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Sadeghi JK, Reza JA, Miller C, Cooke DT, Erkmen C. Death by a thousand delays. JTCVS OPEN 2024; 18:353-359. [PMID: 38690410 PMCID: PMC11056460 DOI: 10.1016/j.xjon.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 10/25/2023] [Accepted: 12/04/2023] [Indexed: 05/02/2024]
Affiliation(s)
- John K. Sadeghi
- Department of Thoracic Medicine and Surgery, Temple University, Philadelphia, Pa
| | - Joseph A. Reza
- Department of Thoracic Medicine and Surgery, Temple University, Philadelphia, Pa
| | - Claire Miller
- Department of Thoracic Medicine and Surgery, Temple University, Philadelphia, Pa
| | - David T. Cooke
- Division of General Thoracic Surgery, University of California, Davis, Davis, Calif
| | - Cherie Erkmen
- Department of Thoracic Medicine and Surgery, Temple University, Philadelphia, Pa
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Sakowitz S, Bakhtiyar SS, Verma A, Ebrahimian S, Vadlakonda A, Mabeza RM, Lee H, Benharash P. Association of time to resection with survival in patients with colon cancer. Surg Endosc 2024; 38:614-623. [PMID: 38012438 DOI: 10.1007/s00464-023-10548-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 10/15/2023] [Indexed: 11/29/2023]
Abstract
PURPOSE Colon cancer (CC) remains a leading cause of cancer-related mortality worldwide, for which colectomy represents the standard of care. Yet, the impact of delayed resection on survival outcomes remains controversial. We assessed the association between time to surgery and 10-year survival in a national cohort of CC patients. METHODS This retrospective cohort study identified all adults who underwent colectomy for Stage I-III CC in the 2004-2020 National Cancer Database. Those who required neoadjuvant therapy or emergent resection < 7 days from diagnosis were excluded. Patients were classified into Early (< 25 days) and Delayed (≥ 25 days) cohorts after an adjusted analysis of the relationship between time to surgery and 10-year survival. Survival at 1-, 5-, and 10-years was assessed via Kaplan-Meier analyses and Cox proportional hazard modeling, adjusting for age, sex, race, income quartile, insurance coverage, Charlson-Deyo comorbidity index, disease stage, location of tumor, receipt of adjuvant chemotherapy, as well as hospital type, location, and case volume. RESULTS Of 165,991 patients, 84,665 (51%) were classified as Early and 81,326 (49%) Delayed. Following risk adjustment, Delayed resection was associated with similar 1-year [hazard ratio (HR) 1.01, 95% confidence interval (CI) 0.97-1.04, P = 0.72], but inferior 5- (HR 1.24, CI 1.22-1.26; P < 0.001) and 10-year survival (HR 1.22, CI 1.20-1.23; P < 0.001). Black race [adjusted odds ratio (AOR) 1.36, CI 1.31-1.41; P < 0.001], Medicaid insurance coverage (AOR 1.34, CI 1.26-1.42; P < 0.001), and care at high-volume hospitals (AOR 1.12, 95%CI 1.08-1.17; P < 0.001) were linked with greater likelihood of Delayed resection. CONCLUSIONS Patients with CC who underwent resection ≥ 25 days following diagnosis demonstrated similar 1-year, but inferior 5- and 10-year survival, compared to those who underwent surgery within 25 days. Socioeconomic factors, including race and Medicaid insurance, were linked with greater odds of delayed resection. Efforts to balance appropriate preoperative evaluation with expedited resection are needed to optimize patient outcomes.
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Affiliation(s)
- Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, CA, USA
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, CA, USA
- Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, CA, USA
| | - Shayan Ebrahimian
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, CA, USA
| | - Amulya Vadlakonda
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, CA, USA
| | - Russyan Mark Mabeza
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, CA, USA
| | - Hanjoo Lee
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, CA, USA
- Division of Colon & Rectal Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, CA, USA.
- Department of Surgery, University of California, Los Angeles, CA, USA.
- UCLA Division of Cardiac Surgery, 64-249 Center for Health Sciences, Los Angeles, CA, 90095, USA.
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Strous MTA, Molenaar CJL, Franssen RFW, van Osch F, Belgers E, Bloemen JG, Slooter GD, Melenhorst J, Heemskerk J, de Bruïne AP, Janssen-Heijnen MLG, Vogelaar FJ. Treatment interval in curative treatment of colon cancer, does it impact (cancer free) survival? A non-inferiority analysis. Br J Cancer 2024; 130:251-259. [PMID: 38087040 PMCID: PMC10803312 DOI: 10.1038/s41416-023-02505-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 10/22/2023] [Accepted: 11/13/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND In treatment of colon cancer, strict waiting-time targets are enforced, leaving professionals no room to lengthen treatment intervals when advisable, for instance to optimise a patient's health status by means of prehabilitation. Good quality studies supporting these targets are lacking. With this study we aim to establish whether a prolonged treatment interval is associated with a clinically relevant deterioration in overall and cancer free survival. METHODS This retrospective multicenter non-inferiority study includes all consecutive patients who underwent elective oncological resection of a biopsy-proven primary non-metastatic colon carcinoma between 2010 and 2016 in six hospitals in the Southern Netherlands. Treatment interval was defined as time between diagnosis and surgical treatment. Cut-off points for treatment interval were ≤35 days and ≤49 days. FINDINGS 3376 patients were included. Cancer recurred in 505 patients (15.0%) For cancer free survival, a treatment interval >35 days and >49 days was non-inferior to a treatment interval ≤35 days. Results for overall survival were inconclusive, but no association was found. CONCLUSION For cancer free survival, a prolonged treatment interval, even over 49 days, is non-inferior to the currently set waiting-time target of ≤35 days. Therefore, the waiting-time targets set as fundamental objective in current treatment guidelines should become directional instead of strict targets.
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Affiliation(s)
- Maud T A Strous
- Department of Surgery, VieCuri Medical Centre, Venlo, The Netherlands.
- Department of Epidemiology, GROW School for Oncology and Developmental Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.
| | | | - Ruud F W Franssen
- Department of Epidemiology, GROW School for Oncology and Developmental Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Frits van Osch
- Department of Epidemiology, VieCuri Medical Centre, Venlo, the Netherlands
| | - Eric Belgers
- Department of Surgery, Zuyderland Hospital, Heerlen, The Netherlands
| | - Johanne G Bloemen
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Gerrit D Slooter
- Department of Surgery, Maxima Medical Centre, Veldhoven, The Netherlands
| | - Jarno Melenhorst
- Department of Epidemiology, GROW School for Oncology and Developmental Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jeroen Heemskerk
- Department of Surgery, Laurentius Hospital, Roermond, The Netherlands
| | | | - Maryska L G Janssen-Heijnen
- Department of Epidemiology, GROW School for Oncology and Developmental Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Epidemiology, VieCuri Medical Centre, Venlo, the Netherlands
| | - F Jeroen Vogelaar
- Department of Surgery, VieCuri Medical Centre, Venlo, The Netherlands
- Department of Epidemiology, GROW School for Oncology and Developmental Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Fwelo P, Afolayan O, Nwosu KOS, Ojaruega AA, Ahaiwe O, Olateju OA, Ezeigwe OJ, Adekunle TE, Bangolo A. Racial and ethnic differences in colon cancer surgery type performed and delayed treatment among people 45 years old and older in the USA between 2007 and 2017: Mediating effect on survival. Surg Oncol 2023; 50:101983. [PMID: 37619508 DOI: 10.1016/j.suronc.2023.101983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/15/2023] [Accepted: 08/13/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND This study examined the associations of socioeconomic status (SES), race/ethnicity, surgery type, and treatment delays with mortality among colon cancer patients. In addition, the study also quantifies the extent to which clinical and SES factors' variations explain the racial/ethnic differences in overall survival. PATIENTS AND METHODS We studied 111,789 adult patients ≥45 years old who were diagnosed with colon cancer between 2010 and 2017, identified from the Surveillance, Epidemiology, and End Results (SEER) database. We performed logistic regression models to examine the association of SES and race/ethnicity with surgery type and first course of treatment delays. We also performed mediation analysis to quantify the extent to which treatment, sociodemographic and clinicopathologic factors mediated racial/ethnic differences in survival. RESULTS Non-Hispanic (NH) Blacks [adjusted Odds Ratio (aOR) = 1.19, 95% CI:1.13-1.25] were significantly more likely to undergo subtotal colectomy and to experience treatment delays [aOR = 1.39, 95% CI: 1.31-1.48] compared to NH Whites. Hispanics [aOR = 1.59, 95% CI: 1.49-1.69] were more likely to experience treatment delays than NH Whites. Delayed first course of treatment explained 23.56% and 56.73% of the lower survival among NH Blacks and Hispanics, respectively, compared to their NH White counterparts. CONCLUSIONS Race/ethnicity is significantly associated with the surgery type performed and the first course of treatment delays. Variations in treatment, SES, and clinicopathological factors significantly explained racial disparities in overall mortality. These disparities highlight the need for multidisciplinary interventions to address the treatment and social factors perpetuating racial disparities in colon cancer mortality.
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Affiliation(s)
- Pierre Fwelo
- UTHealth School of Public Health, Department of Epidemiology, Human Genetics & Environmental Sciences, Houston, TX, USA.
| | - Oladipo Afolayan
- UTHealth School of Public Health, Department of Biostatistics, Houston, TX, USA
| | - Kenechukwu O S Nwosu
- UTHealth School of Public Health, Department of Management, Policy & Community Health, Houston, TX, USA
| | - Akpevwe A Ojaruega
- UTHealth School of Public Health, Department of Epidemiology, Human Genetics & Environmental Sciences, Houston, TX, USA
| | - Onyekachi Ahaiwe
- UTHealth School of Public Health, Department of Epidemiology, Human Genetics & Environmental Sciences, Houston, TX, USA
| | - Olajumoke A Olateju
- University of Houston College of Pharmacy, Department of Pharmaceutical Health Outcomes and Policy, Houston, TX, USA
| | - Ogochukwu Juliet Ezeigwe
- UTHealth School of Public Health, Department of Epidemiology, Human Genetics & Environmental Sciences, Houston, TX, USA
| | - Toluwani E Adekunle
- University of Louisville School of Public Health and Information Sciences (SPHIS), Department of Health Promotion and Behavioral Sciences (HPBS), Louisville, KY, USA
| | - Ayrton Bangolo
- Hackensack Meridian Health/Palisades Medical Center, Department of Internal Medicine, North Bergen, NJ, USA
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Drosdowsky A, Lamb KE, Karahalios A, Bergin RJ, Milley K, Boyd L, IJzerman MJ, Emery JD. The effect of time before diagnosis and treatment on colorectal cancer outcomes: systematic review and dose-response meta-analysis. Br J Cancer 2023; 129:993-1006. [PMID: 37528204 PMCID: PMC10491798 DOI: 10.1038/s41416-023-02377-w] [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: 12/19/2022] [Revised: 06/28/2023] [Accepted: 07/24/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND This systematic review and meta-analysis aimed to evaluate existing evidence on the relationship between diagnostic and treatment intervals and outcomes for colorectal cancer. METHODS Four databases were searched for English language articles assessing the role of time before initial treatment in colorectal cancer on any outcome, including stage and survival. Two reviewers independently screened articles for inclusion and data were synthesised narratively. A dose-response meta-analysis was performed to examine the association between treatment interval and survival. RESULTS One hundred and thirty papers were included in the systematic review, eight were included in the meta-analysis. Forty-five different intervals were considered in the time from first symptom to treatment. The most common finding was of no association between the length of intervals on any outcome. The dose-response meta-analysis showed a U-shaped association between the treatment interval and overall survival with the nadir at 45 days. CONCLUSION The review found inconsistent, but mostly a lack of, association between interval length and colorectal cancer outcomes, but study design and quality were heterogeneous. Meta-analysis suggests survival becomes increasingly poorer for those commencing treatment more than 45 days after diagnosis. REGISTRATION This review was registered, and the protocol is available, in PROSPERO, the international database of systematic reviews, with the registration ID CRD42021255864.
