Colorectal cancer (or bowel cancer) is one of the most common types of cancer in both men and women. Approximately four fifths of these cancers are found in the colon (large intestine), and one fifth in the rectum. Prevention and early detection of colorectal cancer is important. Some of most common symptoms include a change in bowel habit (eg. constipation, and bleeding), mucus discharge, and discomfort or pain in the lower abdomen. The vast majority of colon and rectum cancers are adenocarcinomas, around 10% of these are mucinous (protein contained in mucus). The median age at diagnosis is 70, age adjusted incidence rates are slightly higher in males compared to females. A substantial proportion of cases are in those with a genetic predisposition to colorectal cancer. Diet may also have an influence on the incidence of colorectal cancer, diatry fibre, retinoids, and calcium are thought to be protective, while high intake of animal fats may increases risk. Colorectal cancer may develop from benign polyps (a polyp is a tumour on a stem most commonly found on mucous membranes). World-wide about 782,000 people are diagnosed with colorectal cancer each year.
Cancer Research UK CancerHelp information is examined by both expert and lay reviewers. Content is reviewed every 12 to 18 months. Further info. Statistics for the UK, including incidence, mortality, survival, risk factors and stats related to treatment and symptom relief.
National Cancer Institute Booklets written in simple language, which are regularly reviewed and updated Further info. This site contains information about the disease, diagnosis, staging, and treatment options.
Bowel cancer explained - symptoms, diagnosis and treatment
Macmillan Cancer Support Video: Consultant Clinical Oncologist Amen Sibtain explains bowel cancer, which includes colon and rectal cancer. He gives an overview of the symptoms, diagnosis and treatment of bowel cancer.
The Alliance was founded in 1998 by patients, survivors, cargivers and others whose lives have been toched by colorectal cancer. It provides information, support, advocacy, on-line chat and a toll free Helpline.
ACOR A discussion and support list sponsored by the Association of Cancer Online Resources
Colonoscopy Video Tour: Discovery of a Cancerous Polyp (Colon Cancer)
New York University Langone Medical Center Mark Pochapin MD, narrates a tour of a patient's colon during a colonoscopy where he discovers a cancerous polyp (colon cancer). The patient did not have any abdominal or rectal pain, or any other symptoms associated with colorectal cancer. However, prior to this colonoscopy the patient was diagnosed with anemia due the slow bleeding of this polyp in her colon.
PubMed Central search for free-access publications about Bowel Cancer MeSH term: Colorectal Neoplasms US National Library of Medicine PubMed has over 22 million citations for biomedical literature from MEDLINE, life science journals, and online books. Constantly updated.
Cancer Research UK CancerHelp information is examined by both expert and lay reviewers. Content is reviewed every 12 to 18 months. Further info. Statistics for the UK, including incidence, mortality, survival, risk factors and stats related to treatment and symptom relief.
Between 15-20% of all colorectal cancers are thought to be familial. Some types of colon cancers and pre-disposing conditions are known to have an inherited element, in particular, Lynch Syndrome (hereditary non-polyposis colon cancer, HNPCC) and familial adenomatous polyposis (FAP).
Cancer Institute NSW A screening reminder service established in 1990 to provide information and support to people affected by hereditary cancer, their family members, and their doctors in NSW and the ACT. Screening for Colorectal (Bowel) Cancer
InSiGHT InSiGHT is an international multidisciplinary, scientific organisation. Itaims to improve care of patients and their families with any condition resulting in hereditary gastrointestinal tumours by fostering research and educating health professionals.
Johns Hopkins Colon Cancer Center Introduces hereditary colorectal cancer syndromes, with specific sections on Familial Adenomatous Polyposis (FAP), Hereditary Nonpolyposis Colorectal Cancer (HNPCC), APC I1307K gene mutation, Kid's FAP, and Hyperplastic Polyposis.
This list of publications is regularly updated (Source: PubMed).
Ortiz AP, Guiot HM, Díaz-Miranda OL, et al. Recognizing and treating anal cancer: training medical students and physicians in Puerto Rico. P R Health Sci J. 2013; 32(4):209-12 [PubMed] Related Publications
OBJECTIVE: This training activity aimed at increasing the knowledge of anal cancer screening, diagnostic and treatment options in medical students and physicians, to determine the interest of these individuals in receiving training in the diagnosis and treatment of anal cancer, and to explore any previous training and/or experience with both anal cancer and clinical trials that these individuals might have. METHODS: An educational activity (1.5 contact hours) was attended by a group of medical students, residents and several faculty members, all from the Medical Sciences Campus of the University of Puerto Rico (n = 50). A demographic survey and a 6-item pre- and post-test on anal cancer were given to assess knowledge change. RESULTS: Thirty-four participants (68%) answered the survey. Mean age was 29.6 +/- 6.6 years; 78.8% had not received training in anal cancer screening, 93.9% reported being interested in receiving anal cancer training, and 75.8% expressed an interest in leading or conducting a clinical trial. A significant increase in the test scores was observed after the educational activity (pre-test: 3.4 +/- 1.2; post-test: 4.7 +/- 0.71). Three of the items showed an increase in knowledge by the time the post-test was taken. The first of these items assessed the participants' knowledge regarding the existence of any guidelines for the screening/treatment of patients with human papillomavirus (HPV)-related anal disease. The second of these items attempted to determine whether the participants recognized that anal intraepithelial neoplasia (AIN) 2 is considered to be a high-grade neoplasia. The last of the 3 items was aimed at ascertaining whether or not the participants were aware that warty growths in the anus are not necessarily a manifestation of high-grade AIN. CONCLUSION: This educational activity increased the participants' knowledge of anal cancer and revealed, as well, that most of the participants were interested in future training and in collaborating in a clinical trial. Training physicians from Puerto Rico on anal cancer clinical trials is essential to encourage recruitment of Hispanic patients in these studies now that the guidelines in anal cancer screening and treatment are on their way to be defined.
