The role of primary tumour resection in patients with stage IV colorectal cancer

OBJECTIVE

The management of stage IV colorectal cancer is controversial. Resection of the primary tumour to prevent obstruction, bleeding or perforation is the traditional approach, although survival benefit is undetermined. Management consisting of diverting ostomy, enteric bypass, laser recanalization or endoscopic stenting is an alternative to radical resection. The purpose of this study was to determine the role of resection of the primary tumour in patients with stage IV colorectal cancer, with specific attention paid to survival benefit and safety.

METHOD

This was a retrospective review of all stage IV colon and rectal cancer patients in our tumour registry between 1991 and 2002. Data collected included patient demographics, presenting symptoms, detail from the hospital course including diagnostic data and operative management, complications and survival time (days). Survival analysis was performed to assess the effect of primary tumour resection on long-term survival.

RESULTS

109 patients were studied. Sixty-two (57%) patients (group I) underwent resection of the primary tumour, whereas 47 (43%) patients (group II) were managed without resection. Median survival times for groups I and II were 375 (IQR: 179-759) and 138 (IQR: 35-262) days respectively (P < 0.0001). After controlling for age, sex, tumour location and level of liver involvement as well as liver function, patients who underwent resection still survived longer (HR = 0.34, 95% CI: 0.21-0.55).

CONCLUSION

Palliative resection of the primary tumour plays an essential role in the management of stage IV colorectal cancer. Resection can offer increased survival and is indicated in certain patients with incurable disease. Limited metastatic tumour burden of the liver was associated with better survival in such patients.

The effect of financial incentives on adherence with outpatient human immunodeficiency virus testing referrals from the emergency department

OBJECTIVES

Undiagnosed human immunodeficiency virus (HIV) infection is not uncommon among patients who seek care in urban inner-city emergency departments (EDs). The optimal method for providing appropriate HIV counseling, testing, and referral in this setting is unclear. A previous evaluation of an outpatient referral system for HIV testing among patients seen in the ED demonstrated that only 11% returned to be tested; of those tested, 7% were seropositive. The purpose of this study was to evaluate the effect of a financial incentive on the proportion of referred ED patients who completed outpatient HIV counseling and testing.

METHODS

This was a quasi-experiment performed at an urban county teaching hospital. ED patients identified using Centers for Disease Control and Prevention guidelines as being at risk for HIV infection were referred for outpatient HIV counseling and testing at our institution within one week. This study was divided into three study periods. During the first and third periods, no financial incentive was offered for completing HIV counseling and testing. During the second period, a 25 dollars incentive was offered for completing HIV counseling and testing.

RESULTS

During the study, 372 patients were referred for HIV counseling and testing. During the control periods, 20 (8%) of 252 patients completed HIV counseling and testing; during the intervention period, 27 (23%) of 120 patients completed HIV counseling and testing (odds ratio, 3.4; 95% confidence interval = 1.8 to 6.3). Of the 47 patients who completed HIV counseling and testing, none (0%; 95% confidence interval = 0% to 8%) tested positive for HIV infection.

CONCLUSIONS

The use of a modest financial incentive increased the proportion of patients who completed HIV counseling and testing after being referred from the ED. It is unclear whether the use of a financial incentive increases the identification of HIV-infected patients unaware of their status or if it is cost-effective.