outcomes.

Results

Women were more likely to be diagnosed with disseminated disease among those referred from screening (odds ratio, confidence interval 95% (OR, CI = 7.2, 0.9–55.8) and among those with a diagnostic delay greater than 3 months (OR, CI = 5.1, 1.2–21.6). Women were less likely to receive preoperative radiotherapy if they were younger than 65 years of age (OR, CI = 0.6, 0.3–1.0) and if their tumors were cT3 or cT4 (OR, CI = 0.5, 0.4–0.7).

Conclusions

The gender-specific sensitivity of rectal cancer screening tests, gender differences in referrals and clinical reasons for not prescribing preoperative radiotherapy in women should be further examined. If these gender differences are not clinically justifiable, their elimination might enhance survival.

Impact of age on the use of adjuvant treatments in patients undergoing surgery for colorectal cancer: patients with stage III colon or stage II/III rectal cancer

Background

Many older patients don’t receive appropriate oncological treatment. Our aim was to analyse whether there are age differences in the use of adjuvant chemotherapy and preoperative radiotherapy in patients with colorectal cancer.

Methods

A prospective cohort study was conducted in 22 hospitals including 1157 patients with stage III colon or stage II/III rectal cancer who underwent surgery. Primary outcomes were the use of adjuvant chemotherapy for stage III colon cancer and preoperative radiotherapy for stage II/III rectal cancer. Generalised estimating equations were used to adjust for education, living arrangements, area deprivation, comorbidity and clinical tumour characteristics.

Results

In colon cancer 92% of patients aged under 65 years, 77% of those aged 65 to 80 years and 27% of those aged over 80 years received adjuvant chemotherapy (χ²_trends < 0.001). In rectal cancer preoperative radiotherapy was used in 68% of patients aged under 65 years, 60% of those aged 65 to 80 years, and 42% of those aged over 80 years (χ²_trends < 0.001). Adjusting by comorbidity level, tumour characteristics and socioeconomic level, the odds ratio of use of chemotherapy compared with those under age 65, was 0.3 (0.1–0.6) and 0.04 (0.02–0.09) for those aged 65 to 80 and those aged over 80, respectively; similarly, the odds ratio of use of preoperative radiotherapy was 0.9 (0.6–1.4) and 0.5 (0.3–0.8) compared with those under 65 years of age.

Conclusions

The probability of older patients with colorectal cancer receiving adjuvant chemotherapy and preoperative radiotherapy is lower than that of younger patients; many of them are not receiving the treatments recommended by clinical practice guidelines. Differences in comorbidity, tumour characteristics, curative resection, and socioeconomic factors do not explain this lower probability of treatment. Research is needed to identify the role of physical and cognitive functional status, doctors’ attitudes, and preferences of patients and their relatives, in the use of adjuvant therapies.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5910-z) contains supplementary material, which is available to authorized users.

Colorectal cancer survivors: an investigation of symptom burden and influencing factors

Background

Colorectal cancer is a significant issue internationally, with over 1.3 million people diagnosed annually. Survival rates are increasing as treatments improve, although physical symptoms can persist despite eradication of the tumour. In order to optimize survivorship care, further research is warranted in relation to symptom burden. Therefore, the objectives of this study are to (i) investigate frequency of physical symptoms in colorectal cancer survivors (ii) identify which symptoms occur together (iii) examine the associations between demographic and clinical variables, and symptoms.

Methods

Participants nine months to three years post diagnosis were identified from the population-based National Cancer Registry Ireland. Respondents completed the EORTC QLQ-C30 and EORTC QLQ-CR29. Reported physical symptom frequencies were transformed into continuous scale variables, which were then analysed using one way analysis of variance, general linear modelling and Spearman rank correlations.

Results

There were 496 participants. Fatigue, insomnia and flatulence were the most frequent symptoms, with ≥20% of respondents reporting these to be often present in the previous week. Eight other symptoms were experienced often by 10–20% of respondents. At least one of these eleven most common symptoms was experienced frequently by almost every respondent (99%). 66% of respondents experienced at least two of these symptoms together, and 16% experienced five or more together. Current stoma was the single most common variable associated with increased symptom scores, although statistically significant relationships (p ≤ 0.05) between symptom frequency scores and clinical/demographic variables were generally weak (R-sq value ≤0.08).