Basar N, Ali A, Khan NA, Memon AS Metastasis to ileostomy of mucinous adenocarcinoma of rectum. J Pak Med Assoc. 2013; 63(10):1302-4 [PubMed] Related Publications
Carcinoma of colon and rectum is one of the most common malignancies of gastrointestinal tract. Primary ileostomy cancer following excision of primary tumour is a rare complication although a number of cases have been reported in the last 30 years. This case also reports lymph node metastasis to the adjacent mesenteric lymph nodes. Appearance of ileostomy tumour as synchronous or metachronous lesion is highly debatable. Once diagnosis is confirmed by biopsy enblock excision with or without stomal relocation is the main stay of treatment. Patient education and regular surveillance of patients with long-standing ileostomy is recommended for early detection of this unusual cancer.
Amini AQ, Samo KA, Memon AS Colorectal cancer in younger population: our experience. J Pak Med Assoc. 2013; 63(10):1275-7 [PubMed] Related Publications
OBJECTIVE: To promote awareness regarding increased occurrence of colorectal cancer in younger population and its clinicopathological features compared to older patients. METHODS: The cross-sectional study was conducted from February 2010 to January 2011 on patients with diagnosis of colorectal carcinoma admitted through emergency or outpatients' departments to Surgical Unit 5, Civil Hospital, Karachi. Data regarding age, gender, presentation, site of tumour, surgery performed and Dukes staging was collected and analysed. RESULTS: A total of 23 patients were operated during the study period: 13 (56.52%) males and 10 (43.47%) females. Of them 12 (52.17%) were below the age of 40 years, while 3 (13.04%) patients were in the 11-20 age group. In 7 (30.4%) patients, tumour was irresectable at the time of presentation so a palliative procedure (diversion colostomy or ileostomy) was performed.There was a higher proportion of younger patients with metastatic disease at the time of presentation (n = 9; 75%) while 10 out of 12 patients in the younger age group (83.3%) had a tumour of left colon, particularly rectum. CONCLUSION: Although colorectal cancer is usually a disease of older patients, it is increasingly becoming more common in younger population. Data suggests a leftward distribution for colorectal carcinoma and that younger patients present with more advanced disease and poorer prognosis.
Rymaruk S, Williams J, Kurrimboccus S Carers' perceptions of the enhanced recovery programme in colorectal surgery. J Perioper Pract. 2013; 23(11):246-50 [PubMed] Related Publications
The Enhanced Recovery Programme (ERP) is widely used, especially within colorectal surgery. It is structured around a patient centred decision making process, and the evidence to support the ERP is well documented. Much of the literature focuses on patients' perceptions of the ERP, with qualitative evaluation of their experiences. However, the experience of the ERP from a carer's perspective has yet to be explored.
Samardzić S, Mihaljević S, Dmitrović B, et al. First six years of implementing colorectal cancer screening in the Osijek-Baranja County, Croatia--can we do better? Coll Antropol. 2013; 37(3):913-8 [PubMed] Related Publications
The primary goal of this paper is to evaluate the efficiency of the Colorectal Cancer Screening Program in the Osijek-Baranja County. The screening method for early detection of colorectal cancer was the guaiac Faecal Occult Blood Test (gFOBT) and colonoscopy for gFOBT positive finding. The target population were asymptomatic subjects at average risk, aged 50-74. The responding rate was 20.3% (14.9% of men and 19.3% of women). The percentage of gFOBT positive tests was 8.5% (11.2% of men and 6.6% of women). From the 1,657 individuals who were invited to further assessment (884 men and 773 women), 1,157 underwent a colonoscopy exam (649 men and 508 women). We can conclude that the response to FOBT in our county was extremely poor. 83 carcinomas were found, with almost double findings among men than among women. Our population has a significantly higher number of men with malignant and premalignant changes when compared with women. Considering the higher incidence among men, as well as an increase in incidence in the entire population, we have to take care that our public health programmes are being created with this taken into account, as to increase the response rate, especially among those with a higher risk of developing a disease.
Although staging for colon cancer has become more complex over time, it is not clear that this complexity has improved prognostic assessment. Even with revisions in the 7th edition of the AJCC staging system, a clear rank order of prognosis from substage to substage has not been established. Improved staging models will need to be developed, and attempts at further identifying those high-risk patients within each stage may be clinically useful. Through improved quality measures with lymph node yield, advances in colon cancer staging accuracy have been made over the last decade. Determining how to incorporate ultrastaging and molecular techniques will be the challenge for future staging models.
Langenfeld SJ, Thompson JS, Oleynikov D Laparoscopic colon resection: is it being utilized? Adv Surg. 2013; 47:29-43 [PubMed] Related Publications
Since its inception, the use of laparoscopy for colon surgery has slowly increased, albeit at a slower rate than for cholecystectomy. Initial concerns about the safety and efficacy of laparoscopy have been addressed, and it is now known to have several potential short-term and long-term benefits for the patient. Early studies likely underestimated use of laparoscopy because of coding error. Currently, 40% to 50% of colectomies in the United States are performed laparoscopically, with a 10% to 20% rate of conversion to an open operation. The definitions oflaparoscopy and conversion to open remain at the discretion of the surgeons and their coders. Disparities still exist among use based on several patient, hospital, and surgeon factors. In the future, we will likely see a continuing increase in use as the new generation of surgeons enters practice, and there will be an increasing role for laparoscopy in rectal surgery. The benefit and extent of robotic surgery, natural orifice surgery, and single-incision surgery for minimally invasive colectomies are yet to be defined.
Li K, Li JP, Huang MJ, et al. Quality of life of elderly Chinese rectal cancer patients after preventative anal surgery: a cohort study. Hepatogastroenterology. 2013; 60(126):1376-82 [PubMed] Related Publications
BACKGROUND/AIM: To assess the QOL in rectal cancer patients after preventative anal operation and to discuss the influence of age on perceived quality of life. METHODOLOGY: A prospective study of 342 patients with rectal cancer from May 2011 to January 2012 in the gastrointestinal surgery department was randomly selected and divided into the elderly group and the young group, and the differences in their QOL assessed by the questionnaire QLQ-C30, after preventative anal surgery (7 days) were compared. RESULTS: A total of 207 patients met the study criteria and were divided into the elderly group (≥60 years, 107 cases) and the young group (<60 years, 100 cases). The incidences of complication with pneumonia (p=0.030), wound infection (p=0.024) and ileus (p=0.036) were higher in the elderly group. In the QLQ-C30 assessment, the physical function in the elderly group was worse (p=0.004). Additionally, the fatigue of symptom, sleep disturbance and poor appetite (p<0.001), and global quality of life (p=0.002) were worse in the elderly group too. However, the role and emotional function were better in the elderly group (p<0.001). CONCLUSIONS: The QOL in elderly patients is generally worse than young patients, and a targeted approach should be used.
