Understanding variations in survival for colorectal cancer in Europe: a EUROCARE high resolution study

Small-Area Geographic and Socioeconomic Inequalities in Colorectal Cancer in Cyprus

Colorectal cancer (CRC) is one of the leading causes of death and morbidity worldwide. To date, the relationship between regional deprivation and CRC incidence or mortality has not been studied in the population of Cyprus. The objective of this study was to analyse the geographical variation of CRC incidence and mortality and its possible association with socioeconomic inequalities in Cyprus for the time period of 2000-2015. This is a small-area ecological study in Cyprus, with census tracts as units of spatial analysis. The incidence date, sex, age, postcode, primary site, death date in case of death, or last contact date of all alive CRC cases from 2000-2015 were obtained from the Cyprus Ministry of Health's Health Monitoring Unit. Indirect standardisation was used to calculate the sex and age Standardise Incidence Ratios (SIRs) and Standardised Mortality Ratios (SMRs) of CRC while the smoothed values of SIRs, SMRs, and Mortality to Incidence ratio (M/I ratio) were estimated using the univariate Bayesian Poisson log-linear spatial model. To evaluate the association of CRC incidence and mortality rate with socioeconomic deprivation, we included the national socioeconomic deprivation index as a covariate variable entering in the model either as a continuous variable or as a categorical variable representing quartiles of areas with increasing levels of socioeconomic deprivation. The results showed that there are geographical areas having 15% higher SIR and SMR, with most of those areas located on the east coast of the island. We found higher M/I ratio values in the rural, remote, and less dense areas of the island, while lower rates were observed in the metropolitan areas. We also discovered an inverted U-shape pattern in CRC incidence and mortality with higher rates in the areas classified in the second quartile (Q2-areas) of the socioeconomic deprivation index and lower rates in rural, remote, and less dense areas (Q4-areas). These findings provide useful information at local and national levels and inform decisions about resource allocation to geographically targeted prevention and control plans to increase CRC screening and management.

Prevalence and Trends of Drinking Water Disinfection Byproducts-Related Cancers in Addis Ababa, Ethiopia

BACKGROUND

Disinfection byproducts (DBPs) from chlorinated drinking water have been linked to an increased risk of cancer in the bladder, stomach, colon, and rectum. No studies showed the independent trends and prevalence of these cancers in Ethiopia. Therefore, this study aimed to determine the prevalence and trends of disinfection byproducts-related cancers in Addis Ababa, Ethiopia.

METHODS

Data were collected from the Addis Ababa Cancer Registry. Spatial data sets were produced and classified into households receiving chlorinated surface water and less chlorinated groundwater. The Cochran-Armitage trend test was used to evaluate whether there was a disinfection byproducts-related cancers (DBRCs) trend among communities receiving chlorinated water. Negative binomial regression was used to analyze the incidence rate.

RESULTS

A total of 11, 438 cancer cases were registered between 2012 and 2016, and DBRCs accounted for approximately 17%. The majority of the total cancer cases were female; 7,706 (67%). The prevalence of DBRCs was found to be higher in communities supplied with chlorinated water. From 2012 to 2016, the trend of colon cancer increased (β = 10.3, P value = .034); however, esophageal cancer decreased (β = -6.5, P value = .018). Approximately 56% of colorectal cancer patients and 53% of stomach cancer patients are known to be using chlorinated surface water for drinking regularly. In addition, approximately 57.1% and 54% of kidney and bladder cancer patients, respectively, used chlorinated surface water.

CONCLUSION

The prevalence of DBRCs in this study was found to be high. The colon cancer trend increased substantially from 2012 to 2016. The prevalence of DBRCs was higher in communities supplied with chlorinated surface water. Similarly, the prevalence of DBRCs was higher among males than females. Further study is required to validate the association between DBRCs and water chlorination.

Selected stage IV rectal cancer patients managed by the watch-and-wait approach after pelvic radiotherapy: a good alternative to total mesorectal excision surgery?

AIM

The aim of this study was to assess the clinical and oncological outcome of a selected group of stage IV rectal cancer patients managed by the watch-and-wait approach following a (near-)complete response of the primary rectal tumour after radiotherapy.

METHOD

Patients registered in the Dutch watch-and-wait registry since 2004 were selected when diagnosed with synchronous stage IV rectal cancer. Data on patient characteristics, treatment details, follow-up and survival were collected. The 2-year local regrowth rate, organ-preservation rate, colostomy-free rate, metastatic progression-free rate and 2- and 5-year overall survival were analysed.

RESULTS

After a median follow-up period of 35 months, local regrowth was observed in 17 patients (40.5%). Nine patients underwent subsequent total mesorectal excision, resulting in a permanent colostomy in four patients. The 2-year local regrowth rate was 39.9%, the 2-year organ-preservation rate was 77.1%, the 2-year colostomy-free rate was 88.1%, and the 2-year metastatic progression-free rate was 46.7%. The 2- and 5-year overall survival rates were 92.0% and 67.5%.

CONCLUSION

The watch-and-wait approach can be considered as an alternative to total mesorectal excision in a selected group of stage IV rectal cancer patients with a (near-)complete response following pelvic radiotherapy. Despite a relatively high regrowth rate, total mesorectal excision and a permanent colostomy can be avoided in the majority of these patients.

Tinkering with Time versus Being under the Spell of Time

Drawing upon ethnographic fieldwork in a Danish pediatric oncology ward we explore how children - as cancer patients - respond to the time constraints of cancer treatment that may save their lives but simultaneously hold them under a spell of time. Children respond through practices of what we have called "tinkering with time," which enable them to seize control not of life, but of time. We suggest that tinkering be understood as time work through which children mold their experience of the constraints of time. We regard this as an expression of existential agency that simultaneously sustains children's sense of autonomy.

Colorectal cancer survival in sub-Saharan Africa by age, stage at diagnosis and Human Development Index: A population-based registry study

There are limited population-based survival data for colorectal cancer (CRC) in sub-Saharan Africa. Here, 1707 persons diagnosed with CRC from 2005 to 2015 were randomly selected from 13 population-based cancer registries operating in 11 countries in sub-Saharan Africa. Vital status was ascertained from medical charts or through next of kin. 1-, 3- and 5-year overall and relative survival rates for all registries and for each registry were calculated using the Kaplan-Meier estimator. Multivariable analysis was used to examine the associations of 5-year relative survival with age at diagnosis, stage and country-level Human Development Index (HDI). Observed survival for 1448 patients with CRC across all registries combined was 72.0% (95% CI 69.5-74.4%) at 1 year, 50.4% (95% CI 47.6-53.2%) at 3 years and 43.5% (95% CI 40.6-46.3%) at 5 years. We estimate that relative survival at 5 years in these registry populations is 48.2%. Factors associated with poorer survival included living in a country with lower HDI, late stage at diagnosis and younger or older age at diagnosis (<50 or ≥70 years). For example, the risk of death was 1.6 (95% CI 1.2-2.1) times higher for patients residing in medium-HDI and 2.7 (95% CI 2.2-3.4) times higher for patients residing in low-HDI compared to those residing in high-HDI countries. Survival for CRC remains low in sub-Saharan African countries, though estimates vary considerably by HDI. Strengthening health systems to ensure access to prevention, early diagnosis and appropriate treatment is critical in improving outcomes of CRC in the region.

Trends in the incidence and mortality of colorectal cancer in a brazilian city

OBJECTIVES

This study was conducted to analyze the trends in colorectal cancer (CRC) incidence and mortality in the city of Aracaju, Sergipe State, Brazil, between 1996 and 2015 with Joinpoint Regression Program 4.7.0.0 and to identify the geographical distribution of CRC in the municipality.

RESULTS

A total of 1322 cases of CRC and 467 CRC-related deaths during the study period were included. In total, 40% of the incident cases and 43% of the deaths occurred in men, while 60% of the incident cases and 57% of the deaths occurred in women. Males who were 20 to 44 years old had the most significant trend in growth. Among women, those in the group aged 45 to 64 years had the highest observed annual percent change (APC). In both sexes, mortality was stable. Regarding the geographic distribution, there were constant hotspots in the northeast region of the municipality. This study showed a significant increase in incidence, mainly in young men between 20 and 44 years of age, but stable mortality in Aracaju.

