Abstract
Background
Colonoscopy is the gold standard for colorectal cancer (CRC) diagnosis and screening, but endoscopy services are usually overburdened. This study aims to investigate the ...usefulness of fecal hemoglobin (fHb) and calprotectin (FC) for the identification of patients with high probability of CRC who need urgent referral.
Methods
In a multicenter prospective study, we enrolled symptomatic patients referred from primary care for colonoscopy. Prior to bowel preparation, fHb and FC quantitative tests were performed. The diagnostic performance was estimated for each biomarker/combination. We built a multivariable predictive model based on logistic regression, translated to a nomogram and a risk calculator to assist clinicians in the decision‐making process.
Results
The study included 1224 patients, of whom 69 (5.6%) had CRC. At the fHb cut‐offs of >0 and 10 μg/g, the negative predictive values for CRC were 98.8% (95% confidence interval 97.8%–99.3%) and 98.6% (95%CI 97.7%–99.1%), and the sensitivities were 85.5% (95%CI 75.0%–92.8%) and 79.7% (95%CI 68.3%–88.4%), respectively. When we added the cut‐off of 150 μg/g of FC to both fHb thresholds, the sensitivity of fecal tests improved. In the multivariate logistic regression model, the concentration of fHb was an independent predictor for CRC; age and gender were also independently associated with CRC.
Conclusions
fHb and FC are useful as part of a triage tool to identify those symptomatic patients with high probability of CRC. This can be easily applied by physicians to prioritize high‐risk patients for urgent colonoscopy.
El cáncer colorrectal (CCR), hoy en día es una de las neoplasias con mayor incidencia y mortalidad en España. Su etiología es multifactorial, influyendo tanto alteraciones genéticas/epigenéticas como ...factores ambientales (hábitos, tóxicos, dieta). Estudios demuestran que los programas de cribado actuales como el test inmunológico fecal (FIT), sigmoidoscopia y colonoscopia han disminuido la mortalidad del CCR. Sin embargo, el FIT presenta muchos falsos positivos y negativos, dando lugar a la realización de colonoscopias innecesarias que suponen un gran gasto para la sociedad. Por lo tanto, existe una necesidad de crear un método de detección precoz del CCR no-invasivo y preciso que maximice la correcta identificación de pacientes que tengan que hacerse una colonoscopia y minimice la realización de pruebas innecesarias. Por otro lado, los pacientes con poliposis múltiple de origen desconocido siguen siendo "huérfanos genéticos" hoy en día porque no presentan una mutación constitucional conocida. Por lo tanto la detección de biomarcadores para esta condición también es necesaria. El principal objetivo del primer estudio de la presente tesis doctoral, fue el desarrollo de un método no-invasivo para la detección del CCR mediante el análisis de compuestos orgánicos volátiles (COVs) en heces de pacientes con CCR, adenomas y controles sanos. Los COVs se extrajeron mediante un método y protocolo desarrollado por nuestro grupo de investigación (que está bajo patente) y posterior identificación mediante la cromatografía de gases-espectrometría de masas (GC-MS). Se analizaron muestras de un total de 64 sujetos. Encontramos que 3 COVs se detectaban a distinta concentración entre los distintos grupos de estudio, siendo las diferencias más significativas entre pacientes con CCR y controles sanos. Tras estudiar el potencial de cada compuesto como posible biomarcador de enfermedad, observamos que dos de los tres COVs presentaban diferencias significativas en la abundancia entre CCR y controles, con una sensibilidad y especificidad elevada sugiriendo su potencial como biomarcadores de enfermedad. El segundo estudio de la presente tesis doctoral, se centra en la poliposis colónica múltiple de origen desconocido. El grupo de pacientes seleccionados carecen de mutaciones en genes como APC y MYH (ya que se considerarían Poliposis Adenomatosa Familiar y Poliposis asociada a MYH). En el estudio se incluyeron un total de 135 sujetos (83 enfermos y 52 controles). Se analizaron niveles séricos de citoquinas inflamatorias mediante ensayos ELISA y diversos factores ambientales (DM, hábito tabáquico, IMC, índice HOMA-IR). En este estudio, se detectó por primera vez una asociación entre interleucinas de las Th17 y la PCR con la presencia de polipósis múltiple. Este resultado no descarta la posible implicación de otros genes en la aparición de los pólipos pero el incremento de la IL-17A, IL-23 e IL-6 pertenecientes a la respuesta mediada por las células Th17, sugiere una asociación de esta vía con la aparición de múltiples pólipos colónicos. Nuestro grupo de investigación está llevando a cabo otro estudio para validar estos resultados. En resumen, ambos estudios detectan distintos biomarcadores que podrían ser útiles para diagnosticar; el CCR en el caso del primer estudio mediante el análisis de diversos COVs y la poliposis múltiple de origen desconocido en el caso del segundo estudio analizando la concentración de las tres interleucinas pertenecientes a la vía Th17.
Purpose
To assess the impact of readmission and reoperation on colon or rectal cancer patients in clinical and patient-reported outcome measures (PROMs) and to identify predictors of these events up ...to 1 year after surgery.
Methods
Prospective cohort study of patients diagnosed with colon or rectal cancer who underwent surgery at 1 of 22 hospitals. Medical history, clinical parameters, and PROMs were evaluated as possible predictors. Multivariable multilevel logistic regression and survival models were used in the analyses to create the clinical prediction rules. Models were developed in a derivation sample and validated in a different sample.
