Determining the Optimal Timing for Initiation of Adjuvant Chemotherapy After Resection for Stage II and III Colon Cancer

Return to Intended Oncological Therapy: State of the Art and Perspectives

PURPOSE OF THE REVIEW

Despite advances in surgical procedures, cancer recurrence still affects a substantial proportion of patients for whom surgery is considered a curative therapy. This review aims to provide a comprehensive overview of RIOT, addressing its definition, influencing factors, and clinical implications.

FINDINGS

RIOT can be defined as a continuous variable as the time from surgery to initiation of adjuvant therapies or categorically as whether patients can successfully receive adjuvant therapies or not. Factors influencing RIOT are age, sex, socioeconomic status, access to healthcare, physical performance and comorbidities, and quality of anesthesia and surgical care. Adjuvant therapies such as chemotherapy, radiotherapy, and immunotherapy are often administered to reduce the risk of recurrence after surgery and improve survival. Return to intended oncologic therapy (RIOT) has emerged as a promising outcome metric reflecting patients' functional recovery after surgery and their ability to receive adjuvant therapies.

Risk factors affecting delay of initiating adjuvant chemotherapy for stage III colorectal cancer

PURPOSE

Delay in initiating adjuvant chemotherapy (AC) after curative resection of colorectal cancer (CRC) has been reported to lead to poor prognosis, but few studies have looked at associated factors. This study aimed to identify risk factors for delay in initiating AC.

METHODS

Data from 200 consecutive patients who underwent curative resection and AC for stage III CRC between 2013 and 2018 were retrospectively collected and analyzed.

RESULTS

AC was initiated more than 8 weeks after surgery in 12.5% of patients (the delay group). Compared to those with no delay (the non-delay group), patients in the delay group had significantly higher rates of synchronous double cancers (2.3% vs. 16.0%, p = 0.001), preoperative bowel obstruction (10.3% vs. 32.0%, p = 0.003), laparotomy (56.0% vs. 80.0%, p = 0.02), concomitant resection (2.9% vs. 24.0%, p < 0.001), and postoperative complications (32.0% vs. 56.0%, p = 0.02), and a significantly longer length of hospital stay (median 12 vs. 30 days, p < 0.001). In multivariate analysis, synchronous double cancers (odds ratio 10.2, p = 0.008), preoperative bowel obstruction (odds ratio 4.6, p = 0.01), concomitant resection (odds ratio 5.2, p = 0.03), and postoperative complications of Clavien-Dindo grade ≥ IIIa (odds ratio 4.0, p = 0.03) were identified as independent risk factors for delay in initiating AC.

CONCLUSION

Careful preoperative treatment planning for CRC patients with synchronous double cancers, preoperative bowel obstruction, and concomitant resection, and management for postoperative complication are necessary to avoid delay in initiating AC.

Determining the optimal timing of adjuvant chemotherapy initiation after concurrent chemoradiotherapy in locoregionally advanced nasopharyngeal carcinoma

BACKGROUND

Studies on several malignancies have suggested that the time to commencement of adjuvant chemotherapy (AC) is associated with survival outcomes. There have, however, been no relevant reports of nasopharyngeal carcinoma (NPC).

PATIENTS AND METHODS

This clinical study examined newly diagnosed patients between April 2017 and December 2020. The primary endpoint was progression-free survival (PFS). Inverse probability of treatment weighting was used to control for confounding factors. Cox models with restricted cubic splines, Kaplan-Meier method and log-rank tests were used to evaluate the relationship between AC timing and survival.

RESULTS

A total of 551 patients were identified [median age, 45 years (interquartile range 36-52 years); 383 (69.5%) male]. Restricted cubic splines demonstrated that the timing of AC initiation had a U-shaped association with PFS. The risk of disease progression decreased within 37 days and subsequently increased. From 37 to 90 days, each additional 7-day delay conferred worse PFS of 1.32 months {hazard ratio (HR): 1.14 [95% confidence interval (CI) 1.01-1.28], P = 0.04}. The cut-off value of the receiver operating characteristic curve for initiation was 69.5 days. At a median follow-up of 48 months, the PFS was significantly better in patients initiated within 69.5 days [HR: 2.18 (95% CI 1.17-4.06), log-rank P = 0.009], with a higher 3-year rate [78.8% (95% CI 75.1% to 82.7%) versus 59.0% (95% CI 42.2% to 82.5%)] than beyond 69.5 days. Positive results were also observed in secondary endpoints. The initiation group was an independent prognostic factor [HR: 2.28 (95% CI 1.42-3.66), P < 0.001].

CONCLUSIONS

The optimal timing of AC initiation is ∼37 days after concurrent chemoradiotherapy in patients with locoregionally advanced nasopharyngeal carcinoma. A delay beyond 69.5 days is associated with compromised survival. Efforts should be made to address the reasons for delays and ensure the timely initiation of AC.

Return to intended oncologic therapy after colectomy for stage III colon adenocarcinoma: Does surgical approach matter?

AIM

Return to intended oncologic treatment (RIOT) is an important paradigm for surgically resected cancers requiring multimodal treatment. Benefits of minimally invasive colectomy (MIC) may allow earlier initiation of adjuvant chemotherapy (ACT) and have associated survival benefits. We sought to determine if operative approach affects RIOT timing in resected stage III colon cancer.

METHODS

NCDB identified pathological stage III colon adenocarcinoma patients who underwent resection and received ACT. Propensity score matching and kernel density estimation compared operative approaches and conversion impact on intervals to RIOT.

RESULTS

A total of 15,132 open colectomies (OC) versus 14,107 MIC were included. MIC patients had two-days shorter median length of stay (LOS) (4 vs. 6 days; p < 0.001), one-week shorter median time to RIOT (6 vs. 7 weeks; p = 0.015) comparing 12,867 matched pairs. There was no difference in time interval to RIOT between the LC versus RC, converted MIC vs. OC groups. MIC was a favourable predictor of earlier RIOT (HR 1.14 [1.07-1.22]; p < 0.001).

CONCLUSION

MIC in stage III colon cancer is associated with a shorter time to RIOT when compared to OC. Since timely initiation of ACT may influence cancer outcome, MIC may be oncologically preferable. Prospective studies are needed to assess RIOT and survival outcomes in stage III colon cancer.

The optimal time of starting adjuvant chemotherapy after curative surgery in patients with colorectal cancer

BACKGROUND

Postoperative adjuvant chemotherapy (AC) is now well-accepted as standard for high-risk stage II and stage III colorectal cancer (CRC) patients, however the optimal time to initiate AC remains elusive.

METHODS

A comprehensive literature search was performed using the PubMed and Embase databases. The Hazard ratio (HR) with the corresponding 95% confidence interval (CI) was used as an effect measure to evaluate primary endpoints. All analyses were conducted using Stata software version 12.0 with the Random-effects model.

RESULTS

A total of 30 studies were included in our study. Upon comparison on overall survival (OS), we identified that delaying the initiation of AC for > 8 weeks after operation was significantly associated with poor OS (HR: 1.37; 95% CI: 1.27-1.48; P < 0.01). The poor prognostic value of AC delay for > 8 weeks was not undermined by subgroup analysis based on region, tumor site, sample size and study quality. No obvious differences were observed in survival between AC within 5-8 weeks and ≤ 4 weeks (HR: 1.03; 95% CI: 0.96 -1.10; P = 0.46). Moreover, two studies both highlighted that the survival benefit of AC was still statistically significant when AC was applied 5-6 months after surgery compared with the non-chemotherapy group.