Conclusion

Findings may inform targeted interventions during the nine month to three year post diagnosis timeframe, which would enable supported self-management of symptoms.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4923-3) contains supplementary material, which is available to authorized users.

The impact of socioeconomic status on stage specific prostate cancer survival and mortality before and after introduction of PSA test in Finland

Socioeconomic status (SES) has an impact on prostate cancer (PCa) outcomes. Men with high SES have higher incidence and lower mortality of PCa versus lower SES males. PCa cases diagnosed in Finland in 1985-2014 (N = 95,076) were identified from the Finnish Cancer Registry. Information on education level (EL) was obtained from Statistics Finland. EL was assessed with three-tiered scale: basic, upper secondary and higher education. PCa stage at diagnosis was defined as localized, metastatic or unknown. Years of diagnosis 1985-1994 were defined as pre-PSA period and thereafter as post-PSA period. We report PCa-specific survival (PCSS) and relative risks (RR) for PCa specific mortality (PCSM) among cancer cases in Finland, where healthcare is 100% publicly reimbursed and inequality in healthcare services low. Men with higher EL had markedly better 10-year PCSS: 68 versus 63% in 1985-1994 and 90 versus 85% in 1995-2004 compared to basic EL in localized PCa. The RR for PCSM among men with localized PCa and higher EL compared to basic EL was 0.76(95%confidence interval (CI) 0.66-0.88) in 1985-1994 and 0.61(95%CI 0.53-0.70) in 1995-2004. Variation in PCSS and PCSM between EL categories was evident in metastatic PCa, too. The difference in PCSM between EL categories was larger in the first 10-year post-PSA period than before that but decreased thereafter in localized PCa, suggesting PSA testing became earlier popular among men with high EL. In summary, higher SES/EL benefit PCa survival both in local and disseminated disease and the effect of EL was more pronounced in early post-PSA period.

Time to Definitive Health-Related Quality of Life Score Deterioration in Patients with Resectable Metastatic Colorectal Cancer Treated with FOLFOX4 versus Sequential Dose-Dense FOLFOX7 followed by FOLFIRI: The MIROX Randomized Phase III Trial

Purpose

We previously showed that a sequential chemotherapy with dose-dense oxaliplatin (FOLFOX7) and irinotecan (FOLFIRI; irinotecan plus 5-fluorouracil/leucovorin) is not superior to FOLFOX4 in patients at advanced stage of colorectal cancer with liver metastases. Here we aimed to determine whether time to health-related quality of life (HRQoL) score definitive deterioration (TUDD) differs by study arm.

Methods

HRQoL was evaluated using the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 at baseline and every 4 cycles until the end of the study or death. Functional scale, symptom scale, global health status, and financial difficulties were analyzed. The TUDD was defined as the time interval between randomization and the first decrease in HRQoL score ≥ 5-point with no further improvement in HRQoL score ≥ 5 points or any further HRQoL data. TUDD was estimated using the Kaplan-Meier method and the long-rank test. Cox regression analyses were used to identify HRQoL items influencing TUDD. Sensitivity analyses were done using a multiple imputation method and different definitions of TUDD.

Results

Of the 284 patients, 171 (60.2%) completed HRQoL questionnaires. Cox multivariate analysis showed no statistically significant difference in TUDD for most of the QLQ-C30 scales between treatments. Patients with dyspnea and those without symptoms at baseline had a significantly longer TUDD when there was a delay >12 months between diagnosis of the primary tumor and metastases (HR 0.48 [0.26–0.89]) and when there was diarrhea (HR 0.59 [0.36–0.96]), respectively.

Conclusion

This study shows that TUDD does not differ significantly according to type of treatment. The TUDD method produces meaningful longitudinal HRQoL results that may facilitate effective clinical decision making in patients with mCRC.

Trial Registration

ClinicalTrials.gov NCT00268398

Which women with breast cancer do, and do not, undergo receptor status testing? A population-based study

INTRODUCTION

Receptor status determines of breast cancer treatment and prognosis. In a population-based study, we investigated predictors of receptor test receipt.

