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Chang WH, Lai AG. Pan-cancer analyses of the associations between 109 pre-existing conditions and cancer treatment patterns across 19 adult cancers. Sci Rep 2024; 14:464. [PMID: 38172343 PMCID: PMC10764847 DOI: 10.1038/s41598-024-51161-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 01/01/2024] [Indexed: 01/05/2024] Open
Abstract
Comorbidities present considerable challenges to cancer treatment and care. However, little is known about the effect of comorbidity on cancer treatment decisions across a wide range of cancer types and treatment modalities. Harnessing a cohort of 280,543 patients spanning 19 site-specific cancers, we explored pan-cancer frequencies of 109 comorbidities. Multinomial logistic regression was used to analyse the relationship between comorbidities and cancer treatment types, while binomial logistic regression examined the association between comorbidities and chemotherapy drug types, adjusting for demographic and clinical factors. Patients with comorbidity exhibited lower odds of receiving chemotherapy and multimodality treatment. End-stage renal disease was significantly associated with a decreased odds of receiving chemotherapy and surgery. Patients with prostate cancer who have comorbid non-acute cystitis, obstructive and reflux uropathy, urolithiasis, or hypertension were less likely to receive chemotherapy. Among patients with breast cancer, dementia, left bundle branch block, peripheral arterial disease, epilepsy, Barrett's oesophagus, ischaemic stroke, unstable angina and asthma were associated with lower odds of receiving multimodal chemotherapy, radiotherapy and surgery. Comorbidity is also consistently associated with the lower odds of receiving chemotherapy when comparing across 10 drug classes. Patients with comorbid dementia, intracerebral haemorrhage, subarachnoid haemorrhage, oesophageal varices, liver fibrosis sclerosis and cirrhosis and secondary pulmonary hypertension were less likely to receive antimetabolites. Comorbidity can influence the effectiveness and tolerability of cancer treatment and ultimately, prognosis. Multi-specialty collaborative care is essential for the management of comorbidity during cancer treatment, including prophylactic measures to manage toxicities.
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Affiliation(s)
- Wai Hoong Chang
- Institute of Health Informatics, University College London, London, UK.
| | - Alvina G Lai
- Institute of Health Informatics, University College London, London, UK.
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Chen Y, Shankaran V, Hahn EE, Haupt EC, Bansal A. Underutilization or appropriate care? Assessing adjuvant chemotherapy use and survival in 3 heterogenous subpopulations with stage II/III colorectal cancer within a large integrated health system. J Manag Care Spec Pharm 2023; 29:635-646. [PMID: 37276035 PMCID: PMC10387960 DOI: 10.18553/jmcp.2023.29.6.635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND: Clinical guidelines have recommended adjuvant chemotherapy (ACT) for patients with high-risk stage II colon cancer, although the survival benefit is unclear. ACT is also recommended for patients with stage III colon cancer to reduce the risk of recurrence and mortality. For stage II/III rectal cancer, however, the role of perioperative chemotherapy (PCT, adjuvant or neoadjuvant) remains controversial, resulting in substantial variation in its use in clinical practice. OBJECTIVES: To understand real-world use and predictors of ACT or PCT use and survival outcomes in 3 heterogeneous patient groups with colorectal cancer (CRC), and to inform the evidence gap between guideline-based care and clinical practice. METHODS: This retrospective cohort study included patients with an initial stage II/III CRC diagnosis between 2008 and 2013 identified from Kaiser Permanente Southern California electronic health record databases. Patients were eligible if they were aged 18-74 years at diagnosis and received primary curative surgery. We fitted mixed effects logistic regression models to evaluate predictors of ACT receipt and Cox proportional hazards models on propensity score-matched (PS-matched) samples to assess the association between ACT/PCT receipt and survival. RESULTS: We included 1,690 patients with colon cancer (stage II: 820 and stage III: 870) and 587 patients with rectal cancer (stage II: 241 and stage III: 346). We found that 65% of patients with high-risk stage II colon cancer, 15% of those with stage III colon, and 15% of those with stage II/III rectal cancer did not receive ACT/PCT. Patients with stage II colon cancer with T4 stage (odds ratio [OR] = 5.79, 95% CI = 3.33 - 10.06) and a lower comorbidity score were more likely to receive ACT (high vs low Charlson score: OR = 0.69, 95% CI = 0.55 - 0.87). Patients with stage III rectal cancer were more likely to receive PCT than those with stage II disease (OR = 7.85, 95% CI = 2.07 - 29.74). Patients with another cancer diagnosis prior to CRC diagnosis were less likely to receive PCT (OR = 0.37, 95% CI = 0.16 - 0.85). ACT/PCT use was associated with improved overall survival among patients with high-risk stage II colon cancer (PS-matched hazard ratio [HR] = 0.42, 95% CI = 0.25 - 0.70) and those with stage III CRC (stage III colon: PS-matched HR = 0.3, 95% CI = 0.25 - 0.36; stage III rectal: PS-matched HR = 0.2, 95% CI = 0.13 - 0.31). CONCLUSIONS: We found potential underuse of appropriate chemotherapy treatment in patients with high-risk stage II colon cancer and stage III CRC. Clinicians' and providers' decisions on ACT administration may not be fully guided by the risk of recurrence and 5-year survival benefits in stage II colon cancer. DISCLOSURES: This research was supported by the National Cancer Institute of the National Institutes of Health (NIH) (under R37-CA218413). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
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Affiliation(s)
- Yilin Chen
- CHOICE Institute, School of Pharmacy, University of Washington, Seattle
| | - Veena Shankaran
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, and Division of Medical Oncology, University of Washington, Seattle
| | - Erin E Hahn
- Department of Health Systems Sciences, Bernard J. Tyson School of Medicine, Kaiser Permanente, Pasadena, CA
- Department of Research and Evaluation, Kaiser Permanente, Pasadena, CA
| | - Eric C Haupt
- Department of Research and Evaluation, Kaiser Permanente, Pasadena, CA
| | - Aasthaa Bansal
- CHOICE Institute, School of Pharmacy, University of Washington, Seattle
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Park J, Baik H, Kang SH, Seo SH, Kim KH, Oh MK, Lee HS, Lee SH, Kim KH, An MS. Comparison between oxaliplatin therapy and capecitabine monotherapy for high-risk stage II-III elderly colon cancer patients. Asian J Surg 2021; 45:448-455. [PMID: 34364765 DOI: 10.1016/j.asjsur.2021.07.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 07/05/2021] [Accepted: 07/21/2021] [Indexed: 12/17/2022] Open
Abstract
PURPOSE 45% of colon cancer patients are elderly, yet they are often deviated from standard cancer management. The MOSAIC trial favored FOLFOX over FL with superior oncologic outcomes; however, which regimen is most beneficial in elderly population remains unclear. This study aimed to compare the efficacy of oxaliplatin-added chemotherapy and capecitabine monotherapy in high-risk stage II/stage III elderly colon cancer patients. METHODS Colon cancer patients ≥70 years of age who received adjuvant chemotherapy at Inje University Busan Paik Hospital between February 2009 to April 2016 were included. Patients were separated into the oxaliplatin-added group and capecitabine monotherapy group. The primary outcomes were CSS and OS. RESULTS Of 74 patients, 45 received oxaliplatin-added chemotherapy and 29 received capecitabine monotherapy. There was no difference between the two groups in CSS or OS (p = 0.9670 and p = 0.6801, respectively). The N stage was significantly associated with CSS in both uni/multivariate analysis (p = 0.0565 and p = 0.0347, respectively). The oxaliplatin-added group had more stage III patients, so we performed a subgroup analysis of CSS and OS based on stage, which also showed no significant difference. CONCLUSIONS Capecitabine monotherapy is an oncologically safe regimen compared to oxaliplatin-added regimens in elderly patients with high-risk stage II/stage III colon cancer.
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Affiliation(s)
- Jueun Park
- Department of Surgery, College of Medicine, Busan Paik Hospital, South Korea.
| | - HyungJoo Baik
- Department of Surgery, College of Medicine, Busan Paik Hospital, South Korea.
| | - Sang Hyun Kang
- Department of Surgery, College of Medicine, Busan Paik Hospital, South Korea
| | - Sang Hyuk Seo
- Department of Surgery, College of Medicine, Busan Paik Hospital, South Korea
| | - Kwang Hee Kim
- Department of Surgery, College of Medicine, Busan Paik Hospital, South Korea
| | - Min Kyung Oh
- Clinical Trial Center in Pharmacology, College of Medicine, Busan Paik Hospital, South Korea
| | - Hong Sub Lee
- Internal Medicine, Inje University, College of Medicine, Busan Paik Hospital, South Korea
| | - Sang Heon Lee
- Internal Medicine, Inje University, College of Medicine, Busan Paik Hospital, South Korea
| | - Ki Hyang Kim
- Internal Medicine, Inje University, College of Medicine, Busan Paik Hospital, South Korea
| | - Min Sung An
- Department of Surgery, College of Medicine, Busan Paik Hospital, South Korea.
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Alyami HS, Naser AY, Dahmash EZ, Alyami MH, Belali OM, Assiri AM, Rehman A, Alsaleh AM, Alsaleh HA, Hussein SH, Amer SM, Asiri SA, Almuadi AI. Clinical and Therapeutic Characteristics of Cancer Patients in the Southern Region of Saudi Arabia: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18126654. [PMID: 34205637 PMCID: PMC8296400 DOI: 10.3390/ijerph18126654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/15/2021] [Accepted: 06/16/2021] [Indexed: 12/03/2022]
Abstract
Aims: Due to the continuous changes in modern lifestyle and the need to explore the effect of these changes on the risk of developing cancer, ongoing research on the epidemiology and characteristics of cancer patients is requested. This study explored the epidemiology of cancer, its characteristics, treatment patterns, and risk factors in the southern region of Saudi Arabia. Methods: A retrospective cross-sectional study was conducted using cancer patients’ medical records at Asir Central Hospital in the southern region of Saudi Arabia. Active patients’ records were extracted between January 2013 and December 2019. Results: A total of 2038 patients were identified during the study period, with a mean age of 60.9 (SD: 19.0) years. The patients had survived with their cancer for a median duration of 4 years (IQR: 2–6). Around 4.6% of the patients required ICU admission with a median period of 9 days (IQR: 5–14.75). The death rate during the study period was 10.9%. Around 20.8% of the cases were metastatic, of which 77.8% were at stage four of metastasis, and 19.7% of the patients were receiving chemotherapy for their disease. The most common types of cancer were malignant neoplasms of digestive organs, comprising 40.8% of the sample. Older age (60 years and above) and using specific chronic disease medications were predictors associated with a higher risk of death due to cancer (p < 0.05). Smoking history, using specific chronic disease medications, and having previous surgery were predictors associated with a higher risk of ICU admission (p < 0.05). Conclusion: Breast, colon, and liver cancers were the most prevalent in the southern region of Saudi Arabia. Several modifiable cancer risk factors were identified. The results of this study should support decision-makers in the initiation of programs for key modifiable risk factors that enhance lifestyle changes and reduce cancer risks.
