Early colonoscopy confers survival benefits on colon cancer patients with pre-existing iron deficiency anemia: a nationwide population-based study

Chronic Kidney Disease Prevalence in Patients with Colorectal Cancer Undergoing Surgery

Colorectal cancer (CRC) is a common and mortal disease. Chronic kidney disease (CKD) is the relatively common comorbidity among cancer patients affecting the available therapy and outcomes. However, data on prevalence of CKD in patients with CRC undergoing surgery is limited. The aim of the study was to evaluate the prevalence of CKD in a cohort of 560 consecutive patients with CRC undergoing surgical treatment with curative intent. Neoadjuvant therapy in a form of radiotherapy or radiochemotherapy was administered before the surgery in 67 patients and in 86 patients, respectively. Results: CKD was reported in 10%, diabetes in 25%, and hypertension in 60%, while anemia was reported in 47%. The patients with CKD were more likely to be older and anemic with higher serum CRP, which reflects a general inflammatory state. Relative to patients without this therapy, patients undergoing neoadjuvant radiochemotherapy were older, had significantly lower eGFR and albumin, and higher creatinine, aspartate aminotransferase and INR, before the surgery. All CKD patients, except two, were older than 65 years of age. Conclusions: In order to ensure the best possible outcomes, CKD should be diagnosed and treated appropriately in oncology patients to prevent complications, so they may continue their therapy with the least interruption or discontinuation of treatment.

Awareness of colorectal cancer signs and symptoms: a national cross-sectional study from Palestine

BACKGROUND

In low-resource settings, the awareness level of colorectal cancer (CRC) signs and symptoms plays a crucial role in early detection and treatment. This study examined the public awareness level of CRC signs and symptoms in Palestine and investigated the factors associated with good awareness.

METHODS

This was a national cross-sectional study conducted at hospitals, primary healthcare centers, and public spaces in 11 governorates across Palestine between July 2019 and March 2020. A translated-into-Arabic version of the validated bowel cancer awareness measure (BoCAM) was utilized to assess the awareness level of CRC signs and symptoms. For each correctly identified CRC sign/symptom, one point was given. The total score (ranging from 0 to 12) was calculated and categorized into three categories based on the number of symptoms recognized: poor (0 to 4), fair (5 to 8), and good awareness (9 to 12).

RESULTS

Of 5254 approached, 4877 participants completed the questionnaire (response rate = 92.3%). A total of 4623 questionnaires were included in the analysis; 1923 were from the Gaza Strip and 2700 from the West Bank and Jerusalem (WBJ). Participants from the Gaza Strip were younger, gained lower monthly income, and had less chronic diseases than participants in the WBJ. The most frequently identified CRC sign/symptom was 'lump in the abdomen' while the least was 'pain in the back passage'. Only 1849 participants (40.0%, 95% CI: 39.0%-41.0%) had a good awareness level of CRC signs/symptoms. Participants living in the WBJ were more likely to have good awareness than participants living in the Gaza Strip (42.2% vs. 37.0%; p = 0.002). Knowing someone with cancer (OR = 1.37, 95% CI: 1.21-1.55; p < 0.001) and visiting hospitals (OR = 1.46, 95% CI: 1.25-1.70; p < 0.001) were both associated with higher likelihood of having good awareness. However, male gender (OR = 0.80, 95% CI: 0.68-0.94; p = 0.006) and following a vegetarian diet (OR = 0.59, 95% CI: 0.48-0.73; p < 0.001) were both associated with lower likelihood of having good awareness.

CONCLUSION

Less than half of the study participants had a good awareness level of CRC signs and symptoms. Future education interventions are needed to improve public awareness of CRC in Palestine.

