Impact of old age on resectable colorectal cancer outcomes

Mortality rate and predictors of colorectal cancer patients in Ethiopia: a systematic review and meta-analysis

INTRODUCTION

The incidence of colorectal cancer (CRC) has been increasing in Sub-Saharan countries, including Ethiopia. However, the real mortality rate for CRC patients in Ethiopia has not been established. Therefore, this systematic review and meta-analysis aimed to determine the overall mortality rate and identify predictors among CRC patients in Ethiopia.

METHODS

PubMed, EMBASE, Web of Science, Scopus, Science Direct, and Google Scholar were searched to identify relevant articles. The preferred reporting items for systematic reviews and meta-analyses (PRISMA) were followed. The quality of the included studies was assessed using the Newcastle-Ottawa Scale Critical Appraisal checklist. A random effect model was used to estimate the pooled mortality rate and adjusted hazard ratio (AHR). Publication bias was assessed using funnel plots and Egger's regression test, while heterogeneity was evaluated through the Cochran Q test and I2 statistics.

RESULTS

After reviewing 74 articles, only 7 studies met the criteria and were included in the analysis. The analysis revealed that the overall mortality rate among CRC patients in Ethiopia was 40.5% (95% confidence interval [CI]: 32.05, 48.87) while the survival rates at 1 year, 3 years, and 5 years were 82.3% (95% CI: 73.33, 91.31), 48.8% (95% CI: 43.35, 54.32), and 26.6% (95% CI: 21.26, 31.91) respectively. Subgroup analysis indicated that studies conducted after 2017 had higher mortality rates compared to those studied earlier (43.0% vs. 38.2%). Older age (AHR: 1.89, 95% CI: 1.27, 2.82); being married (AHR: 2.53, 95% CI: 1.79, 3.57); having comorbidities (AHR: 1.84, 95% CI: 1.45, 2.35); having high CEA levels (AHR: 2.06, CI: 1.35, 3.13); being in stage II (AHR: 4.13, 95% CI: 1.85, 9.22), III (AHR: 8.62, 95% CI: 3.88, 19.15), and IV (AHR: 8.06, CI: 2.89, 22.49) were the most important predictors.

CONCLUSION

In Ethiopia, the mortality rate among individuals diagnosed with CRC is high, with two out of five patients dying from this disease. Age, marital status, CEA level, comorbidities, and cancer stage were identified as predictors of mortality in CRC patients. Therefore, early detection and screening should be prioritized, particularly for older patients, those who are married, have comorbidities, elevated CEA levels, and advanced cancer stages.

Sex modifies effects of imaging and CSF biomarkers on cognitive and functional outcomes: a study of Alzheimer's disease

Alzheimer's disease (AD) is a neurodegenerative disorder characterized by memory and functional impairments. Two of 3 patients with AD are biologically female; therefore, the biological underpinnings of this diagnosis disparity may inform interventions slowing the AD progression. To bridge this gap, we conducted analyses of 1078 male and female participants from the Alzheimer's Disease Neuroimaging Initiative to examine associations between levels of cerebral spinal fluid (CSF)/neuroimaging biomarkers and cognitive/functional outcomes. The Chow test was used to quantify sex differences by determining if biological sex affects relationships between the studied biomarkers and outcomes. Multiple magnetic resonance imaging (whole brain, entorhinal cortex, middle temporal gyrus, fusiform gyrus, hippocampus), position emission tomography (AV45), and CSF (P-TAU, TAU) biomarkers were differentially associated with cognitive and functional outcomes. Post-hoc bootstrapped and association analyses confirmed these differential effects and emphasized the necessity of using separate, sex-stratified models. The studied imaging/CSF biomarkers may account for some of the sex-based variation in AD pathophysiology. The identified sex-varying relationships between CSF/imaging biomarkers and cognitive/functional outcomes warrant future biological investigation in independent cohorts.

Preoperative Radiotherapy Decision-Tree for Rectal Cancer Patients: A Real-World Analysis Based on the Swedish Colorectal Cancer Registry

BACKGROUND

There are 3 widely used preoperative radiotherapy (RT) procedures in rectal cancer treatment including long-course RT (LRT), short-course RT with delayed surgery (SRTW), and short-course RT with immediate surgery (SRT). However, further evidence is required to determine which treatment option results in more optimal patient survival.

METHODS

This Swedish Colorectal Cancer Registry-based retrospective study of real-world data included 7766 stage I-III rectal cancer patients, of which 2982, 1089, 763, and 2932 patients received no RT (NRT), LRT, SRTW, and SRT, respectively. The Kaplan-Meier survival curve and Cox proportional hazard multivariate model were used to identify potential risk factors and to examine the independent association of RT with patient survival after adjusting for baseline confounding factors.

