Improved survival of colorectal cancer in Denmark during 2001-2012 - The efforts of several national initiatives

Incidence of late recurrence and second primary cancers 5-10 years after non-metastatic colorectal cancer

The fraction of patients who are cancer-free survivors 5 years after curative-intended surgery for colorectal cancer (CRC) is increasing, suggesting that extending surveillance beyond 5 years may be indicated. Here we estimate the incidence of late recurrence, metachronous CRC, and second primary cancers 5-10 years postoperative. All patients resected for UICC stage I-III CRC in Denmark through 2004-2013 were identified. Through individual-level linkage of nationwide health registry data, recurrence status was determined using a validated algorithm. Cancer-free survivors 5 years after surgery, were included. Cumulative incidence functions (CIF) of late recurrence, metachronous CRC, and second primary cancer 5-10 years postoperative were constructed. Subdistribution hazards ratios (sHR) were computed using Fine-Gray regression. Among 8883 patients, 370 developed late recurrence (5-10-year CIF = 4.1%, 95%CI: 3.7%-4.6%), 270 metachronous CRC (5-10-year CIF = 3.0%, 95%CI: 2.7%-3.4%), and 635 a second primary cancer (5-10-year CIF = 7.2%, 95%CI: 6.7%-7.7%). The risk of late recurrence was reduced for patients operated in 2009-2013 compared to 2004-2008 (2.9% vs. 5.6%, sHR = 0.52, 95% CI: 0.42-0.65). The risk of metachronous CRC was likewise reduced from 4.1% to 2.1% (sHR = 0.50, 95%CI: 0.39-0.65). While the risk of second primary cancer did not change between 2009-2013 and 2004-2008 (7.1% vs. 7.1%, sHR = 0.98, 95% CI: 0.84-1.15). Using nation-wide 10-year follow-up data, we document that the incidences of late recurrence and metachronous CRC are low and decreasing from 2004 to 2013. Thus, despite increasing numbers of long-term cancer survivors, the data do not advocate for extending CRC-specific surveillance beyond 5 years.

A systematic review of population-based studies on metachronous metastases of colorectal cancer

BACKGROUND

The occurrence of metachronous metastases (MM) of colorectal (CRC), colon (CC), and rectal (RC) cancer of population-based studies has not been compiled in a systematic review previously.

METHODS

MEDLINE, Embase, and Cochrane Library were searched for primary studies of any design from inception until January 2021 and updated in August 2023 (CRD42021261648). The PRISMA guidelines were adopted, and the Newcastle-Ottawa Quality Assessment Scale used for risk of bias assessment. Outcomes on overall and organ-specific MM were extracted. A narrative analysis followed.

RESULTS

Out of 2143 unique hits, 162 publications were read in full-text and 37 population-based cohort studies published in 1981-2022 were included. Ten studies adopted time-dependent analyses; eight were registry-based and seven had a low risk of bias. Three studies reported 5-year recurrence rate of MM overall of stages I-III; for CRC, it was 20.5%, for CC, it was 18% and 25.6%, and for RC, it was 23%. Four studies reported 5-year recurrence rate of organ-specific MM of stages I-III-for CRC, it was 2.2% and 5.5% for peritoneal metastases and 5.8% for lung metastases and for CC 4.5% for peritoneal metastases. Twenty-seven studies reported proportions of patients diagnosed with MM, but data on the length of follow-up was incomplete and varied widely. Proportions of patients with CRC stages I-III that developed MM overall was 14.4%-26.1% in 10 studies. In relation to the enrollment period, a downward trend may be discernible.

CONCLUSION

Studies adopting a more appropriate analysis were highly heterogeneous, whereas uncertain data of partly inadequate studies may indicate that MM are overall declining.

Harnessing the Potential of Real-World Evidence in the Treatment of Colorectal Cancer: Where Do We Stand?

OPINION STATEMENT

Treatment guidelines for colorectal cancer (CRC) are primarily based on the results of randomized clinical trials (RCTs), the gold standard methodology to evaluate safety and efficacy of oncological treatments. However, generalizability of trial results is often limited due to stringent eligibility criteria, underrepresentation of specific populations, and more heterogeneity in clinical practice. This may result in an efficacy-effectiveness gap and uncertainty regarding meaningful benefit versus treatment harm. Meanwhile, conduct of traditional RCTs has become increasingly challenging due to identification of a growing number of (small) molecular subtypes. These challenges-combined with the digitalization of health records-have led to growing interest in use of real-world data (RWD) to complement evidence from RCTs. RWD is used to evaluate epidemiological trends, quality of care, treatment effectiveness, long-term (rare) safety, and quality of life (QoL) measures. In addition, RWD is increasingly considered in decision-making by clinicians, regulators, and payers. In this narrative review, we elaborate on these applications in CRC, and provide illustrative examples. As long as the quality of RWD is safeguarded, ongoing developments, such as common data models, federated learning, and predictive modelling, will further unfold its potential. First, whenever possible, we recommend conducting pragmatic trials, such as registry-based RCTs, to optimize generalizability and answer clinical questions that are not addressed in registrational trials. Second, we argue that marketing approval should be conditional for patients who would have been ineligible for the registrational trial, awaiting planned (non) randomized evaluation of outcomes in the real world. Third, high-quality effectiveness results should be incorporated in treatment guidelines to aid in patient counseling. We believe that a coordinated effort from all stakeholders is essential to improve the quality of RWD, create a learning healthcare system with optimal use of trials and real-world evidence (RWE), and ultimately ensure personalized care for every CRC patient.

An evaluation of the replicability of analyses using synthetic health data

Synthetic data generation is being increasingly used as a privacy preserving approach for sharing health data. In addition to protecting privacy, it is important to ensure that generated data has high utility. A common way to assess utility is the ability of synthetic data to replicate results from the real data. Replicability has been defined using two criteria: (a) replicate the results of the analyses on real data, and (b) ensure valid population inferences from the synthetic data. A simulation study using three heterogeneous real-world datasets evaluated the replicability of logistic regression workloads. Eight replicability metrics were evaluated: decision agreement, estimate agreement, standardized difference, confidence interval overlap, bias, confidence interval coverage, statistical power, and precision (empirical SE). The analysis of synthetic data used a multiple imputation approach whereby up to 20 datasets were generated and the fitted logistic regression models were combined using combining rules for fully synthetic datasets. The effects of synthetic data amplification were evaluated, and two types of generative models were used: sequential synthesis using boosted decision trees and a generative adversarial network (GAN). Privacy risk was evaluated using a membership disclosure metric. For sequential synthesis, adjusted model parameters after combining at least ten synthetic datasets gave high decision and estimate agreement, low standardized difference, as well as high confidence interval overlap, low bias, the confidence interval had nominal coverage, and power close to the nominal level. Amplification had only a marginal benefit. Confidence interval coverage from a single synthetic dataset without applying combining rules were erroneous, and statistical power, as expected, was artificially inflated when amplification was used. Sequential synthesis performed considerably better than the GAN across multiple datasets. Membership disclosure risk was low for all datasets and models. For replicable results, the statistical analysis of fully synthetic data should be based on at least ten generated datasets of the same size as the original whose analyses results are combined. Analysis results from synthetic data without applying combining rules can be misleading. Replicability results are dependent on the type of generative model used, with our study suggesting that sequential synthesis has good replicability characteristics for common health research workloads.

Incidence of Recurrence and Time to Recurrence in Stage I to III Colorectal Cancer: A Nationwide Danish Cohort Study

Importance

Management of colorectal cancer (CRC) has been updated continuously over the past 2 decades. While the combination of these initiatives has had implications for improved survival, the implications for rates of recurrence remain unexplored.

Objective

To ascertain the rates of recurrence and describe time to recurrence within 5 years of surgery with curative intent for stages I to III CRC.

Design, Setting, and Participants

This cohort study used the Danish Colorectal Cancer Group Database to identify patients with Union for International Cancer Control (UICC) stages I to III CRC who underwent primary surgery between January 1, 2004, and December 31, 2019. They were followed up until recurrence (event), death (competing event), diagnosis of a second cancer (competing event), emigration (censoring event), 5 years postoperatively (censoring event), or January 1, 2023 (censoring event), whichever came first. Recurrence status was ascertained through individual-level linked data from the Danish Cancer Registry, Danish National Patient Registry, and Danish Pathology Registry using a validated algorithm. Data were analyzed from January 1 to August 8, 2023.

Exposure

Primary surgery performed during 3 calendar periods (2004-2008, 2009-2013, and 2014-2019) stratified by tumor site (colon or rectum) and UICC stage (I, II, and III).

Main Outcomes and Measures

Stage-specific 5-year recurrence reported as the cumulative incidence function (CIF) of recurrence, the association between calendar period of primary surgery and recurrence risk reported as subdistribution hazard ratios (sHRs), and the time from surgery to recurrence.

Results

Of the 34 166 patients with UICC stages I to III CRC (median [IQR] age, 70 [62-77] years); 18 552 males [54.3%]) included in the study, 7027 developed recurrence within 5 years after the primary surgery. For colon cancer, the 5-year CIF of recurrence decreased over the 3 calendar periods from 16.3% to 6.8% for UICC stage I, from 21.9% to 11.6% for UICC stage II, and from 35.3% to 24.6% for UICC stage III colon cancer. For rectal cancer, the 5-year CIF decreased over the 3 periods from 19.9% to 9.5% for stage I, from 25.8% to 18.4% for stage II, and from 38.7% to 28.8% for stage III disease. Patients with stage III disease had a shorter time from surgery to recurrence compared with those with stage I disease (time ratio stage III vs stage I = 0.30; 95% CI, 0.28-0.32). Cancers detected through screening were associated with lower stage-adjusted risks of recurrence (sHR, 0.81; 95% CI, 0.73-0.91) compared with cancers not detected through screening.