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Affiliation(s)
- Allison Drosdowsky
- Department of General Practice and Centre for Cancer Research, The University of Melbourne, Parkville, VIC, Australia.
| | - Karen E Lamb
- Melbourne School of Population and Global Health, The University of Melbourne, Parkville, VIC, Australia
| | - Amalia Karahalios
- Melbourne School of Population and Global Health, The University of Melbourne, Parkville, VIC, Australia
| | - Rebecca J Bergin
- Department of General Practice and Centre for Cancer Research, The University of Melbourne, Parkville, VIC, Australia
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, VIC, Australia
| | - Kristi Milley
- Department of General Practice and Centre for Cancer Research, The University of Melbourne, Parkville, VIC, Australia
- Primary Care Collaborative Cancer Clinical Trials Group (PC4), Carlton, VIC, Australia
| | - Lucy Boyd
- Department of General Practice and Centre for Cancer Research, The University of Melbourne, Parkville, VIC, Australia
| | - Maarten J IJzerman
- Melbourne School of Population and Global Health, The University of Melbourne, Parkville, VIC, Australia
| | - Jon D Emery
- Department of General Practice and Centre for Cancer Research, The University of Melbourne, Parkville, VIC, Australia
- Primary Care Collaborative Cancer Clinical Trials Group (PC4), Carlton, VIC, Australia
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Justesen TF, Gögenur M, Clausen JSR, Mashkoor M, Rosen AW, Gögenur I. The impact of time to surgery on oncological outcomes in stage I-III dMMR colon cancer - A nationwide cohort study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106887. [PMID: 37002178 DOI: 10.1016/j.ejso.2023.03.223] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 03/22/2023] [Indexed: 03/31/2023]
Abstract
INTRODUCTION One of the considerations when investigating neoadjuvant interventions is the prolonging of time from diagnosis to curative surgery (i.e. the treatment interval [TI]). The aim of this study was to investigate the association between the length of TI and overall survival and disease-free survival in patients with deficient mismatch repair (dMMR) colon cancer. MATERIALS AND METHODS This retrospective propensity score-adjusted study included all patients of ≥18 years of age undergoing elective curative surgery for stage I-III, dMMR colon cancer. Data were extracted from four Danish patient databases. Outcomes were investigated in groups with TIs of ≤14 days versus >14 days. Propensity scores were computed using all demographics, diagnoses and measurements. Matching was done in a 1:1 ratio. RESULTS A total of 4130 patients were included in the study with a mean age of 73.8 years and a median follow-up time of 43.9 months. After matching, 2794 patients were included in the analysis of overall survival. No significant difference in overall survival was seen between patients with TIs of ≤14 days versus >14 days (hazard ratio [HR], 0.97; 95% confidence interval [CI], 0.81-1.17; p = 0.78). In the analysis of disease-free survival, 1798 patients were included after matching. This showed no significant difference between patients with TIs of ≤14 days versus >14 days (HR, 0.85; 95% CI, 0.69-1.06; p = 0.14). CONCLUSION No associations were found between TI and overall survival and disease-free survival in patients with stage I-III, dMMR colon cancer undergoing elective curative surgery.
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Affiliation(s)
| | - Mikail Gögenur
- Center for Surgical Science, Zealand University Hospital, Lykkebækvej 1, 4600, Køge, Denmark.
| | - Johan Stub Rønø Clausen
- Center for Surgical Science, Zealand University Hospital, Lykkebækvej 1, 4600, Køge, Denmark.
| | - Maliha Mashkoor
- Center for Surgical Science, Zealand University Hospital, Lykkebækvej 1, 4600, Køge, Denmark.
| | | | - Ismail Gögenur
- Center for Surgical Science, Zealand University Hospital, Lykkebækvej 1, 4600, Køge, Denmark; Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark.
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7
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Rydbeck D, Bock D, Haglind E, Angenete E, Onerup A. Survival in relation to time to start of curative treatment of colon cancer: A national register-based observational noninferiority study. Colorectal Dis 2023; 25:1613-1621. [PMID: 37317006 DOI: 10.1111/codi.16638] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 04/27/2023] [Accepted: 04/30/2023] [Indexed: 06/16/2023]
Abstract
AIM There are ample discussions regarding the timing of treatment, especially in the era after Covid that caused delay to treatment. The aim of this study was to determine whether a delayed start to curative treatment, within 29-56 days after a diagnosis of colon cancer, was noninferior to starting treatment within 28 days, with regard to all-cause mortality. METHOD This is a national register-based observational noninferiority study, with a noninferiority margin of hazard ratio (HR) 1.1, including all patients treated with curative intent for colon cancer in Sweden between 2008 and 2016. The primary outcome was all-cause mortality. Secondary outcomes were length of hospital stay, readmissions and reoperations within 1 year after surgery. Exclusion criteria were emergency surgery, disseminated disease at diagnosis, missing diagnosis date and treatment for another cancer 5 years before colon cancer diagnosis. RESULTS A total of 20 836 individuals were included. A period of 29-56 days from diagnosis to start of curative treatment was noninferior versus starting treatment within 28 days for the primary outcome of all-cause mortality (HR 0.95, 95% CI 0.89-1.00). Starting treatment within 29-56 days was associated with a shorter length of stay (average 9.2 vs. 10 days) but a higher risk of reoperation compared to within 28 days. Post hoc analyses demonstrated that surgical modality was driving survival rather than time to treatment. Overall survival was greater after laparoscopic surgery (HR 0.78, 95% CI 0.69-0.88). CONCLUSION For patients with colon cancer, a period of up to 56 days from diagnosis to the start of curative treatment did not lead to worse overall survival.
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Affiliation(s)
- Daniel Rydbeck
- Department of Surgery, SSORG-Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - David Bock
- Department of Surgery, SSORG-Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eva Haglind
- Department of Surgery, SSORG-Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Eva Angenete
- Department of Surgery, SSORG-Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Aron Onerup
- Department of Surgery, SSORG-Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Pediatric Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
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Curran T. Perioperative Nutritional Considerations in Colon and Rectal Surgery. Clin Colon Rectal Surg 2023; 36:192-197. [PMID: 37113286 PMCID: PMC10125286 DOI: 10.1055/s-0043-1761152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Malnutrition is common in surgical patients and is associated with substantially increased morbidity and mortality. Dedicated assessment of nutritional status is advised by major nutrition and surgical societies. Assessment may utilize comprehensive and validated nutritional assessment tools or targeted history, physical examination with accompanying serologic markers to identify nutritional risk preoperatively. Emergent surgery in malnourished patients should proceed as the clinical situation dictates with consideration of ostomy or primary anastomosis with proximal fecal diversion to mitigate postoperative infectious complications. Nonemergent surgery should be delayed to facilitate nutritional optimization via oral nutritional supplementation preferably and total parenteral nutrition if necessary for at least 7 to 14 days. Exclusive enteral nutrition may be considered to optimize nutritional status and inflammation in patients with Crohn's disease. Immunonutrition use in the preoperative setting is not supported by evidence. Perioperative and postoperative immunonutrition may be of benefit but requires dedicated study in the contemporary era. Close attention to preoperative nutritional status and optimization represents a critical opportunity to improve outcomes in patients undergoing colorectal surgery.
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Affiliation(s)
- Thomas Curran
- Division of Colon and Rectal Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
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9
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Greenberg AL, Brand NR, Zambeli-Ljepović A, Barnes KE, Chiou SH, Rhoads KF, Adam MA, Sarin A. Exploring the complexity and spectrum of racial/ethnic disparities in colon cancer management. Int J Equity Health 2023; 22:68. [PMID: 37060065 PMCID: PMC10105474 DOI: 10.1186/s12939-023-01883-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 04/04/2023] [Indexed: 04/16/2023] Open
Abstract
BACKGROUND Colorectal cancer is a leading cause of morbidity and mortality across U.S. racial/ethnic groups. Existing studies often focus on a particular race/ethnicity or single domain within the care continuum. Granular exploration of disparities among different racial/ethnic groups across the entire colon cancer care continuum is needed. We aimed to characterize differences in colon cancer outcomes by race/ethnicity across each stage of the care continuum. METHODS We used the 2010-2017 National Cancer Database to examine differences in outcomes by race/ethnicity across six domains: clinical stage at presentation; timing of surgery; access to minimally invasive surgery; post-operative outcomes; utilization of chemotherapy; and cumulative incidence of death. Analysis was via multivariable logistic or median regression, with select demographics, hospital factors, and treatment details as covariates. RESULTS 326,003 patients (49.6% female, 24.0% non-White, including 12.7% Black, 6.1% Hispanic/Spanish, 1.3% East Asian, 0.9% Southeast Asian, 0.4% South Asian, 0.3% AIAE, and 0.2% NHOPI) met inclusion criteria. Relative to non-Hispanic White patients: Southeast Asian (OR 1.39, p < 0.01), Hispanic/Spanish (OR 1.11 p < 0.01), and Black (OR 1.09, p < 0.01) patients had increased odds of presenting with advanced clinical stage. Southeast Asian (OR 1.37, p < 0.01), East Asian (OR 1.27, p = 0.05), Hispanic/Spanish (OR 1.05 p = 0.02), and Black (OR 1.05, p < 0.01) patients had increased odds of advanced pathologic stage. Black patients had increased odds of experiencing a surgical delay (OR 1.33, p < 0.01); receiving non-robotic surgery (OR 1.12, p < 0.01); having post-surgical complications (OR 1.29, p < 0.01); initiating chemotherapy more than 90 days post-surgery (OR 1.24, p < 0.01); and omitting chemotherapy altogether (OR 1.12, p = 0.05). Black patients had significantly higher cumulative incidence of death at every pathologic stage relative to non-Hispanic White patients when adjusting for non-modifiable patient factors (p < 0.05, all stages), but these differences were no longer statistically significant when also adjusting for modifiable factors such as insurance status and income. CONCLUSIONS Non-White patients disproportionately experience advanced stage at presentation. Disparities for Black patients are seen across the entire colon cancer care continuum. Targeted interventions may be appropriate for some groups; however, major system-level transformation is needed to address disparities experienced by Black patients.
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Affiliation(s)
- Anya L Greenberg
- Department of Surgery, University of California San Francisco, 550 16Th Street, 6Th Floor, San Francisco, CA, 94158, USA
| | - Nathan R Brand
- Department of Surgery, University of California San Francisco, 550 16Th Street, 6Th Floor, San Francisco, CA, 94158, USA
| | - Alan Zambeli-Ljepović
- Department of Surgery, University of California San Francisco, 550 16Th Street, 6Th Floor, San Francisco, CA, 94158, USA
| | - Katherine E Barnes
- Department of Surgery, University of California San Francisco, 550 16Th Street, 6Th Floor, San Francisco, CA, 94158, USA
| | - Sy Han Chiou
- Department of Surgery, University of California San Francisco, 550 16Th Street, 6Th Floor, San Francisco, CA, 94158, USA
| | - Kim F Rhoads
- Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
| | - Mohamed A Adam
- Department of Surgery, University of California San Francisco, 550 16Th Street, 6Th Floor, San Francisco, CA, 94158, USA
| | - Ankit Sarin
- Department of Surgery, University of California San Francisco, 550 16Th Street, 6Th Floor, San Francisco, CA, 94158, USA.
