Colorectal cancer in young patients: characteristics and outcome

Clinicopathologic Characteristics Influencing Overall Survival of Patients With Early- Versus Average-Onset Colorectal Cancer at a Tertiary Care Center in Indonesia

PURPOSE

There has been a global increase in early-onset colorectal cancer (EOCRC), yet there has been very limited exploration of its impact in Indonesia. This study aimed to determine the clinicopathologic characteristics and the overall survival (OS) of EOCRC compared with those of average-onset colorectal cancer (AOCRC).

METHODS

Medical records were retrospectively reviewed from all patients presenting with colorectal cancer (CRC) at Dr Sardjito General Hospital (Yogyakarta, Indonesia) between 2016 and 2019. Sociodemographic, clinicopathologic, and treatment variables were extracted. t Tests were used to compare characteristics of EOCRC and AOCRC patient groups. The Cox proportional hazards regression model was used to analyze age and other potential prognostic factors.

RESULTS

The total population (N = 1,276) comprised EOCRC (n = 149; 11.7%) and AOCRC (n = 1,127; 88.3%) patients. EOCRC patients were more likely to have a higher education level, be single, have out-of-pocket insurance, be underweight, and have signet ring histology (all P values <.05), compared with AOCRC patients. EOCRC and AOCRC groups had a comparable estimated 5-year OS of 34.2% and 36.9%, respectively. In multivariable analyses, performance status (Eastern Cooperative Oncology Group), hemoglobin level, cancer stage, and treatment intention were independent prognostic factors for OS (all P values <.05).

CONCLUSION

To our knowledge, this first major study of EOCRC in Indonesia highlights its role in the overall burden of CRC and its connection with social determinants of health. Patients with EOCRC are more commonly underweight and generally have a higher proportion of signet ring histology than AOCRC, yet OS in both groups is similar. Future research is required to identify risk factors to inform the content and focus of public health education activities, alongside delineating the biology and causes of early and average onset of the disease.

Clinical significance of serum lactate and lactate dehydrogenase levels for disease severity and clinical outcomes in patients with colorectal cancer admitted to the intensive care unit

Objective

Serum lactate (LA) and lactate dehydrogenase (LDH) levels have a major impact on the clinical treatment of malignant tumors and critically ill patients. Nevertheless, the assessment of disease severity in oncology patients admitted to the intensive care unit (ICU) remains incomplete when considering the serum LA and LDH levels. This study aimed to investigate the significance of serum LDH and LA levels in assessing disease severity and predicting clinical outcomes in patients with colorectal cancer (CRC) admitted to the ICU.

Methods

This retrospective study included patients with CRC who were admitted to the ICU between January 2017 and December 2022. The patients were divided into three groups based on the tumor treatment methods they had received within 3 months before ICU admission: post-chemotherapy group, post-surgery group, and palliative treatment group. The association between serum LA and LDH levels and disease severity and clinical outcomes was analyzed.

Results

Of 137 patients with CRC admitted to the ICU were finally studied. Patients in the post-chemotherapy group exhibited higher serum LA and LDH levels compared to those in the other two groups. Additionally, they had higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores, longer ICU length of stay, and a higher 30-day mortality. We found a significant positive correlation between serum LA levels and APACHE II scores as well as ICU length of stay and 30-day mortality. In contrast, we only observed a significant positive correlation between serum LDH levels and disease severity in the post-chemotherapy group, whereas no significant correlation between LDH levels and 30-day mortality in any of the three groups.

Conclusion

Our study concludes that elevated serum LA levels, rather than LDH levels, are more effective in assessing disease severity and could be used as predictors for clinical outcomes in patients with CRC admitted to the ICU.

Survival Analysis of Patients with Colorectal Cancer Undergoing Combined Treatment: A Retrospective Cohort Study

BACKGROUND

If colorectal cancer (CRC) is diagnosed in the early stages, the patients will have higher survival rates. Although some other factors might affect the survival rate, the type of treatment available based on existing health and therapeutic facilities is extremely important as well. Accordingly, this study aimed to explore the best type of treatment for CRC patients.

STUDY DESIGN

This study employed a retrospective population-based cohort design.

METHODS

The data of 335 patients with CRC in Kurdistan province were collected through a population-based cancer registry system from March 1, 2009 to 2014. Demographic and clinical-pathologic data of the patients were gathered through their medical records, pathology reports, and reference to patients' homes. The survival rate was calculated using the Kaplan-Meier curve, log-rank test, and univariate and multivariate Cox regression. The data were analyzed using Stata 14 software.

RESULTS

In this study, the mean age±standard deviation at diagnosis was 61.7± 1.05 in men and 60.5± 1.12 in women, respectively, and 203 (60.5%) patients were males. There was less mortality rate among the patients who received both surgical and chemotherapy treatments compared to those who did not receive any treatment (Hazard ratio [HR]=0.57, 95% CI: 0.24-0.93).

CONCLUSION

When CRC patients are treated using both surgical and chemotherapy treatments, they will exhibit a higher survival rate. Therefore, it is suggested to use both treatments for CRC patients.

Colorectal Cancer: In the Pursuit of Health Equity

Colorectal cancer mortality has decreased considerably following the adoption of national screening programs, yet, within at-risk subgroups, there continue to be measurable differences in clinical outcomes from variations in screening, receipt of chemotherapy, radiation or surgery, access to clinical trials, research participation, and survivorship. These disparities are well-described and some have worsened over time. Disparities identified have included race and ethnicity, age (specifically young adults), socioeconomic status, insurance access, geography, and environmental exposures. In the context of the COVID-19 pandemic, colorectal cancer care has necessarily shifted dramatically, with broad, immediate uptake of telemedicine, transition to oral medications when feasible, and considerations for sequence of treatment. However, it has additionally marginalized patients with colorectal cancer with historically disparate cancer-specific outcomes; among them, uninsured, low-income, immigrant, and ethnic-minority patients-all of whom are more likely to become infected, be hospitalized, and die of either COVID-19 or colorectal cancer. Herein, we outline measurable disparities, review implemented solutions, and define strategies toward ensuring that all have a fair and just opportunity to be as healthy as possible.