Conclusions and Relevance

In this cohort of patients with CRC, the risk of recurrence decreased in patients with stages I to III disease during the study period. Cancer detection by screening was associated with an even lower risk of recurrence. Time to recurrence differed according to UICC stage. Because the risk of recurrence was so low in selected patient groups, future research is warranted to explore risk-stratified surveillance protocols in patients with CRC.

Combined impact of myosteatosis and liver steatosis on prognosis in stage I-III colorectal cancer patients

BACKGROUND

Myosteatosis and liver steatosis (LS) have been recognized as patient-derived image biomarkers that correlate with prognosis in colorectal cancer (CRC) patients. However, the significance of considering fat deposition in multiple body areas simultaneously has been underestimated. This study aimed to investigate the combined effect of myosteatosis and LS in stage I-III CRC patients.

METHODS

A total of 616 stage I-III CRC patients were included in the study. Myosteatosis was assessed using skeletal muscle radiodensity (SMD), and LS was estimated by calculating the Hounsfield unit of the liver and spleen ratio (LSR). Cox proportional hazard models were utilized to evaluate disease-free survival (DFS). A combination of myosteatosis and LS was proposed, and its discriminatory performance was compared using the C-index.

RESULTS

Among the 616 participants, the median (interquartile) age was 64 (55-72) years, and 240 (38.9%) were female. The median and interquartile range of LSR were determined as 1.106 (0.967-1.225). The optimal cutoff value for LSR was identified as 1.181, leading to the classification of patients into low (410, 66.5%) and high LSR (206, 33.4%) groups. Among the patients, 200 were categorized into the low SMD group, while 416 were allocated to the high SMD group. Both myosteatosis and LS were identified as independent prognostic factors in the multivariable analysis. The combination of these two variables resulted in a three-group classification: high SMD with low LSR group, high SMD with high LSR group, and low SMD group. When comparing the C-index values, the three-group classification exhibited superior discriminatory performance compared with considering myosteatosis and LS separately.

CONCLUSIONS

Myosteatosis was associated with poorer survival, while the presence of LS was linked to a better prognosis in non-metastatic CRC patients. Simultaneously considering fat infiltration can serve as a more effective prognosticator in non-metastatic CRC patients.

Myocardial injury and long-term oncological outcomes in patients undergoing surgery for colorectal cancer

PURPOSE

Myocardial injury after noncardiac surgery (MINS) is associated with increased mortality and postoperative complications. In patients with colorectal cancer (CRC), postoperative complications are a risk factor for cancer recurrence and disease-free survival. This study investigates the association between MINS and long-term oncological outcomes in patients with CRC in an ERAS setting.

METHODS

This retrospective cohort study was conducted at Zealand University Hospital, Denmark, between June 2015 and July 2017. Patients undergoing CRC surgery were included if troponin was measured twice after surgery. Outcomes were all-cause mortality, recurrence, and disease-free survival within five years of surgery.

RESULTS

Among 586 patients, 42 suffered MINS. After five years, 36% of patients with MINS and 26% without MINS had died, p = 0.15. When adjusted for sex, age and UICC, the hazard ratio (aHR) for 1-year all-cause mortality, recurrence, and disease-free survival were 2.40 [0.93-6.22], 1.47 [0.19-11.29], and 2.25 [0.95-5.32] for patients with MINS compared with those without, respectively. Further adjusting for ASA status, performance status, smoking, and laparotomies, the aHR for 3- and 5-year all-cause mortality were 1.05 [0.51-2.15] and 1.11 [0.62-1.99], respectively. Similarly, the aHR for 3- and 5-year recurrence were 1.38 [0.46-4.51], and 1.49 [0.56-3.98] and for 3- and 5-year disease-free survival the aHR were 1.19 [0.63-2.23], and 1.19 [0.70-2.03].

CONCLUSION

In absolute numbers, we found no difference in all-cause mortality and recurrence in patients with and without MINS. In adjusted Cox regression analyses, the hazard was increased for all-cause mortality, recurrence, and disease-free survival in patients with MINS without reaching statistical significance.

Short-term outcomes following total colectomy for inflammatory bowel disease in Denmark after implementation of laparoscopy: a nationwide population-based study

AIM

A laparoscopic approach to total colectomy (TC) for inflammatory bowel disease (IBD) is being increasingly used, but data on its comparative benefits over open TC are conflicting. The aim of this study was to examine 90-day outcomes following laparoscopic and open TC for IBD in a nationwide cohort after the introduction of laparoscopy.

METHOD

IBD patients undergoing TC in Denmark from 2005 to 2017 were identified from the Danish National Patient Registry. We used Kaplan-Meier methodology to estimate mortality and Cox regression analysis to estimate adjusted mortality rate ratios (aMRRs) and adjusted hazard ratios (aHRs) of reoperation, readmission and intensive care unit (ICU) transfer, comparing patients undergoing laparoscopic versus open TC.

RESULTS

We identified 1095 patients undergoing laparoscopic TC and 1523 patients undergoing open TC. Following emergency TC, 90-day mortality was 2.8% (1.6%-4.9%) after laparoscopic TC and 9.1% (7.0%-11.8%) after open TC. Ninety-day mortality was 0.9% (0.3%-2.5%) after laparoscopic TC and 2.6% (1.5%-4.3%) after open elective TC. The aMRRs associated with laparoscopic TC were 0.45 (95% CI 0.25-0.80) in emergency cases and 0.29 (95% CI 0.10-0.86) in elective cases. Risks of readmission were comparable following laparoscopic versus open TC, both in emergency [aHR = 0.93 (95% CI 0.76-1.15)] and elective [aHR = 0.83 (95% CI 0.68-1.02)] cases, while risks of ICU transfer and reoperation were lower following laparoscopic TC, both in emergency cases [aHR = 0.53 (95% CI 0.35-0.82) and aHR = 0.26 (95% CI 0.15-0.47)] and elective [aHR = 0.58 (95% CI 0.35-0.95) and aHR = 0.37 (95% CI 0.21-0.66)] cases.

CONCLUSION

The introduction of laparoscopic TC for IBD in Denmark was not associated with increased mortality or morbidity. In fact, laparoscopic TC for IBD may be associated with lower short-term mortality and morbidity compared with open TC.

Cardiovascular events after elective colorectal cancer surgery in patients with stage I-III disease with no previous cardiovascular disease

BACKGROUND

The risk of cardiovascular events in patients treated for colorectal cancer is debated due to diverging results in previous studies. Colorectal cancer and cardiovascular disease share several risk factors such as physical inactivity, obesity, and smoking. Information about confounding covariates and follow-up time are therefore essential to address the issue. This study aims to investigate the risk of new-onset cardiovascular events for patients with stage I-III colorectal cancer receiving elective surgery compared to a matched population.

MATERIAL AND METHODS

Using a prospective cohort, we compared cardiovascular events among 876 patients treated with elective surgery for incident stage I-III colorectal cancer diagnosed between January 1st, 2001 and December 31st, 2016 to a cancer-free cohort matched by age, sex, and time since enrollment (N = 3504). Regression analyses were adjusted for lifestyle, cardiovascular risk factors, and comorbidity. Multivariable analyses were used to identify risk factors associated with cardiovascular events in the postoperative (<90 days of elective surgery) and long-term phase (>90 days after elective surgery).

RESULTS

After a median follow-up of 3.9 years, the hazard ratio (HR) for incident heart failure was 1.53 (95% CI 1.02-2.28) among patients operated for colorectal cancer. The postoperative risk of myocardial infarction or angina pectoris was associated with the use of lipid-lowering drugs. Long-term risks of cardiovascular events were ASA-score of III+IV and lipid-lowering drugs with HRs ranging from 2.20 to 15.8. Further, the use of antihypertensive drugs was associated with an HR of 2.09 (95% CI 1.06-4.13) for angina pectoris or acute myocardial infarction. Heart failure was associated with being overweight, diabetes, and anastomosis leakage.

CONCLUSION

We observed an increased hazard of heart failure in patients operated on for stage I-III colorectal cancer compared to cancer-free comparisons. We identified several potential risk factors for cardiovascular events within and beyond 90 days of elective surgery.

Evaluating the efficacy and safety of neoadjuvant pembrolizumab in patients with stage I-III MMR-deficient colon cancer: a national, multicentre, prospective, single-arm, phase II study protocol

INTRODUCTION

Within the last two decades, major advances have been made in the surgical approach for patients with colorectal cancer. However, to this day we face considerable challenges in reducing surgery-related complications and improving long-term oncological outcomes. Unprecedented response rates have been achieved in studies investigating immunotherapy in patients with mismatch repair deficient (dMMR) colorectal cancer. This has raised the question of whether neoadjuvant immunotherapy may change the standard of care for localised dMMR colon cancer and pave the way for organ-sparing treatment.

METHODS AND ANALYSIS

This is an investigator-initiated, multicentre, prospective, single-arm, phase II study in patients with stage I-III dMMR colon cancer scheduled for intended curative surgery. Eighty-five patients will be treated with one dose of pembrolizumab (4 mg/kg) and within 5 weeks will undergo a re-evaluation with an endoscopy and a CT scan-to assess tumour response-before standard resection of the tumour. The primary endpoint is the number of patients with pathological complete response, and secondary endpoints include safety (number and severity of adverse events) and postoperative surgical complications. In addition, we aspire to identify predictive biomarkers that can point out patients that achieve pathological complete response.

ETHICS AND DISSEMINATION

The Regional Committee for Health Research and Ethics and the Danish Medicines Agency have approved this study. The study will be performed according to the Helsinki II declaration. Written informed consent will be obtained from all participants. The results of the study will be submitted to peer-reviewed journals for publication and presented at international congresses.

