Risk Factor Profiles Differ for Cancers of Different Regions of the Colorectum.

BACKGROUND & AIMS: The molecular features of colorectal tumors differ with their anatomic location. Colorectal tumors are usually classified as proximal or distal. We collected data from 3 cohorts to identify demographic, clinical, anthropometric, lifestyle, and dietary risk factors for colorectal cancer (CRC) at 7 anatomic subsites. We examined whether the associations differ among refined subsites and whether there are trends in associations from cecum to rectum. METHODS: We collected data from the Nurses' Health Study, Nurses' Health Study 2, and Health Professionals Follow-up Study (45,351 men and 178,016 women, followed for a median 23 years) on 24 risk factors in relation to risk of cancer in cecum, ascending colon, transverse colon, descending colon, sigmoid colon, rectosigmoid junction, and rectum. Hazard ratios were estimated using Cox proportional hazards regression. We tested for linear and nonlinear trends in associations with CRC among subsites and within proximal colon, distal colon, and rectum. RESULTS: We documented 3058 cases of CRC (474 in cecum, 633 in ascending colon, 250 in transverse colon, 221 in descending colon, 750 in sigmoid colon, 202 in rectosigmoid junction, and 528 in rectum). The positive associations with cancer risk decreased, from cecum to rectum, for age and family history of CRC. In contrast, the inverse associations with cancer risk increased, from cecum to rectum, for endoscopic screening and intake of whole grains, cereal fiber, and processed red meat. There was a significant nonlinear trend in the association between CRC and female sex, with hazard ratios ranging from 1.73 for ascending colon cancer to 0.54 for sigmoid colon cancer. For proximal colon cancers, the association with alcohol consumption and smoking before age 30 years increased from the cecum to transverse colon. For distal colon cancers, the positive association with waist circumference in men was greater for descending vs sigmoid colon cancer. CONCLUSIONS: In an analysis of 3058 cases of CRC, we found that risk factor profiles differed for cancers along the colorectum. Proximal vs distal classifications are not sufficient to encompass the regional variations in colorectal tumor features and risk factors.

Insurance Status, Not Race, is Associated With Use of Minimally Invasive Surgical Approach for Rectal Cancer.

OBJECTIVE: To determine the impact of race and insurance on use of minimally invasive (MIS) compared with open techniques for rectal cancer in the United States. BACKGROUND: Race and socioeconomic status have been implicated in disparities of rectal cancer treatment. METHODS: Adults undergoing MIS (laparoscopic or robotic) or open rectal resections for stage I to III rectal adenocarcinoma were included from the National Cancer Database (2010-2012). Multivariate analyses were employed to examine the adjusted association of race and insurance with use of MIS versus open surgery. RESULTS: Among 23,274 patients, 39% underwent MIS and 61% open surgery. Overall, 86% were white, 8% black, and 3% Asian. Factors associated with use of open versus MIS were black race, Medicare/Medicaid insurance, and lack of insurance. However, after adjustment for patient demographic, clinical, and treatment characteristics, black race was not associated with use of MIS versus open surgery [odds ratio [OR] 0.90, P = 0.07). Compared with privately insured patients, uninsured patients (OR 0.52, P < 0.01) and those with Medicare/Medicaid (OR 0.79, P < 0.01) were less likely to receive minimally invasive resections. Lack of insurance was significantly associated with less use of MIS in black (OR 0.59, P = 0.02) or white patients (OR 0.51, P < 0.01). However, among uninsured patients, black race was not associated with lower use of MIS (OR 0.96, P = 0.59). CONCLUSIONS: Insurance status, not race, is associated with utilization of minimally invasive techniques for oncologic rectal resections. Due to the short-term benefits and cost-effectiveness of minimally invasive techniques, hospitals may need to improve access to these techniques, especially for uninsured patients.

Transanal endoscopic microsurgery for residual rectal cancer (ypT0-2) following neoadjuvant chemoradiation therapy: another word of caution.

