Standard treatment of colorectal cancer includes adjuvant chemotherapy for patients with stage III disease (defined by the presence of lymph-node metastases), but not for patients with stage II ...tumors (who have no lymph-node metastases). However, 20 percent of patients with stage II tumors die of recurrent disease. We investigated whether the detection of micrometastases can be used to identify patients with stage II disease who are at high risk for recurrence.
We analyzed 192 lymph nodes from 26 consecutive patients with stage II colorectal cancer, using a carcinoembryonic antigen-specific nested reverse-transcriptase polymerase chain reaction. Five-year follow-up information was obtained on all patients. Observed and adjusted survival rates were assessed in the patients with and the patients without micrometastases.
Micrometastases were detected in one or more lymph nodes from 14 of 26 patients (54 percent). The adjusted five-year survival rate (for which only cancer-related deaths were considered) was 50 percent in this group, whereas in the 12 patients without micrometastases, the survival rate was 91 percent (P=0.02 by the log-rank test). The observed five-year survival rates were 36 percent and 75 percent, respectively (P=0.03). The groups were similar with respect to age, sex, tumor side (location in relation to the flexura lienalis), degree of tumor differentiation (grade), and diameter of the primary tumor.
Molecular detection of micrometastases is a prognostic tool in stage II colorectal cancer.
Monitoring time trends of cancer mortality is essential. Thirty-day mortality is an important surgical outcome measure, though postoperative mortality exceeds to one year after surgery in patients ...with colorectal cancer. The aim of this nationwide observational study was to assess changes over time in 30-day and one-year mortality in patients with stage I–III colorectal cancer.
All surgically treated patients with stage I–III colorectal cancer, diagnosed between 2009 and 2013 were selected from the Netherlands Cancer Registry. Changes in 30-day and one-year mortality were assessed using logistic regression by tumour localisation (colon, rectum) and age group (<75 years, ≥75 years).
Overall, 41,186 patients were included. Among patients with colon cancer ≥75 years, 30-day mortality decreased from 8.3% in 2009 to 6.2% in 2013 (p-value for trend = 0.011), and one-year mortality from 18.5% in 2009 to 15.0% in 2013 (p-value for trend = 0.007).
No significant differences in mortality over time were observed for patients <75 years with colon cancer and for patients with rectal cancer.
Thirty-day and one-year mortality decreased over time in patients ≥75 years with stage I–III colon cancer, though the absolute decrease is small. However, 30-day mortality and in particular the one-year mortality are both still high in older patients with colorectal cancer and will need to be focused on to further improve outcomes for these patient subgroups.
Aim
According to established guidelines, patients with Stage III colon cancer should receive adjuvant chemotherapy. However, a significant proportion do not. This study assessed factors associated ...with the administration of adjuvant chemotherapy and causes of death.
Methods
Patients with Stage III colon cancer who underwent surgery between 2000 and 2009 were selected from two hospitals in the Netherlands. Patient characteristics including comorbidities and treatment preferences, tumour characteristics and follow‐up were extracted from the medical records. The patient and tumour characteristics of patients who did receive chemotherapy were compared with those who did not using chi‐squared analysis. Differences between the groups in causes of death were recorded together with the duration of follow‐up.
Results
A total of 348 patients were included. The median age was 73 years (range 33–93). Over half of the patients received adjuvant chemotherapy (50.6%). Patients who did not receive adjuvant chemotherapy were significantly older (P < 0.001), had more comorbidities (P < 0.001) and were more often living alone (P < 0.001). Patients who received no adjuvant chemotherapy had a reduced overall survival, and the cause of death was more often attributed to other causes (60%) than colon cancer (40%). For patients who received chemotherapy, the cause of death was usually attributed to colon cancer (71%).
Conclusion
Patients who did not receive adjuvant chemotherapy had a worse overall survival and the majority died due to other causes than colon cancer. In our aging society it will become even more important to develop tools to estimate remaining life expectancy in order to improve the selection of older patients for adjuvant treatments.
We hypothesized that T-cell immune interaction affects tumor development and thus clinical outcome. Therefore, we examined the clinical impact of human leukocyte antigen (HLA) class I tumor cell ...expression and regulatory T-cell (Treg) infiltration in breast cancer.
Our study population (N = 677) is consisted of all early breast cancer patients primarily treated with surgery in our center between 1985 and 1994. Formalin-fixed, paraffin-embedded tumor tissue was immunohistochemically stained using HCA2, HC10, and Foxp3 monoclonal antibodies.
HLA class I expression was evaluated by combining results from HCA2 and HC10 antibodies and classified into three groups: loss, downregulation, and expression. Remarkably, only in patients who received chemotherapy, both presence of Treg (P = 0.013) and higher HLA class I expression levels (P = 0.002) resulted in less relapses, independently of other variables. Treg and HLA class I were not of influence on clinical outcome in patients who did not receive chemotherapy.