The Real-Life Data of BRAF Mutation on the Treatment of Colorectal Cancer: a TOG Study

PURPOSE

Colorectal cancer is the third leading diagnosis accounting for nearly 10% of all new cancers worldwide. The distinct features among BRAF mutant colorectal cancers make these tumor groups hard to treat for oncologists. The median overall survival (OS) of these types of cancers is reported to be 9 to 14 months.

METHODS

The study was declared on the Turkish Oncology Study Group Conference and approved. The patients' data was received from the centers who confirmed to participate. The BRAF-mutated patients were included in the study. The demographic features (age, gender, etc.), type of mutation, tumor localizations, histology, microsatellite instability (MSI) status, metastasis patterns chemotherapeutic agents and progression, and death times were recorded.

RESULTS

Thirty-nine patients were enrolled in the study. Sixteen patients had concurrent KRAS mutations, while 7 had NRAS mutations. Most of the patients received doublet chemotherapies in combination with anti-VEGF agents in the first and second line of the treatment. There was a significant difference in OS according to the stage which showed a decreased survival in stage IV patients at the time of diagnosis. Concurrent KRAS mutation resulted in increased OS. The median OS was 47 and 24 months favoring the KRAS mutant group. The patients whose primary tumor operated had better survival when compared with other patients. The median OS of the operated group was 47 months, while the non-operated group was 24 months. Liver metastasis was related to worse prognosis at the time of diagnosis in univariate analysis.

CONCLUSION

In our study we found a high concurrent RAS mutation ratio in a BRAF mutant patient group which was different from prior studies. The concurrent mutations resulted in a favorable outcome in terms of OS which is also different from the current knowledge. More prospective studies are needed especially BRAF-mutated patient population and especially with concurrent RAS mutations.

Clinical characteristics and a rising incidence of early-onset colorectal cancer in a nationwide cohort of 521 patients aged 18-40 years

BACKGROUND

The incidence of early-onset colorectal cancer (eoCRC) has been reported to increase, and patients with eoCRC seem to be diagnosed at more advanced stages compared to elderly patients. The aim of this study was to describe patient and disease characteristics, symptomatology and the incidence of eoCRC in a national cohort.

MATERIALS AND METHODS

521 eoCRC patients (≤40 years old) diagnosed with histologically verified colorectal cancer (CRC) during the years 2001-2013 were identified in national databases and compared to more than 15,000 CRC patients aged 66-75 years. Age-adjusted incidence was calculated for eoCRC patients and various sub-analyses were performed.

RESULTS

More advanced stages were seen in eoCRC patients compared to elderly patients (stage II: p < 0.001, III: p = 0.01 and IV: p < 0.01). Differences were statistically significant in colon cancer, but not in rectal cancer. A significant difference in sex distribution was seen between right and left-sided tumors in the eoCRC group. The age-adjusted incidence rate increased during the study period (1.60-2.55 per 100.000), and significant annual percent changes (APC) were seen in young females (APC = 4.73) and left-sided tumor localization (including rectal cancer) (APC = 4.54), respectively.

CONCLUSION

In this nationwide cohort of eoCRC patients, our results confirm that young patients are diagnosed at advanced stages, and that the incidence of eoCRC is increasing.

The association of age with the clinicopathological characteristics and prognosis of colorectal cancer: a UK single-centre retrospective study

INTRODUCTION

Colorectal cancer (CRC) is uncommon in patients under the age of 40 years and its association with poor histological features and survival is uncertain. This study aimed to evaluate age-related differences in clinicopathological features and prognosis in patients diagnosed with CRC.

METHOD

A single-centre retrospective review of all patients diagnosed with CRC between 2004 and 2013 was performed. Patients were stratified into three age groups: (1) 18-40 years, (2) 41-60 years and (3)> 60 years. Clinicopathological characteristics and outcomes were compared between the three groups.

RESULTS

A total of 1328 patients were included, of whom 57.2% were men. There were 28 (2.1%) patients in group 1, 287 (21.6%) in group 2 and 1013 (76.3%) in group 3. Group 1 had the highest proportion of rectal tumours (57.1% in group 1, 50.2% in group 2 and 31.9% in group 3; P < 0.001). Tumour histology and disease stage were comparable between the groups. Group 1 had significantly worse disease-free survival (DFS) than the two older groups (44%, 78% and 77%, respectively; P = 0.022). Multivariate analysis demonstrated that age was not an independent prognostic factor whereas Stage III disease [hazard ratio (HR) 4.42; 95% CI 2.81-6.94; P < 0.001] and neoadjuvant chemotherapy (HR 1.65; 95% CI 1.06-2.58; P = 0.026) were associated with increased risk of recurrence.

CONCLUSION

Patients under the age of 40 are more likely to present with rectal cancer and have comparable histological features than the older groups. Despite higher rates of adjuvant and neoadjuvant treatment, the young group were found to have worse DFS.