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10
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Drosdowsky A, Lamb KE, Bergin RJ, Boyd L, Milley K, IJzerman MJ, Emery JD. A systematic review of methodological considerations in time to diagnosis and treatment in colorectal cancer research. Cancer Epidemiol 2023; 83:102323. [PMID: 36701982 DOI: 10.1016/j.canep.2023.102323] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 01/06/2023] [Accepted: 01/09/2023] [Indexed: 01/26/2023]
Abstract
Research focusing on timely diagnosis and treatment of colorectal cancer is necessary to improve outcomes for people with cancer. Previous attempts to consolidate research on time to diagnosis and treatment have noted varied methodological approaches and quality, limiting the comparability of findings. This systematic review was conducted to comprehensively assess the scope of methodological issues in this field and provide recommendations for future research. Eligible articles had to assess the role of any interval up to treatment, on any outcome in colorectal cancer, in English, with no limits on publication time. Four databases were searched (Ovid Medline, EMBASE, EMCARE and PsycInfo). Papers were screened by two independent reviewers using a two-stage process of title and abstract followed by full text review. In total, 130 papers were included and had data extracted on specific methodological and statistical features. Several methodological problems were identified across the evidence base. Common issues included arbitrary categorisation of intervals (n = 107, 83%), no adjustment for potential confounders (n = 65, 50%), and lack of justification for included covariates where there was adjustment (n = 40 of 65 papers that performed an adjusted analysis, 62%). Many articles introduced epidemiological biases such as immortal time bias (n = 37 of 80 papers that used survival as an outcome, 46%) and confounding by indication (n = 73, 56%), as well as other biases arising from inclusion of factors outside of their temporal sequence. However, determination of the full extent of these problems was hampered by insufficient reporting. Recommendations include avoiding artificial categorisation of intervals, ensuring bias has not been introduced due to out-of-sequence use of key events and increased use of theoretical frameworks to detect and reduce bias. The development of reporting guidelines and domain-specific risk of bias tools may aid in ensuring future research can reliably contribute to recommendations regarding optimal timing and strengthen the evidence base.
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Affiliation(s)
- Allison Drosdowsky
- Department of General Practice and Centre for Cancer Research, The University of Melbourne, Parkville, Australia.
| | - Karen E Lamb
- Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Australia
| | - Rebecca J Bergin
- Department of General Practice and Centre for Cancer Research, The University of Melbourne, Parkville, Australia; Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Australia
| | - Lucy Boyd
- Department of General Practice and Centre for Cancer Research, The University of Melbourne, Parkville, Australia
| | - Kristi Milley
- Department of General Practice and Centre for Cancer Research, The University of Melbourne, Parkville, Australia; Primary Care Collaborative Cancer Clinical Trials Group (PC4), Carlton, Australia
| | - Maarten J IJzerman
- Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Australia
| | - Jon D Emery
- Department of General Practice and Centre for Cancer Research, The University of Melbourne, Parkville, Australia; Primary Care Collaborative Cancer Clinical Trials Group (PC4), Carlton, Australia
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11
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Zhang WJ, Li YY, Xiang ZH, Deng J, Li W, Lin QL, Fang Y, Liu F, Bai J, Zhang L, Li J. Emerging evidence on the effects of plant-derived microRNAs in colorectal cancer: a review. Food Funct 2023; 14:691-702. [PMID: 36625207 DOI: 10.1039/d2fo03477h] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Food nutrition and human health are still interesting international issues. Early detection, risk assessment and diet are vital to mitigate the load of intestinal diseases and enhance the quality of life. Plant-derived microRNAs could be transferred to mammalian organisms by cross-kingdom regulation which adjusts relevant target genes for their participation in the process of carcinogenesis. But the mechanism of plant-derived microRNAs in colorectal cancer is still unclear. This review aims to summarize the current pathways of plant-derived microRNAs in colorectal cancer including intestinal bacteria, the tumor microenvironment, plant active substances and protein, discuss the direct or indirect effects of plant-derived microRNAs on the occurrence and/or progression of colorectal cancer and explain why plant-derived microRNAs can be used as a potential anti-cancer agent. Moreover, the drawbacks of plant-derived microRNAs are also discussed in terms of both edible plants and synthetic delivery vectors for RNAi interference technology for human disease treatment. This review will provide a potential way for plant-derived microRNAs to target colorectal cancer.
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Affiliation(s)
- Wen Jing Zhang
- National Engineering Laboratory for Deep Process of Rice and Byproducts, College of Food Science and Engineering, Central South University of Forestry and Technology, Changsha, 410004, Hunan, China.
| | - Ying Yi Li
- National Engineering Laboratory for Deep Process of Rice and Byproducts, College of Food Science and Engineering, Central South University of Forestry and Technology, Changsha, 410004, Hunan, China.
| | - Zhen Hang Xiang
- National Engineering Laboratory for Deep Process of Rice and Byproducts, College of Food Science and Engineering, Central South University of Forestry and Technology, Changsha, 410004, Hunan, China.
| | - Jing Deng
- National Engineering Laboratory for Deep Process of Rice and Byproducts, College of Food Science and Engineering, Central South University of Forestry and Technology, Changsha, 410004, Hunan, China.
| | - Wen Li
- National Engineering Laboratory for Deep Process of Rice and Byproducts, College of Food Science and Engineering, Central South University of Forestry and Technology, Changsha, 410004, Hunan, China. .,College of Food Science and Engineering, Nanjing University of Finance and Economics/Collaborative Innovation Center for Modern Grain Circulation and Safety, Nanjing 210023, Jiangsu, China
| | - Qin Lu Lin
- National Engineering Laboratory for Deep Process of Rice and Byproducts, College of Food Science and Engineering, Central South University of Forestry and Technology, Changsha, 410004, Hunan, China.
| | - Yong Fang
- College of Food Science and Engineering, Nanjing University of Finance and Economics/Collaborative Innovation Center for Modern Grain Circulation and Safety, Nanjing 210023, Jiangsu, China
| | - Fang Liu
- National Engineering Laboratory for Deep Process of Rice and Byproducts, College of Food Science and Engineering, Central South University of Forestry and Technology, Changsha, 410004, Hunan, China.
| | - Jie Bai
- National Engineering Laboratory for Deep Process of Rice and Byproducts, College of Food Science and Engineering, Central South University of Forestry and Technology, Changsha, 410004, Hunan, China.
| | - Lin Zhang
- National Engineering Laboratory for Deep Process of Rice and Byproducts, College of Food Science and Engineering, Central South University of Forestry and Technology, Changsha, 410004, Hunan, China.
| | - Juan Li
- National Engineering Laboratory for Deep Process of Rice and Byproducts, College of Food Science and Engineering, Central South University of Forestry and Technology, Changsha, 410004, Hunan, China.
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12
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Castelo M, Sue-Chue-Lam C, Paszat L, Scheer AS, Hansen BE, Kishibe T, Baxter NN. Clinical Delays and Comparative Outcomes in Younger and Older Adults with Colorectal Cancer: A Systematic Review. Curr Oncol 2022; 29:8609-8625. [PMID: 36421332 PMCID: PMC9689013 DOI: 10.3390/curroncol29110679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/03/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
Abstract
Outcome disparities between adults <50 with colorectal cancer (CRC) and older adults may be explained by clinical delays. This study synthesized the literature comparing delays and outcomes between younger and older adults with CRC. Databases were searched until December 2021. We included studies published after 1990 reporting delay in adults <50 that made comparisons to older adults. Comparisons were described narratively and stage between age groups was meta-analyzed. 39 studies were included representing 185,710 younger CRC patients and 1,422,062 older patients. Sixteen delay intervals were compared. Fourteen studies (36%) found significantly longer delays among younger adults, and nine (23%) found shorter delays among younger patients. Twelve studies compared time from symptom onset to diagnosis (N younger = 1538). Five showed significantly longer delays for younger adults. Adults <50 years also had higher odds of advanced stage (16 studies, pooled OR for Stage III/IV 1.76, 95% CI 1.52-2.03). Ten studies compared time from diagnosis to treatment (N younger = 171,726) with 4 showing significantly shorter delays for younger adults. All studies showing longer delays for younger adults examined pre-diagnostic intervals. Three studies compared the impact of delay on younger versus older adult. One showed longer delays were associated with advanced stage and worse survival in younger but not older adults. Longer delays among younger adults with CRC occur in pre-diagnostic intervals.
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Affiliation(s)
- Matthew Castelo
- Department of Surgery, University of Toronto, Toronto, ON M5T 1P5, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Colin Sue-Chue-Lam
- Department of Surgery, University of Toronto, Toronto, ON M5T 1P5, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Lawrence Paszat
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 1P5, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Adena S. Scheer
- Department of Surgery, University of Toronto, Toronto, ON M5T 1P5, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 1P5, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, ON M5B 1W8, Canada
| | - Bettina E. Hansen
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Teruko Kishibe
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, ON M5B 1W8, Canada
| | - Nancy N. Baxter
- Department of Surgery, University of Toronto, Toronto, ON M5T 1P5, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 1P5, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, ON M5B 1W8, Canada
- School of Population and Global Health, University of Melbourne, 207 Bouverie St. Level 5, Melbourne, VIC 3010, Australia
- Correspondence: ; Tel.: +61-43-531-3313
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13
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Castelo M, Sue-Chue-Lam C, Paszat L, Kishibe T, Scheer AS, Hansen BE, Baxter NN. Time to diagnosis and treatment in younger adults with colorectal cancer: A systematic review. PLoS One 2022; 17:e0273396. [PMID: 36094913 PMCID: PMC9467377 DOI: 10.1371/journal.pone.0273396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 08/08/2022] [Indexed: 11/23/2022] Open
Abstract
Background The incidence of colorectal cancer is rising in adults <50 years of age. As a primarily unscreened population, they may have clinically important delays to diagnosis and treatment. This study aimed to review the literature on delay intervals in patients <50 years with colorectal cancer (CRC), and explore associations between longer intervals and outcomes. Methods MEDLINE, Embase, and LILACS were searched until December 2, 2021. We included studies published after 1990 reporting any delay interval in adults <50 with CRC. Interval measures and associations with stage at presentation or survival were synthesized and described in a narrative fashion. Risk of bias was assessed using the Newcastle-Ottawa Scale, Institute of Health Economics Case Series Quality Appraisal Checklist, and the Aarhus Checklist for cancer delay studies. Results 55 studies representing 188,530 younger CRC patients were included. Most studies used primary data collection (64%), and 47% reported a single center. Sixteen unique intervals were measured. The most common interval was symptom onset to diagnosis (21 studies; N = 2,107). By sample size, diagnosis to treatment start was the most reported interval (12 studies; N = 170,463). Four studies examined symptoms onset to treatment start (total interval). The shortest was a mean of 99.5 days and the longest was a median of 217 days. There was substantial heterogeneity in the measurement of intervals, and quality of reporting. Higher-quality studies were more likely to use cancer registries, and be population-based. In four studies reporting the relationship between intervals and cancer stage or survival, there were no clear associations between longer intervals and adverse outcomes. Discussion Adults <50 with CRC may have intervals between symptom onset to treatment start greater than 6 months. Studies reporting intervals among younger patients are limited by inconsistent results and heterogeneous reporting. There is insufficient evidence to determine if longer intervals are associated with advanced stage or worse survival. Other This study’s protocol was registered with the Prospective Register of Systematic Reviews (PROSPERO; registration number CRD42020179707).
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Affiliation(s)
- Matthew Castelo
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Colin Sue-Chue-Lam
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Lawrence Paszat
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Teruko Kishibe
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Adena S. Scheer
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Bettina E. Hansen
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Nancy N. Baxter
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
- * E-mail:
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14
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Vogel JD, Felder SI, Bhama AR, Hawkins AT, Langenfeld SJ, Shaffer VO, Thorsen AJ, Weiser MR, Chang GJ, Lightner AL, Feingold DL, Paquette IM. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Colon Cancer. Dis Colon Rectum 2022; 65:148-177. [PMID: 34775402 DOI: 10.1097/dcr.0000000000002323] [Citation(s) in RCA: 101] [Impact Index Per Article: 50.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
| | | | | | | | | | | | - Amy J Thorsen
- Colon and Rectal Surgery Associates, Minneapolis, Minnesota
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15
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Brajcich BC, Benson AB, Gantt G, Eng OS, Marsh RW, Mulcahy MF, Polite BN, Shogan BD, Yang AD, Merkow RP. Management of colorectal cancer during the COVID-19 pandemic: Recommendations from a statewide multidisciplinary cancer collaborative. J Surg Oncol 2021; 125:560-563. [PMID: 34820843 PMCID: PMC9015333 DOI: 10.1002/jso.26758] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 11/13/2021] [Indexed: 11/09/2022]
Abstract
COVID‐19 has resulted in significant disruptions in cancer care. The Illinois Cancer Collaborative (ILCC), a statewide multidisciplinary cancer collaborative, has developed expert recommendations for triage and management of colorectal cancer when disruptions occur in usual care. Such recommendations would be applicable to future outbreaks of COVID‐19 or other large‐scale disruptions in cancer care.