Prophylactical Low Dose Whole-Liver Irradiation Inhibited Colorectal Liver Metastasis by Regulating Hepatic Niche in Mice

Background

The liver is the most common target for metastatic colorectal cancer. Changes of the local hepatic niche due to hepatic diseases such as cirrhosis decrease the incidence of colorectal cancer liver metastasis. Hepatic niche heterogeneity could influence the risk of hepatic metastasis.

Materials and Methods

We simulated changes of the hepatic niche via prophylactical liver irradiation with a safe dose of 6 Gy. GEO dataset and GO analysis revealed a difference in the expression of matrix metalloproteinase 1 (MMP1) in primary colorectal cancer versus liver metastasis, as well as synchronous versus metachronous liver metastasis. Western blotting, Immunofluorescence and qRT-PCR were conducted to measure protein expressions, location and RNA expressions. Colony formation, wound-healing, transwell assays experiments were performed to determine the malignant biological properties of colorectal cancer cells. shRNA transfection was used to conduct stable transfected cell lines.

Results

Tissue inhibitor of metalloproteinases 1 (TIMP1) expression was significantly higher in metastases lesions than primary tumors. In vivo, TIMP1 expression in the hepatic niche increased after a safe dose of 6 Gy irradiation, along with MMP1 decreased, leading to collagen fiber deposition and impairment of hepatic microcirculation. In vitro, irradiated hepatic stellate cells-conditioned media reduced the migration and clone formation ability of colon cancer cells SW480 and HCT116. Low TIMP1 expression in hepatic stellate cells reduced tumor cell invasion and migration.

Conclusion

Prophylactical 6 Gy whole-liver irradiation could inhibit colorectal cancer liver metastasis by regulating TIMP1/MMP1 balance in the hepatic niche before liver metastatic lesion formed.

Adherence to Clinical Practice Guidelines and Colorectal Cancer Survival: A Retrospective High-Resolution Population-Based Study in Spain

Colorectal cancer (CRC) is the third most common cancer worldwide. Population-based, high-resolution studies are essential for the continuous evaluation and updating of diagnosis and treatment standards. This study aimed to assess adherence to clinical practice guidelines and investigate its relationship with survival. We conducted a retrospective high-resolution population-based study of 1050 incident CRC cases from the cancer registries of Granada and Girona, with a 5-year follow-up. We recorded clinical, diagnostic, and treatment-related information and assessed adherence to nine quality indicators of the relevant CRC guidelines. Overall adherence (on at least 75% of the indicators) significantly reduced the excess risk of death (RER) = 0.35 [95% confidence interval (CI) 0.28-0.45]. Analysis of the separate indicators showed that patients for whom complementary imaging tests were requested had better survival, RER = 0.58 [95% CI 0.46-0.73], as did patients with stage III colon cancer who underwent adjuvant chemotherapy, RER = 0.33, [95% CI 0.16-0.70]. Adherence to clinical practice guidelines can reduce the excess risk of dying from CRC by 65% [95% CI 55-72%]. Ordering complementary imagining tests that improve staging and treatment choice for all CRC patients and adjuvant chemotherapy for stage III colon cancer patients could be especially important. In contrast, controlled delays in starting some treatments appear not to decrease survival.

Effect of Health Care Provider Delays on Short-Term Outcomes in Patients With Colorectal Cancer: Multicenter Population-Based Observational Study

BACKGROUND

The United Kingdom has lower survival figures for all types of cancers compared to many European countries despite similar national expenditures on health. This discrepancy may be linked to long diagnostic and treatment delays.

OBJECTIVE

The aim of this study was to determine whether delays experienced by patients with colorectal cancer (CRC) affect their survival.

METHODS

This observational study utilized the Somerset Cancer Register to identify patients with CRC who were diagnosed on the basis of positive histology findings. The effects of diagnostic and treatment delays and their subdivisions on outcomes were investigated using Cox proportional hazards regression. Kaplan-Meier plots were used to illustrate group differences.

RESULTS

A total of 648 patients (375 males, 57.9% males) were included in this study. We found that neither diagnostic delay nor treatment delay had an effect on the overall survival in patients with CRC (χ²₃=1.5, P=.68; χ23=0.6, P=.90, respectively). Similarly, treatment delays did not affect the outcomes in patients with CRC (χ²₃=5.5, P=.14). The initial Cox regression analysis showed that patients with CRC who had short diagnostic delays were less likely to die than those experiencing long delays (hazard ratio 0.165, 95% CI 0.044-0.616; P=.007). However, this result was nonsignificant following sensitivity analysis.

CONCLUSIONS

Diagnostic and treatment delays had no effect on the survival of this cohort of patients with CRC. The utility of the 2-week wait referral system is therefore questioned. Timely screening with subsequent early referral and access to diagnostics may have a more beneficial effect.

Differentiated thyroid cancer mortality by disease stage in northern England

OBJECTIVE

Mortality from thyroid cancer is reported to be higher in the UK compared with several other European countries, though UK data on mortality by disease stage have not been published. The aim of this study was to ascertain disease-specific mortality by stage in our centre.

DESIGN, PATIENTS AND MEASUREMENTS

This was a cohort study of all patients presenting to a single centre. Four hundred and twenty patients treated between 2000 and 2010 were identified. The medical records and causes of deaths were reviewed and analysed.

RESULTS

Overall disease-specific mortality at 5 and 10 years was 1.4% and 5.8%, respectively. The observed mortality was 58 against 66.3 expected deaths (CI 43.8-75.4) thus yielding an age-standardized mortality rate of 0.87. There were no deaths due to thyroid cancer in patients with stage I disease at 5 or 10 years. The 10-year disease-specific mortality rose with stage (stage II 3.1%, stage III 28.6%, stage IV 30%).

CONCLUSIONS

Thyroid cancer mortality of patients treated at our centre was lower than the official national UK registry and most European figures.

International evaluation of circumferential resection margins after rectal cancer resection: insights from the Swedish and Dutch audits

AIM

This study aimed to determine predictive factors for the circumferential resection margin (CRM) within two northern European countries with supposed similarity in providing rectal cancer care.

METHOD

Data for all patients undergoing rectal resection for clinical tumour node metastasis (TNM) stage I-III rectal cancer were extracted from the Swedish ColoRectal Cancer Registry and the Dutch ColoRectal Audit (2011-2015). Separate analyses were performed for cT1-3 and cT4 stage. Predictive factors for the CRM were determined using univariable and multivariable logistic regression analyses.

RESULTS

A total of 6444 Swedish and 12 089 Dutch patients were analysed. Over time the number of hospitals treating rectal cancer decreased from 52 to 42 in Sweden, and 82 to 79 in the Netherlands. In the Swedish population, proportions of cT4 stage (17% vs 8%), multivisceral resection (14% vs 7%) and abdominoperineal excision (APR) (37% vs 31%) were higher. The overall proportion of patients with a positive CRM (CRM+) was 7.8% in Sweden and 5.4% in the Netherlands. In both populations with cT1-3 stage disease, common independent risk factors for CRM+ were cT3, APR and multivisceral resection. No common risk factors for CRM+ in cT4 stage disease were found. An independent impact of hospital volume on CRM+ could be demonstrated for the cT1-3 Dutch population.

CONCLUSION

Within two northern European countries with implemented clinical auditing, rectal cancer care might potentially be improved by further optimizing the treatment of distal and locally advanced rectal cancer.

Progressive Oncological Surgery Is Associated with Increased Curative Resection Rates and Improved Survival in Metastatic Colorectal Cancer

Background: Secondary resection rates in first-line chemotherapy trials for metastatic colorectal cancer (mCRC) remain below 15%, representing a clear contrast to reports by specialised surgical centres, where progressive liver, peritoneal-surface, and pulmonary surgery increased access to curative-intent treatment. We present a long-term evaluation of oncosurgical management in a single-centre, analysing the aggregate effect of gradual implementation of surgical subspecialties and systemic treatments on mCRC patients’ resection rates and prognosis. Methods: Patients with newly diagnosed mCRC from 2003 to 2014 were retrospectively categorised into palliative treatment (PAT) and curative intent surgery (CIS) and three time periods were analysed for treatment changes and factors associated with survival. Results: Four hundred-twenty patients were treated (PAT:250/CIS:170). Over time periods, the number of presenting patients remained consistent, whereas curative resection rates increased from 29% to 55%, facilitated by an increment of patients undergoing hepatectomy (21 to 35%), pulmonary surgery (6 to 17%), and peritonectomy/intraoperative chemotherapy (0 to 8%). Also, recently, significantly more multi-line systemic treatments were applied. The median survival markedly improved from 21.9 months (2003–2006; 95% confidence interval (CI) 17.3–26.5) to 36.5 months (2011–2014; 95% CI 26.6–46.4; p = 0.018). PAT was a significant factor of poor survival and diagnosis of mCRC in the latest time period was independently associated with a distinctly lower risk for palliative treatment (odds ratio 0.15). Conclusions: In modern eras of medical oncology, achieving appropriate resection rates through utilization of state-of-the-art oncological surgery by dedicated experts represents a cornerstone for long-term survival in mCRC.