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Affiliation(s)
- Hamad S. Alyami
- Department of Pharmaceutics, College of Pharmacy, Najran University, Najran 66262, Saudi Arabia;
- Correspondence: ; Tel.: +966-500095255
| | - Abdallah Y. Naser
- Department of Applied Pharmaceutical Sciences and Clinical Pharmacy, Faculty of Pharmacy, Isra University, Amman 11622, Jordan; (A.Y.N.); (E.Z.D.)
| | - Eman Zmaily Dahmash
- Department of Applied Pharmaceutical Sciences and Clinical Pharmacy, Faculty of Pharmacy, Isra University, Amman 11622, Jordan; (A.Y.N.); (E.Z.D.)
| | - Mohammad H. Alyami
- Department of Pharmaceutics, College of Pharmacy, Najran University, Najran 66262, Saudi Arabia;
| | - Osamah M. Belali
- Pharmaceutical Services Department, Asir Central Hospital, Abha 62529, Saudi Arabia; (O.M.B.); (A.M.A.)
| | - Ahmad M. Assiri
- Pharmaceutical Services Department, Asir Central Hospital, Abha 62529, Saudi Arabia; (O.M.B.); (A.M.A.)
| | - Amjad Rehman
- Oncology Department, Asir Central Hospital, Abha 62529, Saudi Arabia;
| | - Abdulrhman M. Alsaleh
- College of Pharmacy, King Khalid University, Abha 62529, Saudi Arabia; (A.M.A.); (H.A.A.); (S.H.H.); (S.M.A.); (S.A.A.); (A.I.A.)
| | - Hind A. Alsaleh
- College of Pharmacy, King Khalid University, Abha 62529, Saudi Arabia; (A.M.A.); (H.A.A.); (S.H.H.); (S.M.A.); (S.A.A.); (A.I.A.)
| | - Shahad H. Hussein
- College of Pharmacy, King Khalid University, Abha 62529, Saudi Arabia; (A.M.A.); (H.A.A.); (S.H.H.); (S.M.A.); (S.A.A.); (A.I.A.)
| | - Shahad M. Amer
- College of Pharmacy, King Khalid University, Abha 62529, Saudi Arabia; (A.M.A.); (H.A.A.); (S.H.H.); (S.M.A.); (S.A.A.); (A.I.A.)
| | - Sara A. Asiri
- College of Pharmacy, King Khalid University, Abha 62529, Saudi Arabia; (A.M.A.); (H.A.A.); (S.H.H.); (S.M.A.); (S.A.A.); (A.I.A.)
| | - Amjad I. Almuadi
- College of Pharmacy, King Khalid University, Abha 62529, Saudi Arabia; (A.M.A.); (H.A.A.); (S.H.H.); (S.M.A.); (S.A.A.); (A.I.A.)
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van den Berg I, van de Weerd S, van Klaveren D, Coebergh van den Braak RRJ, van Krieken JHJM, Koopman M, Roodhart JML, Medema JP, IJzermans JNM. Daily practice in guideline adherence to adjuvant chemotherapy in stage III colon cancer and predictors of outcome. Eur J Surg Oncol 2021; 47:2060-2068. [PMID: 33745794 DOI: 10.1016/j.ejso.2021.03.236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/09/2021] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Although guidelines recommend adjuvant chemotherapy for stage III colon cancer patients, many patients do not receive adjuvant chemotherapy. The aim of this study was to identify reasons for guideline non-adherence and assess the effect on patient outcomes in a multicenter cohort of stage III colon cancer patients who received surgery plus adjuvant chemotherapy or surgery alone. METHODS Patients who underwent surgery between 2007 and 2017 were included. Reasons for non-adherence were determined. Propensity score analyses with inverse probability weighting were performed to adjust for confounding factors. Cox proportional hazards regression and risk stratified analyses were performed to assess the association of guideline adherence and other potential predictors with recurrence free survival (RFS). RESULTS Data of 575 patients were included of whom 61% received adjuvant chemotherapy. In 87 of 222 patients (39%) who did not receive adjuvant chemotherapy, no reason was documented. Only age was predictive for receiving chemotherapy. Patients who received adjuvant chemotherapy had longer RFS (HR 0.42, 95%CI 0.29-0.62, p < 0.001). High T- and N-stage were associated with poorer RFS HR 2.0 (95%CI 1.58-2.71, p < 0.001) and HR 2.19 (95%CI 1.60-2.99, p < 0.001) respectively. Risk groups were identified with distinct prognosis and treatment effect and a nomogram is presented to visualize individualized RFS differences. CONCLUSION This study shows considerable variation in guideline adherence to adjuvant chemotherapy and poor documentation on reasons for non-adherence. Optimizing adherence and gaining insight in reasons for non-adherence is advocated as this can lead to significant RFS benefit, especially in patients with high T-and N-stage tumors.
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Affiliation(s)
- I van den Berg
- Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - S van de Weerd
- Laboratory for Experimental Oncology and Radiobiology, Center for Experimental and Molecular Medicine, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands; Oncode Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - D van Klaveren
- Erasmus MC - University Medical Center Rotterdam, Department of Public Health, Rotterdam, the Netherlands; Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, USA
| | | | - J H J M van Krieken
- Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - M Koopman
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - J M L Roodhart
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - J P Medema
- Laboratory for Experimental Oncology and Radiobiology, Center for Experimental and Molecular Medicine, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Oncode Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - J N M IJzermans
- Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
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Scheepers ERM, Schiphorst AH, van Huis-Tanja LH, Emmelot-Vonk MH, Hamaker ME. Treatment patterns and primary reasons for adjusted treatment in older and younger patients with stage II or III colorectal cancer. Eur J Surg Oncol 2021; 47:1675-1682. [PMID: 33563486 DOI: 10.1016/j.ejso.2021.01.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 01/10/2021] [Accepted: 01/29/2021] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE This study aims to assess age-related treatment patterns and primary reasons for adjusted treatment in patients with colorectal cancer. METHODS Patients with colorectal cancer stage II or III diagnosed between 2015 and 2018 in the Netherlands were eligible for this study. Data were provided by the Netherlands Cancer Registry and included socio-demographics, clinical characteristics, treatment patterns and primary reasons for adjusted treatment. Treatment patterns and reasons for adjusted treatment were analysed according to age groups. RESULTS Of all 29,620 patients, 30% were aged <65 years (n = 8994), 34% between 65 and 75 years (n = 10,173), 27% between 75 and 85 years (n = 8102) and 8% were ≥85 years (n = 2349). Irrespective of cancer location or stage, older patients received less frequently a combination of surgery and (neo)adjuvant therapy compared to younger patients (decreasing from 55% to 1% in colon cancer patients, and from 71% to 23% in rectal cancer patients aged <65 years and ≥85 years respectively). Omission of surgical treatment increased with age in both patients with colon cancer (ranging from 1% in patients aged <65 years to 16% in those ≥85 years) and rectal cancer (ranging from 12% in patients aged <65 years to 56% in those ≥85 years). The most common reasons for adjusted treatment were patient preference (27%) and functional status (20%), both reasons increased with advancing age. CONCLUSIONS Guideline non-adherence increased with advancing age and omission of standard treatment was mainly based on patient preference and functional status. These findings provides insight in the treatment decision-making process in patients with colorectal cancer. Future research is necessary to further assess patient's role in the treatment decision-making process.
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Affiliation(s)
- E R M Scheepers
- Department of Internal Medicine, Diakonessenhuis, Utrecht, the Netherlands.
| | - A H Schiphorst
- Department of Surgery, Diakonessenhuis, Utrecht, the Netherlands
| | - L H van Huis-Tanja
- Department of Internal Medicine, Diakonessenhuis, Utrecht, the Netherlands
| | - M H Emmelot-Vonk
- Department of Geriatric Medicine, University Medical Centre Utrecht, the Netherlands
| | - M E Hamaker
- Department of Geriatric Medicine, Diakonessenhuis, Utrecht, the Netherlands
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Boakye D, Nagrini R, Ahrens W, Haug U, Günther K. The association of comorbidities with administration of adjuvant chemotherapy in stage III colon cancer patients: a systematic review and meta-analysis. Ther Adv Med Oncol 2021; 13:1758835920986520. [PMID: 33613694 PMCID: PMC7841869 DOI: 10.1177/1758835920986520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 12/17/2020] [Indexed: 12/24/2022] Open
Abstract
Background: Chemotherapy is an established treatment for stage III colon cancer cases. Older age is known to be associated with less chemotherapy use in these patients, but there might be other relevant factors besides age that influence treatment administration. We summarized evidence on associations between comorbidity and adjuvant chemotherapy administration in stage III colon cancer patients in a systematic review and meta-analysis. Methods: We searched the PubMed and Web of Science databases up to 2 June 2020 for studies on comorbidities and chemotherapy use in patients with stage III colon cancer. Summary odds ratios (OR) and 95% confidence intervals (95% CI) were estimated using random-effects models. Subgroup analyses according to year of colon cancer diagnosis, timing of comorbidity assessment, and geographical region were also conducted. Results: Thirty-three studies were included in this review, including 219,406 stage III colon cancer patients overall. Chemotherapy administration was 60.9% (95% CI: 56.9% to 64.9%), increasing from 57.1% before 2001 to 66.3% after 2010. There were inverse associations between comorbidities and chemotherapy administration. Compared with patients with Charlson comorbidity score 0, those with scores 1 (OR = 0.79, 95% CI = 0.72–0.87) and 2+ (OR = 0.49, 95% CI = 0.42–0.56) received chemotherapy less often. Among comorbidities, the strongest predictors of chemotherapy non-use were dementia (OR = 0.37, 95% CI = 0.33–0.54), followed by heart failure (OR = 0.44, 95% CI = 0.28–0.70) and stroke (OR = 0.56, 95% CI = 0.38–0.81). Conclusions: Merely 60% of stage III colon cancer patients receive chemotherapy. Comorbidities are strong predictors of chemotherapy non-use, but the association differs by comorbid condition and is strongest with dementia. Given the survival disadvantage of colon cancer patients with comorbidities, further evidence on the risk–benefit ratio of chemotherapy according to the type and severity of comorbidity and on the extent to which the survival disadvantage of comorbidity is explained by less use or lower tolerability of chemotherapy is needed to foster personalized medical care in these patients.