BACKGROUND: Significant tumor downstaging among patients with rectal cancer following neoadjuvant chemoradiation has raised the issue of offering patients with small residual cancers restricted to the bowel wall an alternative treatment strategy to total mesorectal excision. Transanal endoscopic microsurgery may allow proper primary tumor resection with promising oncological outcomes, less postoperative morbidity, and minimal long-term sexual, urinary, and fecal continence disorders in comparison with radical resection. OBJECTIVE: The aim of this study was to determine the oncological outcomes of patients with residual rectal cancers restricted to the rectal wall (ypT0-2) following neoadjuvant chemoradiation and transanal endoscopic microsurgery. DESIGN: This study considered a prospective cohort of patients with residual rectal cancers following neoadjuvant chemoradiation treated by transanal endoscopic microsurgery and no additional systemic therapy. SETTINGS: This study was a single-institution experience. PATIENTS: Patients with adenocarcinoma of the rectum located no more than 7 cm from the anal verge and endorectal ultrasound- or magnetic resonance-staged cT2-4N0-2M0 treated by neoadjuvant chemoradiation (50.4-54 Gy and 5-fluorouracil-based chemotherapy) were eligible for the study. Patients with small residual tumors (≤3 cm) radiologically staged ycT0-2N0 were treated by transanal endoscopic microsurgery. INTERVENTIONS: Transanal endoscopic microsurgery was performed. MAIN OUTCOME MEASURES: The primary outcome measured was local recurrence. RESULTS: Of the 27 patients treated by transanal endoscopic microsurgery, 3 had ypT0, 6 had ypT1, and 18 had ypT2 cancers. All patients underwent R0 transanal endoscopic microsurgery excision. Local recurrence was observed in 4 (15%) patients after a median follow-up of 15 months. Only lymphovascular invasion was an independent predictive factor for local failure (p = 0.04). Tumor size, ypT status, T-status downstaging, lateral/radial margins, and tumor regression grade were not predictors of local failure. LIMITATIONS: This study was limited by the small sample size and limited follow-up. CONCLUSIONS: A local failure rate of 15% after transanal endoscopic microsurgery for patients with residual rectal cancers restricted to the bowel wall (ypT0-2) may limit the indication of this procedure to highly selected patients as an alternative to standard radical total mesorectal excision.

Risk factors for residual cancer and lymph node metastasis after noncurative endoscopic resection of early colorectal cancer.

BACKGROUND: Endoscopic resection could be a curative treatment for early colorectal cancer without the possibility of lymph node metastasis. However, if the resection margin is positive, and there is a risk of lymph node metastasis, additional surgery should be performed. OBJECTIVE: The aim of this study was to investigate the characteristics of patients who underwent additional surgery to determine risk factors associated with residual tumor and lymph node metastasis. DESIGN: This study is a retrospective analysis. SETTINGS: This study was conducted at a tertiary academic hospital. PATIENTS: We evaluated 85 patients who underwent additional surgery with curative intent after endoscopic resection for early colorectal cancer at the Samsung Medical Center, Seoul, South Korea, between January 2001 and April 2010. MAIN OUTCOME MEASURES: We identified risk factors associated with residual tumor or lymph node metastasis in surgical specimens after noncurative endoscopic resection for early colorectal cancer. RESULTS: Among 85 patients who underwent additional surgery after noncurative endoscopic resection, 76 (89.4%) had submucosal invasion greater than 1000 µm. Twenty-one (24.7%) and 25 patients (29.4%) had a positive lateral or vertical resection margin, and 11 patients (12.9%) had inadequate lifting sign. After additional surgery, patients were divided into 2 groups according to the presence or absence of residual tumor and/or lymph node metastasis. There was no significant difference between the groups in positive lateral margin, but there was a significant difference in positive vertical margin (p = 0.015 with an OR of 15.02). In patients with inadequate lifting sign, the OR was 13.68 (p = 0.013). LIMITATIONS: This study was limited by its retrospective nature. CONCLUSION: There is a greater need for additional surgery in cases with positive vertical resection margin or inadequate lifting sign, because the risk of residual tumor and lymph node metastasis is higher than in other cases.

[Diagnostics of the primary multiple forms of the colorectal cancer].

The issue analyses the diagnostics of the repeated malignant lesions of the colorectal region. The study covers the two decades period (1992-2011 yy). Of the observed patients with primary colorectal tumors, 238 showed the repeated lesions of the region. The article focuses on the on-time diagnostics and differential approach to the repeated malignancies of the colorectal region.

Treatment strategy for recurrent or residual colorectal tumors after endoscopic resection.

BACKGROUND: Piecemeal resection of colorectal neoplasms is associated with a higher risk of recurrent or residual tumors, but nearly all such cases can be cured by additional endoscopic resection (ER). Although the adoption of endoscopic submucosal dissection (ESD) for colorectal neoplasm is continuing, the safety of this treatment for recurrent or residual tumors has not been fully assessed. We evaluated salvage therapy for the treatment of recurrent or residual tumors, and propose an endoscopic treatment strategy for these tumors. METHODS: This retrospective study was conducted for 60 consecutive patients who had with locally recurrent or residual tumor after ER between January 2004 and October 2005. Endoscopic treatment strategy, treatment results, complications and clinical outcomes were recorded. RESULTS: Among 69 lesions in 60 patients, 67 were treated endoscopically, whereas 2 required surgical treatment. Of these 67, 87% (58/67) were resected by endoscopic mucosal resection (EMR) and 13% (9/67) by ESD. En bloc resection rate was 39% (23/58) in the EMR group and 56% (5/9) in the ESD group. One limitation of this study is that it was a single-center retrospective analysis. CONCLUSIONS: ESD is safe and effective for the treatment of recurrent or residual colorectal tumors. However, because of its technical difficulty, the en bloc resection rate is lower than that for the treatment of nonrecurrent lesions.

