The overall incidence of colorectal cancer (CRC) has been decreasing since 1998 but there has been an apparent increase in the incidence of CRC in young adults.
To evaluate age-related disparities in ...secular trends in CRC incidence in the United States.
A retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER) CRC registry. Age at diagnosis was analyzed in 15-year intervals starting at the age of 20 years. SEER*Stat was used to obtain the annual cancer incidence rates, annual percentage change, and corresponding P values for the secular trends. Data were obtained from the National Cancer Institute's SEER registry for all patients diagnosed as having colon or rectal cancer from January 1, 1975, through December 31, 2010 (N = 393 241).
Difference in CRC incidence by age.
The overall age-adjusted CRC incidence rate decreased by 0.92% (95% CI, -1.14 to -0.70) between 1975 and 2010. There has been a steady decline in the incidence of CRC in patients age 50 years or older, but the opposite trend has been observed for young adults. For patients 20 to 34 years, the incidence rates of localized, regional, and distant colon and rectal cancers have increased. An increasing incidence rate was also observed for patients with rectal cancer aged 35 to 49 years. Based on current trends, in 2030, the incidence rates for colon and rectal cancers will increase by 90.0% and 124.2%, respectively, for patients 20 to 34 years and by 27.7% and 46.0%, respectively, for patients 35 to 49 years.
There has been a significant increase in the incidence of CRC diagnosed in young adults, with a decline in older patients. Further studies are needed to determine the cause for these trends and identify potential preventive and early detection strategies.
Background Adequate lymph node evaluation for cancer involvement is important for prognosis and treatment of patients with colon cancer. The number of lymph nodes evaluated may be a measure of ...quality in colon cancer care and appears to be inadequate in most patients treated for colon cancer. We performed a systematic review of the evidence for the association between lymph node evaluation and oncologic outcomes in patients with colon cancer. Methods Medline, Scopus, Cochrane, and the National Guidelines Clearinghouse databases were searched from January 1, 1990, through June 30, 2006, for studies in which survival data as a function of number of lymph nodes evaluated were available. These studies were evaluated for methodologic quality, design, and data source. A total of 61 371 patients were included. Results Seventeen studies from nine countries were eligible for systematic review, including two secondary analyses of multicenter randomized trials of adjuvant chemotherapy for colon cancer, five population-based observational studies, and 10 single-institution retrospective cohort studies. Despite heterogeneity in methodology and differences in threshold numbers of lymph nodes evaluated (range = 6–40 lymph nodes), 16 of 17 studies reported that increased survival of patients with stage II colon cancer was associated with increased numbers of lymph nodes evaluated. Four of six studies with data from stage III patients also reported a positive association with survival among patients with stage III colon cancer. Conclusions The number of lymph nodes evaluated after surgical resection was positively associated with survival of patients with stage II and stage III colon cancer. These results support consideration of the number of lymph nodes evaluated as a measure of the quality of colon cancer care.
Neoadjuvant chemoradiotherapy for rectal cancer is associated with improved local control and may result in complete tumor response. Associations between tumor response and disease control following ...radical resection should be established before tumor response is used to evaluate treatment strategies. The purpose of this study was to assess and compare oncologic outcomes associated with the degree of pathologic response after chemoradiotherapy.
All patients with locally advanced (cT3-4 or cN+ by endorectal ultrasonography, computed tomography, or magnetic resonance imaging) rectal carcinoma diagnosed from 1993 to 2008 at our institution and treated with preoperative chemoradiotherapy and radical resection were identified, and their records were retrospectively reviewed. The median radiation dose was 50.4 Gy with concurrent chemotherapy. Recurrence-free survival (RFS), distant metastasis (DM), and local recurrence (LR) rates were compared among patients with complete (ypT0N0), intermediate (ypT1-2N0), or poor (ypT3-4 or N+) response by using Kaplan-Meier survival analysis and multivariate Cox proportional hazards regression.
In all, 725 patients were classified by tumor response: complete (131; 18.1%), intermediate (210; 29.0%), and poor (384; 53.0%). Age, sex, cN stage, and tumor location were not related to tumor response. Tumor response (complete v intermediate v poor) was associated with 5-year RFS (90.5% v 78.7% v 58.5%; P < .001), 5-year DM rates (7.0% v 10.1% v 26.5%; P < .001), and 5-year LR only rates (0% v 1.4% v 4.4%; P = .002).