MATERIALS AND METHODS

Invasive breast cancers diagnosed 2006-2008 were abstracted from the National Cancer Registry Ireland. Modified Poisson regression with robust error variance was used to identify socio-demographic, health service and clinical predictors of not undergoing ER, PR or HER2 testing.

RESULTS

7619 breast cancers were included. 7% were not tested for any receptor. 92%, 80% and 86% had oestrogen (ER), progesterone (PR) and human epidermal growth factor 2 (HER2) tests, respectively; 73% were tested for all three. For all three tests, unmarried women were significantly less likely to be tested than married women. Current smokers significantly more often had ER and PR tests. Women treated in a high-volume hospital significantly more often had ER and HER2 tests.

CONCLUSION

After adjusting for clinical factors, socio-demographic and service-related factors significantly predicted receptor test receipt. Some factors deserve further investigation, especially marital status. In the interests of equity, the reasons underlying these associations should be further investigated.

Research in cancer care disparities in countries with universal healthcare: mapping the field and its conceptual contours

The paper reviews published studies focused on disparities in receipt of cancer treatments and supportive care services in countries where cancer care is free at the point of access. We map these studies in terms of the equity stratifiers they examined, the countries in which they took place, and the care settings and cancer populations they investigated. Based on this map, we reflect on patterns of scholarly attention to equity and disparity in cancer care. We then consider conceptual challenges and opportunities in the field, including how treatment disparities are defined, how equity stratifiers are defined and conceptualized and how disparities are explained, with special attention to the challenge of psychosocial explanations.

Increasing late stage colorectal cancer and rectal cancer mortality demonstrates the need for screening: a population based study in Ireland, 1994-2010

BACKGROUND

This paper describes trends in colorectal cancer incidence, survival and mortality from 1994 to 2010 in Ireland prior to the introduction of population-based screening.

METHODS

We examined incidence (National Cancer Registry Ireland (NCRI) and mortality (Central Statistics Office) from 1994 to 2010. Age standardised rates (ASR) for incidence and mortality have been calculated, weighted by the European standard population. Annual percentage change was calculated in addition to testing for linear trends in treatment and case fraction of early and late stage disease. Relative survival was calculated considering deaths from all causes.

RESULTS

The colorectal cancer ASR was 63.7 per 100,000 in males and 38.7 per 100,000 in females in 2010. There was little change in the ASR over time in either sex, or when colon and rectal cancers were considered separately; however the number of incident cancers increased significantly during 1994-2010 (1752 to 2298). The case fractions of late stage (III/IV) colon and rectal cancers rose significantly over time. One and 5 year relative survival improved for both sexes between the periods 1994-2008. Colorectal cancer mortality ASRs decreased annually from 1994-2009 by 1.8% (95% CI -2.2, -1.4). Rectal cancer mortality ASRs rose annually by 2.4% (95% CI 1.1, 3.6) and 2.8% (95% CI 1.2, 4.4) in males and females respectively.

CONCLUSIONS

Increases in late-stage disease and rectal cancer mortality demonstrate an urgent need for colorectal cancer screening. However, the narrow age range at which screening is initially being rolled-out in Ireland means that the full potential for reductions in late-stage cancers and incidence and mortality are unlikely to be achieved. While it is possible that the observed increase in rectal cancer mortality may be partly an artefact of cause of death misclassification, it could also be explained by variations in treatment and adherence to best practice guidelines; further investigation is warranted.

Patterns of colorectal cancer care in Europe, Australia, and New Zealand

Colorectal cancer is the second most common cancer in women and the third most common in men worldwide. In this study, we used MEDLINE to conduct a systematic review of existing literature published in English between 2000 and 2010 on patterns of colorectal cancer care. Specifically, this review examined 66 studies conducted in Europe, Australia, and New Zealand to assess patterns of initial care, post-diagnostic surveillance, and end-of-life care for colorectal cancer. The majority of studies in this review reported rates of initial care, and limited research examined either post-diagnostic surveillance or end-of-life care for colorectal cancer. Older colorectal cancer patients and individuals with comorbidities generally received less surgery, chemotherapy, or radiotherapy. Patients with lower socioeconomic status were less likely to receive treatment, and variations in patterns of care were observed by patient demographic and clinical characteristics, geographical location, and hospital setting. However, there was wide variability in data collection and measures, health-care systems, patient populations, and population representativeness, making direct comparisons challenging. Future research and policy efforts should emphasize increased comparability of data systems, promote data standardization, and encourage collaboration between and within European cancer registries and administrative databases.