TRIAL REGISTRATION NUMBER

NCT05662527.

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.

Incidence and clinical predictors of 30-day emergency readmission after colorectal cancer surgery - A nationwide cohort study

AIM

The aim of this study was to investigate the risk and predictors of 30-day emergency readmission and surgical reintervention after discharge from colorectal cancer surgery with curative intent in Denmark.

METHOD

This is a retrospective cohort study using Danish nationwide registry data. We included all patients who underwent colorectal tumour resection with curative intent between 1 January 2005 and 1 December 2018. The primary outcome was 30-day emergency readmission, defined as any emergency hospital visit within 30 days of discharge. Secondary outcomes were 30-day emergency readmission with a minimum duration of 2 days and 30-day emergency readmission including any abdominal procedure. Twenty-three candidate predictors including patient comorbidities, tumour characteristics, surgical treatment and length of stay were evaluated using multivariate logistic regression models. Length of stay was categorized into percentiles and standardized according to year of surgery.

RESULTS

Of the 40 782 patients included in the study, 8360 (20.5%) were readmitted within 30 days of discharge. Median time to readmission was 6 days (interquartile range 2-15 days). A total of 4968 patients (12.2%) were readmitted for at least 2 days, and 793 patients (1.9%) underwent an abdominal procedure during their readmission. The strongest predictors of 30-day readmission were length of stay below the fifth percentile (OR 2.36; P < 0.001) and American Society of Anesthesiologists score IV (OR 2.21; P < 0.001).

CONCLUSION

Emergency readmission is frequent after colorectal cancer surgery with curative intent, and almost 10% of readmitted patients require surgical reintervention. An increased focus on predicting preventable readmissions might facilitate interventions to reduce morbidity and hospital expenses.

Improvements in Survival and Early Retirement Rates - Real-World Evidence on Danish Breast Cancer Patients 2004-2018

Background

Historically, Denmark has had poor survival for cancer patients relative to other western countries with comparable health-care systems. In this study, we examine the long-term cancer impact of a nationwide reform addressing all cancer diagnostics, implemented in 2006. The analyses include patients diagnosed with breast cancer and their spouses (informal caregivers). Patients and their spouses diagnosed before and after the reform were compared. Focus is on the potential impact on overall survival, early retirement, sick leave, unemployment as well as earnings (income).

Methods

In a nationwide retrospective cohort study utilizing the Danish National Patient Register we identified 77,474 breast cancer patients between 1st January 2002 and 31st December 2018. Data was merged with the National Cancer Register, the Central Person Register, the Education Register, the DREAM Register and the Income Register using citizens' personal identification number. Spouses of cancer patients were identified through the Central Person Register. Propensity score matching was applied to match populations before and after the reform. Analyses on matched as well as unmatched populations were performed.

Results

In a matched sample, risk of mortality was reduced by 15% for breast cancer patients diagnosed after the reform. Moreover, there was a 15% reduced risk of early retirement. The patients diagnosed after the reform had reduced income three to five years after diagnosis relative to those diagnosed before the reform, likely due to survival bias and labor market conditions. In an unmatched sample of patients diagnosed two years before or after the reform, mortality was reduced by 7%.

Conclusion

Implementation of the nationwide cancer reform together with advancement in new cancer treatments had a positive impact on survival and reduced risk of early retirement. The results from this study are reassuring that relevant health-care reforms improve cancer outcome.

Identifying Recurrences Among Non-Metastatic Colorectal Cancer Patients Using National Health Data Registries: Validation and Optimization of a Registry-Based Algorithm in a Modern Danish Cohort

Purpose

Colorectal cancer (CRC) recurrence is not routinely recorded in Danish health data registries. Here, we aimed to revalidate a registry-based algorithm to identify recurrences in a contemporary cohort and to investigate the accuracy of estimating the time to recurrence (TTR).

Patients and Methods

We ascertained data on 1129 patients operated for UICC TNM stage I-III CRC during 2012-2017 registered in the CRC biobank at the Department of Molecular Medicine, Aarhus University Hospital, Denmark. Individual-level data were linked with data from the Danish Colorectal Cancer Group database, Danish Cancer Registry, Danish National Registry of Patients, and Danish Pathology Registry. The algorithm identified recurrence based on diagnosis codes of local recurrence or metastases, the receipt of chemotherapy, or a pathological tissue assessment code of recurrence more than 180 days after CRC surgery. A subgroup was selected for validation of the algorithm using medical record reviews as a reference standard.

Results

We found a 3-year cumulative recurrence rate of 20% (95% CI: 17-22%). Manual medical record review identified 80 recurrences in the validation cohort of 522 patients. The algorithm detected recurrence with 94% sensitivity (75/80; 95% CI: 86-98%) and 98% specificity (431/442; 95% CI: 96-99%). The positive and negative predictive values of the algorithm were 87% (95% CI: 78-93%) and 99% (95% CI: 97-100%), respectively. The median difference in TTR (TTR_{Medical_chart}-TTR_algorithm) was -8 days (IQR: -21 to +3 days). Restricting the algorithm to chemotherapy codes from oncology departments increased the positive predictive value from 87% to 94% without changing the negative predictive value (99%).

Conclusion

The algorithm detected recurrence and TTR with high precision in this contemporary cohort. Restriction to chemotherapy codes from oncology departments using department classifications improves the algorithm. The algorithm is suitable for use in future observational studies.

Impact of sociodemographic factors and screening, diagnosis, and treatment strategies on colorectal cancer mortality in Brazil: A 20-year ecological study

Colorectal cancer (CRC) caused 261,060 deaths in Brazil over a 20-year period, with a tendency to increase over time. This study aimed to verify the sociodemographic factors predicting higher mortality caused by CRC and survival rates. Moreover, we aimed to verify whether the performance of screening, diagnostic and treatment procedures had an impact on mortality. Ecological observational study of mortality due to CRC was conducted in Brazil from 2000–2019. The adjustment variable was age, which was used to calculate the age-standardized mortality rate (ASMR). The exposure variables were number of deaths and ASMR. Outcome variables were age-period-cohort, race classification, marital status, geographic region, and screening, diagnostic, and treatment procedures. Age-period-cohort analysis was performed. ANOVA and Kruskal-Wallis test with post hoc tests were used to assess differences in race classification, marital status, and geographic region. Multinomial logistic regression was used to test for interaction among sociodemographic factors. Survival analysis included Kaplan-Meier plot and Cox regression analysis were performed. Multivariate linear regression was used to test prediction using screening, diagnosis, and treatment procedures. In Brazil, mortality from CRC increased after age 45 years. The highest adjusted mortality rates were found among white individuals and in the South of the country (p < 0.05). Single, married, and widowed northern and northeastern persons had a higher risk of death than legally separated southern persons (p < 0.05). Lower survival rates were observed in brown and legally separated individuals and residents from the North (p < 0.05). An increase in first-line chemotherapy and a decrease in second-line chemotherapy were associated with high mortality in the north (p<0.05). In the south, second-line chemotherapy and abdominoperineal rectal resection were associated with high mortality (p < 0.05). Regional differences in sociodemographic factors and clinical procedures can serve as guidelines for adjusting public health policies.

The impact of hepatic steatosis on outcomes of colorectal cancer patients with liver metastases: A systematic review and meta-analysis

Background

It is unclear how hepatic steatosis impacts patient prognosis in the case of colorectal cancer with liver metastases (CRLM). The purpose of this review was to assess the effect of hepatic steatosis on patient survival and disease-free survival (DFS) in the case of CRLM.

Methods

We examined the databases of PubMed, CENTRAL, Embase, Google Scholar, and ScienceDirect for studies reporting outcomes of CRLM patients with and without hepatic steatosis. We performed a random-effects meta-analysis using multivariable adjusted hazard ratios (HR).

Results

Nine studies reporting data of a total of 14,197 patients were included. All patients had undergone surgical intervention. Pooled analysis of seven studies indicated that hepatic steatosis had no statistically significant impact on patient survival in CRLM (HR: 0.92 95% CI: 0.82, 1.04, I² = 82%, p = 0.18). Specifically, we noted that there was a statistically significant improvement in cancer-specific survival amongst patients with hepatic steatosis (two studies; HR: 0.85 95% CI: 0.76, 0.95, I² = 41%, p = 0.005) while there was no difference in overall survival (five studies; HR: 0.97 95% CI: 0.83, 1.13, I² = 78%, p = 0.68). On meta-analysis of four studies, we noted that the presence of hepatic steatosis resulted in statistically significant reduced DFS in patients with CRLM (HR: 1.32 95% CI: 1.08, 1.62, I² = 67%, p = 0.007).

Conclusion

The presence of hepatic steatosis may not influence patient survival in CRLM. However, scarce data is suggestive of poor DFS in CRLM patients with hepatic steatosis. Further prospective studies taking into account different confounding variables are needed to better assess the effect of hepatic steatosis on outcomes of CRLM.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/#searchadvanced], identifier [CRD42022320665].

Trends in rectal cancer incidence, relative survival, and mortality in Denmark during 1978-2018

OBJECTIVE

Rectal cancer is common in developed countries, though incidence varies globally. We assessed time trends in incidence, relative survival and mortality in Denmark.

METHODS

Rectal cancer cases ( N  = 50 461) diagnosed in 1978-2018 were identified in the Danish Cancer Registry. We calculated age-standardized incidence rates, overall and according to sex and age. Average annual percentage changes (AAPC) were estimated using Poisson regression. We estimated 5-year relative survival and evaluated the effect of age, calendar year of diagnosis, sex and stage of disease on mortality using the Cox proportional hazards model.

