The influence of socioeconomic position on adjuvant treatment of stage III colon cancer: a systematic review and meta-analysis.

BACKGROUND: Patients with colon cancer (CC) with low socioeconomic position (SEP) have a worse survival than patients with high SEP. We investigated the association between different socioeconomic indicators and the steps in the treatment trajectory leading to initiation of adjuvant chemotherapy (ACT) for patients with stage III CC. MATERIALS AND METHODS: A systematic review and meta-analyses were conducted in accordance with the MOOSE checklist. MEDLINE and EMBASE were searched for eligible studies. Meta-analyses were performed on the separate socioeconomic indicators with the random-effects model. The heterogeneity across studies was assessed by the Q and the I 2 statistic. RESULTS: In total, 27 observational studies were included. SEP was measured by insurance, income, poverty, employment, education, or an index on an area or individual level. SEP, regardless of indicator, was negatively associated with the steps in the treatment trajectory leading to initiation of ACT among patients with resected stage III CC. The meta-analyses showed that patients with low SEP had a significantly lower odds of receiving ACT and increased odds of delayed treatment start, whereas SEP had no impact on the choice of therapy: combination or single-agent therapy. CONCLUSION: SEP was associated with less initiation of and higher risk for delayed initiation of ACT. Our findings suggest there is a social disparity in receipt of ACT in patients with stage III CC.

The effect of geriatric intervention in frail elderly patients receiving chemotherapy for colorectal cancer: a randomized trial (GERICO).

BACKGROUND: Better surgical techniques, chemotherapy and biological therapy have improved survival in patients with colorectal cancer (CRC), most markedly in younger patients. About half of patients over 70 years receive dose reductions or early treatment discontinuation of the planned adjuvant or first-line treatment due to side effects. The Comprehensive Geriatric Assessment (CGA) is a multidisciplinary evaluation of an elderly individual's health status. This assessment in older patients with cancer can predict survival, chemotherapy toxicity and morbidity. METHODS: This randomized phase II trial (GERICO) is designed to investigate whether comprehensive geriatric assessment and intervention before and during treatment with chemotherapy in frail elderly patients with stages II-IV CRC will increase the number of patients completing chemotherapy. All patients ≥70 years in whom chemotherapy for CRC is planned to start at Herlev and Gentofte Hospital are screened for frailty using the G8 questionnaire at the first visit to the outpatient clinic. The G8 questionnaire is a multi-domain screening tool to identify frail or vulnerable patients at risk of increased toxicity and morbidity. Frail patients are offered inclusion and are then randomized to two groups (the intervention group and the control group). Patients in the intervention group receive a full geriatric assessment of comorbidity, medication, psycho-cognitive function, physical, functional and nutrition status, and interventions are undertaken on identified health issues. Simultaneously, they are treated for their cancer according to international guidelines. Patients in the control group receive the same chemotherapy regimens and standard of care. Primary outcome is number of patients completing scheduled chemotherapy at starting dose. Secondary outcomes are dose reductions, treatment delays, toxicity, time to recurrence, survival, cancer-related mortality and quality of life. DISCUSSION: This ongoing trial is one of the first to evaluate the effect of geriatric intervention in frail elderly patients with CRC. The trial will provide new and valuable knowledge about whether it is beneficial for the elderly patient undergoing chemotherapy to be treated simultaneously by a geriatrician. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT02748811 . The trial was registered retrospectively; registration date 04/28/2016.

A microdosimetric analysis of the interactions of mono-energetic neutrons with human tissue.

Nuclear reactions induced during high-energy radiotherapy produce secondary neutrons that, due to their carcinogenic potential, constitute an important risk for the development of iatrogenic cancer. Experimental and epidemiological findings indicate a marked energy dependence of neutron relative biological effectiveness (RBE) for carcinogenesis, but little is reported on its physical basis. While the exact mechanism of radiation carcinogenesis is yet to be fully elucidated, numerical microdosimetry can be used to predict the biological consequences of a given irradiation based on its microscopic pattern of energy depositions. Building on recent studies, this work investigated the physics underlying neutron RBE by using the microdosimetric quantity dose-mean lineal energy (y‾D) as a proxy. A simulation pipeline was constructed to explicitly calculate the y‾D of radiation fields that consisted of (i) the open source Monte Carlo toolkit Geant4, (ii) its radiobiological extension Geant4-DNA, and (iii) a weighted track-sampling algorithm. This approach was used to study mono-energetic neutrons with initial kinetic energies between 1 eV and 10 MeV at multiple depths in a tissue-equivalent phantom. Spherical sampling volumes with diameters between 2 nm and 1 µm were considered. To obtain a measure of RBE, the neutron y‾D values were divided by those of 250 keV X-rays that were calculated in the same way. Qualitative agreement was found with published radiation protection factors and simulation data, allowing for the dependencies of neutron RBE on depth and energy to be discussed in the context of the neutron interaction cross sections and secondary particle distributions in human tissue.