[Epidemiology, treatment and prognosis of colorectal cancer in young adults in sub-Saharan Africa]

Colorectal cancer is the most common digestive cancer. The objectives of this study was to analyse the frequency, aetiologies, and the therapeutic and progressive aspects of colorectal cancer in young adults in Burkina Faso. This study was a 10-years descriptive study conducted in 2 regional hospitals in Burkina Faso. It included all patients aged 20 to 45 years admitted to these two hospitals for colon cancer or rectal cancer during the study period. A total of 116 patients were included, which was 39.2% of all patients admitted for colorectal cancer during the same period. The average age of the included patients was 35.4 years old. There were 70 male patients (60.3%). Seven patients had a history of chronic inflammatory bowel disease, and six had a family history of colon cancer. The average consultation time was 6.2 months. In 25 cases (19.9%), the cancer was discovered in the context of an abdominal emergency. Ninety-two patients (79.3%) were diagnosed at stage 3 or stage 4 according to the TNM Staging System. The most common histological type was adenocarcinoma (103 cases, 88.9%). Therapeutically, surgery was performed on 87 patients (75%) and chemotherapy was used in 37 cases (31.9%). Sixteen patients received radiotherapy. The intra operative mortality rate was 4.6%. The 5-year survival rate was 17%. In conclusion, colorectal cancer in young adults occurs without obvious risk factors in Burkina Faso. Mortality remains high because of the limited therapeutic arsenal.

The impact of travel time on colorectal cancer stage at diagnosis in a privately insured population

BACKGROUND

Rural residents are less likely to receive screening for colorectal cancer (CRC) than urban residents. However, the mechanisms underlying this disparity, especially among people aged 50-64 years old with private health insurance, are not well understood. We examined the impact of travel time on stage at CRC diagnosis.

METHODS

This retrospective cohort study used data from the Blue Cross and Blue Shield of Nebraska. Members of this private insurance company aged 50-64 years, diagnosed with CRC during the period 2012-2016, and continuously enrolled in the insurance plan for at least 6 months prior to CRC diagnosis, were selected for this study. Using Google Maps, we estimated patients' travel time from their home ZIP code to the ZIP code of their colonoscopy provider. Using logistic regression, we analyzed the association between stage at CRC diagnosis, travel time, use of preventive services (i.e., check-ups or counseling to prevent or detect illness at an early stage) and patient characteristics.

RESULTS

A total of 307 subjects met the inclusion criteria. People who had not used preventive services 6 months prior to CRC diagnosis had 2.80 (95% CI, 1.00-7.90) times the odds of metastatic CRC compared to those who had used these services. No statistically significant association was found between travel time and metastatic CRC diagnosis (P = 0.99; 95% CI, 0.98-1.01).

CONCLUSIONS

The fact that 13% of the study population presented with metastatic CRC suggests some noncompliance with preventive services such as screening guidelines. To increase screening uptake and reduce metastatic cases, employers should offer incentives for their employees to make use of preventive services such as CRC screening.

Colorectal cancer incidence and clinicopathological features in northern Tunisia 2007–2009

Colorectal cancer (CRC) is the third most commonly diagnosed cancer worldwide. The aim of this study was to determine CRC incidence and to describe clinicopathological features in north Tunisia for the period 2007–2009. The North Tunisia Cancer Registry was the source of data for the identification of patients. The age-standardized incidence rates (ASRs) were respectively 13.6 cases (7.5/100,000 for colon cancer and 6.2 for rectal cancer) and 11.1 cases (6.5/100,000 for colon cancer and 4.4 for rectal cancer) per 100,000 among male and female. The ASR varied widely by regions in northern Tunisia.  The most common site in colon cancer was the distal colon comparing to the proximal one (49.0 and 29.9% respectively). Adenocarcinoma was the most common histological type. CRC screening should be strengthened in Tunisia to achieve a reduction of CRC incidence and mortality.

Outcome of rectal cancer in patients aged 30 years or less in the Pakistani population

BACKGROUND

The incidence of rectal cancer is increasing in younger age groups. Limited data is available regarding survival outcome in younger patients with conflicting results from western world. The goal of this study was to determine survival in patients with rectal cancer<30 years of age and compare it with their older counterparts in the Pakistani population.

MATERIALS AND METHODS

A retrospective chart review of patients operated for rectal adenocarcinoma between January 2005 and December 2010 was performed. Patients were divided into two groups, Group 1 aged ≤30 years and Group 2 aged >30 years. Patient characteristics, surgical procedure, histopathological details and number of loco-regional and distant failures were compared. Expected 5 year survival was calculated using Kaplan Meier curves and significance was determined using the Log rank test.

RESULTS

There were 38 patients in group 1 and 144 in group 2. A significantly high number of younger patients presented with poorly differentiated histology (44.7% vs 9.7%) (p=0.0001) and advanced pathological stage (63.1% vs 38.1%) (p=0.04). Predicted overall 5 year survival was 38% versus 57% in groups I and II, respectively (p=0.05). Disease free survival was 37% versus 52% and was significantly different (p=0.007).

CONCLUSIONS

Early onset rectal cancer is associated with poor pathological features and a worse outcome in Pakistani population.

Colorectal cancer in the young, many questions, few answers

At a time where the incidence of colorectal cancer, a disease predominantly of developed nations, is showing a decline in those 50 years of age and older, data from the West is showing a rising incidence of this cancer in young individuals. Central to this has been the 75% increase in rectal cancer incidence in the last four decades. Furthermore, predictive data based on mathematical modelling indicates a 124 percent rise in the incidence of rectal cancer by the year 2030 - a statistic that calls for collective global thought and action. While predominance of colorectal cancer (CRC) is likely to be in that part of the large bowel distal to the splenic flexure, which makes flexible sigmoidoscopic examination an ideal screening tool, the cost and benefit of mass screening in young people remain unknown. In countries where the incidence of young CRC is as high as 35% to 50%, the available data do not seem to indicate that the disease in young people is one of high red meat consuming nations only. Improvement in our understanding of genetic pathways in the aetiology of CRC, chiefly of the MSI, CIN and CIMP pathway, supports the notion that up to 30% of CRC is genetic, and may reflect a familial trait or environmentally induced changes. However, a number of other germline and somatic mutations, some of which remain unidentified, may play a role in the genesis of this cancer and stand in the way of a clear understanding of CRC in the young. Clinically, a proportion of young persons with CRC die early after curative surgery, presumably from aggressive tumour biology, compared with the majority in whom survival after operation will remain unchanged for five years or greater. The challenge in the future will be to determine, by genetic fingerprinting or otherwise, those at risk of developing CRC and the determinants of survival in those who develop CRC. Ultimately, prevention and early detection, just like for those over 50 years with CRC, will determine the outcome of CRC in young persons. At present, aside from those with an established familial tendency, there is no consensus on screening young persons who may be at risk. However, increasing awareness of this cancer in the young and the established benefit of prevention in older persons, must be a message that should be communicated with medical students, primary health care personnel and first contact doctors. The latter constitutes a formidable challenge.

