Hospital volume and outcome in rectal cancer patients; results of a population-based study in the Netherlands

BackgroundClinically staged T1-3 rectal cancer (cT1-3) is generally treated by total mesorectal excision(TME) with or without neoadjuvant therapy and sometimes requires beyond TME-surgery, whereas cT4 rectal cancer often requires both. This study evaluates the outcome of cT1-3 and cT4 rectal cancer according to hospital volume.MethodsPatients undergoing rectal cancer surgery between 2005 and 2013 in the Netherlands were included from the National Cancer Registry. Hospitals were divided into low(1–20), medium(21–50) and high(>50 resections/year) volume for cT1-3 and low(1–4), medium(5–9) and high(≥10 resections/year) volume for cT4 rectal cancer. Cox-proportional hazards model was used for multivariable analysis of overall survival (OS).ResultsA total of 14.050 confirmed cT1-3 patients and 2.104 cT4 patients underwent surgery. In cT1-3 rectal cancer, there was no significant difference in 5-year OS related to high, medium and low hospital volume (70% vs. 69% vs. 69%). In cT4 rectal cancer, treatment in a high volume cT4 hospital was associated with a survival benefit compared to low volume cT4 hospitals (HR 0.81 95%CI 0.67–0.98) adjusted for non-treatment related confounders, but this was not significant after adjustment for neoadjuvant treatment. Patients with cT4-tumours treated in high volume hospitals had a significantly lower age, more synchronous metastases, more patients treated with neoadjuvant therapy and a higher pT-stage.ConclusionHospital volume was not associated with survival in cT1-3 rectal cancer. In cT4 rectal cancer, treatment in high volume cT4 hospitals was associated with improved survival compared to low volume cT4 hospitals, although this association lost statistical significance after correction for neoadjuvant treatment.     

Annual hospital volume and colorectal cancer survival in a population-based nationwide cohort study in Finland

PurposeTo examine the annual hospital volume of surgery in relation to survival in colorectal cancer. Previous studies on hospital volume and survival following colorectal cancer surgery are conflicting.MethodsAll 49 032 patients who underwent resection for colorectal cancer in 1987–2016 in Finland were included, with complete follow-up until December 31, 2019. Primary outcome was 5-year mortality. Cox regression provided hazard ratios (HR) with 95% confidence intervals (CI) for quartiles of annual hospital volume for colorectal surgery, adjusted for calendar period, age, sex, comorbidity, stage, tumor location and oncological therapy. Additionally, colon and rectal cancer surgery were assessed separately. Sensitivity analysis of patients with confirmed curative intent was conducted.ResultsCompared to highest quartile (≥108 resections annually), lowest hospital volume (≤37 resections annually) was associated with slightly increased 5-year all-cause mortality (adjusted HR 1.07, 95% CI 1.02–1.12). A pre-planned subgroup-analysis suggested a slightly improved 5-year survival in high-volume institutions for rectal cancer, but not colon cancer surgery. Sensitivity analysis including only those operated with confirmed curative intent suggested no differences between hospital volume groups in colorectal, colon or rectal cancer for 5-year all-cause mortality.ConclusionHigher hospital volume is associated with slightly improved all-cause 5-year mortality in colorectal cancer surgery, but this effect may be limited to rectal cancer surgery only. Volume-outcome relationship in rectal cancer surgery should be investigated further using large datasets. These results do not support centralization of colon cancer surgery based on hospital volume only.     

Sarcopenia and primary tumor location influence patients outcome after liver resection for colorectal liver metastases