CONCLUSIONS

Delaying the initiation of AC for > 8 weeks after surgery was significantly associated with poor OS. AC started within 8 weeks after surgery brought more benefits to CRC patients. There were no obvious differences in survival benefits between AC within 5-8 weeks and ≤ 4 weeks. Compared to patients not receiving AC after surgery, a delay of approximately 5-6 months was still useful to improve prognosis.

Analysis of delay in adjuvant chemotherapy in locally advanced rectal cancer

BACKGROUND

Adjuvant chemotherapy (AC) after neoadjuvant chemoradiation and surgical resection has been the standard of care for locally advanced rectal cancer. However, there are no evidence-based guidelines regarding the optimal timing of AC for rectal cancer. The objective of this study was to evaluate the effect of AC timing on overall survival for rectal cancer.

METHODS

The National Cancer Database (NCDB) from 2004 to 2016 was queried for primary clinical stage II or III rectal cancer patients who had undergone neoadjuvant chemoradiation followed by surgery and AC. Patients were grouped based on AC initiation: early ≤ 4 weeks, intermediate 4-8 weeks, and delayed ≥ 8 weeks. The primary outcome was overall survival.

RESULTS

We identified 8722 patients, of which 905 (10.4%) received early AC, 4621 (53.0%) intermediate AC, and 3196 (36.6%) delayed AC. Pathological lymph-node metastasis (ypN +) was positive in 73% of early AC, 74% intermediate AC, and 63% delayed AC (p < 0.05). The 5-year survival probability was 71.1% (95% CI 68-74%) for early AC, 73.2% (95% CI 72-75%) intermediate AC, and 65.8% (95% CI 64-68%) delayed AC (p < 0.001). Using Cox proportional hazard modeling, patients undergoing delayed AC had an associated decreased survival compared to patients receiving early AC (HR 1.18; 95% CI 1.028-1.353, p = 0.018) or intermediate AC (HR 1.28; 95% CI 1.179-1.395, p < 0.01).

CONCLUSIONS

Delay in AC administration may be associated with decreased 5-year survival. Compared to early or intermediate AC, patients in the delayed AC group were observed to have increased risk of death, despite having lower proportions with ypN + disease. Patients with higher socioeconomic and education status were more likely to receive early chemotherapy.

Diverting ileostomy is a risk factor for renal impairment during CAPOX therapy

PURPOSE

Temporary ileostomy is sometimes created after colorectal surgery and may cause renal impairment. However, the impact of ileostomy on renal function during adjuvant chemotherapy for colorectal cancer (CRC) remains unknown. The aim of the present study was to examine the effects of ileostomy on renal function during adjuvant chemotherapy.

METHODS

We examined 184 patients who received adjuvant CAPOX therapy (capecitabine and oxaliplatin) for CRC with or without ileostomy between January 2011 and December 2020 at the University of Tokyo Hospital. Clinicopathological factors, including renal function, were retrospectively reviewed in association with temporary ileostomy. Factors associated with reductions in the estimated glomerular filtration rate (eGFR) during CAPOX therapy were analyzed.

RESULTS

Eighteen patients (10%) underwent temporary ileostomy. The maximum decrease in eGFR during CAPOX therapy was significantly higher in patients with than in those without ileostomy (- 16.1 vs. - 5.6 mL/min/1.73m², p = 0.003). A multivariate analysis identified ileostomy as one of factors independently associated with reductions in eGFR during CAPOX therapy (p = 0.003). The cumulative number of readmission due to dehydration was also higher in patients with ileostomy (33% vs. 1%, p < 0.001).

CONCLUSIONS

Ileostomy significantly reduced eGFR during adjuvant CAPOX therapy. Therefore, renal function needs to be monitored during CAPOX therapy, particularly in patients with ileostomy.

Influence of Adjuvant Radiotherapy Timing on Survival Outcomes in High-Risk Patients Receiving Neoadjuvant Treatments

Purpose

To determine the relationship between time to radiotherapy (TTR) and survival outcomes in breast cancer (BC) patients treated with neoadjuvant treatments (NATs).

Methods

Continuous non-metastatic BC patients receiving NAT and adjuvant radiotherapy (RT) from 2009 to 2016 were retrospectively reviewed. A multivariable Cox model with restricted cubic splines (RCSs) was used to determine the panoramic relationship between TTR and survival outcomes. Multivariable analysis was used to control for confounding factors between the groups of TTR.

Results

A total of 315 patients were included. The RCS modeling demonstrated a non-linear relationship between TTR and survival outcomes. The lowest risk for distant metastasis-free survival (DMFS) and recurrence-free survival (RFS) was observed at the TTR of 12 weeks, and the lowest risk of BC-specific survival (BCSS) at 10 weeks. TTR was accordingly transformed into categorical variables as ≤10, 11–20, and &gt;20 weeks. Multivariable analysis revealed that the TTR of ≤10 weeks was an independent prognostic factor for worse DMFS (HR = 2.294, 95% CI 1.079–4.881) and RFS (HR = 2.126, 95% CI 1.038–4.356) compared with the TTR of 10–20 weeks, while the is no difference in DMFS, RFS, and BCSS between TTR &gt;20 weeks and TTR of 10–20 weeks.

Conclusion

There exists a non-linear relationship between TTR after surgery and survival outcomes in patients treated with NAT. Early initiation of RT following surgery does not seem to be associated with a better therapeutic outcome. A relatively flexible recommendation of TTR could be adopted in clinical practice.

Clinical Significance of Early Carcinoembryonic Antigen Change in Patients With Nonmetastatic Colorectal Cancer

Background

This study aimed to evaluate the prognostic significance of preoperative, postoperative, and trajectory changes in carcinoembryonic antigen (CEA) levels in patients with colorectal cancer (CRC).

Methods

This retrospective study included patients who underwent surgical resection for nonmetastatic CRC. The optimal cutoff values of preoperative CEA (CEA-pre), early postoperative CEA (CEA-post), and CEA level change (CEA-delta) were determined to maximize the differences in overall survival (OS) among groups. The patients were divided into three groups according to CEA-trend: normal, low CEA-pre; normalized, high CEA-pre/low CEA-post; elevated, high CEA-pre/high CEA-post. The integrated area under the curve (iAUC) was used to compare the discriminatory power of all variables.

Results

A total of 1019 patients diagnosed with stage I–III CRC were enrolled. The optimal cutoff values of CEA level were determined as 2.3 ng/mL for CEA-pre, 2.3 ng/mL for CEA-post, and -0.93 ng/mL for CEA-delta. Although subgroup dichotomization showed that CEA-pre, CEA-post, CEA-delta, and CEA-trend were all associated with OS in univariate analysis, CEA-trend was the only independent prognostic factor in multivariate analysis. The iAUC of CEA-trend was superior to that of CEA-pre, CEA-post, and CEA-delta. Compared with the normal group, the normalized group showed worse OS (p=.0007) in stage II patients but similar OS (p=.067) in stage III patients.

