Home-based, supervised, and mixed exercise intervention on functional capacity and quality of life of colorectal cancer patients: a meta-analysis.

This systematic review and meta-analysis of randomized controlled trials tested the effects of home-based, supervised, or mixed exercise interventions on the functional capacity (FC) and quality of life (QoL) in colorectal cancer patients. A literature search was performed using the PubMed, Embase, Cochrane, and Medline databases. Two reviewers screened the literature through March 10, 2021 for studies related to exercise and colorectal cancer. Of the 1161 screened studies in the initial search, 13 studies met the eligibility criteria (home-based = 6 studies; supervised or mixed = 7 studies). Overall, 706 patients were enrolled in the trials, and 372 patients were submitted to home-based, supervised, or mixed exercise intervention. The overall results from the main meta-analysis showed a significant effect regarding supervised or mixed intervention (6 studies; p = 0.002; I2 = 43%; PI 0.41-1.39); however, no significant effect was observed for home-based intervention (5 studies; p = 0.05; I2 = 25%; PI - 0.34-0.76). A sensitivity analysis based on studies with intervention adherence ≥ 80% (home-based = 3 studies; supervised or mixed = 4 studies) revealed that home-based intervention or intervention entirely supervised or with some level of supervision (mixed) are effective in improving the QoL and FC of CRC patients. In summary, this meta-analysis verified that supervised and home-based exercise can modify QoL and FC when intervention adherence ≥ 80%. Regardless of the supervision characteristics, future RCTs are strongly encouraged to provide a detailed description of the exercise variables in physical interventions for CRC prescription. This perspective will allow a refined exercise prescription for patients with CRC, mainly according to their clinical status.

Profiling Determinants of Resting Energy Expenditure in Colorectal Cancer.

Background: Understanding resting energy expenditure (REE) is important for determining energy requirements; REE might be altered in individuals with cancer. The objective of this study was to characterize determinants of REE in patients with stages II-IV colorectal cancer (CRC).Methods: REE was measured via indirect calorimetry in patients with newly diagnosed CRC. Computerized tomography images from medical records ascertained skeletal muscle and total adipose tissue cross-sectional areas, which were then transformed to lean soft tissue (LST) and fat mass (FM) values (in kg). Linear regression assessed determinants of REE.Results: 86 patients were included (n = 55, 64.0% male; 60 ± 12 years old; median body mass index: 27.6, interquartile range: 24.3-31.2 kg/m2), with most (n = 40) having stage III disease. Age, sex, and weight were significant predictors of REE [R2 = 0.829, standard error of the estimate (SEE): 128 kcal/day, P < 0.001]. Replacing weight with LST and FM yielded a similar model, with age, sex, LST, and FM predictive of REE (R2 = 0.820, SEE: 129 kcal/day, p < 0.001).Conclusion: Age, sex, weight, LST, and FM were the main contributors to REE. Further investigation of REE changes over time and its relationship to total energy expenditure, dietary intake, and clinical outcomes should be explored.

The clinical impact of preoperative body composition differs between male and female colorectal cancer patients.

AIM: Patient body composition is an important indicator of metabolic status and is associated with cancer progression. Because body composition varies between men and women, we aimed to examine the difference in clinical impact of preoperative body composition according to sex. METHOD: We used an integrated dataset of 559 colorectal cancer (CRC) patients. The association between preoperative body composition indices [body mass index (BMI), visceral to subcutaneous fat area ratio (VSR) and skeletal muscle index (SMI)] and patient outcome, clinicopathological factors and preoperative inflammation and nutritional status was analysed, comparing men and women. RESULTS: Preoperative low BMI and low SMI in men was significantly associated with unfavourable overall survival (OS) [BMI: hazard ratio (HR) 2.22, 95% CI 1.28-4.14, P = 0.004; SMI: HR 2.54, 95% CI 1.61-4.07, P < 0.001] and high VSR in women was significantly associated with unfavourable OS (HR 1.79, 95% CI 1.03-3.02, P = 0.040). Additionally, low SMI in men was significantly associated with deeper tumour invasion and greater distant metastasis and high VSR in women was significantly associated with advanced age, right-sided tumour, lower total lymphocyte count and lower albumin levels. Interestingly, low BMI in men was significantly associated with deeper tumour invasion, but also with favourable inflammation and nutritional status (lower C-reactive protein and higher albumin). CONCLUSION: The clinical impact of preoperative body composition differed between men and women: SMI in men and VSR in women were good prognosticators. Our findings may provide a novel insight for CRC treatment strategies.