Tural D, Selcukbiricik F, Özturk MA, et al. The relation between pathological complete response and clinical outcome in patients with rectal cancer. Hepatogastroenterology. 2013; 60(126):1365-70 [PubMed] Related Publications
BACKGROUND/AIMS: Preoperative chemoradiotherapy (CRT) is the standard treatment modality in locally advanced rectal cancer. The primary aim was to correlate pathological complete response (pCR) with patient outcome, and the secondary objective was to identify predictive factors of pCR. METHODOLOGY: Patients with clinical stage II/III rectal cancer who received preoperative CRT between 2002 and 2010 were retrospectively studied.The median radiotherapy dose was 54 Gy (range, 45 to 64 Gy), and all patients received concurrent infusional 5-fluorouracil-based chemotherapy. RESULTS: Median follow-up time was 48.3 months (range, 24 to 96 months) and 51 months (range, 44 to 110 months) for no-pCR and pCR groups, respectively. Eighteen patients (18.6%) had pCR. The 5-year overall survival was 95% for patients with pCR and 74.8% in patients without pCR (p=0.009). The 5-year local relapse free survival was 87.5% and 95% for the no-pCR and pCR groups, respectively (p=0.09). The 5-year distant relapse free survival was 93% in pCR group and 79.8% in no-pCR group (p=0.02). The 5-year distant free survival was 94% and 66% in patients with and without pCR, respectively (p=0.017). The clinical T4 (p=0.043) and pretreatment carcinoembryonic antigen level (CEA) >5ng/mL (p=0.012) were significantly associated with a lower pCR rate. In the multivariate logistic regression analysis, pretreatment CEA level >5ng/mL (p=0.008) was the only independent factor associated with a lower pCR rate. CONCLUSIONS: Patients with pCR after preoperative CRT had a significantly improved outcome. Furthermore, the pretreatment CEA level was independently associated with pCR.
Halabi WJ, Jafari MD, Nguyen VQ, et al. Blood transfusions in colorectal cancer surgery: incidence, outcomes, and predictive factors: an American College of Surgeons National Surgical Quality Improvement Program analysis. Am J Surg. 2013; 206(6):1024-32; discussion 1032-3 [PubMed] Related Publications
BACKGROUND: Data analyzing the short-term outcomes and predictors of blood transfusions (BTs) in colorectal cancer (CRC) surgery are limited. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (2005 to 2010) was retrospectively reviewed for CRC cases performed with or without BT. Patient demographics, comorbidities, and operative variables were analyzed. Multivariate regression analysis was performed examining the effect of BT on outcomes. The LASSO algorithm for logistic regression was used to build a predictive model for BT taking into account preoperative and operative variables. RESULTS: A total of 27,120 patients underwent CRC, and 3,815 (14.07%) had BTs. Transfusions were associated with increased mortality (odds ratio [OR], 1.78), morbidity (OR, 2.38), length of stay (mean difference, 3.52 days), pneumonia (OR, 2.70), and surgical-site infection (OR, 1.45). This effect was "dose dependent," as patients receiving ≥3 U of blood had increased morbidity (OR, 1.53), lengths of stay (mean difference, 1.82 days), pneumonia (OR, 2.52), and surgical-site infections (OR, 1.60) compared with those receiving 1 to 2 U. Predictors of BT were hematocrit <38%, open surgery, proctectomy, low platelet count, American Society of Anesthesiologists class IV or V, total colectomy, metastatic cancer, emergency, ascites, and infection. All P values were < .05. CONCLUSIONS: BTs are associated with worse short-term outcomes after CRC surgery. Knowledge of predictive factors will help in risk stratification and counseling.
BACKGROUND: The Quality Initiative in Rectal Cancer (QIRC) trial targeted surgeon intraoperative technique and not radiation therapy (RT) use. We performed a post hoc analysis of RT use among patients in the QIRC trial, not by arm of trial but rather for the entire group. We wished to identify associations between local recurrence risk and use of preoperative, postoperative or no RT. METHODS: We compared demographic, tumour and process of care measures among patients receiving preoperative, postoperative or no RT. A multivariable Cox regression model assessed local recurrence risk. RESULTS: The QIRC trial enrolled 1015 patients at 16 hospitals between 2002 and 2004. Radiation therapy use did not differ between trial arms, and median follow-up was 3.6 years. For the preoperative, postoperative and no RT groups, respectively, the percentage of patients was 12.8%, 19.3% and 67.9%; the percentage of stage II/III tumours was 57.0%, 88.7% and 48.1%; and the local recurrence rate was 5.3%, 10.2% and 5.5% (p = 0.05). After controlling for patient and tumour characteristics, including tumour stage, the hazard ratio (HR) for local recurrence was increased in the postoperative RT versus the no RT group (HR 1.64, 95% confidence interval 1.04-2.58, p = 0.027). CONCLUSION: Use of preoperative RT was low; most patients with stage II/III disease did not receive RT and, as expected, the postoperative RT group had the highest risk of local recurrence. Our results suggest opportunities to improve rectal cancer RT use in Ontario.