Conclusion

The optimal cutoff value of CEA level in the preoperative and postoperative periods was determined to be 2.3 ng/mL, and the combination of CEA-pre and CEA-post showed better prognostic stratification. However, its prognostic significance may differ depending on the CRC stage.

Response prediction and risk stratification of patients with rectal cancer after neoadjuvant therapy through an analysis of circulating tumour DNA

Background

Multiple approaches based on cell-free DNA (cfDNA) have been applied to detect minimal residual disease (MRD) and to predict prognosis or recurrence. However, a comparison of the approaches used in different cohorts and studies is difficult. We aimed to compare multiple approaches for MRD analysis after neoadjuvant therapy (NAT) in patients with locally advanced rectal cancer (LARC).

Methods

Sixty patients with LARC from a multicentre, phase II/III randomized trial were included, with tissue and blood samples collected. For each cfDNA sample, we profiled MRD using 3 approaches: personalized assay targeting tumour-informed mutations, universal panel of genes frequently mutated in colorectal cancer (CRC), and low depth sequencing for copy number alterations (CNAs).

Findings

Positive MRD based on post-NAT personalized assay was significantly associated with an increased risk of recurrence (HR = 27.38; log-rank P < 0.0001). MRD analysis based on universal panel (HR = 5.18; log-rank P = 0.00086) and CNAs analysis (HR = 9.24; log-rank P = 0.00017) showed a compromised performance in predicting recurrence. Both the personalized assay and universal panel showed complementary pattern to CNAs analysis in detecting cases with recurrence and the combination of the two types of biomarkers may lead to better performance.

Interpretation

The combination of mutation profiling and CNA profiling can improve the detection of MRD, which may help optimize the treatment strategies for patients with LARC.

Simulating the Dynamic Intra-Tumor Heterogeneity and Therapeutic Responses

A tumor is a complex tissue comprised of heterogeneous cell subpopulations which exhibit substantial diversity at morphological, genetic and epigenetic levels. Under the selective pressure of cancer therapies, a minor treatment-resistant subpopulation could survive and repopulate. Therefore, the intra-tumor heterogeneity is recognized as a major obstacle to effective treatment. In this paper, we propose a stochastic clonal expansion model to simulate the dynamic evolution of tumor subpopulations and the therapeutic effect at different times during tumor progression. The model is incorporated in the CES webserver, for the convenience of simulation according to initial user input. Based on this model, we investigate the influence of various factors on tumor progression and treatment consequences and present conclusions drawn from observations, highlighting the importance of treatment timing. The model provides an intuitive illustration to deepen the understanding of temporal intra-tumor heterogeneity dynamics and treatment responses, thus helping the improvement of personalized diagnostic and therapeutic strategies.

Are patients living far from hospital at higher risk of late adjuvant chemotherapy for colon cancer?

INTRODUCTION

Late adjuvant chemotherapy (aCT) administration after colectomy (> 56 days) is known to be associated with impaired prognosis. We aim to identify risk factors associated with late aCT, especially the travel time between patients' home and hospital.

METHOD

We performed a retrospective monocentre cohort study. Patients included had a colectomy for a stage III or "high risk" stage II colon cancer between 2009 and 2015 performed at a French university hospital. Risk factors for late aCT were identified using a fractional polynomial logistic regression.

RESULTS

Ninety-four patients were included. The risk of late aCT was associated with travel time length, emergent colectomy, the need for scheduled care before aCT, and length of time between colectomy and postoperative multidisciplinary meeting advising aCT.

CONCLUSION

Our study suggests that, in patients with colon cancer, factors unrelated to disease severity and complexity could be associated with a higher risk of late aCT.

Strengths and Limitations of Registries in Surgical Oncology Research

Over the past two decades, there has been a dramatic increase in studies based on large multi-institutional tumor registries. Applications of such databases span various research themes including epidemiology, oncology, surgical techniques, perioperative outcomes, and prognosis. Although these databases are acquired relatively easily, offer larger sample sizes and improved generalizability compared with institutional data, acknowledging limitations within analysis and cautious interpretation of data is important. Questionable conclusions can result when insufficient attention is paid to issues such as data quality and depth, potential sources of bias and missing data. This article reviews research themes and important limitations of these databases. The contemporary reporting of these issues in the literature and an increased awareness among surgical oncologists of potential applications and limitations will ensure that studies in the surgical oncology literature achieve high standards of methodological quality and clinical utility.

Anesthesia Medications and Interaction with Chemotherapeutic Agents

Cancer is now a leading health concern worldwide. In an effort to provide these patients with adequate care, coordination between anesthesiologists and surgeons is crucial. In cancer-related treatment, it is very clear that radio-chemotherapy and medical procedures are important. There are some obstacles to anesthesia when dealing with cancer treatment, such as physiological disturbances, tumor-related symptoms, and toxicity in traditional chemotherapy treatment. Therefore, it is important that a multisystemic, multidisciplinary and patient-centered approach is used to preserve perioperative homeostasis and immune function integrity. Adding adjuvants can help increase patient safety and satisfaction and improve clinical efficacy. Correctly paired anesthetic procedures and medications will reduce perioperative inflammatory and immune changes that could potentially contribute to improved results for future cancer patients. Further research into best practice strategies is required which will help to enhance the acute and long-term effects of cancer care in clinical practice.

A Single Institution Propensity Score Weighted Analysis of Time to Chemotherapy After Minimally Invasive Versus Open Colorectal Surgery

BACKGROUND

Oncologic outcomes for colon cancer are optimal when chemotherapy is started within 6 to 8 weeks after surgery. The study objective was to investigate the impact of operative modality and urgency on the time interval from surgery to adjuvant chemotherapy.

METHODS

This is a retrospective institutional tumor registry cohort study of open and laparoscopic/robotic colorectal resections for stage II-IV cancer between April 2010 and January 2018. Primary outcome was time from surgery to chemotherapy. Predictor variables were adjusted for imbalances by propensity score weighting.

RESULTS

A total of 220 patients met inclusion criteria: 171 elective (108 laparoscopic/robotic and 63 open) and 49 urgent colectomies. After propensity score weighting, there was no significant difference in time to chemotherapy between elective minimally invasive and open surgical approaches (48 days vs. 58 days, P = .187). Only 68.9% of minimally invasive and 50.8% of open colectomy patients started chemotherapy within 8 weeks of surgery. There was a significant difference (P = .037) among surgical sites with rectal resections having the longest (55 days), and right colectomies having the shortest (46 days), time to chemotherapy. Patients who had urgent operations had significantly longer hospital length of stay (P < .001) and higher post-discharge emergency department visit rates (P < .001) than the elective operation group. However, there was no significant difference in time to chemotherapy.

DISCUSSION

Neither operative modality nor operative urgency resulted in a significant difference in postoperative time to initiating chemotherapy. Future efforts should be focused on identifying postoperative recovery criteria and optimum multidisciplinary communication methods that allow recovered patients to start chemotherapy sooner.