Estimation of Physiological Ability and Surgical Stress Score Is a Useful Prognostic Indicator for Elderly Patients with Colorectal Cancer.

BACKGROUND: The incidence of colorectal cancer (CRC) among the elderly has been increasing. Therefore, determining postoperative prognosis factors in elderly CRC patients has clinical importance. This study retrospectively investigated the prognostic significance of the estimation of physiological ability and surgical stress (E-PASS) in elderly CRC patients. METHODS: This study enrolled 166 elderly patients aged 75 or more with a histopathological diagnosis of colorectal adenocarcinoma who underwent curative surgery. RESULTS: According to the results of receiver operating characteristic analysis, the patients were divided into the following 2 groups based on the comprehensive risk score (CRS): CRS of ≥0.05 (CRSHigh) and CRS of < 0.05 (CRSLow). The 5-year overall survival rates of CRSHigh group and CRSLow group were 51.1 and 89.6%, respectively, and the difference was statistically significant (p < 0.001). Furthermore, 5-year disease-specific survival rates of CRSHigh group and CRSLow group were 81.4 and 96.3%, respectively, and the difference was statistically significant (p = 0.017). Also, multivariate analysis indicated that CRS was an independent prognostic indicator in elderly CRC patients. With regard to the cause of death, both recurrence and cancer-unrelated deaths were observed significantly more in the CRSHigh group than in the CRSLow group. CONCLUSIONS: E-PASS was a useful prognostic indicator in elderly CRC patients.

Determinants of change in resting energy expenditure in patients with stage III/IV colorectal cancer.

BACKGROUND & AIMS: Resting energy expenditure (REE) is variable in cancer and might be influenced by changes in tumor burden, systemic inflammation, and body composition. The objective of this study was to assess REE change and the predictors of such in patients with stage III or IV colorectal cancer. METHODS: REE was measured via indirect calorimetry and fat mass and fat-free mass (FFM) were assessed using dual X-ray absorptiometry as part of a unique analysis of two studies. C-reactive protein (CRP) was measured as an inflammatory marker. Linear regression was used to assess the determinants of REE at baseline and REE change, with days between baseline and follow-up measures included as a covariate. RESULTS: One-hundred and nine patients were included at baseline (59.6% male; 67 ± 12 years; body mass index 24.1 ± 4.3 kg/m2); 49 had follow-up data (61.2% male; 65 ± 12 years; body mass index 25.4 ± 4.3 kg/m2), with median follow-up of 119 days (interquartile range: 113-127 days). At baseline, age, FFM, and CRP explained 68.9% of the variability in REE. A wide variability in REE change over time was observed, ranging from -156 to 370 kcal/day, or -13.0 to 15.7%/100 days. CRP change (1.7 ± 0.4 mg/L, p < 0.001) and stage (81.3 ± 38.7, p = 0.042) predicted REE change in multivariate analysis, controlling for age, FFM change, and days between visits (R2: 0.417 ± 88.2, p < 0.001). CONCLUSIONS: Age, FFM, and CRP predicted REE at a single time point. REE change was highly variable and explained by inflammation and stage. Future research should investigate the validity and feasibility of incorporating these measures into energy needs recommendations.

Multifrequency Bioelectrical Impedance Analysis Compared With Computed Tomography for Assessment of Skeletal Muscle Mass in Primary Colorectal Malignancy: A Predictor of Short-Term Outcome After Surgery.