BACKGROUND: Theory suggests the uptake of a medical innovation is influenced by how potential adopters perceive innovation characteristics and by characteristics of potential adopters. Innovation adoption is slow among the first 20% of individuals in a target group and then accelerates. The Quality Initiative in Rectal Cancer (QIRC) trial assessed if rectal cancer surgery outcomes could be improved through surgeon participation in the QIRC strategy. We tested if traditional uptake of innovation concepts applied to surgeons in the experimental arm of the trial. METHODS: The QIRC strategy included workshops, access to opinion leaders, intraoperative demonstrations, postoperative questionnaires, and audit and feedback. For intraoperative demonstrations, a participating surgeon invited an outside surgeon to demonstrate optimal rectal surgery techniques. We used surgeon timing in a demonstration to differentiate early and late adopters of the QIRC strategy. Surgeons completed surveys on perceptions of the strategy and personal characteristics. RESULTS: Nineteen of 56 surgeons (34%) requested an operative demonstration on their first case of rectal surgery. Early and late adopters had similar perceptions of the QIRC strategy and similar characteristics. Late adopters were less likely than early adopters to perceive an advantage for the surgical techniques promoted by the trial (p = 0.023). CONCLUSION: Most traditional diffusion of innovation concepts did not apply to surgeons in the QIRC trial, with the exception of the importance of perceptions of comparative advantage.
Roulston A, Wilkinson P, Haynes T, Campbell J Complementary therapy: perceptions of older people with lung or colorectal cancer. Int J Palliat Nurs. 2013; 19(7):333-9 [PubMed] Related Publications
AIM: To explore how older people with lung and colorectal cancer view registered complementary therapy (CT) services in Northern Ireland. BACKGROUND: A literature review highlighted gaps around information, access, and communication between patients and health professionals regarding CT services. METHODS: Using structured interviews, a survey of 68 patients in one hospital and one hospice was conducted in Belfast, Northern Ireland. RESULTS: All respondents felt that CT services should be better promoted and more easily accessible to older people with cancer. Some patients were concerned about the lack of written information provided regarding CT services, which they believed led to poorer uptake and uncertainty regarding the potential benefits. Others were concerned that engaging in or disclosing CT usage might negatively affect existing relationships with medical professionals. CONCLUSION: Patients should be offered high quality written information on CT services to enable choice, improve knowledge, and promote wider access. Increased physician education may facilitate provision of such information.
Puthli A, Tiwari R, Mishra KP Biochanin A enhances the radiotoxicity in colon tumor cells in vitro. J Environ Pathol Toxicol Oncol. 2013; 32(3):189-203 [PubMed] Related Publications
Herbs and other plant-based compounds have increasingly been recognized as useful for the prevention and treatment of cancer. There exists enormous scope for screening and evaluation of herbal/plant products to develop an effective radiosensitizer and radioprotector that is relevant for cancer therapy. Anticancer agents that can effectively trigger the process of cell death in tumor cells need to be developed. This study describes the effect of the flavonoid biochanin A (BCA), administered alone or in combination with gamma radiation, on the growth of radioresistant human colon cancer HT29 cells in vitro. Proliferation studies were carried out using MTT assay with increasing concentration of BCA (1-100 µM) followed by gamma irradiation at a dose of 2 Gy. Induced reactive oxygen species, mitochondrial membrane potential, lipid peroxidation, and caspase-3 activation were measured by fluorescence assays and the magnitude of induced apoptosis in cells was evaluated by flow cytometry. Cellular DNA damage was determined by comet assay. Combined treatment caused a significant decrease in cell proliferation, a substantial increase in the generation of reactive oxygen species, enhanced lipid peroxidation, and increased mitochondrial membrane potential in treated HT29 cells compared with controls. Significantly enhanced apoptosis and DNA damage were found with a combination of drug and radiation treatments. Furthermore, it was found that combined treatment yielded an additive increase of caspase-3 in these cells. Our findings indicate that BCA acts as a remarkable pro-oxidant, significantly enhancing the radiotoxicity of colon cancer cells in vitro.
Wang W, Wang R, Wang Y, et al. Preoperative colonic lesion localization with charcoal nanoparticle tattooing for laparoscopic colorectal surgery. J Biomed Nanotechnol. 2013; 9(12):2123-5 [PubMed] Related Publications
The efficiency and safety of charcoal nanoparticle tattooing in localizing unpalpable colonic small lesions for later laparoscopy is described. Twenty six patients were enrolled for this prospective study. Tumor sites were localized with charcoal nanoparticles during colonoscopy for later laparoscopic colorectal operations. In all patients, the entire colon was examined preoperatively by colonoscopy and 0.5 ml (5 mg) of charcoal nanoparticle was injected submucosally near lesions or polypectomy sites. During laparoscopic colorectal operations for these biopsy-proven tumors, tumors were easily identified. The mean resection margin was 3.13 +/- 2.01 cm. The mean length of resected intestinal segment was 12.69 +/- 4.39 cm. No tumor was found at the resection line as indicated by postoperative pathological examination. Most importantly, no wrong segment was resected. Thus we show that easy identification of tumor can be achieved by preoperative tattooing with charcoal nanoparticles. Further studies regarding the long-term tattooing of tumor with charcoal nanoparticles are warranted.
Jorgensen ML, Young JM, Dobbins TA, Solomon MJ Assessment of abdominoperineal resection rate as a surrogate marker of hospital quality in rectal cancer surgery. Br J Surg. 2013; 100(12):1655-63 [PubMed] Related Publications
BACKGROUND: Rates of abdominoperineal resection (APR) have been suggested as a solitary surrogate marker for comparing overall hospital quality in rectal cancer surgery. This study investigated the value of this marker by examining the associations between hospital APR rates and other quality indicators. METHODS: Hospital-level correlations between risk-adjusted APR rates for low rectal cancer and six risk-adjusted outcomes and six care processes were performed (such as 30-day mortality, complications, timely treatment). The ability of APR rates to discriminate between hospitals' performance was examined by means of hospital variance results in multilevel regression models and funnel plots. RESULTS: A linked population-based data set identified 1703 patients diagnosed in 2007 and 2008 who underwent surgery for rectal cancer. Some 15.9 (95 per cent confidence interval (c.i.) 14.2 to 17.6) per cent of these patients had an APR. Among 707 people with low rectal cancer, 38.2 (34.6 to 41.8) per cent underwent APR. Although risk-adjusted hospital rates of APR for low rectal cancer varied by up to 100 per cent, only one hospital (1 per cent) fell outside funnel plot limits and hospital variance in multilevel models was not very large. Lower hospital rates of APR for low rectal cancer did not correlate significantly with better hospital-level outcomes or process measures, except for recording of pathological stage (r = -0.55, P = 0.019). Patients were significantly more likely to undergo APR for low rectal cancer if they attended a non-tertiary metropolitan hospital (adjusted odds ratio 2.14, 95 per cent c.i. 1.11 to 4.15). CONCLUSION: APR rates do not appear to be a useful surrogate marker of overall hospital performance in rectal cancer surgery.
