Does young age influence the prognosis of colorectal cancer: a population-based analysis

Colorectal cancer survival disparities in the five regions of Georgia

BACKGROUND/OBJECTIVE

The objective of this study was to examine 5-year colorectal cancer survival rates. We also determined whether demographics, tumor characteristics, and treatment modality were associated with 5-year CRC survival in the Clayton, West Central, East Central, Southeast, and Northeast Georgia regions because the significant higher CRC mortality rates in these regions in comparison to the overall rates in the State of Georgia.

METHODS

We conducted a retrospective cohort analysis using data from the 1975-2016 Surveillance, Epidemiology, and End Results program aggregated CRC patients to these five regions. Five-year CRC survival was calculated and stratified by the five regions of Georgia, using the Kaplan-Meier method with log-rank test. Cox proportional hazard regression was used to examine the mentioned association in these five regions.

RESULTS

Among 11,023 CRC patients, 5-year CRC survival was lowest in Clayton (65.9%) compared to the West Central (69.0%), East Central (68.2%), Southeast (70.5%), and Northeast regions (69.5%) (p-value = 0.02). In multivariable analysis, greater risk of CRC death was found in the Clayton region compared to the West Central (HR, 1.12; 95%, 1.00-1.25) region when adjusting for demographics, tumor characteristics, and treatment modality. Among Clayton Georgians, age of 75+ years (HR, 2.13; 95%, 1.56-2.89), grade 3 & 4 tumors (HR, 2.22; 95%, 1.64-3.00), and distant stage (HR, 20.95; 95%, 15.99-27.45) were negatively associated with CRC survival.

CONCLUSION

We observed place-based differences in CRC survival with significantly lower survival rates in the Clayton region. Factors associated with higher risk of CRC death include older age at diagnosis, high-grade tumors, and distant stage CRC among Clayton Georgians. Our study provides important evidence to all relevant stakeholders in furthering the development of culturally tailored CRC screening interventions aimed at CRC early detection and improved outcomes.

Younger patients with colorectal cancer may have better long-term survival after surgery: a retrospective study based on propensity score matching analysis

BACKGROUND

The relationship between postoperative long-term prognosis and age in colorectal cancer patients remains controversial. The purpose of this study based on a Chinese CRC cohort is to determine the disparity in long-term survival outcomes between younger and older colorectal cancer (CRC) patients after surgery using a propensity score matching (PSM).

METHODS

Data for this study was derived from the CRC cohort of the Database from Colorectal Cancer (DACCA) at West China Hospital of Sichuan University from January 2007 to September 2022. The long‑term prognoses were compared between younger and older groups.

RESULTS

A total of 2374 CRC patients were evaluated in this study, including 1039 older patients and 1335 younger ones. After 1:1 ratio PSM, each group contained 784 CRC patients. There was no significant difference in baseline information after PSM (p < 0.05). Multivariate analysis showed that younger age was an independent predictor of better overall survival (OS) (p < 0.001, HR = 1.750, 95% CI = 1.407-2.177) and disease-specific survival (DSS) (p < 0.001, HR = 1.718, 95% CI = 1.369-2.157). In terms of different tumor pathological stages after PSM, in comparison to older group, younger group had better OS in stage II (p < 0.001), stage III (p = 0.0085), and stage IV (p = 0.0014) and better DSS in stage II (p = 0.0035), stage III (p = 0.0081), and stage IV (p < 0.001).

CONCLUSION

Younger CRC patients have better prognosis than older CRC patients after surgery, especially, and have better OS and DSS in stages II, III, and IV CRC. Younger CRC patient may gain greater benefit from CRC resection and combined therapy. As for the cut-off age, it may be determined by a specific model suitable for local patients.

Nomograms for predicting overall survival in colorectal cancer patients with metastasis to the liver, lung, bone, and brain

BACKGROUND

The aim of this study was to identify the heterogeneous and homogeneous prognostic factors associated with distant metastasis to the liver, lung, bone, and brain in colorectal cancer (CRC) patients and then construct nomograms to predict the prognosis.

METHODS

CRC patients registered in the surveillance, epidemiology, and end results database between 2010 and 2017 were included. A Cox regression model was used to analyse homogeneous and heterogeneous prognostic factors, and Kaplan‒Meier analysis was performed to estimate overall survival (OS). Predictive nomograms were constructed, and their performance was evaluated with C-indexes, calibration curves and the area under the receiver operating characteristic (ROC) curve (AUC).

RESULTS

A total of 37,641 patients with distant metastasis to the liver, lung, bone, and brain were included. The median survival times of patients with liver metastasis, lung metastasis, bone metastasis, and brain metastasis were 12.00 months (95% CI 11.73-12.27 months), 10.00 months (95% CI 9.60-10.41 months), 5.00 months (95% CI 4.52-5.48 months), and 3.00 months (95% CI 2.28-3.72 months), respectively. An older age, higher N stage, elevated carcinoembryonic antigen level, no surgery at the primary site and no/unknown treatment with chemotherapy were identified as homogeneous prognostic factors for the four types of metastases. The calibration curves, C-indexes and AUCs exhibited good performance for predicting the OS of patients with distant metastases to the liver, lung, bone, and brain.

CONCLUSIONS

CRC patients with distant metastasis to the liver, lung, bone, and brain exhibited homogeneous and heterogeneous prognostic factors, all of which were associated with shorter survival. The nomograms showed good accuracy and may be used as tools for clinicians to predict the prognosis of CRC patients with distant metastasis.

Clinical presentation, treatment patterns, and outcomes of colorectal cancer patients at Tikur Anbessa Specialized Hospital in Addis Ababa, Ethiopia: A prospective cohort study

BACKGROUND

Colorectal cancer (CRC) is the third most common cause of cancer death in both genders worldwide.

AIMS

This study aimed to evaluate the outcomes and prognostic factors of CRC patients at Tikur Anbessa Specialized Hospital in Ethiopia.

METHODS AND RESULTS

A prospective cohort study was conducted on 209 patients from January 2020 to September 2022. Kaplan-Meier curves and bivariate and multivariate Cox regression analyses were used to analyze overall and progression-free survival, with a significance value of P < .05. Results showed an overall mortality rate was 67.46% (95% confidence interval [CI]: 61.0-74.0), while the 1-year overall survival (OS) rate was 63.16% (95% CI: 56.23-69.29), with a median follow-up duration of 20 months. The median OS and progression-free survival times were 17 and 11 months, respectively. Age above 40 years (hazard ratio [HR] = 1.53, 1.02-2.29, p < .040), lower educational level (high school and below) (HR = 2.20, 1.24-3.90, p < .007), poor performance status (HR = 1.60, 1.03-2.48, p < .035), Hgb ≤12.5 g/dL (HR = 1.55, 1.03-2.08, p < .035), T-4 disease (HR = 6.05, 2.28-16.02, p < .000), and metastases at diagnosis (HR = 8.53, 3.77-19.25, p < .000) were all associated with poorer survival.

CONCLUSION

These findings suggest that poor survival of CRC patients in Ethiopia is largely due to advanced stage of the disease and lack of timely treatment, and highlight the urgent need for improved access to cancer treatment in the region.

Comparison of the short- and long-term prognosis of early-onset colorectal cancer compared with later-onset colorectal cancer: A systematic review and meta-analysis

Background and Aims

The annual incidence of early-onset colorectal cancer (EOCRC) is increasing at an alarming rate. The prognosis of EOCRC remains controversial, and whether the early onset is a risk factor for colorectal cancer remains unclear.

Methods

We searched four electronic bibliographic databases from database inception to April 25, 2022 for studies that included both early- and later-onset patients and performed a prognostic analysis. Random-effects models were used to summarize the prognostic information extracted by the investigators, including overall survival (OS), cancer-special survival (CSS), and disease-free survival (DFS). Network meta-analysis (NMA) was used to compare patients' long-term prognoses in different age subgroups.

Results

After 694 reports were screened, 13 studies were included in the final analysis, with a total of 448,781 CRC cases. In the meta-analysis of the 5-year OS, EOCRC had a better prognosis compared to LOCRC (hazard ratio [HR] 0.87, 95% confidence interval [CI], 0.74-0.99; relative risk [RR] 0.83, 95% CI, 0.78-0.89). No difference in prognosis was found between the two groups in terms of 5-year CSS (RR 0.99, 95% CI, 0.93-1.05), 5-year DFS (RR 0.90, 95% CI, 0.74-1.09), and short-term OS. In the NMA, patients aged <30 years had the worst outcome (surface under the cumulative ranking curve [SUCRA], 15.8%) in 5-year OS; consistent results were observed in the analysis of 5-year CSS (<30 years, SUCRA 4.5%), but the difference was not statistically significant.

Conclusion

Although patients with early-onset CRC had better OS than those with later-onset CRC, there was no difference in the CSS. Meanwhile, the trend for survival was worse in younger patients, especially in those ages 18-29 years. Thus, more attention should be paid to early diagnosis and treatment of EOCRC.

Systematic Review and Meta‐Analysis Registration

The systematic review and Meta-analysis protocol was registered with PROSPERO (registration number CRD42022334697).

Demographic and clinico-pathological characteristics of colorectal cancer in Kirkuk governorate, Iraq

BACKGROUND

World-wide Colorectal cancer (CRC) is the third most common cancer with one million new cases a year. Historically, a higher incidence of this disease has been recorded among the elderly in the western countries, but it is increasing in developing countries and in younger age groups.

