Diagnostic value of rectal bleeding in predicting colorectal cancer: a systematic review

Colorectal Cancer Fast Tracks: Cancer Yield and the Predictive Value of Entry Criteria

BACKGROUND

Fast-track pathways for diagnosing colorectal cancer (CRC) have been implemented in several European countries. In Sweden, a substantial number of CRC are diagnosed via the Swedish Standardized Course of Care for colorectal cancer (SCC-CRC). We evaluated the SCC-CRC in terms of CRC yield, and predictive values and odds ratios (OR) for the entry criteria.

METHODS

We retrospectively analyzed all 2539 patients referred for SCC-CRC colonoscopy between September 2016 and December 2020. Entry criteria and colonoscopy outcomes were analyzed.

RESULTS

CRC yield was 16.4%. Highest positive predictive values (PPVs) were seen for abnormal radiology (PPV 30.5%, OR 4.7 (95% CI 3.4-6.4) p < 0.001), abnormal rectal examination (PPV 28%, OR 3.6 (95% CI 2.7-4.8) p < 0.001), and anemia (PPV 24.8%, OR 2.2 (95% CI 1.5-3.1) p < 0.001). Some entry criteria showed no significant risk increase, i.e., visible blood in stool/rectal bleeding, change in bowel habits, and the combination of changed bowel habits plus anemia. A positive fecal immunochemical test (FIT), although not part of the SCC-CRC, showed the highest OR: 9.9 (95% CI 4.5-21.7) p < 0.001) and PPV of 18.8%.

CONCLUSIONS

CRC yield from the SCC-CRC is slightly higher compared to other European fast tracks. A number of entry criteria showed no benefit towards assessing CRC risk. FIT testing should be included in CRC fast tracks to increase diagnostic efficacy.

A New Nomogram for Predicting the Postoperative Overall Survival in Patients with Middle-Aged and Elderly Rectal Cancer: A Single Center Retrospective Study in Chinese Population

Purpose

Patients with middle-aged and elderly rectal cancer (MERC) usually have poor prognosis after surgery. This study aimed to develop a nomogram to achieve individualized prediction of overall survival (OS) in patients with MERC and to guide follow-up and subsequent diagnosis and treatment plans.

Patients and Methods

A total of 349 patients were randomly assigned to the training and validation cohorts in a 7:3 ratio. Multivariate Cox regression analysis was performed using the results of univariate Cox regression analysis to confirm independent prognostic factors of OS. Thereafter, the nomogram was built using the “rms” package. Subsequently, discriminative ability and calibration of the nomogram were evaluated using receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA). Integrated discrimination improvement (IDI), net reclassification improvement (NRI), and the area under the ROC curves (AUC) were compared between the nomogram and the tumor-node-metastasis (TNM) staging system (8th edition). Finally, we established a predictive model to assess the survival benefit of patients with MERC by calculating nomogram scores for each patient.

Results

Six variables were identified as independent prognostic factors and included in the nomogram: smoking history, family history, hematochezia, tumor size, N stage, and M stage. Based on these factors, we successfully constructed a nomogram and evaluated its discriminative and predictive abilities using ROC curves, calibration curves, and DCA. ROC curves, IDI, and NRI showed that the nomogram had outstanding clinical utility compared with the TNM staging system (8th edition) for OS prediction. The predictive model successfully distinguished between high-, medium-, and low-risk MERC patients.

Conclusion

Our nomogram provided a more satisfactory survival prediction ability than the TNM staging system (8th edition) for MERC patients. In addition, the nomogram was able to accurately categorize patients into different risk groups after surgery.

Diagnostic utility of serum dipeptidyl peptidase (DPP- IV) /CD26 as a serum marker in Egyptian patients with colorectal cancer

BACKGROUND

Colorectal cancer (CRC) is considered a major cause of morbidity and mortality in Egypt. Colonoscopy is the standard for detection of lesions. The combination of screening methods is effective. Decrease and loss of DPP-IV/CD26 expression and activity are found in microenvironments of specific tumors which are related to impaired immune functions.

AIM OF THE WORK

To study sCD26 as a noninvasive test in Egyptian patients with CRC as well as their correlation to CEA, CA 19-9 & other -biochemical parameters and determine the possibility to use it as a diagnostic tool for CRC.

PATIENTS AND METHODS

This study included 40 patients divided into two groups: group I: comprised 20 patients with CRC, group II: comprised 20 patients with other colorectal disease together with 20 healthy control.

RESULTS

There was highly significant decrease in sCD26 in group I in comparison to group II and III. CD26 at cutoff 4.69 mg/mL, its sensitivity was 85% and its specificity was 87.5%.

CONCLUSION

CD26 is involved in the pathogenesis of colorectal diseases; sCD26 is diminished in CRC patients suggesting the potential utility of a sCD26 for diagnosis.