IntroductionRight-sided and left-sided colorectal cancer (CRC) is known to differ in their molecular carcinogenic pathways. The prevalence of sarcopenia is known to worsen the outcome after hepatic resection. We sought to investigate the prevalence of sarcopenia and its prognostic application according to the primary CRC tumor site.Methods355 patients (62% male) who underwent liver resection in our center were identified. Clinicopathologic characteristics and long-term outcomes were stratified by sarcopenia and primary tumor location (right-sided vs. left-sided). Tumors in the coecum, right sided and transverse colon were defined as right-sided, tumors in the left colon and rectum were defined as left-sided. Sarcopenia was assessed using the skeletal muscle index (SMI) with a measurement of the skeletal muscle area at the level L3.ResultsPatients who underwent right sided colectomy (n = 233, 65%) showed a higher prevalence of sarcopenia (35.2% vs. 23.9%, p = 0.03). These patients also had higher chances for postoperative complications with Clavien Dindo >3 (OR 1.21 CI95% 0.9–1.81, p = 0.05) and higher odds for mortality related to CRC (HR 1.2 CI95% 0.8–1.8, p = 0.03).On multivariable analysis prevalence of sarcopenia remained independently associated with worse overall survival and disease free survival (overall survival: HR 1.47 CI 95% 1.03–2.46, p = 0.03; HR 1.74 CI95% 1.09–3.4, p = 0.05 respectively).ConclusionSarcopenia is known to have a worse prognosis in patients with CRLM and CRC. Depending on the primary location sarcopenia has a variable effect on the outcome after liver resection.     

Annual hospital volume of surgery for gastrointestinal cancer in relation to prognosis

BackgroundStudies examining hospital volume for surgery for various gastrointestinal (GI) cancer types have shown conflicting results regarding the influence on long-term prognosis. The aim of this study was to examine annual hospital volume in relation to long-term survival after elective surgery for all GI cancers (esophagus, stomach, liver, pancreas, bile ducts, small bowel, colon, and rectum).MethodsPopulation-based cohort study including all 45,908 patients who underwent elective surgery for GI cancers in Sweden in 2005–2013. Follow-up was until 2016 for disease-specific 5-year mortality (main outcome) and 2018 for all-cause 5-year mortality (secondary outcome). Hospitals were divided into quartiles for each GI cancer according to a 4-year average annual volume of the year of surgery and three years earlier. Multivariable Cox regression provided hazard ratios (HRs) with 95% confidence intervals (CIs), adjusted for relevant confounders.ResultsHigher hospital volume was associated with a survival benefit in the large group of patients (n = 26,688) who underwent colon cancer resection, with HR 0.89 (95% CI 0.84–0.96) for disease-specific 5-year mortality comparing the highest with the lowest quartile. Higher hospital volume improved 5-year mortality in sub-groups of patients who underwent surgery for cancer of the esophagus, pancreas, and rectum. No such improvements were found for cancer of the stomach, liver, bile ducts, or small bowel.ConclusionLong-term survival was improved at higher volume hospitals for some GI cancers (colon, esophagus, pancreas, rectum), but not for others (stomach, liver, bile ducts, small bowel).     

Consumption of meat,traditional and modern processed meat and colorectal cancer risk among the Moroccan population: A large-scale case–control study

The current study aimed to investigate the relationship between red and white meat subtypes, processed meat (divided into traditional “Khlii, Kaddid” and industrially processed meat) and colorectal cancer (CRC) risk, considering CRC subsites, in Moroccan adults. A case–control study was conducted including 2,906 matched case–control pairs recruited from the five largest university hospitals in Morocco. Dietary data were collected through a validated Food Frequency Questionnaire (FFQ). Multivariable odds ratios (OR) and 95% confidence intervals (CI), for the association of CRC risk with meat consumption (high vs. low intake), were estimated using conditional logistic regression models, adjusted for relevant confounding variables. Overall, consumption of red meat was positively associated with colon cancer and CRC risk (OR = 1.23, 95% CI = 1.05–1.44; OR = 1.14, 95% CI = 1.02–1.27), respectively. In contrast, no significant association was observed between the consumption of red meat and rectal cancer risk (OR = 1.05, 95% = 0.90–1.23). Interestingly, while processed meat from industrial processes was positively associated with colon cancer, rectal cancer and CRC (OR = 1.61, 95% CI = 1.27–2.04; OR = 1.73, 95% CI = 1.34–2.23; OR = 1.67, 95% CI = 1.41–1.98), processed meat prepared using traditional methods was inversely associated with colon cancer and CRC risk (OR = 0.74, 95% CI = 0.57–0.98; OR = 0.77, 95% CI = 0.64–0.93), respectively. Furthermore, positive associations were observed between poultry intake and colon cancer risk among men (OR = 1.27, 95% CI = 1.01–1.59). Our study showed similar associations between the consumption of red meat and CRC risk in Morocco as in developed countries, while inverse associations were found for traditionally processed meat products. This is the first study to investigate the differential effects of traditional vs. westernized processed meat products in a developing country. Other studies are needed to confirm these findings and to understand the physiological pathways underlying these associations.     