Randomized trial of simplified LV5FU2 versus FOLFOX7 followed by FOLFIRI (MIROX) in patients with initially resectable metastatic colorectal cancer: a GERCOR study

OBJECTIVES

To evaluate the MIROX strategy (6 FOLFOX7 cycles followed by 6 FOLFIRI cycles) in patients with resected or resectable metastases from colorectal cancer.

METHODS

This trial compared the MIROX strategy to 12 cycles of simplified LV5FU2 (sLV5FU2). Chemotherapy was perioperative or adjuvant, at the investigator's decision, with stratification for this parameter. The primary objective was disease-free survival (DFS). The trial was interrupted in 2004, following the results of the adjuvant MOSAIC trial showing superiority of FOLFOX4 over LV5FU2.

RESULTS

Thirty-nine patients were included: 20 in MIROX arm and 19 in sLV5FU2 arm. Median DFS was higher in the MIROX arm (not reached versus 24.8 months, P = 0.044). MIROX regimen was well tolerated; 5/20 patients experienced a Grade 3 sensoryneuropathy.

CONCLUSION

The MIROX strategy demonstrated promising efficacy, but this must be considered cautiously due to the small number of patients included. The pragmatic approach adopted for the treatment chronology is feasible.

[Tolerance and efficacy of preoperative radiation therapy for elderly patients treated for rectal cancer]

PURPOSE

To retrospectively assess the impact of age on tolerance and oncologic outcomes treated by neoadjuvant treatment for patients of 70 years old or above with locally advanced rectal cancer.

PATIENTS AND METHODS

Ninety-one consecutive patients were divided into three groups: group 1 from 70 to 75 years (n=31); group 2: 76 to 79 years (n=31) and group 3, patients aged 80 years or above (n=29). Radiation therapy was delivered according two schemes: 25Gy in five fractions (short scheme) or 45 to 50Gy with a classical fractionation (long scheme). Long scheme patients received a concomitant chemotherapy with 5-fluoro-uracile alone or associated with oxaliplatin.

RESULTS

The three groups were comparable for performance status, Charlson's score and T staging. Long scheme radiation therapy and chemotherapy were performed in 77.5, 74.5 and 48.3% of patients (P=0.03) and 77.4, 71 and 41.4% (P=0.006) in the groups 1, 2 and 3, respectively. All patients treated with the short scheme irradiation received the treatment without any acute toxicity. In the long scheme group, 65% of patients received the treatment on time and grade 3 or above toxicity was observed in 12% of patients who did not receive oxaliplatin and in 48% of patients who received oxaliplatin. The overall survival rate at 3 and 5 years was 66.9% and 60.8% in the group 1, 90.5% and 75.9% in the group 2 and 80.5% and 73.8% in the group 3 (P=0.15).

CONCLUSION

Neoadjuvant treatment is feasible with encouraging survival rates for patients aged 70 years and older. Short scheme radiation therapy seems to be an interesting option in this population.

Inequity in access to guideline-recommended colorectal cancer treatment in Nova Scotia, Canada

Cancer continues to be one of the heaviest burdens of disease in Canada, and assessing potential inequities in access to cancer care may serve as a barometer of the health of Canadian health systems. This study tackled three limitations of the current literature by clearly differentiating between inequality and inequity, by assessing inequity in receipt of care and wait times for care, and by taking advantage of inequity indices to enhance comparability of inequities between studies and populations. We measured income-, age-, sex- and distance-related inequities among colorectal cancer (CRC) patients in Nova Scotia by accounting for clinical guidelines and patient need. Results reveal statistically significant inequity in access to chemotherapy and radiotherapy for CRC by age, sex and distance, but not income. This study demonstrates the importance of carefully examining inequity in access to cancer care and highlights one method to report and compare inequities with conceptual clarity.