Construction of a preoperative scoring system to predict the difficulty level of colorectal endoscopic submucosal dissection.

BACKGROUND: We attempted to examine the factors contributing to the difficulty in performance of colorectal ESD, with the aim of constructing a scoring system that could help in prediction of the difficulty level of the procedure. METHODS AND MATERIALS: The data were analyzed from two viewpoints: to determine the factors contributing to 1) non-en bloc resection and the factors contributing to 2) a slow resection speed. Factors falling under these two categories contributing to difficulty in performance of ESD were extracted and used to construct a scoring system. The validity of this scoring system was evaluated by calculating the correlation between the score and the resection speed in a different dataset. RESULTS: Based on the results of our analysis, we assigned scores for various factors as follows: 4 points for EMR of a scarred lesion, 1 point for tumors with a diameter of ≥ 30 mm, 2 points for lesions located in the liver/splenic flexure, 1 point for lesions located in the transverse colon, 3 points for LST-NG-PD/depressed lesions, 1 point for protruded lesions and LST-NG-F lesions (range 0-10). In the validation study, the rank correlation coefficient between the score according to the scoring system and the resection speed was -0.130, representing a weak and negative correlation (P = 0.03). We defined the difficulty level depending on the sum of the scores: 0-2, low difficulty level; 3-5, intermediate difficulty level; ≥ 6, high difficulty level. The average resection speed was 12.6 mm2/min in the group with scores of 0-2, 8.1 mm2/min in the group with scores of 3-5, and 5.5 mm2/min in the group with scores of ≥ 6 (11.2 mm2/min in all lesions). CONCLUSION: Our colorectal ESD scoring system would be useful for selection of operators with the appropriate skill level in the procedure for colorectal ESD cases.

Role of positron emission tomography-computed tomography in the management of anal cancer.

PURPOSE: Pre- and post-treatment staging of anal cancer are often inaccurate. The role of positron emission tomograpy-computed tomography (PET-CT) in anal cancer is yet to be defined. The aim of the study was to compare PET-CT with CT scan, sentinel node biopsy results of inguinal lymph nodes, and anal biopsy results in staging and in follow-up of anal cancer. METHODS AND MATERIALS: Fifty-three consecutive patients diagnosed with anal cancer underwent PET-CT. Results were compared with computed tomography (CT), performed in 40 patients, and with sentinel node biopsy (SNB) (41 patients) at pretreatment workup. Early follow-up consisted of a digital rectal examination, an anoscopy, a PET-CT scan, and anal biopsies performed at 1 and 3 months after the end of treatment. Data sets were then compared. RESULTS: At pretreatment assessment, anal cancer was identified by PET-CT in 47 patients (88.7%) and by CT in 30 patients (75%). The detection rates rose to 97.9% with PET-CT and to 82.9% with CT (P=.042) when the 5 patients who had undergone surgery prior to this assessment and whose margins were positive at histological examination were censored. Perirectal and/or pelvic nodes were considered metastatic by PET-CT in 14 of 53 patients (26.4%) and by CT in 7 of 40 patients (17.5%). SNB was superior to both PET-CT and CT in detecting inguinal lymph nodes. PET-CT upstaged 37.5% of patients and downstaged 25% of patients. Radiation fields were changed in 12.6% of patients. PET-CT at 3 months was more accurate than PET-CT at 1 month in evaluating outcomes after chemoradiation therapy treatment: sensitivity was 100% vs 66.6%, and specificity was 97.4% vs 92.5%, respectively. Median follow-up was 20.3 months. CONCLUSIONS: In this series, PET-CT detected the primary tumor more often than CT. Staging of perirectal/pelvic or inguinal lymph nodes was better with PET-CT. SNB was more accurate in staging inguinal lymph nodes.

Transanal endoscopic microsurgery: a necessary requirement?

INTRODUCTION: There has been a gradual introduction of transanal endoscopic microsurgery (TEM) into UK practice although the uptake remains variable. This study aimed to assess the availability, application and referral pattern of TEM amongst colorectal surgeons. METHODS: A questionnaire was sent to all consultant members of the Association of Coloproctology. This considered their practice, the availability, application and referral pattern for TEM, and their views on application regarding a selection of rectal tumour scenarios. RESULTS: There were 142 replies representing 116 hospitals and 297 colorectal surgeons. The median catchment area was 280,000 (range 70,000-1,000,000). TEM was available in 18% of hospitals and 72% either performed or referred patents for TEM. Of 21 units performing TEM, 15 received referrals. From 305 TEM procedures performed over the previous year, 206 were referred cases. Eighty-five per cent of consultants considered TEM a necessary technique for optimum management of rectal lesions. Although 61% of consultants considered endoanal excision optimal for low benign rectal tumours, 58% said TEM was optimal for midrectal lesions and between 30% and 55% for high rectal lesions depending if the tumour position was anterior or posterior, respectively. One-third of consultants would perform TEM for a low T1 rectal carcinoma although half would proceed to anterior resection. DISCUSSION: TEM is considered to have a significant role in the optimal management of rectal lesions. The presence of the technique in a limited number of hospitals does appear to provide adequate resources although audit should continue to be centralized.