AIM

This study aims to find whether CRC cancer is progressively affecting the younger age groups known as early onset (< 50 years). In addition, it describes the pathological characteristics of CRC in early onset CRC cases.

METHOD

The study is retrospective cross-sectional. It was conducted over a period of five months from October 1st 2019 till 1st March 1st 2020. Data were drawn from patients with CRC from their medical records at Kirkuk Oncology Centre (KOC) and from the IRAQI National CANCER REGISTRY (INCR) over thirteen years period from 2006 to 2018. The basic data we obtained for each patient include sex, age, and stage, grade of the disease at diagnosis and mode of presentation.

RESULTS

The Initial study population included 654 patients of both genders and all ages. CRC occurred in < 5.5/100,000 population per year which accounted for < 8% of total malignancies (2006-2018). The patients were divided into two groups; an early onset (< 50 years) group and a late onset CRC (⩾ 50 years) group. The final study population provided enough data for 238 patients for the years (2014-2018) with an age range of 20-91 and a mean of 54.4 years. The males were ∼54% while ∼46% were females. The age group under 50 years (early onset CRC) was ∼41% (no 98) while those who are 50 years and older (late onset) stood for 59% (no 140). There were no statistical differences between the two age groups regarding stage, grade, or presenting symptom.

CONCLUSION

CRC is common in early onsets or young age groups with similar pathological characteristics to those of the late onset cancer. Accordingly, even mild lower gastrointestinal symptoms should be taken seriously. The study points toward an increasing awareness of the population on the importance of colorectal cancer. Also, conducting more surveillance studies and investigations would be recommended for early detections of the disease in young populations.

Enterotypical Prevotella and three novel bacterial biomarkers in preoperative stool predict the clinical outcome of colorectal cancer

BACKGROUND

A significant proportion of colorectal cancer (CRC) patients suffer from early recurrence and progression after surgical treatment. Although the gut microbiota is considered as a key player in the initiation and progression of CRC, most prospective studies have been focused on a particular pathobionts such as Fusobacterium nucleatum. Here, we aimed to identify novel prognostic bacteria for CRC by examining the preoperative gut microbiota through 16S ribosomal RNA gene sequencing.

RESULTS

We collected stool samples from 333 patients with primary CRC within 2 weeks before surgery and followed up the patients for a median of 27.6 months for progression and 43.6 months for survival. The sequence and prognosis data were assessed using the log-rank test and multivariate Cox proportional hazard analysis. The gut microbiota was associated with the clinical outcomes of CRC patients (P_progress = 0.011, P_decease = 0.007). In particular, the high abundance of Prevotella, a representative genus of human enterotypes, indicated lower risks of CRC progression (P = 0.026) and decease (P = 0.0056), while the occurrence of Alistipes assigned to Bacteroides sp., Pyramidobacter piscolens, Dialister invisus, and Fusobacterium nucleatum indicated a high risk of progression. A microbiota-derived hazard score considering the five prognostic bacteria accurately predicted CRC progression in 1000 random subsamples; it outperformed widely accepted clinical biomarkers such as carcinoembryonic antigen and lymphatic invasion, after adjustment for the clinicopathological stage (adjusted HR 2.07 [95% CI, 1.61-2.64], P = 7.8e-9, C-index = 0.78). PICRUSt2 suggested that microbial pathways pertaining to thiamine salvage and L-histidine degradation underlie the different prognoses.

CONCLUSIONS

The enterotypical genus Prevotella was demonstrated to be useful in improving CRC prognosis, and combined with the four pathobionts, our hazard score based on the gut microbiota should provide an important asset in predicting medical outcomes for CRC patients. Video Abstract.

Young-onset colorectal cancer: Insights from an English population-based study

AIM

Young colorectal cancer (CRC) patients are reported to have more aggressive disease, an advanced stage at diagnosis and conflicting survival outcomes. The aim of this study was to analyse the demographics, clinicopathological features and prognosis of young CRC at a population-based level in England.

METHOD

This is a retrospective review of all CRC patients using data from Public Health England collated from regional cancer registries in England between 2010 and 2014. Those aged 40 years and below were classified as young and those over 40 were classified as older.

RESULTS

Overall, 167,501 patients had CRC. Of these, 3757 patients (2.2%) were young. Right-sided cancers were more common in younger patients (48.2% vs. 32.9%, p < 0.001). Favourable histological grade (well or moderately differentiated) was present in 83.1% and 73.5% of young and older patients, respectively. The percentage of young and older patients being diagnosed at an early stage (Stages 1 and 2) was similar at 40.6% vs. 42.9%. The 5-year age- and gender-adjusted relative survival (cancer specific) was significantly better for young patients when compared with older patients diagnosed with CRC. Additionally, overall 5-year survival was better for younger patients (71.6% and 47.2%, p < 0.001 in young and older CRC patients respectively).

CONCLUSION

The increased right-sided colon cancer in young CRC patients in England warrants attention. Contrary to previous reports, they do not present at later stage. Young CRC patients have better overall and relative survival than older patients with CRC.

Laparoscopic ovarian transposition in teenage and young women with locally advanced rectal cancer: Respite amidst cancer chaos

AIM

Ovarian transposition is an established surgical technique to salvage ovaries in premenopausal women requiring pelvic radiation. The success rate of ovarian transposition varies widely depending on the route, technique of surgery, type of cancer and treatment. Here, we aimed to analyse the effectiveness of laparoscopic ovarian transposition (LOT) in teenage and young women prior to pelvic radiation in locally advanced rectal cancers (LARC).

METHODS

Patients who underwent LOT for rectal cancers were retrieved from a prospectively maintained database from June 2013-September 2019. Disease characteristics, return of menstrual function and oncological outcomes were analysed.

RESULTS

A total of 46 women with a mean age of 25.2 years who underwent LOT at the cancer centre were included in the study. Seventy percent were nulliparous. All patients were fit for discharge by 24 h. Mean time to start radiation was 19.6 days (range 3-47 days). Median follow-up of patients was 42 months. A total of 41 patients were assessable for ovarian function, 65.5% had resumption of menses. Median ovarian survival was 79 months and 5-year ovarian survival was 54%. Median overall survival from rectal cancer was 51 months.

CONCLUSION

Laparoscopic ovarian transposition is a safe and effective technique of ovarian protection from the gonadotoxic effects of pelvic radiation in LARC. It does not delay primary treatment and does not compromise oncological outcomes. Long-term follow-up is required to evaluate fertility and quality of life.

The Characterization and Outcomes of Colorectal Malignancy in Patients ≤40 Years of Age: A Single-Center Experience

BACKGROUND

Implementation of screening modalities has led to a decreased incidence of colorectal malignancies. Unfortunately, overall incidence has remained unchanged as cases have increased in patients below the suggested screening age. Therefore, we evaluated characteristics and oncological outcomes of malignancies in patients ≤40 years of age.

METHODS

Single-center retrospective analysis of prospectively collected data of malignancies in patients ≤40 years evaluated in our institution between 2010 and 2016. Basic descriptors for demographic, clinical, histologic, and genetic data were collected. Disease-free survival (DFS) and 5-year overall survival (OS) were compared for patients between 30-40 years and <30 years.

RESULTS

Fifty-six patients ≤40 years were identified, 44 of whom (96.5%) had adenocarcinomas. Most common malignancy location was the rectum (64.3%). Despite aggressive tumor characteristics such as moderate/poor differentiation (88.6%), lymphovascular invasion (26.8%), perineural invasion (21.4%), and advanced tumor stage T3/T4 (60.7%), OS rate was 94.6%. Both age groups had similar oncologic characteristics. There was a trend toward worse OS (2/11 and 1/45, P = .06) but not for DFS (7/11 and 15/43, P = .18) in patients <30 years of age compared to 30-40 years. There were no differences in OS (3/44 vs 0/88, P = .44) or DFS (17/42 vs 3/8, P = .80) between sporadic vs non-sporadic malignancies, respectively.

CONCLUSIONS

Patients ≤40 years of age with malignancy have advanced tumor stages and aggressive tumor characteristics at diagnosis. Although there is higher OS risk for patients <30 compared to those aged 30-40 years, no differences were found for DFS between these two groups.

Survival in Young-Onset Metastatic Colorectal Cancer: Findings From Cancer and Leukemia Group B (Alliance)/SWOG 80405

BACKGROUND

The incidence of young-onset colorectal cancer (yoCRC) is increasing. It is unknown if there are survival differences between young and older patients with metastatic colorectal cancer (mCRC).

METHODS

We studied the association of age with survival in 2326 mCRC patients enrolled in the Cancer and Leukemia Group B and SWOG 80405 trial, a multicenter, randomized trial of first-line chemotherapy plus biologics. The primary and secondary outcomes of this study were overall survival (OS) and progression-free survival (PFS), respectively, which were assessed by Kaplan-Meier method and compared among younger vs older patients with the log-rank test. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated based on Cox proportional hazards modeling, adjusting for known prognostic variables. All statistical tests were 2-sided.

RESULTS

Of 2326 eligible subjects, 514 (22.1%) were younger than age 50 years at study entry (yoCRC cohort). The median age of yoCRC patients was 44.3 vs 62.5 years in patients aged 50 years and older. There was no statistically significant difference in OS between yoCRC vs older-onset patients (median = 27.07 vs 26.12 months; adjusted HR = 0.98, 95% CI = 0.88 to 1.10; P = .78). The median PFS was also similar in yoCRC vs older patients (10.87 vs 10.55 months) with an adjusted hazard ratio of 1.02 (95% CI = 0.92 to 1.13; P = .67). Patients younger than age 35 years had the shortest OS with median OS of 21.95 vs 26.12 months in older-onset patients with an adjusted hazard ratio of 1.08 (95% CI = 0.81 to 1.44; Ptrend = .93).