BACKGROUND: Herein, we evaluate the accuracy and reliability of multifrequency bioelectrical impedance analysis (BIA) to assess skeletal muscle mass (SMM) in the colorectal cancer patient compared with computed tomography (CT) scan and also analyze the association between SMM of BIA and postoperative outcomes. METHODS: From March to May 2017, the body composition of patients scheduled for elective surgery due to primary colorectal cancer in our institution was analyzed at the time of admission using BIA (InBody S20, Biospace Co Ltd, Seoul, South Korea). The relationship between the single cross-sectional area of skeletal muscle at the lumbar region using preoperative CT scan and the SMM determined via BIA were assessed. Postoperative outcomes were compared according to different status of SMM on BIA categorized into 3 groups (low, medium, or high). RESULTS: Fifty patients were analyzed, and the length of hospital stay was shorter and the initiation of oral diet was significantly earlier in the group with high SMM than in other groups (P = 0.001 and 0.038, respectively). The SMM on BIA showed a very significant correlation with skeletal muscle index using CT scan (0.705 of correlation coefficients, P < 0.001) and also strongly correlated with skeletal muscle index after adjusting for age, weight, and BMI on multivariate analysis (ß = 0.391 ± 0.057, P < 0.001). CONCLUSION: SMM determined by BIA is strongly correlated with SMM estimated by CT scan. Authors suppose that BIA could be an alternative to CT scan for the assessment of SMM in colorectal cancer patients.

Facilitators and Barriers to Adoption of a Healthy Diet in Survivors of Colorectal Cancer.

PURPOSE: Adherence to dietary guidelines and consumption of a high-quality diet are essential to rebuild strength and to decrease tumor recurrence and mortality in patients with colorectal cancer. We examined the associations of the diet quality of patients who have colorectal cancer with the characteristics of the patients and their families, the patient's perceived barriers to following the diet, and the family's attempts to change the diet. DESIGN: A cross-sectional study design was employed. Patients with colorectal cancer were recruited from National University Hospitals in South Korea. Enrolled patients were over 19 years old. Enrolled relatives served as the primary caregivers of the patients. METHODS: A total of 216 patients who had colorectal cancer and their family caregivers were enrolled. We assessed patients' diet quality, their perceived barriers to following the dietary plan, and family caregivers' attempts to improve diet quality. FINDINGS: Patients with colorectal cancer were less likely to have healthy eating habits if they perceived barriers to the recommended dietary plan, and more likely to have healthy eating habits if they had family caregivers who attempted to change their own dietary habits. CONCLUSIONS: Strategies that target patients' perceived barriers to following a healthy diet and that encourage family members to facilitate the adoption of a healthy diet can be integrated into the treatment plan of patients with colorectal cancer. CLINICAL RELEVANCE: The results can be used as evidence for promoting the notion that diet interventions for patients with colorectal cancer focus on the patient-family dyad, which support overall quality of care in oncology care hospitals.

Understanding Symptom Burden in Patients With Advanced Cancer Living in Rural Areas.

OBJECTIVES: To evaluate the feasibility of using a biobehavioral approach to examine symptom burden in rural residents with advanced cancer. SAMPLE & SETTING: 21 patients with advanced lung, colorectal, or pancreatic cancer were enrolled at the University of Iowa in Iowa City. METHODS & VARIABLES: Using Cleeland's cytokine-immunologic model of symptom expression, symptom burden (i.e., severity, count, and interference) and inflammatory cytokines were measured for 24 weeks. Potential predictors included demographics, clinical characteristics, optimism, social support, and cancer-related stress. Descriptive statistics, Wilcoxon rank-sum, and Fisher's exact test were used for analysis. RESULTS: Recruitment and retention rates were similar for rural and nonrural patients. Demographics, optimism, and social support were no different between groups. The cancer-related stress total score for rural patients was nearly half of the score of nonrural patients, with rural patients reporting significantly less avoidance. Symptom severity for the five worst symptoms remained moderate during the 24 weeks, whereas nonrural residents reported steady declines in severity of their five worst symptoms. Significant differences in inflammatory cytokines between groups were only found at one time point. IMPLICATIONS FOR NURSING: Rural residents who seek care at a cancer center may be clinically and demographically more similar to their nonrural counterparts than to rural residents seeking local care.

A new diagnostic index for sarcopenia and its association with short-term postoperative complications in patients undergoing surgery for colorectal cancer.

