Nonresectional management of colorectal cancer: multidisciplinary factors that influence treatment strategy

Factors associated with survival in older patients with stage I-III colorectal carcinoma who were not managed curatively in the Netherlands

AIM

Some patients with stage I-III colorectal cancer (CRC) do not undergo tumor resection. Little is known about survival of these non-curatively managed patients. The aim of this study is to report all-cause mortality and to identify which factors are associated with survival in these patients.

METHODS

A retrospective review of electronic medical records was performed in two hospitals in the Netherlands. Patients diagnosed with CRC without distant metastases (radiologically determined stage I-III) and managed without tumor resection between 2011 and 2017 were included. The primary outcome was all-cause mortality. The effect of several variables on survival was evaluated with a multivariate logistic regression.

RESULTS

Of the 107 patients with stage I-III CRC that did not undergo resection of the primary tumor, 80% died within two years; median survival time was 8.5 months (IQR 2.5-22 months). Malnutrition risk (OR 6.36 (CI 1.21-33.25); p = 0.03) and comorbidity burden (OR 1.51 (CI 1.05-2.18 p = 0.03) were significantly associated with decreased survival after two years in a multivariate model. Age and disease stage were not. When treatment decision was mainly patient driven instead of based on the multi-disciplinary tumor board's decision, survival was longer (mean overall survival 16 months vs 10 months, respectively) p < 0.05.

CONCLUSION

Survival of patients with radiologically determined stage I-III CRC who did not undergo surgical resection was approximately 20% at two years and associated with the number of comorbidities, malnutrition risk status and dependent living, but not with age or disease stage.

Effect of Quxie capsule in patients with colorectal cancer: A systematic review and meta-analysis

OBJECTIVE

To investigate whether the Quxie capsule can decrease relapse, metastasis, and symptoms, as well as alleviate the side effects in colorectal cancer (CRC) patients.

METHODS

A comprehensive literature search of multiple databases was performed. Two reviewers independently selected trials that assessed the relapse-metastasis rate, degree of symptoms, and side effects of Quxie capsule for CRC. The meta-analysis was performed using Review Manager 5.3.

RESULTS

This meta-analysis included 6 studies, with a total of 408 cases. The quality of the included studies was generally low, with only 1 trial of high quality. A statistically significant difference was observed in the relapse-metastasis rate between the Quxie capsule and control groups after 2-years follow-up (n = 185, relative risk (RR) = 0.13, 95% confidence interval (CI) 0.04-0.46; P = .002). The Quxie capsule was found to reduce the traditional Chinese medicine symptom score as compared to the control (n = 208, weighted mean differences (WMD) = -4.15, 95% CI -7.30 to -1.00; P = .010), while it showed no significant improvement in the Karnofsky Performance Status score (n = 138, WMD = 5.05; 95% CI -2.95 to 13.04; P = .22). There was no difference in adverse events between the 2 groups (P = .66).

CONCLUSION

This systematic review and meta-analysis showed no clear superiority of Quxie capsule for CRC patients receiving chemotherapy. The effect of Quxie capsule in CRC patients should be examined by high quality, large sample size, multi-center RCTs, with longer follow-up.

Management of patients with incurable colorectal cancer: a retrospective audit

AIM

Counselling patients and their relatives about non-curative management options in colorectal cancer is difficult because of a paucity of published data. This study aims to determine outcomes in patients unsuitable for curative surgery and the rates of subsequent surgical intervention.

METHOD

This was an analysis of all colorectal cancers managed without curative surgery in a district general hospital from a prospectively maintained cancer registry between 2009 and 2016, as decided by a multidisciplinary team. Primary outcomes were overall survival and secondary outcomes were subsequent intervention rates and impact of tumour stage.

RESULTS

In all, 183 patients out of 976 patients (18.8%) were identified. The median age at diagnosis was 81 years [interquartile range (IQR) 71-87 years]. Overall median survival from diagnosis was 205 days (IQR 60-532 days). One-year mortality was 62.3%. Patients were classified into two groups depending on the reason for a non-curable approach: patient-related (PR) or disease-related (DR). The difference in survival between PR (median 277 days, IQR 70-593) and DR (median 179 days, IQR 51-450) was 98 days (P = 0.023). Twenty-four patients were alive at the end of the study period; 19 out of 91 cases in PR (20.8%) and five out of 92 cases in DR (5.4%). Overall intervention rates were 11.9%, with higher rates in the DR group (P = 0.005). Disease stage was not associated with subsequent surgical intervention between the two groups (P = 0.392).

CONCLUSION

Life expectancy for non-curatively managed patients within our unit was 6.8 months with one in nine patients requiring subsequent surgical admission for palliation. This information may be useful when counselling patients with incurable colorectal malignancy.

Improved patient survivals with colorectal cancer under multidisciplinary team care: A nationwide cohort study of 25,766 patients in Taiwan

OBJECTIVES

The evidence of improved survival in patients of colorectal cancer (CRC) receiving multidisciplinary team (MDT) care remains inconclusive.

METHODS

All patients with incident CRC but no prior cancer history in 2005-2008 were included and followed till 2010. A logistic regression model was used to predict the associated factors to participate in the MDT care model. The propensity score method was included under Cox proportional hazards model to reduce potential bias and to conduct survival analyses.

RESULTS

In total, 25,766 patients were included; the mean follow-up period was 35.1 months. The factors associated with participating in MDT included receiving treatments at regional hospitals, at private hospitals, and stage III cancer (all p values <0.001). The favorable survival factors included participating in MDT (HR=0.91, p=0.001), age of 45-75, top-ranked income group, receiving treatments at district hospitals, or at hospitals or with doctors that had higher service volumes (all p values <0.05). Regarding individual stages, the risk of mortality was significantly lower at stage IV (HR=0.88, p=0.002).

CONCLUSION

Colorectal cancer patients with participation in MDT have a lower mortality risk; the improvements of survival exist in all colorectal cancer patients, especially in those with stage IV disease.

Colorectal cancer in the elderly and the influence of lead time bias: better survival does not equate with improved life expectancy

AIMS

Poorer outcomes in those aged ≥80 years who undergo colorectal cancer surgery have been previously reported. Little is known about the natural history of those managed non-operatively. We explored outcomes in all patients with colorectal cancer aged ≥80 years at time of diagnosis based on treatment received.

METHODS

Patients ≥80 years diagnosed with colorectal cancer in one hospital trust between 1998 and 2011 were identified from a prospectively maintained database. Primary endpoints were age at diagnosis, age at death/censor and mortality at 30, 90 and 365 days.

RESULTS

Six hundred sixty-eight patients were identified. Four hundred twelve (61.7%) underwent surgery, 44 (6.6%) received endoscopic therapy and 212 (31.7%) had no active treatment. Of those who underwent surgery, 359 (87.1%) had resectional surgery, 34 (8.3%) defunctioning only, 13 (3.2%) received bypass surgery and 6 (1.5%) had an open and close laparotomy. The mean age at diagnosis was younger in those who underwent surgical resection (83.7 years) compared to those having defunctioning surgery (84.9 years, P = 0.043), endoscopic therapy (85.1 years, P = 0.008) or no surgical intervention (85.6 years, P < 0.001). There was no significant difference in the mean age of death or censor between groups.

CONCLUSIONS

There was no significant difference in age at death or censor between treatment groups among patients aged ≥80 years presenting with colorectal cancer, suggesting that differences in the observed survival time are heavily influenced by lead time bias. Age at death or censor should be reported in addition to survival times in this age group to enable fair comparison of outcomes.