CONCLUSION

In this large study of mCRC patients, there were no statistically significant differences in survival between patients with yoCRC and CRC patients aged 50 years and older.

Characteristics and Predictors of Long-Time Survivors in Non-Metastatic Gastric Signet Ring Cell Carcinoma: A Large Population-Based Study

Objective

Gastric signet ring cell carcinoma (SRCC) is a distinct entity with a relatively poor prognosis. This study analyzed the clinicopathological characteristics of long-time survivors (LTSs) and identified independent predictors of long-term survival (LTS) in non-metastatic gastric SRCC.

Methods

Data from 3906 patients with non-metastatic gastric SRCC were retrieved from Surveillance, Epidemiology and End Results according to the inclusion and exclusion criteria. Patients were randomly divided into training and validation cohorts. Predictors of LTS in the training cohort were identified by multivariate logistic regression. A nomogram-based predictive model for LTS was constructed in non-metastatic gastric SRCC.

Results

There were 800 patients who survived for >5 years and were defined as TLSs. Young age, other race (not black or white population), female gender, married status, small tumor size, low tumor infiltration, and negative lymph node involvement were independent predictors of LTS in non-metastatic gastric SRCC. These seven variables were incorporated into a nomogram model for predicting LTS. The calibration curve showed good consistency between observed and predicted probability of LTS, and the receiver operating characteristic curve showed acceptable discriminative capacity in the training and validation cohorts.

Conclusion

This study provides an overview of the features of patients with non-metastatic gastric SRCC. Age, race, sex, marital status, tumor size, tumor infiltration, and lymph node involvement were identified as independent predictors of LTS.

A Prediction Model for Tumor Recurrence in Stage II–III Colorectal Cancer Patients: From a Machine Learning Model to Genomic Profiling

Background: Colorectal cancer (CRC) is one of the most prevalent malignant diseases worldwide. Risk prediction for tumor recurrence is important for making effective treatment decisions and for the survival outcomes of patients with CRC after surgery. Herein, we aimed to explore a prediction algorithm and the risk factors for postoperative tumor recurrence using a machine learning (ML) approach with standardized pathology reports for patients with stage II and III CRC. Methods: Pertinent clinicopathological features were compiled from medical records and standardized pathology reports of patients with stage II and III CRC. Four ML models based on logistic regression (LR), random forest (RF), classification and regression decision trees (CARTs), and support vector machine (SVM) were applied for the development of the prediction algorithm. The area under the curve (AUC) of the ML models was determined in order to compare the prediction accuracy. Genomic studies were performed using a panel-targeted next-generation sequencing approach. Results: A total of 1073 patients who received curative intent surgery at the National Cheng Kung University Hospital between January 2004 and January 2019 were included. Based on conventional statistical methods, chemotherapy (p = 0.003), endophytic tumor configuration (p = 0.008), TNM stage III disease (p < 0.001), pT4 (p < 0.001), pN2 (p < 0.001), increased numbers of lymph node metastases (p < 0.001), higher lymph node ratios (LNR) (p < 0.001), lymphovascular invasion (p < 0.001), perineural invasion (p < 0.001), tumor budding (p = 0.004), and neoadjuvant chemoradiotherapy (p = 0.025) were found to be correlated with the tumor recurrence of patients with stage II–III CRC. While comparing the performance of different ML models for predicting cancer recurrence, the AUCs for LR, RF, CART, and SVM were found to be 0.678, 0.639, 0.593, and 0.581, respectively. The LR model had a better accuracy value of 0.87 and a specificity value of 1 in the testing set. Two prognostic factors, age and LNR, were selected by multivariable analysis and the four ML models. In terms of age, older patients received fewer cycles of chemotherapy and radiotherapy (p < 0.001). Right-sided colon tumors (p = 0.002), larger tumor sizes (p = 0.008) and tumor volumes (p = 0.049), TNM stage II disease (p < 0.001), and advanced pT3–4 stage diseases (p = 0.04) were found to be correlated with the older age of patients. However, pN2 diseases (p = 0.005), lymph node metastasis number (p = 0.001), LNR (p = 0.004), perineural invasion (p = 0.018), and overall survival rate (p < 0.001) were found to be decreased in older patients. Furthermore, PIK3CA and DNMT3A mutations (p = 0.032 and 0.039, respectively) were more frequently found in older patients with stage II–III CRC compared to their younger counterparts. Conclusions: This study demonstrated that ML models have a comparable predictive power for determining cancer recurrence in patients with stage II–III CRC after surgery. Advanced age and high LNR were significant risk factors for cancer recurrence, as determined by ML algorithms and multivariable analyses. Distinctive genomic profiles may contribute to discrete clinical behaviors and survival outcomes between patients of different age groups. Studies incorporating complete molecular and genomic profiles in cancer prediction models are beneficial for patients with stage II–III CRC.

Discovery of a novel and a rare Kristen rat sarcoma viral oncogene homolog (KRAS) gene mutation in colorectal cancer patients

Colorectal cancer (CRC) is one of the most important causes of morbidity and mortality in the developed world and is gradually more frequent in the developing world including Saudi Arabia. According to the Saudi Cancer Registry report 2015, CRC is the most common cancer in men (14.9%) and the second most prevalent cancer. Oncogenic mutations in the KRAS gene play a central role in tumorigenesis and are mutated in 30-40% of all CRC patients. To explore the prevalence of KRAS gene mutations in the Saudi population, we collected 80 CRC tumor tissues and sequenced the KRAS gene using automated sequencing technologies. The chromatograms presented mutations in 26 patients (32.5%) in four different codons, that is, 12, 13, 17, and 31. Most of the mutations were identified in codon 12 in 16 patients (61.5% of all mutations). We identified a novel mutation c.51 G>A in codon 17, where serine was substituted by arginine (S17R) in four patients. We also identified a very rare mutation, c.91 G>A, in which glutamic acid was replaced by lysine (E31K) in three patients. In conclusion, our findings further the knowledge about KRAS mutations in different ethnic groups is indispensable to fully understand their role in the development and progression of CRC.

Impact of Socioeconomic Status on Cancer Incidence Risk, Cancer Staging, and Survival of Patients with Colorectal Cancer under Universal Health Insurance Coverage in Taiwan

This study examined the impact of socioeconomic status on colorectal cancer risk, staging, and survival under the National Health Insurance (NHI) system in Taiwan. Monthly salary and education level were used as measures of socioeconomic status to observe the risk of colorectal cancer among individuals aged 40 years or above in 2006-2015 and survival outcomes of patients with colorectal cancer until the end of 2016. Data from 286,792 individuals were used in this study. Individuals with a monthly salary ≤Q1 were at a significantly lower incidence risk of colorectal cancer than those with a monthly salary >Q3 (HR = 0.80, 95% CI = 0.74-0.85), while those with elementary or lower education were at a significantly higher risk than those with junior college, university, or higher education (HR = 1.18, 95% CI = 1.06-1.31). The results show that socioeconomic status had no significant impact on colorectal cancer stage at diagnosis. Although salary was not associated with their risk of mortality, patients with colorectal cancer who had elementary or lower education incurred a significantly higher risk of mortality than those who had junior college, university, or higher education (HR = 1.39, 95% CI = 1.07-1.77). Education level is a significant determinant of the incidence risk and survival in patients with colorectal cancer, but only income significantly impacts incidence risk.

Opposing effects of BRCA1 mRNA expression on patient survival in breast and colorectal cancer and variations among African American, Asian, and younger patients

Breast cancer (BC) and colorectal cancer (CRC) are common and show poor survival in advanced stages. Using The Cancer Genome Atlas (TCGA) computational tool cBioPortal, we evaluated overall patient survival in BRCA1 mRNA-low versus -high cohorts (<-1.29 versus >1.05 SD from mean BRCA1 expression, respectively). Analysis included 1082 BC patients with mRNA data (PanCancer Atlas), 382 CRCs (Firehose Legacy) and 592 CRCs (PanCancer Atlas). As previously reported, BRCA1 mRNA-low tumor expression positively correlated with BC patient survival but was negatively associated in CRC. We observed a correlation between BRCA1 mRNA-high and age <45 years at CRC diagnosis using a Fisher's exact test [Firehose Legacy database (p-value = 0.0091); CRC PanCancer Atlas (p-value = 0.0778)]. We correlated BRCA1 mRNA-low expression and basal BC (p-value = 0.0016) and BRCA1 mRNA-low tumors and frequency of African American patients (p-value = 0.0448) with BC. Other trends included higher frequency of advanced lymph node stage and mucinous adenocarcinoma among BRCA1 mRNA-low CRC and higher frequency of males in BRCA1 mRNA-high BC and CRC. African Americans more frequently had BRCA1 mRNA-low BC and BRCA1 mRNA-high CRC and the opposite was observed among Asians. Using a gene co-expression tool (cBioPortal), we observed TOP2A and ATAD5 levels correlate (Spearman's correlation>0.6) with BRCA1 in BC and CRC, whereas LMNB2 correlates with BRCA1 in CRC, suggesting tissue-specific BRCA1 interactions. Our results indicate potential for BRCA1 mRNA expression levels as a prognostic biomarker in BC and CRC, suggest tissue-specificity in BRCA1 molecular interactions, and point to BRCA1 mRNA-high levels as a characteristic of CRC tumors in younger versus older individuals.