AIM: Sarcopenia is a robust prognostic indicator of outcomes after surgery for colorectal cancer (CRC). However, there are no serum markers routinely available for estimating skeletal muscle mass (SMM). The present study aimed to describe a new sarcopenia index (SI), serum creatinine (Scr) × cystatin C-based glomerular filtration rate, and investigate its association with short-term complications after curative resection of CRC. METHOD: Consecutive patients who underwent curative resection of CRC from December 2011 to January 2017 were retrospectively identified. Skeletal muscle cross-sectional area was analysed on L3 computed tomographic images. Receiver operating characteristic curve analysis showed that the cutoff points of SI for sarcopenia were below 56.1 in men and below 43.7 in women. Patients were classified into low and high SI groups in accordance with these cutoff values. The association between SI and body composition and the impact of preoperative SI on postoperative outcomes were analysed. RESULTS: Among 417 patients, SI showed a stronger correlation with skeletal muscle area (SMA) (r = 0.537, P < 0.001) than with the Scr/cystatin C ratio (r = 0.469, P < 0.001) and Scr (r = 0.447, P < 0.001). The low SI group had a lower SMA, lower preoperative haemoglobin, a higher prevalence of sarcopenia and experienced more postoperative complications compared with the high SI group (all P < 0.001). Multivariate logistic regression analysis showed that the independent risk factors for overall complications were low preoperative haemoglobin, low SI, sarcopenia and American Society of Anesthesiologists grade ≥ 3. CONCLUSION: This new SI is a simple and useful surrogate marker for estimating SMM, and is associated with outcomes after CRC surgery.

Effects of health-related quality of life on health service utilisation in patients with colorectal neoplasms.

This study was to assess the impact of HRQOL on health service utilisation using four different count data models. The HRQOL was measured using the Short-Form Six-Dimension instrument and the functional assessment of cancer therapy-colorectal whereas health service utilisation was measured by the number of monthly clinical consultations and the number of monthly hospitalisation. Different count data models (Poisson's regression, negative binomial regression, zero-inflated Poisson's regression and zero-inflated negative binomial regression) were used to assess the association between HRQOL and health service utilisation. A performance comparison was made between the models. Goodness-of-fit statistics (the Pearson's chi-squared test statistic, the Akaike and Bayesian information criteria) were used to determine the best-fitting model. The negative binomial model performed the best in assessing the association between HRQOL measures and health service utilisation in patients with colorectal neoplasm and thus recommended. Physical well-being of patients was negatively and significantly associated with the monthly rate of health service utilisation after controlling for patient demographics. Both physical and function well-beings of patients were negatively and significantly associated with the number of monthly hospitalisations. If the data for the condition-specific FACT-C are not available, SF-6D showed a very strong negative relationship with health service utilisation. Such models can be used to guide the allocation of clinical resources and funding for the care of colorectal cancer patients.

Quality of life and cost effectiveness in a randomized trial of patients with colorectal cancer and peritoneal metastases.

BACKGROUND: The aim was to compare health-related quality-of-life (HRQOL) and cost-effectiveness between cytoreductive surgery with intraperitoneal chemotherapy (CRS + IPC) and systemic chemotherapy for patients with colorectal peritoneal metastases. METHODS: Patients included in the Swedish Peritoneal Trial comparing CRS + IPC and systemic chemotherapy completed the EORTC QLQ-C30 and SF-36 questionnaires at baseline, 2, 4, 6, 12, 18, and 24 months. HRQOL at 24 months was the primary endpoint. EORTC sum score, SF-36 physical and mental component scores at 24 months were calculated and compared for each arm and then referenced against general population values. Two quality-adjusted life-year (QALY) indices were applied (EORTC-8D and SF-6D) and an incremental cost-effectiveness ratio (ICER) per QALY gained was calculated. A projected life-time ICER per QALY gained was calculated using predicted survival according to Swedish population statistics. RESULTS: No statistical differences in HRQOL between the arms were noted at 24 months. Descriptively, survivors in the surgery arm had higher summary scores than the general population at 24 months, whereas survivors in the chemotherapy arm had lower scores. The projected life-time QALY benefit was 3.8 QALYs in favor of the surgery arm (p=0.06) with an ICER per QALY gained at 310,000 SEK (EORTC-8D) or 362,000 SEK (SF-6D) corresponding to 26,700-31,200 GBP. CONCLUSION: The HRQOL in patients with colorectal peritoneal metastases undergoing CRS + IPC appear similar to those receiving systemic chemotherapy. Two-year survivors in the CRS + IPC arm have comparable HRQOL to a general population reference. The treatment is cost-effective according to NICE guidelines.