Results
Readmission and reoperation were related to clinical outcomes and changes in some PROMs. Predictors of readmission in colon cancer were ASA class (odds ratio (OR) 4.5), TNM (OR for TNM III 3.24, TNM IV 4.55), evidence of residual tumor (R2) (OR 3.96), and medical (OR 1.96) and infectious (OR 2.01) complications within 30 days after surgery, while for rectal cancer, the predictors identified were age (OR 1.03), R2 (OR 6.48), infectious complications within 30 days (OR 2.29), hemoglobin (OR 3.26), lymph node ratio (OR 2.35), and surgical complications within 1 month (OR 3.04). Predictors of reoperation were TNM IV (OR 5.06), surgical complications within 30 days (OR 1.98), and type and site of tumor (OR 1.72) in colon cancer and being male (OR 1.52), age (OR 1.80), stoma (OR 1.87), and surgical complications within 1 month (OR 1.95) in rectal cancer.
Conclusions
Our clinical prediction rule models are easy to use and could help to develop and implement interventions to reduce preventable readmissions and reoperations.
Trial registration
https://clinicaltrials.gov/ct2/show/NCT02488161
Identifier: NCT02488161
Purpose
To identify and validate risk factors that contribute to prolonged length of hospital stay (LOS) in patients undergoing resection for colorectal cancer.
Methods
This prospective cohort study ...included 1955 patients admitted to 22 hospitals for primary resection of colorectal cancer. Multivariate analyses were used to identify and validate risk factors, randomizing patients into a derivation and a validation cohort. Multiple correspondence and cluster analysis were performed to identify clinical subtypes based on LOS.
Results
The strongest independent predictors of prolonged LOS were postoperative reintervention, surgical site infection, open surgery, and distant metastasis. The multiple correspondence and cluster analysis provided three groups of patients in relation to prolonged LOS: patients with the longest LOS included the highest percentage of patients with open surgery, distant metastasis, deep surgical site infections, emergency admissions, additional diagnostic factors, and highly contaminated surgical sites. Patients with prolonged LOS (> 14 days) were more likely to develop adverse outcomes within 30 days after discharge.
Conclusions
Patients undergoing resection of colorectal cancer cluster into different groups based on LOS of the index admission. Those with prolonged LOS were more likely to develop adverse outcomes within 30 days after discharge. Some of the strongest independent predictors of prolonged LOS, such as surgical infections or open surgery, could be modified to reduce LOS and, in turn, other adverse outcomes.
Trial registration
NCT02488161
Background
Few economic evaluations have assessed laparoscopy for colon cancer. This study aimed to compare the cost-effectiveness of laparoscopic and open surgery for the treatment of colon cancer.
...Method
A cost-effectiveness analysis was performed comparing two groups of patients treated according to standard clinical practice (REDISSEC-CARESS/CCR cohort) by laparoscopic or open surgery. Data were collected from health records on clinical characteristics and resource use over 2 years after surgery. To calculate the incremental cost-effectiveness ratio, costs and quality-adjusted life years (QALYs) were obtained for each patient. Clinical heterogeneity was addressed using propensity score and joint multivariable analysis (seemingly unrelated regression) that included interactions between TNM stage, age, and surgical procedure to perform subgroup analysis.
Results
The sample was composed of 1591 patients, 963 who underwent laparoscopy and 628 open surgery. Using propensity score and regression analysis, we found that laparoscopy was associated with more QALYs and less resource use than open surgery (0.0163 QALYs, 95% CI 0.0114–0.0212; and − €3461, 95% CI − 3337 to − 3586). Costs were lower for laparoscopy in all subgroups. In the subgroups younger than 80 years old, utility was higher in patients who underwent laparoscopy. Nevertheless, open surgery had better outcomes in older patients in stages I–II (0.0618 QALYs) and IV (0.5090 QALYs).
Conclusion
Overall, laparoscopy appears to be dominant, resulting in more QALYs and lower costs. Nevertheless, while laparoscopy required fewer resources in all subgroups, outcomes may be negatively affected in elderly patients, representing an opportunity for shared decision making between surgeons and patients.
ClinicalTrials.gov Identifier: NCT02488161
Traditionally Type 2 Diabetes Mellitus (T2DM) was associated with older age, but is now being increasingly diagnosed in younger populations due to the increasing prevalence of obesity and inactivity. ...We aimed to evaluate whether a tool developed for community use to identify adolescents at high lifetime risk of developing T2DM agreed with a risk assessment conducted by a clinician using data collected from five European countries. We also assessed whether the tool could be simplified.
To evaluate the tool we collected data from 636 adolescents aged 12-14 years from five European countries. Each participant's data were then assessed by two clinicians independently, who judged each participant to be at either low or high risk of developing T2DM in their lifetime. This was used as the gold standard to which the tool was evaluated and refined.
The refined tool categorised adolescents at high risk if they were overweight/obese and had at least one other risk factor (High waist circumference, family history of diabetes, parental obesity, not breast fed, high sugar intake, high screen time, low physical activity and low fruit and vegetable intake). Of those found to be at high risk by the clinicians, 93% were also deemed high risk by the tool. The specificity shows that 67% of those deemed at low risk by the clinicians were also found to be a low risk by the tool.
We have evaluated a tool for identifying adolescents with risk factors associated with the development of T2DM in the future. Future work to externally validate the tool using prospective data including T2DM incidence is required.
PDF