The gut microflora assay in patients with colorectal cancer: in feces or tissue samples?

Gut microbiota is the complex community of microorganisms that live in the digestive tracts of humans and other animals, including insects. The relationship between gut microbiota and human health is mutualistic and altered bacterial compositions in fecal and mucosal specimens of colon in patients with cancer compared to healthy subjects were observed. Thereby, studying the gut microbiota, their interactions with the host and their alterations in colorectal cancer (CRC) patients could be helpful to diagnose and treat the disease in earlier stages. In CRC research, the most common samples are feces and tumor tissues. Interestingly, scientists have quite different views regarding gut microbiota composition of feces and tissues. Some believe bacterial populations in feces and mucosa are completely distinct and differ in composition and diversity while some others declare similar variations. Actually, both types of specimens have some advantages and disadvantages in survey of gut microbiota. Fecal samples serve as a noninvasive approach for screening tests while mucosal associated samples are more powerful for identification of bacteria with adenoma and CRC initiation and growth. Here we have discussed the advantages and disadvantages of two type of specimens in CRC investigations and also discussed the similarities and differences of microbial composition between stool and tissue specimens.

Surgical treatment and survival from colorectal cancer in Denmark, England, Norway, and Sweden: a population-based study

BACKGROUND

Survival from colorectal cancer has been shown to be lower in Denmark and England than in comparable high-income countries. We used data from national colorectal cancer registries to assess whether differences in the proportion of patients receiving resectional surgery could contribute to international differences in colorectal cancer survival.

METHODS

In this population-based study, we collected data from all patients aged 18-99 years diagnosed with primary, invasive, colorectal adenocarcinoma from Jan 1, 2010, to Dec 31, 2012, in Denmark, England, Norway, and Sweden, from national colorectal cancer registries. We estimated age-standardised net survival using multivariable modelling, and we compared the proportion of patients receiving resectional surgery by stage and age. We used logistic regression to predict the resectional surgery status patients would have had if they had been treated as in the best performing country, given their individual characteristics.

FINDINGS

We extracted registry data for 139 457 adult patients with invasive colorectal adenocarcinoma: 12 958 patients in Denmark, 97 466 in England, 11 450 in Norway, and 17 583 in Sweden. 3-year colon cancer survival was lower in England (63·9%, 95% CI 63·5-64·3) and Denmark (65·7%, 64·7-66·8) than in Norway (69·5%, 68·4-70·5) and Sweden (72·1%, 71·2-73·0). Rectal cancer survival was lower in England (69·7%, 69·1-70·3) than in the other three countries (Denmark 72·5%, 71·1-74·0; Sweden 74·1%, 72·7-75·4; and Norway 75·0%, 73·1-76·8). We found no significant differences in survival for patients with stage I disease in any of the four countries. 3-year survival after stage II or III rectal cancer and stage IV colon cancer was consistently lower in England (stage II rectal cancer 86·4%, 95% CI 85·0-87·6; stage III rectal cancer 75·5%, 74·2-76·7; and stage IV colon cancer 20·5%, 19·9-21·1) than in Norway (94·1%, 91·5-96·0; 83·4%, 80·1-86·1; and 33·0%, 31·0-35·1) and Sweden (92·9%, 90·8-94·6; 80·6%, 78·2-82·7; and 23·7%, 22·0-25·3). 3-year survival after stage II rectal cancer and stage IV colon cancer was also lower in England than in Denmark (stage II rectal cancer 91·2%, 88·8-93·1; and stage IV colon cancer 23·5%, 21·9-25·1). The total proportion of patients treated with resectional surgery ranged from 47 803 (68·4%) of 69 867 patients in England to 9582 (81·3%) of 11 786 in Sweden for colon cancer, and from 16 544 (59·9%) of 27 599 in England to 4106 (70·8%) of 5797 in Sweden for rectal cancer. This range was widest for patients older than 75 years (colon cancer 19 078 [59·7%] of 31 946 patients in England to 4429 [80·9%] of 5474 in Sweden; rectal cancer 4663 [45·7%] of 10 195 in England to 1342 [61·9%] of 2169 in Sweden), and the proportion of patients treated with resectional surgery was consistently lowest in England. The age gradient of the decline in the proportion of patients treated with resectional surgery was steeper in England than in the other three countries in all stage categories. In the hypothetical scenario where all patients were treated as in Sweden, given their age, sex, and disease stage, the largest increase in resectional surgery would be for patients with stage III rectal cancer in England (increasing from 70·3% to 88·2%).

INTERPRETATION

Survival from colon cancer and rectal cancer in England and colon cancer in Denmark was lower than in Norway and Sweden. Survival paralleled the relative provision of resectional surgery in these countries. Differences in patient selection for surgery, especially in patients older than 75 years or individuals with advanced disease, might partly explain these differences in international colorectal cancer survival.

FUNDING

Early Diagnosis Policy Research Grant from Cancer Research UK (C7923/A18348).

Cisatracurium Retards Cell Migration and Invasion Upon Upregulation of p53 and Inhibits the Aggressiveness of Colorectal Cancer

Colorectal cancer (CRC) is reported to be the third and fourth, most diagnosed and cause of cancer associated deaths respectively. In 2012 for instance, about 1.4 million new cases were reported, and approximately 700,000 deaths recorded. Survival from CRC is dependent on the stage at which it is diagnosed coupled with appropriate surgical and medical intervention. Cisatracurium is widely used for skeletal muscle relaxation during abdominal surgeries, including bowel and colon surgeries. Recent studies reported that cisatracurium inhibits progression of human cancer cells, however, the mechanisms leading to the inhibition are yet to be completely understood. To elucidate mechanisms resulting particularly in tumor cell growth and metastasis, we developed ex vivo and in in vivo xenograft models of CRC. Cisatracurium caused upregulation of p53 and its down-stream genes and proteins known to regulate proliferation and metastasis in vitro and in vivo. Genomic analyses of CRC following cisatracurium treatment revealed moderate to high DNA damage, while functional analyses demonstrated significant tumor cells growth regression, as well as repression of migration and invasion. Importantly, cisatracurium increased E-Cadherin and CALD-1 but decreased SNAI-1 and SLUG levels in vitro and in vivo. Together, the findings demonstrate that elevation of p53 upon cisatracurium-induced genomic injury, represent a potential mechanism by which cisatracurium result in the suppression of CRC progression and metastasis.

Socioeconomic differences in selection for liver resection in metastatic colorectal cancer and the impact on survival

BACKGROUND

Socioeconomic inequalities in colorectal cancer (CRC) survival are well recognised. The aim of this study was to describe the impact of socioeconomic deprivation on survival in patients with synchronous CRC liver-limited metastases, and to investigate if any survival inequalities are explained by differences in liver resection rates.

METHODS

Patients in the National Bowel Cancer Audit diagnosed with CRC between 2010 and 2016 in the English National Health Service were included. Linked Hospital Episode Statistics data were used to identify the presence of liver metastases and whether a liver resection had been performed. Multivariable random-effects logistic regression was used to estimate the odds ratio (OR) of liver resection by Index of Multiple Deprivation (IMD) quintile. Cox-proportional hazards model was used to compare 3-year survival.

RESULTS

13,656 patients were included, of whom 2213 (16.2%) underwent liver resection. Patients in the least deprived IMD quintile were more likely to undergo liver resection than those in the most deprived quintile (adjusted OR 1.42, 95% confidence interval (CI) 1.18-1.70). Patients in the least deprived quintile had better 3-year survival (least deprived vs. most deprived quintile, 22.3% vs. 17.4%; adjusted hazard ratio (HR) 1.20, 1.11-1.30). Adjusting for liver resection attenuated, but did not remove, this effect. There was no difference in survival between IMD quintile when restricted to patients who underwent liver resection (adjusted HR 0.97, 0.76-1.23).