Efficacy and toxicity of adjuvant chemotherapy in elderly patients with colorectal cancer: the ACCORE study.

BACKGROUND: Elderly patients with primary colorectal cancer (CRC) are less frequently treated with adjuvant chemotherapy than younger patients due to concerns regarding toxicity and efficiency. We investigated how age, performance status (PS) and comorbidity influence treatment outcomes. PATIENTS AND METHODS: A retrospective single-centre study of 529 patients with stages II-III CRC treated with adjuvant chemotherapy (5-fluorouracil/capecitabine+/÷oxaliplatin) from 2001 to 2011 at Herlev Hospital, Denmark. Baseline characteristics, chemotherapy and outcome were analysed with respect to age after adjusting for PS and comorbidity. RESULTS: Elderly patients (>70 years) had significantly more comorbidity (p<0.001) and poorer PS (p=0.001) than younger patients. Elderly were more frequently treated with single-agent therapy (p=0.001) and at lower initial dose (p<0.001). There was no age-dependent difference in 3-year disease-free survival (DFS; HR 1.09, 95% CI 0.80 to 1.47, p=0.59), in grade 3-5 toxicity (29% vs 28%, p=0.86) or in 10-year CRC mortality (28%, HR 1.07, p=0.71). In elderly patients, a reduction in chemotherapy dose intensity compared with full dose had no impact on DFS or CRC mortality. Elderly patients receiving <50% of planned cycles had shorter DFS (HR=1.78, p=0.020) and higher CRC mortality (HR=2.17, p=0.027) than elderly receiving all cycles. Poor PS in younger and elderly patients was related to shorter DFS (HR=1.95, p=0.002; HR=1.6, p=0.035, respectively) and overall survival (OS; HR=2.28, p<0.001; HR=2.03, p=0.002). Comorbidity in younger patients was significantly related to shorter DFS (HR 2.72, p<0.001), OS (HR 3.16, p<0.001) and higher CRC mortality (HR 2.70, p=0.001). CONCLUSIONS: Choice of regimen, primary dose reduction and given dose intensity in patients treated with adjuvant chemotherapy for CRC were highly dependent on age. However, age had no impact on DFS and CRC mortality. Comorbidity in younger patients and PS in all patients were associated with shorter DFS and higher CRC mortality.

Post-operative recovery profile after laparoscopic cholecystectomy: a prospective, observational study of a multimodal anaesthetic regime.

BACKGROUND: Laparoscopic cholecystectomy is now often an ambulatory procedure, but dependent on short-term post-operative complaints of pain and post-operative nausea and vomiting (PONV). The efficacy of post-anaesthesia care units (PACUs) is therefore important to facilitate return to normal functions. We investigated the feasibility and efficacy of a standardized, evidence-based anaesthesia/analgesic regime to identify residual problems in the early post-operative phase. METHODS: One hundred and thirty-four consecutive patients admitted for elective laparoscopic cholecystectomy at Hvidovre University Hospital between 15 March and 30 September 2005 were included in the study. The standardized, evidence-based regime consisted of total intravenous (i.v.) anaesthesia (propofol-remifentanil), well-defined fluid therapy, dexamethasone, ketorolac, ondansetron, sufentanil and incisional bupivacaine intra-operatively, and in the PACU on demand (prn) administration of sufentanil, morphine, paracetamol, ondansetron, droperidol, oral fluids and oxygen (if SpO(2) < 93%) with PACU discharge using a modified Aldrete score. RESULTS: Protocol violations were moderate and occurred unsystematically, 8% had medical violations and 10% did not receive the pre-planned fluid amount. Severe PONV was seen in 2%. Thirteen per cent experienced severe pain, and the presence of any pain and/or PONV were predictors of an extended PACU stay. Mean oxygen demand was 46 min (range, 0-300 min), which influenced time to discharge (mean, 88 min). There were on average 2.7 treatment interventions (range, 0-11) before discharge. CONCLUSION: An evidence-based, multimodal approach to the anaesthetic/analgesic management in laparoscopic cholecystectomy is feasible and advantageous in the early post-operative phase. Pain and PONV are predictors of a complicated recovery profile and deserve further attention. Transient oxygen desaturations postpone discharge from the PACU, but the clinical significance of this fact is questionable.

Benchmarking patient satisfaction.

Asking the patient is a critical step-but the format of a patient satisfaction survey has a significant impact on your perceptions. Design it carefully.