RESULTS

RT effects on survival differed by age and clinical T stage (cT) subgroups. Subsequent survival analysis by age and cT subgroups confirmed that patients ≥70 years old with cT4 benefited from any RT (P < .001, NRT as reference) and equally from any RT (P > .05 pairwise between RTs). In contrast, for cT3 patients ≥70 years, SRT and LRT were associated with better survival than SRTW (P < .001). In patients <70 years, LRT and SRTW had superior survival benefits in cT4 patients but inferior to SRT (P < .001); SRT was the only effective treatment in the cT3N+ subgroup (P = .032); patients with cT3N0 and <70 years did not benefit from any RT.

CONCLUSION

This study suggests that preoperative RT strategies may have varying effects on the survival of rectal cancer patients, depending on their age and clinical stage.

Robotic Rectal Resection for Rectal Cancer in Elderly Patients: A Systematic Review and Meta-Analysis

Rectal cancer is estimated to increase due to an expanding aging population, thus affecting elderly patients more frequently. The optimal surgical treatment for this type of patient remains controversial because they are often excluded from or underrepresented in trials. This meta-analysis aimed to evaluate the feasibility and the safety of robotic surgery in elderly patients (>70 years old) undergoing curative treatment for rectal cancer. Studies comparing elderly (E) and young (Y) patients submitted to robotic rectal resection were searched on PubMed, Embase, and the Cochrane Library. Data regarding surgical oncologic quality, post-operative, and survival outcomes were extracted. Overall, 322 patients underwent robotic resection (81 in the E group and 241 in the Y group) for rectal cancer. No differences between the two groups were found regarding distal margins and the number of nodes yielded (12.70 in the E group vs. 14.02 in the Y group, p = 0.16). No differences were found in conversion rate, postoperative morbidity, mortality, and length of stay. Survival outcomes were only reported in one study. The results of this study suggest that elderly patients can be submitted to robotic resection for rectal cancer with the same oncologic surgical quality offered to young patients, without increasing postoperative mortality and morbidity.

Elderly patients over 80 years undergoing colorectal cancer resection: Development and validation of a predictive nomogram for survival

BACKGROUND

Surgery remains the primary treatment for localized colorectal cancer (CRC). Improving surgical decision-making for elderly CRC patients necessitates an accurate predictive tool.

AIM

To build a nomogram to predict the overall survival of elderly patients over 80 years undergoing CRC resection.

METHODS

Two hundred and ninety-five elderly CRC patients over 80 years undergoing surgery at Singapore General Hospital between 2018 and 2021 were identified from the American College of Surgeons – National Surgical Quality Improvement Program (ACS-NSQIP) database. Prognostic variables were selected using univariate Cox regression, and clinical feature selection was performed by the least absolute shrinkage and selection operator regression. A nomogram for 1- and 3-year overall survival was constructed based on 60% of the study cohort and tested on the remaining 40%. The performance of the nomogram was evaluated using the concordance index (C-index), area under the receiver operating characteristic curve (AUC), and calibration plots. Risk groups were stratified using the total risk points derived from the nomogram and the optimal cut-off point. Survival curves were compared between the high- and low-risk groups.

RESULTS

Eight predictors: Age, Charlson comorbidity index, body mass index, serum albumin level, distant metastasis, emergency surgery, postoperative pneumonia, and postoperative myocardial infarction, were included in the nomogram. The AUC values for the 1-year survival were 0.843 and 0.826 for the training and validation cohorts, respectively. The AUC values for the 3-year survival were 0.788 and 0.750 for the training and validation cohorts, respectively. C-index values of the training cohort (0.845) and validation cohort (0.793) suggested the excellent discriminative ability of the nomogram. Calibration curves demonstrated a good consistency between the predictions and actual observations of overall survival in both training and validation cohorts. A significant difference in overall survival was seen between elderly patients stratified into low- and high-risk groups (P < 0.001).

CONCLUSION

We constructed and validated a nomogram predicting 1- and 3-year survival probability in elderly patients over 80 years undergoing CRC resection, thereby facilitating holistic and informed decision-making among these patients.

Laparoscopic versus open surgery for elderly patients with colorectal cancer: a systematic review and meta-analysis of matched studies

BACKGROUND

To compare clinical and survival outcomes between laparoscopic versus open surgery in elderly colorectal cancer patients.

METHODS

PubMed, Embase and Scopus databases were systematically searched. The review included studies that were either randomized controlled trials (RCTs) or observational in design. STATA was used for statistical analysis.