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Affiliation(s)
| | - Rajini Nagrini
- Department of Epidemiological Methods and Etiological Research, Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
| | - Wolfgang Ahrens
- Department of Epidemiological Methods and Etiological Research, Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
- Institute of Statistics, Faculty of Mathematics and Computer Science, University of Bremen, Bremen, Germany
| | - Ulrike Haug
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
- Faculty of Human and Health Sciences, University of Bremen, Bremen, Germany
| | - Kathrin Günther
- Department of Epidemiological Methods and Etiological Research, Leibniz Institute for Prevention Research and Epidemiology – BIPS, Bremen, Germany
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Recurrence Risk after Radical Colorectal Cancer Surgery-Less Than before, But How High Is It? Cancers (Basel) 2020; 12:cancers12113308. [PMID: 33182510 PMCID: PMC7696064 DOI: 10.3390/cancers12113308] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 10/27/2020] [Accepted: 11/06/2020] [Indexed: 02/06/2023] Open
Abstract
Simple Summary Evidence indicates that recurrence risk after colon cancer today is less than it was when trials performed decades ago showed that adjuvant chemotherapy reduces the risk and prolong disease-free and overall survival. After rectal cancer surgery, local recurrence rates have decreased but it is unclear if systemic recurrences have. After a systematic review of available literature reporting recurrence risks after curative colorectal cancer surgery we report that the risks are lower today than they were in the past and that this risk reduction is not solely ascribed to the use of adjuvant therapy. Adjuvant therapy always means overtreatment of many patients, already cured by the surgery. Fewer recurrences mean that progress in the care of these patients has happened but also that the present guidelines giving recommendations based upon old data must be adjusted. The relative gains from adding chemotherapy are not altered, but the absolute number of patients gaining is less. Abstract Adjuvant chemotherapy aims at eradicating tumour cells sometimes present after radical surgery for a colorectal cancer (CRC) and thereby diminish the recurrence rate and prolong time to recurrence (TTR). Remaining tumour cells will lead to recurrent disease that is usually fatal. Adjuvant therapy is administered based upon the estimated recurrence risk, which in turn defines the need for this treatment. This systematic overview aims at describing whether the need has decreased since trials showing that adjuvant chemotherapy provides benefits in colon cancer were performed decades ago. Thanks to other improvements than the administration of adjuvant chemotherapy, such as better staging, improved surgery, the use of radiotherapy and more careful pathology, recurrence risks have decreased. Methodological difficulties including intertrial comparisons decades apart and the present selective use of adjuvant therapy prevent an accurate estimate of the magnitude of the decreased need. Furthermore, most trials do not report recurrence rates or TTR, only disease-free and overall survival (DFS/OS). Fewer colon cancer patients, particularly in stage II but also in stage III, today display a sufficient need for adjuvant treatment considering the burden of treatment, especially when oxaliplatin is added. In rectal cancer, neo-adjuvant treatment will be increasingly used, diminishing the need for adjuvant treatment.
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Konradsen AA, Lund CM, Vistisen KK, Albieri V, Dalton SO, Nielsen DL. The influence of socioeconomic position on adjuvant treatment of stage III colon cancer: a systematic review and meta-analysis. Acta Oncol 2020; 59:1291-1299. [PMID: 32525420 DOI: 10.1080/0284186x.2020.1772501] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Patients with colon cancer (CC) with low socioeconomic position (SEP) have a worse survival than patients with high SEP. We investigated the association between different socioeconomic indicators and the steps in the treatment trajectory leading to initiation of adjuvant chemotherapy (ACT) for patients with stage III CC. MATERIALS AND METHODS A systematic review and meta-analyses were conducted in accordance with the MOOSE checklist. MEDLINE and EMBASE were searched for eligible studies. Meta-analyses were performed on the separate socioeconomic indicators with the random-effects model. The heterogeneity across studies was assessed by the Q and the I 2 statistic. RESULTS In total, 27 observational studies were included. SEP was measured by insurance, income, poverty, employment, education, or an index on an area or individual level. SEP, regardless of indicator, was negatively associated with the steps in the treatment trajectory leading to initiation of ACT among patients with resected stage III CC. The meta-analyses showed that patients with low SEP had a significantly lower odds of receiving ACT and increased odds of delayed treatment start, whereas SEP had no impact on the choice of therapy: combination or single-agent therapy. CONCLUSION SEP was associated with less initiation of and higher risk for delayed initiation of ACT. Our findings suggest there is a social disparity in receipt of ACT in patients with stage III CC.
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Affiliation(s)
- A. A. Konradsen
- Department of Oncology, Copenhagen University Hospital, Herlev and Gentofte, Denmark
| | - C. M. Lund
- Department of Medicine, Copenhagen University Hospital, Herlev and Gentofte, Denmark
- Copenage, Copenhagen Center for Clinical Age Research, University of Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Denmark
| | - K. K. Vistisen
- Department of Oncology, Copenhagen University Hospital, Herlev and Gentofte, Denmark
| | - V. Albieri
- Statistics and Data Analysis Department, Danish Cancer Society, Research Center, Copenhagen, Denmark
| | - S. O. Dalton
- Department of Clinical Oncology & Palliative Services, Zealand University Hospital, Naestved, Denmark
- Suvivorship and Inequality in Cancer, Danish Cancer Society, Research Center, Copenhagen, Denmark
| | - D. L. Nielsen
- Department of Oncology, Copenhagen University Hospital, Herlev and Gentofte, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Denmark
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Simillis C, Singh HKSI, Afxentiou T, Mills S, Warren OJ, Smith JJ, Riddle P, Adamina M, Cunningham D, Tekkis PP. Postoperative chemotherapy improves survival in patients with resected high-risk Stage II colorectal cancer: results of a systematic review and meta-analysis. Colorectal Dis 2020; 22:1231-1244. [PMID: 31999888 DOI: 10.1111/codi.14994] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/07/2020] [Indexed: 02/08/2023]
Abstract
AIM The aim was to assess the benefit of adjuvant chemotherapy in high-risk Stage II colorectal cancer. METHOD A systematic literature review and meta-analysis was performed comparing survival in patients with resected Stage II colorectal cancer and high-risk features having postoperative chemotherapy vs no chemotherapy. RESULTS Of 1031 articles screened, 29 were included, reporting on 183 749 participants. Adjuvant chemotherapy significantly improved overall survival [hazard ratio (HR) 0.61, P < 0.0001], disease-specific survival (HR = 0.73, P = 0.05) and disease-free survival (HR = 0.59, P < 0.0001) compared to no chemotherapy. Adjuvant chemotherapy significantly increased 5-year overall survival (OR = 0.53, P = 0.0008) and 5-year disease-free survival (OR = 0.50, P = 0.001). Overall survival and disease-free survival remained significantly prolonged during subgroup analysis of studies published from 2015 onwards (HR = 0.60, P < 0.0001; HR = 0.65, P = 0.0001; respectively), in patients with two or more high-risk features (HR = 0.59, P = 0.0001; HR = 0.70, P = 0.03; respectively) and in colon cancer (HR = 0.61, P < 0.0001; HR = 0.51, P = 0.0001; respectively). Overall survival, disease-specific survival and disease-free survival during subgroup analysis of individual high-risk features were T4 tumour (HR = 0.58, P < 0.0001; HR = 0.50, P = 0.003; HR = 0.75, P = 0.05), < 12 lymph nodes harvested (HR = 0.67, P = 0.0002; HR = 0.80, P = 0.17; HR = 0.72, P = 0.02), poor differentiation (HR = 0.84, P = 0.35; HR = 0.85, P = 0.23; HR = 0.61, P = 0.41), lymphovascular or perineural invasion (HR = 0.55, P = 0.05; HR = 0.59, P = 0.11; HR = 0.76, P = 0.05) and emergency surgery (HR = 0.60, P = 0.02; HR = 0.68, P = 0.19). CONCLUSION Adjuvant chemotherapy in high-risk Stage II colorectal cancer results in a modest survival improvement and should be considered on an individual patient basis. Due to potential heterogeneity and selection bias of the included studies, and lack of separate rectal cancer data, further large randomized trials with predefined inclusion criteria and standardized chemotherapy regimens are required.