Evidence for improved prognosis of colorectal cancer diagnosed following the detection of iron deficiency anaemia

Iron deficiency anaemia (IDA) is common in colorectal cancer (CRC), especially, in right-sided CRC which is known to have an overall worse prognosis. The associations between diagnostic pathway (Bowel Cancer Screening Programme (BCSP), IDA, symptomatic) and tumour side/stage was assessed using logistic regression models in 1138 CRC cases presenting during 2010-2016 at a single secondary-care centre in the UK. In the IDA sub-group, the relationship between CRC stage and the event of having a blood count prior to CRC diagnosis was examined using Bayesian parametric survival model. IDA was found as the only significant predictor of right-sided CRC (OR 10.61, 95% CI 7.02-16.52). Early-stage CRC was associated with both the IDA (OR 1.65, 95% CI 1.18-2.29) and BCSP pathway (OR 2.42, 95% CI 1.75-3.37). At any age, the risk of detecting CRC at late-stage was higher in those without a previous blood count check (hazard ratio 1.53, 95% credibility interval 1.08-2.14). The findings of this retrospective observational study suggest a benefit from diagnosing CRC through the detection of IDA, and warrant further research into the prognosis benefit of systematic approach to blood count monitoring of the at-risk population.

Iron deficiency in children at the time of initial neuroblastoma diagnosis

IMPORTANCE

There is a high incidence of iron deficiency in children worldwide. Notably, however, while iron deficiency is the most common cause of anemia, little is known about the prevalence and different types of iron deficiency in neuroblastoma patients.

OBJECTIVE

The aim of the present study was to investigate the prevalence of iron deficiency in patients newly diagnosed with neuroblastoma.

METHODS

A total of 195 newly diagnosed neuroblastoma patients from November 2015 to January 2018 were analyzed retrospectively. The survival analysis was estimated by the Kaplan-Meier method.

RESULTS

Of the 195 neuroblastoma patients included in the study, 121 (62.1%) had iron deficiency, 55 (28.2%) had absolute iron deficiency, and 66 (33.9%) had functional iron deficiency. Being aged ≥ 18 months, tumor originating in the abdomen, International Neuroblastoma Risk Group Staging System M, high-risk neuroblastoma, lactate dehydrogenase ≥ 1500 U/L, neuron-specific enolase ≥ 100 U/L, unfavorable histologic category, MYCN amplification, chromosome 1p loss, and bone marrow metastasis were associated with significantly higher rates of functional iron deficiency (P < 0.05).

INTERPRETATION

Functional iron deficiency at the time of initial neuroblastoma diagnosis predicted lower event-free survival. Long-term effects of iron supplementation in neuroblastoma patients with different types of iron deficiency need to be further studied.

Long-term outcomes in patients newly diagnosed with iron deficiency anaemia in general practice: a retrospective cohort study

OBJECTIVES

To describe all iron deficiency anaemia (IDA)-related causes during follow-up of patients newly diagnosed with IDA and to assess whether a delayed colorectal cancer (CRC) diagnosis influences survival.

DESIGN AND SETTING

Retrospective cohort study of patients from general practices in the Dordrecht area, the Netherlands.

PARTICIPANTS

Men and women aged ≥50 years with a new diagnosis of IDA (ie, no anaemia 2 years previously).

METHOD

From February 2007 to February 2018, all relevant data were collected from the files of the referral hospital. Early IDA-related cause was defined as established within 18 weeks after IDA diagnosis. Cox proportional-hazards regression was used to analyse survival of patients with CRC diagnosis.

RESULTS

587 patients with IDA were included with a median follow-up of 4.6 years. Early and late IDA-related causes could be established in 32% and 8% of patients, respectively. Early and late CRC was found in 8% and 2% of patients, respectively, and were located mainly right sided. After adjustment for age, gender and TNM classification, mortality risk was lower in patients with IDA with early CRC diagnosis, but not significantly (HR 0.30, 95% CI 0.09 to 1.02).

CONCLUSION

Even with extended follow-up, the cause of IDA remains elusive in the majority of patients with IDA in general practice. However, patients with IDA are at increased risk for in particular right-sided CRC and a late diagnosis of CRC appears to have a detrimental effect on survival in patients with IDA.

Preadmission use of antidepressants and risk of complications and death after colorectal cancer surgery: a nationwide population-based cohort study

AIM

Few studies have evaluated how preadmission use of antidepressants affects outcomes in colorectal cancer (CRC) patients after they have undergone surgery. Therefore, our aim is to examine whether preadmission use of antidepressants increased the risk of complications and death in patients who underwent CRC surgery.