Identification of factors predictive of postoperative morbidity and short-term mortality in older patients after colorectal carcinoma resection: A single-center retrospective study

Objectives

The aim of this study is to investigate the effect of age on patient outcome after colorectal carcinoma (CRC) resection in patients over 65?years of age.

Variation in treatment and outcome of patients with rectal cancer by region,hospital type and volume in the Netherlands

BackgroundAim of this study was to describe treatment patterns and outcome according to region and hospital type and volume among patients with rectal cancer in the Netherlands.MethodsAll patients with rectal carcinoma diagnosed in the period 2001–2006 were selected from the Netherlands Cancer Registry. Logistic regression analyses were performed to examine the influence of relevant factors on the odds of receiving preoperative radiotherapy and on the odds of postoperative mortality. Relative survival analysis was used to estimate relative excess risk of dying according to hospital type and volume.ResultsIn total, 16 039 patients were selected. Patients diagnosed in a teaching or university hospital had a lower odds (OR 0.85; 95% CI 0.73–0.99 and OR 0.70; 95% CI 0.52–0.92) and patients diagnosed in a hospital performing >50 resections per year had a higher odds (OR 1.95; 95% CI 1.09–1.76) of receiving preoperative radiotherapy. A large variation between individual hospitals in rates of preoperative radiotherapy and between Comprehensive Cancer Centre-regions in the administration of preoperative chemoradiation was revealed. Postoperative mortality was not correlated to hospital type or volume. Patients with T1-M0 tumours diagnosed in a hospital with >50 resections per year had a better survival compared to patients diagnosed in a hospital with <25 resections per year (RER 0.11; 95% CI 0.02–0.78).ConclusionThis study demonstrated variation in treatment and outcome of patients with rectal cancer in the Netherlands, with differences related to hospital volume and hospitals teaching or academic status. However, variation in treatment patterns between individual hospitals proved to be much larger than could be explained by the investigated characteristics. Future studies should focus on the reasons behind these differences, which could lead to a higher proportion of patients receiving optimal treatment for their stage of the disease.     

Breast magnetic resonance imaging use in patients undergoing neoadjuvant chemotherapy is associated with less mastectomies in large ductal cancers but not in lobular cancers

BackgroundTo assess the impact of breast magnetic resonance imaging (MRI) use on surgical outcome per histological breast cancer subtype in patients treated with neoadjuvant chemotherapy.Patients and methodsAll patients aged 18–70 years who underwent neoadjuvant chemotherapy for stage I–III invasive breast cancer in the Netherlands in the years 2011–2013 were identified from the Netherlands Cancer Registry. Patients with cT4 tumours were excluded from the analysis. Use of breast MRI and impact on surgical treatment, resection margins and detection of contralateral breast cancer were analysed by multivariable analyses.ResultsBreast MRI was performed in 2879 (83.9%) out of 3433 patients treated with neoadjuvant chemotherapy. Younger age (odds ratio [OR] 1.42; 95% confidence interval [CI] 1.17–1.71 for 18–50 years compared with 50–70 years), larger tumour stage (OR 1.46 [95% CI 1.15–1.86] for cT3, compared to cT1–2 tumours) and multifocality (OR 1.30; 95% CI 1.04–1.61, versus unifocality) were associated with increased breast MRI use. In ductal breast cancer, after stratification for cT-status, breast MRI use is associated with a significant lower OR for mastectomy as final surgery in cT3 tumours (OR 0.45, 95% CI 0.21–0.99). Resection margin involvement and detection of contralateral breast cancer were not associated with breast MRI use.ConclusionIn patients treated with neoadjuvant chemotherapy, the use of breast MRI was associated with a reduced mastectomy rate, particularly in patients with large invasive ductal breast tumours but not in patients with lobular breast cancer.     