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Affiliation(s)
- C Simillis
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - H K S I Singh
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - T Afxentiou
- Department of Clinical Oncology, Imperial College Healthcare NHS Trust, London, UK
| | - S Mills
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - O J Warren
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - J J Smith
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - P Riddle
- Department of Clinical Oncology, Imperial College Healthcare NHS Trust, London, UK
| | - M Adamina
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - D Cunningham
- Gastrointestinal Unit, The Royal Marsden Hospital, London, UK
| | - P P Tekkis
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK.,Gastrointestinal Unit, The Royal Marsden Hospital, London, UK
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11
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Schraa SJ, van Rooijen KL, van der Kruijssen DEW, Rubio Alarcón C, Phallen J, Sausen M, Simmons J, Coupé VMH, van Grevenstein WMU, Elias S, Verkooijen HM, Laclé MM, Bosch LJW, van den Broek D, Meijer GA, Velculescu VE, Fijneman RJA, Vink GR, Koopman M. Circulating tumor DNA guided adjuvant chemotherapy in stage II colon cancer (MEDOCC-CrEATE): study protocol for a trial within a cohort study. BMC Cancer 2020; 20:790. [PMID: 32819390 PMCID: PMC7441668 DOI: 10.1186/s12885-020-07252-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 08/03/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Accurate detection of patients with minimal residual disease (MRD) after surgery for stage II colon cancer (CC) remains an urgent unmet clinical need to improve selection of patients who might benefit form adjuvant chemotherapy (ACT). Presence of circulating tumor DNA (ctDNA) is indicative for MRD and has high predictive value for recurrent disease. The MEDOCC-CrEATE trial investigates how many stage II CC patients with detectable ctDNA after surgery will accept ACT and whether ACT reduces the risk of recurrence in these patients. METHODS/DESIGN MEDOCC-CrEATE follows the 'trial within cohorts' (TwiCs) design. Patients with colorectal cancer (CRC) are included in the Prospective Dutch ColoRectal Cancer cohort (PLCRC) and give informed consent for collection of clinical data, tissue and blood samples, and consent for future randomization. MEDOCC-CrEATE is a subcohort within PLCRC consisting of 1320 stage II CC patients without indication for ACT according to current guidelines, who are randomized 1:1 into an experimental and a control arm. In the experimental arm, post-surgery blood samples and tissue are analyzed for tissue-informed detection of plasma ctDNA, using the PGDx elio™ platform. Patients with detectable ctDNA will be offered ACT consisting of 8 cycles of capecitabine plus oxaliplatin while patients without detectable ctDNA and patients in the control group will standard follow-up according to guideline. The primary endpoint is the proportion of patients receiving ACT when ctDNA is detectable after resection. The main secondary outcome is 2-year recurrence rate (RR), but also includes 5-year RR, disease free survival, overall survival, time to recurrence, quality of life and cost-effectiveness. Data will be analyzed by intention to treat. DISCUSSION The MEDOCC-CrEATE trial will provide insight into the willingness of stage II CC patients to be treated with ACT guided by ctDNA biomarker testing and whether ACT will prevent recurrences in a high-risk population. Use of the TwiCs design provides the opportunity to randomize patients before ctDNA measurement, avoiding ethical dilemmas of ctDNA status disclosure in the control group. TRIAL REGISTRATION Netherlands Trial Register: NL6281/NTR6455 . Registered 18 May 2017, https://www.trialregister.nl/trial/6281.
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Affiliation(s)
- S J Schraa
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - K L van Rooijen
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - D E W van der Kruijssen
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - C Rubio Alarcón
- Department of Pathology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - J Phallen
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - M Sausen
- Personal Genome Diagnostics, Baltimore, MD, 21224, USA
| | - J Simmons
- Personal Genome Diagnostics, Baltimore, MD, 21224, USA
| | - V M H Coupé
- Department of Epidemiology and Biostatistics, Amsterdam University Medical Centers, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - W M U van Grevenstein
- Department of Surgical Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - S Elias
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - H M Verkooijen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - M M Laclé
- Department of Pathology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - L J W Bosch
- Department of Pathology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - D van den Broek
- Department of Laboratory Medicine, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - G A Meijer
- Department of Pathology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - V E Velculescu
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - R J A Fijneman
- Department of Pathology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - G R Vink
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - M Koopman
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
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12
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Aparicio T, Canouï-Poitrine F, Caillet P, François E, Cudennec T, Carola E, Albrand G, Bouvier AM, Petri C, Couturier B, Phelip JM, Bengrine-Lefevre L, Paillaud E. Treatment guidelines of metastatic colorectal cancer in older patients from the French Society of Geriatric Oncology (SoFOG). Dig Liver Dis 2020; 52:493-505. [PMID: 32029404 DOI: 10.1016/j.dld.2019.12.145] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 12/21/2019] [Accepted: 12/23/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Several guidelines dedicated to metastatic colorectal cancer (mCRC) are available. Since 2013 no recent guidelines are specifically dedicated to older patients and based on a systematic review. MATERIALS AND METHODS A multidisciplinary Task Force with digestive oncologists, geriatricians and methodologists from the SoFOG was formed in 2016 to update recommendations on medical treatment of mCRC based on a systematic review of publications from 2000 to 2018. Search strategy has followed a standardized protocol from the formulation of clinical questions and definition of a search algorithm to the selection of complete articles for recommendations. RESULTS The four selected key questions were: For which older patients with mCRC can we considered: (1) Any chemotherapy, (2) Mono or poly-chemotherapy, (3) Anti-angiogenic therapy, (4) Other targeted therapy. Main recommendations for older patients are: (1) Omission of chemotherapy should be discussed with a geriatrician for patients with severe comorbidities, advanced dementia, uncontrolled psychiatric disorder or severe loss of autonomy. (2) If tumor response is not the main aim, a mono-chemotherapy with 5-fluorouracil combined with bevacizumab is recommended as first-line. (3) For patients with symptoms related to metastases or with a planned metastasis ablation, a doublet chemotherapy combined with bevacizumab or anti-EGFR antibody in the context of a RAS wild type tumor is recommended as first-line. Preliminary data suggest that regorafenib may be used, in its registered indication, in patients under 80 with a performance status of 0 and no autonomy alterations and that trifluridine-tipiracil may be used with a tight supervising of hematological function.
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Affiliation(s)
- Thomas Aparicio
- Department of Gastroenterology and Digestive Oncology, Saint Louis Hospital, AP-HP, University of Paris, Paris, France.
| | - Florence Canouï-Poitrine
- Clinical Epidemiology and Ageing Unit, Henri Mondor Hospital, APHP, EA 7376, CEpiA- IMRB, University of Paris-Est, Créteil, France
| | - Philippe Caillet
- Department of Geriatry, Georges Pompidou Hospital, APHP, University of Paris, Paris, France
| | - Eric François
- Department of Medical Oncology, Antoine-Lacassagne Center, University Côte d'Azur, Nice, France
| | - Tristan Cudennec
- Department of Geriatry, Ambroise Paré Hospital, APHP, University Versailles - Saint Quentin, Boulogne-Billancourt, France
| | - Elisabeth Carola
- Department of Medical Oncology, Public Sud de l'Oise Hospital, Creil, France
| | - Gilles Albrand
- Department of Geriatry, Lyon-Sud Hospital, Hospices Civils de Lyon, Pierre Bénite, France
| | - Anne-Marie Bouvier
- Digestive Cancer Registry of Burgundy, INSERM UMR1231 EPICAD University of Burgundy Franche Comté, Dijon, France
| | - Camille Petri
- Clinical Epidemiology and Ageing Unit, Henri Mondor Hospital, APHP, EA 7376, CEpiA- IMRB, University of Paris-Est, Créteil, France
| | - Bérengère Couturier
- Clinical Epidemiology and Ageing Unit, Henri Mondor Hospital, APHP, EA 7376, CEpiA- IMRB, University of Paris-Est, Créteil, France
| | - Jean-Marc Phelip
- Department of Gastroenterology and Digestive Oncology, Saint-Etienne Hospital, University Jean Monnet, Saint-Priest-en-Jarez, France
| | | | - Elena Paillaud
- Department of Geriatry, Georges Pompidou Hospital, APHP, University of Paris, Paris, France
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13
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Abstract
BACKGROUND An aging population combined with an increased colorectal cancer (CRC) incidence in the older population will increase its prevalence in the elderly, questioning how many years of life are lost (YLLs) in these patients. PATIENTS AND METHODS Data from 32,568 Dutch CRC patients ≥ 80 years were used to estimate the number of YLLs after diagnosis, using a reference age-, sex- and year-of-onset-matched cohort derived from national life tables. YLLs were additionally adjusted by comorbidities. Number needed to treat (NNT) was used as measure of surgical effect size. RESULTS Surgery was applied in 74.9% of patients leading to 1.3 YLLs, being superior in 86.1% of cases with respect to alternative therapies (YLLs 4.8 years) and resulting in a number of two patients needed to operate to achieve one positive outcome. YLLs and NNTs depended on CRC stage, patient' age and comorbidities. For Stage I-II patients in the best clinical conditions (80-85 years without comorbidities), YLLs increased up to 4.1 years after surgery and up to 8.8 years without surgery (NNT 3). For Stage III patients, the NNT of surgery varied between 2 when they were in the best clinical conditions and 4 when they were older with high comorbidities. In Stage IV patients, the NNT ranged between 6 and 31. CONCLUSIONS YLLs represents a novel approach to evaluate CRC prognosis. Stage I-III surgical patients can have a life expectancy similar to that of general population, being the NNT of surgery reasonably small compared with alternatives. Personalized comorbidity data are needed to confirm present findings.
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14
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A real-life study on the implementation and effectiveness of exemestane plus everolimus per hospital type in patients with advanced breast cancer. A study of the Southeast Netherlands Advanced Breast Cancer registry. Breast 2019; 44:46-51. [PMID: 30641299 DOI: 10.1016/j.breast.2019.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 12/22/2018] [Accepted: 01/02/2019] [Indexed: 11/24/2022] Open
Abstract
PURPOSE We aimed to assess the implementation and effectiveness of exemestane plus everolimus treatment per hospital type in real-life, shortly after approval of everolimus. METHODS Advanced breast cancer patients treated with exemestane plus everolimus in 2012-2014 were included from the SONABRE registry. Progression-free survival (PFS) and a 12-week conditional PFS (post-hoc) were estimated by Kaplan-Meier method. The multivariable Cox proportional hazards model was performed by type of hospital and adjusted for patient, tumour and treatment characteristics. RESULTS We included 122 patients, comprising 48 patients treated in academic (N = 1), 56 in teaching (N = 4), and 18 in non-teaching (N = 2) hospitals. The median PFS was 6.3 months (95% Confidence Interval (CI) 4.0-8.6) overall, and 8.5 months (95% CI 7.7-9.3), 4.2 months (95% CI 2.0-6.3), and 5.5 months (95% CI 4.2-6.7) for the patients treated in academic, teaching and non-teaching hospitals, respectively. The adjusted Hazard Ratio (HR) for PFS-events was 1.5 (95% CI 1.0-2.2) and 1.0 (95% CI 0.5-1.9) respectively for patients treated at teaching and non-teaching hospitals versus the academic hospital. The adjusted HR for 12-week conditional PFS-events was not different between hospital types. In the first 12-week treatment period, treatment was discontinued due to early progression in one out of 48 patients in the academic versus nine out of 74 patients in the non-academic hospitals, confirmed by imaging in one and two patients, respectively. CONCLUSIONS In our study, the median PFS was borderline significantly different between hospital types, possibly the result of a different assessment approach in the first 12-week treatment period.