RESULTS

The meta-analysis was conducted with 24 studies. Compared with elderly subjects with open surgery, those undergoing laparoscopic surgery had a lower risk of mortality (within 3 months postoperatively) (RR 0.70, 95% CI: 0.53, 0.94). The long-term overall survival (HR 0.96, 95% CI: 0.89, 1.04), disease-free survival (HR 1.02, 95% CI: 0.93, 1.13), risk of recurrence (RR 1.44, 95% CI: 0.90, 2.30) and readmission (RR 1.11, 95% CI: 0.88, 1.40) rates were statistically similar in both the groups. The operative time (in minutes) was higher (WMD 30.37, 95% CI: 17.75, 43.0) and the blood loss (in ml) was lower (WMD -78.85, 95% CI: -101.96, -55.75) in those undergoing laparoscopic surgery. The length of hospital stay (in days) (WMD -2.53, 95% CI: -3.11, -1.95) and the time of return of bowel movements (in days) (WMD -1.06, 95% CI: -1.20, -0.93) was lower in those with laparoscopic surgery. The pooled risk of complications was lower in those with laparoscopic surgery (RR 0.66, 95% CI: 0.60, 0.74), compared with open surgery.

CONCLUSIONS

Findings suggest that in elderly subjects with colorectal cancer, laparoscopic surgery appears to be more beneficial than open surgery and should be prioritized, subject to the availability of required technical skills and facilities.

Clinical Validation of Implementing Enhanced Recovery After Surgery Protocol in Elderly Colorectal Cancer Patients

Purpose

The aim of this study was to evaluate the safety and feasibility of applying enhanced recovery after surgery (ERAS) protocol in elderly colorectal cancer patients.

Methods

The medical records of patients who underwent elective colorectal cancer surgery at our institution, from January 2017 to December 2017, were reviewed. Patients were divided into 2 groups: the young group (YG, patients aged 70 and under 70 years) and the old group (OG, patients over 70 years old). Perioperative outcomes and length of hospital stay were compared between both groups.

Results

In total, 335 patients were enrolled; 237 were YG and 98 were OG. Despite the poorer baseline characteristics of OG, the perioperative outcomes were similar. Length of hospital stay was not different between the groups (YG, 5 days vs. OG, 5 days; P=0.320). When comparing the postoperative complications using the comprehensive complication index (CCI), there was no significant difference (YG, 8.0±13.2 vs. OG, 11.7±23.0; P=0.130). In regression analysis, old age (>70 years) was not a risk factor for high CCI in all patients. In multivariate analysis, C-reactive protein (CRP) level on postoperative day (POD) 3 to 4 was the only strong predictive factor for high CCI in elderly patients.

Conclusion

Implementing the ERAS protocol in patients aged >70 years is safe and feasible. High CRP (≥6.47 mg/dL) on POD 3 to 4 can be used as a safety index to postpone discharge in elderly patients.

Ferroptosis-related genes are potential prognostic molecular markers for patients with colorectal cancer

Ferroptosis is a newly discovered programmed cell death that plays a vital role in the occurrence and development of tumors. However, little is known about its prognostic value of ferroptosis-related genes (FRGs) in colorectal cancer (CRC). This study was to investigate the clinical significance of FRGs on overall survival (OS) of patients with CRC. The mRNA expression profiles and corresponding clinical data of CRC patients were downloaded from public databases. Least absolute shrinkage and selection operator (LASSO) Cox regression was applied to identify hub FRGs and establish a novel ferroptosis-related gene signature in predicting OS in training cohort, and assessed in the validation cohort. Then, the genomic-clinicopathologic nomogram integrating risk scores and clinicopathological features were established. Thirteen FRGs were identified to be most significantly related to the OS of CRC patients. Based on the LASSO Cox regression algorithm, we selected 10 genes from 13 FRGs to establish a prognostic risk signature. The log-rank test and Kaplan-Meier analysis confirmed the predictive value of the risk scores for OS in CRC patients. The time-dependent receiver operating characteristic (tdROC) of signature indicates the showed powerful prediction ability in both training cohort and validation cohort. Then, a genomic-clinicopathologic nomogram integrating age, stage, and risk scores was established and demonstrated high predictive accuracy and clinical value, which was validated through tdROC and calibration curves. The ferroptosis-related gene signature and genomic-clinicopathologic nomogram could be used to predict the prognosis of CRC patients and might also be potential therapeutic targets.

Do Elderly Patients With Stage I-II Hepatocellular Carcinoma Benefit From More Radical Surgeries? A Population-Based Analysis

Background and Aims: The best treatment modalities for elderly patients with stage I–II HCC (hepatocellular carcinoma) remain controversial in an era of a shortage of liver donors.