Predictive values of colorectal cancer alarm symptoms in the general population: a nationwide cohort study

Background

Alarm symptoms are used in many cancer referral guidelines. The objectives were to determine the 1-year predictive values (PVs) of colorectal cancer (CRC) alarm symptoms in the general population and to describe the proportion of alarm symptoms reported prior to diagnosis.

Methods

A nationwide prospective cohort of 69,060 individuals ≥40 years randomly selected from the Danish population was invited to complete a survey regarding symptoms and healthcare-seeking in 2012. Information on CRC diagnoses in a 12-month follow-up came from the Danish Cancer Registry. PVs and positive and negative likelihood ratios were calculated.

Results

A total of 37,455 individuals participated (response rate 54.2%). Sixty-four individuals were diagnosed with CRC. The single symptom with the highest positive PVs (PPV) and LR+ was rectal bleeding. PPVs were generally higher among individuals aged ≥75 years and highest among those reporting at least one specific alarm symptom that led to a GP contact.

Conclusion

In general, the PPVs of CRC alarm symptoms are low and the NPVs high, especially in the youngest age groups. The LR +  show a relative association with specific symptoms like rectal bleeding. Future campaigns on early diagnosis of CRC should focus on healthcare-seeking when experiencing rectal bleeding and target older people with the highest incidence.

A symptom-based model to predict colorectal cancer in low-resource countries: Results from a prospective study of patients at high risk for colorectal cancer

BACKGROUND

Colorectal cancer (CRC) rates in low-resource countries, which typically lack CRC screening programs, are rising. This study determined whether a risk model for patients with rectal bleeding could identify patients with curable CRC.

METHODS

This prospective, cross-sectional study evaluated a model constructed from data from 1 hospital and validated at 2 other hospitals. The primary endpoint was the ability of the model to predict CRC, as diagnosed by colonoscopy, from clinical characteristics. The secondary endpoint was to determine the percentage of patients who had CRC.

RESULTS

Consecutive patients who were 45 years old or older and had self-reported rectal bleeding for more than 1 week were evaluated. From January 2014 to July 2016, 362 patients answered a questionnaire and underwent colonoscopy. In the validation cohort, 56% of patients with rectal bleeding, weight loss, and changes in bowel habits had CRC, whereas 2% of patients with bleeding alone did. Overall, 18.2% of the patients had CRC, and 8.6% had adenomas. The proportion of CRC patients with potentially curable stage II or III disease was 74%, whereas the historical rate was 36%. The combination of rectal bleeding with both symptoms significantly predicted CRC in the validation set (odds ratio, 12.8; 95% confidence interval, 4.6-35.4; P < .001).

CONCLUSIONS

In low-resource settings, patients with rectal bleeding, weight loss, and changes in bowel habits should be classified as high risk for CRC. Patients with a high risk score should be prioritized for colonoscopy to increase the number of patients diagnosed with potentially curable CRC. Cancer 2018;124:2766-2773. © 2018 American Cancer Society.

Health-Seeking Behavior and Barriers to Care in Patients With Rectal Bleeding in Nigeria

Purpose Colorectal cancer (CRC) incidence rates are steadily increasing in Nigeria. Organized screening is still largely unused because of financial and logistical barriers; most CRCs are detected by symptoms. One symptom of CRC is rectal bleeding. This study sought to determine health-seeking behavior and barriers to care in patients with rectal bleeding in Nigeria. This study also surveyed physicians to determine major breakdowns in access to care. Methods The recruitment process for this study involved patients referred for colonoscopy because of rectal bleeding as well as response to a media advertisement for a free colonoscopy. Physicians were recruited at the African Research Group for Oncology meeting. Patient responses were scored on the basis of knowledge of rectal bleeding. The physician questionnaire was supporting information and mainly descriptive in nature. Results A total of 82 patients and 45 physicians participated in this study. Less than 40% of patients knew that rectal bleeding could be caused by cancer. Major barriers to care were resolution of the symptom (42%), no consideration of the bleeding as problematic (40%), and financial constraint (22%). Education was strongly correlated with knowledge of rectal bleeding and health-seeking behavior. Although physicians regularly saw patients with rectal bleeding, most of them provided a differential diagnosis of hemorrhoids and few referred patients for colonoscopy. Conclusion General awareness about the signs of colorectal cancer is lacking. This demonstrates the strong need for patient education programs about this issue. Physicians should also receive additional training on differentiation of a potential cancer diagnosis from something more benign, such as hemorrhoids.

[Role of Colonoscopy in Patients with Hematochezia]

BACKGROUND/AIMS

Although colonoscopy is not indicated in patients with hematochezia, many surgeons, internists, and physicians are recommending colonoscopy for these patients in Korea. The aim of this study is to evaluate the diagnostic value of colonoscopy for patients with hematochezia.