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.

Risk factors for mortality in major digestive surgery in the elderly: a multicenter prospective study

OBJECTIVE

To identify the mortality risk factors of elderly patients (≥65 years old) during major digestive surgery, as defined according to the complexity of the operation.

BACKGROUND

In the aging populations of developed countries, the incidence rate of major digestive surgery is currently on the rise and is associated with a high mortality rate. Consequently, validated indicators must be developed to improve elderly patients' surgical care and outcomes.

METHODS

We acquired data from a multicenter prospective cohort that included 3322 consecutive patients undergoing major digestive surgery across 47 different facilities. We assessed 27 pre-, intra-, and postoperative demographic and clinical variables. A multivariate analysis was used to identify the independent risk factors of mortality in elderly patients (n = 1796). Young patients were used as a control group, and the end-point was defined as 30-day postoperative mortality.

RESULTS

In the entire cohort, postoperative mortality increased significantly among patients aged 65-74 years, and an age ≥65 years was by itself an independent risk factor for mortality (odds ratio [OR], 2.21; 95% confidence interval [CI], 1.36-3.59; P = 0.001). The mortality rate among elderly patients was 10.6%. Six independent risk factors of mortality were characteristic of the elderly patients: age ≥85 years (OR, 2.62; 95% CI, 1.08-6.31; P = 0.032), emergency (OR, 3.42; 95% CI, 1.67-6.99; P = 0.001), anemia (OR, 1.80; 95% CI, 1.02-3.17; P = 0.041), white cell count > 10,000/mm³ (OR, 1.90; 95% CI, 1.08-3.35; P = 0.024), ASA class IV (OR, 9.86; 95% CI, 1.77-54.7; P = 0.009) and a palliative cancer operation (OR, 4.03; 95% CI, 1.99-8.19; P < 0.001).

CONCLUSION

Characterization of independent validated risk indicators for mortality in elderly patients undergoing major digestive surgery is essential and may lead to an efficient specific workup, which constitutes a necessary step to developing a dedicated score for elderly patients.

Rectal cancer surgery: volume-outcome analysis

PURPOSE

There is strong evidence supporting the importance of the volume-outcome relationship with respect to lung and pancreatic cancers. This relationship for rectal cancer surgery however remains unclear. We review the currently available literature to assess the evidence base for volume outcome in relation to rectal cancer surgery.

METHODS

We analysed the Medline "PubMed" online database using the keyword search parameters of "rectal cancer", "hospital volume or caseload", "surgeon volume or caseload", "outcomes", "mortality", "approach", "local recurrence" and "morbidity" for the time period 1997-2009. Five hundred twenty-six generic articles were identified. Articles that were not specific for, or separately identified, rectal cancer surgery in their individual analysis were excluded. Eighteen articles remained for review. We assessed short-term morbidity and long-term outcomes such as sphincter preservation, mortality and local recurrence rates.

RESULTS

Considerable variance was noted in the definition of high volume and low volume. Postoperative length of stay was lower and sphincter-preserving surgery was more commonly performed in high-volume hospitals and by high-volume surgeons. Surgeon specialisation was an important factor influencing sphincter preservation, survival and local recurrence rates. Volume was found to have no negative relationship with mortality and a positive one with local recurrence. Interestingly, there was no association found between hospital or surgeon caseload and postoperative morbidity.

CONCLUSION

There is a paucity of evidence in the literature regarding the volume-outcome relationship with regard to rectal cancer surgery. High-volume institutions yielded shorter lengths of stay. However, the key finding was that high-volume surgeons that specialised in colorectal surgery yielded objectively improved outcomes for patients with rectal cancer.

Have developments in palliative care services impacted on place of death of colorectal cancer patients in Ireland? A population-based study

BACKGROUND

Whether developments in palliative care have impacted on where cancer patients die is unknown. We investigated time trends in place of death for colorectal cancer.

METHODS

Details were abstracted on 10,175 colorectal cancer deaths during 1994-2004. Time trends were analysed by joinpoint regression.