METHOD

Using the Danish Colorectal Cancer Group Database we identified patients who underwent CRC surgery in Denmark from 2005 to 2012. We identified prescriptions for antidepressants redeemed within 1 year prior to surgery and categorized patients as current users (≤ 90 days), former users (91-365 days) and nonusers. All patients were followed from surgery to 30 days thereafter or to death. We calculated 30-day rates of complications, intensive care unit (ICU) admission and mortality and compared these between users and nonusers using logistic and Cox regression adjusting for potential confounders.

RESULTS

Of 27 374 patients, 8.9% were current users and 3.0% were former users. Antidepressant users were older and had more comorbidity but a similar cancer stage. Compared with nonusers, current users had a higher risk of postoperative reoperation [adjusted odds ratio (aORs) = 1.15 (95% CI 1.02-1.30)], medical complications [aORs = 1.41 (95% CI 1.25-1.60)] and increased ICU admission rate [adjusted hazard ratio (aHR) = 1.32 (95% CI 1.21-1.45)]. The 30-day mortality was 11.4% for current users, 9.1% for former users and 6.2% for nonusers [aHR = 1.34 (95% CI 1.17-1.53) for current vs nonusers].

CONCLUSION

Patients with preadmission use of antidepressants had a higher risk of complications and ICU admission, and higher 30-day mortality following CRC surgery than nonusers.

A Combination of Fecal Immunochemical Test Results and Iron Deficiency Anemia for Detection of Advanced Colorectal Neoplasia in Asymptomatic Men

PURPOSE

A substantial proportion of patients with colorectal cancer (CRC) present with iron deficiency anemia (IDA), and fecal immunochemical test (FIT) has proven to be an effective method for detecting the majority of CRC cases. A combination strategy of FIT results and IDA may be useful for risk stratification for detecting advanced colorectal neoplasia (ACRN). We compared the prevalence of ACRN among four groups stratified by FIT results and the presence of IDA.

MATERIALS AND METHODS

A cross-sectional study was performed on asymptomatic male participants who underwent both FIT and colonoscopy between 2010 and 2014 as part of a comprehensive health screening program in Korea.

RESULTS

Of 17236 participants, 522 (3.0%) showed positive FIT results and 26 (0.2%) had IDA. The mean age of the study participants was 40.8 years. The participants were classified into four groups: positive FIT result/IDA (G1, n=7), positive FIT result/no IDA (G2, n=515), negative FIT result/IDA (G3, n=19), and negative FIT result/no IDA (G4, n=16695). The prevalences of ACRN in G1, G2, G3, and G4 were 28.6, 13.4, 5.3, and 1.5%, respectively (p<0.001) and those of CRC were 28.6, 1.6, 0.0, and 0.01%, respectively (p<0.001). Subjects with positive FIT results and IDA had an increased risk of ACRN and CRC in both group aged <50 and ≥50 years.

CONCLUSION

Subjects with positive FIT results and IDA had an increased risk of ACRN. Our results suggest that a combination strategy of FIT and IDA may be helpful in selecting and prioritizing asymptomatic men for colonoscopy.

Early Colonoscopy Improves the Outcome of Patients With Symptomatic Colorectal Cancer

BACKGROUND

Long waiting times from early symptoms to diagnosis and treatment may influence the staging and prognosis of patients with colorectal cancer. We analyzed the effect of colonoscopy timing on the outcome of these patients.

OBJECTIVE

This study aimed to compare the outcome (tumoral staging and long-term survival) of patients with suspected colorectal cancer according to diagnostic colonoscopy timing.

DESIGN

This study is an analysis of a prospectively maintained database.

SETTINGS

The study was conducted at the Open Access Endoscopy Service of the tertiary public healthcare center Hospital Universitario de Canarias, in the Spanish island of Tenerife.

PATIENTS

Consecutive patients diagnosed of colorectal cancer between February 2008 and October 2010, fulfilling 1 or more National Institute for Health and Clinical Excellence criteria, were assigned to early colonoscopy (<30 days from referral) or to standard-schedule colonoscopy at the discretion of the referring physician. Tumor staging (TNM classification) at diagnosis and long-term survival after treatment were compared in both strategies.