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15
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van Beek MWH, Roukens M, Jacobs WCH, Timmer-Bonte JNH, Kramers C. Real-World Adverse Effects of Capecitabine Toxicity in an Elderly Population. Drugs Real World Outcomes 2018; 5:161-167. [PMID: 29934933 PMCID: PMC6119165 DOI: 10.1007/s40801-018-0138-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Few studies have assessed the safety and effectiveness of the numerous available chemotherapeutic therapies for geriatric oncology patients. Most safety studies are conducted in large trials, and there is some uncertainty surrounding whether the results would be the same in typical daily use. OBJECTIVE This retrospective study aims to assess the adverse effects of real-world capecitabine use in elderly patients. METHODS We reviewed the records of patients treated with capecitabine in an oncology department of a University Clinic in Nijmegen, The Netherlands. We scored adverse effects such as hand-foot syndrome and diarrhea, and dosage adjustments and the reasons for them. In total, 132 patients were included, 69 of whom were aged 70 years or below (mean age: 57 years), while 63 were aged older than 70 years (mean age: 74 years). RESULTS Patients aged over 70 years experienced more serious adverse effects than younger patients. Grade 2 or 3 hand-foot syndrome toxicity was experienced by 20.2% of patients aged younger than 70 years and by 34.9% of patients older than 70 years (p = 0.059). Grade 2, 3, or 4 diarrhea was experienced by 17.4% of the patients aged younger than 70 years but by 31.7% of the patients aged older than 70 years (p = 0.044). Dosage was adjusted for 27/69 patients in the younger group and 52/63 patients in the older group (p = 0.001). CONCLUSION The difference in observed adverse effects cannot be the sole explanation for the high incidence of observed dose adjustments. A prospective follow-up study of elderly patients using capecitabine outside clinical trials is needed to evaluate the optimum balance between adverse effects and efficacy.
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Affiliation(s)
- Michiel W H van Beek
- Department of Pharmacology-Toxicology, Radboud University Medical Center, Nijmegen, The Netherlands. .,Department of Clinical Geriatrics, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands.
| | - Monique Roukens
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Clinical Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | | | - Cees Kramers
- Department of Pharmacology-Toxicology, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Clinical Pharmacy, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
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16
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Heins MJ, de Jong JD, Spronk I, Ho VKY, Brink M, Korevaar JC. Adherence to cancer treatment guidelines: influence of general and cancer-specific guideline characteristics. Eur J Public Health 2018; 27:616-620. [PMID: 28013246 DOI: 10.1093/eurpub/ckw234] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Guideline adherence remains a challenge in clinical practice, despite guidelines' ascribed potential to improve patient outcomes. We studied the level of adherence to recommendations from Dutch national cancer treatment guidelines, and the influence of general and cancer-specific guideline characteristics on adherence. Methods Based on data from a national cancer registry, adherence was evaluated for 15 treatment recommendations for breast, colorectal, prostate and lung cancer, and melanoma. Recommendations were selected by representatives of the medical specialist associations responsible for developing and implementing the guidelines. We used multivariable multilevel analysis to calculate mean adherence and variation between individual hospitals. Results Mean adherence to the different treatment recommendations ranged from 40 to 99%. Adherence differed only slightly between older and newer guidelines and between recommendations with low, moderate or high levels of evidence (range 79-84% and 77-91%, respectively), while adherence differed more between recommendations for different cancer types (range 54-99%), different treatment modalities (adherence ranged from 40 to 92%) or recommendations that advised against or recommended in favour of particular treatment (adherence ranged from 75 to 98%). Conclusion We found significant variation in adherence between different cancer treatment guidelines. While some guideline characteristics that seem to explain this variation may be considered difficult to modify, the potential for variance across cancer types and treatment modalities suggests that adherence could be further improved. At the same time, these results warrant tailored strategies for the improvement of adherence to clinical practice guidelines.
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Affiliation(s)
- Marianne J Heins
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Judith D de Jong
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Inge Spronk
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Vincent K Y Ho
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - Mirian Brink
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - Joke C Korevaar
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
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17
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Better Late than Never? Adherence to Adjuvant Therapy Guidelines for Stage III Colon Cancer in an Underserved Region. J Gastrointest Surg 2018; 22:138-145. [PMID: 29119529 DOI: 10.1007/s11605-017-3620-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 10/26/2017] [Indexed: 01/31/2023]
Abstract
INTRODUCTION In 2008, the American College of Surgeons Commission on Cancer (CoC) issued a quality guideline for stage III colon cancer (CC) recommending adjuvant chemotherapy (AC) within 120 days of diagnosis. We examined adherence in a healthcare system serving a region with disparities in CC outcomes. METHODS In a retrospective analysis of patients (2005-2014) with stage III CC in a multi-hospital healthcare system, the associations between adherence, clinicopathologic, demographic, geographic, and socioeconomic data and overall survival (OS) were examined. RESULTS Of 1171 CC patients, 438 (37.4%) had stage III disease with 63% (n = 276) receiving AC and 37% (n = 162) not. AC conferred a 5-year OS advantage (62.4 vs. 42.5%, p < 0.0001). Younger age independently predicted AC receipt (OR = 0.95, p < 0.0001). Of 252 AC patients < 80 years, 75.8% were CoC guideline compliant (GC) whereas 24.2% were not (nGC). Although there was no OS difference between GC and nGC, both had superior survival (p < 0.0001) compared to non-AC patients. Surgical complications trended towards independent association with non-compliance (p = 0.07) CONCLUSION: Guideline compliance in our system (63%) is lower than the CoC Estimated Performance Rate (72.4%). Age influenced absolute receipt of AC while surgical complications may impact guideline compliance. Even when administered beyond 120 days, AC was associated with a survival benefit.
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18
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Keikes L, van Oijen MGH, Lemmens VEPP, Koopman M, Punt CJA. Evaluation of Guideline Adherence in Colorectal Cancer Treatment in The Netherlands: A Survey Among Medical Oncologists by the Dutch Colorectal Cancer Group. Clin Colorectal Cancer 2017; 17:58-64. [PMID: 29157662 DOI: 10.1016/j.clcc.2017.10.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 10/03/2017] [Accepted: 10/13/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Clinical guidelines are generated to preserve high-quality evidence-based care. Data on the implementation of guidelines into clinical practice are scarce, despite that guideline adherence prevents over- and undertreatment and correlates with survival. Therefore, we investigated guideline adherence for the systemic treatment in high-risk stage II and stage III colon cancer and metastatic colorectal cancer. PATIENTS AND METHODS In all Dutch hospitals (n = 88) 1 medical oncologist involved in colorectal cancer care was approached to participate. An online survey was conducted regarding the local standard of care for adjuvant chemotherapy in high-risk stage II and stage III colon cancer and first-line treatment regimens in metastatic colorectal cancer. Frequency tables were provided for categorical variables and compared for differences in guideline adherence according to hospital type (academic/teaching/regional). RESULTS The overall response rate was 70% (62 of 88). Reported guideline adherence was at least 60% of all presented settings. For high-risk stage II and stage III colon cancer, treatment strategies agreed with national guidelines in 66% and 84% of hospitals, and overtreatment patterns were identified in 28% and 13%, respectively. Targeted therapy was not routinely administered as first-line treatment in metastatic colorectal cancer (range from 63% to 71% in different settings). No differences in guideline adherence were observed among different hospital types. CONCLUSION Guideline adherence as reported by medical oncologists in The Netherlands is suboptimal. Possible explanations include unawareness or disagreement with the guidelines, or local financial restrictions. Our results recommend additional support of guideline implementation and monitoring in clinical practice, and investigating underlying causes in case of nonadherence.
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Affiliation(s)
- Lotte Keikes
- Cancer Center Amsterdam, Department of Medical Oncology, Academic Medical Center, Amsterdam, The Netherlands.
| | - Martijn G H van Oijen
- Cancer Center Amsterdam, Department of Medical Oncology, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Miriam Koopman
- Department of Medical Oncology, University Medical Center, Utrecht, The Netherlands
| | - Cornelis J A Punt
- Cancer Center Amsterdam, Department of Medical Oncology, Academic Medical Center, Amsterdam, The Netherlands
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19
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van den Broek CBM, Puylaert CCEM, Breugom AJ, Bastiaannet E, de Craen AJM, van de Velde CJH, Liefers GJ, Portielje JEA. Administration of adjuvant chemotherapy in older patients with Stage III colon cancer: an observational study. Colorectal Dis 2017; 19:O358-O364. [PMID: 28873267 DOI: 10.1111/codi.13876] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 07/31/2017] [Indexed: 02/08/2023]
Abstract
AIM According to established guidelines, patients with Stage III colon cancer should receive adjuvant chemotherapy. However, a significant proportion do not. This study assessed factors associated with the administration of adjuvant chemotherapy and causes of death. METHODS Patients with Stage III colon cancer who underwent surgery between 2000 and 2009 were selected from two hospitals in the Netherlands. Patient characteristics including comorbidities and treatment preferences, tumour characteristics and follow-up were extracted from the medical records. The patient and tumour characteristics of patients who did receive chemotherapy were compared with those who did not using chi-squared analysis. Differences between the groups in causes of death were recorded together with the duration of follow-up. RESULTS A total of 348 patients were included. The median age was 73 years (range 33-93). Over half of the patients received adjuvant chemotherapy (50.6%). Patients who did not receive adjuvant chemotherapy were significantly older (P < 0.001), had more comorbidities (P < 0.001) and were more often living alone (P < 0.001). Patients who received no adjuvant chemotherapy had a reduced overall survival, and the cause of death was more often attributed to other causes (60%) than colon cancer (40%). For patients who received chemotherapy, the cause of death was usually attributed to colon cancer (71%). CONCLUSION Patients who did not receive adjuvant chemotherapy had a worse overall survival and the majority died due to other causes than colon cancer. In our aging society it will become even more important to develop tools to estimate remaining life expectancy in order to improve the selection of older patients for adjuvant treatments.