RESULTS

Nearly half (49%) of deaths occurred in acute hospitals, 29% at home, 13% in hospices and 7% in nursing homes. Hospital deaths were unchanged over time. Hospice deaths rose from 6% in 1994 to 17% in 2003. Home deaths decreased significantly, but only in health boards with hospices [estimated annual percentage change (EAPC) = -3.6%, 95%CI -4.19 to -2.97%, p < 0.001]. Nursing home deaths rose significantly in areas without hospices (EAPC = 8.0%, 95%CI 2.27 to -13.94%, p = 0.011).

CONCLUSIONS

Most colorectal cancer deaths occur in hospital. Availability of hospice facilities is a key determinant of where the burden of death falls. The results suggest unmet demand for hospice care in Ireland.

Impact of socioeconomic status on prostate cancer diagnosis, treatment, and prognosis

BACKGROUND

The objective of the current study was to evaluate the impact of socioeconomic disparities on prostate cancer presentation, treatment, and prognosis in Geneva, Switzerland, in which healthcare costs, medical coverage, and life expectancy are considered to be among the highest in the world.

METHODS

This population-based study included all patients diagnosed with invasive prostate cancer among the resident population between 1995 and 2005. Patients were divided into 3 socioeconomic groups according to their last known occupation. Compared were patient and tumor characteristics and treatment patterns between socioeconomic groups. Cox multivariate regression analysis was used to assess and explain socioeconomic inequalities in prostate cancer-specific mortality.

RESULTS

Compared with patients of high socioeconomic class, those of low socioeconomic class were more often foreigners, were found less frequently to have screen-detected cancer, were found to have a more advanced stage of disease at diagnosis, and less often had information regarding disease characteristics and staging. These patients underwent prostatectomy less frequently and were more often managed with watchful waiting. The risk of dying as a result of prostate cancer (hazards ratio [HR]) in patients of a low versus high socioeconomic status was increased 2-fold (95% confidence interval [95% CI], 1.5-2.6). After adjustment for patient and tumor characteristics and treatment, the mortality risk was no longer found to be significantly increased (HR, 1.2; 95% CI, 0.8-1.6).

CONCLUSIONS

In the current study, patients of low socioeconomic class were found to be at increased risk of dying as a result of their prostate cancer. This increased mortality is largely attributable to delayed diagnosis, poor diagnostic workup, and less invasive treatments in these individuals.

E-selectin gene S128R polymorphism is associated with poor prognosis in patients with stage II or III colorectal cancer

Some host-related factors may predict the risk of metastasis after surgery of colorectal cancer (CRC). The endothelial adhesion molecule E-selectin is implicated in the metastatic spread of CRC. We postulated that some polymorphisms within the E-selectin gene, especially the S128R polymorphism, may increase the risk of metastases by facilitating adhesion of tumour cells to the endothelium. We collected blood samples for DNA extraction from 264 patients treated for stage II or III CRC and from 310 healthy controls in order to assess three polymorphisms within the E-selectin gene (S128R, G98T and L554F) and one within the P-selectin gene (V640L). Genotypes were analysed by the allelic discrimination TaqMan real-time PCR assay. The S128R polymorphism was detected in 59 patients (22.3%) and was strictly correlated with the G98T polymorphism. In multivariate analysis, the S128R polymorphism was associated with shorter event-free survival (EFS) and overall survival (OS) in the whole population (EFS: P=.003, HR 1.82, 95% CI 1.23-2.70; OS: P<10(-4), HR 4.31, 95% CI 2.46-10.99), in patients with stage II CRC(EFS: P=.04, HR 1.92, 95% CI 1.02-3.60; OS: P=.02, HR 4.44, 95% CI 1.16-17.03), and in patients with stage III CRC (EFS: P=.04, HR 1.68, 95% CI 1.01-2.80; OS: P=.001, HR 4.04, 95% CI 1.73-9.46). L554F and V640L polymorphisms had no prognostic value. The S128R polymorphism is a constitutional factor associated with a higher risk of relapse and death in patients treated for CRC. This polymorphism detection may permit better selection of patients suitable for adjuvant therapy, especially among those with stage II disease.