RESULTS

The incidence of rectal cancer tended to decrease in all age groups and both sexes during 1978-1997, but increased since 1998, more in men (AAPC = 2.05%; 95% CI,1.80; 2.31) than in women (AAPC = 0.99%; 95% CI,0.68; 1.30). It increased in men until 79 years and in women up to 59 years. Mortality decreased over time when adjusting for age, stage and sex. Overall, men had the highest 5-year mortality after adjusting for age, calendar period and stage. Five-year relative survival improved (1978-2018) for all stages. Initially, the overall 5-year relative survival tended to be better for women, but in recent years, it has been similar in both sexes.

CONCLUSION

Incidence of rectal cancer increased in the last two decades, most markedly in women 59 years and younger. Mortality decreased when adjusting for age and stage. Relative survival improved over time more for men than for women, so in recent years, it has been virtually identical in men and women.

Finding Waldo: The Evolving Paradigm of Circulating Tumor DNA (ctDNA)—Guided Minimal Residual Disease (MRD) Assessment in Colorectal Cancer (CRC)

Simple Summary

After the surgical removal of colorectal cancer (CRC), residual cancer cells undetectable by standard blood tests and imaging studies are responsible for cancer recurrence. Currently, chemotherapy is often administered after surgery to eradicate residual cancer cells, a decision guided by clinical and pathologic criteria, which are imprecise. Circulating tumor DNA (ctDNA) consists of DNA fragments in the bloodstream derived from cancer cells, and the presence of ctDNA likely indicates the presence of residual cancer cells. The current article discusses how ctDNA technology can help guide treatment in patients with CRC after curative surgery.

Abstract

Circulating tumor DNA (ctDNA), the tumor-derived cell-free DNA fragments in the bloodstream carrying tumor-specific genetic and epigenetic alterations, represents an emerging novel tool for minimal residual disease (MRD) assessment in patients with resected colorectal cancer (CRC). For many decades, precise risk-stratification following curative-intent colorectal surgery has remained an enduring challenge. The current risk stratification strategy relies on clinicopathologic characteristics of the tumors that lacks precision and results in over-and undertreatment in a significant proportion of patients. Consequently, a biomarker that can reliably identify patients harboring MRD would be of critical importance in refining patient selection for adjuvant therapy. Several prospective cohort studies have provided compelling data suggesting that ctDNA could be a robust biomarker for MRD that outperforms all existing clinicopathologic criteria. Numerous clinical trials are currently underway to validate the ctDNA-guided MRD assessment and adjuvant treatment strategies. Once validated, the ctDNA technology will likely transform the adjuvant therapy paradigm of colorectal cancer, supporting ctDNA-guided treatment escalation and de-escalation. The current article presents a comprehensive overview of the published studies supporting the utility of ctDNA for MRD assessment in patients with CRC. We also discuss ongoing ctDNA-guided adjuvant clinical trials that will likely shape future adjuvant therapy strategies for patients with CRC.

Long-term oncological outcomes in patients undergoing laparoscopic versus open surgery for colon cancer: A nationwide cohort study

AIM

To estimate the effect of laparoscopy versus laparotomy on recurrence status in patients undergoing intended curative resection for stage I-III colon cancer using nationwide data.

METHOD

A retrospective cohort study using prospectively collected nationwide quality assurance data on all patients undergoing elective, intended curative surgery for UICC stage I-III colon cancer in Denmark from 1 January 2010, through 31 December 2013. The association between laparoscopic versus open surgery and recurrence status was investigated using cause-specific hazard and subdistribution hazard models with death from any cause as a competing event.

RESULTS

In total, 4369 patients undergoing elective intended curative surgery for colon cancer were included in the analysis. Overall, 3243 (74.2%) patients underwent laparoscopic surgery. During a median follow-up time of 84 months, 1191 (27.2%) patients experienced recurrence, and 1304 (29.8%) patients died. The cause-specific hazard of recurrence following laparoscopic versus open surgery was HR_CS  = 1.08, 95% CI: 0.90-1.28, p = 0.422. The subdistribution hazard of recurrence following laparoscopic versus open surgery was HR_SD =0.99, 95% CI: 0.84-1.16, p = 0.880.

CONCLUSION

Elective laparoscopic resection for UICC stage I-III colon cancer is oncologically safe and comparable with open resection. These results confirm the external validity of previous RCTs in everyday clinical settings.

Concurrent use of statins and neoadjuvant chemoradiotherapy for rectal cancer: a systematic review and meta-analysis

PURPOSE

Statins are used primarily in patients with cardiovascular disease. More recently, they have demonstrated benefit in oncology patients. In vitro models have shown decreased rectal tumor cell viability in cells receiving chemoradiation and statin therapy. In vivo models have been less clear. This study aims to elucidate the impact of concurrent use of statins on the efficacy of neoadjuvant therapy for rectal cancer.

METHODS

Search of Medline, EMBASE, and CENTRAL was performed. Articles were included if they reported complete pathological response (pCR), long-term oncologic outcomes, or chemoradiotherapy-induced toxicity in patients with rectal cancer receiving concurrent statin and neoadjuvant therapy. A pairwise meta-analyses was performed using inverse variance random effects.

RESULTS

From 1564 citations, six studies with 726 patients on statin therapy (24.5% female, age: 63.6 years) and 1863 patients not on statin therapy (35.6% female, age: 60.9 years) were included. There was no significant difference in pCR rate between patients on statin therapy and patients not on statin therapy (RR 1.23, 95%CI 0.98-1.54, p = 0.08). Similarly, no difference existed between groups in long-term oncologic outcomes (5-year overall survival: RR 1.03, 95%CI 0.86-1.24, p = 0.75; 5-year disease-free survival: RR 1.04, 95%CI 0.85-1.26, p = 0.73). Chemoradiotherapy-induced toxicities were similar between groups.

CONCLUSION

The concurrent use of statin and neoadjuvant therapy did not significantly impact short- or long-term oncologic outcomes in patients with rectal cancer. Yet, despite pooling of data, this study remained inadequately powered. Larger, prospective studies are required to further elucidate the impact of statins on patients undergoing neoadjuvant therapy for rectal cancer.

Accurate population-based model for individual prediction of colon cancer recurrence

BACKGROUND

Prediction models are useful tools in the clinical management of colon cancer patients, particularly when estimating the recurrence rate and, thus, the need for adjuvant treatment. However, the most used models (MSKCC, ACCENT) are based on several decades-old patient series from clinical trials, likely overestimating the current risk of recurrence, especially in low-risk groups, as outcomes have improved over time. The aim was to develop and validate an updated model for the prediction of recurrence within 5 years after surgery using routinely collected clinicopathologic variables.

MATERIAL AND METHODS

A population-based cohort from the Swedish Colorectal Cancer Registry of 16,134 stage I-III colon cancer cases was used. A multivariable model was constructed using Cox proportional hazards regression. Three-quarters of the cases were used for model development and one quarter for internal validation. External validation was performed using 12,769 stage II-III patients from the Norwegian Colorectal Cancer Registry. The model was compared to previous nomograms.

RESULTS

The nomogram consisted of eight variables: sex, sidedness, pT-substages, number of positive and found lymph nodes, emergency surgery, lymphovascular and perineural invasion. The area under the curve (AUC) was 0.78 in the model, 0.76 in internal validation, and 0.70 in external validation. The model calibrated well, especially in low-risk patients, and performed better than existing nomograms in the Swedish registry data. The new nomogram's AUC was equal to that of the MSKCC but the calibration was better.

CONCLUSION

The nomogram based on recently operated patients from a population registry predicts recurrence risk more accurately than previous nomograms. It performs best in the low-risk groups where the risk-benefit ratio of adjuvant treatment is debatable and the need for an accurate prediction model is the largest.

Influence of age on surgical treatment and postoperative outcomes of patients with colorectal cancer in Denmark and Yorkshire, England

AIM

Denmark and Yorkshire are demographically similar and both have undergone changes in their management of colorectal cancer to improve outcomes. The differential provision of surgical treatment, especially in the older age groups, may contribute to the magnitude of improved survival rates. This study aimed to identify differences in the management of colorectal cancer surgery and postoperative outcomes according to patient age between Denmark and Yorkshire.

METHOD

This was a retrospective population-based study of colorectal cancer patients diagnosed in Denmark and Yorkshire between 2005 and 2016. Proportions of patients undergoing major surgical resection, postoperative mortality and relative survival were compared between Denmark and Yorkshire across several age groups (18-59, 60-69, 70-79 and ≥80 years) and over time.

RESULTS

The use of major surgical resection was higher in Denmark than in Yorkshire, especially for patients aged ≥80 years (70.5% versus 50.5% for colon cancer, 49.3% versus 38.1% for rectal cancer). Thirty-day postoperative mortality for Danish patients aged ≥80 years was significantly higher than that for Yorkshire patients with colonic cancer [OR (95% CI) = 1.22 (1.07, 1.38)] but not for rectal cancer or for 1-year postoperative mortality. Relative survival significantly increased in all patients aged ≥80 years except for Yorkshire patients with colonic cancer.

CONCLUSION

This study suggests that there are major differences between the management of elderly patients with colorectal cancer between the two populations. Improved selection for surgery and better peri- and postoperative care in these patients appears to improve long-term outcomes, but may come at the cost of a higher 30-day mortality.

Routine CT evaluation of central vascular ligation in patients undergoing complete mesocolic excision for sigmoid colon cancer

AIM

Objective and reproducible quality measures of complete mesocolic excision (CME) for colon cancer are not currently available. This study aimed to measure the inferior mesenteric stump length following CME for sigmoid colon cancer and explore surgical, pathological and oncological outcomes in patients with a stump length of <10 mm vs. ≥10 mm.