How health-related quality of life assessment should be used in advanced colorectal cancer clinical trials.

Traditionally, the efficacy of cancer treatment in patients with advance or metastatic disease in clinical studies has been studied using overall survival and more recently tumor-based end points such as progression-free survival, measurements of response to treatment. However, these seem not to be the relevant clinical end points in current situation if such end points were no validated as surrogate of overall survival to demonstrate the clinical efficacy. Appropriate, meaningful, primary patient-oriented and patient-reported end points that adequately measure the effects of new therapeutic interventions are then crucial for the advancement of clinical research in metastatic colorectal cancer to complement the results of tumor-based end points. Health-related quality of life (HRQoL) is effectively an evaluation of quality of life and its relationship with health over time. HRQoL includes the patient report at least of the way a disease or its treatment affects its physical, emotional and social well-being. Over the past few years, several phase III trials in a variety of solid cancers have assessed the incremental value of HRQoL in addition to the traditional end points of tumor response and survival results. HRQoL could provide not only complementary clinical data to the primary outcomes, but also more precise predictive and prognostic value. This end point is useful for both clinicians and patients in order to achieve the dogma of precision medicine. The present article examines the use of HRQoL in phase III metastatic colorectal cancer clinical trials, outlines the importance of HRQoL assessment methods, analysis, and results presentation. Moreover, it discusses the relevance of including HRQoL as a primary/co-primary end point to support the progression-free survival results and to assess efficacy of treatment in the advanced disease setting.

Assessment of Nutritional and Inflammatory Status to Determine the Prevalence of Malnutrition in Patients Undergoing Surgery for Colorectal Carcinoma.

BACKGROUND/AIM: Colorectal Cancer is the fourth most frequent cause of cancer death worldwide and its incidence increases from 50 years of age. It is often associated with protein-caloric malnutrition and 20% of cancer deaths occur due to this event. The aim of this study was to assess the prevalence of malnutrition and inflammatory status in 78 patients undergoing surgery for colorectal carcinoma. PATIENTS AND METHODS: Nutritional Status was assessed by Mini Nutritional Assessment (MNA). Serum levels of interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) were measured by ELISA, while albumin, C-reactive protein (CRP) and transferrin (TRF) were tested using an immunometric assay. RESULTS: The mean MNA score in colorectal patients was 20.4±8.4, while 23/78 patients (29.4%) were well nourished, 36/78 (46.1%) were at risk of malnutrition and 19/78 (24.3%) were malnourished, reporting in the previous six months from the date of diagnosis a significant weight loss (>10 kg), muscle mass loss and severe reduction of food intake due to loss of appetite and altered taste perception. The serum means of IL-6, TNF-α and CRP, were significantly higher in colorectal patients compared to the control group (p<0.001, p<0.0001, p<0.0001, respectively) while lower TRF, albumin and HCT serum levels in cancer patients vs. healthy subjects (p<0.0001; p<0.0001 and p<0.0001) were found. CONCLUSION: more than 50% of colorectal cancer patients were malnourished or at risk of malnutrition and reported an imbalance between nutritional and inflammatory status. They, therefore, require a nutritional intervention before treatment in order to have a more effective response and improve quality of life.

The cost of survival: an exploration of colorectal cancer survivors' experiences of pain.