CONCLUSIONS

Deprived CRC patients with synchronous liver-limited metastases have worse survival than more affluent patients. Lower rates of liver resection in more deprived patients is a contributory factor.

Individual invitation letters lead to significant increase in attendance for screening colonoscopies: Results of a pilot study in Northern Hesse, Germany

Background

Colorectal cancer (CRC) is the second most common cancer in Germany. Screening colonoscopies are considered an effective tool for early detection and prevention of CRC and are recommended in Germany for citizens over the age of 55. To increase the participation rate for screening colonoscopies, an invitation procedure was initiated in parts of Germany for patients between the ages of 55 and 75 who had never undergone a screening colonoscopy before.

Methods

We examined the number of participating patients before, during, and after the invitation procedure and compared the number of the participating patients who received a cover letter with the participating patients from the control group. Additionally, we classified the findings of the colonoscopies including CRC, advanced adenomas, and polyps.

Results

During the invitation period, the participation rate of the invitation group increased from 220 patients to 531 patients compared to 1256 to 1693 in the control group. The increase was significantly greater in patients with cover letters (+141% vs.+35%, p < 0.0001). Also, significantly more polyps and adenomas were found in patients from the invitation letter group (254 (+102%) vs. 679 (-9%), p < 0.0001).

Conclusions

Our study clearly indicates that personal invitation letters are an effective measure to increase overall participation rates in screening colonoscopies.

Reduced risk of emergency admission for colorectal cancer associated with the introduction of bowel cancer screening across England: a retrospective national cohort study

AIM

We wanted to find out if roll-out of the bowel cancer screening programme (BCSP) across England was associated with a reduced risk of emergency hospital admission for people presenting with colorectal cancer (CRC) during this period.

METHOD

This is a retrospective cohort study of 27 763 incident cases of CRC over a 1-year period during the roll-out of screening across parts of England. The primary outcome was the number of emergency (unplanned) hospital admissions during the diagnostic pathway. The primary exposure was to those living in an area where the BCSP was active at the time of diagnosis. Patients were categorized into three exposure groups: BCSP not active (reference group), BCSP active < 6 months or BCSP active ≥ 6 months.

RESULTS

The risk of emergency admission for CRC in England was associated with increasing age, female gender, comorbidity and social deprivation. After adjusting for these factors in logistic regression, the odds ratio (OR) for emergency admission in patients diagnosed ≥ 6 months after the start-up of local screening was 0.83 (CI 0.76-0.90). The magnitude of risk reduction was greatest for cases of screening age (OR 0.75; CI 0.63-0.90) but this effect was apparent also for cases outside the 60-69-year age group (OR 0.85; CI 0.77-0.94). Living in an area with active BCSP conferred no reduction in risk of emergency admission for people diagnosed with oesophagogastric cancer during the same period.

CONCLUSION

The start-up of bowel cancer screening in England was associated with a substantial reduction in the risk of emergency admission for CRC in people of all ages. This suggests that the roll-out of the programme had indirect benefits beyond those related directly to participation in screening.

Looking at Differences in Stage and Treatment of Colorectal Cancers across Italy: A EUROCARE-5 High Resolution Study

Aims and background

The high incidence and the estimate of a five-year relative survival of 59% for colorectal cancer in Italy were the main reasons to investigate the management of Italian patients with colorectal cancer diagnosed in the early 2000s.

Methods

Samples of adult (≥15 years) patients diagnosed in 2003–2005 with a colorectal cancer were randomly selected in 8 Italian population-based cancer registries. The z test was used to evaluate differences in proportions of Dukes stage, patients with at least 12 examined lymph nodes, and of cases treated with curative surgery plus chemotherapy or plus radiotherapy and diagnosed with colon or rectal tumors, respectively. Logistic regression models were used to estimate odds ratios of receiving the selected treatment in each cancer registry, age group and stage category, by anatomical subsite.

Results

A total of 3,938 colorectal cancer patients were analyzed. About 40% of the cases were over 75 years of age at diagnosis and at Dukes A + B stages. Higher proportions of early stages were found in the northern cancer registries. High percentages of resection with a curative intent were observed in Reggio Emilia (northern Italy), in 15 to 74-year-old patients, and at Dukes B stage. At least 12 lymph nodes were more frequently examined in the north of the country. After adjusting for age and stage, no significant differences were seen in the odds ratios of receiving surgery plus chemotherapy between cancer registries, whereas surgery plus radiotherapy was more frequent in Napoli (southern Italy) and less frequent in Biella (northern Italy).

Conclusions

Some disparities in staging and treatment of colorectal cancer patients persist across Italy. National oncological plans still need to reduce inequalities in provision and access to proper care.

Possible missed opportunities for diagnosing colorectal cancer in Dutch primary care: a multimethods approach

BACKGROUND

Early detection of colorectal cancer (CRC) is important to achieve better survival. Discriminating symptoms suggestive of CRC from benign conditions is a challenge for GPs because most known 'alarm symptoms' have low predictive values.

AIM

To further understand the diagnostic process of CRC in general practice in terms of healthcare use and by analysing factors related to diagnostic intervals.

DESIGN AND SETTING

A multimethod approach comprising a historical, prospective registry study and qualitative content analysis.

METHOD

Healthcare use in the year before referral for colonoscopy was compared between patients diagnosed with CRC and an age-, sex,- and GP-matched control population. Qualitative content analysis was performed on free texts in electronic patient records from a purposive sample of patients with CRC.

RESULTS

Patients with CRC (n = 287) had 41% (25-59%) more face-to-face contacts and 21% (7-37%) more medication prescriptions than controls (n = 828). Forty-six per cent of patients with CRC had two or more contacts for digestive reasons, compared with 12.2% of controls, more often for symptoms than diagnoses. From qualitative analysis two themes emerged: 'possible missed diagnostic opportunities' and 'improvements in diagnostic process unlikely'. Possible missed diagnostic opportunities were related to patients waiting before presenting symptoms, doctors attributing symptoms to comorbid conditions or medication use, or doctors sticking to an initial diagnosis.

CONCLUSION

Fewer missed diagnostic opportunities might occur if GPs are aware of pitfalls in diagnosing CRC: the assumption that symptoms are caused by comorbid conditions or medication, or relating complaints to pre-existing medical conditions. GPs also need to be aware that repeated digestive complaints warrant rethinking an earlier diagnosis.

Clinical assessment to determine the risk of bowel cancer using Symptoms, Age, Mass and Iron deficiency anaemia (SAMI)

BACKGROUND

The aim of this study was to identify characteristics with independent predictive value for bowel cancer for use in the clinical assessment of patients attending colorectal outpatient clinics.

METHODS

This was a 22-year (1986-2007) retrospective cohort analysis of data collected prospectively from patients who attended colorectal surgical outpatient clinics in Portsmouth. The data set was split randomly into two groups of patients to generate and validate a predictive model. Multivariable logistic regression was used to create and validate a system to predict outcome. Receiver operating characteristic (ROC) curves and Hosmer-Lemeshow test were used to evaluate the model's predictive capability. The likelihood of bowel cancer was expressed as the odds ratio (OR).

RESULTS

Data from 29 005 patients were analysed. Discrimination of the model for bowel cancer was high in the development (C-statistic 0·87, 95 per cent c.i. 0·85 to 0·88) and validation (C-statistic 0·86, 0·84 to 0·87) groups. The most important co-variables in the final model were: age (OR 3·17-27·10), rectal (OR 31·48) or abdominal (OR 1·83-8·45) mass, iron deficiency anaemia (IDA) (OR 4·42-8·38), rectal bleeding and change in bowel habit in combination (OR 5·37), change in bowel habit without rectal bleeding, with or without abdominal pain (OR 2·12-2·52), and rectal bleeding with no perianal symptoms and without change in bowel habit (OR 2·91). Some 91·5 per cent of bowel cancers presented with these characteristics, 40·4 per cent with a mass and/or IDA. In patients with at least one of these characteristics the overall risk of having cancer was 10·0 (range 6·5-50·4) per cent, compared with 1·1 (0·3-2·3) per cent in patients without them.