METHOD

This was a single-centre, retrospective cohort study including patients undergoing minimally invasive surgery for sigmoid colon cancer between May 2013 and May 2015. Follow-up CT scans were reviewed, and a vascular stump cut-off of <10 mm for adequate central ligation of the inferior mesenteric artery was applied. Differences in perioperative, histopathological and oncological outcome parameters (overall, disease-free and recurrence-free survival) were explored between <10 mm vs. ≥10 mm groups.

RESULTS

A total of 127 patients (43% female) with a median age of 68 years were included. The median follow-up time was 68 months. CT measurements showed good interrater agreement (90% absolute agreement) and reliability among raters (kappa = 0.77, 95% CI 0.53-1.00, p < 0.001). A stump length ≥10 mm was associated with longer operating time (150 vs. 180 min, p = 0.021), intramesocolic resection (p = 0.008), and a shorter distance from the bowel wall to vascular tie (120 vs. 102 mm, p = 0.005).

CONCLUSION

An arterial stump length ≥10 mm in sigmoid resection for colon cancer was associated with key clinical quality measures. Measurement of arterial stump length using routine follow-up CT may serve as a quality indicator of vascular ligation in CME surgery.

Completeness and accuracy of the registration of recurrences in the Swedish Colorectal Cancer Registry (SCRCR) and an update of recurrence risk in colon cancer

BACKGROUND

The completeness and accuracy of the registration of synchronous metastases and recurrences in the Swedish Colorectal Cancer Registry has not been investigated. Knowing how accurate these parameters are in the registry is a prerequisite to adequately measure the current recurrence risk.

METHODS

All charts for patients diagnosed with stage I-III colorectal cancer (CRC) in two regions were reviewed. In one of the regions, all registrations of synchronous metastases were similarly investigated. After the database had been corrected, recurrence risk in colon cancer was calculated stratified by risk group as suggested by ESMO in 2020.

RESULTS

In patients operated upon more than five years ago (N = 1235), there were 20 (1.6%) recurrences not reported. In more recent patients, more recurrences were unreported (4.0%). Few synchronous metastases were wrongly registered (3.6%) and, likewise, few synchronous metastases were not registered (about 1%). The five-year recurrence risk in stage II was 6% for low-risk, 11% for intermediate risk, and 23% for high-risk colon cancer patients. In stage III, it was 25% in low- and 45% in high-risk patients. Incorporation of risk factors in stage III modified the risks substantially even if this is not considered by ESMO. Adjuvant chemotherapy lowered the risk in stage III but not to any relevant extent in stage II.

CONCLUSION

The registration of recurrences in the registry after 5 years is accurate to between 1 and 2% but less accurate earlier. A small number of unreported recurrences and falsely reported recurrences were discovered in the chart review. The recurrence risk in this validated and updated patient series matches what has been recently reported, except for the risk of recurrence in stage II low risk colon cancers which seem to be even a few percentage points lower (6 vs. 9%).

Prediction of 90-day mortality after surgery for colorectal cancer using standardized nationwide quality-assurance data

Background

Personalized risk assessment provides opportunities for tailoring treatment, optimizing healthcare resources and improving outcome. The aim of this study was to develop a 90-day mortality-risk prediction model for identification of high- and low-risk patients undergoing surgery for colorectal cancer.

Methods

This was a nationwide cohort study using records from the Danish Colorectal Cancer Group database that included all patients undergoing surgery for colorectal cancer between 1 January 2004 and 31 December 2015. A least absolute shrinkage and selection operator logistic regression prediction model was developed using 121 pre- and intraoperative variables and internally validated in a hold-out test data set. The accuracy of the model was assessed in terms of discrimination and calibration.

Results

In total, 49 607 patients were registered in the database. After exclusion of 16 680 individuals, 32 927 patients were included in the analysis. Overall, 1754 (5.3 per cent) deaths were recorded. Targeting high-risk individuals, the model identified 5.5 per cent of all patients facing a risk of 90-day mortality exceeding 35 per cent, corresponding to a 6.7 times greater risk than the average population. Targeting low-risk individuals, the model identified 20.9 per cent of patients facing a risk less than 0.3 per cent, corresponding to a 17.7 times lower risk compared with the average population. The model exhibited discriminatory power with an area under the receiver operating characteristics curve of 85.3 per cent (95 per cent c.i. 83.6 to 87.0) and excellent calibration with a Brier score of 0.04 and 32 per cent average precision.

Conclusion

Pre- and intraoperative data, as captured in national health registries, can be used to predict 90-day mortality accurately after colorectal cancer surgery.

Hepatic Steatosis Predicts Higher Incidence of Recurrence in Colorectal Cancer Liver Metastasis Patients

Purpose: Colorectal liver metastasis (CRLM) is the major cause of death due to colorectal cancer. Although great efforts have been made in treatment of CRLM, about 60–70% of patients will develop hepatic recurrence. Hepatic steatosis was reported to provide fertile soil for metastasis. However, whether hepatic steatosis predicts higher incidence of CRLM recurrence is not clear. Therefore, we aimed to determine the role of hepatic steatosis in CRLM recurrence in the present study.

Methods: Consecutive CRLM patients undergoing curative treatment were retrospectively enrolled and CT liver-spleen attenuation ratio was used to detect the presence of hepatic steatosis. In patients with hepatic steatosis, we also detected the presence of fibrosis. Besides, a systematic literature search was performed to do meta-analysis to further analyze the association between hepatic steatosis and CRLM recurrence.

Results: A total of 195 eligible patients were included in our center. Patients with hepatic steatosis had a significantly worse overall (P = 0.0049) and hepatic recurrence-free survival (RFS) (P = 0.0012). Univariate and multivariate analysis confirmed its essential role in prediction of RFS. Besides, hepatic fibrosis is associated with worse overall RFS (P = 0.039) and hepatic RFS (P = 0.048). In meta-analysis, we included other four studies, with a total of 1,370 patients in the case group, and 3,735 patients in the control group. The odds ratio was 1.98 (95% CI: 1.25–3.14, P = 0.004), indicating that patients with steatosis had a significantly higher incidence of CRLM recurrence.

Conclusion: In summary, patients with hepatic steatosis had a significantly worse overall and hepatic RFS and it's associated with higher incidence of CRLM recurrence.

Emergency Laparotomy in Denmark: A Nationwide Descriptive Study

BACKGROUND

The term 'emergency open abdominal surgery' covers a range of common procedures with high complication and mortality risks; however, previous studies have not included descriptive analyses of the patients undergoing the procedures. The aim of this study is to present a nationwide description of all patients who undergo an emergency bowel resection, ostomy placement or drainage involving laparotomy at Danish hospitals and to report the 30- and 365-day mortality risks.

METHOD

We identified all of the patients in the Danish National Patient Register aged 18 + who underwent emergency open abdominal surgery in the form of a laparotomy during the period 2003-14. Using Poisson and logistic regression models, we analyzed incidence rates and mortality risk.

RESULT

The sample consisted of 15,680 patients, with an overall open abdominal surgery incidence rate of 30.4 cases per 100,000 person-years. The 30-day mortality risk was 19.3% for both sexes, and increased with age (at 80-89, mortality risk was 39.4% for males and 34.5% for females). The 30-day mortality risk fell by 5.4% during the study period, from 22.2% to 16.7%.

CONCLUSION

Open abdominal surgery is a common, high-risk procedure with a high incidence rate and mortality risk, especially for elderly patients. The incidence rate and mortality risk fell during the period studied. In Denmark, there is no standard post-discharge care program for patients who undergo emergency laparotomies. Our results support the need to investigate standardized post-operative follow-up and rehabilitation plans to reduce mortality.

Nurse-led standardized intervention for low anterior resection syndrome. A population-based pilot study

AIM

Our aim was to study the implementation of the low anterior resection syndrome (LARS) score in a clinical setting and to evaluate a nurse-led standardized intervention for bowel dysfunction following rectal cancer surgery.

METHOD

All patients who underwent curatively intended, restorative rectal cancer resection in a single centre between 2012 and 2016 were screened using the LARS score. At clinical follow-up, patients with major LARS were offered treatment in a nurse-led clinic. Data were retrospectively collected from patients' electronic medical records.

RESULTS

In total, 190 out of 286 (66%) patients were screened with the LARS score of whom 89 had major LARS. A total of 86 patients requested treatment for their bowel dysfunction and the majority obtained acceptable function after nurse-led optimized conservative treatment. Seventeen patients went on to transanal irrigation, and seven patients were treated with biofeedback. Five patients were referred for surgery, three for gastroenterological evaluation. After treatment in the clinic, patients achieved a statistically significant decrease in median LARS score from 37 (interquartile range 34-39) to 31 (interquartile range 23-34) (P < 0.001), and the prevalence of major LARS fell from 95% to 53% (P < 0.001).

CONCLUSION

Screening for LARS was not optimal as one-third of patients were not screened. The majority of patients with major LARS requested treatment for their symptoms and could be successfully treated with standardized interventions managed in a nurse-led setting.

Improvement of Survival over Time for Colorectal Cancer Patients: A Population-Based Study

Purpose: In this study, we analyzed the mortality and survival of colorectal cancer patients in Lithuania. Methods: This was a national cohort study. Population-based data from the Lithuanian Cancer Registry and period analyses were collected. Overall, 20,980 colorectal cancer patients were included. We examined the changes in colorectal cancer mortality and survival rates between 1998 and 2012 according to cancer anatomical sub-sites and stages. We calculated the 5-year relative survival estimates using period analysis. Results: Overall, 20,980 colorectal cancer cases reported from 1998 to 2012 were included in the study. The total number of newly diagnosed colorectal cancers increased from 1998–2002 to 2008–2012 by 12.1%. The highest number of colorectal cancers was localized and increased from 33.9% to 42.0%. The number of cancers with regional metastases and advanced cancers decreased by 11.1% and 15.5%, respectively. An increased number of new cases was observed for almost all colon cancer sub-sites. The overall 5-year relative survival rate increased from 37.9% in 1998–2002 to 51.5% in 2008–2012. We showed an increase in survival rates for all stages and all sub-sites. In the most recent period, patients with a localized disease had a 5-year survival rate of 78.6%, while survival estimates for advanced cancer patients remained low at 6.6%. Conclusion: Although survival rates variated in colorectal cancer patients according to disease stages and sub-sites, we showed increased survival rates for all patients.