BACKGROUND: The Institute of Medicine report 'From Cancer Patient to Cancer Survivor' has drawn widespread attention to the experiences of cancer survivors. Research examining the symptom experiences of survivors are proliferative within the literature but limited by samples which include multiple tumor groups and varying inclusion criteria. This cross-sectional quantitative study seeks to examine pain and quality of life (QoL) in the context of colorectal cancer (CRC) survivorship, as defined by the Institute of Medicine. MATERIAL AND METHODS: A purposive sample of CRC survivors (n = 252) attending hospitals and cancer support centers in the Republic of Ireland were recruited between September 2014 and January 2016. Self-rated health (SRH), QoL and pain were assessed in the sample using the EuroQOL questionnaire, the Functional Assessment of Therapy-Colorectal (FACT-C) questionnaire, and symptom experience items. RESULTS: One hundred participants (40%) indicated they had pain on the day of the survey or in the past week. Of those with pain, many also experienced a lack of energy (95%), bowel dysfunction (74%), sleep disturbance (76%) or interference with their ability to enjoy life (75%). Pain was associated with younger age, female gender, current chemotherapy treatment, and previous radiotherapy treatment. Although participants reported positive QoL scores, statistical analysis revealed pain was linked to significantly poorer SRH and overall QoL, and poorer physical, emotional, functional, social/family and CRC-specific wellbeing, compared to those who did not indicate pain. DISCUSSION: Pain was experienced by almost two fifths of CRC survivors up to five years after treatment and was associated with poorer SRH and QoL. In light of these findings, healthcare professionals must endeavor to manage cancer survivors' needs in a manner which is cognizant of the burden of pain and in the context of other symptoms and morbidities experienced by long-term cancer survivors.

No Differences in Symptom Burden Between Colorectal Cancer Patients Receiving Curative Versus Palliative Chemotherapy.

CONTEXT: Colorectal cancer (CRC) is one of the most common cancers worldwide. Patients with CRC may have multiple cooccurring symptoms as a result of their disease or its treatment. Little is known about potential differences in symptom burden in CRC patients scheduled to receive curative versus palliative chemotherapy (CTX). OBJECTIVES: The purposes of this study were to investigate the overall symptom burden of patients with CRC before their first CTX treatment or before the initiation of a new CTX regimen and to evaluate for differences in symptom occurrence, severity, and distress between patients with CRC who were scheduled to receive curative versus palliative CTX. METHODS: Consecutive patients with CRC were recruited (n = 120), and symptoms were assessed using the Memorial Symptom Assessment Scale before the initiation of the CTX. The most common symptoms that occurred in ≥30% of the patients were evaluated. Differences in occurrence rates and severity and distress scores between the curative (n = 68) and palliative (n = 52) patient groups were evaluated using binary logistic regression and ordinal logistic regression analyses, respectively. RESULTS: In both groups, patients reported an average of 10 cooccurring symptoms. Worrying (65%), lack of energy (59%), feeling drowsy (54%), feeling bloated (53%), pain (51%), and difficulty sleeping (50%) were the most prevalent symptoms. Problems with sexual interest had the highest severity and distress scores in both groups. For the 13 most common symptoms, no significant differences were found between the two patient groups on any of the Memorial Symptom Assessment Scale dimensions (i.e., occurrence, severity, distress). CONCLUSION: Regardless of the reason for CTX, CRC patients experience a large number of cooccurring symptoms.

Systematic review recommends the European Organization for Research and Treatment of Cancer colorectal cancer-specific module for measuring quality of life in colorectal cancer patients.

OBJECTIVES: To critically appraise the measurement properties of standardized health-related quality of life (HRQOL) instruments for colorectal cancer (CRC) patients and to provide recommendations on the choice of HRQOL instruments. STUDY DESIGN AND SETTING: Systematic review of English language literature published between January 1985 and May 2014 identified through a database search of PubMed, Web of Science, Embase, and Ovid MEDLINE. HRQOL instruments were rated on methodological quality and overall levels of evidence using a Consensus-based Standards for the selection of health Measurement Instrument checklist. RESULTS: Internal consistency and hypothesis testing were evaluated most frequently in 63 studies identified. The Functional Assessment of Cancer Therapy-Colorectal (FACT-C) was the most extensively evaluated. The highest number of positive ratings in the overall level of evidence was found in the CRC-specific quality of life questionnaire module (QLQ-CR38) in European Organization for Research and Treatment of Cancer (EORTC) module, followed by the Memorial Sloan Kettering Cancer Center Bowel instrument, FACT-C, and Quick-FLIC. The EORTC QLQ-CR38 had the most positive ratings on measurement property and was recommended. CONCLUSION: The EORTC QLQ-CR38 was recommended to assess HRQOL in patients with CRC, regardless of disease stage and primary tumor site.