Young AL, Adair R, Culverwell A, et al. Variation in referral practice for patients with colorectal cancer liver metastases. Br J Surg. 2013; 100(12):1627-32 [PubMed] Related Publications
BACKGROUND: Half of patients with colorectal cancer develop liver metastases. There remains great variability between hospitals in rates of liver resection for colorectal cancer liver metastases (CLM). This study aimed to determine how many patients with potentially resectable CLM are not seen by specialist liver surgeons. METHODS: Patients presenting with new CLM in a cancer network consisting of a tertiary centre and seven attached hospitals were studied prospectively over 12 months. Data were collected retrospectively for patients who did not have a complete data set. Outcomes for patients referred to the liver tertiary centre were collated. The radiology of tumours deemed inoperable by the local colorectal specialist teams was reviewed by specialist liver surgeons and radiologists. RESULTS: In total, 631 patients with CLM were assessed. Prospective data were complete for 241 patients, and 64 (26.6 per cent) of these were referred to the specialist liver team for consideration of resection. No decision was documented for 16 patients (6.6 per cent). Of those not referred, 30 (18.6 per cent) were deemed unfit or refused and 131 (81.4 per cent) were thought inoperable. Referral rates varied between hospitals (13-43.6 per cent). Of 131 patients deemed fit but inoperable by the colorectal specialist teams, 38 (29.0 per cent) were deemed operable and 20 (15.3 per cent) had equivocal imaging when assessed retrospectively by liver specialists. In total, 142 of the 631 patients were referred to liver specialists for consideration of treatments, and 107 (75.4 per cent) treated with curative intent. CONCLUSION: A considerable number of patients with potentially resectable CLM are not assessed by specialist liver teams. Improved referral rates could greatly improve resection rates for CLM, which may improve outcomes for patients with colorectal cancer.
Steele CB, Rim SH, Joseph DA, et al. Colorectal cancer incidence and screening - United States, 2008 and 2010. MMWR Surveill Summ. 2013; 62 Suppl 3:53-60 [PubMed] Related Publications
Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the United States among cancers that affect both men and women. Screening for CRC reduces incidence and mortality. In 2008, the U.S. Preventive Services Task Force (USPSTF) recommended that persons aged 50-75 years at average risk for CRC be screened for the disease by using one or more of the following methods: fecal occult blood testing (FOBT) every year, sigmoidoscopy every 5 years (with high-sensitivity FOBT every 3 years), or colonoscopy every 10 years.
Zhang JX, Song W, Chen ZH, et al. Prognostic and predictive value of a microRNA signature in stage II colon cancer: a microRNA expression analysis. Lancet Oncol. 2013; 14(13):1295-306 [PubMed] Related Publications
BACKGROUND: Current staging methods do not accurately predict the risk of disease recurrence and benefit of adjuvant chemotherapy for patients who have had surgery for stage II colon cancer. We postulated that expression patterns of multiple microRNAs (miRNAs) could, if combined into a single model, improve postoperative risk stratification and prediction of chemotherapy benefit for these patients. METHOD: Using miRNA microarrays, we analysed 40 paired stage II colon cancer tumours and adjacent normal mucosa tissues, and identified 35 miRNAs that were differentially expressed between tumours and normal tissue. Using paraffin-embedded specimens from a further 138 patients with stage II colon cancer, we confirmed differential expression of these miRNAs using qRT-PCR. We then built a six-miRNA-based classifier using the LASSO Cox regression model, based on the association between the expression of every miRNA and the duration of individual patients' disease-free survival. We validated the prognostic and predictive accuracy of this classifier in both the internal testing group of 138 patients, and an external independent group of 460 patients. FINDINGS: Using the LASSO model, we built a classifier based on the six miRNAs: miR-21-5p, miR-20a-5p, miR-103a-3p, miR-106b-5p, miR-143-5p, and miR-215. Using this tool, we were able to classify patients between those at high risk of disease progression (high-risk group), and those at low risk of disease progression (low-risk group). Disease-free survival was significantly different between these groups in every set of patients. In the initial training group of patients, 5-year disease-free survival was 89% (95% CI 77·3-94·4) for the low-risk group, and 60% (46·3-71·0) for the high-risk group (hazard ratio [HR] 4·24, 95% CI 2·13-8·47; p<0·0001). In the internal testing set of patients, 5-year disease-free survival was 85% (95% CI 74·3-91·8) for the low-risk group, and 57% (42·8-68·5) for the high-risk group (HR 3·63, 1·86-7·01; p<0·0001), and in the independent validation set of patients, was 85% (79·6-89·0) for the low-risk group and 54% (46·4-61·1) for the high-risk group (HR 3·70, 2·56-5·35; p<0·0001). The six-miRNA-based classifier was an independent prognostic factor for, and had better prognostic value than, clinicopathological risk factors and mismatch repair status. In an ad-hoc analysis, the patients in the high-risk group were found to have a favourable response to adjuvant chemotherapy (HR 1·69, 1·17-2·45; p=0·0054). We developed two nomograms for clinical use that integrated the six-miRNA-based classifier and four clinicopathological risk factors to predict which patients might benefit from adjuvant chemotherapy after surgery for stage II colon cancer. CONCLUSION: Our six-miRNA-based classifier is a reliable prognostic and predictive tool for disease recurrence in patients with stage II colon cancer, and might be able to predict which patients benefit from adjuvant chemotherapy. It might facilitate patient counselling and individualise management of patients with this disease. FUNDING: Natural Science Foundation of China.