Common dietary patterns and risk of cancers of the colon and rectum: Analysis from the United Kingdom Women's Cohort Study (UKWCS)

Few prospective cohort studies in the UK have specifically focused on the associations between commonly consumed dietary patterns and colorectal cancer (CRC). The aim of our study was to assess whether red meat, poultry, fish and vegetarian dietary patterns are associated with differences in the incidence of cancers of colon and rectum in the UKWCS. Four common dietary patterns were defined based on a hierarchy of consumption of red meat, poultry and fish for each cohort participant, using a 217‐item food frequency questionnaire. Cox proportional hazards regression was used to provide adjusted hazard ratios (HR) and 95% confidence intervals (CI) for CRC. A total of 32,147 women recruited and surveyed between 1995 and 1998 were followed up for a mean of 17.2 years (426,798 person‐years). A total of 462 incident CRC cases were documented; 335 colon cancers (172 proximal and 119 distal) and 152 in the rectum. In multivariable‐adjusted models, there was no evidence of a reduction in risk of overall CRC (HR = 0.86, 95% CI: 0.66–1.12), colon cancer (HR = 0.77, 95% CI: 0.56–1.05) or rectal cancer (HR = 1.04, 95% CI: 0.66–1.63) when comparing grouped red meat free diets with diets containing red meat. Exploratory analysis suggested a reduced risk of distal colon cancer in grouped red meat free diets (HR = 0.56, 95% CI: 0.34–0.95), though numbers with this outcome were small. These results indicate that a protective association of red meat free diets specifically on distal colon cancer merits confirmation in a larger study.     

Disparities in quality of care for colon cancer between hospitals in the Netherlands

BackgroundAim of this study was to describe treatment patterns and outcome according to region, and according to hospital types and volumes among patients with colon cancer in the Netherlands.MethodsAll patients with invasive colon carcinoma diagnosed in the period 2001–2006 were selected from the Netherlands Cancer Registry. Logistic regression analyses were performed to examine the influence of relevant factors on the odds of having adequate lymph node evaluation, receiving adjuvant chemotherapy and postoperative mortality. Relative survival analysis was used to estimate relative excess risk of dying according to hospital type and volume.ResultsIn total, 39 907 patients were selected. Patients diagnosed in a university hospital had a higher odds (OR 2.47; 95% CI 2.19–2.78) and patients diagnosed in a hospital with >100 colon carcinoma diagnoses annually had a lower odds (OR 0.70; 95% CI 0.64–0.77) of having ≥10 lymph nodes evaluated. The odds of receiving adjuvant chemotherapy was lower in patients diagnosed in teaching hospitals (OR 0.85; 95% CI 0.73–0.98) and university hospitals (OR 0.56; 95% CI 0.45–0.70) compared to patients diagnosed in non-teaching hospitals. Funnel plots showed large variation in these two outcome measures between individual hospitals. No differences in postoperative mortality were found between hospital types or volumes. Patients diagnosed in university hospitals and patients diagnosed in hospitals with >50 diagnoses of colon carcinoma per year had a better survival.ConclusionsVariation in treatment and outcome of patients with colon cancer in the Netherlands was revealed, with differences between hospital types and volumes. However, variation seemed mainly based on the level of the individual hospital.     

Red meat and cancer risk in a network of case–control studies focusing on cooking practices