CONCLUSION

A clinical assessment that systematically identifies or excludes four symptom-age combinations, a mass and IDA (SAMI) stratifies patients as having a low and higher risk of having bowel cancer. This could improve patient selection for referral and investigation.

Global patterns and trends in colorectal cancer incidence and mortality

OBJECTIVE

The global burden of colorectal cancer (CRC) is expected to increase by 60% to more than 2.2 million new cases and 1.1 million deaths by 2030. In this study, we aim to describe the recent CRC incidence and mortality patterns and trends linking the findings to the prospects of reducing the burden through cancer prevention and care.

DESIGN

Estimates of sex-specific CRC incidence and mortality rates in 2012 were extracted from the GLOBOCAN database. Temporal patterns were assessed for 37 countries using data from Cancer Incidence in Five Continents (CI5) volumes I-X and the WHO mortality database. Trends were assessed via the annual percentage change using joinpoint regression and discussed in relation to human development levels.

RESULTS

CRC incidence and mortality rates vary up to 10-fold worldwide, with distinct gradients across human development levels, pointing towards widening disparities and an increasing burden in countries in transition. Generally, CRC incidence and mortality rates are still rising rapidly in many low-income and middle-income countries; stabilising or decreasing trends tend to be seen in highly developed countries where rates remain among the highest in the world.

CONCLUSIONS

Patterns and trends in CRC incidence and mortality correlate with present human development levels and their incremental changes might reflect the adoption of more western lifestyles. Targeted resource-dependent interventions, including primary prevention in low-income, supplemented with early detection in high-income settings, are needed to reduce the number of patients with CRC in future decades.

MRI for Local Staging of Colon Cancer: Can MRI Become the Optimal Staging Modality for Patients With Colon Cancer?

BACKGROUND

Colon cancer is currently staged with CT. However, MRI is superior in the detection of colorectal liver metastasis, and MRI is standard in local staging of rectal cancer. Optimal (local) staging of colon cancer could become crucial in selecting patients for neoadjuvant treatment in the near future (Fluoropyrimidine Oxaliplatin and Targeted Receptor Preoperative Therapy trial).

OBJECTIVE

The purpose of this study was to evaluate the diagnostic performance of MRI for local staging of colon cancer.

DESIGN

This was a retrospective study.

SETTINGS

The study was conducted at the Maastricht University Medical Centre.

PATIENTS

In total, 55 patients with biopsy-proven colon carcinoma were included.

MAIN OUTCOME MEASURES

All of the patients underwent an MRI (1.5-tesla; T2 and diffusion-weighted imaging) of the abdomen and were retrospectively analyzed by 2 blinded, independent readers. Histopathology after resection was the reference standard. Both readers evaluated tumor characteristics, including invasion through bowel wall (T3/T4 tumors), invasion beyond bowel wall of ≥5 mm and/or invasion of surrounding organs (T3cd/T4), serosal involvement, extramural vascular invasion, and malignant lymph nodes (N+). Interobserver agreement was compared using κ statistics.

RESULTS

MRI had a high sensitivity (72%-91%) and specificity (84%-89%) in detecting T3/T4 tumors (35/55) and a low sensitivity (43%-67%) and high specificity (75%-88%) in detecting T3cd/T4 tumors (15/55). For detecting serosal involvement and extramural vascular invasion, MRI had a high sensitivity and moderate specificity, as well as a moderate sensitivity and specificity in the detection of nodal involvement. Interobserver agreements were predominantly good; the more experienced reader achieved better results in the majority of these categories.

LIMITATIONS

The study was limited by its retrospective nature and moderate number of inclusions.

CONCLUSIONS

MRI has a good sensitivity for tumor invasion through the bowel wall, extramural vascular invasion, and serosal involvement. In addition, together with its superior liver imaging, MRI might become the optimal staging modality for colon cancer. However, more research is needed to confirm this. See Video Abstract at http://links.lww.com/DCR/A309.

Predicting the presence of colon cancer in members of a health maintenance organisation by evaluating analytes from standard laboratory records

Background:

A valid risk prediction model for colorectal cancer (CRC) could be used to identify individuals in the population who would most benefit from CRC screening. We evaluated the potential for information derived from a panel of blood tests to predict a diagnosis of CRC from 1 month to 3 years in the future.

Methods:

We abstracted information on 1755 CRC cases and 54 730 matched cancer-free controls who had one or more blood tests recorded in the electronic records of Maccabi Health Services (MHS) during the period 30–180 days before diagnosis. A scoring model (CRC score) was constructed using the study subjects' blood test results. We calculated the odds ratio for being diagnosed with CRC after the date of blood draw, according to CRC score and time from blood draw.

Results:

The odds ratio for having CRC detected within 6 months for those with a score of four or greater (vs three or less) was 7.3 (95% CI: 6.3–8.5) for men and was 7.8 (95% CI: 6.7–9.1) for women.

Conclusions:

Information taken from routine blood tests can be used to predict the risk of being diagnosed with CRC in the near future.

Evaluation of prognostic factors effect on survival time in patients with colorectal cancer, based on Weibull Competing-Risks Model

AIM

The aim of this study was to assess the association between survival of patients with colorectal cancer and prognostic factors in a competing risk parametric model using Weibull distribution.

BACKGROUND

The prognosis of colorectal cancer is relatively good in terms of survival time. In many prognostic studies, patients may be exposed to several types of competing events. These different causes of death are called competing risks.

METHODS

Data was recorded from 372 patients with colorectal cancer who registered in the Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences (Tehran, Iran) from 2004 to 2015 in a retrospective study. Analysis was performed using competing risks model and Weibull distribution. Software used for data analysis was R, and significance level was regarded as 0.05.

RESULTS

The result indicated that, at the end of follow-up, 111 (29.8%) deaths were from colorectal cancer and 14 (3.8%) deaths were due to other diseases. The average body mass index (BMI) was 24.61(SD 3.98). The mean survival time for a patient in 372 was 62.05(SD 48.78) month with median equals to 48 months. According to competing-risks method, only stageIII (HR, 1.69; 95% CI, 1.246-2.315 ), stageIV( HR, 4.51; 95% CI,2.91-6.99 ) and BMI( HR, 0.96; 95% CI, 0.96-0.975) have a significant effect on patient's survival time.

CONCLUSION

This study indicated pathologic stage (III,IV) and BMI as the prognosis, using a Weibull model with competing risks analysis, while other models without the competing events lead to significant predictors which may be due to over-estimation.

Adjuvant chemotherapy and relative survival of patients with stage II colon cancer - A EURECCA international comparison between the Netherlands, Denmark, Sweden, England, Ireland, Belgium, and Lithuania

BACKGROUND

The aim of the present EURECCA international comparison is to compare adjuvant chemotherapy and relative survival of patients with stage II colon cancer between European countries.

METHODS

Population-based national cohort data (2004-2009) from the Netherlands (NL), Denmark (DK), Sweden (SE), England (ENG), Ireland (IE), and Belgium (BE) were obtained, as well as single-centre data from Lithuania. All surgically treated patients with stage II colon cancer were included. The proportion of patients receiving adjuvant chemotherapy was calculated and compared between countries. Besides, relative survival was calculated and compared between countries.

RESULTS

Overall, 59,154 patients were included. The proportion of patients receiving adjuvant chemotherapy ranged from 7.1% to 29.0% (p < 0.001). Compared with NL, a better adjusted relative survival was observed in SE (stage II: relative excess risks (RER) 0.53, 95% confidence interval (CI) 0.44-0.64; p < 0.001), and BE (stage II: RER 0.84, 95% CI 0.76-0.92; p < 0.001), and in IE for patients with stage IIA disease (RER 0.80, 95% CI 0.65-0.98; p = 0.03).

CONCLUSION

The proportion of patients with stage II colon cancer receiving adjuvant chemotherapy varied largely between seven European countries. No clear linear pattern between adjuvant chemotherapy and adjusted relative survival was observed. Compared with NL, SE and BE showed an improved adjusted relative survival for stage II disease, and IE for patients with stage IIA disease only. Further research into selection criteria for adjuvant chemotherapy could eventually lead to individually tailored, optimal treatment of patients with stage II colon cancer.

Has the 'Fast-Track' referral system affected the route of presentation and/or clinical outcomes in patients with colorectal cancer?