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Affiliation(s)
- C B M van den Broek
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - C C E M Puylaert
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - A J Breugom
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - E Bastiaannet
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.,Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - A J M de Craen
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - C J H van de Velde
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - G-J Liefers
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - J E A Portielje
- Department of Clinical Oncology, HAGA Hospital, The Hague, The Netherlands
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Verhoeff SR, van Erning FN, Lemmens VEPP, de Wilt JHW, Pruijt JFM. Adjuvant chemotherapy is not associated with improved survival for all high-risk factors in stage II colon cancer. Int J Cancer 2016; 139:187-93. [PMID: 26914273 DOI: 10.1002/ijc.30053] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Accepted: 02/05/2016] [Indexed: 02/01/2023]
Abstract
Adjuvant chemotherapy can be considered in high-risk stage II colon cancer comprising pT4, poor/undifferentiated grade, vascular invasion, emergency surgery and/or <10 evaluated lymph nodes (LNs). Adjuvant chemotherapy administration and its effect on survival was evaluated for each known risk factor. All patients with high-risk stage II colon cancer who underwent resection and were diagnosed in the Netherlands between 2008 and 2012 were included. After stratification by risk factor(s) (vascular invasion could not be included), Cox regression was used to discriminate the independent association of adjuvant chemotherapy with the probability of death. Relative survival was used to estimate disease-specific survival. A total of 4,940 of 10,935 patients with stage II colon cancer were identified as high risk, of whom 790 (16%) patients received adjuvant chemotherapy. Patients with a pT4 received adjuvant chemotherapy more often (37%). Probability of death in pT4 patients receiving chemotherapy was lower compared to non-recipients (3-year overall survival 91% vs. 73%, HR 0.43, 95% CI 0.28-0.66). The relative excess risk (RER) of dying was also lower for pT4 patients receiving chemotherapy compared to non-recipients (3-year relative survival 94% vs. 85%, RER 0.36, 95% CI 0.17-0.74). For patients with only poor/undifferentiated grade, emergency surgery or <10 LNs evaluated, no association between receipt of adjuvant chemotherapy and survival was observed. In high-risk stage II colon cancer, adjuvant chemotherapy was associated with higher survival in pT4 only. To prevent unnecessary chemotherapy-induced toxicity, further refinement of patient subgroups within stage II colon cancer who could benefit from adjuvant chemotherapy seems indicated.
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Affiliation(s)
- S R Verhoeff
- Department of Internal Medicine, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - F N van Erning
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Eindhoven, The Netherlands.,Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - V E P P Lemmens
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Eindhoven, The Netherlands.,Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - J H W de Wilt
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - J F M Pruijt
- Department of Internal Medicine, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
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Joslin CE, Brewer KC, Davis FG, Hoskins K, Peterson CE, Pauls HA. The effect of neighborhood-level socioeconomic status on racial differences in ovarian cancer treatment in a population-based analysis in Chicago. Gynecol Oncol 2014; 135:285-91. [PMID: 25173584 PMCID: PMC4443897 DOI: 10.1016/j.ygyno.2014.08.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 08/20/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Less than half of women with ovarian cancer and blacks specifically receive therapy adherent to National Comprehensive Cancer Network (NCCN) guidelines. The purpose is to assess the effect of neighborhood-level socioeconomic status (SES) on black-white treatment differences in a population-based analysis in a highly-segregated community. METHODS Illinois State Cancer Registry data for invasive epithelial ovarian cancer cases diagnosed in Cook County, IL in non-Hispanic white (NHW) or black (NHB) women from 1998 to 2009 was analyzed. As few women receive NCCN-adherent care, variables were constructed to assess extent of treatment, including receipt of: 1) debulking surgery; 2) any surgery; 3) multi-agent chemotherapy; and 4) any chemotherapy. Two measures (concentrated affluence and disadvantage) were used to estimate neighborhood-level SES. Multivariable logistic regression was used to compute odds ratios (OR) and 95% confidence intervals (95% CI), with generalized linear mixed models to account for hierarchical data. RESULTS 2766 (81.0%) NHW and 647 (19.0%) NHB women were diagnosed. Adjusting for covariates, NHB were less likely to receive debulking surgery (OR: 0.39; 95% CI: 0.30-0.50), any surgery (OR: 0.38; 95%CI: 0.29-0.49), multi-agent chemotherapy (OR: 0.56; 95% CI: 0.45-0.71) and any chemotherapy (OR: 0.58; 95% CI: 0.45-0.74). Concentrated affluence but not disadvantage was significant in final models for multi-agent and any chemotherapy, but not debulking or any surgery. CONCLUSIONS Results identify black-white differences consistent across treatments that persist despite adjustment for neighborhood-level SES. IMPACT Results advance inequality awareness beyond "ideal" NCCN-adherent care, indicating inequality exists in delivery of even the most basic oncologic care.
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Affiliation(s)
- Charlotte E Joslin
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, United States; Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, United States; University of Illinois at Chicago Cancer Center, Cancer Control and Population Science Research Program, United States.
| | - Katherine C Brewer
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, United States
| | - Faith G Davis
- School of Public Health, University of Alberta, Canada
| | - Kent Hoskins
- University of Illinois at Chicago Cancer Center, Cancer Control and Population Science Research Program, United States; Department of Hematology/Oncology, University of Illinois at Chicago, United States
| | - Caryn E Peterson
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, United States
| | - Heather A Pauls
- Institute for Health Research and Policy (IHRP), University of Illinois at Chicago, United States
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van Erning FN, Bernards N, Creemers GJ, Vreugdenhil A, Lensen CJPA, Lemmens VEPP. Administration of adjuvant oxaliplatin to patients with stage III colon cancer is affected by age and hospital. Acta Oncol 2014; 53:975-80. [PMID: 24446744 DOI: 10.3109/0284186x.2013.878470] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Felice N van Erning
- Eindhoven Cancer Registry, Comprehensive Cancer Centre South , Eindhoven , The Netherlands
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Does patient age still affect receipt of adjuvant therapy for colorectal cancer in New South Wales, Australia? J Geriatr Oncol 2014; 5:323-30. [PMID: 24656735 DOI: 10.1016/j.jgo.2014.02.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 01/14/2014] [Accepted: 02/26/2014] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To investigate the effect of patient age on receipt of stage-appropriate adjuvant therapy for colorectal cancer in New South Wales, Australia. MATERIALS AND METHODS A linked population-based dataset was used to examine the records of 580 people with lymph node-positive colon cancer and 498 people with high-risk rectal cancer who underwent surgery following diagnosis in 2007/2008. Multilevel logistic regression models were used to determine whether age remained an independent predictor of adjuvant therapy utilisation after accounting for significant patient, surgeon and hospital characteristics. RESULTS Overall, 65-73% of eligible patients received chemotherapy and 42-53% received radiotherapy. Increasing age was strongly associated with decreasing likelihood of receiving chemotherapy for lymph node-positive colon cancer (p<0.001) and radiotherapy for high-risk rectal cancer (p=0.003), even after adjusting for confounders such as Charlson comorbidity score and ASA health status. People aged over 70years for chemotherapy and over 75years for radiotherapy were significantly less likely to receive treatment than those aged less than 65. Emergency resection, intensive care admission, and not having a current partner also independently predicted chemotherapy nonreceipt. Other predictors of radiotherapy nonreceipt included being female, not being discussed at multidisciplinary meeting, and lower T stage. Adjuvant therapy rates varied widely between hospitals where surgery was performed. CONCLUSION There are continuing age disparities in adjuvant therapy utilisation in NSW that are not explained by patients' comorbidities or health status. Further exploration of these complex treatment decisions is needed. Variation by hospital and patient characteristics indicates opportunities to improve patient care and outcomes.
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Chawla N, Butler EN, Lund J, Warren JL, Harlan LC, Yabroff KR. Patterns of colorectal cancer care in Europe, Australia, and New Zealand. J Natl Cancer Inst Monogr 2014; 2013:36-61. [PMID: 23962509 DOI: 10.1093/jncimonographs/lgt009] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Neetu Chawla
- Health Services and Economics Branch/Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Dr, Room 3E346, Rockville, MD 20852, USA
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The impact of organisational external peer review on colorectal cancer treatment and survival in the Netherlands. Br J Cancer 2014; 110:850-8. [PMID: 24423922 PMCID: PMC3929891 DOI: 10.1038/bjc.2013.814] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/19/2013] [Accepted: 12/09/2013] [Indexed: 01/07/2023] Open
Abstract
Background: Organisational external peer review was introduced in 1994 in the Netherlands to improve multidisciplinary cancer care. We examined the clinical impact of this programme on colorectal cancer care. Methods: Patients with primary colorectal cancer were included from 23 participating hospitals and 7 controls. Hospitals from the intervention group were dichotomised by their implementation proportion (IP) of the recommendations from each peer review (high IP vs low IP). Outcome measures were the introduction of new multidisciplinary therapies and survival. Results: In total, 45 705 patients were included (1990–2010). Patients from intervention hospitals more frequently received adjuvant chemotherapy for stage III colon cancer. T2–3/M0 rectal cancer patients from hospitals with a high IP had a higher chance of receiving preoperative radiotherapy (OR 1.31, 95% CI 1.11–1.55) compared with the controls and low IP group (OR 0.75, 95% CI 0.63–0.88). There were no differences in the use of preoperative chemoradiation for T4/M0 rectal cancer. Survival was slightly higher in colon cancer patients from intervention hospitals but unrelated to the phase of the programme in which the hospital was at the time of diagnosis. Conclusions: Some positive effects of external peer review on cancer care were found, but the results need to be interpreted cautiously due to the ambiguity of the outcomes and possible confounding factors.