METHODS

We retrospectively reviewed the data of colonoscopy between January 2010 and December 2010. A total of 321 patients among 3,038 colonoscopies (10.6%) underwent colonoscopy to evaluate the cause of hematochezia. The patients with previous colorectal surgery (2) or polypectomy (5) were excluded. We analyzed endoscopic diagnoses. Advanced neoplastic polyps were defined as adenomas with villous histology or high grade dysplasia, or adenomas more than 10 mm in diameter.

RESULTS

Hemorrhoid was the most common diagnosis (217 cases, 67.6%). Polyps were detected in 93 patients (29.0%), but advanced neoplastic polyps were found in only 14 cases (4.4%). Colorectal cancers were diagnosed in 18 patients (5.6%) including 14 rectal cancers. There was no cancer located above sigmoid-descending junction. Diverticuli were detected in 41 patients (12.8%) but there was only one case of suspected diverticular bleeding. Colitis was diagnosed in 24 patients (7.5%). Other lesions included acute anal fissure, rectal tumor, stercoral ulcer, and radiation proctitis.

CONCLUSIONS

The colonoscopy had little value in patients with hematochezia because the most pathologic lesions were located below sigmoid colon. The first choice of diagnosis in patients with hematochezia is sigmoidoscopy.

Clinical study of anesthetization by dezocine combined with propofol for indolent colonoscopy

AIM: To assess the use of dezocine combined with propofol for the anesthetization of patients undergoing indolent colonoscopy.

METHODS: A cross-sectional survey of patients undergoing indolent colonoscopy in the Xinjiang People’s Hospital was conducted from April 1 to April 30, 2015. The survey collected patient general information and anesthesia data, including overall medical experience and pain management. Thirty minutes after colonoscopy surgery, samples of venous blood were collected and the biochemical indicators of gastrointestinal function were analyzed.

RESULTS: There were 98 female and 62 male respondents. Indolent colonoscopy was found to be more suitable for mid to older-aged patients. The necessary conditions for the diagnosis of digestive diseases were required in 65 of the 73 inpatients. Adverse reactions to the intraoperative process included two cases of body movement and two cases of respiratory depression. Gastrin and vasoactive intestinal peptide levels were slightly increased. However, somatostatin and endothelin levels were slightly decreased.

CONCLUSION: This study revealed that dezocine combined with propofol can be successfully used for the anesthetization of indolent colonoscopy patients without pain and should be widely used.

Recurrence risk and prognostic parameters in stage I rectal cancers

BACKGROUND

The standard therapy for stage I rectum cancer is surgical resection. Currently, there is no strong evidence to suggest that any type of adjuvant therapy is beneficial. The risks of local relapse and distant metastasis are higher in rectal tumors. Therefore, while there is no clearly defined absolute indication for adjuvant therapy in lymph node negative colon cancers, rectum tumors that are T3N0 and higher require adjuvant treatment. Due to the more aggressive nature of rectal cancers, we explored the clinical and pathologic factors that could predict the risk of relapse in Stage I (T1-T2) disease and whether there was any progression-free survival benefit to adjuvant therapy.

MATERIALS AND METHODS

This multicenter study was carried out by the Anatolian Society of Medical Oncology. A total of 178 patients with rectal cancers who underwent curative surgery between January 1994 and August 2012 in 13 centers were included in the study. Patient demographics, including survival data and tumor characteristics were obtained from medical charts.

RESULTS

The median age was 58 years (range 26-85 years). Most tumors were well or moderately differentiated. For adjuvant treatment, 13 patients (7.3%) received radiotherapy alone, 12 patients (6.7%) received chemotherapy alone and 15 patients (8.4%) were given chemoradiotherapy. Median follow up was 29 months (3-225 months). Some 42 patients (23.6%) had relapse during follow up; 30 with local recurrence (71.4%) whereas 12 (28.6%) were distant metastases. Among the patients, 5-year DFS was 64% and OS was 82%. Mucinous histology and receiving adjuvant therapy were found to have statistically insignificant correlations with relapse and survival.

CONCLUSIONS

In our retrospective analysis, approximately one quarter of patients exhibited either local or systemic relapse. The rates of relapse were slightly higher in the patients who had no adjuvant therapy. There may thus be a role for adjuvant therapy in high-risk stage I rectal tumors.

Prognostic significance of Beclin-1 expression in colorectal cancer: a meta-analysis

OBJECTIVE

Beclin-1 has recently been observed as an essential marker of autophagy in several cancers. However, the prognostic role of Beclin-1 in colorectal neoplasia remains controversial. Our study aimed to evaluate the potential association between Beclin-1 expression and the outcome of colorectal cancer patients.