BACKGROUND

The aim of this study is to determine whether the 'Fast-Track' referral system has changed the route by which patients present with colorectal cancer (CRC) and whether the route of presentation has any effect on clinical outcome.

METHODS

A retrospective cohort study of patients diagnosed with CRC under the care of two consultant colorectal surgeons between April 2006 and December 2012. The route by which patients presented was categorised as Fast-Track (FT), non-Fast-Track (non-FT) or acute. Outcome variables were operative intent, disease stage and 2- and 5-year survival.

RESULTS

A total of 558 patients were identified. One hundred ninety-seven patients (35.3 %) were referred as FT, 108 (19.4 %) presented acutely and 253 patients (45.3 %) presented via other routes (non-FT). Over the study period, the route of presentation did not change significantly (P = 0.135). There was no significant difference between FT and non-FT groups in terms of the proportion of patients undergoing potentially curative surgery (70.6 vs 74.3 %, P = 0.092) or with node-negative disease (48.2 vs 52.2 %, P = 0.796) nor was there any difference in 2-year or 5-year survival (74.1 vs 73.9 %, P = 0.837 and 52.3 vs 53.8 %, P = 0.889, respectively). Patients who presented acutely were less likely to undergo curative resection, had more advanced disease and had worse 2- and 5-year survival.

CONCLUSIONS

The Fast-Track referral system has not affected the route by which patients present with CRC nor has it had any effect on clinical outcomes. Alternative strategies are required if the desired improvement in outcomes is to be achieved.

Colorectal Cancer Patient Characteristics, Treatment and Survival in Oman--a Single Center Study

BACKGROUND

Colorectal cancer is the most common gastrointestinal cancer in Oman with an increasing incidence. We here report the presenting features, treatment outcomes and survival in a University hospital in Oman and compare our data with regional and international studies.

MATERIALS AND METHODS

Medical records of patients with colorectal cancer were reviewed retrospectively between June 2000 and December 2013 and were followed until June 2014.

RESULTS

A total of 162 patients were diagnosed with colorectal cancer. The majority were males (58.6%), with a median age of 56 years. Rectum was involved in 29.6% of patients, followed by ascending and sigmoid colon. The majority of patients had stage III (42.6%) and stage IV (32.7%) disease at presentation. K-Ras status was checked for 79 patients, and 41 (51.9%) featured the wild type. Median relapse free survival was 22 months. Median overall survival for all patients was 43 months. Observed 5 year overall survival (OS) for stages I, II and III was 100%, 60% and 60% respectively. On Log rank univariate analysis, age, BMI, diabetes, hypertension, metformin use, stage, clinical nodal status for rectal cancer, pathological T and nodal status, site of metastasis, surgical intervention, chemotherapy, radiotherapy, chemotherapy regimen, no of cycles of chemotherapy, response, RFS, site of recurrence and administration of 2nd line chemotherapy were significant factors affecting OS. On Cox regression multivariate analysis none of the factors independently affected the OS.

CONCLUSIONS

The majority of patients present with advanced disease and at young age. The survival rates are comparable to the published regional and international literature.

Global cancer surgery: delivering safe, affordable, and timely cancer surgery

Surgery is essential for global cancer care in all resource settings. Of the 15.2 million new cases of cancer in 2015, over 80% of cases will need surgery, some several times. By 2030, we estimate that annually 45 million surgical procedures will be needed worldwide. Yet, less than 25% of patients with cancer worldwide actually get safe, affordable, or timely surgery. This Commission on global cancer surgery, building on Global Surgery 2030, has examined the state of global cancer surgery through an analysis of the burden of surgical disease and breadth of cancer surgery, economics and financing, factors for strengthening surgical systems for cancer with multiple-country studies, the research agenda, and the political factors that frame policy making in this area. We found wide equity and economic gaps in global cancer surgery. Many patients throughout the world do not have access to cancer surgery, and the failure to train more cancer surgeons and strengthen systems could result in as much as US $6.2 trillion in lost cumulative gross domestic product by 2030. Many of the key adjunct treatment modalities for cancer surgery--e.g., pathology and imaging--are also inadequate. Our analysis identified substantial issues, but also highlights solutions and innovations. Issues of access, a paucity of investment in public surgical systems, low investment in research, and training and education gaps are remarkably widespread. Solutions include better regulated public systems, international partnerships, super-centralisation of surgical services, novel surgical clinical trials, and new approaches to improve quality and scale up cancer surgical systems through education and training. Our key messages are directed at many global stakeholders, but the central message is that to deliver safe, affordable, and timely cancer surgery to all, surgery must be at the heart of global and national cancer control planning.

The Relationship between Neighborhood Immigrant Composition, Limited English Proficiency, and Late-Stage Colorectal Cancer Diagnosis in California

Despite the availability of effective early detection technologies, more than half (61%) of colorectal cancers in the United States and 55% in California are identified at an advanced stage. Data on colorectal cancer patients (N = 35,030) diagnosed from 2005 to 2007 were obtained from the California Cancer Registry. Multivariate analyses found a relationship among neighborhood concentration of recent immigrants, neighborhood rates of limited English proficiency, and late-stage colorectal cancer diagnosis. Hispanics living in neighborhoods with a greater percentage of recent immigrants (compared to the lowest percentage) had greater odds (OR 1.57, 95% CI 1.22, 2.02) of late-stage diagnosis whereas Hispanics living in neighborhoods with the highest percentage of limited English proficiency (compared to the lowest percentage) had lower odds (OR .71, 95% CI .51, .99) of late-stage diagnosis. These relationships were not observed for other ethnic groups. Results highlight the complex relationship among race/ethnicity, neighborhood characteristics, and colorectal cancer stage at diagnosis.

On-going improvement and persistent differences in the survival for patients with colon and rectum cancer across Europe 1999-2007 - Results from the EUROCARE-5 study

BACKGROUND

Previous population-based studies revealed major variation in survival for patients with colorectal cancer (CRC) in Europe by age and between different countries and regions, but also a sustained improvement in survival for patients with CRC in recent years. This EUROCARE-5 paper aims to update available knowledge from previous studies and to provide the latest survival estimates for CRC patients from Europe.

METHODS

The study analysed data of patients diagnosed with CRC from population-based cancer registries diagnosed in 29 European countries. Estimates of 1-year and 5-year relative survival (RS) were derived for patients diagnosed in 2000-2007 by European region, country and age at diagnosis. Additionally to these cohort estimates, time trends in 5-year RS were obtained for the calendar periods 1999-2001 and 2005-2007, using the period analysis methodology.

RESULTS

European average 5-year RS for patients diagnosed with colon and rectum cancer was 57% and 56%, respectively. The analyses showed persistent differences in cancer survival across Europe with lowest survival for CRC patients observed in Eastern Europe. The analyses further showed a strong gradient in age-specific survival. Even though the study revealed sustained improvement in patient survival between 1999-2001 and 2005-2007 (absolute increase of 4 and 6 percentage points for colon and rectum, respectively), the differences in the survival for CRC patients observed at the beginning of the millennium persisted over time.

CONCLUSION

Although survival for CRC patients in Europe improved markedly in the study period, significant geographic variations and a strong age gradient still persisted. Enhanced access to effective diagnostic procedures and treatment options might be the keys to reducing the existing disparities in the survival of CRC patients across Europe.

Age-specific cancer survival in Estonia: recent trends and data quality

Background

A number of population-based studies have demonstrated lower cancer survival in elderly patients than among middle-aged or younger patients. Also, data quality in cancer registries has been shown to be associated with age. The objective of this study was to examine the recent age-specific cancer survival trends and age-specific quality of cancer data in Estonia.

Methods

Using Estonian Cancer Registry data, we calculated relative survival ratios (RSRs) for eight common cancers in Estonia in 1995–1999 (cohort method) and 2005–2009 (period method) for four major age groups (15–54, 55–64, 65–74, and 75–84 years at diagnosis). The main data quality indicators were calculated, and the age-specific effect of missing death certificate initiated (DCI) cases on survival was estimated comparing 5-year RSRs computed from the complete data set with those from data set without DCI cases.