Treatment response to neoadjuvant chemoradiotherapy among patients with locally advanced rectal cancer undergoing radical resection is an early surrogate marker and correlate to oncologic outcomes. These data provide guidance with response-stratified oncologic benchmarks for comparisons of novel treatment strategies.
Purpose
We evaluated clinical features and survival outcomes among patients with signet ring and mucinous histologies of colorectal adenocarcinoma by using data from the National Cancer Data Base ...(NCDB).
Methods
Patients aged 18–90 years with colorectal adenocarcinoma diagnosed between 1998 and 2002 were identified from the NCDB. Site-stratified (colon vs. rectum) survival analysis was performed by multivariate relative survival adjusted for multiple clinicopathologic and treatment variables.
Results
The study included 244,794 patients: 25,546 (10%) with mucinous, 2,260 (1%) with signet ring, and 216,988 (89%) with nonmucinous, non–signet ring adenocarcinoma. Mucinous and signet ring cancers were more frequently right-sided (60% and 62%, respectively) than were nonmucinous, non–signet ring adenocarcinomas (42%,
P
< 0.001). Signet ring histology was associated with a higher stage (
P
< 0.001), and 77.2% of signet ring tumors were high-grade lesions, compared with 20% of mucinous and 17% of non–signet ring, nonmucinous adenocarcinomas (
P
< 0.001). After adjustment for covariates, signet ring histology was independently associated with higher risk of death hazard ratio (HR) 1.42, 95% confidence interval (CI) 1.33–1.51, and HR 1.57, CI 1.38–1.77, for tumors located in the colon and rectum, respectively. Mucinous tumors of the rectum (HR 1.22, CI 1.16–1.29), but not the colon (HR 1.03, CI 1.00–1.06), were associated with increased risk of death.
Conclusions
Signet ring cell adenocarcinomas of the colon and rectum and mucinous adenocarcinomas of the rectum are associated with poorer survival. These aggressive histologic variants of colorectal adenocarcinoma should be targeted for research initiatives to improve outcomes.
Background Perineal wound complications after chemoradiotherapy and abdominoperineal resection (APR) for anorectal cancer occur in up to 60% of patients, including perineal abscess and wound ...dehiscence. Vertical rectus abdominis myocutaneous (VRAM) flaps have been used in an attempt to reduce these complications by obliterating the noncollapsible dead space with vascularized tissue and closing the perineal skin defect with nonirradiated flap skin. Many surgeons are reluctant to use VRAM flaps unless primary closure is not possible. Study Design All patients who underwent chemoradiotherapy and APR during a 12-year period at the University of Texas MD Anderson Cancer Center were retrospectively reviewed. Patient, tumor, and treatment characteristics and surgical complications and outcomes were compared between patients who underwent VRAM flap reconstruction of wounds that could have been closed primarily (flap group, n = 35) and those who had primary closure of the perineal wound (control group, n = 76). Results Overall, there were no significant differences in the incidence of perineal wound complications between the groups; the flap group had a significantly lower incidence of perineal abscess (9% versus 37%, p = 0.002), major perineal wound dehiscence (9% versus 30%, p = 0.014), and drainage procedures required for perineal/pelvic fluid collections (3% versus 25%, p = 0.003) than the control group had. Despite flap harvest and the need for donor site closure in the flap group, there was no significant difference in abdominal wall complications between groups during the study’s mean patient followup of 3.8 years. Conclusions VRAM flap reconstruction of irradiated APR defects reduces major perineal wound complications without increasing early abdominal wall complications. Strong consideration should be given to immediate VRAM flap reconstruction after chemoradiation and APR.