We showed that HLA class I and Treg affect prognosis exclusively in chemotherapy-treated patients and are therefore one of the few predictive factors for chemotherapy response in early breast cancer patients. Chemotherapy may selectively eliminate Treg, thus enabling CTLs to kill tumor cells that have retained HLA class I expression. As a consequence, HLA class I and Treg can predict response to chemotherapy with high discriminative power. These markers could be applied in response prediction to chemotherapy in breast cancer patients.
Over 40% of breast cancer patients are diagnosed above the age of 65. Treatment of these elderly patients will probably vary over countries. The aim of this study was to make an international ...comparison (several European countries and the US) of surgical and radiation treatment for elderly women with early stage breast cancer. Survival comparisons were also made. Data were obtained from national or regional population-based registries in the Netherlands, Switzerland, Ireland, Belgium, Germany, and Portugal. For the US patients were selected from the Surveillance, Epidemiology, and End Results (SEER) database. Early stage breast cancer patients aged ≥65 diagnosed between 1995 and 2005 were included. An international comparison was made for breast and axillary surgery, radiotherapy after breast conserving surgery (BCS), and relative or cause-specific survival. Overall, 204.885 patients were included. The proportion of patients not receiving any surgery increased with age in many countries; however, differences between countries were large. In most countries more than half of all elderly patients received breast conserving surgery (BCS), with the highest percentage in Switzerland. The proportion of elderly patients that received radiotherapy after BCS decreased with age in all countries. Moreover, in all countries the proportion of patients who do not receive axillary surgery increased with age. No large differences in survival between countries were recorded. International comparisons of surgical treatment for elderly women with early stage breast cancer are scarce. This study showed large international differences in treatment of elderly early stage breast cancer patients, with the most striking result the large proportion of elderly who did not undergo surgery at all. Despite large treatment differences, survival does not seem to be affected in a major way.
Background
The decision to perform surgery for patients with T1 colorectal cancer hinges on the estimated risk of lymph node metastasis, residual tumour and risks of surgery. The aim of this ...observational study was to compare surgical outcomes for T1 colorectal cancer with those for more advanced colorectal cancer.
Methods
This was a population‐based cohort study of patients treated surgically for pT1–3 colorectal cancer between 2009 and 2016, using data from the Dutch ColoRectal Audit. Postoperative complications (overall, surgical, severe complications and mortality) were compared using multivariable logistic regression. A risk stratification table was developed based on factors independently associated with severe complications (reintervention and/or mortality) after elective surgery.
Results
Of 39 813 patients, 5170 had pT1 colorectal cancer. No statistically significant differences were observed between patients with pT1 and pT2–3 disease in the rate of severe complications (8·3 versus 9·5 per cent respectively; odds ratio (OR) 0·89, 95 per cent c.i. 0·80 to 1·01, P = 0·061), surgical complications (12·6 versus 13·5 per cent; OR 0·93, 0·84 to 1·02, P = 0·119) or mortality (1·7 versus 2·5 per cent; OR 0·94, 0·74 to 1·19, P = 0·604). Male sex, higher ASA grade, previous abdominal surgery, open approach and type of procedure were associated with a higher severe complication rate in patients with pT1 colorectal cancer.
Conclusion
Elective bowel resection was associated with similar morbidity and mortality rates in patients with pT1 and those with pT2–3 colorectal carcinoma.
Clinicians should be aware that the risks associated with elective bowel resection for pT1 colorectal cancer are similar to those for elective surgery in more advanced colorectal cancer. The risk stratification table provided in this study might help to estimate the risk for individual patients, thereby enhancing shared decision‐making.
Complications after surgery for T1 colorectal carcinoma
The potential benefit of surgery of the primary tumour in patients with asymptomatic metastatic colorectal cancer is debated. This EURECCA international comparison analyses treatment strategies and ...overall survival in the Netherlands and Norway in patients with incurable metastatic colorectal cancer.
National cohorts (2007–2013) from the Netherlands and Norway including all patients with synchronous metastatic colorectal cancer were compared on treatment strategy and overall survival. Using country as an instrumental variable, we assessed the effect of different treatment strategies on mortality in the first year.
Of 21,196 patients (16,144 Dutch and 5052 Norwegian), 38.6% Dutch and 51.5% (p < 0.001) Norwegian patients underwent resection of the primary tumour. In the Netherlands, 58.2% received chemotherapy compared with 21.4% in Norway. Radiotherapy was given in 9.5% of Dutch patients and 7.2% of Norwegian patients. Using the Netherlands as reference, the adjusted HR for overall survival was 0.96 (95% CI 0.93–0.99; p = 0.024). Instrumental variable analysis showed an adjusted OR of 1.00 (95% CI 0.99–1.02; p = 0.741).
Treatment strategies varied significantly between the Netherlands and Norway, with more surgery and less radiotherapy in Norway. Adjusted overall survival was better in Norway for all patients and patients <75 years, but not for patients ≥75 years. Instrumental variable analysis showed no benefit in one-year mortality for a treatment strategy with a higher proportion of surgery and a lower proportion of radiotherapy. Our findings emphasise the need for further research to select patients with incurable metastatic colorectal cancer for different treatment options.