Colorectal cancer in the young - outcomes following surgical management?

INTRODUCTION

Colorectal cancer (CRC) is the third most common cancer, accounting for approximately 10% of all cancer deaths. The incidence of CRC in young adults and the adolescent population is increasing. This study aims to highlight short-term outcomes for young patients with CRC.

METHODS

Data were collected retrospectively for all patients aged less than 50 years diagnosed with CRC at a university teaching hospital between October 2012 and June 2018. The primary endpoints were disease-free survival (DFS) and overall survival (OS).

RESULTS

A total of 120 patients (65 males, 55 females) with CRC aged under 50 years were initially included; 20 did not receive surgical treatment (12 metastatic adenocarcinoma, 5 metastatic squamous cell cancer (SCC), 3 neuroendocrine tumours (NET)), and 13 patients had insufficient data for analysis and were excluded. A total of 87 patients underwent surgical intervention and 66 with diagnosis of adenocarcinoma were included in survival analysis. Median age of patients was 42 years (19-49 years). Cancer recurrence was seen in 14 patients, 10 showing local, 3 liver and 1 lung metastasis. The median OS was 28 months (3-156 months). The median DFS was 13 months (3-85 months). Overall 5-year survival and DFS were 72% and 59%, respectively. Median survival in the group who did not undergo surgery was 4.5 months (1-15 months).

CONCLUSIONS

CRC is often more advanced and aggressive in younger patients. Current guidelines can result in young patients being investigated/treated for other gastrointestinal conditions before referral for CRC investigation.

Treatment and Outcomes of Colorectal Cancer in Armenia: A Real-World Experience From a Developing Country

PURPOSE

In Armenia, colorectal cancer (CRC) is one of the most frequently diagnosed cancers. It is in the third place by incidence. The aim of this study was to evaluate treatment and outcomes of CRC in Armenia during the last 9 years.

MATERIALS AND METHODS

For this retrospective hospital-based study, we have collected data from two main oncology centers in Armenia: National Oncology Center and “Muratsan” Hospital of Yerevan State Medical University. The information about patients with CRC who were treated at these two centers between January 1, 2010 and July 1, 2018 was collected from the medical records. Log-rank test and Kaplan-Meier curves were used for survival analysis. Prognostic factors were identified by Cox regression.

RESULTS

A total of 602 patients with CRC were involved in the final analysis. Median follow-up time was 37 months (range, 3-207 months). A total of 8.6% of patients had stage I, 32.9% stage II, 38.0% stage III, and 17.6% stage IV cancer; for 2.7% patients, the stage was unknown. The main independent prognostic factors for overall survival (OS) were tumor stage, grade, and histology. Adjuvant chemotherapy has been shown to improve survival in stage II colon cancer and stage III rectal but not in stage II rectal cancer. Radiotherapy did not yield survival improvement in stage II or III rectal cancer. Three- and 5-year OS rates were 62.9% and 51.8% for all stages combined and 79.7% and 68.5% for stages I-II, 62.5% and 48.4% for stage III, and 24.4% and 17% for stage IV respectively.

CONCLUSION

As seen from our results, our survival rates are lower than those of the developed world. Additional research is needed to identify the underlying reasons and to improve patients’ treatment and outcomes in Armenia.

Age-Associated Proteomic Signatures and Potential Clinically Actionable Targets of Colorectal Cancer

The occurrence and prevalence of colorectal cancer (CRC) is closely associated with age. More than 90% of patients with CRC are diagnosed after 50 years of age. However, CRC incidence of young individuals has been increasing since 1990s, whereas the overall CRC frequency is declining. Distinct overall survival rates between young and aged patients with CRC have been established. Tremendous efforts have been made to clarify the underlying mechanisms of age-dependent clinical differences, but it still remains elusive. Here, we performed proteomic profiling of 50 patients with CRC and revealed proteomic signatures of CRC across age groups. Gene set enrichment analysis showed that distinct age-dependent clinical outcomes might mainly attribute to varied MYC targets V1/V2, E2F targets and G2M checkpoint gene sets, which were associated with cancer cell proliferation, cell apoptosis, tumor growth, and tumor metastasis. Multiple linear regression analysis revealed a large number of functional proteins, such as NOP2, CSE1L, NHP2, NOC2L and CDK1, with adjusted expression significantly correlated with age (p < 0.05). Among them, NHP2 is a core component of the telomerase complex associated with age. High NHP2 expression predicted poor overall survival, with a more significant correlation in aged patients with CRC. Knockdown of NHP2 significantly suppressed cancer cell proliferation. In addition, we revealed some age-related potential clinically actionable targets, such as PSEN1, TSPO, and CDK1, which might be more suitable for patients with late-onset CRC. Collectively, this study identifies age-associated proteomic signatures and potential therapeutic targets of CRC and may help make a precise decision on CRC treatment.

•

The proteomic signatures of early-onset CRC are disclosed.

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Alterations of some proteins between cancerous and normal tissues are age-correlated.

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NHP2, overexpressed in tumors especially in aged patients, predicts poor prognosis.

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Potential age-dependent druggable targets and their inhibitors are summarized.

Survival of colorectal cancer patients in Brunei Darussalam: comparison between 2002-09 and 2010-17

Background

Colorectal cancer (CRC) is a major cause of cancer-related mortality worldwide. It is the second leading cause of cancer death in men and women in Brunei Darussalam in 2017, posing a major burden on society.

Methods

This retrospective cohort study (n = 1035 patients diagnosed with CRC in Brunei Darussalam from 1st January 2002 until 31st December 2017) aims to compare the overall survival rates of CRC patients (2002–2017), to compare survival rates between two study periods (2002–2009 and 2010–2017) and to identify prognostic factors of CRC. Kaplan-Meier estimator and log-rank tests were performed to analyse the overall survival rates of CRC patients. Multiple Cox regression was performed to determine the prognostic factors of CRC with adjusted hazard ratios (Adj. HRs) reported.

Results

The 1-, 3- and 5-year survival rates of CRC patients are 78.6, 62.5, and 56.0% respectively from 2002 to 2017. The 1-, 3-, and 5-year survival rates of CRC patients for 2002–2009 are 82.2, 69.6, and 64.7%; 77.0, 59.1, and 51.3% for 2010–2017 respectively. A significant difference in CRC patients’ survival rate was observed between the two study periods, age groups, ethnic groups, cancer stages, and sites of cancer (p < 0.05). The Adjusted Hazard Ratios (Adj. HRs) were significantly higher in the 2010–17 period (Adj. HR = 1.78, p < 0.001), older age group ( ≥ 60 years) (Adj. HR = 1.93, p = 0.005), distant cancer (Adj. HR = 4.69, p < 0.010), tumor at transverse colon and splenic flexure of colon (Adj. HR = 2.44, p = 0.009), and lower in the Chinese(Adj. HR = 0.63, p = 0.003).

Conclusion

This study highlights the lower survival rates of CRC patients in 2010–2017, Malays, older patients, distant cancer, and tumors located at the latter half of the proximal colon (transverse colon), and predominantly LCRC (splenic flexure, descending colon, sigmoid colon, overlapping lesion colon and colon (NOS), as well as the rectosigmoid junction and rectum (NOS)). Age, ethnicity, cancer stage, and tumor location are significant prognostic factors for CRC. These findings underscore the importance of public health policies and programmes to enhance awareness on CRC from screening to developing strategies for early detection and management, to reduce CRC-associated mortality.

Real-World Outcomes of Oxaliplatin-Based Chemotherapy on R0 Resected Colonic Liver Metastasis

INTRODUCTION

In resected colonic liver metastasis (CLM), randomized studies of oxaliplatin-based chemotherapy have demonstrated improvements in disease-free survival (DFS), but not overall survival (OS). Additionally, oxaliplatin regimens have not been compared to non-oxaliplatin chemotherapy. Despite limited evidence, perioperative chemotherapy is often used in the management of CLM. The primary aim of this study was to assess the impact of oxaliplatin chemotherapy regimens on OS in patients who have undergone resection of CLM in a real-world setting.

PATIENTS AND METHODS

Patients who underwent resection of CLM in the provinces of Alberta and British Columbia, Canada, were identified from 1996 to 2016. Perioperative (pre- and/or post-) systemic therapy was categorized as oxaliplatin or non-oxaliplatin-based chemotherapy or no chemotherapy. The primary and secondary outcomes were OS and DFS, respectively.

RESULTS

We identified 511 patients who underwent R0 resection of CLM. A significant difference in median OS was identified among the oxaliplatin, non-oxaliplatin, and no-chemotherapy groups of 100, 60, and 59 months, respectively (P = .009). In multivariate analysis, patients who received oxaliplatin regimens had a lower risk of death (hazard ratio, 0.68; 95% confidence interval, 0.51-0.92; P = .012), whereas the non-oxaliplatin chemotherapy group did not (hazard ratio, 0.88; 95% confidence interval, 0.65-1.20; P = .422) compared with no chemotherapy.

CONCLUSIONS

In this multicenter, retrospective, population-based study, perioperative oxaliplatin-based chemotherapy was associated with improved OS in conjunction with R0 resection of CLM. Further studies should evaluate the optimal duration and sequencing of perioperative chemotherapy in relation to curative-intent surgical resection of CLM.

Presentation and survival among patients with colorectal cancer before the age of screening: a systematic review and meta-analysis

Background

The incidence of colorectal cancer in North America is rising among patients younger than 50 years. Available data are conflicting regarding presentation and outcomes in this population. This review aimed to synthesize literature regarding young patients with colorectal cancer with respect to patient demographics, disease extent and survival, compared with patients older than 50 years.

