Effects of change in rectal cancer management on outcomes in British Columbia.

BACKGROUND: In a province-wide audit of patients undergoing treatment for rectal cancer in British Columbia in 1996, the 4-year rate of pelvic recurrence for stage 3 rectal cancer was 27%. The management guidelines were changed in 2002 to include adjuvant short-course preoperative radiation and total mesorectal excision surgical techniques. Education workshops were held to implement the protocol change. METHODS: We performed a provincial audit of rectal cancer cases for patients treated in the year after the protocol change, and we compared the pelvic recurrence rates with those from the audit performed in 1996. RESULTS: During a 12-month period beginning Oct. 1, 2003, a total of 367 patients underwent radical resection of rectal cancer with a curative intent. Preoperative adjuvant radiotherapy was used in 54% of cases (197/367). Median follow-up was 34.5 months, and 91% of patients were followed for at least 2 years. Relative to the 1996 cohort, there was a decreasing trend in 2-year overall pelvic recurrence rates in the 2003/04 cohort (9.6% v. 6.9%) and a significant decrease in recurrence among patients with stage 3 cancers (18.2% v. 9.2%; p = 0.020). Use of adjuvant radiation increased significantly (37% v. 65%; p < 0.001), and negative radial margins were achieved in 87% (319/367) of cases. CONCLUSION: The rates of pelvic recurrence were improved after changes in the management guidelines advocating increased use of total mesorectal excision surgery and preoperative radiation. Knowledge translation with an integrated strategy among surgeons and medical and radiation oncologists was successful in improving population outcomes among patients with rectal cancer.

Effect of emergent presentation on outcome from rectal cancer management.

BACKGROUND: We have previously reported outcomes for all rectal cancers in BC in 1996. We found that our local recurrence rates and survival were suboptimal relative to current standards in recent literature. METHODS: In this retrospective, population-based study, we report the influence of emergent presentation (obstruction, perforation, massive hemorrhage) on outcomes, types of surgical procedures and use of staging investigations, and use of adjuvant radiation and chemotherapy. RESULTS: There were 452 invasive adenocarcinomas of the rectum of which 45 were emergent and 407 nonemergent. Disease-specific survival at 4 years for emergent and nonemergent stage II cancers were 66% versus 80%, respectively, and for stage III cancers, 60% versus 73%, respectively (P <0.04). Local recurrence rates at 4 years for emergent and nonemergent stage II cancers were 20% versus 15%, respectively, and for stage III cancers, 70% and 20%, respectively (P <0.05). Surgical resection more frequently involved a stoma for emergent (60%) than for nonemergent (35%) cases (P <0.01). Percent of patients having complete staging investigations were similar between emergent (42%) and nonemergent patients (39%). Adjuvant radiation was given in similar proportion to emergent (61%) and nonemergent (55%) patients. Adjuvant chemotherapy was given to a slightly higher proportion of emergent patients (63%) than nonemergent patients (43%). CONCLUSIONS: We conclude that outcome from rectal cancer management is worse for emergent than nonemergent presentation. Since there is no difference in use of staging investigations or adjuvant therapy, the difference in outcome is likely due to difference in surgical technique between emergent and nonemergent cases.

Chronic arm morbidity after curative breast cancer treatment: prevalence and impact on quality of life.

PURPOSE: To determine the prevalence of and contributing factors for chronic arm morbidity including lymphedema in breast cancer patients after treatment and to assess the impact of arm morbidity on quality of life (QOL). PATIENTS AND METHODS: A four-question screening questionnaire was developed and mailed to a random sample of 744 breast cancer patients treated curatively in two cancer centers from 1993 to 1997. Patients were without recurrence and at least 2 years from diagnosis. Respondents were classified as with or without arm-related symptoms on the basis of the survey. Stratified random samples from each group were then invited for a detailed assessment of their symptoms and signs, including the presence of lymphedema. Their QOL was assessed by the European Organization for Research and Treatment of Cancer QOL Questionnaire C-30 and by a detailed arm problem questionnaire that assessed various aspects of daily arm functioning. RESULTS: Approximately half of all screened patients were symptomatic and 12.5% of all assessed patients had lymphedema. Axillary dissection (AD) and axillary radiotherapy (RT) after dissection were statistically significantly related to the occurrence of arm symptoms (odds ratio for AD = 3.3, P <.001; odds ratio for RT = 3.1, P <.001). Symptomatic patients and patients with lymphedema both had impaired QOL compared with asymptomatic patients. CONCLUSION: Treatment for breast cancer is associated with considerable arm morbidity, which has a negative impact on QOL. Arm morbidity should be carefully monitored in future studies involving local treatment modalities for breast cancer.

Effects of positive resection margin and tumor distance from anus on rectal cancer treatment outcomes.

PURPOSE: Rectal cancer outcome depends on stage, technical aspects of surgical excision, and use of adjuvant chemoradiation. Here, we examine effects of positive resection margin and tumor distance from the anus in stage 2 and 3 cancers on 4-year disease-specific survival and recurrence. METHODS: We reviewed all 495 rectal cancer patients registered in British Columbia in 1996. RESULTS: There were 481 cases analyzed: 29 in situ, 134 stage 1, 107 stage 2, 100 stage 3, 83 stage 4, and 28 unknown stage. Survival was significantly affected by presence of positive resection margin in stage 2 and 3 cancers, P = 0.0001. Lower tumor distance from the anus for stage 2 and 3 cancers worsened survival, P = 0.0007, and overall recurrence, P =0.016, but not local recurrence, P = 0.11. Adjuvant postoperative combined radiation and chemotherapy in stage 2 and 3 cancers significantly improved survival, P = 0.070 and local recurrence, P = 0.018, but not overall recurrence, P = 0.19. CONCLUSIONS: Presence of positive resection margin and tumor distance from the anus affect survival, local recurrence, and overall recurrence. Adjuvant postoperative combined radiation and chemotherapy improved our outcomes. Our local recurrence rates for rectal cancers are worse than currently reported standards of less than 10%. Improved surgical excision and use of adjuvant preoperative radiation and chemotherapy may improve outcome.

Morbidity and mortality associated with intraperitoneal chemotherapy for Pseudomyxoma peritonei.

BACKGROUND: Many centers include intraperitoneal chemotherapy for treatment of pseudomyxoma peritonei. This study documented the morbidity of intraperitoneal chemotherapy in a single institution. METHODS: A retrospective review of pseudomyxoma peritonei over a 6-year period was undertaken. Treatment, morbidity, and outcome were documented. RESULTS: Eleven patients were identified with an average of 1.9 debulking procedures and 0.8 chemotherapy courses (0.3 complete). Intraperitoneal chemotherapy was not completed in 5 patients because of complications (56%): severe abdominal pain, seizure, neutropenia, and thrombocytopenia (the latter resulted in 1 patient's death). There was no association between incomplete chemotherapy and recurrence. Recurrence was 64% in those without chemotherapy and 44% in those with. Follow-up averaged 26 months and actual 3-year survival was 60%. CONCLUSIONS: Intraperitoneal chemotherapeutic morbidity and mortality were 56% and 11%, respectively. Chemotherapy was associated with decreased recurrence. To optimize outcomes, multicenter prospective trials will likely be required to further refine intraperitoneal chemotherapy protocols.