Net survival for colorectal cancer in Cuiabá and Várzea Grande (state of Mato Grosso), Brazil

In studies of cancer survival, Population-Based Cancer Registries (PBCRs) can provide an overview of the disease for places that have this source of information available. In Brazil, PBCR is officially available in 22 state capitals and 8 cities in the interior of the country. PBCR data from Cuiabá and Várzea Grande, state of Mato Grosso, in Midwestern Brazil, were used to estimate the survival rate of colon (C18), rectosigmoid junction (C19) and rectum (C20) cancer cases diagnosed in 2000-2009 according to the International Classification of Diseases, 10th Revision. Five-year survival rate was estimated by the unbiased and consistent net survival estimator, which is used in the country estimates of the global surveillance of cancer survival programme CONCORD Group, for all cases, and also by sex, age group, diagnosis period and place of residence. The probability of death and the number of years of life lost to illness were also estimated. The estimated standardised 5-year survival rate for colorectal cancer was 45.46% (95% CI: 43.09%-47.96%) in the cities of Cuiabá and Várzea Grande. There was no difference between the curves when the survival rate was assessed by diagnostic period (2000-2004 and 2005-2009), sex, age group or city of residence. The gross 5-year probability of death from the disease was 51.2%, accounting for 6.4% of the gross probability of death from other causes, with 2.07 being the years of life lost to illness. The results obtained for Cuiabá and Várzea Grande are compatible with survival rates estimated for Brazil in the CONCORD study, but demonstrate the need to identify reasons why we continue to have low survival rates when compared to most countries involved in the global study mentioned. The results may reflect late diagnosis, difficult access and delays in starting treatment.

Assessment of Cancer Center Variation in Textbook Oncologic Outcomes Following Colectomy for Adenocarcinoma

BACKGROUND

Traditional metrics may inadequately represent rates of attaining optimal oncologic care. We evaluated a composite "textbook oncologic outcome" (TOO) to assess the incidence of achieving an "optimal" clinical result after colon adenocarcinoma (CA) resection.

METHODS

The National Cancer Database (NCDB) was queried to identify patients undergoing colectomy for non-metastatic CA between 2010 and 2015. TOO was defined as a margin negative resection with an AJCC compliant lymph node evaluation, no prolonged length of stay (LOS) or 30-day readmission/mortality, as well as receipt of stage appropriate adjuvant chemotherapy.

RESULTS

Among 170,120 patients who underwent colectomy at 1315 hospitals, 93,204 (54.8%) achieved TOO with large variations observed among facilities. While certain factors were achieved nearly universally (R0 margin, 95.6%; no 30-day mortality, 97.2%), avoidance of prolonged LOS (77.3%) and appropriate adjuvant chemotherapy (83.0%) were achieved less consistently. On multivariable analysis, Black race/ethnicity (OR 0.82, 95% CI 0.80-0.85), Medicaid insurance (OR 0.64, 0.61-0.68), and low-volume facility (< 50/year) (OR 0.83, 0.77-0.89) were associated with decreased likelihood of TOO. Achievement of TOO was associated with improved long-term survival (HR 0.45; 95% CI 0.44-0.46).

CONCLUSIONS

Roughly one-half of patients undergoing resection of CA achieved an optimal clinical outcome. TOO may be a more useful quality metric to assess patient-centric composite outcomes following surgical procedures.

High level of unmet needs and anxiety are associated with delayed initiation of adjuvant chemotherapy for colorectal cancer patients

AIMS

Adjuvant chemotherapy is recommended for patients with curatively resected colorectal cancer. The aim of this study is to evaluate the impact of unmet supportive care needs and anxiety on the initiation of postoperative adjuvant chemotherapy in colorectal cancer patients.

METHODS

This is a retrospective study from a single tertiary referral hospital. Patients diagnosed with colorectal cancer who met the inclusion criteria were included. The Hospital Anxiety and Depression Scale (HADS) and modified 34-item Supportive Care Needs Survey (SCNS-SF34) were applied to assess patient's anxiety level and unmet needs. The time intervals between initiation of adjuvant chemotherapy and operation were recorded. Factors associated with delayed initiation of chemotherapy were investigated in univariate and multivariate analysis.

RESULTS

A total of 135 patients with colorectal cancer were included. In total, 16.3% (22/135) and 5.2% (7/135) reported symptoms of anxiety and depression. In multivariate analysis, low to moderate income status, postoperative complications, anxiety, and high level of unmet needs are independent risk factors for late initiation of chemotherapy.

CONCLUSIONS

Our findings showed that psychological problems such as anxiety and high unmet supportive needs are correlated with delayed initiation of adjuvant chemotherapy in colorectal cancer patients.

Prognostic significance of postsurgery circulating tumor DNA in nonmetastatic colorectal cancer: Individual patient pooled analysis of three cohort studies

Studies in multiple solid tumor types have demonstrated the prognostic significance of ctDNA analysis after curative intent surgery. A combined analysis of data across completed studies could further our understanding of circulating tumor DNA (ctDNA) as a prognostic marker and inform future trial design. We combined individual patient data from three independent cohort studies of nonmetastatic colorectal cancer (CRC). Plasma samples were collected 4 to 10 weeks after surgery. Mutations in ctDNA were assayed using a massively parallel sequencing technique called SafeSeqS. We analyzed 485 CRC patients (230 Stage II colon, 96 Stage III colon, and 159 locally advanced rectum). ctDNA was detected after surgery in 59 (12%) patients overall (11.0%, 12.5% and 13.8% for samples taken at 4-6, 6-8 and 8-10 weeks; P = .740). ctDNA detection was associated with poorer 5-year recurrence-free (38.6% vs 85.5%; P < .001) and overall survival (64.6% vs 89.4%; P < .001). The predictive accuracy of postsurgery ctDNA for recurrence was higher than that of individual clinicopathologic risk features. Recurrence risk increased exponentially with increasing ctDNA mutant allele frequency (MAF) (hazard ratio, 1.2, 2.5 and 5.8 for MAF of 0.1%, 0.5% and 1%). Postsurgery ctDNA was detected in 3 of 20 (15%) patients with locoregional and 27 of 60 (45%) with distant recurrence (P = .018). This analysis demonstrates a consistent long-term impact of ctDNA as a prognostic marker across nonmetastatic CRC, where ctDNA outperforms other clinicopathologic risk factors and MAF further stratifies recurrence risk. ctDNA is a better predictor of distant vs locoregional recurrence.

Adjuvant Chemotherapy in Elderly Colorectal Cancer Patients

The value of adjuvant chemotherapy in elderly patients has been the subject of many overviews, with opinions varying from “not effective”, since randomized trials have not been performed, to “as effective as in young individuals”, based upon many retrospective analyses of randomized trials that have included patients of all ages. In the absence of randomized trials performed specifically with elderly patients, retrospective analyses demonstrate that the influence on the time to tumour recurrence (TTR) may be the same as in young individuals, but that endpoints that include death for any reason, such as recurrence-free survival (RFS), disease-free survival (DFS), and overall survival (OS), are poorer in the elderly. This is particularly true if oxaliplatin has been part of the treatment. The need for adjuvant chemotherapy after colorectal cancer surgery in elderly patients is basically the same as that in younger patients. The reduction in recurrence risks may be similar, provided the chosen treatment is tolerated but survival gains are less. Adding oxaliplatin to a fluoropyrimidine is probably not beneficial in individuals above a biological age of approximately 70 years. If an oxaliplatin combination is administered to elderly patients, three months of therapy is in all probability the most realistic goal.