Prognostic factors in the patients with T2N0M0 colorectal cancer

BACKGROUND

The 5-year survival rate of the patients with stage I colorectal cancer is about 90%; therefore, adjuvant therapy has not been recommended after radical resection; however, about 16-26% of T2N0M0 patients will be dead at 5 years despite radical curative resection. It indicated that there is a defined group of patients who are at high risk for relapse or metastasis despite radical operation. This study aimed to find the patients with T2N0M0 colorectal cancer at high risk for relapse or metastasis.

METHODS

From January 1993 to December 2014, 812 patients with histologically confirmed stage T2N0M0 primary colorectal cancer treated by radical surgery with complete clinical follow-up data were eligible for this study. The medical records of all patients were collected and were retrospectively analyzed. Survival rates were calculated using Kaplan-Meier method, and survival cures were compared using the log-rank test. Cox proportional hazards model was used to analyze the significant factors defined in univariate test.

RESULTS

The 5-year and 10-year overall survival rates were 81.9 and 67.7%, respectively. Male gender, old age, lymphovascular permeation, perineural invasion, and poor differentiation were associated with low cancer-specific survival rates in Kaplan-Meier analysis. Multivariate analyses revealed old age, lymphovascular permeation, perineural invasion, and poor differentiation as significant independent factors predicting worse prognosis (P < 0.05).

CONCLUSIONS

Old age, lymphovascular permeation, perineural invasion, and poor differentiation are risk factors for the worse prognostic patients with T2N0M0 colorectal patients who would potential benefit from more aggressive therapy.

Colorectal cancer in young patients: is it a distinct clinical entity?

BACKGROUND

The incidence of colorectal cancer in young patients is increasing. It remains unclear if the disease has unique features in this age group.

METHODS

This was a single-center, retrospective cohort study which included patients diagnosed with colorectal cancer at age ≤40 years in 1997-2013 matched 1:2 by year of diagnosis with consecutive colorectal cancer patients diagnosed at age >50 years during the same period. Patients aged 41-50 years were not included in the study, to accentuate potential age-related differences. Clinicopathological characteristics, treatment, and outcome were compared between groups.

RESULTS

The cohort included 330 patients, followed for a median time of 65.9 months (range 4.7-211). Several significant differences were noted. The younger group had a different ethnic composition. They had higher rates of family history of colorectal cancer (p = 0.003), hereditary colorectal cancer syndromes (p < 0.0001), and inflammatory bowel disease (p = 0.007), and a lower rate of polyps (p < 0.0001). They were more likely to present with stage III or IV disease (p = 0.001), angiolymphatic invasion, signet cell ring adenocarcinoma, and rectal tumors (p = 0.02). Younger patients more frequently received treatment. Young patients had a worse estimated 5-year disease-free survival rate (57.6  vs. 70 %, p = 0.039), but this did not retain significance when analyzed by stage (p = 0.092). Estimated 5-year overall survival rates were 59.1 and 62.1 % in the younger and the control group, respectively (p = 0.565).

CONCLUSIONS

Colorectal cancer among young patients may constitute a distinct clinical entity. Further research is needed to validate our findings and define the optimal approach in this population.

Segmental versus extended resection for sporadic colorectal cancer in young patients

BACKGROUND AND OBJECTIVES

Guidelines on the management of colon cancer state that extensive colectomy should be "considered" for patients of young age (<50). This study aimed to compare the risk of metachronous cancer, overall recurrence and mortality between segmental and extended colon resections in patients under the age of 50 with sporadic CRC.

METHODS

We performed a retrospective review of patients age <50 undergoing surgery for CRC from 1991 to 2009. Patients were divided into two groups based on extent of resection: segmental versus extended. The primary outcomes analyzed were metachronous tumors, disease recurrence, and overall survival.

RESULTS

Two hundred seventy one patients underwent segmental resection and 30 underwent extended resection. 3.3% in the segmental resection group developed metachronous CRC versus 0% in the extended resection group (P = 0.61). There was no significant difference in the risk of recurrence or mortality for those who underwent a segmental resection compared to those with an extended resection. In a regression model, type of surgery was not an independent risk factor for recurrence or mortality.

CONCLUSIONS

Extended colectomy for sporadic CRC in patients younger than 50 does not improve disease-free or overall survival. Further study to determine if segmental resection is appropriate oncologic treatment is warranted.

Clinical features and outcome of sporadic colorectal carcinoma in young patients: a cross-sectional analysis from a developing country

Background. Early onset colorectal carcinoma (CRC) is rare and has been hypothesized to be a biologically and clinically distinct entity personifying aggressive disease and worse survival. Methods. Data for 131 patients was collected by retrospective chart review. Cox proportional hazard model was used to compute prevalence ratios and 95% confidence intervals. Results. Early onset sporadic CRC accounted for 32% of all CRC treated in the specified time period. The mean age was 33.3 ± 7.9 years and the male to female ratio was 2 : 1. Colon and rectal cancers accounted for 55% and 45% of patients, respectively. 96% of rectal carcinoma patients received appropriate therapy as opposed to 65% of colon cancers. On multivariable analysis, appropriate reception of therapy (PR 4.99; 95% CI, 1.21–20.6) and signet ring morphology (PR 2.40; 95% CI, 1.33–4.32) were significantly associated with rectal cancers as opposed to colon cancer. Kaplan-Meier analysis revealed a trend towards inferior survival for rectal carcinoma 2 years after diagnosis. Conclusion.A high prevalence of early onset CRC was noted in the study. A trend towards inferior survival was seen in patients with rectal cancer. This finding raises the possibility of rectal carcinoma being an aggressive subset of young CRC.