Recurrence Risk after Radical Colorectal Cancer Surgery-Less Than before, But How High Is It?

Simple Summary

Evidence indicates that recurrence risk after colon cancer today is less than it was when trials performed decades ago showed that adjuvant chemotherapy reduces the risk and prolong disease-free and overall survival. After rectal cancer surgery, local recurrence rates have decreased but it is unclear if systemic recurrences have. After a systematic review of available literature reporting recurrence risks after curative colorectal cancer surgery we report that the risks are lower today than they were in the past and that this risk reduction is not solely ascribed to the use of adjuvant therapy. Adjuvant therapy always means overtreatment of many patients, already cured by the surgery. Fewer recurrences mean that progress in the care of these patients has happened but also that the present guidelines giving recommendations based upon old data must be adjusted. The relative gains from adding chemotherapy are not altered, but the absolute number of patients gaining is less.

Abstract

Adjuvant chemotherapy aims at eradicating tumour cells sometimes present after radical surgery for a colorectal cancer (CRC) and thereby diminish the recurrence rate and prolong time to recurrence (TTR). Remaining tumour cells will lead to recurrent disease that is usually fatal. Adjuvant therapy is administered based upon the estimated recurrence risk, which in turn defines the need for this treatment. This systematic overview aims at describing whether the need has decreased since trials showing that adjuvant chemotherapy provides benefits in colon cancer were performed decades ago. Thanks to other improvements than the administration of adjuvant chemotherapy, such as better staging, improved surgery, the use of radiotherapy and more careful pathology, recurrence risks have decreased. Methodological difficulties including intertrial comparisons decades apart and the present selective use of adjuvant therapy prevent an accurate estimate of the magnitude of the decreased need. Furthermore, most trials do not report recurrence rates or TTR, only disease-free and overall survival (DFS/OS). Fewer colon cancer patients, particularly in stage II but also in stage III, today display a sufficient need for adjuvant treatment considering the burden of treatment, especially when oxaliplatin is added. In rectal cancer, neo-adjuvant treatment will be increasingly used, diminishing the need for adjuvant treatment.

Mortality and complication management after surgery for colorectal cancer depending on the DKG minimum amounts for hospital volume

BACKGROUND

The German Cancer Society ("Deutsche Krebsgesellschaft"; DKG) certifies on a volunteer base colorectal cancer centers based on, among other things, minimum operative amounts (at least 30 oncological colon cancer resections and 20 oncological rectal cancer resections per year). In this work, nationwide hospital mortality and death after documented complications ('Failure to Rescue' = FtR) were evaluated depending on the fulfillment of the minimum amounts.

METHODS

This is a retrospective analysis of the nationwide hospital billing data (DRG data, 2012-2017). Categorization is based on the DKG minimum quantities (fully, partially or not fulfilled).

RESULTS

Of 287,227 patients analyzed, 56.5% were operated in centers that met the DKG minimum amounts. The overall hospital mortality rate was 5.0%. In centers which met the minimum quantities, it was significantly lower (4.3%) than in hospitals which partially (5.7%) or not (6.2%) met the minimum quantities. The risk-adjusted hospital mortality rate for patients in hospitals who meet the minimum amount was 20% lower (OR 0.80; 95% CI [0.74-0.87], p < 0.001). For complications, both surgical and non-surgical, there was an unadjusted and adjusted lower FtR in hospitals that met the minimum amounts (e.g. anastomotic leak: 11.2% vs. 15.6%, p < 0.001; pulmonary artery embolism 21.3% vs. 28.2%, p = 0.001).

CONCLUSION

There is a 1/3 lower mortality and FtR rate after surgery for a colon or rectal cancer in centers fulfilling the DKG minimum amounts. The presented data implicate that there is an urgent need for a nationwide centralization program.

Metastasis directed treatment of brain metastases from colorectal cancer - a Danish population-based cohort study

Background: Brain metastases (BMs) are an uncommon presentation of metastatic colorectal cancer (mCRC) with reported incidence of about 2-4%. Today, there is an increased awareness towards a metastasis directed treatment approach with either surgical resection, stereotactic radiotherapy (SRT) or both. We examined patient characteristics and survival for patients treated with a localized modality for BM from CRC in a nationwide population-based study.Methods: A registry-based cohort study of all patients with a resected primary colorectal cancer and localized treatment of BM during 2000-2013. We computed descriptive statistics and analysed overall survival by the Kaplan-Meier method and Cox regression.Results: A total of 38131 patients had surgery for a primary CRC and 235 patients were recorded with a metastasis directed treatment for BM, comprising resection alone (n = 158), SRT alone (n = 51) and combined resection and SRT (n = 26). Rectal primary tumor (48.9% vs. 36.2%, p < .001) and lung metastasectomy (11.9 vs 2.8%, p < .001) were more frequent in the BM group. The median survival of patients receiving localized treatment for BM was 9.6 months (95% confidence interval (CI) 7.2-10.8). The 1- and 5-year overall survival were 41.7% (95% CI 35-48%) and 11.2% (95% CI 6.9-16.3%). In multivariate analysis, nodal stage was associated with increased mortality with a hazard ratio of 1.63 (95% CI 1.07-2.60, p = .03) for N2 stage with reference to N0.Conclusion: We report a median overall survival of 9.6 months for patients receiving localized treatment for BM from CRC. Lung metastases and rectal primary tumor are more common in the population treated for BM.

Demand for weekend outpatient chemotherapy among patients with cancer in Japan

BACKGROUND

Advanced cancer therapeutics have improved patient survival, leading to an increase in the number of patients who require long-term outpatient chemotherapy. However, the available schedule options for chemotherapy are generally limited to traditional business hours.

METHOD

In 2017, we surveyed 721 patients with cancer in Okayama, Japan, regarding their preferences for evening and weekend (Friday evening, Saturday, and Sunday) chemotherapy appointments.

RESULTS

A preference for evening and weekend appointment options was indicated by 37% of the respondents. Patients who requested weekend chemotherapy were younger, female, with no spouse or partner, living alone, employed, and currently receiving treatment. Among these factors, age and employment status were significantly associated with a preference for weekend chemotherapy, according to multivariate analysis.

CONCLUSION

Our findings reveal a demand for evening and weekend outpatient chemotherapy, especially among young, employed patients.

The Validity of Registered Synchronous Peritoneal Metastases from Colorectal Cancer in the Danish Medical Registries

Introduction

Treatment options for peritoneal metastases (PM) from colorectal cancer (CRC) have increased, their efficiency should be monitored. For this purpose, register-based data on PM can be used, if valid.

Purpose

We aimed to evaluate the completeness and positive predictive value (PPV) of synchronous peritoneal metastases (S-PM) registered among CRC patients in the Danish National Patient Register (DNPR) and/or the Danish National Pathology Register (the DNPatR) using the Danish Colorectal Cancer Group database (DCCG) as a reference.

Patients and Methods

We identified Danish patients with newly diagnosed primary CRC in the DCCG during 2014–2015. S-PM were routinely registered in the DCCG. We excluded patients with non-CRC cancers and identified S-PM using all three registries. We estimated the completeness and the PPV of registered S-PM in the DNPR, the DNPatR and the DNPR and/or the DNPatR (DNPR/DNPatR) in combination using the DCCG as the reference. We stratified by age, gender, WHO performance status, tumour location and distant metastases to liver and/or lungs.

Results

We identified 9142 patients with CRC in DCCG. In DCCG, 366 patients were registered with S-PM, among whom 213 in DCCG only, whereas 153 in DCCG and in at least one of DNPR and/or DNPatR. In DNPR/DNPatR, S-PM was registered with a completeness of 42% [95% CI: 37–47] and a PPV of 60% [95% CI: 54–66]. In the DNPR only, the completeness was 32% [95% CI: 27–37] and the PPV 57% [95% CI: 50–64]. The completeness in the DNPatR was 19% [95% CI: 15–23] and the PPV was 76% [95% CI: 68–85]. In the DNPR/DNPatR patients aged <60 years (57% [95% CI: 46–69]), patients with WHO performance status 0 (46% [95% CI: 37–54]) and patients with no distant metastases (58% [95% CI: 50–65]) were registered with a higher completeness.

Conclusion

Our algorithm demonstrates that the DNPR/DNPatR captures less than half of CRC patients with S-PM. Potential candidates for curative treatment options are registered with a higher completeness. Clinicians should be encouraged to register the presence of S-PM to increase the validity of register-based S-PM data.

How Soon Should Patients With Colon Cancer Undergo Definitive Resection?

BACKGROUND

Timing of surgery has been shown to affect outcomes in many forms of cancer, but definitive national data do not exist to determine the effect of time to surgery on survival in colon cancer.

OBJECTIVE

This study aimed to determine whether a delay in definitive surgery in colon cancer significantly affects survival.

DATA SOURCES

A retrospective cohort study using 2 independent population-based databases, The Surveillance, Epidemiology, and End Results Medicare-linked database and the National Cancer Database, was performed.

STUDY SELECTION

All patients had American Joint Committee on Cancer stage 1 through 3 colon cancer. Patients were more than 18 years of age in the National Cancer Database cohort and older than 66 years of age in the Medicare cohort. Patients had a minimum of 3 years of follow-up.

MAIN OUTCOME MEASURES

The main outcome was overall survival as a function of time between diagnosis and surgery in 4 intervals (1-2, 3-4, 5-6, >6 weeks).