BackgroundConsumption of red meat has been related to increased risk of several cancers. Cooking methods could modify the magnitude of this association, as production of chemicals depends on the temperature and duration of cooking.MethodsWe analyzed data from a network of case–control studies conducted in Italy and Switzerland between 1991 and 2009. The studies included 1465 oral and pharyngeal, 198 nasopharyngeal, 851 laryngeal, 505 esophageal, 230 stomach, 1463 colon, 927 rectal, 326 pancreatic, 3034 breast, 454 endometrial, 1031 ovarian, 1294 prostate and 767 renal cancer cases. Controls included 11 656 patients admitted for acute, non-neoplastic conditions. Odds ratios (ORs) and confidence intervals (CIs) were estimated by multiple logistic regression models, adjusted for known confounding factors.ResultsDaily intake of red meat was significantly associated with the risk of cancer of the oral cavity and pharynx (OR for increase of 50 g/day = 1.38; 95% CI: 1.26–1.52), nasopharynx (OR = 1.29; 95% CI: 1.04–1.60), larynx (OR = 1.46; 95% CI: 1.30–1.64), esophagus (OR = 1.46; 95% CI: 1.23–1.72), colon (OR = 1.17; 95% CI: 1.08–1.26), rectum (OR = 1.22; 95% CI:1.11–1.33), pancreas (OR = 1.51; 95% CI: 1.25–1.82), breast (OR = 1.12; 95% CI: 1.04–1.19), endometrium (OR = 1.30; 95% CI: 1.10–1.55) and ovary (OR = 1.29; 95% CI: 1.16–1.43). Fried meat was associated with a higher risk of cancer of oral cavity and pharynx (OR = 2.80; 95% CI: 2.02–3.89) and esophagus (OR = 4.52; 95% CI: 2.50–8.18). Risk of prostate cancer increased for meat cooked by roasting/grilling (OR = 1.31; 95% CI: 1.12–1.54). No heterogeneity according to cooking methods emerged for other cancers. Nonetheless, significant associations with boiled/stewed meat also emerged for cancer of the nasopharynx (OR = 1.97; 95% CI: 1.30–3.00) and stomach (OR = 1.86; 95% CI: 1.20–2.87).ConclusionsOur analysis confirmed red meat consumption as a risk factor for several cancer sites, with a limited impact of cooking methods. These findings, thus, call for a limitation of its consumption in populations of Western countries.     

Surgical treatment of primary locally advanced rectal cancer in Norway

AimsMost reports on locally advanced rectal cancer come from specialized centres, with a selected patient material. The purpose of this study was to examine the results after surgical treatment of patients with locally advanced rectal cancer at a population level.MethodsNational cohort study of 896 patients undergoing surgery for a locally advanced primary adenocarcinoma of the rectum from November 1993 to December 2001.ResultsSurgery with resection was undertaken in 724 patients and 172 patients underwent palliative procedures. Of 557 patients treated for cure, a R0 resection was achieved in 342 (61%). In a multivariate analysis, pre-operative radiotherapy was the only factor with a positive association with R0 status (odds ratio 3.7, 95% confidence interval (CI) 2.1–6.4). Five-year local recurrence rates were 18% (CI 14–23) for R0 resections and 40% (CI 26–52) for R1 resections. Overall 5-year survival rate was 23%; for the group of patients with a R0 resection the survival rate was 49%.ConclusionThe radical resection rate and survival rates in this national study were similar to those reported from specialized centres.     

Adherence to the World Cancer Research Fund/American Institute for Cancer Research recommendations and colorectal cancer risk

BackgroundThe World Cancer Research Fund (WCRF) and the American Institute for Cancer Research (AICR) released in 2007 eight recommendations for cancer prevention on body fatness, diet and physical activity. Our aim is to evaluate the relation between adherence to these recommendations and colorectal cancer (CRC) risk.MethodsWe pooled data from two Italian case–control studies including overall 2419 patients with CRC and 4723 controls. Adherence to the WCRF/AICR guidelines was summarised through a score incorporating seven of the WCRF/AICR recommendations, with higher scores indicating higher adherence to the guidelines. Odds ratios (ORs) of colorectal cancer were estimated using multiple logistic regression models.ResultsHigher adherence to the WCRF/AICR recommendations was associated with a significantly reduced CRC risk (OR 0.67, 95% confidence interval, CI, 0.56–0.80 for a score ≥5 versus <3.5), with a significant trend of decreasing risk for increasing adherence (p < 0.001). Consistent results were found for colon (OR 0.67) and rectal cancer (OR 0.67). Inverse associations were observed with the diet-specific WCRF/AICR score (OR 0.71, 95% CI, 0.61–0.84 for ≥3.5 versus <2.5 points) and with specific recommendations on body fatness (OR 0.82, 95% CI, 0.70–0.97), physical activity (OR 0.86, 95% CI, 0.75–1.00), foods and drinks that promote weight gain (OR 0.70, 95% CI, 0.56–0.89), foods of plant origin (OR 0.56, 95% CI, 0.42–0.76), limiting alcohol (OR 0.87, 95% CI, 0.77–0.99) and salt intake (OR 0.63, 95% CI, 0.48–0.84).ConclusionOur study indicated that adherence to the WCRF/AICR recommendations is inversely related to CRC risk.     