The influence of age on the outcome of treatment of elderly patients with colorectal cancer

OBJECTIVES

We investigated factors associated with post-operative mortality rates in those aged ≥60, and in particular, the relative survival of age bands within this group.

METHODS

Secondary analysis of a large comprehensive cohort of the elderly treated for colorectal cancer in the North of England during 1998-2003. We investigated seven risk factors associated with 30-day and 6-month post-operative mortality from colorectal surgery.

RESULTS

6083 patients aged ≥60 underwent colorectal cancer surgery. Approximately 8% had died within 30 days of surgery and 17% had died within 6 months. Thirty-day mortality was greater in the elderly (80 years+) compared to the young-old (60-69 years) (adjusted OR: 3.2, 95% CI 2.4 to 4.4). There was neither a significant difference between the proportions offered curative resections across the age-groups, nor was there a significant association between intent of surgery and 30-day mortality. Six-month mortality rose with age, but the association was stronger in those having curative surgery (adjusted OR: 3.8, 95% CI 2.8 to 5.2) than palliative surgery (adjusted OR: 1.5, 95% CI 1.1 to 2.1). Mortality from emergency surgery at 6-months was particularly high in elderly females.

CONCLUSIONS

This large population study adds more weight to the findings that age itself is a major risk factor in the outcome of colorectal surgery in elderly and that 30-day mortality underestimates the longer-term outcome in this age group. There was no significant association between radical resections and 30-day mortality in elderly patients compared to the younger age groups; however, a disproportionately higher mortality at 6 months was seen in elderly female patients.

Prognostic and survival analysis of 837 Chinese colorectal cancer patients

AIM: To develop a prognostic model to predict survival of patients with colorectal cancer (CRC).

METHODS: Survival data of 837 CRC patients undergoing surgery between 1996 and 2006 were collected and analyzed by univariate analysis and Cox proportional hazard regression model to reveal the prognostic factors for CRC. All data were recorded using a standard data form and analyzed using SPSS version 18.0 (SPSS, Chicago, IL, United States). Survival curves were calculated by the Kaplan-Meier method. The log rank test was used to assess differences in survival. Univariate hazard ratios and significant and independent predictors of disease-specific survival and were identified by Cox proportional hazard analysis. The stepwise procedure was set to a threshold of 0.05. Statistical significance was defined as P < 0.05.

RESULTS: The survival rate was 74% at 3 years and 68% at 5 years. The results of univariate analysis suggested age, preoperative obstruction, serum carcinoembryonic antigen level at diagnosis, status of resection, tumor size, histological grade, pathological type, lymphovascular invasion, invasion of adjacent organs, and tumor node metastasis (TNM) staging were positive prognostic factors (P < 0.05). Lymph node ratio (LNR) was also a strong prognostic factor in stage III CRC (P < 0.0001). We divided 341 stage III patients into three groups according to LNR values (LNR1, LNR ≤ 0.33, n = 211; LNR2, LNR 0.34-0.66, n = 76; and LNR3, LNR ≥ 0.67, n = 54). Univariate analysis showed a significant statistical difference in 3-year survival among these groups: LNR1, 73%; LNR2, 55%; and LNR3, 42% (P < 0.0001). The multivariate analysis results showed that histological grade, depth of bowel wall invasion, and number of metastatic lymph nodes were the most important prognostic factors for CRC if we did not consider the interaction of the TNM staging system (P < 0.05). When the TNM staging was taken into account, histological grade lost its statistical significance, while the specific TNM staging system showed a statistically significant difference (P < 0.0001).

CONCLUSION: The overall survival of CRC patients has improved between 1996 and 2006. LNR is a powerful factor for estimating the survival of stage III CRC patients.

Characteristics and long-term survival of colorectal cancer patients aged 44 years and younger

BACKGROUND

This study was to investigate the clinicopathologic characteristics and prognosis of colorectal cancer (CRC) patients aged 44 years and younger.

METHODS

Patients were identified from a prospectively maintained CRC database and divided into two groups by age: younger and older group (≤44 and >44 years). Clinicopathologic characteristics and postoperative outcomes were compared.

RESULTS

There were 530 patients aged ≤44 years at diagnosis. More patients in the younger group had a family history of CRC compared with older patients. Younger patients were more likely than older patients to have larger tumours, infiltrative growth type tumours, poorly differentiated tumours, mucinous and signet-ring cell adenocarcinoma, and advanced TNM stages. Compared to older patients, more younger patients received chemotherapy and died of cancer-related causes. Overall survival, disease-free survival and cancer-specific survival of younger patients were comparable to older patients. Blood transfusion, TNM stage, histological grade and disease recurrence were independently associated with survival in the younger group.

CONCLUSIONS

Despite younger patients having unfavourable clinicopathologic features, younger age at diagnosis of CRC appears to be associated with similar oncologic outcomes as compared to older patients.

Metastatic signet ring colon cancer in a Caribbean young adult and review of the literature

Colorectal cancer is the third most common neoplasm diagnosed in the USA, with less than 3% of patients younger than 40 years. Although most of the literature indicates that younger patients present with a higher stage and grade of cancer, mortality is not clearly correlated. Furthermore, the literature pertaining to colorectal cancer in the nonwhite youth is limited. In this case report, we report a case of aggressive colorectal cancer metastasizing in a young Afro-Caribbean woman with no known risk factors. The aim of this report is to raise awareness of this entity in the younger population, particularly in Afro-Caribbeans, which remains a highly understudied group compared with the rest of the US population.