Methods

We searched Medline, Embase, the Cochrane Central Register of Controlled Trials and PubMed for articles published between 1990 and the time of search. Articles comparing North American patients with colorectal cancer younger and older than 50 years were eligible for inclusion. We used a random-effects model to pool odds ratios.

Results

Eight retrospective studies were eligible for inclusion (n = 790 959). Mean age was 42.6 years (standard deviation [SD] 5.07) in the younger group, and 69.1 years (SD 9.25) in the older group. Young patients were more likely to present with regional (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.16–1.40) and distant disease (OR 1.47, 95%CI 1.30–1.67). Considering patients at all stages of disease, differences in 5-year overall survival (OR 1.54, 95%CI 0.96–2.47) and cancer-specific survival (OR 1.01, 95%CI 0.91–1.13) were not statistically significant between groups. However, when controlling for disease extent, 5-year cancer-specific survival was significantly higher among young patients with local (OR 1.69, 95%CI 1.43–1.99), regional (OR 1.37, 95%CI 1.16–1.63) and distant disease (OR 1.79, 95%CI 1.45–2.21).

Conclusion

North American patients presenting with colorectal cancer before the age of 50 years are more likely to have advanced disease. Although overall and cancer-specific survival is not significantly different between these groups, younger patients have improved survival when controlling for cancer stage.

Disaggregating Data on Pacific Islander Gastric Cancer Patients Reveals Survival Disparity

PURPOSE

The incidence and prognosis of Pacific Islanders with gastric cancer is not well documented as previous studies have often aggregated this population with Asians. The purpose of our study was to describe patient and tumor characteristics, as well as prognostic factors of Pacific Islanders with gastric cancer.

METHODS

Patients diagnosed with gastroesophageal junction or gastric adenocarcinoma between 2000 and 2014 were identified in the tumor registry of the largest hospital in Hawaii. Overall survival of Asians, Whites, and Pacific Islanders were calculated using the Kaplan-Meier method and log-rank test. Cox proportional hazards regression models were constructed to assess predictors of survival adjusting for clinical and pathological factors.

RESULTS

A total of 615 patients were included in the final analysis. Pacific Islanders were found to present at a younger age, were more often uninsured or had Medicaid insurance, and were diagnosed with a higher stage of cancer compared to their Asian and White counterparts. Pacific Islanders were less likely to undergo surgery even after adjusting for stage. Race was a prognostic factor and survival was lowest among Pacific Islanders, but only if the model was unadjusted for treatment.

CONCLUSIONS

We present an analysis of the largest cohort of Pacific Islander gastric cancer patients. Pacific Islanders have different sociodemographic characteristics and inferior survival compared to Asian patients and should be independently studied.

Clinicopathological Characteristics and Outcome of Adolescent and Young Adult-Onset Microsatellite Stable Colorectal Cancer Patients

Purpose: Colorectal cancer (CRC) incidence is increasing in adults younger than 50 years. This study evaluated clinicopathological characteristics and outcome of adolescent and young adult (AYA)-onset sporadic CRC patients. Methods: Medical records of patients who were diagnosed adenocarcinoma of colon or rectum at Siriraj Hospital between 2007 and 2018 were retrospectively reviewed. The patients were classified into two groups: AYA-onset CRC (age 15-39 years) and adult-onset CRC (age >50 years). Associations between sporadic microsatellite stable (MSS) AYA-/adult-onset CRC and clinicopathological features and outcome were evaluated. Results: A total of 203 patients were diagnosed with AYA-onset CRC with no known history of familial CRC syndromes, 119 had data on mismatch repair status; 98 confirmed MSS CRC. AYA-onset CRC patients were commonly found with left-sided rather than right-sided tumors (77.1% vs. 22%) and late stage of disease (80.7% in stage III-IV vs. 19.3% in stage I-II). Compared with adult-onset CRC (218 patients), AYA-onset MSS CRC had more patients with female gender (p = 0.038), perineural invasion (p = 0.003), and signet ring cell/mucinous histology (p = 0.132). On univariate analysis, male gender and mucinous/signet ring cell histology had worse overall survival (OS) (p = 0.004 and p = 0.072, respectively) and remained significant in multivariate analysis for signet ring cell histology (p = 0.008). There was no difference in disease-free survival and OS between both age groups. Conclusions: Sporadic MSS AYA-onset CRC patients were associated with female gender and aggressive pathological characteristics. However, there was no difference in survival outcome between AYA-onset and adult-onset groups.

Evaluation of determinants for age disparities in the survival improvement of colon cancer: results from a cohort of more than 486,000 patients in the United States

Over the past two decades, elderly colon cancer patients experienced less improvement in survival than their younger counterparts, yet the contributing factors remain unknown. We aimed to evaluate factors that may contribute to the age disparity of survival improvement among patients with colon cancer. Using data from the National Cancer Database, we identified patients diagnosed with colon cancer between 2004 and 2012 with follow-up data up to 2017. The hazard ratios (HR) and 95% confidence intervals (CI) for 5-year OS associated with study variables were estimated using multivariable Cox regression. Among 486,284 patients included in this study, elderly patients (aged ≥75) had a lower adherence to National Comprehensive Cancer Network (NCCN) treatment guidelines (% of non-adherence: 45.3%) than younger patients (aged <50, 19.3%; P<0.001). After adjusting for demographics, access to care and clinical characteristics, compared with patients diagnosed between 2004 and 2006, younger and older patients diagnosed between 2010 and 2012 experienced 16% (HR: 0.84, 95% CI: 0.81-0.88) and 6% (HR: 0.94, 95% CI: 0.93-0.95) reductions in mortality (P for interaction=1.42×10-5), respectively. After an additional adjustment for guideline adherence status, no significant difference in the improvement of survival was noted (P for interaction=0.17). The association patterns were similar regardless of tumor stage, race, and high comorbidity scores (all P for interaction>0.05). Several patient-related factors were identified in association with noncompliance to NCCN guidelines, including comorbidity status. However, over 60% of noncompliance elderly patients had a Charlson comorbidity score of 0. The observed age disparity in survival improvement among colon cancer patients was primarily explained by a slower improvement in adherence to NCCN treatment guidelines in elderly than younger patients. Many older adults were not receiving recommended therapies despite minimal comorbidities. Our findings call for measures to increase adherence to treatment guidelines among elderly patients to improve survival.

Recurrence, death risk, and related factors in patients with stage 0 colorectal cancer: A nationwide population-based study

In this study, the National Health Insurance Research Database of Taiwan was used to examine the recurrence and death risk for stage 0 colorectal cancer patients. We examined stage 0 colorectal cancer patients to identify factors causing recurrence and death.This is a retrospective study, and stage 0 colorectal cancer patients that are registered in the Taiwan Cancer Registry of the Health Promotion Administration in 2007 to 2012 were included. The database was linked to the National Health Insurance Research Database, and subjects were followed up until the end of 2016. The mean follow-up period was 69 months. Bivariate analysis methods (log-rank test) and Cox proportional hazards model were used to evaluate the risk of recurrence and death and demographic characteristics, economic factors, environmental factors, health factors, treatment and hospitals, and absence/presence of postoperative tests were used to examine related risk factors.Our study showed that the 5-year recurrence rate and 5-year mortality rate for stage 0 colorectal cancer are 1.68% and 0.6%, respectively. For stage 0 colorectal cancer, age (61-74 years) is the only factor affecting recurrence in patients (hazard ratio (HR) = 2.44; 95% CI: 1.41-4.22), while age >75 years (HR = 4.35; 95% CI: 1.14-16.68) and Charlson Comorbidity Index >4 points (HR = 7.20, 95% CI: 2.60-19.94) can increase the risk of death. In contrast, patients who underwent one (HR = 0.27, 95% CI: 0.10-0.71) and two or more colonoscopies (HR = 0.26, 95% CI: 0.10-0.70) within 2 years after surgery can reduce the risk of death from stage 0 colorectal cancer. In addition, the risk of recurrence is higher in patients who underwent colonoscopic polypectomy (HR = 2.07, 95% CI: 0.98-4.33) and patients with rectal cancer (HR = 2.74, 95% CI: 0.96-7.83), but these differences are not statistically significant (P > .05).From this study, we can see that age and comorbidity index increase the risk of recurrence and death for stage 0 colorectal cancer, while postoperative colonoscopy can decrease the risk of death.

Colorectal cancer in younger adults from a Bi-National Colorectal Cancer Audit registry

BACKGROUND

The incidence of colorectal cancer (CRC) in younger adults (<50 years old) is rising worldwide, at a rate of 1% per annum since mid-1980s. The clinical concern is that younger adults may have more advanced disease leading to poorer prognosis compared to their older cohort due to lack of screening. Therefore, the aim of this study is to assess the incidence and short-term outcomes of colorectal cancer in younger adults.

METHODS

This is a retrospective study from a prospectively maintained bi-national database from 2007 to 2018.

