Quality of treatment in routine care in a population sample of rectal cancer patients

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.

Preoperative tumour staging with multidisciplinary team assessment improves the outcome in locally advanced primary rectal cancer

AIM

Multidisciplinary team meetings have been introduced as a result of developments in preoperative radiological tumour staging and neoadjuvant treatment. Multidisciplinary team recommendations will influence treatment decisions but their effect on patient outcome is unknown. The aim of this study was to assess outcome in relation to preoperative local and distant staging, with or without multidisciplinary team assessment.

METHODS

A population-based registry of all patients with rectal cancer, treated in the Stockholm region from 1995 to 2004, identified 303 patients with locally advanced primary rectal cancer. The patients were classified into three groups: group 1, preoperative local and distant radiological tumour staging with discussion at a multidisciplinary team meeting; group 2, preoperative staging but no multidisciplinary team assessment; and group 3, no proper preoperative radiological staging.

RESULTS

Neoadjuvant treatment was more prevalent in groups 1 and 2 than in group 3. The incidence of R0 resection differed significantly between the groups (52% in group 1, 43% in group 2 and 21% in group 3; P < 0.001). Local tumour control was achieved in 57%, 36%, and 19% of patients in groups 1, 2 and 3, respectively (P < 0.001). The estimated overall 5-year survival of patients was 30%, 28% and 12% in groups 1, 2 and 3, respectively.

CONCLUSION

Preoperative radiological tumour staging in patients with locally advanced primary rectal cancer and discussion at a multidisciplinary team meeting increases the proportion of patients receiving neoadjuvant treatment and cancer-specific end-points.

Evaluation of quality indicators following implementation of total mesorectal excision in primarily resected rectal cancer changed future management

BACKGROUND AND AIMS

We evaluated the outcome of primarily resected rectal cancer patients immediately after the implementation of total meserectal excision (TME) based on potential quality indicators.

PATIENTS AND METHODS

Following initial teaching of two staff surgeons (PMS and AHH) by RJ Heald, 164 consecutive patients were analyzed. The following quality indicators were evaluated: (a) frequency of local recurrence, (b) number of resected lymph nodes, (c) selection of operative technique depending on tumor localization, (d) use of a protective loop ileostomy, and (e) frequency and type of adjuvant therapy.

RESULTS

Local recurrence rate was 8.5% after a minimum follow-up of 5 years. An increasing pT category (p < 0.02) and the presence of lymph node metastases (pN+, p < 0.05) were significantly associated with local recurrence rates. The number of resected lymph nodes was significantly associated with nodal metastases rate (p < 0.02). Patients with distal third rectal cancer underwent significantly more often an abdominoperineal amputation (p < 0.0001). Clinical course, but not the rate of anastomotic leakage (9.5%) itself was influenced by using a protective loop ileostomy. Forty-two (29.7%) patients received adjuvant therapy; however, local recurrence rate was higher in patients with adjuvant chemo-/radiotherapy (14.2% vs. 6.1%).

CONCLUSIONS

The local recurrence rate of 8.5% demonstrates that through consequent implementation of TME excellent onclogical results can be achieved. The number of resected lymph nodes significantly influenced the pN category. The primary construction of a protective loop ileostomy after TME became standard. Neoadjuvant chemoradiation was systematically introduced in order to improve local tumor control and prevent abdominoperineal amputations. No conclusions can be drawn concerning adjuvant therapy.

[Intra-operative local tumor cell dissemination in rectal carcinoma surgery: effect of operation principles and neoadjuvant therapy]

BACKGROUND

The influence of surgical principles and neoadjuvant therapy on the frequency of local tumor cell dissemination (LTCD) in rectal carcinoma surgery and its consequences for local recurrence and survival rates were analyzed.

PATIENTS AND METHODS

Data from the Erlangen registry for colorectal carcinomas (ERCRC) from 1969-2008 were compared with data from the literature published in 1980-2008.

RESULTS

LTCD was observed in 6.7% in the ERCRC (n=2764) and a frequency of 6.9% was reported in in the literature (n=13,395). In the course of time and especially since the introduction of total mesorectal excision (TME) surgery, the incidence of LTCD has significantly decreased. Neoadjuvant treatment did not influence the frequency of LTCD. Following LTCD the rate of local recurrence significantly increased and the 5 year survival rate significantly decreased. This also applied to patients with neoadjuvant therapy.

CONCLUSIONS

Even in the era of TME surgery attention must to be paid to avoidance of LTCD. It is obligatory to document the occurrence of LTCD and it must be taken into consideration in routine quality assurance. In cases of LTCD postoperative chemoradiation is indicated for patients without neoadjuvant irradiation.

Radiotherapy treatment delays and their influence on tumour control achieved by various fractionation schedules

There is often a considerable delay from initial tumour diagnosis to the start of radiotherapy treatment. This paper extends the calculations of a previous paper on the effects of delays before the initiation of radiotherapy treatment to include results from a variety of practical fractionation regimes for three different types of tumour: squamous cell carcinoma (head and neck), breast and prostate. The linear quadratic model of radiation effect, logarithmic tumour growth (coupled with delay times where relevant) and the Poisson model for tumour control probability (TCP) are used to calculate the change in TCP for delays between diagnosis and treatment. Within the limitations of radiobiological modelling, these data can be used to tentatively assess the interactions between delays, dose fractionation and TCP. The results show that delays in the start of radiotherapy treatment do have an adverse effect on tumour control for fast-growing tumours. For example, calculations predict a reduction in local tumour control of up to 1.5% per week's delay for head and neck cancers treated following surgery. In addition, there may be a variety of fractionation regimes that will yield very similar clinical results for each tumour type. It is shown theoretically that, for the tumour types considered here, it is possible to increase the dose per fraction and decrease the number of fractions while maintaining or increasing TCP relative to standard 2 Gy fractionation regimes, although there may be some advantage to using hyperfractionated regimes for head and neck cancers in order to reduce normal tissue effects.