Laparoscopic staged colon-first resection for metastatic colorectal cancer: Perioperative and midterm outcomes from a single-center experience

INTRODUCTION

The present study aimed to evaluate the short- and mid-term outcomes of laparoscopic colon-first staged resection for colorectal cancer (CRC) and colorectal cancer liver metastases (CRCLM).

METHODS

This study included patients with metastatic CRC who underwent laparoscopic surgical staged resection for the primary tumor and CRCLM between June 2013 and December 2018. Data collection included the baseline patient's and tumor features, the perioperative and histopathologic outcomes from both surgical procedures, and the oncologic follow-up.

RESULTS

Twenty-five patients were eligible for the study. Three major and 22 minor laparoscopic liver resections were performed following laparoscopic CRC surgery. Five patients required conversion to laparotomy during CRCLM resection, but no conversion was needed for the colorectal procedures. The rate of severe intraoperative complications (CLASSIC grade III-IV) was 8% and 16% during CRC and CRCLM resection, respectively. Three patients (12%) developed major postoperative complications (Clavien-Dindo grade > III) after both interventions, including one death due to intraoperative bleeding. During a median follow-up of 30 months, 15 patients were diagnosed with disease recurrence. The 3-year disease-free survival and overall survival were 33.3% and 73.9%, respectively.

CONCLUSIONS

Laparoscopic staged resection for CRC and CRCLM is safe, feasible, and offers acceptable midterm oncological outcomes in patients with metastatic colorectal cancer.

Influence of donor brain death duration on outcomes following heart transplantation: A United Network for Organ Sharing Registry analysis

OBJECTIVES

We hypothesized that an increased duration of donor brain death may worsen survival following orthotopic heart transplantation.

METHODS

The United Network for Organ Sharing Registry was queried for first-time, adult recipients of heart transplant from 2006 to 2018. Cox proportional hazards with penalized smooth splines was used to stratify patients based on donor brain death interval: shorter (<22 hours), reference (22-42 hours), and longer (>42 hours). Overall survival was estimated using Kaplan-Meier and Cox proportional hazards models.

RESULTS

A total of 22,960 patients met study criteria (9.2% shorter, 55.0% reference, and 35.8% longer). Longer brain death duration recipients were more likely to have a later year of transplant and have a mechanical bridge to transplant, whereas longer duration donors were more likely to be black and die of anoxia compared with shorter duration and reference donors. Compared with reference, neither shorter (hazard ratio, 1.02; 95% confidence interval, 0.94-1.12) nor longer donor brain death interval (hazard ratio, 1.01; 95% CI, 0.94-1.08) was associated with posttransplant survival in either unadjusted or multivariable analyses (both P values >0.6).

CONCLUSIONS

Longer duration of brain death was not associated with worse survival following heart transplantation. Donors with prolonged interval of brain death should not necessarily be excluded based on brain death period alone.

Reporting colon cancer staging using a template

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Template reporting increases key colon tumour descriptors.

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Template reporting was used for less than a third of the patients.

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High risk of underreporting.

Purpose

The purpose of this study was to evaluate the effect of completeness of the radiological reports in primary local staging colon cancer when using a template.

Methods

The study used primary staging reports retrieved from the departments RIS/PACS. Five key tumour descriptors were evaluated within each report: tumour morphology (polypoid or annular), information on tumour breach of the colon wall (≥ T3), tumour out-growth in mm, nodal status and TNM in conclusion. The failure to provide a description of the presence or absence of a feature in a report counted as ‘not reported’. To allow comparisons between reporting styles, the template or free-text style of reporting was also recorded.

Results

During a two year period, a total of 666 patients CT reports were evaluated at the colorectal center multidisciplinary team (MDT) conference. In 200 of these reports a template was used. Information on tumour morphology (polypoid or annular) was present in 81% of the template reports vs 9% in free-text style. The figures in percentage for information on tumour breach of the colon wall (≥ T3) were 93% vs 48 %, tumour out-growth in mm: 51% vs 17%, nodal status: 99% vs 86% and TNM in conclusion: 98% vs 51%. P < 0.0001.

Conclusion

The present study provides additional support for the routine use of template reports to improve imaging reporting standards in colonic cancer.

Association of the Addition of Oral Antibiotics to Mechanical Bowel Preparation for Left Colon and Rectal Cancer Resections With Reduction of Surgical Site Infections

Importance

Surgical site infections (SSIs) after colorectal surgery remain a significant complication, particularly for patients with cancer, because they can delay the administration of adjuvant therapy. A combination of oral antibiotics and mechanical bowel preparation (MBP) is a potential, yet controversial, SSI prevention strategy.

Objective

To determine the association of the addition of oral antibiotics to MBP with preventing SSIs in left colon and rectal cancer resections and its association with the timely administration of adjuvant therapy.

Design, Setting, and Participants

A retrospective review was performed of 89 patients undergoing left colon and rectal cancer resections from October 1, 2013, to December 31, 2016, at a single institution. A bowel regimen of oral antibiotics and MBP (neomycin sulfate, metronidazole hydrochloride, and magnesium citrate) was implemented August 1, 2015. Patients receiving MBP and oral antibiotics and those undergoing MBP without oral antibiotics were compared using univariate analysis. Multivariable logistic regression controlling for factors that may affect SSIs was used to evaluate the association between use of oral antibiotics and MBP and the occurrence of SSIs.

Main Outcomes and Measures

Surgical site infections within 30 days of the index procedure and time to adjuvant therapy.

Results

Of the 89 patients (5 women and 84 men; mean [SD] age, 65.3 [9.2] years) in the study, 49 underwent surgery with MBP but without oral antibiotics and 40 underwent surgery with MBP and oral antibiotics. The patients who received oral antibiotics and MBP were younger than those who received only MBP (mean [SD] age, 62.6 [9.1] vs 67.5 [8.8] years; P = .01), but these 2 cohorts of patients were otherwise similar in baseline demographic, clinical, and cancer characteristics. Surgical approach (minimally invasive vs open) and case type were similarly distributed; however, the median operative time of patients who received oral antibiotics and MBP was longer than that of patients who received MBP only (391 minutes [interquartile range, 302-550 minutes] vs 348 minutes [interquartile range, 248-425 minutes]; P = .03). The overall SSI rate was lower for patients who received oral antibiotics and MBP than for patients who received MBP only (3 [8%] vs 13 [27%]; P = .03), with no deep or organ space SSIs or anastomotic leaks in patients who received oral antibiotics and MBP compared with 9 organ space SSIs (18%; P = .004) and 5 anastomotic leaks (10%; P = .06) in patients who received MBP only. Despite this finding, there was no difference in median days to adjuvant therapy between the 2 cohorts (60 days [interquartile range, 46-73 days] for patients who received MBP only vs 72 days [interquartile range, 59-85 days] for patients who received oral antibiotics and MBP; P = .13). Oral antibiotics and MBP (odds ratio, 0.11; 95% CI, 0.02-0.86; P = .04) and minimally invasive surgery (odds ratio, 0.22; 95% CI, 0.05-0.89; P = .03) were independently associated with reduced odds of SSIs.

Conclusions and Relevance

The combination of oral antibiotics and MBP is associated with a significant decrease in the rate of SSIs and should be considered for patients undergoing elective left colon and rectal cancer resections.