RESULTS

The Medicare cohort demonstrated an adjusted 5-year survival of 8% to 14% higher in patients with a surgical delay between 3 and 6 weeks, with significantly lower hazard ratios in that interval. The National Cancer Database cohort demonstrated an adjusted 5-year survival of 9% to 16% higher in patients with surgery 3 to 6 weeks after diagnosis, with comparatively similar improvements in survival hazard.

LIMITATIONS

Because this was a retrospective study of administrative databases, with Medicare data limited to billing data, the causality of outcomes must be interpreted with caution.

CONCLUSIONS

The ideal timing of definitive resection in colon cancer is between 3 and 6 weeks after initial diagnosis. All efforts should be made for patients to obtain definitive surgery within this interval to achieve a modest but significant improvement in overall survival. See Video Abstract at http://links.lww.com/DCR/B76. ¿CUÁNDO DEBEN SOMETERSE LOS PACIENTES CON CÁNCER DE COLON A UNA RESECCIÓN DEFINITIVA?: Se ha demostrado que el momento de la cirugía afecta los resultados en muchas formas de cáncer, pero no existen datos nacionales definitivos para determinar el efecto del tiempo hasta la cirugía en la supervivencia en el cáncer de colon.Determinar si un retraso en la cirugía definitiva en el cáncer de colon afecta significativamente la supervivencia.Un estudio de cohorte retrospectivo que utiliza dos bases de datos independientes basadas en la población; Se realizó la base de datos vinculada a la vigilancia, la epidemiología y los resultados finales y la base de datos nacional del cáncer.Pacientes con cáncer de colon en estadíos 1 a 3 del Comité Estadounidense Conjunto sobre el Cáncer. Los pacientes tenían más de 18 años en la cohorte de la National Cancer Database y más de 66 años en la cohorte de Medicare. Los pacientes tuvieron un mínimo de 3 años de seguimiento.El resultado principal fue la supervivencia general en función del tiempo entre el diagnóstico y la cirugía en 4 intervalos (1-2, 3-4, 5-6, y mas de 6 semanas).La cohorte de Medicare demostró una supervivencia ajustada de 5 años de 8 a 14% más en pacientes con un retraso quirúrgico entre 3 a 6 semanas, con razones de riesgo significativamente más bajas en ese intervalo. La cohorte de la National Cancer Database demostró una supervivencia ajustada a 5 años de 9 a 16% más en pacientes con cirugía de 3 a 6 semanas después del diagnóstico, con mejoras comparativamente similares en el riesgo de supervivencia.Dado que este fue un estudio retrospectivo de bases de datos administrativas, con datos de Medicare limitados a datos de facturación, la causalidad de los resultados debe interpretarse con precaución.El momento ideal para la resección definitiva en el cáncer de colon es entre tres y seis semanas después del diagnóstico inicial. Se deben hacer todos los esfuerzos para que los pacientes obtengan una cirugía definitiva dentro de este intervalo para lograr una mejora modesta pero significativa en la supervivencia general. Consulte Video Resumen en http://links.lww.com/DCR/B76.

Overall risk and risk factors for metachronous peritoneal metastasis after colorectal cancer surgery: a nationwide cohort study

Background

This study aimed to identify the cumulative incidence and risk factors of metachronous peritoneal metastasis (M‐PM) from colorectal cancer in patients who had intended curative treatment.

Methods

Patients with colorectal cancer were identified using the Danish Colorectal Cancer Group database for 2006–2015. The Danish Pathology Registry and the Danish National Patient Registry were used to identify M‐PM to 2017. Risk factors were estimated by multivariable absolute risk regression, treating death and other cancers as competing risks. Overall risk and risk differences (RDs) were estimated at 1, 3 and 5 years.

Results

In 22 586 patients with colorectal cancer, the overall risk of M‐PM was reported to be 0·9 (95 per cent c.i. 0·8 to 1·0) per cent at 1 year, 1·9 (1·8 to 2·1) per cent at 3 years and 2·2 (2·0 to 2·4) per cent at 5 years. Advanced tumour category ((y)pT4 versus (y)pT1) increased the RD of both M‐PM (2·9 (95 per cent c.i. 2·1 to 3·7) at 1 year and 6·0 (4·9 to 7·2) at 3 years) and lymph node involvement ((y)pN2 versus (y)pN0) (2·5 (1·8 to 3·2) at year and 4·3 (3·2 to 5·3) at 3 years). No further increase in risk was observed at 5 years. In a subanalysis, tumour‐involved resection margin (R1 versus R0) was associated with M‐PM with a RD of 3·9 (1·6 to 6·2) at 1 year and 5·9 (2·6 to 9·3) at 3 years.

Conclusion

The overall risk of M‐PM in patients with colorectal cancer is low, but is increased in advanced T and N status. Follow‐up of at least 3 years after colorectal cancer surgery may be necessary, given the potential curative treatment of early diagnosed M‐PM.

Overall treatment outcome - analysis of long-term results of rectal cancer treatment on the basis of a new parameter

INTRODUCTION

Outcomes of rectal cancer treatment depend on preoperative staging and the effectiveness of treatments. According to disease staging, different variants of combined therapy (surgery, chemo- and radiotherapy) are used. Available parameters such as overall survival rates and disease- free survival rates as well as the presence of recurrence are inaccurate and should be jointly considered.

MATERIAL AND METHODS

Data from 138 patients with rectal cancer (I-III WHO), who were radically operated on in the period 2001-2004 in Bydgoszcz Oncology Centre were analysed. Among this group 84 patients were radically operated on one week after preoperative radiotherapy 5 × 5 Gy (sRT). We established a new parameter, the overall treatment outcome (OTO), based on the finding that there was no recurrence (local recurrence, distant metastases) of the disease within 5 years, which is generally considered a good result for the treatment of rectal cancer.

RESULTS

Among all patients (n = 138) and patients following sRT (n = 84) 7.4%...5.9% local recurrence and 24%...29% distant metastases were observed in 5-year follow-up. Recurrence was found in 30% and 31% of patients, respectively. Analysis of results on the basis of the OTO parameter demonstrated that among all groups of patients a worse treatment outcome is related to the number of lymph nodes involved, pN, pT, cancer stage (WHO) and to pN and patient age in the sRT group (p < 0.005).

CONCLUSIONS

In using a combined therapy, it is possible to optimise rectal cancer treatment outcomes. The OTO parameter is a useful tool for defining these results of cancer combination treatment.

Factors influencing harmonized health data collection, sharing and linkage in Denmark and Switzerland: A systematic review

INTRODUCTION

The digitalization of medicine has led to a considerable growth of heterogeneous health datasets, which could improve healthcare research if integrated into the clinical life cycle. This process requires, amongst other things, the harmonization of these datasets, which is a prerequisite to improve their quality, re-usability and interoperability. However, there is a wide range of factors that either hinder or favor the harmonized collection, sharing and linkage of health data.

OBJECTIVE

This systematic review aims to identify barriers and facilitators to health data harmonization-including data sharing and linkage-by a comparative analysis of studies from Denmark and Switzerland.

METHODS

Publications from PubMed, Web of Science, EMBASE and CINAHL involving cross-institutional or cross-border collection, sharing or linkage of health data from Denmark or Switzerland were searched to identify the reported barriers and facilitators to data harmonization.

RESULTS

Of the 345 projects included, 240 were single-country and 105 were multinational studies. Regarding national projects, a Swiss study reported on average more barriers and facilitators than a Danish study. Barriers and facilitators of a technical nature were most frequently reported.

CONCLUSION

This systematic review gathered evidence from Denmark and Switzerland on barriers and facilitators concerning data harmonization, sharing and linkage. Barriers and facilitators were strictly interrelated with the national context where projects were carried out. Structural changes, such as legislation implemented at the national level, were mirrored in the projects. This underlines the impact of national strategies in the field of health data. Our findings also suggest that more openness and clarity in the reporting of both barriers and facilitators to data harmonization constitute a key element to promote the successful management of new projects using health data and the implementation of proper policies in this field. Our study findings are thus meaningful beyond these two countries.

Regional multidisciplinary team intervention programme to improve colorectal cancer outcomes: study protocol for the Yorkshire Cancer Research Bowel Cancer Improvement Programme (YCR BCIP)

INTRODUCTION

Although colorectal cancer outcomes in England are improving, they remain poorer than many comparable countries. Yorkshire Cancer Research has, therefore, established a Bowel Cancer Improvement Programme (YCR BCIP) to improve colorectal cancer outcomes within Yorkshire and Humber, a region representative of the nation. It aims to do this by quantifying variation in practice, engaging with the colorectal multidisciplinary teams (MDTs) to understand this and developing educational interventions to minimise it and improve outcomes.

METHODS AND ANALYSIS

Initially, routine health datasets will be used to quantify variation in the demographics, management and outcomes of patients across the Yorkshire and Humber region and results presented to MDTs. The YCR BCIP is seeking to supplement these existing data with patient-reported health-related quality of life information (patient-reported outcome measures, PROMs) and tissue sample analysis. Specialty groups (surgery, radiology, pathology, clinical oncology, medical oncology, clinical nurse specialists and anaesthetics) have been established to provide oversight and direction for their clinical area within the programme, to review data and analysis and to develop appropriate educational initiatives.

ETHICS AND DISSEMINATION

The YCR BCIP is aiming to address the variation in practice to significantly improve colorectal cancer outcomes across the Yorkshire and Humber region. PROMs and tissue sample collection and analysis will help to capture the information required to fully assess care in the region. Engagement of the region's MDTs with their data will lead to a range of educational initiatives, studies and clinical audits that aim to optimise practice across the region.