Background An increasing number of patients with synchronous colorectal liver metastases (CLM) are candidates for resection. The optimal treatment sequence in these patients has not been defined. ...Study Design Data on 156 consecutive patients with synchronous resectable CLM and intact primary were reviewed. Surgical strategies were defined as combined (combined resection of primary and liver), classic (primary before liver), and reverse (liver before primary) after preoperative chemotherapy. Postoperative morbidity and mortality rates and overall survival were analyzed. Results One hundred forty-two patients (83%) had resection of all disease. Seventy-two patients underwent classic, 43 combined, and 27 reverse strategies. Median numbers of CLMs per patient were 1 in the combined, 3 in the classic, and 4 in the reverse strategy group (p = 0.01 classic vs reverse; p < 0.001 reverse vs combined). Postoperative mortality rates in the combined, classic, and reverse strategies were 5%, 3%, and 0%, respectively (p = NS), and postoperative cumulative morbidity rates were 47%, 51%, and 31%, respectively (p = NS). Three-year and 5-year overall survival rates were, respectively, 65% and 55% in the combined, 58% and 48% in the classic, and 79% and 39% in the reverse strategy (NS). On multivariate analysis, liver tumor size >3 cm (hazard ratio HR 2.72, 95% CI 1.52 to 4.88) and cumulative postoperative morbidity (HR 1.8, 95% CI 1.03 to 3.19) were independently associated with overall survival after surgery. Conclusions The classic, combined, or reverse surgical strategies in patients with synchronous presentation of CLM are associated with similar outcomes. The reverse strategy can be considered as an alternative option in patients with advanced CLM and an asymptomatic primary.
Purpose After preoperative chemoradiotherapy followed by total mesorectal excision for locally advanced rectal cancer, patients who experience local or systemic relapse of disease may be eligible for ...curative salvage surgery, but the benefit of this surgery has not been fully investigated. The purpose of this study was to characterize recurrence patterns and investigate the impact of salvage surgery on survival in patients with rectal cancer after receiving multidisciplinary treatment. Patients and Methods Patients with locally advanced (cT3-4 or cN+) rectal cancer who were treated with preoperative chemoradiotherapy followed by total mesorectal excision at our institution during 1993 to 2008 were identified. We examined patterns of recurrence location, time to recurrence, treatment factors, and survival. Results A total of 735 patients were included. Tumors were mostly midrectal to lower rectal cancer, with a median distance from the anal verge of 5.0 cm. The most common recurrence site was the lung followed by the liver. Median time to recurrence was shorter in liver-only recurrence (11.2 months) than in lung-only recurrence (18.2 months) or locoregional-only recurrence (24.7 months; P = .001). Salvage surgery was performed in 57% of patients with single-site recurrence and was associated with longer survival after recurrence in patients with lung-only and liver-only recurrence ( P < .001) but not in those with locoregional-only recurrence ( P = .353). Conclusion We found a predilection for lung recurrence in patients with rectal cancer after multidisciplinary treatment. Salvage surgery was associated with prolonged survival in patients with lung-only and liver-only recurrence, but not in those with locoregional recurrence, which demonstrates a need for careful consideration of the indications for resection.
DNA mismatch repair deficiency (dMMR) hallmarks consensus molecular subtype 1 of colorectal cancer. It is being routinely tested, but little is known about dMMR rectal cancers. The efficacy of novel ...treatment strategies cannot be established without benchmarking the outcomes of dMMR rectal cancer with current therapy. We aimed to delineate the impact of dMMR on prognosis, the predicted response to fluoropyrimidine-based neoadjuvant therapy, and implications of germline alterations in the MMR genes in rectal cancer.
Between 1992 and 2012, 62 patients with dMMR rectal cancers underwent multimodality therapy. Oncologic treatment and outcomes as well as clinical genetics work-up were examined. Overall and rectal cancer-specific survival were calculated by the Kaplan-Meier method.
The median age at diagnosis was 41 years. MMR deficiency was most commonly due to alterations in MSH2 (53%) or MSH6 (23%). After a median follow-up of 6.8 years, the 5-year rectal cancer-specific survival was 100% for stage I and II, 85.1% for stage III, and 60.0% for stage IV disease. Fluoropyrimidine-based neoadjuvant chemoradiation was associated with a complete pathologic response rate of 27.6%. The extent of surgical resection was influenced by synchronous colonic disease at presentation, tumor height, clinical stage, and pelvic radiation. An informed decision for a limited resection focusing on proctectomy did not compromise overall survival. Five of the 11 (45.5%) deaths during follow-up were due to extracolorectal malignancies.
dMMR rectal cancer had excellent prognosis and pathologic response with current multimodality therapy including an individualized surgical treatment plan. Identification of a dMMR rectal cancer should trigger germline testing, followed by lifelong surveillance for both colorectal and extracolorectal malignancies. We herein provide genotype-specific outcome benchmarks for comparison with novel interventions.
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