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Affiliation(s)
- Brian C Brajcich
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, Illinois, USA
| | - Al B Benson
- Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Gerald Gantt
- Department of Surgery, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Oliver S Eng
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Robert W Marsh
- Department of Medical Oncology, NorthShore University HealthSystem, University of Chicago, Chicago, Illinois, USA
| | - Mary F Mulcahy
- Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Blase N Polite
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Benjamin D Shogan
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Anthony D Yang
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, Illinois, USA
| | - Ryan P Merkow
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, Illinois, USA
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16
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Lo BD, Caturegli G, Stem M, Biju K, Safar B, Efron JE, Rajput A, Atallah C. The Impact of Surgical Delays on Short- and Long-Term Survival Among Colon Cancer Patients. Am Surg 2021; 87:1783-1792. [PMID: 34666557 DOI: 10.1177/00031348211047511] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The purpose of this study was to assess the impact of surgical delays on short- and long-term survival among colon cancer patients. METHODS Adult patients undergoing surgery for stage I, II, or III colon cancer were identified from the National Cancer Database (2010-2016). After categorization by wait times from diagnosis to surgery (<1 week, 1-3 weeks, 3-6 weeks, 6-9 weeks, 9-12 weeks, and >12 weeks), 30-day mortality, 90-day mortality, and 5-year overall survival were compared between patients both overall and after stratification by pathological disease stage. RESULTS Among 187 394 colon cancer patients, 24.2% waited <1 week, 30.5% waited 1-3 weeks, 29.0% waited 3-6 weeks, 9.7% waited 6-9 weeks, 3.3% waited 9-12 weeks, and 3.3% waited >12 weeks for surgery. Patients undergoing surgery 3-6 weeks after colon cancer diagnosis exhibited the best 30-day mortality (1.3%), 90-day mortality (2.3%), and 5-year overall survival (71.8%) (P < .001 for all). After risk-adjusting for confounders, all wait times beyond 6 weeks were associated with worse 5-year overall survival (6-9 weeks: HR 1.10, 95% CI 1.06-1.15; 9-12 weeks: HR 1.25, 95% CI 1.18-1.33; >12 weeks: HR 1.43, 95% CI 1.35-1.52; P < .001 for all). Subgroup analysis after stratification by disease stage demonstrated that patients with stage III colon cancer were able to wait up to 9 weeks before exhibiting worse 5-year overall survival, compared to 6 weeks for patients with stage I or II disease. CONCLUSIONS Colon cancer patients should undergo surgery 3-6 weeks after diagnosis, as all surgical delays beyond 6 weeks were associated with worse 30-day mortality, 90-day mortality, and 5-year overall survival.
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Affiliation(s)
- Brian D Lo
- Colorectal Research Unit, Department of Surgery, 1500The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Giorgio Caturegli
- Colorectal Research Unit, Department of Surgery, 1500The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Miloslawa Stem
- Colorectal Research Unit, Department of Surgery, 1500The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kevin Biju
- Colorectal Research Unit, Department of Surgery, 1500The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bashar Safar
- Colorectal Research Unit, Department of Surgery, 1500The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan E Efron
- Colorectal Research Unit, Department of Surgery, 1500The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ashwani Rajput
- Colorectal Research Unit, Department of Surgery, 1500The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chady Atallah
- Colorectal Research Unit, Department of Surgery, 1500The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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17
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What's the magic number? Impact of time to initiation of treatment for rectal cancer. Surgery 2021; 171:1185-1192. [PMID: 34565608 PMCID: PMC8940728 DOI: 10.1016/j.surg.2021.08.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 07/20/2021] [Accepted: 08/17/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND National guidelines, including the National Accreditation Program for Rectal Cancer, recommend initiation of rectal cancer treatment within 60 days of diagnosis; however, the effect of timely treatment initiation on oncologic outcomes is unclear. The purpose of this study was to evaluate the impact on oncologic outcomes of initiation of rectal cancer treatment within 60 days of diagnosis. METHODS This was a retrospective review of stage II/III rectal cancer patients performed using the United States Rectal Cancer Consortium, a collaboration of 6 academic medical centers. Patients with clinical stage II/III rectal cancer who underwent radical resection between January 1, 2010 and December 31, 2018 were included. The primary exposure was treatment initiation, defined as either resection or initiation of chemotherapy or chemoradiotherapy, within 60 days of diagnosis. The primary outcome was disease recurrence, and the secondary outcome was all-cause mortality. RESULTS A total of 1,031 patients meeting inclusion criteria were included in the analysis. Treatment was initiated within 60 days of diagnosis in 830 patients (80.5%) and after 60 days in 201 patients (20.3%). In multivariable logistic regression, older age, non-White race, and residence greater than 100 miles from the treatment center were significantly associated with delay in treatment beyond 60 days. In survival analysis, 167 patients (16.2%) experienced recurrent disease, and 127 patients (12.3%) died of any cause. In an adjusted model accounting for pathologic staging, treatment sequence, distance to care, age, comorbidities, treatment center, and receipt of adjuvant chemotherapy, neither progression-free survival nor all-cause mortality was significantly associated with timely initiation of therapy with hazard ratios of 1.09 (0.70, 1.69) and 1.03 (0.63, 1.66), respectively. CONCLUSION This study found no difference in oncologic outcomes with initiation of treatment beyond 60 days.
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18
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Franssen RFW, Strous MTA, Bongers BC, Vogelaar FJ, Janssen-Heijnen MLG. The Association Between Treatment Interval and Survival in Patients With Colon or Rectal Cancer: A Systematic Review. World J Surg 2021; 45:2924-2937. [PMID: 34175967 PMCID: PMC8322003 DOI: 10.1007/s00268-021-06188-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Surgery for colon or rectal cancer is associated with a high incidence of complications, especially in patients with a low aerobic fitness. Those patients might benefit from a comprehensive preoperative workup including prehabilitation. However, time between diagnosis and treatment is often limited due to current treatment guidelines. To date, it is unclear whether the treatment interval can be extended without compromising survival. METHODS A systematic review concerning the association between treatment intervals and survival in patients who underwent elective curative surgery for colon or rectal cancer was performed. A search up to December 2020 was conducted in PubMed, Cinahl and Embase. Original research articles were eligible. Quality assessment was performed using the Downs and Black checklist. RESULTS Eleven observational studies were included (897 947 patients). In colon cancer, treatment intervals that were statistically significant associated with reduced overall survival or cancer-specific survival ranged between > 30 and > 84 days. In rectal cancer, only one out of four studies showed that treatment intervals > 49 days was associated with reduced cancer-specific survival. CONCLUSIONS This systematic review identified that studies investigating the association between treatment intervals and survival are heterogeneous with regard to treatment interval definitions, treatment interval time intervals and used outcome measures. These aspects need standardization before a reliable estimate of an optimal treatment interval can be made. In addition, further research should focus on establishing optimal treatment intervals in patients at high risk for postoperative complications, as particularly these patients might benefit from extended diagnosis to treatment intervals permitting comprehensive preoperative preparation.
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Affiliation(s)
- Ruud F W Franssen
- Department of Clinical Physical Therapy, VieCuri Medical Center, Venlo Tegelseweg, Venlo, 210 5912BL, The Netherlands.
- Department of Epidemiology, GROW School for Oncology and Developmental Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.
| | - Maud T A Strous
- Department of Epidemiology, GROW School for Oncology and Developmental Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Surgery, VieCuri Medical Center, Venlo, The Netherlands
| | - Bart C Bongers
- Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - F Jeroen Vogelaar
- Department of Surgery, VieCuri Medical Center, Venlo, The Netherlands
| | - Maryska L G Janssen-Heijnen
- Department of Epidemiology, GROW School for Oncology and Developmental Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Epidemiology, VieCuri Medical Center, Venlo, The Netherlands
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19
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Whittaker TM, Abdelrazek MEG, Fitzpatrick AJ, Froud JLJ, Kelly JR, Williamson JS, Williams GL. Delay to elective colorectal cancer surgery and implications for survival: a systematic review and meta-analysis. Colorectal Dis 2021; 23:1699-1711. [PMID: 33714235 PMCID: PMC8251304 DOI: 10.1111/codi.15625] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/26/2021] [Accepted: 02/21/2021] [Indexed: 12/11/2022]
Abstract
AIM The Covid-19 pandemic has delayed elective colorectal cancer (CRC) surgery. The aim of this study was to see whether or not this may affect overall survival (OS) and disease-free survival (DFS). METHOD A systematic review was carried out according to PRISMA guidelines (PROSPERO ID: CRD42020189158). Medline, EMBASE and Scopus were interrogated. Patients aged over 18 years with a diagnosis of colon or rectal cancer who received elective surgery as their primary treatment were included. Delay to elective surgery was defined as the period between CRC diagnosis and the day of surgery. Meta-analysis of the outcomes OS and DFS were conducted. Forest plots, funnel plots and tests of heterogeneity were produced. An estimated number needed to harm (NNH) was calculated for statistically significant pooled hazard ratios (HRs). RESULTS Of 3753 articles identified, seven met the inclusion criteria. Encompassing 314 560 patients, three of the seven studies showed that a delay to elective resection is associated with poorer OS or DFS. OS was assessed at a 1 month delay, the HR for six datasets was 1.13 (95% CI 1.02-1.26, p = 0.020) and at 3 months the pooled HR for three datasets was 1.57 (95% CI 1.16-2.12, p = 0.004). The estimated NNH for a delay at 1 month and 3 months was 35 and 10 respectively. Delay was nonsignificantly negatively associated with DFS on meta-analysis. CONCLUSION This review recommends that elective surgery for CRC patients is not postponed longer than 4 weeks, as available evidence suggests extended delays from diagnosis are associated with poorer outcomes. Focused research is essential so patient groups can be prioritized based on risk factors in future delays or pandemics.
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20
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de la Portilla de Juan F, Reyes Díaz ML, Ramallo Solía I. Impact of the pandemic on surgical activity in colorectal cancer in Spain. Results of a national survey. Cir Esp 2021; 99:500-505. [PMID: 34210653 DOI: 10.1016/j.cireng.2021.06.009] [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: 06/08/2020] [Accepted: 07/22/2020] [Indexed: 01/05/2023]
Abstract
INTRODUCTION The pandemic has had an impact on colorectal cancer surgery in hospitals. In 2020, up to 75% of colorectal cancer patients are estimated to require surgery. No objective data on the impact of the pandemic on the management of surgical waiting lists is available. We conducted a survey in colorectal surgery units to assess the impact on colorectal cancer surgery waiting lists. METHOD All personnel in charge of colorectal surgery units nationwide received a survey (from February to April, 2020) with eight questions divided into three sections-cessation date of colorectal cancer surgeries, number of patients waiting for treatment, and use of neoadjuvant therapy to postpone surgery. RESULTS Sixty-seven units participated in the study, with 79.1% of units ceasing some type of activity (32.8% total and 46.3% partial cessation) and 20.9% continuing all surgical activity. In addition, 65% of units used or prolonged neoadjuvant therapy in rectal cancer patients and 40% of units performed at least five emergency colorectal cancer surgeries. It was estimated that at least one month of intense surgical activity will be required to catch up. CONCLUSIONS Currently, patients from units with a long waiting list must be redistributed, at least within the country. In the future, in the event of a second wave of the pandemic, an effective program to manage each unit's resources should be developed to prevent total collapse.