RESULTS

There were 1540 younger adults diagnosed with CRC, with a rise from 5.8% in 2007 to 8.4% in 2018. Majority had lower American Society of Anaesthesiologists (ASA) scores (89%), rectal cancers (46.1%) and higher tumour stage (65.4%). As a consequence, they were likely to have higher circumferential resection margin positivity (6%, P = 0.02) and to receive adjuvant chemotherapy (57.1%, P < 0.001) compared to their older cohort. Multivariate analysis showed disadvantaged socioeconomic status (odds ratio (OR) 3.3, 95% confidence interval (CI) 1.37-7.94, P < 0.001) and increasing tumour stage (OR 14.9, 95% CI 1.89-116.9, P < 0.001) were independent predictors for circumferential resection margin positivity whereas being female (OR 0.71, 95% CI 0.53-0.95, P = 0.02), higher ASA score (OR 175.3, 95% CI 26.7-1035.5, P < 0.001), urgent surgery (OR 2.75, 95% CI 1.84-4.11, P < 0.001) and anastomotic leak (OR 5.02, 95% CI 3.32-7.58, P < 0.001) were predictors of inpatient mortality.

CONCLUSION

There is a steady rise in the incidence of colorectal cancer in younger adults. Both physicians and younger adults should be aware of the potential risk of colorectal cancer (CRC) and appropriate investigations performed so not to delay the diagnosis.

Family history of colorectal cancer and survival: a Swedish population-based study

OBJECTIVES

A family history of colorectal cancer (CRC) is an established risk factor for developing CRC, whilst the impact of family history on prognosis is unclear. The present study assessed the association between family history and prognosis and, based on current evidence, explored whether this association was modified by age at diagnosis.

METHODS

Using data from the Swedish Colorectal Cancer Registry (SCRCR) linked with the Multigeneration Register and the National Cancer Register, we identified 31 801 patients with a CRC diagnosed between 2007 and 2016. The SCRCR is a clinically rich database which includes information on the cancer stage, grade, location, treatment, complications and postoperative follow-up.

RESULTS

We estimated excess mortality rate ratios (EMRR) for relative survival and hazard ratios (HR) for disease-free survival with 95% confidence intervals (CIs) using flexible parametric models. We found no association between family history and relative survival (EMRR = 0.96, 95% CIs: 0.89-1.03, P = 0.21) or disease-free survival (HR = 0.98, 95% CIs: 0.91-1.06, P = 0.64). However, age was found to modify the impact of family history on prognosis. Young patients (<50 at diagnosis) with a positive family history had less advanced (i.e. stages I and II) cancers than those with no family history (OR = 0.71, 95% CI: 0.56-0.89, P = 0.004) and lower excess mortality even after adjusting for cancer stage (EMMR = 0.63, 95% CIs: 0.47-0.84, P = 0.002).

CONCLUSIONS

Our results suggest that young individuals with a family history of CRC may have greater health awareness, attend opportunistic screening and adopt lifestyle changes, leading to earlier diagnosis and better prognosis.

Clinicopathological features and oncological outcomes of patients with young-onset rectal cancer

BACKGROUND

The incidence of rectal cancer among adults aged less than 50 years is rising. Survival data are limited and conflicting, and the oncological benefit of standard neoadjuvant and adjuvant therapies is unclear.

METHODS

Disease-specific outcomes of patients diagnosed with rectal cancer undergoing surgical resection with curative intent between 2006 and 2016 were analysed.

RESULTS

A total of 797 patients with rectal cancer were identified, of whom 685 had surgery with curative intent. Seventy patients were younger than 50 years and 615 were aged 50 years or more. Clinical stage did not differ between the two age groups. Patients aged less than 50 years were more likely to have microsatellite instability (9 versus 1·6 per cent; P = 0·003) and Lynch syndrome (7 versus 0 per cent; P < 0·001). Younger patients were also more likely to receive neoadjuvant chemoradiotherapy (67 versus 53·3 per cent; P = 0·003) and adjuvant chemotherapy (41 versus 24·2 per cent; P = 0·006). Five-year overall survival was better in those under 50 years old (80 versus 72 per cent; P = 0·013). The 5-year disease-free survival rate was 81 per cent in both age groups (P = 0·711). There were no significant differences in the development of locoregional recurrence or distant metastases.

CONCLUSION

Despite accessing more treatment, young patients have disease-specific outcomes comparable to those of their older counterparts.

Analysis of factors potentially predicting prognosis of colorectal cancer

BACKGROUND

Accurate assessment of the prognosis after colorectal cancer surgery is of great significance in patients with colorectal cancer. However, there is no systematic analysis of factors affecting the prognosis of colorectal cancer currently.

AIM

To systematically analyze the influence of clinical data and serological and histological indicators on the prognosis of patients with colorectal cancer, and to explore the indicators that can accurately assess the prognosis of patients with colorectal cancer.

METHODS

A total of 374 patients with colorectal cancer were enrolled. The clinical data, tumor-node-metastasis (TNM) stage, and Dukes stage were recorded. All patients received examinations including carcinoembryonic antigen (CEA), carbohydrate antigen 199, C-reactive protein, albumin, D-dimer, and fibrinogen as well as routine blood tests one week before surgery. The tumor location, size, depth of invasion, lymph node metastasis, and distant metastasis were recorded during surgery. The pathological tissue typing and expression of proliferating cell nuclear antigen (PCNA) and p53 were observed. All patients were followed for 3 years, and patients with endpoint events were defined as a poor prognosis group, and the remaining patients were defined as a good prognosis group. The differences in clinical data, serology, and histology were analyzed between the two groups. Multivariate COX regression was used to analyze the independent influencing factors for the prognosis of colorectal cancer. The receiver operating characteristic curve was used to evaluate the predictive value of each of the independent influencing factors and their combination for the prognosis of colorectal cancer.

RESULTS

The follow-up outcomes showed that 81 patients were in the good prognosis group and 274 patients in the poor prognosis group. The TNM stage, PCNA, Glasgow prognostic score (GPS), neutrophil-lymphocyte ratio (NLR), C-reactive protein/albumin ratio (CAR), D-dimer, and CEA were independent influencing factors for the prognosis of colorectal cancer (P = 0.000). NLR had the highest predictive power for colorectal cancer prognosis [area under the receiver operating characteristic curve (AUC) = 0.925], followed by D-dimer (AUC = 0.879) and GPS (AUC = 0.872). The accuracy of the combination of all indicators in predicting the prognosis of colorectal cancer was the highest (AUC = 0.973), which was significantly higher than that of any of the indicators alone (P < 0.05). The sensitivity and specificity of the combination were 92.59% and 90.51%, respectively.

CONCLUSION

The independent influence factors for the prognosis of colorectal cancer include TNM stage, PCNA, GPS, NLR, CAR, D-dimer, and CEA. The combined assessment of the independent factors is the most accurate predictor of the prognosis after colorectal cancer surgery.

Clinicopathological features and survival of colorectal cancer patients younger than 50 years: a retrospective comparative study

BACKGROUND

Colorectal cancer (CRC) is a disease of old age, but its incidence has been rising among younger population compared to older ones. Nevertheless, there is a controversy over survival of younger patients compared to the older ones. Therefore, in the current study, we investigated the clinicopathological features and survival of the younger (< 50 years) versus older (≥ 50 years) CRC patients.

RESULTS

The younger and older groups consisted of 39.4% and 60.6% of patients, respectively. Both age groups were comparable regarding the symptom presentation and duration, and pre-operative carcinoembryonic antigen (CEA). The younger patients were diagnosed with a higher proportion of poorly differentiated (14.7% vs. 8.3%; p < 0.001) and more advanced tumors (53.2% vs. 45.9%; p = 0.266). The rectum tumor site was significantly more common among the younger patients (p = 0.021). The overall survival (OS) (p = 0.278), the cancer-specific survival (CSS) (p = 0.233), and the disease-free survival (DFS) (p = 0.497) did not differ significantly between the two groups. Based on Cox regression model, elevated pre-operative CEA level (HR = 1.41; 95%CI of 1.01-1.97), advanced tumor stage (6.06; 95%CI of 3.03-12.15), and poorly differentiated tumor (HR = 1.69; 95%CI of 1.05-2.71) were associated with decreased survival.

CONCLUSIONS

The younger patients did not have poor prognosis compared to the older ones despite having an advanced tumor stage and a poor tumor differentiation.

Familial and non-familial risk factors associated with colorectal cancer survival in young and middle-aged patients

BACKGROUND

Survival following colorectal cancer (CRC) survival may be influenced by a number of factors including family history, individual medical history, and comorbidities. The impact of these factors may vary based on the patient's age.

METHODS

The study cohort consisted of individuals born in Western Australia between 1945 and 1996, who had been diagnosed with CRC prior to 2015 (n = 3220). Hospital, cancer, and mortality data were extracted for each patient from state health records and were used to identify potential risk factors associated with CRC survival. Family linkage data, in combination with cancer registry data, were used to identify first-degree family members with a history of CRC. The association between survival following CRC diagnosis and identified risk factors was examined using Cox proportional hazard models.

RESULTS

Age and sex were not significantly associated with survival in young patients. However, in middle-aged patients increasing age (HR 1.03, 95% CI 1.01-1.05, p = 0.003) and being male (HR 0.72, 95% CI 0.60-0.87, p < 0.001) were associated with reduced survival. Being diagnosed with polyps and having a colonoscopy prior to CRC diagnosis were associated with improved survival in both young and middle-aged patients, while a history of non-CRC and liver disease was associated with reduced survival. In middle-aged patients, having diabetes-related hospital admissions (HR 1.53, 95% CI 1.15-2.03, p = 0.004) was associated with reduced survival.

CONCLUSIONS

In both young and middle-aged patients with CRC, factors associated with early screening and detection were associated with increased CRC survival while a history of liver disease and non-CRC was associated with decreased CRC survival.