Plasma methionine,choline, betaine,and dimethylglycine in relation to colorectal cancer risk in the European Prospective Investigation into Cancer and Nutrition (EPIC)

BackgroundDisturbances in one carbon metabolism may contribute to carcinogenesis by affecting methylation and synthesis of DNA. Choline and its oxidation product betaine are involved in this metabolism and can serve as alternative methyl group donors when folate status is low.Patients and methodsWe conducted a case–control study nested within the European Prospective Investigation into Cancer and Nutrition (EPIC), to investigate plasma concentrations of the methyl donors methionine, choline, betaine (trimethylglycine), and dimethylglycine (DMG) in relation to colorectal cancer (CRC) risk. Our study included 1367 incident CRC cases (965 colon and 402 rectum) and 2323 controls matched by gender, age group, and study center. Multivariate-adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs) for CRC risk were estimated by conditional logistic regression, comparing the fifth to the first quintile of plasma concentrations.ResultsOverall, methionine (OR: 0.79, 95% CI: 0.63–0.99, P-trend = 0.05), choline (OR: 0.77, 95% CI: 0.60–0.99, P-trend = 0.07), and betaine (OR: 0.85, 95% CI: 0.66–1.09, P-trend = 0.06) concentrations were inversely associated with CRC risk of borderline significance. In participants with folate concentration below the median of 11.3 nmol/l, high betaine concentration was associated with reduced CRC risk (OR: 0.71, 95% CI: 0.50–1.00, P-trend = 0.02), which was not observed for those having a higher folate status. Among women, but not men, high choline concentration was associated with decreased CRC risk (OR: 0.62, 95% CI: 0.43–0.88, P-trend = 0.01). Plasma DMG was not associated with CRC risk.ConclusionsIndividuals with high plasma concentrations of methionine, choline, and betaine may be at reduced risk of CRC.     

Lack of association between diagnostic and therapeutic delay and stage of colorectal cancer

BackgroundA recent review suggests that there is no association between diagnostic and therapeutic delays and survival in colorectal cancer patients. However, the effect of tumour stage on the relationship between delay and survival in CRC should be clarified. We review here the evidence on the relationship between diagnostic and therapeutic delays and stage in colorectal cancer.MethodsWe conducted a systematic review of Medline, Embase, Cancerlit and the Cochrane Database of Systematic Reviews to identify publications published between 1965 and 2006 dealing with delay, stage and colorectal cancer. A meta-analysis was performed based on the estimation of the odds ratios (OR) and on a random effects model.ResultsWe identified 50 studies, representing 18,649 patients. Thirty studies were excluded due to excessively restricted samples (e.g. exclusion of patients with intestinal obstruction or who died 1–3 months after surgery) or because they studied only a portion of the delay. Of the 37 remaining studies, great variability was noted in connection with the type of classification used for disease stage and the type of measurement used for the delay. Meta-analysis was performed based on 17 studies that included 5209 patients. The combined OR was 0.98 (95% confidence interval (CI): 0.76–1.25), suggesting a lack of association between delay and disease stage. In four studies, cancers of the colon and rectum were dealt with separately, and a meta-analysis was performed using the data for colon cancer (1001 patients) and for rectal cancer (799 patients). In both cases, the combined ORs overlapped 1.0, and showed opposite associations when studied separately: 0.86 (95% CI: 0.63–1.19) for the colon (i.e. more delay is associated with the earlier stage at diagnosis) and 1.93 (95% CI: 0.89-4.219) for the rectum (i.e. less delay is associated with the earlier stage).ConclusionsWhen colorectal cancers are taken as a whole, there appears to be no association between diagnostic delay and disease stage when diagnosis is made. However, when cancers of the colon and the rectum are studied separately, there may be an opposite association. More studies about this issue are needed with larger and unrestricted samples.     