Nationwide cohort study of the impact of education, income and social isolation on survival after acute colorectal cancer surgery

Background

Acute colorectal cancer surgery has been associated with a high postoperative mortality. The primary aim of this study was to examine the association between socioeconomic position and the likelihood of undergoing acute versus elective colorectal cancer surgery. A secondary aim was to determine 1‐year survival among patients treated with acute surgery.

Methods

All patients who had undergone a surgical procedure according to the Danish Colorectal Cancer Group (DCCG.dk) database, or who were registered with stent or diverting stoma in the National Patient Register from 2007 to 2015, were reviewed. Socioeconomic position was determined by highest attained educational level, income, urbanicity and cohabitation status, obtained from administrative registries. Co‐variables included age, sex, year of surgery, Charlson Co‐morbidity Index score, smoking status, alcohol consumption, BMI, stage and tumour localization. Logistic regression analysis was performed to determine the likelihood of acute colorectal cancer surgery, and Kaplan–Meier and Cox proportional hazards regression methods were used for analysis of 1‐year overall survival.

Results

In total, 35 661 patients were included; 5310 (14·9 per cent) had acute surgery. Short and medium education in patients younger than 65 years (odds ratio (OR) 1·58, 95 per cent c.i. 1·32 to 1·91, and OR 1·34, 1·15 to 1·55 respectively), low income (OR 1·12, 1·01 to 1·24) and living alone (OR 1·35, 1·26 to 1·46) were associated with acute surgery. Overall, 40·7 per cent of patients died within 1 year of surgery. Short education (hazard ratio (HR) 1·18, 95 per cent c.i. 1·03 to 1·36), low income (HR 1·16, 1·01 to 1·34) and living alone (HR 1·25, 1·13 to 1·38) were associated with reduced 1‐year survival after acute surgery.

Conclusion

Low socioeconomic position was associated with an increased likelihood of undergoing acute colorectal cancer surgery, and with reduced 1‐year overall survival after acute surgery.

Integrated Biobanking and Tumor Model Establishment of Human Colorectal Carcinoma Provides Excellent Tools for Preclinical Research

Over the time period from 2006 to 2017, consecutive patients operated on at the University Medical Center Rostock participated in the comprehensive biobanking and tumor-modelling approach known as the HROC collection. Samples were collected using strict standard operating procedures including blood (serum and lymphocytes), tumor tissue (vital and snap frozen), and adjacent normal epithelium. Patient and tumor data including classification, molecular type, clinical outcome, and results of the model establishment are the essential pillars. Overall, 149 patient-derived xenografts with 34 primary and 35 secondary cell lines were successfully established and encompass all colorectal carcinoma anatomic sites, grading and staging types, and molecular classes. The HROC collection represents one of the largest model assortments from consecutive clinical colorectal carcinoma (CRC) cases worldwide. Statistical analysis identified a variety of clinicopathological and molecular factors associated with model success in univariate analysis. Several of them not identified before include localization, mutational status of K-Ras and B-Raf, MSI-status, and grading and staging parameters. In a multivariate analysis model, success solely correlated positively with the nodal status N1 and mutations in the genes K-Ras and B-Raf. These results imply that generating CRC tumor models on the individual patient level is worth considering especially for advanced tumor cases with a dismal prognosis.

The Value of Clinical Colorectal Cancer Registries in Colorectal Cancer Research: A Systematic Review

Importance

Clinical colorectal cancer registries (CCCRs) are potentially powerful tools in colorectal cancer research. They are resource intensive, but to our knowledge, no formal review of their value exists. While quality control, clinical audit, and benchmarking are important factors in assessing the value of maintaining CCCRs, they are difficult to quantify. This study focuses on registry research output as a measure of value; the study hypothesizes that CCCRs do not produce sufficient published research output of clinical significance to justify the resources required to maintain them.

Objective

To assess the value of maintaining CCCRs by identifying and characterizing existing CCCRs and measuring their comparative research impact.

Evidence Review

We searched MEDLINE (PubMed) and Google Scholar for articles published from January 1990 to July 2016 that identified multi-institutional CCCRs with peer-reviewed published outcomes. Purely population-based registries were excluded. We then searched the same databases in the same time period for articles that were published by each included CCCR. The articles must have been based on outcomes relating to individual CCCR data. We categorized published outcomes into oncological, surgical, or other outcomes. We measured the research impact of each CCCR using the number of articles, citation index, impact factor, and Altmetric score.

Findings

A total of 18 CCCRs were identified, with sample sizes between 104 and 1 400 000 cases. Data fields, published aims, and outcomes were similar between registries. The most frequently published outcomes related to anastomotic leak following colorectal surgery. The National Cancer Database formed the basis of the highest number of publications (66), the Northern Region Colorectal Cancer Audit Group had the highest median article citation number (28.5), the National Bowel Cancer Audit had the highest median impact factor (4.72), and the National Cancer Database had the highest median Altmetric score (4.5).

Conclusions and Relevance

There is a significant body of colorectal cancer outcomes research generated from the CCCRs. However, given the enormous resources required, the overall research output and impact of CCCRs is low in proportion to the size of the data sets. These registries hold key oncological and surgical outcomes data; focusing on data linkage between registries and developing automated data collection will enable international comparisons in colorectal cancer management and will increase the research impact of CCCRs, thereby increasing their value.

Analysis of Plasma Cell-Free DNA by Ultradeep Sequencing in Patients With Stages I to III Colorectal Cancer

Importance

Novel sensitive methods for detection and monitoring of residual disease can improve postoperative risk stratification with implications for patient selection for adjuvant chemotherapy (ACT), ACT duration, intensity of radiologic surveillance, and, ultimately, outcome for patients with colorectal cancer (CRC).

Objective

To investigate the association of circulating tumor DNA (ctDNA) with recurrence using longitudinal data from ultradeep sequencing of plasma cell-free DNA in patients with CRC before and after surgery, during and after ACT, and during surveillance.

Design, Setting, and Participants

In this prospective, multicenter cohort study, ctDNA was quantified in the preoperative and postoperative settings of stages I to III CRC by personalized multiplex, polymerase chain reaction-based, next-generation sequencing. The study enrolled 130 patients at the surgical departments of Aarhus University Hospital, Randers Hospital, and Herning Hospital in Denmark from May 1, 2014, to January 31, 2017. Plasma samples (n = 829) were collected before surgery, postoperatively at day 30, and every third month for up to 3 years.

Main Outcomes and Measures

Outcomes were ctDNA measurement, clinical recurrence, and recurrence-free survival.

Results

A total of 130 patients with stages I to III CRC (mean [SD] age, 67.9 [10.1] years; 74 [56.9%] male) were enrolled in the study; 5 patients discontinued participation, leaving 125 patients for analysis. Preoperatively, ctDNA was detectable in 108 of 122 patients (88.5%). After definitive treatment, longitudinal ctDNA analysis identified 14 of 16 relapses (87.5%). At postoperative day 30, ctDNA-positive patients were 7 times more likely to relapse than ctDNA-negative patients (hazard ratio [HR], 7.2; 95% CI, 2.7-19.0; P < .001). Similarly, shortly after ACT ctDNA-positive patients were 17 times (HR, 17.5; 95% CI, 5.4-56.5; P < .001) more likely to relapse. All 7 patients who were ctDNA positive after ACT experienced relapse. Monitoring during and after ACT indicated that 3 of the 10 ctDNA-positive patients (30.0%) were cleared by ACT. During surveillance after definitive therapy, ctDNA-positive patients were more than 40 times more likely to experience disease recurrence than ctDNA-negative patients (HR, 43.5; 95% CI, 9.8-193.5 P < .001). In all multivariate analyses, ctDNA status was independently associated with relapse after adjusting for known clinicopathologic risk factors. Serial ctDNA analyses revealed disease recurrence up to 16.5 months ahead of standard-of-care radiologic imaging (mean, 8.7 months; range, 0.8-16.5 months). Actionable mutations were identified in 81.8% of the ctDNA-positive relapse samples.

Conclusions and Relevance

Circulating tumor DNA analysis can potentially change the postoperative management of CRC by enabling risk stratification, ACT monitoring, and early relapse detection.

Time to colonoscopy, cancer probability, and precursor lesions in the Danish colorectal cancer screening program

Purpose

The aim of this study was to investigate the effect of response time from the Fecal Immunochemical Test (FIT) based screening invitation to the conclusive screening Optical Colonoscopy (OC) on the risk of detecting colorectal cancer (CRC), advanced stage disease and precursor lesions.

Patients and methods

We used a cross-sectional study design and included all 62,554 screening participants registered in the Danish Colorectal Cancer Screening Database who tested FIT-positive between March 2014 and December 2016. The main exposure was response time, measured as the time from initial invitation to the conclusive OC. Our main outcomes were the probability of being diagnosed with CRC, advanced stage disease or precursor lesions.

Results

Of the 62,554 FIT-positive participants, 53,171 (85%) received an OC and were eligible for analysis (median age 63.7 years, 56% men). In this group, 3,639 cancers were registered, 2,890 of which were registered with a defined stage of disease (79%), and 1,042 (36%) of these were advanced stage (UICC III & IV). In addition, 17,732 high-risk and 10,605 low-risk adenomas were identified. Compared to participants receiving the conclusive examination within 30 days, those receiving the examination more than 90 days after initial invitation were 3.49 times more likely to be diagnosed with any CRC (OR 3.49 [95% CI, 3.13–3.89]) and 2.10 times more likely to have advanced stage disease (OR 2.10 [95% CI, 1.73–2.56]). Those waiting for the longest were also more likely to have one or more high-risk adenomas (OR 1.59 [95% CI, 1.50–1.68]).

Conclusion

Increased screening response time was associated with a higher probability of detecting high-risk adenomas, any stage CRC and advanced stage cancer. More research is needed to explain what causes these associations.