Concordance with national guidelines for colorectal cancer care in New South Wales: a population‐based patterns of care study

OBJECTIVE

To investigate predictors of evidence-based surgical care in a population-based sample of patients with newly diagnosed colorectal cancer.

DESIGN, PATIENTS AND SETTING

Prospective audit of all new patients with colorectal cancer reported to the New South Wales Central Cancer Registry between 1 February 2000 and 31 January 2001.

MAIN OUTCOME MEASURES

Concordance with seven guidelines from the 1999 Australian evidence-based guidelines for colorectal cancer; predictors of guideline concordance; the mean proportion of relevant guidelines followed for individual patients.

RESULTS

Questionnaires were received for 3095 patients (91.6%). Between 0 and 100% of relevant guidelines were followed for individual patients (median, 67%). Concordance with individual guidelines varied considerably. Patient age independently predicted non-concordance with guidelines for adjuvant therapy and preoperative radiotherapy. Adjuvant chemotherapy was more likely if a patient with node-positive colon cancer was treated in a metropolitan hospital or by a general surgeon. Surgeons with a high caseload or specialty in colorectal cancer were more likely to perform colonic pouch reconstruction, prescribe thromboembolism or antibiotic prophylaxis, and were less likely to refer patients with high-risk rectal cancer for adjuvant radiotherapy. Bowel preparation was less likely among older patients and in high-caseload hospitals.

CONCLUSION

Effective strategies to fully implement national colorectal cancer guidelines are needed. In particular, increasing the use of appropriate adjuvant therapy should be a priority, especially among older people.

Rectal cancer delivery of radiotherapy in adequate time and with adequate dose is influenced by treatment center, treatment schedule, and gender and is prognostic parameter for local control: Results of study CAO/ARO/AIO-94

PURPOSE

The impact of the delivery of radiotherapy (RT) on treatment results in rectal cancer patients is unknown.

METHODS AND MATERIALS

The data from 788 patients with rectal cancer treated within the German CAO/AIO/ARO-94 phase III trial were analyzed concerning the impact of the delivery of RT (adequate RT: minimal radiation RT dose delivered, 4300 cGy for neoadjuvant RT or 4700 cGy for adjuvant RT; completion of RT in <44 days for neoadjuvant RT or <49 days for adjuvant RT) in different centers on the locoregional recurrence rate (LRR) and disease-free survival (DFS) at 5 years. The LRR, DFS, and delivery of RT were analyzed as endpoints in multivariate analysis.

RESULTS

A significant difference was found between the centers and the delivery of RT. The overall delivery of RT was a prognostic factor for the LRR (no RT, 29.6% +/- 7.8%; inadequate RT, 21.2% +/- 5.6%; adequate RT, 6.8% +/- 1.4%; p = 0.0001) and DFS (no RT, 55.1% +/- 9.1%; inadequate RT, 57.4% +/- 6.3%; adequate RT, 69.1% +/- 2.3%; p = 0.02). Postoperatively, delivery of RT was a prognostic factor for LRR on multivariate analysis (together with pathologic stage) but not for DFS (independent parameters, pathologic stage and age). Preoperatively, on multivariate analysis, pathologic stage, but not delivery of RT, was an independent prognostic parameter for LRR and DFS (together with adequate chemotherapy). On multivariate analysis, the treatment center, treatment schedule (neoadjuvant vs. adjuvant RT), and gender were prognostic parameters for adequate RT.

CONCLUSION

Delivery of RT should be regarded as a prognostic factor for LRR in rectal cancer and is influenced by the treatment center, treatment schedule, and patient gender.

Establishment of serum protein pattern model for screening rectal carcinoma by SELDI-TOF-MS

AIM: To establish a serum protein pattern model for screening rectal carcinoma.

METHODS: The proteomic spectra of patients with rectal carcinoma, rectal polypus, and healthy people were obtained by surface-enhanced laser desorption/ionization time-of-flight mass spectrometry (SELD-TOF-MS) on WCX-2 chips. The collected data were compared and analyzed by Biomaker Wizard software (BPS) to set up the primary serum protein pattern model for screening rectal carcinoma. Then the pattern was evaluated by masked test.

RESULTS: A total of 26 protein was significantly different between the rectal carcinoma and normal controls (P < 0.05), among which 4 (m/z 9 295, 3 730, 3 938, and 4 095) were selected to set up an optimal serum protein biomarker pattern model. And the correct rate of this model was 96.8% (93/96). Its sensitivity and specificity was 95.0% (38/40) and 93.4% (45/48), respectively, when tested by masked samples.

CONCLUSION: The discovered serum protein pattern model can efficiently identify patients with and without rectal carcinoma. SELDI-TOF-MS plays a valuable role in the diagnosis of rectal carcinoma and the discovery of new tumor-specific protein biomarkers.