Methods: From the SEER database (Surveillance, Epidemiology, and End Results program), 2,371 elderly patients were sampled as Cohort 1. OS (Overall Survival) and CSS (Cancer-Specific Survival) were compared between the Non-surgery and Surgery groups. A stratification analysis in a CSS Cox model was also conducted among sub-groups, and propensity score matching was performed to generate Cohort 2 (746 pairs), reducing the influences of confounders.

Results: For Cohort 1, the median follow-up times of the Non-surgery and Surgery groups were 11 months (95% CI, confidence interval: 9.74–12.26) vs. 49 months (44.80–53.21) in OS, and 14 months (12.33–15.67) vs. 74 months (64.74–83.26) in CSS, respectively. In the stratification analysis, for the elderly patients (age >= 70 years), Larger Resection was associated with a higher HR (hazard ratio) than Segmental Resection: 0.30 (95% CI, confidence interval: 0.22–0.41) vs. 0.29 (0.21–0.38) in 70–74 year-olds; 0.26 (0.18–0.38) vs. 0.23 (0.16–0.32) in 75–79 year-olds; 0.32 (0.21–0.49) vs. 0.21 (0.13–0.32) in those 80+ years old. For Cohort 2, a similar result could be seen in the CSS Cox forest plot. The HRs of Larger Resection and Segmental Resection were 0.27 (0.21–0.33) and 0.25 (0.20–0.31), respectively.

Conclusions: It is cautiously recommended that, when liver transplantation is not available, segmental or wedge liver resection is the better treatment choice for elderly patients with stage I–II HCC (AJCC edition 6), especially those over 70 years old, compared with other surgeries, based on the SEER data.

A nomogram for predicting cancer-specific survival in different age groups for operable gastric cancer: a population-based study

Background

The age thresholds for differentiating young and elderly patients are still under debate. This study aimed to evaluate the cut-off age for differentiating patients along with the prognostic value of age for operable gastric cancer (GC).

Methods

Patients diagnosed with resected gastric adenocarcinoma were identified from the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) database (training cohort and internal validation cohort) and Liaoning Cancer Hospital (external validation cohort). Kaplan-Meier plots were used to compare cancer-specific survival (CSS) across different age groups. Univariate and multivariate analysis was conducted using a Cox regression model. Predictive ability of the nomogram was determined by the Harrell’s concordance index (C-index), calibration curves, and Akaike’s Information Criterion (AIC).

Results

A total of 17,339 patients with GC were included. According to the univariate analysis results, CSS was similar among patients aged 20–69 years old, started to worsen for patients over the age of 70, and was the worst for patients older than 79 years in the training cohort. Thus, we further divided the age groups into 20–69, 70–79, and >79, and multivariate analysis showed that patients above 70 years of age had worse CSS. The nomogram was established based on the results of the multivariate analysis. The C-indexes for the training, internal, and external validation cohorts were 0.7531, 0.7344, and 0.7431, respectively.

Conclusions

This study showed that age had a relative predictive ability for CSS, 70 years should be the cut-off age, and age ≥70 years is an independent prognostic risk factor for GC patients who undergo surgery. These data highlight the importance of individualized treatment to improve the prognosis of patients with GC.

Genome-Wide Identification of a Novel Autophagy-Related Signature for Colorectal Cancer

Background:

Plenty of evidence has suggested that autophagy plays a crucial role in the biological processes of cancers. This study aimed to screen autophagy-related genes (ARGs) and establish a novel a scoring system for colorectal cancer (CRC).

Methods:

Autophagy-related genes sequencing data and the corresponding clinical data of CRC in The Cancer Genome Atlas were used as training data set. The GSE39582 data set from the Gene Expression Omnibus was used as validation set. An autophagy-related signature was developed in training set using univariate Cox analysis followed by stepwise multivariate Cox analysis and assessed in the validation set. Then we analyzed the function and pathways of ARGs using Gene Ontology and Kyoto Encyclopedia of Genes and Genomes (KEGG) database. Finally, a prognostic nomogram combining the autophagy-related risk score and clinicopathological characteristics was developed according to multivariate Cox analysis.

Results:

After univariate and multivariate analysis, 3 ARGs were used to construct autophagy-related signature. The KEGG pathway analyses showed several significantly enriched oncological signatures, such as p53 signaling pathway, apoptosis, human cytomegalovirus infection, platinum drug resistance, necroptosis, and ErbB signaling pathway. Patients were divided into high- and low-risk groups, and patients with high risk had significantly shorter overall survival (OS) than low-risk patients in both training set and validation set. Furthermore, the nomogram for predicting 3- and 5-year OS was established based on autophagy-based risk score and clinicopathologic factors. The area under the curve and calibration curves indicated that the nomogram showed well accuracy of prediction.

Conclusions:

Our proposed autophagy-based signature has important prognostic value and may provide a promising tool for the development of personalized therapy.