Impact of Donor Brain Death Duration on Outcomes After Lung Transplantation

BACKGROUND

Donor brain death duration (BDD) may impact posttransplant graft function and survival in lung transplant.

METHODS

We queried the 2007 to 2018 United Network for Organ Sharing Registry for adult recipients undergoing first-time isolated lung transplant. Cox proportional hazard modeling with splines enabled identification of 3 donor brain death intervals for subsequent analysis: short (<24 hours), reference (24-60 hours), and long (>60 hours). The primary outcome was posttransplant survival.

RESULTS

In total, 19,721 donors and recipients met inclusion criteria. Median time from donor brain death until cross-clamp was 36.6 hours (interquartile range, 19.5). Unadjusted overall survival between cohorts was equivalent (log-rank P = .42); however, longer BDD was associated with improved bronchiolitis obliterans syndrome (BOS)-free survival (log-rank P < .001). On multivariable Cox proportional hazards regression, BDD was not associated with recipient survival (P > .05). Similarly, logistic regression did not identify an independent association between BDD and primary graft dysfunction (P > .05). Increased BDD was, however, associated with a decreased risk of acute rejection (long vs reference; adjusted odds ratio, 0.78; 95% confidence interval, 0.64-0.94) and improved BOS-free survival (long vs reference; adjusted hazard ratio, 0.88; 95% confidence interval, 0.81-0.96).

CONCLUSIONS

Donor BDD is not associated with posttransplant survival or primary graft dysfunction. Long donor BDD, however, is associated with a decreased risk for acute rejection and improved BOS-free survival. Therefore, lung allografts from donors with a prolonged length of time from brain death until explant should not be viewed less favorably by donor selection centers.

Timing of Adjuvant Chemotherapy and Survival in Colorectal, Gastric, and Pancreatic Cancer. A Systematic Review and Meta-Analysis

(1) Background: The optimal timing of adjuvant chemotherapy (CT) in gastrointestinal malignancies is still a matter of debate. For colorectal cancer, it is recommended to start post-operative treatment within eight weeks. The objective of this study was to assess the clinical effects of starting adjuvant CT within or after 6–8 weeks post-surgery in colorectal, gastric, and pancreatic cancer. (2) Methods: MEDLINE, EMBASE, and the Cochrane Library were searched in December 2018. Publications comparing the outcomes of patients treated with adjuvant CT administered before (early) or after (delayed) 6–8 weeks post-surgery for colorectal, gastric, and pancreatic cancer were identified. The primary endpoint was overall survival (OS). (3) Results: Out of 8752 publications identified, 34 comparative studies assessing a total of 141,853 patients were included. Meta-analysis indicated a statistically significant increased risk of death with delayed CT (>6–8 weeks post-surgery) in colorectal cancer (hazard ratio (HR) = 1.27, 95% confidence interval (CI) 1.21–1.33; p <0.001). Similarly, for gastric cancer, delaying adjuvant CT was associated with inferior overall survival (HR = 1.2, 95% CI 1.04–1.38; p = 0.01). Conversely, the benefit of earlier CT was not evident in pancreatic cancer (HR = 1, 95% CI 1–1.01; p = 0.37). Conclusions: Starting adjuvant CT within 6–8 weeks post-surgery is associated with a significant survival benefit for colorectal and gastric cancer, but not for pancreatic cancer.

Multimodal prehabilitation in colorectal cancer patients to improve functional capacity and reduce postoperative complications: the first international randomized controlled trial for multimodal prehabilitation

BACKGROUND

Colorectal cancer (CRC) is the second most prevalent type of cancer in the world. Surgery is the only curative option. However, postoperative complications occur in up to 50% of patients and are associated with higher morbidity and mortality rates, lower health related quality of life (HRQoL) and increased expenditure in health care. The number and severity of complications are closely related to preoperative functional capacity, nutritional state, psychological state, and smoking behavior. Traditional approaches have targeted the postoperative period for rehabilitation and lifestyle changes. However, recent evidence shows that the preoperative period might be the optimal moment for intervention. This study will determine the impact of multimodal prehabilitation on patients' functional capacity and postoperative complications.

METHODS/DESIGN

This international multicenter, prospective, randomized controlled trial will include 714 patients undergoing colorectal surgery for cancer. Patients will be allocated to the intervention group, which will receive 4 weeks of prehabilitation (group 1, prehab), or the control group, which will receive no prehabilitation (group 2, no prehab). Both groups will receive perioperative care in accordance with the enhanced recovery after surgery (ERAS) guidelines. The primary outcomes for measurement will be functional capacity (as assessed using the six-minute walk test (6MWT)) and postoperative status determined with the Comprehensive Complication Index (CCI). Secondary outcomes will include HRQoL, length of hospital stay (LOS) and a cost-effectiveness analysis.

DISCUSSION

Multimodal prehabilitation is expected to enhance patients' functional capacity and to reduce postoperative complications. It may therefore result in increased survival and improved HRQoL. This is the first international multicenter study investigating multimodal prehabilitation for patients undergoing colorectal surgery for cancer.

TRIAL REGISTRATION

Trial Registry: NTR5947 - date of registration: 1 August 2016.

Prospective study on the safety and feasibility of early ileostomy closure 2 weeks after lower anterior resection for rectal cancer

Purpose

Transient loop ileostomies in rectal cancer surgery are generally closed after 2 or more months to allow adequate time for anastomotic healing. Maintaining the ileostomy may cause medical, surgical, or psychological complications; it also reduces the quality of life, and increase treatment costs. We performed this study to evaluate the safety and feasibility of early ileostomy closure 2 weeks postoperatively.

Methods

If a patient who underwent total mesorectal excision had 2 or more risk factors for anastomotic leakage, a loop ileostomy was created. After confirmation of intact anastomosis via sigmoidoscopy and proctography 1 week postoperatively, the patient was enrolled and ileostomy was closed 2 weeks postoperatively. The primary endpoint was the frequency of complication after ileostomy repair.

Results

Thirty patients were enrolled in the study and 6 were excluded due to anastomotic leakage. Except for 1 case of wound infection (4.2%), no patient experienced any complication including newly developed leakage after the ileostomy closure. The mean duration to repair was 13.1 days (range, 8–16 days) and mean duration to the start of adjuvant treatment after radical surgery was 5.37 weeks (range, 3.0–8.1 weeks).

Conclusion

Transient loop ileostomy, which is confirmed to be intact endoscopically and radiologically, can be safely closed 2 weeks postoperatively without requiring a significant delay in adjuvant chemotherapy.

Impact of Tumor Deposits on Oncologic Outcomes in Stage III Colon Cancer

BACKGROUND

The prognosis of tumor deposits in stage III colon adenocarcinoma is poorly described.

OBJECTIVE

The purpose of this study was to determine the impact of tumor deposits on oncologic outcomes in patients with stage III colon cancer.

DESIGN

This was a multicenter retrospective cohort study.

SETTINGS

The 2010 to 2014 National Cancer Database was queried for patients with resected stage III colon adenocarcinoma on final pathology.

PATIENTS

Patients were divided into 3 groups: lymph nodes+tumor deposits-, lymph nodes+tumor deposits+, and lymph nodes-tumor deposits+.

MAIN OUTCOME MEASURES

The main outcome was 5-year overall survival.