Katoh H, Wang D, Daikoku T, et al. CXCR2-expressing myeloid-derived suppressor cells are essential to promote colitis-associated tumorigenesis. Cancer Cell. 2013; 24(5):631-44 [PubMed] Related Publications
A large body of evidence indicates that chronic inflammation is one of several key risk factors for cancer initiation, progression, and metastasis. However, the underlying mechanisms responsible for the contribution of inflammation and inflammatory mediators to cancer remain elusive. Here, we present genetic evidence that loss of CXCR2 dramatically suppresses chronic colonic inflammation and colitis-associated tumorigenesis through inhibiting infiltration of myeloid-derived suppressor cells (MDSCs) into colonic mucosa and tumors in a mouse model of colitis-associated cancer. CXCR2 ligands were elevated in inflamed colonic mucosa and tumors and induced MDSC chemotaxis. Adoptive transfer of wild-type MDSCs into Cxcr2(-/-) mice restored AOM/DSS-induced tumor progression. MDSCs accelerated tumor growth by inhibiting CD8(+) T cell cytotoxic activity.
Byrne BE, Mamidanna R, Vincent CA, Faiz O Population-based cohort study comparing 30- and 90-day institutional mortality rates after colorectal surgery. Br J Surg. 2013; 100(13):1810-7 [PubMed] Related Publications
BACKGROUND: Surgical mortality results are increasingly being reported and published in the public domain as indicators of surgical quality. This study examined how mortality outlier status at 90 days after colorectal surgery compares with mortality at 30 days and subsequent intervals in the first year after surgery. METHODS: All adults undergoing elective and emergency colorectal resection between April 2001 and February 2007 in English National Health Service (NHS) Trusts were identified from administrative data. Funnel plots of postoperative case mix-adjusted institutional mortality rate against caseload were created for 30, 90, 180 and 365 days. High- or low-mortality unit status of individual Trusts was defined as breaching upper or lower third standard deviation confidence limits on the funnel plot for 90-day mortality. RESULTS: A total of 171 688 patients from 153 NHS Trusts were included. Some 14 537 (8·5 per cent) died within 30 days of surgery, 19 466 (11·3 per cent) within 90 days, 23 942 (13·9 per cent) within 180 days and 31 782 (18·5 per cent) within 365 days. Eight institutions were identified as high-mortality units, including all four units with high outlying status at 30 days. Twelve units were low-mortality units, of which six were also low outliers at 30 days. Ninety-day mortality correlated strongly with later mortality results (rs = 0·957, P < 0·001 versus 180-day mortality; rs = 0·860, P < 0·001 versus 365-day mortality). CONCLUSION: Extending mortality reporting to 90 days identifies a greater number of mortality outliers when compared with the 30-day death rate. Ninety-day mortality is proposed as the preferred indicator of perioperative outcome for local analysis and public reporting.
Gorissen KJ, Tuynman JB, Fryer E, et al. Local recurrence after stenting for obstructing left-sided colonic cancer. Br J Surg. 2013; 100(13):1805-9 [PubMed] Related Publications
BACKGROUND: Self-expanding metallic stents (SEMS) may be used in acute obstructing left-sided colonic cancers to avoid high-risk emergency surgery. However, oncological safety remains uncertain. This study evaluated the long-term oncological outcome of SEMS as a bridge to elective curative surgery versus emergency resection. METHODS: A consecutive prospective cohort of patients admitted with obstructing left-sided colonic cancer between 2006 and 2012 was analysed. The decision to stent as a bridge to surgery or to perform emergency surgery was made by the on-call consultant colorectal surgeon in conjunction with a consultant interventional radiologist; when appropriate, they performed the stent procedure together. Primary outcomes were local and distant recurrence, and overall survival. Secondary outcomes were postoperative complications, in-hospital mortality, proportion of procedures undertaken laparoscopically, and anastomosis and stoma rates. RESULTS: In total, 105 patients with obstructing left-sided colonic cancer were treated with curative intent; 62 were treated with SEMS as a bridge to surgery and 43 had emergency resection. In patients aged 75 years or less, stenting and delayed surgery was associated with a higher local recurrence rate compared with emergency surgery at the end of follow-up (32 versus 8 per cent; P = 0·038). This did not translate into a significant difference in overall survival. CONCLUSION: SEMS was associated with an increased local recurrence rate.
Shindoh J, Tzeng CW, Aloia TA, et al. Portal vein embolization improves rate of resection of extensive colorectal liver metastases without worsening survival. Br J Surg. 2013; 100(13):1777-83 [PubMed] Related Publications
BACKGROUND: Most patients requiring an extended right hepatectomy (ERH) have an inadequate standardized future liver remnant (sFLR) and need preoperative portal vein embolization (PVE). However, the clinical and oncological impact of PVE in such patients remains unclear. METHODS: All consecutive patients presenting at the M. D. Anderson Cancer Center with colorectal liver metastases (CLM) requiring ERH at presentation from 1995 to 2012 were studied. Surgical and oncological outcomes were compared between patients with adequate and inadequate sFLRs at presentation. RESULTS: Of the 265 patients requiring ERH, 126 (47·5 per cent) had an adequate sFLR at presentation, of whom 123 underwent a curative resection. Of the 139 patients (52·5 per cent) who had an inadequate sFLR and underwent PVE, 87 (62·6 per cent) had a curative resection. Thus, the curative resection rate was increased from 46·4 per cent (123 of 265) at baseline to 79·2 per cent (210 of 265) following PVE. Among patients who underwent ERH, major complication and 90-day mortality rates were similar in the no-PVE and PVE groups (22·0 and 4·1 per cent versus 31 and 7 per cent respectively); overall and disease-free survival rates were also similar in these two groups. Of patients with an inadequate sFLR at presentation, those who underwent ERH had a significantly better median overall survival (50·2 months) than patients who had non-curative surgery (21·3 months) or did not undergo surgery (24·7 months) (P = 0·002). CONCLUSION: PVE enabled curative resection in two-thirds of patients with CLM who had an inadequate sFLR and were unable to tolerate ERH at presentation. Patients who underwent curative resection after PVE had overall and disease-free survival rates equivalent to those of patients who did not need PVE.