Abstract Introduction About 3–10% of breast cancer patients have distant metastases (Stage IV) at initial presentation; standard treatment (in the Netherlands) of these patients consists of ...palliative systemic therapy. However, retrospective studies have shown an improved survival in patients who received surgery for their primary tumor. The aim of this study was to assess characteristics associated with surgical treatment and to determine the impact on survival in women with stage IV breast cancer. Methods A cohort of women with a diagnosis of breast cancer and concomitant distant metastases was retrospectively studied. Patient characteristics, treatment and survival distilled from medical files were evaluated using univariate and multivariable analysis. Results Of 171 patients included in this analysis, 59 underwent surgery. In multivariable analysis lower age, no medication use, lower clinical T-stage and lower grade were associated with receiving surgery. In 21 of the 59 patients (35%) who received surgery it was unknown at the time of surgery that the patient had metastatic disease. Stratified survival analyses showed an association between surgery and improved survival for young patients (HR 0.3; p = 0.02), without comorbidity (HR 0.4; p = 0.002), with no medication use (HR 0.5; p = 0.009), with a small tumor (HR 0.4; p = 0.01), no regional lymph node involvement (HR 0.4; p = 0.01), with positive Estrogen (HR 0.6; p = 0.02) or Progesterone receptor (HR 0.4; p = 0.03) and with only visceral metastases (HR 0.5; p = 0.03). In multivariable analyses, younger patients and patients without comorbidity that received surgery had an increased survival (HR 0.3; p = 0.03 and HR 0.5; p = 0.03, respectively). Conclusion This study showed that patients with the most favorable profile receive local surgery and that a survival gain for operated patients was seen in young patients and in patients without comorbidity.
Abstract
Background
Surgery is increasingly being omitted in older patients with operable breast cancer in the Netherlands. Although omission of surgery can be considered in frail older patients, it ...may lead to inferior outcomes in non-frail patients. Therefore, the aim of this study was to evaluate the effect of omission of surgery on relative and overall survival in older patients with operable breast cancer.
Methods
Patients aged 80 years or older diagnosed with stage I–II hormone receptor-positive breast cancer between 2003 and 2009 were selected from the Netherlands Cancer Registry. An instrumental variable approach was applied to minimize confounding, using hospital variation in rate of primary surgery. Relative and overall survival was compared between patients treated in hospitals with different rates of surgery.
Results
Overall, 6464 patients were included. Relative survival was lower for patients treated in hospitals with lower compared with higher surgical rates (90·2 versus 92·4 per cent respectively after 5 years; 71·6 versus 88·2 per cent after 10 years). The relative excess risk for patients treated in hospitals with lower surgical rates was 2·00 (95 per cent c.i. 1·17 to 3·40). Overall survival rates were also lower among patients treated in hospitals with lower compared with higher surgical rates (48·3 versus 51·3 per cent after 5 years; 15·0 versus 19·7 per cent after 10 years respectively; adjusted hazard ratio 1·07, 95 per cent c.i. 1·00 to 1·14).
Conclusion
Omission of surgery is associated with worse relative and overall survival in patients aged 80 years or more with stage I–II hormone receptor-positive breast cancer. Future research should focus on the effect on quality of life and physical functioning.
Graphical Abstract
Although the selection criteria for omission of surgery in early-stage breast cancer are ill defined in guidelines, the percentage of patients receiving surgical treatment declines in older age groups. This study evaluated the effect of omission of surgery on survival in patients aged 80 years and older. Omission of surgery was associated with worse relative and overall survival, but no effect was observed in the first 5 years.
Graphical Abstract
Surgery superior
There seem to be socioeconomically differences in survival for females with breast cancer, usually associated with a higher stage of disease. However, differences within tumor size have not been ...studied. Aim of this study is to assess differences in survival according to socioeconomic status (SES), stratified for tumor size and stage at diagnosis, for females with breast cancer in the Netherlands. All females diagnosed with breast cancer (1995–2005) were selected from the Netherlands Cancer Registry. Patients were linked to a SES database according to postal code. A multivariable logistic regression was used to assess factors associated with SES. Overall survival (OS) and relative survival (RS) were calculated. Overall, 127,599 patients were included. Higher SES was associated with lower T-stage (
P
< 0.0001). A decreased survival (OS and RS) was found for patients with a lower SES. Also within different size groups, RS was different. Overall, 10-year OS for the high SES group was 65 and 58% for the low SES group (hazard ratio 1.1,
P
< 0.001) and RS was 79 versus 74% (relative excess risk, RER 1.2;
P
< 0.001). The socioeconomic differences remained statistically significant (
P
< 0.001) after adjustment for age, year of diagnosis, grade, TNM stage, and treatment. For the lowest SES group 777 deaths could be avoided. Socioeconomic differences in survival of breast cancer patients were observed in the Netherlands. Higher stage at diagnosis of patients with a lower SES only partly explains the decreased survival. Policies aimed at the reduction of socioeconomic health inequalities might be important to improve survival of breast cancer.
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