RESULTS

Of 74,577 patients, there were 55,800 patients with lymph nodes+tumor deposits-, 13,740 patients with lymph nodes+tumor deposits+, and 5037 patients with lymph nodes-tumor deposits+. The groups had similar patient and facility characteristics, but patients with lymph nodes+tumor deposits+ had more advanced tumor characteristics. Patients with lymph nodes-tumor deposits+ were less likely to receive adjuvant systemic therapy (52% vs 74% lymph nodes+tumor deposits- and 75% lymph nodes+tumor deposits+, p < 0.001) and had a longer delay to initiation of adjuvant treatment (>8 weeks; 43% vs 33% lymph nodes+tumor deposits- and 33% lymph nodes+tumor deposits+, p < 0.001). Patients with lymph nodes+tumor deposits+ had the lowest 5-year overall survival (46.0% vs 63.4% lymph nodes+tumor deposits- vs 61.9% lymph nodes-tumor deposits+, p < 0.001). On multivariate analysis, patients with lymph nodes-tumor deposits+ had similar 5-year overall survival compared with patients with lymph nodes+tumor deposits- with ≤3 positive lymph nodes (HR, 0.93; 95% CI, 0.87-1.01). Patients with lymph nodes+tumor deposits+ had worse prognosis regardless of the number of involved lymph nodes (≤3 +lymph nodes: HR, 1.37; 95% CI, 1.28-1.47 and ≥4 +lymph nodes: HR, 1.30; 95% CI, 1.22-1.38). Of those not receiving adjuvant treatment, patients with lymph nodes-tumor deposits+ were younger and had more adverse tumor features than lymph node+ disease. Lymph nodes-tumor deposits+ was independently associated with less delivery of adjuvant systemic therapy (OR, 0.81; 95% CI, 0.80-0.82).

LIMITATIONS

This study was limited by its retrospective analysis of a prospective database.

CONCLUSIONS

The prognosis of patients with N1c disease is similar to nodal involvement without tumor deposits, yet these patients were less likely to receive adjuvant systemic therapy. Improvement in the delivery of appropriate care in these patients may increase survival and should be a target of future quality initiatives. See Video Abstract at http://links.lww.com/DCR/A666.

Minimally invasive surgery for stage III colon adenocarcinoma is associated with less delay to initiation of adjuvant systemic therapy and improved survival

BACKGROUND

Minimally invasive surgery (MIS) may improve surgical recovery and reduce time to adjuvant systemic therapy after colon cancer resection. The objective of this study was to determine the effect of MIS on the initiation of adjuvant systemic therapy and survival in patients with stage III colon cancer.

METHODS

The 2010-2014 National Cancer Database was queried for patients with resected stage III colon adenocarcinoma, and divided into MIS, which included laparoscopic and robotic approaches, and open surgery. Propensity-score matching was used to balanced open and MIS groups. The main outcome measures were delayed initiation of adjuvant systemic therapy (defined as > 8 weeks after surgery) and 5-year overall survival (OS). Multiple Cox regression was performed to identify independent predictors for 5-year OS, including an interaction between delayed systemic therapy and MIS, and adjusted for clustering at the hospital level.

RESULTS

There were 86,680 patients that were included in this study. Overall, 45% (38,713) underwent MIS colectomy, of which 93% underwent laparoscopic and 7% robotic surgery. After matching, 33,183 open patients were balanced to 33,183 MIS patients. Patient, tumor, and facility characteristics were similar in the matched cohort. More patients in the MIS group received adjuvant therapy within 8 weeks of surgery (49% vs. 42%, p < 0.001), and fewer MIS patients did not receive any systemic therapy (30% vs. 35%, p < 0.001). Delayed initiation of systemic therapy > 8 weeks was associated with worse 5-year OS (HR 1.27, 95%CI 1.19-1.36). MIS was independently associated with improved survival (HR 0.92, 95%CI 0.86-0.97). This relationship remained even if 90-day mortality was excluded.

CONCLUSIONS

MIS approaches are associated with less delay to the initiation of adjuvant systemic therapy and improved survival in patients with stage III colon adenocarcinoma. Surgeons should favor MIS approaches for the treatment of stage III colon adenocarcinoma whenever possible.

Delay in Adjuvant Chemotherapy and Survival Advantage in Stage III Colon Cancer

BACKGROUND

Adjuvant chemotherapy after resection is the standard of care for stage III colon cancer, yet many patients omit chemotherapy. We aimed to describe the impact of delayed chemotherapy on overall survival across multiple time points.

STUDY DESIGN

The 2006 to 2014 National Cancer Data Base (NCDB) was queried for patients with single primary stage III adenocarcinoma of the colon. Patients were grouped by receipt and timing of chemotherapy from resection date: chemotherapy omitted, <6 weeks, 6 to 8 weeks, 8 to 12 weeks, 12 to 24 weeks, and >24 weeks. Subgroup analyses were performed for those with comorbidities and those who had postoperative complications. Overall survival was compared using Cox proportional hazard modeling, adjusting for patient, tumor, and facility characteristics.

RESULTS

In total, 72,057 patients were included; 20,807 omitted chemotherapy, 22,705 received it at <6 weeks, 15,412 between 6 and 8 weeks, 9,049 between 8 and 12 weeks, 3,595 between 12 and 24 weeks, and 489 at >24 weeks after resection. Compared with patients who omitted chemotherapy, patients who received chemotherapy at <6 weeks (hazard ratio [HR] 0.44), 6 to 8 weeks (HR 0.45), 8 to 12 weeks (HR 0.52), 12 to 24 weeks (HR 0.61), and >24 weeks (HR 0.68) had superior overall survival (p < 0.001). This survival benefit was preserved across subgroups (p < 0.001).

CONCLUSIONS

After resection of stage III colon cancer, patients should receive adjuvant chemotherapy within 6 to 8 weeks for maximal benefit. However, chemotherapy should be offered to patients who are outside the optimal window, who have significant comorbidities, or who have had a complication more than 24 weeks from resection to improve the overall survival compared with omitting chemotherapy.

The impact of delayed commencement of adjuvant chemotherapy (eight or more weeks) on survival in stage II and III colon cancer: a national population-based cohort study

BACKGROUND

To examine the impact of chemotherapy delay on survival in patients with stage II or III colon cancer and the factors associated with the delay (≥8 weeks) of adjuvant chemotherapy.

METHODS

Patients undergoing curative resection and adjuvant chemotherapy in a national population-based cohort were included.

RESULTS

Among 5355 patients, 154 (2.9%) received chemotherapy more than 8 weeks after surgery. Based on a multivariate analysis, the risk factors associated with chemotherapy delay ≥8 weeks were older age [65 to 74 years (hazard ratio [HR]=1.48) and ≥75 years (HR=1.69), p=0.0354], medical aid status in the health security system (HR=1.76, p=0.0345), and emergency surgery (HR=2.43, p=0.0002). Using an 8-week cutoff, the 3-year overall survival rate was 89.62% and 80.98% in the <8 weeks and ≥8 weeks groups, respectively (p=0.008). Independent prognostic factors for inferior overall survival included chemotherapy delay ≥8 weeks (HR=1.49, p=0.0365), older age [65 to 74 years (HR=1.94) and ≥75 years (HR=3.41), p<0.0001], TNM stage III (HR=2.46, p<0.0001), emergency surgery (HR=1.89, p<0.0001), American Society of Anesthesiologists score of 3 or higher (HR=1.50, p<0.0001), and higher transfusion amounts (HR=1.09, p=0.0392).