Factors associated with survival in older patients with stage I-III colorectal carcinoma who were not managed curatively in the Netherlands

AimSome patients with stage I-III colorectal cancer (CRC) do not undergo tumor resection. Little is known about survival of these non-curatively managed patients. The aim of this study is to report all-cause mortality and to identify which factors are associated with survival in these patients.MethodsA retrospective review of electronic medical records was performed in two hospitals in the Netherlands. Patients diagnosed with CRC without distant metastases (radiologically determined stage I-III) and managed without tumor resection between 2011 and 2017 were included. The primary outcome was all-cause mortality. The effect of several variables on survival was evaluated with a multivariate logistic regression.ResultsOf the 107 patients with stage I-III CRC that did not undergo resection of the primary tumor, 80% died within two years; median survival time was 8.5 months (IQR 2.5–22 months). Malnutrition risk (OR 6.36 (CI 1.21–33.25); p = 0.03) and comorbidity burden (OR 1.51 (CI 1.05–2.18 p = 0.03) were significantly associated with decreased survival after two years in a multivariate model. Age and disease stage were not. When treatment decision was mainly patient driven instead of based on the multi-disciplinary tumor board's decision, survival was longer (mean overall survival 16 months vs 10 months, respectively) p < 0.05.ConclusionSurvival of patients with radiologically determined stage I-III CRC who did not undergo surgical resection was approximately 20% at two years and associated with the number of comorbidities, malnutrition risk status and dependent living, but not with age or disease stage.     

Influence of the introduction of caseload requirements on indication for visceral cancer surgery in Switzerland

BackgroundIn 2013 Swiss health authorities implemented annual hospital caseload requirements (CR) for five areas of visceral surgery. We assess the impact of the implementation of CR on indication for surgery in esophageal, pancreatic and rectal cancer.Materials and methodsRetrospective analysis of national registry data of all inpatient admissions between January 1st^, 2005 and December 31st^, 2015. Primary end-point was the age-adjusted resection rate for esophageal, pancreatic and rectal cancer among patients with at least one cancer-specific hospitalization per year. We calculated age-adjusted rate ratios for period effects before and after implementation of CR and odds ratios (OR) based on a generalized estimation equation. A relative increase of 5% in age-adjusted relative risk was set a priori as relevant from a health policy perspective.ResultsAge-adjusted resection rates before and after the implementation of CR were 0.12 and 0.13 (Relative Risk [RR] 1.08; 95%-Confidence Interval [CI] 0.85–1.36) in esophageal cancer, 0.22 and 0.26 (RR 1.17; 95%-CI 0.85–1.58) in pancreatic cancer and 0.38 and 0.43 (RR 1.14; 95%-CI 0.99–1.30) in rectal cancer.In adjusted models OR for resection after the implementation of CR were 1.40 (95%-CI 1.24–1.58) in esophageal cancer, 1.05 (95%-CI 0.96–1.15) in pancreatic cancer and 0.92 (95%-CI 0.87–0.97) in rectal cancer.ConclusionImplementation of CR was associated with an increase of resection rates above the a priori set margins in all resections groups. In adjusted models, odds for resection were significantly higher for esophageal cancer, while they remained unchanged for pancreatic and decreased for rectal cancer.     

A systematic review and meta-analysis comparing surgical and oncological outcomes of upper rectal,rectosigmoid and sigmoid tumours

AimManagement paradigms for tumours from the sigmoid colon to the lower rectum vary significantly. The upper rectum (UR) represents the transition point both anatomically and in treatment protocols. Above the UR is clearly defined and managed as colon cancer and below is managed as rectal cancer. This study compares outcomes between sigmoid, rectosigmoid and UR tumours to establish if differences exist in operative and oncological outcomes.MethodsElectronic databases were searched for published studies with comparative data on peri-operative and oncological outcome for upper rectal and sigmoid/rectosigmoid (SRS) tumours treated without neoadjuvant radiation. The search adhered to PRISMA guidelines (Preferred Reporting Items in Systematic Reviews and Meta-analyses) guidelines. Data was combined using random-effects models.ResultsSeven comparative series examined outcomes in 4355 patients. There was no difference in ASA grade (OR, 1.28; 95% CI, 0.99–1.67; P = 0.06), T3/T4 tumours (OR, 1.24; 95% CI, 0.95–1.63; P = 0.12), or lymph node positivity (OR, 0.97; 95% CI, 0.70–1.36; P = 0.87). UR cancers had higher rates of operative morbidity (OR, 0.72; 95% CI, 0.55–0.93; P = 0.01) and anastomotic leak (OR, 0.47; 95% CI, 0.31–0.71; P = 0.0004). There was no difference in local recurrence (OR, 0.63; 95% CI, 0.37–1.08; P = 0.10). SRS tumours had lower rates of distant recurrence (OR, 0.83; 95% CI, 0.68–1.0; P = 0.05). Rectosigmoid operative and cancer outcomes were closer to UR than sigmoid.ConclusionsBased on existing data, UR and rectosigmoid tumours have higher morbidity, leak rates and distant recurrence than more proximal tumours.     