Barrow P, Khan M, Lalloo F, et al. Systematic review of the impact of registration and screening on colorectal cancer incidence and mortality in familial adenomatous polyposis and Lynch syndrome. Br J Surg. 2013; 100(13):1719-31 [PubMed] Related Publications
BACKGROUND: The British Society of Gastroenterology recommends that all familial adenomatous polyposis (FAP) and Lynch syndrome (LS) families are screened in the context of a registry. This systematic review was performed to appraise the published evidence for registration and screening in relation to colorectal cancer (CRC) incidence and mortality. METHODS: Five electronic databases were searched using a combination of medical subject heading terms and free-text keywords. Titles and abstracts were scrutinized by two independent reviewers. Inclusion criteria were English-language studies describing CRC incidence and/or mortality in patients with FAP or LS, with comparison of either: screened and unscreened patients, or time periods before and after establishment of the registry. RESULTS: Of 4668 abstracts identified, 185 full-text articles were selected; 43 studies fulfilled the inclusion criteria. No randomized clinical trial evidence was identified. For FAP, 33 of 33 studies described a significant reduction of CRC incidence and mortality with registration and screening. For LS, nine of ten studies described a reduction of CRC incidence and mortality with registration and screening. Five studies (FAP, 2; LS, 3) provided evidence for complete prevention of CRC-related deaths during surveillance. Clinical and statistical heterogeneity prevented pooling of data for meta-analysis. CONCLUSION: Studies consistently report that registration and screening result in a reduction of CRC incidence and mortality in patients with FAP and LS (level 2a evidence, grade B recommendation). Funding and managerial support for hereditary CRC registries should be made available.
Kim MJ, Lee EJ, Suh JP, et al. Traditional serrated adenoma of the colorectum: clinicopathologic implications and endoscopic findings of the precursor lesions. Am J Clin Pathol. 2013; 140(6):898-911 [PubMed] Related Publications
OBJECTIVES: To investigate the clinicopathologic and endoscopic features of precursor lesions associated with traditional serrated adenomas (TSAs). METHODS: Mutation studies for BRAF, KRAS, PIK3CA, and EGFR and immunohistochemical staining for Ki-67 were performed on 107 TSAs from 104 patients. RESULTS: Nondysplastic hyperplastic polyp (HP) or sessile serrated adenoma/polyp (SSA/P) precursor lesions were found in 56 (52.3%) TSAs, among which 32 (57.1%) cases showed a flat-elevated lesion with a type II pit pattern during endoscopy. TSAs with an SSA/P precursor lesion were usually found in the proximal colon, while TSAs with an HP or with no precursor lesion were mainly located in the distal colon and rectum (P < .001). TSAs with a precursor lesion showed a lower frequency of conventional epithelial dysplasia and KRAS mutation as well as a higher frequency of BRAF mutation compared with those with no precursor lesion (P = .002, P < .001, and P < .001, respectively). CONCLUSIONS: A significant proportion of HP or SSA/P precursor lesions accompanied by TSAs can be detected by endoscopy based on both their flat-elevated growth and type II pit patterns. The heterogeneity of TSAs in terms of clinicopathologic and molecular features correlated with the status or type of precursor lesions.
Yamada Y, Takahari D, Matsumoto H, et al. Leucovorin, fluorouracil, and oxaliplatin plus bevacizumab versus S-1 and oxaliplatin plus bevacizumab in patients with metastatic colorectal cancer (SOFT): an open-label, non-inferiority, randomised phase 3 trial. Lancet Oncol. 2013; 14(13):1278-86 [PubMed] Related Publications
BACKGROUND: Studies done in Asia have shown that a regimen of S-1 plus oxaliplatin (SOX) has promising efficacy and safety in patients with metastatic colorectal cancer. We aimed to establish whether SOX plus bevacizumab is non-inferior to mFOLFOX6 (modified regimen of leucovorin, fluorouracil, and oxaliplatin) plus bevacizumab as first-line chemotherapy for metastatic colorectal cancer. METHODS: We undertook an open-label, non-inferiority, randomised phase 3 trial in 82 sites in Japan. We enrolled individuals aged 20-80 years who had metastatic colorectal cancer, had an Eastern Cooperative Oncology Group performance status of 0 or 1, had assessable lesions, had received no previous chemotherapy or radiotherapy, could take drugs orally, and had adequate organ function. Eligible patients were randomly assigned (1:1) to receive either mFOLFOX6 plus bevacizumab (on day 1 of each 2-week cycle, 5 mg/kg intravenous infusion of bevacizumab and a simultaneous intravenous infusion of 85 mg/m(2) oxaliplatin, 200 mg/m(2)l-leucovorin, 400 mg/m(2) bolus fluorouracil, and 2400 mg/m(2) infusional fluorouracil) or SOX plus bevacizumab (on day 1 of each 3-week cycle, 7·5 mg/kg intravenous infusion of bevacizumab and 130 mg/m(2) intravenous infusion of oxaliplatin; assigned dose of S-1 twice a day from after dinner on day 1 to after breakfast on day 15, followed by 7-day break). Randomisation was done centrally with the minimisation method, with stratification by institution and whether postoperative adjuvant chemotherapy had been given. Participants, investigators, and data analysts were not masked to treatment assignment. The primary endpoint was progression-free survival (PFS), which was defined as the interval between enrolment and progressive disease (≥20% increase in sum of longest dimensions of target lesions from baseline, or appearance of new lesions) or death, whichever came first. The primary analysis was done by modified intention to treat. This trial is registered with the Japan Pharmaceutical Information Center, number JapicCTI-090699. FINDINGS: Between Feb 1, 2009, and March 31, 2011, 512 patients underwent randomisation. 256 patients assigned to receive SOX plus bevacizumab and 255 assigned to receive mFOLFOX6 plus bevacizumab were included in the primary analysis. Median PFS was 11·5 months (95% CI 10·7-13·2) in the group assigned to mFOLFOX6 plus bevacizumab and 11·7 months (10·7-12·9) in the group assigned to SOX plus bevacizumab (HR 1·04, 95% CI 0·86-1·27; less than non-inferiority margin of 1·33, pnon-inferiority=0·014). The most common haematological adverse events of grade 3 or higher were leucopenia (21 [8%] of 249 patients given mFOLFOX6 plus bevacizumab included in safety analysis vs six [2%] of 250 given SOX plus bevacizumab; p=0·0029) and neutropenia (84 [34%] vs 22 [9%]; p<0·0001). Grade 3 or higher anorexia (13 [5%] vs three [1%]; p=0·019) and diarrhoea (23 [9%] vs seven [3%]; p=0·0040) were significantly more common in patients given SOX plus bevacizumab than in those given mFOLFOX6 plus bevacizumab. We recorded seven treatment-related deaths (three in the group given mFOLFOX6 plus bevacizumab; four in that given SOX plus bevacizumab). INTERPRETATION: SOX plus bevacizumab is non-inferior to mFOLFOX6 plus bevacizumab with respect to PFS as first-line treatment for metastatic colorectal cancer, and could become standard treatment in Asian populations. FUNDING: Taiho.