Results

We observed overall rise in 5-year RSR for all eight cancers over the study period, with a considerable variation by age, with the lowest survival among the oldest patients. The widest age gradient in 5-year RSR was seen for bladder cancer (20% units in 2005–2009), followed by cancers of lung (16% units), kidney (15% units), breast and prostate (13% units), stomach and rectum (11% units), and colon (5% units). All data quality indicators, including proportion of cases with unknown stage showed a similar age-related pattern with the lowest quality in the oldest age group. The effect of missing DCI cases on survival estimates increased by age and was around 3% units for prostate and kidney cancers among the oldest patients.

Conclusion

Young or middle-aged patients in Estonia experienced larger survival gain since the late 1990s than elderly patients. Decreasing quality of cancer registry data along with increasing patient age suggests less thorough clinical investigations in older age groups.

Cancer survival in China, 2003-2005: a population-based study

Limited population-based cancer registry data available in China until now has hampered efforts to inform cancer control policy. Following extensive efforts to improve the systematic cancer surveillance in this country, we report on the largest pooled analysis of cancer survival data in China to date. Of 21 population-based cancer registries, data from 17 registries (n = 138,852 cancer records) were included in the final analysis. Cases were diagnosed in 2003-2005 and followed until the end of 2010. Age-standardized relative survival was calculated using region-specific life tables for all cancers combined and 26 individual cancers. Estimates were further stratified by sex and geographical area. The age-standardized 5-year relative survival for all cancers was 30.9% (95% confidence intervals: 30.6%-31.2%). Female breast cancer had high survival (73.0%) followed by cancers of the colorectum (47.2%), stomach (27.4%), esophagus (20.9%), with lung and liver cancer having poor survival (16.1% and 10.1%), respectively. Survival for women was generally higher than for men. Survival for rural patients was about half that of their urban counterparts for all cancers combined (21.8% vs. 39.5%); the pattern was similar for individual major cancers except esophageal cancer. The poor population survival rates in China emphasize the urgent need for government policy changes and investment to improve health services. While the causes for the striking urban-rural disparities observed are not fully understood, increasing access of health service in rural areas and providing basic health-care to the disadvantaged populations will be essential for reducing this disparity in the future.

Variation in colorectal cancer treatment and survival: a cohort study covering the East Anglia region

AIM

National guidelines for colorectal cancer management aim to optimize cancer outcomes irrespective of postcode. However, in order to ensure equal performance of cancer services, variation in outcome must be monitored and intelligently assessed. In this study, detailed regional cancer registry data were used to quantify and explore the reasons for variation in colorectal cancer outcomes at nine hospitals in East Anglia.

METHOD

We analysed data on colorectal cancers registered by the Eastern Cancer Registry and Information Centre (ECRIC) between 1999 and 2005. Tumours were grouped by site, in keeping with surgical resection. Multivariable Cox regression models were used to identify the effects of patient, disease and treatment variables on an individual's risk of death.

RESULTS

After adjusting for demographic, disease and treatment variables there were significant differences in survival among hospitals in emergency admissions with cancer of the right colon, in elective admissions with cancer of the left, sigmoid or recto-sigmoid colon and in emergency admissions with cancer of the rectum. There were also differences among hospitals in terms of perioperative death, nonsurgical management and numbers of nodes examined. For rectal cancers, rates of anterior resection compared with abdominoperineal excision differed, as well as the use of neoadjuvant radiotherapy.

CONCLUSION

Detailed analysis of demographic, disease and treatment factors are required when comparing the survival of individuals with colorectal cancer across hospitals. The results imply that cancer management was not consistent across East Anglia in 1999-2005 but the reasons for this are uncertain. Nevertheless, 5-year age-standardized survival with colon cancer in the Anglia Cancer Network region is currently among the best in the UK.

Findings on interval colonoscopies: an auditable performance indicator for colonoscopy quality?

OBJECTIVE

An important marker of colonoscopy quality is detection of pathology and incidence of missed pathology. Back-to-back colonoscopies cannot ethically be performed for quality assurance alone yet may be required for clinical reasons. This study aims to investigate the incidence of new findings in colonoscopies repeated within a 12 month period and considers the role of such an analysis in the assessment of colonoscopy quality.

DESIGN

All colonoscopies performed over a 3-year period at an endoscopy training unit were studied. Colonoscopies repeated within a 12-month period were analysed.

RESULTS

5747 colonoscopies were performed over the study period. 137 repeat colonoscopies were included with median interval from initial colonoscopy of 174 days. 19 (14%) repeat colonoscopies yielded new findings including one cancer, 234 days following a normal colonoscopy. Additional polyps were identified in 13 colonoscopies indicating a missed polyp rate of 9%. In these, a median number of two polyps per colonoscopy with median size 5.5 mm were found. There was no morbidity associated with repeat colonoscopy in this series. New findings on repeat colonoscopy appeared more likely following initial colonoscopy by non-consultant non-training grade endoscopists (23% vs 11%, p=0.09) yet small numbers involved preclude meaningful comparison.

CONCLUSIONS

Analysis of clinically indicated repeat colonoscopies and rate of detection of new pathology may offer utility in colonoscopy quality assurance and would offer a direct assessment of the most important aspect of colonoscopy quality.

Optimising faecal occult blood screening:retrospective analysis of NHS Bowel Cancer Screening data to improve the screening algorithm

BACKGROUND

Colorectal neoplasia causes bleeding, enabling detection using Faecal Occult Blood tests (FOBt). The National Health Service (NHS) Bowel Cancer Screening Programme (BCSP) guaiac-based FOBt (gFOBt) kits contain six sample windows (or 'spots') and each kit returns either a positive, unclear or negative result. Test kits with five or six positive windows are termed 'abnormal' and the subject is referred for further investigation, usually colonoscopy. If 1-4 windows are positive, the result is initially 'unclear' and up to two further kits are submitted, further positivity leads to colonoscopy ('weak positive'). If no further blood is detected, the test is deemed 'normal' and subjects are tested again in 2 years' time. We studied the association between spot positivity % (SP%) and neoplasia.

METHODS

Subjects in the Southern Hub completing the first of two consecutive episodes between April 2009 and March 2011 were studied. Each episode included up to three kits and a maximum of 18 windows (spots). For each positivity combination, the percentage of positive spots out of the total number of spots completed by an individual in a single-screening episode was derived and named 'SP%'. Fifty-five combinations of SP can occur if the position of positive/negative spots on the same test card is ignored.The proportion of individuals for whom neoplasia was identified in Episode 2 was derived for each of the 55 spot combinations. In addition, the Episode 1 spot pattern was analysed for subjects with cancer detected in Episode 2.

RESULTS

During Episode 2, 284,261 subjects completed gFOBT screening and colonoscopies were performed on 3891 (1.4%) subjects. At colonoscopy, cancer was detected in 7.4% (n=286) and a further 39.8% (n=1550) had adenomas. Cancer was detected in 21.3% of subjects with an abnormal first kit (five or six positive spots) and in 5.9% of those with a weak positive test result.The proportion of cancers detected was positively correlated with SP%, with an R(2) correlation (linear) of 0.89. As the SP% increased from 11 to 100%, so the colorectal cancer (CRC) detection rate increased from 4 to 25%. At the lower SP%s, from 11to 25%, the CRC risk was relatively static at ~4%. Above an SP% of 25%, every 10-percentage points increase in the SP%, was associated with an increase in cancer detection of 2.5%.

CONCLUSIONS

This study demonstrated a strong correlation between SP% and cancer detection within the NHS BCSP. At the population level, subjects' cancer risk ranged from 4 to 25% and correlated with the gFOBt spot pattern.Some subjects with an SP% of 11% proceed to colonoscopy, whereas others with an SP% of 22% do not. Colonoscopy on patients with four positive spots in kit 1 (SP% 22%) would, we estimate, detect cancer in ~4% of cases and increase overall colonoscopy volume by 6%. This study also demonstrated how screening programme data could be used to guide its ongoing implementation and inform other programmes.

The association of time between diagnosis and major resection with poorer colorectal cancer survival: a retrospective cohort study

Background

Colorectal cancer survival in the UK is lower than in other developed countries, but the association of time interval between diagnosis and treatment on excess mortality remains unclear.

Methods

Using data from cancer registries in England, we identified 46,511 patients with localised colorectal cancer between 1996–2009, who were 15 years and older, and who underwent a major surgical resection within 62 days of diagnosis. We used relative survival and excess risk modeling to investigate the association of time between diagnosis and major resection (exposure) with survival (outcome).