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Affiliation(s)
- Fernando de la Portilla de Juan
- Asociación Española de Coloproctología, Madrid, Spain; Unidad de Coloproctología, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Instituto de Biomedicina de Sevilla/CSIC, Sevilla, Spain.
| | - María Luisa Reyes Díaz
- Unidad de Coloproctología, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Instituto de Biomedicina de Sevilla/CSIC, Sevilla, Spain
| | - Irene Ramallo Solía
- Unidad de Coloproctología, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Instituto de Biomedicina de Sevilla/CSIC, Sevilla, Spain
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21
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Longer time-to-treatment but better survival for colorectal cancer patients presumptively not diagnosed in a hospital. Cancer Causes Control 2021; 32:1185-1191. [PMID: 34160709 DOI: 10.1007/s10552-021-01464-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 06/14/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To evaluate time-to-treatment and survival time in colorectal cancer (CRC) patients who presumptively were not diagnosed in a hospital. METHODS Colorectal tumor-level data from Georgia Cancer Registry (GCR) was merged with American Hospital Association data for 2010-2015 using hospital identification number. Patients with tumors lacking a diagnosis hospital in the GCR were classified as presumptive non-hospital diagnosis (PNHD). Cox proportional hazard models were used to model PNHD and time-to-treatment and time-to-death following cancer diagnosis, stratified by race and controlling for personal and tumor characteristics. RESULTS PNHD (n = 6,885, 29.6%) was associated with a lower likelihood of treatment at a given point in time (i.e., longer time-to-treatment), but did not differ for Black (HR = 0.77, 95% CI: 0.73, 0.82) and White (HR = 0.73, 95% CI: 0.71, 0.76) patients. Time-to-death was longer (i.e., better survival) with PNHD, which also did not differ for Black (HR = 0.70, 95% CI: 0.64, 0.76) and White (HR = 0.71, 95% CI: 0.67, 0.75) patients. These results were not explained by confounding factors or differences in tumor stage at diagnosis. CONCLUSIONS These observations warrant further research to understand whether there are potentially modifiable factors associated with the diagnosing location that can be used to benefit patient treatment trajectory and survival.
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22
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DE Rosa M, Pasculli A, Rondelli F, Mariani L, Avenia S, Ceccarelli G, Testini M, Avenia N, Bugiantella W. Could diagnostic and therapeutic delay affect the prognosis of gastrointestinal primary malignancies in the COVID-19 pandemic era? A literature review. Minerva Surg 2021; 76:467-476. [PMID: 33890444 DOI: 10.23736/s2724-5691.21.08736-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Emergency situations, as the Covid-19 pandemic that is striking the world nowadays, stress the national health systems which are forced to rapidly reorganizing their sources. Therefore, many elective diagnostic and surgical procedures are being suspended or significantly delayed. Moreover, patients might find it difficult to refer to physicians and delay the diagnostic and even the therapeutic procedures because of emotional or logistic problems. The effect of diagnostic and therapeutic delay on survival in patients affected by gastrointestinal malignancies is still unclear. METHODS We carried out a review of the available literature, in order to determine whether the delay in performing diagnosis and curative-intent surgical procedures affects the oncological outcomes in patients with oesophageal, gastric, colorectal cancers, and colorectal liver metastasis. RESULTS The findings indicate that for oesophageal, gastric and colon cancers delaying surgery up to 2 months after the end of the staging process does not worsen the oncological outcomes. Oesophageal cancer should undergo surgery within 7-8 weeks after the end of neoadjuvant chemoradiation. Rectal cancers should undergo surgery within 31 days after the diagnostic process and within 12 weeks after neoadjuvant therapy. Adjuvant therapy should start within 4 weeks after surgery, especially in gastric cancer; a delay up to 42 days may be allowed for oesophageal cancer undergoing adjuvant radiotherapy. CONCLUSIONS Gastrointestinal malignancies can be safely managed taking into account that reasonable delays of planned treatments appear a generally safe approach, not having a significant impact on long-term oncological outcome.
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Affiliation(s)
- Michele DE Rosa
- General Surgery, San Giovanni Battista Hospital, USL Umbria 2, Foligno, Perugia, Italy
| | - Alessandro Pasculli
- Department of Biomedical Sciences and Human Oncology - Unit Of Endocrine, Digestive And Emergency Surgery, University A. Moro of Bari, Polyclinic of Bari, Bari, Italy
| | - Fabio Rondelli
- General and Specialized Surgery, Santa Maria Hospital, Terni, Italy.,Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Lorenzo Mariani
- General Surgery, San Giovanni Battista Hospital, USL Umbria 2, Foligno, Perugia, Italy
| | - Stefano Avenia
- Postgraduate School of General Surgery, University of Perugia, Perugia, Italy
| | - Graziano Ceccarelli
- General Surgery, San Giovanni Battista Hospital, USL Umbria 2, Foligno, Perugia, Italy
| | - Mario Testini
- Department of Biomedical Sciences and Human Oncology - Unit Of Endocrine, Digestive And Emergency Surgery, University A. Moro of Bari, Polyclinic of Bari, Bari, Italy
| | - Nicola Avenia
- General and Specialized Surgery, Santa Maria Hospital, Terni, Italy.,Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Walter Bugiantella
- General Surgery, San Giovanni Battista Hospital, USL Umbria 2, Foligno, Perugia, Italy -
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23
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Molenaar CJL, Janssen L, van der Peet DL, Winter DC, Roumen RMH, Slooter GD. Conflicting Guidelines: A Systematic Review on the Proper Interval for Colorectal Cancer Treatment. World J Surg 2021; 45:2235-2250. [PMID: 33813632 DOI: 10.1007/s00268-021-06075-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Timely treatment for colorectal cancer (CRC) is a quality indicator in oncological care. However, patients with CRC might benefit more from preoperative optimization rather than rapid treatment initiation. The objectives of this study are (1) to determine the definition of the CRC treatment interval, (2) to study international recommendations regarding this interval and (3) to study whether length of the interval is associated with outcome. METHODS We performed a systematic search of the literature in June 2020 through MEDLINE, EMBASE and Cochrane databases, complemented with a web search and a survey among colorectal surgeons worldwide. Full-text papers including subjects with CRC and a description of the treatment interval were included. RESULTS Definition of the treatment interval varies widely in published studies, especially due to different starting points of the interval. Date of diagnosis is often used as start of the interval, determined with date of pathological confirmation. The end of the interval is rather consistently determined with date of initiation of any primary treatment. Recommendations on the timeline of the treatment interval range between and within countries from two weeks between decision to treat and surgery, to treatment within seven weeks after pathological diagnosis. Finally, there is no decisive evidence that a longer treatment interval is associated with worse outcome. CONCLUSIONS The interval from diagnosis to treatment for CRC treatment could be used for prehabilitation to benefit patient recovery. It may be that this strategy is more beneficial than urgently proceeding with treatment.
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Affiliation(s)
- Charlotte J L Molenaar
- Department of Surgery, Máxima MC, De Run 4600, P.O. Box 7777, 5504 DB, Veldhoven, The Netherlands.
| | - Loes Janssen
- Department of Surgery, Máxima MC, De Run 4600, P.O. Box 7777, 5504 DB, Veldhoven, The Netherlands
| | - Donald L van der Peet
- Department of Surgery, Amsterdam UMC, Location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Desmond C Winter
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin, D04T6F4, Ireland
| | - Rudi M H Roumen
- Department of Surgery, Máxima MC, De Run 4600, P.O. Box 7777, 5504 DB, Veldhoven, The Netherlands
| | - Gerrit D Slooter
- Department of Surgery, Máxima MC, De Run 4600, P.O. Box 7777, 5504 DB, Veldhoven, The Netherlands
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24
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Degeling K, Baxter NN, Emery J, Jenkins MA, Franchini F, Gibbs P, Mann GB, McArthur G, Solomon BJ, IJzerman MJ. An inverse stage-shift model to estimate the excess mortality and health economic impact of delayed access to cancer services due to the COVID-19 pandemic. Asia Pac J Clin Oncol 2021; 17:359-367. [PMID: 33567163 PMCID: PMC8014813 DOI: 10.1111/ajco.13505] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/07/2020] [Indexed: 11/30/2022]
Abstract
AIM Decreased cancer incidence and reported changes to clinical management indicate that the COVID-19 pandemic has delayed cancer diagnosis and treatment. This study aimed to develop and apply a flexible model to estimate the impact of delayed diagnosis and treatment on survival outcomes and healthcare costs based on a shift in the disease stage at treatment initiation. METHODS A model was developed and made publicly available to estimate population-level health economic outcomes by extrapolating and weighing stage-specific outcomes by the distribution of stages at treatment initiation. It was applied to estimate the impact of 3- and 6-month delays based on Australian data for stage I breast cancer, colorectal cancer, and lung cancer patients, and for T1 melanoma. Two approaches were explored to estimate stage shifts following a delay: (a) based on the relation between time to treatment initiation and overall survival (breast, colorectal, and lung cancer), and (b) based on the tumor growth rate (melanoma). RESULTS Using a conservative once-off 3-month delay and considering only shifts from stage I/T1 to stage II/T2, 88 excess deaths and $12 million excess healthcare costs were predicted in Australia over 5 years for all patients diagnosed in 2020. For a 6-month delay, excess mortality and healthcare costs were 349 deaths and $46 million over 5 years. CONCLUSIONS The health and economic impacts of delays in treatment initiation cause an imminent policy concern. More accurate individual patient data on shifts in stage of disease during and after the COVID-19 pandemic are critical for further analyses.
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Affiliation(s)
- Koen Degeling
- Centre for Cancer Research and Centre for Health Policy, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia.,Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Nancy N Baxter
- Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Jon Emery
- Centre for Cancer Research and Department of General Practice, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Mark A Jenkins
- Centre for Epidemiology and Biostatistics, School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Fanny Franchini
- Centre for Cancer Research and Centre for Health Policy, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia.,Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia.,Department of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Peter Gibbs
- Division of Personalised Oncology, Walter and Eliza Hall Research Institute, Melbourne, Australia.,Department Medical Oncology, Western Health, Melbourne, Australia
| | - G Bruce Mann
- Department of Surgery, University of Melbourne, Melbourne, Australia
| | - Grant McArthur
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.,Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Benjamin J Solomon
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.,Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Maarten J IJzerman
- Centre for Cancer Research and Centre for Health Policy, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia.,Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia.,Department of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Australia.,Health Technology and Services Research, Technical Medical Centre, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, the Netherlands
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25
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Colorectal surgery during the COVID-19 outbreak: do we need to change? Updates Surg 2021; 73:173-177. [PMID: 33387170 PMCID: PMC7778389 DOI: 10.1007/s13304-020-00947-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 12/08/2020] [Indexed: 12/26/2022]
Abstract
The outbreak of COVID-19 has led some leading surgical societies to postpone colorectal cancer resections, support the employment of low-risk strategies in patients requiring colorectal surgery, such as construction of a stoma rather than primary anastomosis, in order to minimize the risk of potentially life-threatening complications. They have also recommended against the use of the laparoscopic approach. However, the evidence supporting these recommendations is scarce. The aim of this study was to assess the outcomes of colorectal resections during the COVID-19 pandemic. This is a retrospective review of a prospective institutional database. All consecutive patients undergoing elective or emergent colorectal resections between March 9 and April 15, 2020, were compared to those treated in the same period of time in 2019. Despite an overall reduction in the surgical activity of 56.3% in 2020, the two groups were similar in terms of absolute numbers of colorectal resections, type of surgery and use of laparoscopy. The overall postoperative complications rate was similar: 20% in 2019 versus 14.9% in 2020 (p = 0.518), without any difference in terms of severity. No patient during the postoperative course got infected by COVID-19, as well as none from the surgical team. Median length of hospital stay was 5 days in both groups (p = 0.555). Postponing surgery in colorectal cancer patients and performing more stomas rather than direct anastomosis is not justified. The routine use of laparoscopy should not be abandoned, thus not depriving patients of its clinically relevant early short-term benefits over open surgery.