Colorectal cancer in Saudi Arabia as the proof-of-principle model for implementing strategies of predictive, preventive, and personalized medicine in healthcare

Colorectal cancer (CRC) is the most commonly diagnosed cancer among Saudi males and ranks third in females with up to 73% of cases diagnosed at late stage. This review provides an analysis of CRC situation in the Kingdom of Saudi Arabia (KSA) from healthcare perspective. A PUBMED (1986-2018) search was done to identify publications focusing on CRC in KSA. Due to reports of increased CRC incidence among young age group (< 50), and given the young population of KSA, the disease may burden the national healthcare system in the next decades. Environmental factors attributed to increasing incidence rates of CRC include red meat consumption, sedentary lifestyle, and increased calorie intake. Despite substantial investment in healthcare, attention to predictive diagnostics and targeted prevention is lacking. There is a need to develop national screening guidelines based on evidence that supports a reduction in incidence and mortality of CRC when screening is implemented. Future approaches are discussed based on multi-level diagnostics, risk assessment, and population screening programs focused on the needs of young populations that among others present the contents of the advanced approach by predictive, preventive, and personalized medicine. Recommendations are provided that could help to develop policies at regional and national levels. Countries with demographics and lifestyle similar to KSA may gain insights from this review to shape their policies and procedures.

Differences in biological behaviors between young and elderly patients with colorectal cancer

Background

We investigated the differences in biological behaviors of sporadic colorectal cancer (CRC) between young and elderly patients. CRC is a common cancer, with a mean age at onset of > 65 years. However, recent reports indicate increasing rates in younger populations. The biological behaviors of sporadic CRC in elderly patients could differ from those in young patients.

Methods

Between September 2007 and August 2012, we selected 723 CRC patients from our institution. The patients were divided into Group Y (n = 127, aged ≤50 years) and Group O (n = 596, aged >50 years). The clinicopathologic and oncologic outcomes in the two groups were compared.

Results

Group Y tumors were characterized by higher incidences of mucin production (13.4% vs. 6.7%; P = 0.017), high microsatellite instability (MSI-H) (19.8% vs. 5.2%; P < 0.001), and N2 stage (32.3% vs. 22.1%; P = 0.020) than those in Group O. The recurrence rates were similar in both groups (14.9% vs. 17.3%; P = 0.665). The 5-year overall survival and disease-free survival did not differ. Multivariate analysis indicated that cellular differentiation and pathologic stage were significant prognostic factors for 5-year overall survival.

Conclusion

Although age was not a prognostic factor for overall survival and young patients did not show a worse prognosis, there were differences in mucin production, MSI-H, and N2 stage between the two groups. Further studies are needed to clarify the clinical and biological characteristics of CRC, improve its treatment strategies, and promote better outcomes in young patients.

Integrative analysis from multi-centre studies identifies a function-derived personalized multi-gene signature of outcome in colorectal cancer

Colorectal cancer (CRC) is highly heterogeneous leading to variable prognosis and treatment responses. Therefore, it is necessary to explore novel personalized and reproducible prognostic signatures to aid clinical decision‐making. The present study combined large‐scale gene expression profiles and clinical data of 1828 patients with CRC from multi‐centre studies and identified a personalized gene prognostic signature consisting of 46 unique genes (called function‐derived personalized gene signature [FunPGS]) from an integrated statistics and function‐derived perspective. In the meta‐training and multiple independent validation cohorts, the FunPGS effectively discriminated patients with CRC with significantly different prognosis at the individual level and remained as an independent factor upon adjusting for clinical covariates in multivariate analysis. Furthermore, the FunPGS demonstrated superior performance for risk stratification with respect to other recently reported signatures and clinical factors. The complementary value of the molecular signature and clinical factors was further explored, and it was observed that the composite signature called IMCPS greatly improved the predictive performance of survival estimation relative to molecular signatures or clinical factors alone. With further prospective validation in clinical trials, the FunPGS may become a promising and powerful personalized prognostic tool for stratifying patients with CRC in order to achieve an optimal systemic therapy.

Histopathological Prognostic Factors for Colic Adenocarcinoma

The majority of colorectal carcinomas are adenocarcinomas derived from the colic mucosae cell, more frequently moderately differentiated. The purpose of this study was to determine de incidence of CRC and the relationship between histopathological risk factors in patients with colic adenocarcinomas. The study included 144 cases of CRC diagnosed within the Pathology Laboratory of the Clinical County Hospital of Craiova in the year 2017.The biological material consisted in samples from colectomies and hemicolectomies provided from patients admitted within the surgical clinics of the same hospital, then fixed with 10% buffered formalin and afterwards processed using the classic histopathological technique of paraffin inclusion and staining with hematoxylin and eosin. We observed certain histopathological parameters such as: pattern, grading, stage, vascular invasion and neural invasion. The mean age of diagnostic was 68.6 ± 11.2, and it was predominantly male patients (64.6%). Most cases presented with mucinous pattern (31.9%) and cribriform comedocarcinoma type (29.9%). The majority were classified as stage III B (34%), being moderately differentiated (64.6%) and associated with vascular invasion (47.2%) and perineural invasion (25.7%). Statistical analysis indicated significant relationships between tumor stage and differentiation grade (p<0.01, χ²test), as well as between tumor stage and vascular invasion (p<0.05, χ²test), without including perineural invasion (p<0.05, χ²test).

More Synchronous Peritoneal Disease but Longer Survival in Younger Patients with Carcinomatosis from Colorectal Cancer Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

Colonoscopy to detect colorectal cancer (CRC) is recommended starting at age 50 years; however, CRC rates are increasing in the prescreening population. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) has been proven effective in select patients with peritoneal carcinomatosis (PC) from CRC, although it has not been evaluated specifically in patients < 50 years.

METHODS

CRC patients aged < 50 years at diagnosis undergoing CRS/HIPEC 2007-2017 were compared with those aged ≥ 50 years. Age distribution was analyzed in patients undergoing colectomy alone versus CRS/HIPEC for CRC 1993-2013.

RESULTS

A total of 98 patients underwent CRS/HIPEC, of which 44% were < 50 years. Younger patients were more likely to present with synchronous peritoneal metastases (p = 0.050). Receipt of perioperative chemotherapy was comparable (p = not significant [NS]). Charlson Comorbidity Index and ECOG score were similar (p = NS). Tumor grade was similar (p = NS). Peritoneal Carcinomatosis Index, total organs resected, and anastomoses created were comparable (p = NS). Major Clavien-Dindo morbidity and LOS were similar (p = NS). Younger patients survived longer after CRS/HIPEC (p = 0.011). Demographic data from patients undergoing colectomy (n = 225) and CRS/HIPEC (n = 98) showed that age < 50 years was increasingly common with the more aggressive procedure (9% and 44% respectively, p < 0.001).

CONCLUSIONS

Younger patients with PC from CRC presented more often with peritoneal metastases at the time of diagnosis. Yet despite similar perioperative features at CRS/HIPEC, they survived longer than older patients. Patients undergoing CRS/HIPEC are overall younger than those undergoing index colectomy.

Biomarkers for Stratification in Colorectal Cancer: MicroRNAs

Colorectal cancer (CRC) is one of the most widely recognized and deadly malignancies worldwide. In spite of the fact that the death rates have declined over the previous decade, particularly because of enhanced screening or potential treatment alternatives, CRC still remains the third leading cause of cancer-related mortality in the world, with an estimated incidence of over 1 million new cases and approximately 600 000 deaths estimated yearly. Unlike prostate and lung cancer, CRC is not easily detectable in its early stage, which may also account for its high mortality rate. MicroRNAs (miRNAs) are a class of noncoding RNAs. The roles of these noncoding RNAs have been implicated in cancer pathogenesis, most especially CRC, due to their ability to posttranscriptionally regulate the expression of oncogenes and tumor suppressor genes. Dysregulated expression of many miRNAs regulates the expression of hundreds of growth regulatory genes and pathways that are important in the multistep model of colorectal carcinogenesis. If CRC is detected early, it is a largely treatable disease. Early diagnosis, including the identification of premalignant adenomas, is regarded a major concept for improving patient survival in CRC treatment. Several lines of research suggest that miRNAs are closely implicated in the metastatic process in CRC and some of these miRNAs could be useful as promising clinical tools for identifying specific stages of CRC due to their differential expression. This review discusses the correlation between CRC staging relative to the specific expression of miRNA for early detection, treatment, and disease management.

Maternal stress and early-onset colorectal cancer

Early-onset colorectal cancer (EOCRC) is defined as colorectal cancer (CRC) diagnosed before the age of 50. Alarmingly, there has been a significant increase in EOCRC diagnoses' worldwide over the past several decades. Emerging data suggest EOCRCs have distinguishing clinical, pathological, biological and molecular features; and thus, are a fundamentally different subtype of CRCs. Unfortunately, there is no simple explanation for the causes of EOCRC. Scientifically rigorous studies are needed to determine what may be driving the challenging epidemiology of EOCRC. We contend here that a reasonable hypothesis is that prenatal risk factors such as maternal stress and associated sleeping disorders influence offspring epigenetic make-up, and shape immune system and gut health contributing to an increased risk for EOCRC.

Nomogram Predicting Survival After Recurrence in Patients With Stage I to III Colon Cancer: A Nationwide Multicenter Study

BACKGROUND

Although a number of studies have been conducted to investigate factors affecting colon cancer recurrence and patient overall survival after surgical treatment, no prognostic risk models have been proposed for predicting survival specifically after postsurgical recurrence.