MAIN OUTCOME MEASURES

The primary outcomes measured were the stage at presentation and overall survival, as determined by prompt or standard referral.

RESULTS

Overall, 257 patients with colorectal cancer were diagnosed (101 at early colonoscopy and 156 at standard-schedule colonoscopy). TNM stages I and II were found in 52 (54.2%) and 60 (41.7%) patients in the early colonoscopy group and standard-schedule colonoscopy group. Stage IV was confirmed in 13 patients (13.5%) diagnosed in the early colonoscopy group and in 40 (28%) detected in the standard-schedule colonoscopy group. Survival rates at 12 and 60 months after treatment were significantly higher in the early colonoscopy group compared with the standard-schedule colonoscopy group (p < 0.001).

LIMITATIONS

Controlled randomization of early versus standard-referral colonoscopy, size and scope of analysis, the time interval from symptom onset to first physician assessment, and the different locations of colorectal cancer between groups were limitations of the study.

CONCLUSIONS

Colonoscopy within 30 days from referral improves outcome in patients with symptomatic colorectal cancer. See Video Abstract at http://journals.lww.com/dcrjournal/Pages/videogallery.aspx.

Drug dispensings among elderly in the year before colon cancer diagnosis versus matched cancer-free controls

WHAT IS KNOWN AND OBJECTIVE

The concomitant use of multiple drugs is common among the general population of elderly. The aim of this study was to provide an overview of which drugs are dispensed to elderly in the year before colon cancer diagnosis and to compare this with cancer-free controls.

METHODS

Data from the Eindhoven Cancer Registry were linked to the PHARMO Database Network. Patients with colon cancer aged ≥70 years were included and matched with controls on gender, year of birth and postal code. Proportions of cases and controls with ≥1 dispensing of each WHO ATC-2-level drug during the total year and during each quarter of the year were calculated and differences between cases and controls tested.

RESULTS AND DISCUSSION

Proportion of cases with ≥1 drug dispensing was highest for drugs for constipation (cases vs. controls 58% vs. 10%), antithrombotics (42% vs. 33%), drugs for acid-related disorders (35% vs. 22%), antibacterials (34% vs. 24%), agents acting on the renin-angiotensin system (33% vs. 27%), beta-blockers (33% vs. 23%), lipid-modifying agents (29% vs. 22%), diuretics (29% vs. 21%), psycholeptics (25% vs. 18%) and antianaemics (23% vs. 6%). The proportion of cases with ≥1 drug dispensing increased from the first to the last quarter of the year for drugs for constipation (7%-53%), drugs for acid-related disorders (16%-27%), antibacterials (12%-16%), beta-blockers (26%-28%), psycholeptics (15%-19%) and antianaemics (6%-18%). Elevated proportions of cases with ≥1 drug dispensing for several drugs are mostly related to comorbidity, although increasing proportions of cases with ≥1 drug dispensing for certain drugs during the year can be attributed to the incidence of colon cancer.

WHAT IS NEW AND CONCLUSION

We have provided insight into which drugs are commonly used in the year preceding colon cancer diagnosis. This may trigger general practitioners and medical specialists to further evaluate the patient.

Outcome and late effects among acute myeloid leukemia survivors: a nationwide population-based study

BACKGROUND

Understanding of pathogenesis and treatment for acute myeloid leukemia (AML) is growing. However, studies regarding the outcomes and late effects among AML survivors are relatively limited.

METHODS

This nationwide population-based study used medical records from the Taiwanese National Health Insurance Research Database. A total of 3356 AML patients diagnosed from 2000 to 2008 were analyzed. The physiological and psychological morbidities in AML survivors were compared to those identified from a normal population. This study also compared late effects among AML survivors treated by intensive chemotherapy alone and allogeneic hematopoietic stem cell transplantation (allo-HSCT).