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26
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Johnson BA, Waddimba AC, Ogola GO, Fleshman JW, Preskitt JT. A systematic review and meta-analysis of surgery delays and survival in breast, lung and colon cancers: Implication for surgical triage during the COVID-19 pandemic. Am J Surg 2020; 222:311-318. [PMID: 33317814 PMCID: PMC7834494 DOI: 10.1016/j.amjsurg.2020.12.015] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 12/02/2020] [Accepted: 12/06/2020] [Indexed: 02/08/2023]
Abstract
Background Thousands of cancer surgeries were delayed during the peak of the COVID-19 pandemic. This study examines if surgical delays impact survival for breast, lung and colon cancers. Methods PubMed/MEDLINE, EMBASE, Cochrane Library and Web of Science were searched. Articles evaluating the relationship between delays in surgery and overall survival (OS), disease-free survival (DFS) or cancer-specific survival (CSS) were included. Results Of the 14,422 articles screened, 25 were included in the review and 18 (totaling 2,533,355 patients) were pooled for meta-analyses. Delaying surgery for 12 weeks may decrease OS in breast (HR 1.46, 95%CI 1.28–1.65), lung (HR 1.04, 95%CI 1.02–1.06) and colon (HR 1.24, 95%CI 1.12–1.38) cancers. When breast cancers were analyzed by stage, OS was decreased in stages I (HR 1.27, 95%CI 1.16–1.40) and II (HR 1.13, 95%CI 1.02–1.24) but not in stage III (HR 1.20, 95%CI 0.94–1.53). Conclusion Delaying breast, lung and colon cancer surgeries during the COVID-19 pandemic may decrease survival. Delaying cancer surgeries during the COVID-19 pandemic may impact survival. Surgical delays of 12 weeks decreases survival in breast, lung and colon cancers. Surgical delays worsen survival in stage I and II breast cancers but not stage III. Triage recommendations for future waves of COVID-19 should consider this evidence.
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Affiliation(s)
- Brett A Johnson
- College of Medicine, Texas A&M Health Science Center, Dallas Campus, Texas, United States; Division of Surgical Oncology, Department of Surgery, Baylor University Medical Center, Dallas, TX, United States.
| | - Anthony C Waddimba
- Health Systems Science, Department of Surgery, Baylor University Medical Center, Dallas, TX, United States; Baylor Scott and White Research Institute, Dallas, TX, United States.
| | - Gerald O Ogola
- Baylor Scott and White Research Institute, Dallas, TX, United States; Biostatistics, Department of Surgery, Baylor University Medical Center, Dallas, TX, United States.
| | - James W Fleshman
- Division of Colon and Rectal Surgery, Department of Surgery, Baylor University Medical Center, Dallas, TX, United States.
| | - John T Preskitt
- Division of Surgical Oncology, Department of Surgery, Baylor University Medical Center, Dallas, TX, United States.
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27
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de la Portilla de Juan F, Reyes Díaz ML, Ramallo Solía I. [Impact of the pandemic on surgical activity in colorectal cancer in Spain. Results of a national survey]. Cir Esp 2020; 99:S0009-739X(20)30265-7. [PMID: 34629479 PMCID: PMC7462580 DOI: 10.1016/j.ciresp.2020.07.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 07/22/2020] [Indexed: 01/05/2023]
Abstract
INTRODUCTION The pandemic has had an impact on colorectal cancer surgery in hospitals. In 2020, up to 75% of colorectal cancer patients are estimated to require surgery. No objective data on the impact of the pandemic on the management of surgical waiting lists is available. We conducted a survey in colorectal surgery units to assess the impact on colorectal cancer surgery waiting lists. METHOD All personnel in charge of colorectal surgery units nationwide received a survey (from February to April, 2020) with eight questions divided into three sections-cessation date of colorectal cancer surgeries, number of patients waiting for treatment, and use of neoadjuvant therapy to postpone surgery. RESULTS Sixty-seven units participated in the study, with 79.1% of units ceasing some type of activity (32.8% total and 46.3% partial cessation) and 20.9% continuing all surgical activity. In addition, 65% of units used or prolonged neoadjuvant therapy in rectal cancer patients and 40% of units performed at least five emergency colorectal cancer surgeries. It was estimated that at least one month of intense surgical activity will be required to catch up. CONCLUSIONS Currently, patients from units with a long waiting list must be redistributed, at least within the country. In the future, in the event of a second wave of the pandemic, an effective program to manage each unit's resources should be developed to prevent total collapse.
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Affiliation(s)
- Fernando de la Portilla de Juan
- Asociación Española de Coloproctología, Madrid, España
- Unidad de Coloproctología. Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Instituto de Biomedicina de Sevilla/CSIC, Sevilla, España
| | - María Luisa Reyes Díaz
- Unidad de Coloproctología. Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Instituto de Biomedicina de Sevilla/CSIC, Sevilla, España
| | - Irene Ramallo Solía
- Unidad de Coloproctología. Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Instituto de Biomedicina de Sevilla/CSIC, Sevilla, España
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28
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Management Considerations for the Surgical Treatment of Colorectal Cancer During the Global Covid-19 Pandemic. Ann Surg 2020; 272:e98-e105. [PMID: 32452949 PMCID: PMC7373490 DOI: 10.1097/sla.0000000000004029] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Objective: The COVID-19 pandemic requires to conscientiously weigh “timely surgical intervention” for colorectal cancer against efforts to conserve hospital resources and protect patients and health care providers. Summary Background Data: Professional societies provided ad-hoc guidance at the outset of the COVID-19 pandemic on deferral of surgical and perioperative interventions, but these lack specific parameters to determine the optimal timing of surgery. Methods: Using the GRADE system, published evidence was analyzed to generate weighted statements for stage, site, acuity of presentation, and hospital setting to specify when surgery should be pursued, the time and duration of oncologically acceptable delays, and when to utilize nonsurgical modalities to bridge the waiting period. Results: Colorectal cancer surgeries—prioritized as emergency, urgent with imminent emergency or oncologically urgent, or elective—were matched against the phases of the pandemic. Surgery in COVID-19-positive patients must be avoided. Emergent and imminent emergent cases should mostly proceed unless resources are exhausted. Standard practices allow for postponement of elective cases and deferral to nonsurgical modalities of stage II/III rectal and metastatic colorectal cancer. Oncologically urgent cases may be delayed for 6(–12) weeks without jeopardizing oncological outcomes. Outside established principles, administration of nonsurgical modalities is not justified and increases the vulnerability of patients. Conclusions: The COVID-19 pandemic has stressed already limited health care resources and forced rationing, triage, and prioritization of care in general, specifically of surgical interventions. Established guidelines allow for modifications of optimal timing and type of surgery for colorectal cancer during an unrelated pandemic.
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29
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Lazzeri G, Troiano G, Porchia BR, Centauri F, Mezzatesta V, Presicce G, Matarrese D, Gusinu R. Waiting times for prostate cancer: A review. J Public Health Res 2020; 9:1778. [PMID: 32550222 PMCID: PMC7282316 DOI: 10.4081/jphr.2020.1778] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 05/26/2020] [Indexed: 11/23/2022] Open
Abstract
Prostate cancer is one of the most common diagnosed cancers in men and the waiting time has become an important issue not only for clinical reasons, but also mostly for the psychological implications on patients. The aim of our study was to review and analyze the literature on waiting times for prostate cancer. In February-March 2019 we performed a search for original peerreviewed papers in the electronic database PubMed (MEDLINE). The key search terms were "prostate cancer AND waiting list", "prostate cancer AND waiting times". We included in our narrative review articles in Italian, English or French, published in 2009-2019 containing original data about the waiting times for prostate cancer. The literature search yielded 680 publications. Finally, we identified 8 manuscripts eligible for the review. The articles were published between 2010 and 2019; the studies involved a minimum of 16 to a maximum of 95438 participants. Studies have been conducted in 6 countries. The waiting times from cancer suspicion to histopathological diagnosis and to treatment had an important reduction in the last years, and this constant decrease could lead to an increase of patients' satisfaction.
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Affiliation(s)
- Giacomo Lazzeri
- Department of Molecular and Developmental Medicine, University of Siena.,Hospital Direction, Azienda Ospedaliera Universitaria Senese
| | | | | | | | | | | | | | - Roberto Gusinu
- Medical Chief Director, Azienda Ospedaliera Universitaria Senese, Italy
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30
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Boffa DJ, Mallin K, Herrin J, Resio B, Salazar MC, Palis B, Facktor M, McCabe R, Nelson H, Shulman LN. Survival After Cancer Treatment at Top-Ranked US Cancer Hospitals vs Affiliates of Top-Ranked Cancer Hospitals. JAMA Netw Open 2020; 3:e203942. [PMID: 32453382 PMCID: PMC7251445 DOI: 10.1001/jamanetworkopen.2020.3942] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE Hospital networks formed around top-ranked cancer hospitals represent an opportunity to optimize complex cancer care in the community. OBJECTIVE To compare the short- and long-term survival after complex cancer treatment at top-ranked cancer hospitals and the affiliates of top-ranked hospitals. DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted using data from the unabridged version of the National Cancer Database. Included patients were individuals 18 years or older who underwent surgical treatment for esophageal, gastric, lung, pancreatic, colorectal, or bladder cancer diagnosed between January 1, 2012, and December 31, 2016. Patient outcomes after complex surgical procedures for cancer at top-ranked cancer hospitals (as ranked in top 50 by US News and World Report) were compared with outcomes at affiliates of top-ranked cancer hospitals (affiliation listed in American Hospitals Association survey and confirmed by search of internet presence). Data were analyzed from July through December 2019. EXPOSURES Undergoing complex cancer treatment at a top-ranked cancer hospital or an affiliated hospital. MAIN OUTCOMES AND MEASURES The association of affiliate status with short-term survival (ie, 90-day mortality) was compared using logistic regression, and the association of affiliate status with long-term survival was compared using time-to-event models, adjusting for patient demographic, payer, clinical, and treatment factors. RESULTS Among 119 834 patients who underwent surgical treatment for cancer, 79 981 patients (66.7%) were treated at top-ranked cancer hospitals (median [interquartile range] age, 66 [58-74] years; 40 910 [54.9%] men) and 39 853 patients (33.3%) were treated at affiliate hospitals (median [interquartile range] age, 69 [60-77] years; 19 004 [50.0%] men). In a pooled analysis of all cancer types, adjusted perioperative mortality within 90 days of surgical treatment was higher at affiliate hospitals compared with top-ranked hospitals (odds ratio, 1.67 [95% CI, 1.49-1.89]; P < .001). Adjusted long-term survival following cancer treatment at affiliate hospitals was only 77% that of top-ranked hospitals (time ratio, 0.77 [95% CI, 0.72-0.83]; P < .001). The survival advantage was not fully explained by differences in annual surgical volume, with both long- and short-term survival remaining superior at top-ranked hospitals even after models were adjusted for volume. CONCLUSIONS AND RELEVANCE These findings suggest that short- and long-term survival after complex cancer treatment were superior at top-ranked hospitals compared with affiliates of top-ranked hospitals. Further study of cancer care within top-ranked cancer networks could reveal collaborative opportunities to improve survival across a broad contingent of the US population.