Despite aggressive histopathology survival is not impaired in young patients with colorectal cancer : CRC in patients under 50 years of age

PURPOSE

Colorectal carcinoma (CRC) is generally a disease of persons older than 50 years. Concerning younger patients, controversies still exist regarding features and prognosis of CRC. We performed this study to characterize CRC in young patients (≤50 years) as well as to evaluate outcome in comparison with older patients (>50 years) with CRC.

METHODS

Clinical and histopathological parameters of 244 patients aged 50 years or less were compared with 1,718 patients aged more than 50 years.

RESULTS

Compared with older patients, the younger had less adenocarcinomas (82.8% vs. 89.1%; p = 0.004) and less postoperative complications (18.4% vs. 28.7%; p = 0.001), and less Union Internationale Contre le Cancer stage I colon cancers (22.9% vs. 13.6%, p = 0.046) but elevated overall 5-year survival rates for M0 colon and rectal cancers (p = 0.005; p < 0.001). In young patients, the minority suffered from hereditary cancer syndromes (7.4%) and inflammatory bowel diseases (7.0%). Furthermore, up to 40% of young patients denied any cancers in their families. Cancer-related survival rates were significantly elevated in young patients with M0 rectal carcinoma (p = 0.014), whereas in M0 colon cancers, no differences were detectable (p = 0.542). In case of the presence of distant metastases, overall and cancer-related survival rates were similar in old and young patients.

CONCLUSION

Although young patients present with more aggressive histopathological subtypes and less early stages, cancer-related survival is not less favourable compared with older patients.

Colorectal cancer in young patients in Israel: a distinct clinicopathological entity?

PURPOSE

This study was designed to characterize the entity of colorectal cancer (CRC) in young patients and to evaluate whether it has any unique epidemiological or clinicopathological features.

METHODS

The study population consisted of all consecutive young (≤50 years old at diagnosis) patients with CRC who were diagnosed during the years 1997-2007 and were treated at our institution, and a matching group of patients (>50 years at diagnosis). The medical files of these patients were reviewed, and the epidemiological, clinical, and pathological features of both groups were compared.

RESULTS

There were 406 patients: 203 in each group. The features of the older group were typical for patients with CRC, but the younger group showed female predominance, different ethnic composition, prevalence of family history of cancer and hereditary CRC syndromes, and lower incidence of polyps. The incidence of left-sided tumors and advanced stages (III-IV) at diagnosis was higher in the younger patients. Mucinous/signet ring histology, grade, stage, lymphatic and vascular invasion were all predictive of survival, whereas age was not.

CONCLUSIONS

Colorectal cancer in young patients was found to display a cluster of unique characteristics but fewer than previously reported and young age by itself was not found to impact patient outcome.

Do young patients with colorectal cancer have a poorer prognosis than old patients?

BACKGROUND

Colorectal cancer (CRC) is generally a disease of the older population. The prognosis and clinicopathologic features of CRC in the young, compared with those in older patients, continue to be debated. The aim of this study was to compare the survival, clinicopathologic features, and tumor markers of CRC in patients aged 40 y or younger and older patients.

METHODS

A total of 230 patients with CRC of stage I-III were assessed retrospectively, with an endpoint of recurrence or metastasis after curative operation. The markers CEA, MMP-2, and p27(kip1) were studied by immunohistochemistry in all patients.

RESULTS

The young group comprised 28 (12.2%) patients aged 40 y or younger with a median age of 36 y. The remaining 202 patients (87.8%) comprised the old group, with a median age of 61 y. There were no statistical differences in gender distribution, tumor sites, tumor size, or gross type between the young and old groups. The young group had a higher incidence of mucinous adenocarcinoma (17.9%) than the old group (6.4%) (P = 0.035). The distribution of stage, differentiation grade, and extent of venous invasion were similar. The median disease-free survival time was 60 mo for the young group and 49 mo for the old. Univariate analysis revealed that this difference was not significant (P = 0.1158). Multivariate Cox regression analysis also demonstrated that the age of the patient was not an independent factor for the prognosis of CRC. There were no statistical differences between the young and old groups in the expression of CEA, MMP-2, or p27(kip1).

CONCLUSIONS

The results of this study indicated that there was a subtle difference in the incidence of mucinous adenocarcinoma between young and old patients with CRC. However, stage I-III young patients had a similar disease-free survival period as the older patients. Other clinicopathologic characteristics, and tumor markers such as CEA, MMP-2, and p27(kip1), were also similar between young and old CRC patients.

Colorectal carcinoma in young adults: a retrospective study on Indian patients: 2000-2008

AIM

To highlight an increased incidence of colorectal cancer (CRC) amongst young Indian adults.

METHOD

A retrospective study of 305 cases of CRC admitted to SSKM Hospital, Kolkata, India during 2000-2008 was carried out.

RESULTS

The ratio (0.64) of under-40 to above-40 CRC patients reported in this study is comparable to those from premier Oncology Centers in India (∼0.52) and is higher than those in the Indian National Cancer Registry (∼0.20) and international average (0.07). Distinctive tumour characteristics in younger patients including left-sided lesion (69.7%), presentation at an advanced (III/IV) stage (60%), poor histological differentiation (50%) and predominance of mucin-secreting adenocarcinoma (80%) are similar to those reported in the international literature. Some features are suggestive of hereditary non polyposis colorectal cancer syndrome, which may be a possible reason for the high proportion of young CRC patients.

CONCLUSION

A high index of suspicion for CRC among young Indian adults is necessary.

Young patients with colorectal cancer have poor survival in the first twenty months after operation and predictable survival in the medium and long-term: analysis of survival and prognostic markers

Objectives

This study compares clinico-pathological features in young (<40 years) and older patients (>50 years) with colorectal cancer, survival in the young and the influence of pre-operative clinical and histological factors on survival.