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Søgaard M, Thomsen RW, Bossen KS, Sørensen HT, Nørgaard M. The impact of comorbidity on cancer survival: a review. Clin Epidemiol 2013; 5:3-29. [PMID: 24227920 PMCID: PMC3820483 DOI: 10.2147/clep.s47150] [Citation(s) in RCA: 385] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background A number of studies have shown poorer survival among cancer patients with comorbidity. Several mechanisms may underlie this finding. In this review we summarize the current literature on the association between patient comorbidity and cancer prognosis. Prognostic factors examined include tumor biology, diagnosis, treatment, clinical quality, and adherence. Methods All English-language articles published during 2002–2012 on the association between comorbidity and survival among patients with colon cancer, breast cancer, and lung cancer were identified from PubMed, MEDLINE and Embase. Titles and abstracts were reviewed to identify eligible studies and their main results were then extracted. Results Our search yielded more than 2,500 articles related to comorbidity and cancer, but few investigated the prognostic impact of comorbidity as a primary aim. Most studies found that cancer patients with comorbidity had poorer survival than those without comorbidity, with 5-year mortality hazard ratios ranging from 1.1 to 5.8. Few studies examined the influence of specific chronic conditions. In general, comorbidity does not appear to be associated with more aggressive types of cancer or other differences in tumor biology. Presence of specific severe comorbidities or psychiatric disorders were found to be associated with delayed cancer diagnosis in some studies, while chronic diseases requiring regular medical visits were associated with earlier cancer detection in others. Another finding was that patients with comorbidity do not receive standard cancer treatments such as surgery, chemotherapy, and radiation therapy as often as patients without comorbidity, and their chance of completing a course of cancer treatment is lower. Postoperative complications and mortality are higher in patients with comorbidity. It is unclear from the literature whether the apparent undertreatment reflects appropriate consideration of greater toxicity risk, poorer clinical quality, patient preferences, or poor adherence among patients with comorbidity. Conclusion Despite increasing recognition of the importance of comorbid illnesses among cancer patients, major challenges remain. Both treatment effectiveness and compliance appear compromised among cancer patients with comorbidity. Data on clinical quality is limited.
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Affiliation(s)
- Mette Søgaard
- Department of Clinical Epidemiology, Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
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van Erning FN, Creemers GJ, De Hingh IHJT, Loosveld OJL, Goey SH, Lemmens VEPP. Reduced risk of distant recurrence after adjuvant chemotherapy in patients with stage III colon cancer aged 75 years or older. Ann Oncol 2013; 24:2839-44. [PMID: 23933560 DOI: 10.1093/annonc/mdt334] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Little is known about the effects of adjuvant chemotherapy on the risk of distant recurrence in elderly with stage III colon cancer, treated in daily practice. PATIENTS AND METHODS One thousand two hundred and ninety-one stage III colon cancer patients diagnosed in the southern Netherlands between 2003 and 2008 were included. Propensity score matching was applied to create a subsample to reduce bias caused by differences between patients receiving adjuvant chemotherapy and patients not receiving adjuvant chemotherapy. For both the total study population and the propensity score matched sample, Cox regression analysis was used to discriminate independent risk factors for distant recurrence. RESULTS Adjuvant chemotherapy (CT) was correlated with a reduced risk of distant recurrence in both the total study population [hazard ratio (HR) CT versus nCT 0.55, 95% confidence interval (CI) 0.42-0.70] and in the propensity score matched sample (HR CT versus nCT 0.46, 95% CI 0.33-0.63). In separate analyses for patients aged <75 and ≥75 years, the effect of adjuvant chemotherapy on the risk of distant recurrence remained comparable for both age groups (HR CT versus nCT 0.50, 95% CI 0.37-0.68 and 0.57, 95% CI 0.36-0.90, respectively). CONCLUSION Distant recurrence risks at higher age definitely warrant consideration of adjuvant chemotherapy for elderly stage III colon cancer patients. This decision should be based on a multidisciplinary and functional assessment of the patient, not on age.
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Affiliation(s)
- F N van Erning
- Eindhoven Cancer Registry, Comprehensive Cancer Centre South, Eindhoven
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Cascinu S. Adjuvant chemotherapy in colon cancer: can we improve quality of care? Dig Liver Dis 2013; 45:637-8. [PMID: 23871099 DOI: 10.1016/j.dld.2013.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2013] [Accepted: 04/30/2013] [Indexed: 12/11/2022]
Affiliation(s)
- Stefano Cascinu
- Department of Medical Oncology and Center for Cancer Genetics, Università Politecnica delle Marche, Ancona, Italy.
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Mitry E, Rollot F, Jooste V, Guiu B, Lepage C, Ghiringhelli F, Faivre J, Bouvier AM. Improvement in survival of metastatic colorectal cancer: are the benefits of clinical trials reproduced in population-based studies? Eur J Cancer 2013; 49:2919-25. [PMID: 23642328 DOI: 10.1016/j.ejca.2013.04.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Revised: 03/29/2013] [Accepted: 04/01/2013] [Indexed: 11/16/2022]
Abstract
AIM OF THE STUDY To describe trends in survival of non-resectable metastatic colorectal cancer (MCRC) over a 34-year period in a French population-based registry taking into account major advances in medical therapy. PATIENTS AND METHODS 3804 patients with non-resectable metastatic colorectal cancer diagnosed between 1976 and 2009 were included. Three periods (1976-96, 1997-2004 and 2005-09) were considered. RESULTS The proportion of patients receiving chemotherapy dramatically increased from 19% to 57% between the first two periods, then increased steadily thereafter reaching 59% during the last period (p<0.001). Median relative survival increased from 5.9 months during the 1976-96 period to 10.2 months during the 1997-2004 period but, despite the availability of targeted therapies, remained at 9.5 months during the 2005-09 period. During the last study period, less than 10% of elderly patients received targeted therapies compared to more than 40% for younger patients. Their median relative survival was 5.0 months compared to 15.6 months in younger patients. CONCLUSION There was an improvement in survival in relation with the increased use of more effective medical treatment. However, at a population-based level, patients are not all treated equally and most of them, especially the elderly, do not benefit from the most up-to-date treatment options.
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Affiliation(s)
- E Mitry
- Institut Curie, Département d'Oncologie Médicale, 35 Rue Dailly, 92210 Saint-Cloud, France
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Hermosillo-Rodriguez J, Anaya DA, Sada Y, Walder A, Amspoker AB, Berger DH, Naik AD. The effect of age and comorbidity on patient-centered health outcomes in patients receiving adjuvant chemotherapy for colon cancer. J Geriatr Oncol 2013; 4:99-106. [PMID: 24071534 DOI: 10.1016/j.jgo.2012.12.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Revised: 09/28/2012] [Accepted: 12/02/2012] [Indexed: 12/29/2022]
Abstract
OBJECTIVES While the impact of age, comorbidity and receipt of adjuvant chemotherapy on survival are known, less is known about their effect on patient-centered outcomes including living situation and unplanned health care services. The current study describes the impact of age and comorbidity on patient-centered outcomes in patients with colon cancer. MATERIALS AND METHODS Patients with resected stage III colon cancer and high risk stage II colon cancer were identified from a colorectal cancer center database. Using data collected from chart abstraction, we describe unplanned health care utilization and trajectories of living situation (use of home health, skilled nursing facility, etc.) among high-risk stage II and III colon cancer patients with regard to age categories and receipt of adjuvant chemotherapy. RESULTS Among 126 eligible patients, 66% received adjuvant chemotherapy and 34% did not. Older patients receiving chemotherapy were more likely to be living independently (81%) compared to those older patients who did not receive chemotherapy (63%). Older patients receiving chemotherapy were less likely to be started on an oxaliplatin-containing regimen compared to younger patients (54% vs. 81%, p=0.02). On multivariate analysis, both diabetes mellitus (OR 3.70 [95% CI 1.3-10.2]) and chronic obstructive pulmonary disease (OR 4.26 [95% CI 1.1-16.0]) were significantly associated with unplanned health care service use. CONCLUSION Medical oncologists appear to factor clinical and sociodemographic variables when making recommendations for adjuvant chemotherapy. Older patients deemed eligible for chemotherapy did not experience significant changes in living situation. Among patients with colon cancer receiving adjuvant chemotherapy, diabetes mellitus and COPD are associated with emergency visits and hospital admissions.
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Hoeben KWJ, van Steenbergen LN, van de Wouw AJ, Rutten HJ, van Spronsen DJ, Janssen-Heijnen MLG. Treatment and complications in elderly stage III colon cancer patients in the Netherlands. Ann Oncol 2012; 24:974-9. [PMID: 23136227 DOI: 10.1093/annonc/mds576] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND We evaluated which patient factors were associated with treatment tolerance and outcome in elderly colon cancer patients. DESIGN Population-based data from five regions included in the Netherlands Cancer Registry were used. Patients with resected stage III colon cancer aged ≥75 years diagnosed in 1997-2004 who received adjuvant chemotherapy (N = 216) were included as well as a random sample (N = 341) of patients who only underwent surgery. RESULTS The most common motives for withholding adjuvant chemotherapy were a combination of high age, co-morbidity and poor performance status (PS, 43%) or refusal by the patient or family (17%). In 57% of patients receiving chemotherapy, adaptations were made in treatment regimens. Patients who received adjuvant chemotherapy developed more complications (52%) than those with surgery alone (41%). For the selection of patients who had survived the first year after surgery, receiving adjuvant chemotherapy resulted in better 5-year overall survival (52% versus 34%), even after adjustment for differences in age, co-morbidity and PS. CONCLUSION Despite high toxicity rates and adjustments in treatment regimens, elderly patients who received chemotherapy seemed to have a better survival. Prospective studies are needed for evaluating which patient characteristics predict the risks and benefits of adjuvant chemotherapy in elderly colon cancer patients.