OBJECTIVE

We aimed to identify factors affecting the survival of the patients with recurrent colon cancer and to construct a nomogram for predicting their survival.

DESIGN

This was a retrospective study.

SETTINGS

This study used the Japanese Study Group for Postoperative Follow-Up of Colorectal Cancer database, which contains retrospectively collected data of all consecutive patients with stage I to III colorectal cancer who underwent surgical curative resection between 1997 and 2008 at 23 referral institutions.

PATIENTS

A total of 2563 patients with stage I to III colon cancer who experienced recurrence after surgery were included in the present study.

MAIN OUTCOME MEASURES

A nomogram predicting survival was constructed using a training cohort composed of patients from 15 hospitals (n = 1721) using a Cox regression hazard model analysis. The clinical applicability of this nomogram was validated in patients from the 8 remaining hospitals (the validation cohort; n = 842).

RESULTS

Eight factors (age, location of the primary tumor, histopathological type, positive lymph node status, presence of peritoneal metastasis, number of organs involved in the first recurrence, treatment for recurrence, and the interval between initial surgery and recurrence) were identified as nomogram variables. Our nomogram showed good calibration, with concordance indexes of 0.744 in the training cohort and 0.730 in the validation cohort. The survival curves stratified by the risk score calculated by the nomogram were almost identical for the training and validation cohorts.

LIMITATIONS

The study was conducted using the data until 2008, and more advanced chemotherapeutic agents and multidisciplinary therapies that might have improved the outcomes predicted by our nomogram were not available. In addition, treatment strategies for recurrence might differ between countries.

CONCLUSIONS

Our nomogram, which is based on a nationwide multicenter study, is the first statistical model predicting survival after recurrence in patients with stage I to III colon cancer. It promises to be of use in postoperative colon cancer surveillance. See Video Abstract at http://links.lww.com/DCR/A687.

Alcohol consumption promotes colorectal carcinoma metastasis via a CCL5-induced and AMPK-pathway-mediated activation of autophagy

There is a definite relationship between alcohol consumption and colorectal cancer (CRC) development. We investigated effect of alcohol consumption on CRC patients’ progression and prognosis by utilizing epidemiological data and found patients with alcohol consumption increased risks of tumor-node-metastasis (TNM), organ metastasis and poorer prognosis. Because their tumor tissues displayed increased expression of C-C chemokine ligand 5 (CCL5), we hypothesized CCL5 might participate in cancer progression in such patients. Ethanol increased the secretion of CCL5 in two CRC cell lines, HT29 and DLD-1. Treatment with CCL5 directly increased migratory ability of these cells, whereas neutralization or knockdown of CCL5 can partially block alcohol-stimulated migration. We further investigated underlying mechanism of CCL5-induced migration. Our results indicated that effects of CCL5 on migration are mediated by the ability of CCL5 to induce autophagy, a cellular process known to be critical for migration. Using high-throughput sequencing and western blotting, we found induction of autophagy by CCL5 takes place via AMPK pathway. Aforementioned ethanol increases CCL5 secretion, CCL5 activates autophagy through AMPK pathway, and autophagy increases migration was confirmed by experiments with autophagy or AMPK inhibitors. To sum up, our study demonstrates that chronic alcohol consumption may promote metastasis of CRC through CCL5-induced autophagy.

Socioeconomic and demographic inequalities in stage at diagnosis and survival among colorectal cancer patients: evidence from a Swiss population-based study

Socioeconomic inequalities in cancer stage at diagnosis and survival are important public health issues. This study investigates the association between socioeconomic position (SEP) and colorectal cancer (CRC) stage at diagnosis and survival in Switzerland, a European country with highest level of medical facilities and life expectancy. We used population-based CRC data from seven Swiss cantonal cancer registries 2001-2008 (N = 10,088) linked to the Swiss National Cohort (SNC). Follow-up information was available until the end of 2013. SEP was estimated based on education. The association between cancer stage and SEP was assessed using logistic regression models including cancer localization (colon/rectum), sex, age, civil status, urbanity of residence, language region, and nationality (Swiss/non-Swiss). Survival was analyzed using competing risk regressions reporting subhazard ratios (SHRs) for the risk of dying due to CRC. We observed a social gradient for later stage CRC with adjusted odds ratios (ORs) of 1.11 (95% CI: 0.97-1.19) and 1.28 (95% CI: 1.08-1.50) for middle and low SEP compared to high SEP. Further, single compared to married people had elevated odds of being diagnosed at later stages. Survival was lower in patients with CRC with low SEP in the unadjusted model (SHR: 1.18, 95% CI: 1.07-1.30). After adjustment for stage at diagnosis and further sociodemographic characteristics, significant survival inequalities by SEP disappeared but remained for non-Swiss compared to Swiss citizens and for patients living in nonurban areas compared to their urban counterparts. Swiss public health strategies should facilitate equal access to CRC screening and optimal CRC care for all social groups and in all regions of Switzerland.

Curative treatment for metastatic colorectal cancer in the young population: is it worth it?

Background

A significant proportion of patients with colorectal cancer (CRC) presents with metastatic disease. In younger patients, a more aggressive approach is often adopted in an attempt to achieve cure and improve survival. The aim of this paper is to review the management and outcomes of young patients with metastatic CRC.

Methods

All patients under 50 years diagnosed with CRC in a single institution from January 2007 to December 2015 were reviewed. Patient demographics, details of their treatments, progress and outcomes of treatment were collected for our review.

Results

There were 154 newly diagnosed CRC patients who were <50 years old during the study period. Thirty-three patients (21.4%) had stage IV disease on presentation. Seventeen (51.5%) of these 33 patients were treated with curative intent; 9 (52.9%) of whom underwent upfront surgical resection alone while the remaining 8 (47.1%) patients had neoadjuvant therapy followed by surgical resection. Among the 16 patients who were treated with palliative intent, 9 (56.3%) had surgery while 7 (43.7%) had definitive chemo- or radio-therapy. There was no significant difference in the median survival of patients treated with curative and palliative intent (29 vs. 24 months, P=0.140).

Conclusions

Young CRC patients with stage IV disease typically survive for 2 years upon diagnosis. Those who were treated and underwent surgery with curative intent have a slightly longer but not statistically significant median survival than those treated with palliative intent. The role of aggressive treatment in these young patients with metastatic patients merits further evaluation.

The impact of young age on the prognosis for colorectal cancer: a population-based study in Taiwan

Background

The impact of age as a prognostic factor for patients with colorectal cancer (CRC) remains controversial, possibly due to heterogeneity between studies in terms of patient numbers, percentage of patients undergoing curative resection, percentage of patients receiving neoadjuvant therapy, or failure to adjust for potential confounding factors. This study used colorectal cancer survival data from the Taiwan Cancer Registry database in order to comprehensively analyze age as a prognostic factor.

Methods

Survival data were analyzed for 62 060 CRC patients diagnosed with adenocarcinoma, mucinous adenocarcinoma, or signet-ring cell carcinoma of the colon and rectum between 1998 and 2005. The rates of all-cause mortality and CRC-related mortality were determined using Kaplan-Meier analysis, and the log-rank test was used to compare differences in survival between different age groups. The crude and adjusted hazard ratios for all-cause and CRC-related mortalities were calculated according to the estimates from the univariable and multivariable Cox proportional hazard models.

Results

Patients in the ≤40 and the 41-50 age groups had a higher proportion of mucinous adenocarcinoma (P < 0.001) and signet-ring cell carcinoma (P < 0.001) compared to the older age groups. After adjusting for gender, histology, and tumor site, patients in the ≤40 age group had a poorer overall survival (OS) and cancer-specific survival compared to patients in the 41-50 and 51-60, and 61-70 age groups (P < 0.001), but a better OS and cancer-specific survival compared to patients in the 71-80 and >80 age groups (P < 0.001).

Conclusions

Our study indicated that age is an important consideration while determining the clinical management of CRC patients.

The risk and survival outcome of subsequent primary colorectal cancer after the first primary colorectal cancer: cases from 1973 to 2012

Background

Among colorectal cancer (CRC) survivors, how the prior tumor location affects the risk of subsequent primary colorectal cancer (SPCRC) and the outcome of those suffering from SPCRC remain unknown.

Methods

CRC cases diagnosed from 1973 to 2012 were screened for SPCRC development using the Surveillance, Epidemiology, and End Results database. The relative risk of SPCRC was estimated using the standardized incidence ratio. Survivals were analyzed using the Kaplan–Meier and Cox regression model.

Results

The overall risk of SPCRC increased by 27% in CRC survivors compared to that of the general population. The risk increased in patients with both prior right colon cancer (RCC) and left colon cancer (LCC), and was concentrated in the first 5 years after the prior diagnosis, and among young patients. Among the 6701 SPCRC patients identified, patients with prior RCC were more likely to be elderly, female, and with more low or undifferentiated disease than those with prior LCC or rectal cancer (ReC). The overall survivals differed by both prior tumor location (P < 0.0001) and age (P < 0.0001), and the difference by tumor location remained significant when adjusted or stratified by any other potential prognostic factor except age. The cancer specific survivals differed by age (P < 0.0001) rather than by prior tumor location (P = 0.455).

Conclusions

The overall risk of SPCRC increased among patients with both prior RCC and LCC, but not among those with ReC. The different survival outcomes in CRC survivors suffering from SPCRC were largely explained by the patient age but not by the prior tumor location.

Electronic supplementary material

The online version of this article (10.1186/s12885-017-3765-8) contains supplementary material, which is available to authorized users.