Materials and methods

A twelve year prospective database of colorectal cancer was analysed. Fifty-three young patients were compared with forty seven consecutive older patients over fifty years old. An analysis of survival was undertaken in young patients using Kaplan Meier graphs, non parametric methods, Cox's Proportional Hazard Ratios and Weibull Hazard models.

Results

Young patients comprised 13.4 percent of 397 with colorectal cancer. Duration of symptoms and presentation in the young was similar to older patients (median, range; young patients; 6 months, 2 weeks to 2 years, older patients; 4 months, 4 weeks to 3 years, p > 0.05). In both groups, the majority presented without bowel obstruction (young - 81%, older - 94%). Cancer proximal to the splenic flexure was present more in young than in older patients. Synchronous cancers were found exclusively in the young. Mucinous tumours were seen in 16% of young and 4% of older patients (p < 0.05). Ninety four percent of young cancer deaths were within 20 months of operation. At median follow up of 50 months in the young, overall survival was 70% and disease free survival 66%. American Joint Committee on Cancer (AJCC) stage 4 and use of pre-operative chemoradiation in rectal cancer was associated with poor survival in the young.

Conclusion

If patients, who are less than 40 years old with colorectal cancer, survive twenty months after operation, the prognosis improves and their survival becomes predictable.

Presentation and outcomes of patients aged 30 years and younger with colorectal cancer: a 20-year retrospective review

Age may influence the clinicopathological characteristics and outcome of colorectal cancer. The aim of this study is to retrospectively review the characteristics and outcomes of patients diagnosed at age 30 years and younger. All patients diagnosed with colorectal adenocarcinoma at age 30 years or younger, referred to the British Columbia Cancer Agency between 1985 and 2005, were identified. Abstracted data included demographics, presenting symptoms, risk factors, stage at presentation, treatment received and overall survival. Survival analysis was by the method of Kaplan-Meier. From 16,732 patients with colorectal cancer, 78 (0.47%) were younger than or equal to 30 years of age. Sufficient data were available for 62 patients. Twenty-three patients (37%) had a rectal primary, and 52% of colon primaries were proximal. Seventeen patients (27%) presented with metastatic disease. The stage distribution among the 45 patients with localized disease was stage I 9%, stage II 42% and stage III 49%. A positive family history was reported in 27% of patients. Pain and bleeding were the most common symptomatic presentations. Five-year overall survival was 44% in the entire cohort; 54% in stage I-III disease and 12% in stage IV disease. Very young patients with colorectal cancer represent<0.5% of all referred cases in British Columbia. The majority presented without a positive family history. The 5-year survival for patients in our young cohort with localized disease appears inferior to that expected, although 5-year survival among patients with stage IV disease was observed to be higher than expected.

Combined chemotherapy of hydroxycampothecin with oxaliplatin as an adjuvant treatment for human colorectal cancer

Colorectal cancer (CRC) is a major cause of morbidity and mortality for cancer worldwide, but many patients with CRC are resistant to chemotherapy. We therefore investigated the therapeutic mechanism and clinical effect of combined chemotherapy of hydroxycampothecin (HCPT) with oxaliplatin (L-OHP) on CRC. HCPT represents a potential antitumor agent of Chinese herb. Mice carrying the xenografted human LS174T CRC cells were injected into peritoneal cavities with different drugs: HCPT + L-OHP (OH), HCPT, L-OHP, or saline. Treatment of mice with OH caused the decrease in the volume of tumor and the expression of p53, but increased the apoptotic rate and Fas-L expression, compared to those of animals treated with HCPT or L-OHP, or control animals. Thus, the combination of HCPT with L-OHP could more effectively induce the apoptosis of CRC cells. Furthermore, 56 patients with CRC were treated with HCPT and L-OHP (28 cases, OH group) or L-OHP plus leucovorin plus 5-fluorouracil (28 cases, OFL group), then reviewed the response rate, survival rate and toxicity. The one-year survival rate was 35.07% in OH group and 24.21% in OFL group. However, the occurrence of anemia (51.8%) or diarrhea (60.7%) was higher in OH group than that of 19.6% or 46.4% in OFL group. The clinical results suggest that HCPT plus L-OHP combined chemotherapy could increase the survival time of patients. Taken together, the present study indicates that the combined chemotherapy of HCPT with L-OHP could become a new adjuvant treatment for CRC.

Evaluation of clinical, laboratory and morphologic prognostic factors in colon cancer

BACKGROUND

The long-term prognosis of patients with colon cancer is dependent on many factors. To investigate the influence of a series of clinical, laboratory and morphological variables on prognosis of colon carcinoma we conducted a retrospective analysis of our data.

METHODS

Ninety-two patients with colon cancer, who underwent surgical resection between January 1999 and December 2001, were analyzed. On survival analysis, demographics, clinical, laboratory and pathomorphological parameters were tested for their potential prognostic value. Furthermore, univariate and multivariate analysis of the above mentioned data were performed considering the depth of tumour invasion into the bowel wall as independent variable.

RESULTS

On survival analysis we found that depth of tumour invasion (P < 0.001; F-ratio 2.11), type of operation (P < 0.001; F-ratio 3.51) and CT scanning (P < 0.001; F-ratio 5.21) were predictors of survival. Considering the degree of mural invasion as independent variable, on univariate analysis, we observed that mucorrhea, anismus, hematocrit, WBC count, fibrinogen value and CT scanning were significantly related to the degree of mural invasion of the cancer. On the multivariate analysis, fibrinogen value was the most statistically significant variable (P < 0.001) with the highest F-ratio (F-ratio 5.86). Finally, in the present study, the tumour site was significantly related neither to the survival nor to the mural invasion of the tumour.

CONCLUSION

The various clinical, laboratory and patho-morphological parameters showed different prognostic value for colon carcinoma. In the future, preoperative prognostic markers will probably gain relevance in order to make a proper choice between surgery, chemotherapy and radiotherapy. Nevertheless, current data do not provide sufficient evidence for preoperative stratification of high and low risk patients. Further assessments in prospective large studies are warranted.