Mansvelt B, Dili A, Molle G, et al. Transanal endoscopic microsurgery for rectal tumours using a Single Incision Laparoscopic Port. Acta Chir Belg. 2013 Jul-Aug; 113(4):245-8 [PubMed] Related Publications
BACKGROUND: Transanal endoscopic microsurgery (TEM), first described by Buess enables a less aggressive approach of benign rectal lesions, or even early rectal cancer in a curative intent. MATERIALS AND METHODS: The SILS Port, initially designed for laparoscopic surgery, was successfully used for 20 TEM procedures in 16 patients. Local resection was sufficient in 15 procedures (benign tumours or pT1) out of 20, whereas 5 TEM operations required additional surgery: 3 rectal resections (pT1Nx, pT1sm3Nx and pT2N1) and 1 TEM revision (1 patient refused the rectal resection (pT1Nx). Postoperative complications following Dindo-Clavien were: grade II in 4 patients (pain: 2; fever: 1; bleeding: 1) and grade IIIb in 2 patients (bleeding). No long-term faecal incontinence was noted. CONCLUSION: TEM using the SILS Port is a safe and effective procedure for local resection of benign and certain malignant tumours. Using such a cheaper device, TEM procedure could be available in any operating theatre.
Rafael S, Vidaurreta M, Veganzones S, et al. A9 region in EPHB2 mutation is frequent in tumors with microsatellite instability. Analysis of prognosis. Anticancer Res. 2013; 33(11):5159-63 [PubMed] Related Publications
AIM: The aim of the present study was to determine the relation of EPH tyrosine kinase receptor B2 (EPHB2) A9 region mutation and microsatellite instability (MSI); and to analyze their influence in prognosis of patients with sporadic colorectal cancer (CRC). PATIENTS AND METHODS: A total of 481 patients with CRC were examined. MSI (NCI criteria) and EPHB2 were analyzed using PCR and fragment analysis software. RESULTS: EPHB2 mutation was detected in 3.1% of patients. Mutation of EPHB2 was associated with location and with MSI status. We considered low instability (L-MSI) when only one marker showed instability, high instability (H-MSI) when two or more markers were positive and microsatelllite stable (MSS) when no instability was detected. The stratified analysis of overall survival (OS) and disease-free survival (DFS) in MSI according to EPHB2 status revealed no statistically significant differences. However, the risk of recurrence of H-MSI tumors with EPHB2 mutation carriers was 3.6-times higher than in non-mutation carriers. CONCLUSION: The frequency of EPHB2 mutation is higher in patients with H-MSI than MSS tumors. Promising results were found regarding the prognostic influence of EPHB2 in H-MSI.
Kim YW, Jan KM, Jung DH, et al. Histological inflammatory cell infiltration is associated with the number of lymph nodes retrieved in colorectal cancer. Anticancer Res. 2013; 33(11):5143-50 [PubMed] Related Publications
BACKGROUND: Antitumor immune response is suggested to be a factor affecting the number of nodes retrieved after colorectal cancer surgery. The purpose of this study was to evaluate the correlation of antitumor immune response with the number of retrieved nodes. PATIENTS AND METHODS: Patients with colorectal cancer (n=63, TNM stage II and III) were enrolled. Inflammatory cell infiltration (ICI) was assessed on hematoxylin and eosin staining and T-cell markers (CD3, CD8, CD45RO) were evaluated using immunohistochemical methods. RESULTS: On univariate analysis, high ICI, CD3 and CD8 expression were associated with a greater number of nodes being retrieved. On multivariate analysis, tumors of the right colon (p=0.01) and high ICI (p=0.04) were independent predictors of a greater retrieval of nodes. TNM stage III tumor with low ICI was associated with reduced cancer-specific survival (p=0.02). CONCLUSION: ICI influences the number of nodes retrieved and affects survival of patients with stage III disease. Antitumor immune response may be an underlying factor determining the number of nodes retrieved after surgery for colorectal cancer.
Miyazaki T, Tanaka N, Sano A, et al. Clinical significance of total colonoscopy for screening of colon lesions in patients with esophageal cancer. Anticancer Res. 2013; 33(11):5113-7 [PubMed] Related Publications
AIM: The objective of the present study was to evaluate the significance of pre-treatment screening for patients with esophageal cancer. PATIENTS AND METHODS: A retrospective evaluation of the clinical significance of total colonoscopy in 136 patients with primary esophageal cancer was performed. RESULTS: Twenty-three patients (16.9%) had diverticula, and five (3.7%) had colon cancer. Benign polyps were present in 57 patients (41.9%); 37 of these patients underwent endoscopic treatment, one underwent surgery (esophagectomy). Twenty-seven out of 32 patients (84.4%) who underwent histopathological studies had tubular adenoma. Significant associations were found between presence of colorectal lesions and body weight, body-mass index (p<0.001), Brinkman index (p<0.001), and the Sake index (p<0.05). CONCLUSION: Screening for colorectal lesions using total colonoscopy is important in patients with esophageal cancer, especially for those with a high body-mass index, and those who smoke or drink heavily.