MATERIALS AND METHODS

All related studies were systematically searched in Pubmed, Embase, Springer and Chinese National Knowledge Infrastructure databases (CNKI), and then a meta-analysis was performed to determine the association of Beclin-1 expression with clinical outcomes. Finally, a total of 6 articles were included in our analysis.

RESULTS

Our data showed that high Beclin-1 expression in patients with CRC was associated with poor prognosis in terms of tumor distant metastasis (OR=2.090, 95%CI=1.061-4.119, p=0.033) and overall survival (RR=1.422, 95%CI=1.032-1.959, p=0.031). However, we did not found any correlation between Beclin-1 over-expression and tumor differentiation (OR=1.711, 95%CI=0.920-3.183, p=0.090). In addition, there was no evidence of publication bias as suggested by Egger's tests for tumor distant metastasis (p=1.000), differentiation (p=1.000) and OS (p=0.308).

CONCLUSIONS

Our present meta-analysis indicated that elevated Beclin-1 expression iss associated with tumor metastasis and a poor prognosis in patients with CRC. Beclin-1 might serve as an efficient prognostic indicator in CRC, and could be a new molecular target in CRC therapy.

Rectal bleeding and implications for surgical care in Nepal

BACKGROUND

Because rectal bleeding is a cardinal symptom of many colorectal diseases including colorectal cancers, its presence alone could give insight into the prevalence of these conditions where direct population screening is lacking. In South Asia, which is home to over one fifth of the world's population, there is paucity of epidemiologic data on colorectal diseases, particularly in the lower-income countries such as Nepal. The aim of this study was to enumerate the prevalence of rectal bleeding in Nepal and increase understanding of colorectal diseases as a health problem in the South Asian region.

METHODS

A countrywide survey using the Surgeons OverSeas Assessment of Surgical Need tool was administered from May 25-June 12, 2014 in 15 of the 75 districts of Nepal, randomly selected proportional to population. In each district, three Village Development Committees were selected randomly, two rural and one urban based on the Demographic Health Survey methodology. Individuals were interviewed to determine the period and point prevalence of rectal bleeding and patterns of health-seeking behavior related to surgical care for this problem. Individuals aged >18 y were included in this analysis.

RESULTS

A total of 1350 households and 2695 individuals were surveyed with a 97% response rate. Thirty-eight individuals (55% male) of the 1941 individuals ≥ 18 y stated they had experienced rectal bleeding (2.0%, 95% confidence interval 1.4%-2.7%), with a mean age of 45.5 (standard deviation 2.2). Of these 38 individuals, 30 stated they currently experience rectal bleeding. Health Care was sought in 18 participants with current rectal bleeding, with two major procedures performed, one an operation for an anal fistula. For those who sought health care but did not receive surgical care, reasons included no need (4), not available (6), fear and/or no trust (5), and no money for health care (1). For those with current rectal bleeding who did not seek health care, reasons included no need (1), not available (2), fear and/or no trust (6), and no money for health care (3). Twenty-three individuals had an unmet surgical need secondary to rectal bleeding (1.2%, 95% confidence interval 0.8%-1.8%).

CONCLUSIONS

The Nepal health care system at present does not emphasize the importance of surveillance colonoscopies or initial diagnostics by a primary care physician for rectal bleeding. Our data demonstrate limited access for patients to undergo evaluation of rectal bleeding by a health care professional and that potentially there are people in Nepal with rectal bleeding that may have undiagnosed colorectal cancer. Further advocacy for preventative medicine and easier access to surgical care in lower-income countries is crucial to avoid emergency surgeries, advanced stage malignancies, or fatalities from treatable conditions.

A systemic analysis of S-1 regimens for treatment of patients with colon cancer

BACKGROUND

Fluorouracil-based regimens have been widely accepted and recommended in the guidelines for treating patients with early or advanced staged colon cancer, although results are controversial. Here we performed a systemic analysis to evaluate the impact of S-1 based regimens on response and survival of patients with colon cancer.

METHODS

Clinical studies evaluating the impact of S-1 based regimens on response and survival of patients with colon cancer were identified using a predefined search strategy. Summary response rates (RRs) to treatment were calculated.

RESULTS

Six clinical studies which including 227 patients with advanced colorectal cancer were considered eligible for inclusion. Two studies were conducted using combination of S-1 and Oxaliplatin, and four studies featured S-1 and irinotecan. Systemic analysis showed that, in all patients, pooled RRs was 43.17%. Major adverse effects were hematological toxicities, gastrointestinal disturbance, neurosensory toxicity. No treatment related death occurred.

CONCLUSION

This systemic analysis suggests that S-1 based regimens, both with oxaliplatin or irinotean are associated with acceptable response and toxicity in patients with colon cancer.