Results

Compared to patients who had major resection within 25–38 days of diagnosis, patients with a shorter time interval between diagnosis and resection and those waiting longer for resection had higher excess mortality (Excess Hazards Ratio, EHR <25 vs 25–38 days: 1.50; 95% Confidence Interval, CI: 1.37 to 1.66; EHR 39–62 vs 25–38 days : 1.16; 95% CI: 1.04 to 1.29). Excess mortality was associated with age (EHR 75+ vs. 15–44 year olds: 2.62; 95% CI: 2.00 to 3.42) and deprivation (EHR most vs. least deprived: 1.27; 95% CI: 1.12 to 1.45), but time between diagnosis and resection did not explain these differences.

Conclusion

Within 62 days of diagnosis, a U-shaped association of time between diagnosis and major resection with excess mortality for localised colorectal cancer was evident. This indicates a complicated treatment pathway, particularly for patients who had resection earlier than 25 days, and requires further investigation.

Gender differences in survival and the use of primary care prior to diagnosis of three cancers: an analysis of routinely collected UK general practice data

Objective

To explore whether there are gender differences in the number of GP recorded cases, the probability of survival and consulting pattern prior to diagnosis amongst patients with three non-sex-specific cancers.

Design

Cross sectional study.

Setting

UK primary care.

Subjects

12,189 patients aged 16 years or over diagnosed with colorectal cancer (CRC), 11,081 patients with lung cancer and 4,352 patients with malignant melanoma, with first record of cancer diagnosis during 1997–2006.

Main outcome measures

Cancer cases recorded in primary care; probability of survival following diagnosis; and number of GP contacts within the 24 months preceding diagnosis.

Results

From 1997–2006, overall rates of GP recorded CRC and lung cancer cases recorded were higher in men than in women, but rates of malignant melanoma were higher in women than in men. Gender differences in survival were small; 49% of men and 53% of women survived at least 5 years following CRC diagnosis; 9% of men and 12% of women with lung cancer, and 77% of men and 86% of women with malignant melanoma. The adjusted male to female relative hazard ratio of death in all patients was 1.20 (95%CI 1.13–1.30), 1.24 (95%CI 1.16–1.33) and 1.73 (95%CI 1.51–2.00) for CRC, lung cancer and malignant melanoma respectively. However, gender differences in the relative risk were much smaller amongst those who died during follow-up. For each cancer, there was little evidence of gender difference in the percentage who consulted and the number of GP contacts made within 24 months prior to diagnosis.

Conclusions

This study found that patterns of consulting prior to cancer diagnosis differed little between two genders, providing no support for the hypothesis that gender differences in survival are explained by gender differences in consultation for more serious illness, and suggests the need for a more critical view of gender and consultation.

How might healthcare systems influence speed of cancer diagnosis: a narrative review

Striking differences exist in outcomes for cancer between developed countries with comparable healthcare systems. We compare the healthcare systems of 3 countries (Denmark, Norway, Sweden), 3 UK jurisdictions (England, Wales and Northern Ireland), 3 Canadian provinces (British Columbia, Manitoba, Ontario) and 2 Australian states (New South Wales, Victoria) using a framework which assesses the possible contribution of primary care systems to a range of health outcomes, drawing on key characteristics influencing population health.

For many of the characteristics we investigated there are no significant differences between those countries with poorer cancer outcomes (England and Denmark) and the rest. In particular, regulation, financing, the existence of patient lists, the GP gatekeeping role, direct access to secondary care, the degree of comprehensiveness of primary care services, the level of cost sharing and the type of primary care providers within healthcare systems were not specifically and consistently associated with differences between countries. Factors that could have an influence on patient and professional behaviour, and consequently contribute to delays in cancer diagnosis and poorer cancer outcomes in some countries, include centralisation of services, free movement of patients between primary care providers, access to secondary care, and the existence of patient list systems.

It was not possible to establish a causal correlation between healthcare system characteristics and cancer outcomes. Further studies should explore in greater depth the associations between single health system factors and cancer outcomes, recognising that in complex systems where context is all-important, it will be difficult to establish causal relationships. Better understanding of the interaction between healthcare system variables and patient and professional behaviour may generate new hypotheses for further research.

•

We examined cancer outcomes in six developed countries with comparable healthcare systems.

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Clear differences exist in cancer outcomes between countries with comparable healthcare systems.

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Centralisation, movement of patients between providers, access to secondary care, and list systems appear influential.

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Better understanding of interactions between system variables and patient and professional behaviour may improve outcomes.

Cost-effectiveness of colorectal cancer screening in Germany: current endoscopic and fecal testing strategies versus plasma methylated Septin 9 DNA

BACKGROUND AND STUDY AIMS

Colorectal cancer (CRC) screening strategies in Germany include guaiac-based fecal occult blood testing (gFOBT) starting at age 50 and a switch to colonoscopy at age 55 or continued gFOBT testing, but screening utilization is limited. Blood-based biomarkers, such as methylated Septin 9 DNA ( (m) SEPT9), may improve screening rates. We performed a cost-effectiveness analysis of current and emerging CRC screening strategies in Germany.

METHODS

Using a validated Markov model, we compared annual gFOBT for ages 50 through 54 followed by biennial testing until age 75 (FOBT) or by colonoscopy at ages 55 and 65 (FOBT/COLO 55,65), substitution of fecal immunochemical testing (FIT) for gFOBT (FIT, FIT/COLO 55,65), and annual or biennial plasma (m) SEPT9 testing. We also considered persons who utilize only colonoscopy and varied age at colonoscopy utilization.

RESULTS

The current strategies were more effective and less costly than no screening. FIT was more effective and less costly than (m) SEPT9 testing. FIT/COLO 55,65 cost €12 200 per quality-adjusted life-years gained in comparison with FIT. (m) SEPT9-based screening was cost-effective in comparison with no screening but was dominated by other cost-saving strategies. Differential screening utilization and adherence greatly affected incremental results between strategies. In probabilistic analyses, FIT was preferred in 49 % and FIT/COLO 55,65 in 47 % of iterations.

CONCLUSION

Currently available CRC screening strategies in Germany, including hybrid fecal testing/colonoscopy, are likely to be cost-saving. Current strategies appear superior to (m) SEPT9-based screening. The impact of blood-based biomarkers is likely to depend on utilization and adherence as much as on test performance characteristics and cost.

Patterns of colorectal cancer care in Europe, Australia, and New Zealand

Colorectal cancer is the second most common cancer in women and the third most common in men worldwide. In this study, we used MEDLINE to conduct a systematic review of existing literature published in English between 2000 and 2010 on patterns of colorectal cancer care. Specifically, this review examined 66 studies conducted in Europe, Australia, and New Zealand to assess patterns of initial care, post-diagnostic surveillance, and end-of-life care for colorectal cancer. The majority of studies in this review reported rates of initial care, and limited research examined either post-diagnostic surveillance or end-of-life care for colorectal cancer. Older colorectal cancer patients and individuals with comorbidities generally received less surgery, chemotherapy, or radiotherapy. Patients with lower socioeconomic status were less likely to receive treatment, and variations in patterns of care were observed by patient demographic and clinical characteristics, geographical location, and hospital setting. However, there was wide variability in data collection and measures, health-care systems, patient populations, and population representativeness, making direct comparisons challenging. Future research and policy efforts should emphasize increased comparability of data systems, promote data standardization, and encourage collaboration between and within European cancer registries and administrative databases.

Surgery for rectal cancer-what is on the horizon?

The management of rectal cancer has improved considerably in recent decades. Surgery remains the cornerstone of the treatment. However, the role of preoperative imaging has made it possible to optimize the treatment plan in rectal patients. Neoadjuvant treatment may be indicated in efforts to sterilize possible tumor deposits outside the surgical field, or may be used to downsize and downstage the tumor itself. The optimal sequence of treatment modalities can be determined by a multidisciplinary team, who not only use pretreatment imaging, but also review pathologic results after surgery. The pathologist plays a pivotal role in providing feedback about the success of surgery, i.e., the distance between the tumor and the circumferential resection margin, the quality of surgery, and the effect of neoadjuvant treatment. Registry and auditing of all treatment variables can further improve outcomes. In this century, rectal cancer treatment has become a team effort.