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Affiliation(s)
- K W J Hoeben
- Department of Medical Oncology, VieCuri Medical Centre, Venlo, the Netherlands
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van Steenbergen LN, Lemmens VEPP, Rutten HJT, Wymenga ANM, Nortier JWR, Janssen-Heijnen MLG. Increased adjuvant treatment and improved survival in elderly stage III colon cancer patients in The Netherlands. Ann Oncol 2012; 23:2805-2811. [PMID: 22562836 DOI: 10.1093/annonc/mds102] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We determined to what extent patients with colon cancer stage III ≥ 75 years received adjuvant chemotherapy and the impact on overall and disease-specific survival. PATIENTS AND METHODS Data from The Netherlands Cancer Registry on all 8051 patients with colon cancer stage III ≥ 75 years diagnosed in 1997-2009 were included. Trends in adjuvant chemotherapy administration were analysed and multivariable overall and disease-specific survival analyses were performed. RESULTS The proportion of stage III colon cancer patients ≥ 75 years who received adjuvant chemotherapy increased from 12%in 1997-2000 to 23% in 2007-2009 (P < 0.0001), with a marked age gradient and large geographic variation. Five-year overall survival increased over time from 28% in 1997-2000 to 35% in 2004-2006 (P < 0.0001). Sixty percent of patients died of colorectal cancer. Adjuvant chemotherapy was the strongest positive predictor of survival in this retrospective study (hazard ratio = 0.5; 95% confidence interval: 0.4-0.5). CONCLUSION There has been an increase in administration of adjuvant chemotherapy to elderly patients with stage III colon cancer in The Netherlands since 1997. Survival of elderly patients with stage III colon cancer increased over time, at least partly due to stage migration. The large effect of adjuvant chemotherapy on survival in this study is likely to be associated with the selection of fitter patients for adjuvant treatment.
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Affiliation(s)
| | - V E P P Lemmens
- Eindhoven Cancer Registry, Comprehensive Cancer Centre South, Eindhoven; Department of Public Health, Erasmus University Medical Centre, Rotterdam
| | - H J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven
| | - A N M Wymenga
- Department of Internal Medicine, Medisch Spectrum Twente, Enschede
| | | | - M L G Janssen-Heijnen
- Eindhoven Cancer Registry, Comprehensive Cancer Centre South, Eindhoven; Department of Clinical Epidemiology, Viecuri Medical Centre, Venlo, The Netherlands
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Pharmacogenetics of oxaliplatin as adjuvant treatment in colon carcinoma: are single nucleotide polymorphisms in GSTP1, ERCC1, and ERCC2 good predictive markers? Mol Diagn Ther 2012; 15:277-83. [PMID: 21958378 DOI: 10.1007/bf03256419] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE Adjuvant chemotherapy improves survival in stage III colon cancer patients. However, a subgroup of patients still develops recurrent disease at some point in time, partly because of the ineffectiveness of the chemotherapy. Predictive markers of response are therefore crucial. Our aim was to study the predictive value of functional polymorphisms in genes involved in the metabolism of oxaliplatin and in DNA repair in stage III colon cancer patients. MATERIALS AND METHODS Normal DNA was isolated from 98 patients diagnosed with stage III colon carcinoma. Single nucleotide polymorphisms (SNPs) in three genes (the excision repair cross-complementing genes ERCC1 [19007T>C] and ERCC2 [2251A>C], and the glutathione S-transferase pi 1 gene [GSTP1 313A>G]) were tested by PCR followed by digestion with restriction enzymes or by direct sequencing. These genes and SNPs were selected on the basis of their reported associations with oxaliplatin response in colorectal cancer. RESULTS The genotype frequencies were in Hardy-Weinberg equilibrium. GSTP1 and ERCC2 polymorphisms were significantly associated with sex. The AA genotype of GSTP1 313A>G was more frequent in men than in women (59% vs 30%, p = 0.02), and the CC genotype of ERCC2 2251A>C was significantly more frequent in women than in men (24% vs 6%, p = 0.02). In univariate and multivariate survival analysis, none of the tested polymorphisms seemed to influence disease-free survival. The GSTP1 AA genotype had different effects on survival between men and women; homozygous A men had significantly worse cancer-specific survival and overall survival than women with the same genotype (log rank p = 0.029 and p = 0.015, respectively). CONCLUSION None of the tested polymorphisms is likely to be a reliable marker of response to oxaliplatin therapy. The GSTP1 313A>G homozygous A genotype may have a prognostic value in male patients.
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Fariña Sarasqueta A, van Lijnschoten G, Lemmens VEPP, Rutten HJT, van den Brule AJC. Pharmacogenetics of oxaliplatin as adjuvant treatment in colon carcinoma: are single nucleotide polymorphisms in GSTP1, ERCC1, and ERCC2 good predictive markers? Mol Diagn Ther 2012. [PMID: 21958378 DOI: 10.2165/11592080-000000000-00000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE Adjuvant chemotherapy improves survival in stage III colon cancer patients. However, a subgroup of patients still develops recurrent disease at some point in time, partly because of the ineffectiveness of the chemotherapy. Predictive markers of response are therefore crucial. Our aim was to study the predictive value of functional polymorphisms in genes involved in the metabolism of oxaliplatin and in DNA repair in stage III colon cancer patients. MATERIALS AND METHODS Normal DNA was isolated from 98 patients diagnosed with stage III colon carcinoma. Single nucleotide polymorphisms (SNPs) in three genes (the excision repair cross-complementing genes ERCC1 [19007T>C] and ERCC2 [2251A>C], and the glutathione S-transferase pi 1 gene [GSTP1 313A>G]) were tested by PCR followed by digestion with restriction enzymes or by direct sequencing. These genes and SNPs were selected on the basis of their reported associations with oxaliplatin response in colorectal cancer. RESULTS The genotype frequencies were in Hardy-Weinberg equilibrium. GSTP1 and ERCC2 polymorphisms were significantly associated with sex. The AA genotype of GSTP1 313A>G was more frequent in men than in women (59% vs 30%, p = 0.02), and the CC genotype of ERCC2 2251A>C was significantly more frequent in women than in men (24% vs 6%, p = 0.02). In univariate and multivariate survival analysis, none of the tested polymorphisms seemed to influence disease-free survival. The GSTP1 AA genotype had different effects on survival between men and women; homozygous A men had significantly worse cancer-specific survival and overall survival than women with the same genotype (log rank p = 0.029 and p = 0.015, respectively). CONCLUSION None of the tested polymorphisms is likely to be a reliable marker of response to oxaliplatin therapy. The GSTP1 313A>G homozygous A genotype may have a prognostic value in male patients.
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Lower treatment intensity and poorer survival in metastatic colorectal cancer patients who live alone. Br J Cancer 2012; 107:189-94. [PMID: 22576591 PMCID: PMC3389401 DOI: 10.1038/bjc.2012.186] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Socioeconomic status (SES) and social support influences cancer survival. If SES and social support affects cancer treatment has not been thoroughly explored. Methods: A cohort consisting of all patients who were initially diagnosed with or who developed metastatic colorectal cancer (mCRC, n=781) in three Scandinavian university hospitals from October 2003 to August 2006 was set up. Clinical and socioeconomic data were registered prospectively. Results: Patients living alone more often had synchronous metastases at presentation and were less often treated with combination chemotherapy than those cohabitating (HR 0.19, 95% CI 0.04–0.85, P=0.03). Surgical removal of metastases was less common in patients living alone (HR 0.29, 95% CI 0.10–0.86, P=0.02) but more common among university-educated patients (HR 2.22, 95% CI 1.10–4.49, P=0.02). Smoking, being married and having children did not influence treatment or survival. Median survival was 7.7 months in patients living alone and 11.7 months in patients living with someone (P<0.001). Living alone remained a prognostic factor for survival after correction for age and comorbidity. Conclusion: Patients living alone received less combination chemotherapy and less secondary surgery. Living alone is a strong independent risk factor for poor survival in mCRC.
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van Gils CWM, Koopman M, Mol L, Redekop WK, Uyl-de Groot CA, Punt CJA. Adjuvant chemotherapy in stage III colon cancer: guideline implementation, patterns of use and outcomes in daily practice in The Netherlands. Acta Oncol 2012; 51:57-64. [PMID: 22122695 DOI: 10.3109/0284186x.2011.633930] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Little is known about how well guidelines about adjuvant chemotherapy in colon cancer are followed in daily practice. We evaluated the current guideline, which is based on the MOSAIC trial, by examining implementation, treatment patterns and disease-free survival. MATERIAL AND METHODS We analysed a population-based cohort of 391 patients treated with adjuvant chemotherapy for stage III colon cancer in 2005-2006. Data were gathered from the Dutch Cancer Registry and medical records of 19 hospitals. Patients were classified according to whether or not they fulfilled MOSAIC trial eligibility criteria. RESULTS The administered regimens were: fluorouracil-leucovorin (17 patients), capecitabine (93), fluorouracil-leucovorin plus oxaliplatin (145), and capecitabine plus oxaliplatin (136). After its inclusion in national guidelines, oxaliplatin was prescribed in 16 hospitals within six months. Patients receiving oxaliplatin were younger and had less comorbidity than other patients. Dose schedules corresponded well with guidelines. Two-year disease-free survival probability of oxaliplatin patients meeting MOSAIC eligibility criteria was 78.4% (95% CI 72.5-84.3), which was comparable to MOSAIC trial results. CONCLUSION Guidelines for adjuvant chemotherapy in stage III colon cancer are generally well followed in daily practice. However, uncertainty remains regarding the optimal treatment of elderly patients and patients with comorbidities, which underscores the need for practical clinical trials including these patients.
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Affiliation(s)
- Chantal W M van Gils
- Institute for Medical Technology Assessment, Department of Health Policy and Management, Erasmus University Rotterdam, The Netherlands.
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Impact of chemotherapy on health status and symptom burden of colon cancer survivors: A population-based study. Eur J Cancer 2011; 47:1798-807. [DOI: 10.1016/j.ejca.2011.02.006] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Revised: 02/01/2011] [Accepted: 02/03/2011] [Indexed: 11/24/2022]
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Bibliography. Supportive care. Current world literature. Curr Opin Oncol 2011; 23:415-6. [PMID: 21654394 DOI: 10.1097/cco.0b013e328348d4f4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Elferink M, Wouters M, Krijnen P, Lemmens V, Jansen-Landheer M, van de Velde C, Siesling S, Tollenaar R. Disparities in quality of care for colon cancer between hospitals in the Netherlands. Eur J Surg Oncol 2010; 36 Suppl 1:S64-73. [DOI: 10.1016/j.ejso.2010.05.026] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Accepted: 05/27/2010] [Indexed: 02/06/2023] Open
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