RESULTS

The incidence of AML in Taiwan has increased from 1.07 per 100,000 persons in 2000 to 2.17 per 100,000 persons in 2008 (p < 0.0001). With the median overall survival (OS) time of 0.98 years, 25.0 % of AML patients in this study cohort received best supportive care alone. Compared to the normal population, AML survivors had higher rates of hypertension (hazard ratio [HR] 1.69; 95 % confidence interval [CI] 1.18-2.42; p < 0.01), cardiovascular disease (HR 2.53; 95 % CI 1.39-4.61; p < 0.01), diabetes (HR 2.27; 95 % CI 1.48-3.48; p < 0.001), and psychological disorders (HR 1.45; 95 % CI 1.04-2.04; p < 0.05). Although patients undergoing allo-HSCT had a better OS than did patients treated with intensive chemotherapy alone (median not reached vs. 1.53 years; p < 0.0001), diabetes was found more often among allo-HSCT recipients than among patients receiving intensive chemotherapy only (HR 2.93; 95 % CI 1.21-7.08; p < 0.05).

CONCLUSION

Regular physical and psychological surveillance of AML survivors is needed especially for those receiving allo-HSCT.

Colorectal cancer diagnosis: Pitfalls and opportunities

Colorectal cancer (CRC) is a major health problem in the Western world. The diagnostic process is a challenge in all health systems for many reasons: There are often no specific symptoms; lower abdominal symptoms are very common and mostly related to non-neoplastic diseases, not CRC; diagnosis of CRC is mainly based on colonoscopy, an invasive procedure; and the resource for diagnosis is usually scarce. Furthermore, the available predictive models for CRC are based on the evaluation of symptoms, and their diagnostic accuracy is limited. Moreover, diagnosis is a complex process involving a sequence of events related to the patient, the initial consulting physician and the health system. Understanding this process is the first step in identifying avoidable factors and reducing the effects of diagnostic delay on the prognosis of CRC. In this article, we describe the predictive value of symptoms for CRC detection. We summarize the available evidence concerning the diagnostic process, as well as the factors implicated in its delay and the methods proposed to reduce it. We describe the different prioritization criteria and predictive models for CRC detection, specifically addressing the two-week wait referral guideline from the National Institute of Clinical Excellence in terms of efficacy, efficiency and diagnostic accuracy. Finally, we collected information on the usefulness of biomarkers, specifically the faecal immunochemical test, as non-invasive diagnostic tests for CRC detection in symptomatic patients.

Optimal Sequence of Irinotecan and Oxaliplatin-Based Regimens in Metastatic Colorectal Cancer: A Population-Based Observational Study

The optimal sequence of irinotecan and oxaliplatin-based regimens for metastatic colorectal cancer remains unclear. We conducted a population-based observational study by retrospectively reviewing records from Taiwan’s National Health Insurance Research Database to explore this issue. Patients aged ≥20 years with metastatic colorectal cancer newly diagnosed between 2004 and 2008 (n = 9490) were enrolled in current study. Among these 9490 patients, 3895 patients (41.04%) did not receive any chemotherapy within the first three months after catastrophic illness registration. Patients who received best supportive care were older and had higher Charlson comorbidity indexes and incidences of comorbidities than those who received irinotecan-based regimens, oxaliplatin-based regimens, and 5-fluorouracil/capecitabine alone. Patients who received irinotecan followed by oxaliplatin-based regimens and those who received the reverse sequence were further stratified into arm A (n = 542) and arm B (n = 1156), respectively. The median first time to next treatment was not significantly different between arm A and arm B (210 days vs. 196 days; p = 0.17). However, the median second time to next treatment was longer in arm A than in arm B (155 days vs. 123 days; p = 0.006), which translated into a better overall survival (487 days vs. 454 days; p = 0.02). The crossover rate was higher in arm A than in arm B (47.84% vs. 41.61%; p<0.001). Multivariate Cox regression analyses showed that overall survival was comparable between the two chemotherapy sequences (p = 0.27). Our study suggested that irinotecan followed by oxaliplatin-based regimens might be a better chemotherapy treatment option for metastatic colorectal cancer than the reverse sequence given the higher crossover rate and potential overall survival benefit.