Prediction scores for complication and recurrence after multivisceral resection in gastric cancer

BackgroundMultivisceral resection (MVR) is indicated in T4b gastric cancer (GC) when R0 can be achieved. Patient's selection for MVR is imperative, since it carries an increased risk for postoperative complications (POC) and disease recurrence. This study aims to elaborate prediction scores for POC and recurrence after MVR for cT4b GC.MethodsPatients who underwent MVR with curative intent due to cT4b gastric adenocarcinoma were selected from our prospective database. Scoring models were based on the variables identified as risk factors for the studied outcome. Through binary regression the model that best predicted the outcome was created.ResultsFrom 237 MVRs, 58 fulfilled the inclusion criteria. Males were 70.7%, mean age was 61.8 years. A pT4b was confirmed in 34 patients, 29 had 2 or more adjacent organs removed. Major POC occurred in 25.9%, mortality was 8.6%. Overall survival (OS) and disease-free survival (DFS) were similar for pT4b and non-pT4b. DFS was worse for pN+ and when >2 adjacent organs were removed. Scoring models included 5 and 6 parameters for POC and recurrence, respectively, and their accuracy was 80.6% (95%CI = 0.69–0.92) and 78% (95%CI = 0.66–0.90). The POC and recurrence rates in low- and high-score groups were statistically different (p < 0.001 and p = 0.004, respectively). Patients with high-risk for POC had lower OS (p = 0.036) and DFS was worse in the high-recurrence risk group (p = 0.008).ConclusionThe proposed scoring systems accurately predict POC and recurrence in GC patients undergoing MVR. These models are easy to use and can assist in the adoption of an individualized approach.     

Role of major resection in pulmonary metastasectomy for colorectal cancer in the Spanish prospective multicenter study (GECMP-CCR)

BackgroundPatients with pulmonary metastases from colorectal cancer (CRC) may benefit from aggressive surgical therapy. The objective of this study was to determine the role of major anatomic resection for pulmonary metastasectomy to improve survival when compared with limited pulmonary resection.Patients and methodsData of 522 patients (64.2% men, mean age 64.5 years) who underwent pulmonary resections with curative intent for CRC metastases over a 2-year period were reviewed. All patients were followed for a minimum of 3 years. Disease-specific survival (DSS) and disease-free survival (DFS) were assessed with the Kaplan–Meier method. Factors associated with DSS and DFS were analyzed using a Cox proportional hazards regression model.ResultsA total of 394 (75.6%) patients underwent wedge resection, 19 (3.6%) anatomic segmentectomy, 5 (0.9%) lesser resections not described, 100 (19.3%) lobectomy, and 4 (0.8%) pneumonectomy. Accordingly, 104 (19.9%) patients were treated with major anatomic resection and 418 (80.1%) with lesser resection. Operations were carried out with video-assisted thoracoscopic surgery (VATS) in 93 patients. The overall DSS and DFS were 55 and 28.3 months, respectively. Significant differences in DSS and DFS in favor of major resection versus lesser resection (DSS median not reached versus 52.2 months, P = 0.03; DFS median not reached versus 23.9 months, P < 0.001) were found. In the multivariate analysis, major resection appeared to be a protective factor in DSS [hazard ratio (HR) 0.6, 95% confidence interval (CI) 0.41–0.96, P = 0.031] and DFS (HR 0.5, 95% CI 0.36–0.75, P < 0.001). The surgical approach (VATS versus open surgical resection) had no effect on outcome.ConclusionMajor anatomic resection with lymphadenectomy for pulmonary metastasectomy can be considered in selected CRC patient with sufficient functional reserve to improve the DSS and DFS. Further prospective randomized studies are needed to confirm the present results.