Laparoscopy for colorectal cancer.

The laparoscopic approach for colorectal cancer resection has been evolved from an experimental procedure with oncological concerns to routine daily practice within a period of two decades. Numerous randomized controlled trials and meta-analyses have shown that laparoscopic resection results in faster recovery with similar oncological outcome compared to an open approach, both for colon and rectal cancer. Besides improved cosmesis, other long-term advantages seem to be less adhesion related small bowel obstruction and reduced incisional hernia rate. Adequate patient selection and surgical experience are of crucial importance. Experience can be gradually expanded step by step, by increasing the complexity of the procedure. A decision to convert should be made early in the procedure, because the outcome after a reactive conversion is worse than initial open resection or strategic conversion. The additive value of new techniques such as robotic surgery has to be proven in randomized studies including a cost-effectiveness assessment.

Strain assessment in surgically resected inflammatory and neoplastic bowel lesions.

PURPOSE: To investigate whether ultrasound-based strain imaging can discriminate between colorectal adenocarcinomas and stenotic Crohn's lesions in newly resected surgical specimens. MATERIALS AND METHODS: Resected surgical specimens from 27 patients electively operated for colorectal tumors or stenotic lesions from Crohn's disease were prospectively examined with ultrasonography using a Hitachi HV 900 US scanner with real-time elastography (RTE). Three different methods were applied to assess tissue strain: A four-level categorical visual classification, a continuous visual analog scale (VAS, 0 - 100) and a strain ratio (SR) measurement between the lesion and surrounding reference tissue. The imaged sections were marked and subsequently examined by a pathologist. Results from RTE were evaluated according to diagnosis, degree of fibrosis, inflammatory parameters, tumor stage and grade. RESULTS: 16 sections from Crohn's lesions, 18 sections from adenocarcinomas and 4 sections from adenomas were examined. Both adenocarcinomas and Crohn's lesions were found to be harder than the surrounding tissue, but they could not be discriminated from each other by any of the strain imaging evaluation methods. All adenocarcinomas had significantly higher strain ratios than adenomas. The categorical classification differentiated poorly between Crohn's lesions, adenocarcinomas and adenomas. Categorical evaluation and VAS score showed fair interobserver agreement. SR measurements provided semi-quantitative strain data and added improved information about elasticity properties, despite substantial intra-observer variation. CONCLUSION: Sonoelastography with SR measurements and visual evaluation of strain differences could not differentiate stenotic Crohn's lesions from adenocarcinomas in resected bowel specimens. A small number of adenomas were found to be significantly softer than adenocarcinomas using the same evaluation methods. The tumor stage or grade did not have a significant impact on the elastography results.

The sexual health care needs after colorectal cancer: the view of patients, partners, and health care professionals.

PURPOSE: Sexual dysfunction among patients with colorectal cancer is frequently reported. Studies examining patients' sexual health care needs are rare. We examined the sexual health care needs after colorectal cancer treatment according to patients, partners, and health care professionals (HCPs). Factors that impede or facilitate the quality of this care were identified. METHOD: Participants were recruited from three Dutch hospitals: St. Elisabeth, TweeSteden, and Catharina hospitals. Patients (n = 21), partners (n = 9), and 10 HCPs participated in eight focus groups. RESULTS: It is important to regularly evaluate and manage sexual issues. This does not always occur. Almost all participants reported a lack of knowledge and feelings of embarrassment or inappropriateness as barriers to discuss sexuality. HCPs reported stereotypical assumptions regarding the need for care based on age, sex, and partner status. The HCPs debated on whose responsibility it is that sexuality is discussed with patients. Factors within the organization, such as insufficient re-discussion of sexuality during (long-term) follow-up and unsatisfactory (knowledge of the) referral system impeded sexual health care. The HCPs could facilitate adequate sexual health care by providing patient-tailored information and permission to discuss sex, normalizing sexual issues, and establishing an adequate referral system. It is up to the patients and partners to demarcate the extent of sexual health care needed. CONCLUSIONS: Our findings illustrate the need for patient-tailored sexual health care and the complexity of providing/receiving this care. An adequate referral system and training are needed to help HCPs engage in providing satisfactory sexual health care.