CONCLUSIONS

This study shows that delayed commencement of adjuvant chemotherapy, defined as ≥ 8 weeks, is associated with inferior overall survival in colon cancer patients with stage II or III disease. The delay to initiation of adjuvant chemotherapy is influenced by several multidimensional factors, including patient factors (older age), insurance status (medical aid), and treatment-related factors (emergency surgery).

What We Know About Stage II and III Colon Cancer: It's Still Not Enough

The introduction of oxaliplatin as adjuvant treatment for stage III colon cancer in 2004 has been the last practice changing progress in adjuvant treatment for patients with early colon cancer. Since then, many prognostic and predictive biomarkers have been studied, but only DNA mismatch repair status has been validated as having an important prognostic value. Accordingly, TNM and clinical-pathological patterns, such as pT4 lesions and lymph node sampling <12 nodes, are the main factors that guide physicians' choice regarding adjuvant treatment. More recently, many biomarkers showed promising results: POLE, ErbB2, CDX2, SMAD4, BRAF and KRAS. In addition to these, immune-contexture, molecular classification, and gene signatures could become new ways to better classify colon cancer patients with more discriminatory power than TNM. The aim of this review is to report the state-of-the-art of prognostic and predictive factors in the adjuvant setting and which of these could modify clinical practice and maybe replace TNM classification.

Association of Delayed Adjuvant Chemotherapy With Survival After Lung Cancer Surgery

IMPORTANCE

Adjuvant chemotherapy offers a survival benefit to a number of staging scenarios in non-small-cell lung cancer. Variable recovery from lung cancer surgery may delay a patient's ability to tolerate adjuvant chemotherapy, yet the urgency of chemotherapy initiation is unclear.

OBJECTIVE

To assess differences in survival according to the time interval between non-small-cell lung cancer resection and the initiation of postoperative chemotherapy to determine the association between adjuvant treatment timing and efficacy.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective observational study examined treatment-naive patients with completely resected non-small-cell lung cancer who received postoperative multiagent chemotherapy between 18 and 127 days after resection between January 2004 and December 2012. The study population was limited to patients with lymph node metastases, tumors 4 cm or larger, or local extension. Patients were identified from the National Cancer Database, a hospital-based tumor registry that captures more than 70% of incident lung cancer cases in the United States. The association between time to initiation of adjuvant chemotherapy and survival was evaluated using Cox models with restricted cubic splines.

EXPOSURES

Adjuvant chemotherapy administered at different time points after surgery.

MAIN OUTCOMES AND MEASURES

Effectiveness of adjuvant chemotherapy according to time to initiation after surgery.

RESULTS

A total of 12 473 patients (median [interquartile range] age, 64 [57-70] years) were identified: 3073 patients (25%) with stage I disease; 5981 patients (48%), stage II; and 3419 patients (27%), stage III. A Cox model with restricted cubic splines identified the lowest mortality risk when chemotherapy was started 50 days postoperatively (95% CI, 39-56 days). Initiation of chemotherapy after this interval (57-127 days; ie, the later cohort) did not increase mortality (hazard ratio [HR], 1.037; 95% CI, 0.972-1.105; P = .27). Furthermore, in a Cox model of 3976 propensity-matched pairs, patients who received chemotherapy during the later interval had a lower mortality risk than those treated with surgery only (HR, 0.664; 95% CI, 0.623-0.707; P < .001).

CONCLUSIONS AND RELEVANCE

In the National Cancer Database, adjuvant chemotherapy remained efficacious when started 7 to 18 weeks after non-small-cell lung cancer resection. Patients who recover slowly from non-small-cell lung cancer surgery may still benefit from delayed adjuvant chemotherapy started up to 4 months after surgery.

Is there an optimal time to initiate adjuvant chemotherapy to predict benefit of survival in non-small cell lung cancer?

Objective

Adjuvant chemotherapy (AC) after curative resection is known to improve the survival of patients with non-small cell lung cancer (NSCLC); however, few studies have reported the correlation between the time to initiation of AC (TTAC) and survival in NSCLC patients.

Methods

The clinical data of 925 NSCLC patients who received curative resection and post-operative AC at the Cancer Hospital of Chinese Academy of Medical Sciences between 2003 and 2013 were retrospectively analyzed. TTAC was measured from the date of surgery to the initiation of AC. Disease-free survival (DFS) was defined as the duration from surgery to the time of tumor recurrence or last follow-up evaluation. The optimal cut-off value of TTAC was determined by maximally selected log-rank statistics. The DFS curve was estimated using the Kaplan-Meier method, and the Cox proportional hazards regression model was used to identify risk factors independently associated with DFS. Propensity score matching (PSM) was performed for survival analysis using the match data.

Results

The optimal discriminating cut-off value of TTAC was set at d 35 after curative resection based on which the patients were assigned into two groups: group A (≤35 d) and group B (>35 d). There was no significant difference in the DFS between the two groups (P=0.246), indicating that the TTAC is not an independent prognostic factor for DFS. A further comparison continued to show no significant difference in the DFS among 258 PSM pairs (P=0.283).

Conclusions

There was no significant correlation between the TTAC and DFS in NSCLC patients. Studies with larger samples are needed to further verify this conclusion.

Laparoscopic colectomy for cancer: Improved compliance with guidelines for chemotherapy and survival

BACKGROUND

Laparoscopic surgery for colon cancer has been demonstrated in clinical trials to have short-term benefits when compared to the open surgical approach. Guidelines of the National Comprehensive Cancer Network recommend that patients with stage III or high-risk stage II colon cancer undergo adjuvant chemotherapy. We hypothesized that laparoscopic colectomy is associated with increased compliance to recommendations for chemotherapy, a lesser time to start of chemotherapy, and increased overall survival.

METHODS

The National Cancer Data Base was queried to identify patients with stage III or high-risk stage II colon cancer (T4, positive margins, <12 lymph nodes, or high tumor grade) diagnosed 2010-2012. Patients were divided into laparoscopic colectomy and open colectomy groups. Intent-to-treat analysis was used with converted cases included in the laparoscopic colectomy group. Rates of receiving adjuvant chemotherapy, time from diagnosis and date of operation to start of chemotherapy, and overall survival were compared.

RESULTS

A total of 48,257 patients were included for analysis; 18,801 patients underwent laparoscopic colectomy and 29,456 underwent open colectomy. Laparoscopic colectomy patients received adjuvant chemotherapy at a somewhat greater rate than open colectomy (66.2% vs 59.4%, P < .01). Among patients who received chemotherapy, mean time to start of chemotherapy after definitive resection was somewhat less for laparoscopic colectomy than open colectomy (48.7 vs 52.7 days, P < .01). Two-year overall survival was greater for laparoscopic colectomy than open colectomy (81.9% vs 73.2%, P < .01).

CONCLUSION

Compared to open colectomy, laparoscopic colectomy is associated with somewhat greater rates of compliance with guidelines for adjuvant chemotherapy for stage III and high-risk stage II colon cancer, as well as a slightly lesser time to start of chemotherapy and improved overall survival.