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Affiliation(s)
- Daniel J. Boffa
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Katherine Mallin
- American College of Surgeons Cancer Programs, National Cancer Database, Chicago, Illinois
| | - Jeph Herrin
- Cancer Outcomes Public Policy and Effectiveness Research Center, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Benjamin Resio
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Michelle C. Salazar
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Bryan Palis
- American College of Surgeons Cancer Programs, National Cancer Database, Chicago, Illinois
| | - Matthew Facktor
- Department of Thoracic Surgery, Geisinger Heart Institute, Danville, Pennsylvania
| | - Ryan McCabe
- American College of Surgeons Cancer Programs, National Cancer Database, Chicago, Illinois
| | - Heidi Nelson
- American College of Surgeons Cancer Programs, Chicago, Illinois
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31
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Grass F, Behm KT, Duchalais E, Crippa J, Spears GM, Harmsen WS, Hübner M, Mathis KL, Kelley SR, Pemberton JH, Dozois EJ, Larson DW. Impact of delay to surgery on survival in stage I-III colon cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2020; 46:455-461. [PMID: 31806516 DOI: 10.1016/j.ejso.2019.11.513] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 10/11/2019] [Accepted: 11/27/2019] [Indexed: 11/18/2022]
Abstract
PURPOSE To assess the impact of delay from diagnosis to curative surgery on survival in patients with non-metastatic colon cancer. METHODS National Cancer database (NCDB) analysis (2004-2013) including all consecutive patients diagnosed with stage I-III colon cancer and treated with primary elective curative surgery. Short and long delays were defined as lower and upper quartiles of time from diagnosis to treatment, respectively. Age-, sex-, race-, tumor stage and location-, adjuvant treatment-, comorbidity- and socioeconomic factors-adjusted overall survival (OS) was compared between the two groups (short vs. long delay). A multivariable Cox regression model was used to identify the independent impact of each factor on OS. RESULTS Time to treatment was <16 days in the short delay group (31,171 patients) and ≥37 days in the long delay group (29,617 patients). OS was 75.4 vs. 71.9% at 5 years and 56.6 vs. 49.7% at 10 years in short and long delay groups, respectively (both p < 0.0001). Besides demographic (comorbidities, advanced age) and pathological factors (transverse and right-vs. left-sided location, advanced tumor stage, poor differentiation, positive microscopic margins), treatment delay had a significant impact on OS (HR 1.06, 95% CI 1.05-1.07 per 14 day-delay) upon multivariable analysis. The adjusted hazard ratio for death increased continuously with delay times of longer than 30 days, to become significant after a delay of 40 days. CONCLUSION This analysis using a national cancer database revealed a significant impact on OS when surgeries for resectable colon cancer were delayed beyond 40 days from time of diagnosis.
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Affiliation(s)
- Fabian Grass
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA; Department of Visceral Surgery, Lausanne University Hospital, Bugnon 46, 1011, Lausanne, Switzerland
| | - Kevin T Behm
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Emilie Duchalais
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Jacopo Crippa
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Grant M Spears
- Department of Biostatistics, Mayo Clinic, Rochester, MN, 55905, USA
| | | | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital, Bugnon 46, 1011, Lausanne, Switzerland
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Scott R Kelley
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - John H Pemberton
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Eric J Dozois
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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Minicozzi P, Vicentini M, Innos K, Castro C, Guevara M, Stracci F, Carmona-Garcia M, Rodriguez-Barranco M, Vanschoenbeek K, Rapiti E, Katalinic A, Marcos-Gragera R, Van Eycken L, Sánchez MJ, Bielska-Lasota M, Rossi PG, Sant M. Comorbidities, timing of treatments, and chemotherapy use influence outcomes in stage III colon cancer: A population-based European study. Eur J Surg Oncol 2020; 46:1151-1159. [PMID: 32147427 DOI: 10.1016/j.ejso.2020.02.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/21/2020] [Accepted: 02/18/2020] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION For stage III colon cancer (CC), surgery followed by chemotherapy is the main curative approach, although optimum times between diagnosis and surgery, and surgery and chemotherapy, have not been established. MATERIALS AND METHODS We analysed a population-based sample of 1912 stage III CC cases diagnosed in eight European countries in 2009-2013 aiming to estimate: (i) odds of receiving postoperative chemotherapy, overall and within eight weeks of surgery; (ii) risks of death/relapse, according to treatment, Charlson Comorbidity Index, time from diagnosis to surgery for emergency and elective cases, and time from surgery to chemotherapy; and (iii) time-trends in chemotherapy use. RESULTS Overall, 97% of cases received surgery and 65% postoperative chemotherapy, with 71% of these receiving chemotherapy within eight weeks of surgery. Risks of death and relapse were higher for cases starting chemotherapy with delay, but better than for cases not given chemotherapy. Fewer patients with high comorbidities received chemotherapy than those with low (P < 0.001). Chemotherapy timing did not vary (P = 0.250) between high and low comorbidity cases. Electively-operated cases with low comorbidities received surgery more promptly than high comorbidity cases. Risks of death and relapse were lower for elective cases given surgery after four weeks than cases given surgery within a week. High comorbidities were always independently associated with poorer outcomes. Chemotherapy use increased over time. CONCLUSIONS Our data indicate that promptly-administered postoperative chemotherapy maximizes its benefit, and that careful assessment of comorbidities is important before treatment. The survival benefit associated with slightly delayed elective surgery deserves further investigation.
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Affiliation(s)
- Pamela Minicozzi
- Analytical Epidemiology and Health Impact Unit, Research Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Massimo Vicentini
- Epidemiology Unit, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Italy
| | - Kaire Innos
- Department of Epidemiology and Biostatistics, National Institute for Health Development, Tallinn, Estonia
| | - Clara Castro
- Cancer Epidemiology Group, IPO Porto Research Center (CI-IPOP), Portuguese Oncology Institute of Porto (IPO Porto), Porto, Portugal; EpiUnit, Institute of Public Health, University of Porto, Porto, Portugal
| | - Marcela Guevara
- Navarra Public Health Institute, Pamplona, Spain; IdiSNA, Navarra Institute for Health Research, Pamplona, Spain; Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Fabrizio Stracci
- Department of Experimental Medicine, Section of Public Health, University of Perugia, Perugia, Italy; Umbria Cancer Registry, Perugia, Italy
| | - MaCarmen Carmona-Garcia
- Medical Oncology Department, Catalan Institute of Oncology, Universitary Hospital Dr Josep Trueta, Girona, Spain; Descriptive Epidemiology, Genetics and Cancer Prevention Group, Biomedical Research Institute (IDIBGI), Girona, Spain
| | - Miguel Rodriguez-Barranco
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; Andalusian School of Public Health (EASP), Granada, Spain; Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), Granada, Spain
| | | | - Elisabetta Rapiti
- Geneva Cancer Registry, Global Health Institute, University of Geneva, Switzerland
| | | | - Rafael Marcos-Gragera
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; Descriptive Epidemiology, Genetics and Cancer Prevention Group, Biomedical Research Institute (IDIBGI), Girona, Spain; School of Medicine, University of Girona (UdG), Girona, Spain; Epidemiology Unit and Girona Cancer Registry, Oncology Coordination Plan, Department of Health Government of Catalonia, Catalan Institute of Oncology, Girona, Spain
| | | | - Maria José Sánchez
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; Andalusian School of Public Health (EASP), Granada, Spain; Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), Granada, Spain; Universidad de Granada (UGR), Granada, Spain
| | | | - Paolo Giorgi Rossi
- Epidemiology Unit, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Italy
| | - Milena Sant
- Analytical Epidemiology and Health Impact Unit, Research Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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The Association Between Wait Times for Colorectal Cancer Treatment and Health Care Costs: A Population-Based Analysis. Dis Colon Rectum 2020; 63:160-171. [PMID: 31842159 DOI: 10.1097/dcr.0000000000001517] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Health care costs and wait times for colorectal cancer treatment are increasing in Canada, but the association between the 2 remains unclear. OBJECTIVE This study aimed to determine the association between wait times and health care costs and utilization. DESIGN This is a population-based retrospective cohort study. SETTING This study was conducted in Manitoba, Canada. PATIENTS Patients diagnosed with colorectal cancer between 2004 and 2014 were sorted and ranked into quintiles based on the time from index contact for a colorectal cancer-related symptom to first treatment. MAIN OUTCOME MEASURES The primary outcome is risk-adjusted health care costs, and the secondary outcomes include health care utilization and overall mortality. RESULTS We included a total of 6936 patients. Total wait times ranged between 0 and 762 days. In comparison with very short wait times, longer wait times were associated with significantly increased costs (short: mean cost ratio 1.21; 95% CI, 1.10-1.32; moderate: mean cost ratio 1.30; 95% CI, 1.19-1.43; long: mean cost ratio 1.48; 95% CI, 1.33-1.64; and very long: mean cost ratio 1.39; 95% CI, 1.26-1.54). Compared with very short wait times, longer wait times were associated with significantly lower risk of mortality (short: HR, 0.78; 95% CI, 0.71-0.86; moderate: HR, 0.72; 95% CI, 0.65-0.80; long: HR, 0.73; 95% CI, 0.66-0.82; very long: HR, 0.76; 95% CI, 0.68-0.85). The median number of pretreatment radiological and endoscopic investigations and surgeon clinic visits increased over the study period across all wait time categories. LIMITATIONS This is a nonrandomized, retrospective cohort study with potentially limited generalizability. CONCLUSION Patients with very short and short wait times are likely those diagnosed with life-threatening complications of colorectal cancer. Outside this window, patients with longer wait times experience increased health care costs and utilization with similar overall mortality. Improved care coordination and patient navigation may help contain the increasing wait times and associated increasing health care costs and utilization. See Video Abstract at http://links.lww.com/DCR/B81. ASOCIACIÓN ENTRE LOS TIEMPOS DE ESPERA PARA EL TRATAMIENTO DE UN CÁNCER COLORRECTAL Y LOS COSTOS DE ATENCIÓN MÉDICA: UN ANÁLISIS DE POBLACIÓN: los costos de atención médica y los tiempos de espera para el tratamiento del cáncer colorrectal están aumentando en Canadá, pero la asociación entre los dos sigue sin estar clara.determinar la asociación entre los tiempos de espera y los costos y la utilización de la atención médicaun estudio de cohorte retrospectivo basado en la población.Manitoba, Canadálos pacientes diagnosticados con cáncer colorrectal entre 2004-2014 se clasificaron y sub-clasificaron en quintiles según el tiempo desde el primer contacto índice de síntomas relacionados con cáncer colorrectal hasta el primer tratamiento.El resultado primario son los costos de atención médica ajustados al riesgo, y los resultados secundarios incluyen la utilización de la atención médica y la mortalidad general.Incluimos un total de 6,936 pacientes. Los tiempos de espera totales oscilaron entre 0-762 días. En comparación con los tiempos de espera muy cortos, los tiempos de espera más largos se asociaron con costos significativamente mayores (Corto: relación de costo promedio 1.21, intervalo de confianza del 95% 1.10-1.32; Moderado: relación de costo promedio 1.30, intervalo de confianza del 95% 1.19-1.43; Largo: media relación de costo 1.48, intervalo de confianza del 95% 1.33-1.64; Muy largo: relación de costo promedio 1.39, intervalo de confianza del 95% 1.26-1.54). En comparación con tiempos de espera muy cortos, los tiempos de espera más largos se asociaron con un riesgo de mortalidad significativamente menor (Corto: razón de riesgo 0.78, intervalo de confianza del 95% 0.71-0.86; Moderado: razón de riesgo 0.72, intervalo de confianza del 95% 0.65-0.80; Largo: peligro cociente 0.73, intervalo de confianza del 95% 0.66-0.82; Muy largo: cociente de riesgos 0.76, intervalo de confianza del 95% 0.68-0.85). La mediana del número de investigaciones radiológicas y endoscópicas previas al tratamiento y las visitas al cirujano aumentaron durante el período de estudio en todas las categorías de tiempo de espera.estudio de cohortes retrospectivo, no aleatorio con generalización potencialmente limitadalos pacientes con tiempos de espera « muy cortos » y « cortos » son probablemente aquellos diagnosticados con complicaciones potencialmente mortales del cáncer colorrectal. Fuera de esta ventana, los pacientes con tiempos de espera más largos experimentan mayores costos de atención médica y utilización con una mortalidad general similar. La coordinación mejorada de la atención y la navegación del paciente pueden ayudar a contener el aumento de los tiempos de espera y el aumento de los costos y la utilización de la atención médica. Consulte Video Resumen en http://links.lww.com/DCR/B81. (Traducción-Dr. Edgar Xavier Delgadillo).