Colorectal carcinoma: a retrospective, descriptive study of age, gender, subsite, stage, and differentiation in Iran from 1995 to 2001 as observed in Tehran University

PURPOSE

Colorectal carcinoma is one of the most common cancers in the world as well as in Iran. There are differences in subsite of the carcinoma when considering age and gender. This study was designed to describe the distribution of colorectal carcinoma by age at diagnosis, gender, and subsite of the tumor. These factors also are evaluated in conjunction with disease stage and tumor differentiation at the time of diagnosis.

METHODS

Data from 419 patients from a population that receives no screening between April 1995 and March 2001 operated on in the Cancer Institute and Imam Khomieni Hospital with a diagnosis of colorectal cancer were used to describe distribution of the colorectal carcinoma by age, gender, tumor subsite and pathology, and stage at diagnosis.

RESULTS

There were 403 (96.2 percent) cases of adenocarcinoma. Males and females constituted 52.4 and 47.6 percent of cases, respectively. The mean age was 52.3 years. Patients were divided into two age groups (40 years and younger, and older than 40 years); 16.4 percent of patients had tumors in the proximal colon and 83.6 percent in distal parts. Most patients were Stage II and III (48.1 and 33.4 percent, respectively). Tumor subsite distribution was almost the same between the two age groups (aged 40 years and younger: proximal, 18.5 percent, and distal, 81.5 percent; older than aged 40 years: proximal, 15.7 percent, and distal, 84.3 percent). Most patients in the younger age group were Stage III (45 percent) and in the older age group were Stage II (53.2 percent; P<0.001). Tumor differentiation proportions in patients aged 40 years and younger were: good, 24.4 percent; moderate, 53.6 percent; poor, 22 percent; and in patients older than aged 40 years were: good, 41.5 percent; moderate, 52.6 percent; poor, 5.9 percent (P<0.001). There were no differences in stage and tumor differentiation between two genders, but most of the patients with tumors in proximal colon were males (62.5 percent; P=0.1).

CONCLUSIONS

Most of the colorectal carcinomas were in distal parts in our study, so most of these carcinomas can be detected by proctosigmoidoscopy. Because younger patients had more advanced disease, the importance of screening and "clinical suspicion" in the young is important.

Prognostic factors of young patients with colon cancer after surgery

AIM: To investigate the prognostic factors of 96 young patients with colon cancer within a cancer center by univariate and multivariate analysis.

METHODS: A total of 723 patients with colon cancer were treated surgically during a period of 10 years. Ninty six of them were 40 years old or younger. R0, R1 and R2 operations were performed in 69 (71.9%), 4 (4.1%) and 23 patients (24%), respectively. Left hemicolectomy was performed in 43 patients, right hemicolectomy in 37 patients, transverse colon resection in 9 patients and low anterior resection in 7 patients. Cox multivariate regression analysis was performed to identify predictors of survival.

RESULTS: The operation mortality was 0%, 54 patients died within 111 mo after operation due to occurrence or metastases of the tumor. Liver, lung and bone metastases occurred in 3, 1 and 5 patients, respectively. The mean survival time for all patients was 77.9 ± 5.01 mo and the overall 3-, 5- and 10- year survival rates were 66.68%，58.14% and 46.54%, respectively. In the univariate survival analysis, patient age，type of operation, radical resection, blood transfusion, histological type, diameter of tumor, depth of tumor invasion, lymphatic invasion, distant metastases, liver metastases and TNM stage were found to be predictors of survival in young patients with colon cancer. In the Cox-regression analysis, blood transfusion and lymphatic invasion were determined as independent prognostic factors of survival.

CONCLUSIONS: Age, type of operation, radical resection, blood transfusion, histological type, diameter of tumor, depth of tumor invasion, lymphatic invasion, distant metastasis and TNM stage are the predictors of survival in young patients with colon cancer after surgery.

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Anatomic site distribution and clinic pathologic characteristics of colorectal cancer in young Chinese

AIM

To study the anatomic site distribution and pathologic characteristics of colorectal cancer (CRC) in young Chinese.

METHODS

A retrospective study was undertaken. Data were collected from 1 370 patients in Nan Fang Hospital from 1974 to 1999, including 309 patients younger than 40 years and 1 061 patients older than 40 years. The median age was 54 years. All patients with colorectal adenocarcinomas were diagnosed by histology and underwent surgery.

RESULTS

Overall, 22.3% (309/1370) of CRC patients were young people. The proportion of males in the young group was 57.0% vs 58.3% in the aged group (P>0.05, x² = 0.16). 24.1% of young group vs 25.1% of aged group had lesions in the proximal colon and 72.4% vs 71.2% had cancers located in distal colorectum (P>0.05, x² = 0.42). Adenocarcinoma was the most common histologic type in both groups. 71.5% of young group vs 83.4% of aged group was adenocarcinoma (P <0.01, x² = 18.09), 17.4% vs 12.0% was mucinous adenocarcinoma (P<0.05, x²=4.70) and 5.5% vs 1.1% was signet-ring cell carcinoma (P<0.01, x² = 30.20). 18.2% of young group vs 24.9% of aged group was early stage (Duke's stage A) and 81.9% vs 75.1% was advanced stage (Duke's stage B, C, D) (P <0.05, x² = 5.13). 20.9% of young group vs 11.1% of aged group was poor differentiation (P<0.01, x² = 14.75) and 59.5% vs 34.3% had lymphatic metastasis (P<0.01, x² = 53.25).

CONCLUSION

CRC of young people has no significant difference from middle-aged and old people in either gender distribution or anatomic site distribution, but the former has some clinical pathologic characteristics that are different from the latter. CRC in young people has relatively worse prognosis. The therapeutic effects depend on paying attention to these clinical pathologic characteristics and early diagnosis and early treatment.