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Gastrointestinal Malignancies and the COVID-19 Pandemic: Evidence-Based Triage to Surgery. J Gastrointest Surg 2020; 24:2357-2373. [PMID: 32607860 PMCID: PMC7325836 DOI: 10.1007/s11605-020-04712-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 06/22/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The COVID-19 pandemic has led to widespread cancelation of electively scheduled surgeries, including for colorectal, pancreatic, and gastric cancer. The American College of Surgeons and the Society of Surgical Oncology have released guidelines for triage of these procedures. We seek to synthesize available evidence on delayed resection and oncologic outcomes, while also providing a critical assessment of the released guidelines. METHODS A systematic review was conducted to identify literature between 2005 and 2020 investigating the impact of time to surgery on oncologic outcomes in colorectal, pancreatic, and gastric cancer. RESULTS For colorectal cancer, 1066 abstracts were screened and 43 papers were included. In primarily resected colon cancer, delay over 30 to 40 days is associated with lower survival. In rectal cancer, time to surgery over 7 to 8 weeks following neoadjuvant therapy is associated with decreased survival. Three hundred ninety-four abstracts were screened for pancreatic cancer and nine studies were included. Two studies demonstrate increased unexpected progression with delayed surgery over 30 days. Out of 633 abstracts screened for gastric cancer, six studies were included. No identified study demonstrated worse survival with increased time to surgery. CONCLUSION Moderate evidence suggests that delayed resection of colorectal cancer worsens survival; the impact of time to surgery on gastric and pancreatic cancer outcomes is uncertain. Early resection of gastrointestinal malignancies provides the best chance for curative therapy. During the COVID-19 pandemic, prioritization of procedures should account for available evidence on time to surgery and oncologic outcomes.
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Trepanier M, Paradis T, Kouyoumdjian A, Dumitra T, Charlebois P, Stein BS, Liberman AS, Schwartzman K, Carli F, Fried GM, Feldman LS, Lee L. The Impact of Delays to Definitive Surgical Care on Survival in Colorectal Cancer Patients. J Gastrointest Surg 2020; 24:115-122. [PMID: 31367895 DOI: 10.1007/s11605-019-04328-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 07/08/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Treatment delay may have detrimental effects on cancer outcomes. The impact of longer delays on colorectal cancer outcomes remains poorly described. The objective of this study was to determine the effect of delays to curative-intent surgical resection on survival in colorectal cancer patients. METHODS All adult patients undergoing elective resection of primary non-metastatic colorectal adenocarcinoma from January 2009 to December 2014 were reviewed. Treatment delays were defined as the time from tissue diagnosis to definitive surgery, categorized as < 4, 4 to < 8, and ≥ 8 weeks. Primary outcomes were 5-year disease-free (DFS) and overall survival (OS). Statistical analysis included Kaplan-Meier curves and Cox regression models. RESULTS A total of 408 patients were included (83.2% colon;15.8% rectal) with a mean follow-up of 58.4 months (SD29.9). Fourteen percent (14.0%) of patients underwent resection < 4 weeks, 40.0% 4 to < 8 weeks, and 46.1% ≥ 8 weeks. More rectal cancer patients had treatment delay ≥ 8 weeks compared with colonic tumors (69.8% vs. 41.4%, p < 0.001). Cumulative 5-year DFS and OS were similar between groups (p = 0.558; p = 0.572). After adjusting for confounders, surgical delays were not independently associated with DFS and OS. CONCLUSIONS Treatment delays > 4 weeks were not associated with worse oncologic outcomes. Delaying surgery to optimize patients can safely be considered without compromising survival.
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Affiliation(s)
- Maude Trepanier
- Department of Surgery, McGill University Health Centre, 1650 Cedar ave, D16-116, Montreal, QC, H3G 1A4, Canada
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Tiffany Paradis
- Faculty of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Araz Kouyoumdjian
- Faculty of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Teodora Dumitra
- Department of Surgery, McGill University Health Centre, 1650 Cedar ave, D16-116, Montreal, QC, H3G 1A4, Canada
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Patrick Charlebois
- Department of Surgery, McGill University Health Centre, 1650 Cedar ave, D16-116, Montreal, QC, H3G 1A4, Canada
| | - Barry S Stein
- Department of Surgery, McGill University Health Centre, 1650 Cedar ave, D16-116, Montreal, QC, H3G 1A4, Canada
| | - A Sender Liberman
- Department of Surgery, McGill University Health Centre, 1650 Cedar ave, D16-116, Montreal, QC, H3G 1A4, Canada
| | - Kevin Schwartzman
- Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
- Department of Epidemiology, McGill University, Montreal, QC, Canada
| | - Franco Carli
- Department of Anesthesiology, McGill University Health Centre, Montreal, QC, Canada
| | - Gerald M Fried
- Department of Surgery, McGill University Health Centre, 1650 Cedar ave, D16-116, Montreal, QC, H3G 1A4, Canada
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Liane S Feldman
- Department of Surgery, McGill University Health Centre, 1650 Cedar ave, D16-116, Montreal, QC, H3G 1A4, Canada
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Lawrence Lee
- Department of Surgery, McGill University Health Centre, 1650 Cedar ave, D16-116, Montreal, QC, H3G 1A4, Canada.
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.
- Department of Epidemiology, McGill University, Montreal, QC, Canada.
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Strous MT, Janssen-Heijnen ML, Vogelaar F. Impact of therapeutic delay in colorectal cancer on overall survival and cancer recurrence – is there a safe timeframe for prehabilitation? EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2019; 45:2295-2301. [DOI: 10.1016/j.ejso.2019.07.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 05/19/2019] [Accepted: 07/03/2019] [Indexed: 11/17/2022]
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Chemopreventive effect of the polysaccharides from Grifola frondosa in colitis-associated colorectal cancer by modulating the Wnt/β-catenin/GSK-3β signaling pathway in C57BL/6 mice. J Funct Foods 2019. [DOI: 10.1016/j.jff.2019.103578] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Roder D, Karapetis CS, Olver I, Keefe D, Padbury R, Moore J, Joshi R, Wattchow D, Worthley DL, Miller CL, Holden C, Buckley E, Powell K, Buranyi-Trevarton D, Fusco K, Price T. Time from diagnosis to treatment of colorectal cancer in a South Australian clinical registry cohort: how it varies and relates to survival. BMJ Open 2019; 9:e031421. [PMID: 31575579 PMCID: PMC6797269 DOI: 10.1136/bmjopen-2019-031421] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES Some early studies indicated lower survival with longer time from diagnosis to cancer treatment, but others showed the reverse. We investigated time to treatment of colorectal cancer and associations with survival. SETTING AND PARTICIPANTS Clinical registry data for colorectal cancer cases diagnosed in 2000-2010 at four major public hospitals in South Australia and treated by surgery (n=1675), radiotherapy (n=616) and/or systemic therapy (n=1556). DESIGN A historic cohort design, with rank-order tests for ordinal clinical and sociodemographic predictors and multiple logistic regression for comparing time from diagnosis to treatment. Unadjusted Kaplan-Meier estimates and adjusted Cox proportional hazards regression were used to investigate disease-specific survival by time to treatment. OUTCOME MEASURES Time to treatment and survival from diagnosis to death from colorectal cancer. RESULTS Treatment (any type) commenced for 87% of surgical cases <60 days of diagnosis, with 80% having surgery within this period. Of those receiving radiotherapy, 59% began this treatment <60 days, and of those receiving systemic therapy, the corresponding proportion was 56%. Adjusted analyses showed treatment delay >60 days was more likely for rectal cancers, 2006-2010 diagnoses, residents of northern than other metropolitan regions and for surgery, younger ages <50 years and unexpectedly, those residing closer to metropolitan services. Adjusting for clinical and sociodemographic factors, and diagnostic year, better survival occurred in <2 years from diagnosis for time to treatment >30 days. Survival in the 3-10 years postdiagnosis generally did not differ by time to treatment, except for lower survival for any treatment >90 days for surgical cases. CONCLUSIONS The lower survival <2 years from diagnosis for treatment <30 days of diagnosis is consistent with other studies attributed to preferencing more complicated cases for earlier care. Lower 3-10 years survival for surgical cases first treated >90 days from diagnosis is consistent with previously reported U-shaped relationships.
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Affiliation(s)
- David Roder
- Cancer Research Institute, University of South Australia, Adelaide, South Australia, Australia
| | | | - Ian Olver
- Cancer Research Institute, University of South Australia, Adelaide, South Australia, Australia
| | - Dorothy Keefe
- South Australian Cancer Service, South Australia Department of Health, Adelaide, South Australia, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Robert Padbury
- Medical Oncology, Flinders University, Adelaide, South Australia, Australia
- Surgery and Perioperative Medicine, Southern Adelaide Local Health Network, Bedford Park, South Australia, Australia
| | - James Moore
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Colorectal Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Rohit Joshi
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Cancer Research and Clinical Trials, Adelaide Oncology and Haematology, North Adelaide, South Australlia, Australia
| | - David Wattchow
- Medical Oncology, Flinders University, Adelaide, South Australia, Australia
- Surgery and Perioperative Medicine, Southern Adelaide Local Health Network, Bedford Park, South Australia, Australia
| | - Dan L Worthley
- Gastrointestinal Cancer Biology, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Caroline Louise Miller
- Population Health, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- School of Public Health, The University of Adelaide, Adelaide, South Australia, Australia
| | - Carol Holden
- Population Health, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Elizabeth Buckley
- Cancer Research Institute, University of South Australia, Adelaide, South Australia, Australia
| | - Kate Powell
- Population Health, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Dianne Buranyi-Trevarton
- South Australian Cancer Service, South Australia Department of Health, Adelaide, South Australia, Australia
| | - Kellie Fusco
- Cancer Research Institute, University of South Australia, Adelaide, South Australia, Australia
| | - Timothy Price
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Clinical Cancer Research, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
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Does Metabolic Syndrome Increase the Risk of Postoperative Complications in Patients Undergoing Colorectal Cancer Surgery? Dis Colon Rectum 2019; 62:849-858. [PMID: 31188186 DOI: 10.1097/dcr.0000000000001334] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Metabolic syndrome is associated with poorer postoperative outcomes after various abdominal operations. However, the impact of metabolic syndrome on outcomes after colorectal cancer surgery remains poorly described. OBJECTIVE The purpose of this study was to determine the association between metabolic syndrome and short-term postoperative outcomes in patients undergoing elective colorectal cancer surgery. DESIGN This was a retrospective cohort study. SETTINGS This study used a national multicenter database. PATIENTS Adult patients who underwent elective colectomy for colorectal cancer from 2010 to 2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. MAIN OUTCOME MEASURES Thirty-day postoperative mortality and morbidity, unplanned reoperation, unplanned readmission, operative time, and length of stay were measured. RESULTS A total of 91,566 patients were analyzed; 7603 (8.3%) had metabolic syndrome. On unadjusted analysis, metabolic syndrome was associated with an increased risk of 30-day overall morbidity, pulmonary complications, renal complications, septic complications, cardiac complications, wound complications, blood transfusion, longer length of stay, and unplanned readmissions. On multivariable analysis, metabolic syndrome remained significantly associated with renal complications (OR = 1.44 (95% CI, 1.29-1.60)), superficial surgical site infection (OR = 1.46 (95% CI, 1.32-1.60)), deep surgical site infection (OR = 1.40 (95% CI, 1.15-1.70)), wound dehiscence (OR = 1.47 (95% CI, 1.20-1.80)), and unplanned readmissions (HR = 1.24 (95% CI, 1.15-1.34)). The risks of overall morbidity, cardiac and septic complications, and prolonged length of stay for laparoscopic procedures were significantly associated with diabetes mellitus rather than metabolic syndrome as a composite entity. LIMITATIONS This study was limited by its retrospective design and inability to analyze outcomes beyond 30 days. CONCLUSIONS Patients with metabolic syndrome undergoing elective surgery for colorectal cancer have an increased risk of 30-day postoperative renal complications, wound complications, and unplanned hospital readmissions. A multidisciplinary approach involving lifestyle modifications and pharmacologic interventions to improve the components of metabolic syndrome should be implemented preoperatively for these patients. See Video Abstract at http://links.lww.com/DCR/A909.
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