Accuracy and reliability of the endoscopic classification of chronic radiation-induced proctopathy using a novel grading method.

GOALS: To assess a novel grading method of radiation proctitis for intraobserver and interobserver agreement among endoscopists. BACKGROUND: There are no established criteria for the endoscopic classification of chronic radiation-induced proctopathy. We introduce a classification system based on telangiectasia density and vascular coalescence. Accuracy and reproducibility of this system were examined. STUDY: A total of 131 endoscopic images of the rectum in 74 consecutive patients undergoing lower endoscopy who had received pelvic radiation therapy were analyzed. Each image was duplicated, reversed, and rotated 90 degrees for a total of 262 images. These were shown in random order to 13 endoscopist evaluators (6 attending physicians, 7 gastroenterology fellows) using an online computer testing program. Each image was scored from grade 0 to 3 using criteria from the rectal telangiectasia density (RTD) classification we developed. Kappa (kappa) statistics and percent agreement were used to quantify the reproducibility and level of agreement. RESULTS: Intraobserver agreement: The mean (SD) for kappa among the 13 raters was 0.58 (0.09); 95% confidence interval [CI] = 0.527-0.636. Interobserver agreement: The estimated kappa across all 13 raters was 0.518 (95% CI = 0.506-0.530). For the 7 trainees, kappa was 0.547 (95% CI = 0.523-0.571). For the 6 attending physicians, the kappa was 0.481 (95% CI = 0.453-0.509). As another indicator of agreement, all 13 evaluators agreed on 30 (22.9%) of images, differed by no more than 1 grade on 60 (45.8%) images, no more than 2 grades on 33 (25.2%) of images, and no more than 3 grades on 8 of the images (6.1%); 73% of patients referred for bleeding control were RTD grade 2 or 3. CONCLUSIONS: The RTD grading scale for radiation proctopathy is reproducible among endoscopists. Hematochezia is associated with high RTD grade.

Screening for colorectal cancer by primary-care physicians in Long Island (New York) and Connecticut.

Postal questionnaires on colorectal cancer screening practices were received from samples of primary-care physicians in Long Island, New York (LI-NY) (N = 190, 66.4% response rate), and in Connecticut (N = 215, 71.7% response rate). About 90% reported ever screening asymptomatic patients 50 years of age or older by fecal occult-blood test (FOBT), and 76-86% reported generally recommending such screening annually. Proportions who generally recommended screening by proctoscopy, 48% in LI-NY and 54% in CT, were higher than those reported in a 1984 survey by the American Cancer Society. About 40-43% of physicians, however, reported using proctoscopy (i.e., flexible sigmoidoscopy [FS]) only if the FOBT was positive. The major factors influencing screening by FS were the low probability of finding a lesion, cost to the patient, and patient fear or discomfort. Training in the use of FS, reported by 25-35% of physicians, was significantly more frequent in younger physicians (i.e., less than 50 vs. 50+ years of age). Differences in responses between physicians in LI-NY and CT were generally small. Over 90% of physicians reportedly obtained information on family history of cancer and 77-80% on family history of colorectal cancer for asymptomatic patients 40 years of age and older. A pragmatic approach to increasing screening for colorectal cancer is discussed, emphasizing higher-risk patients as defined by family history of cancer and personal medical history.

Survey of physicians' attitudes and practices in early cancer detection.

Most primary care physicians are already involved in some form of cancer detection in asymptomatic patients, and most say their involvement is increasing. With the exception of the proctoscopic examination and mammography, major detection procedures are being used with asymptomatic patients by a majority of physicians. In many instances, physicians' use of detection procedures does not conform with guidelines for the cancer-related checkup recommended by the American Cancer Society. Although they may disagree with some guidelines, most physicians agree they are generally helpful. Physicians disagree with guidelines for mammography, because they feel the cost of the test and radiation exposure associated with its use argue against patients' being tested annually, or being tested at all in the absence of symptoms. In contrast, belief that testing is needed at least once a year is the basis for physicians' disagreement with Pap test guidelines. Physicians also resist discontinuing use of the chest x-ray for early cancer detection, because they want to screen smokers annually. While there is substantial agreement on the value of proctoscopy in cancer detection in asymptomatic people, many physicians are not doing a proctoscopic exam if a patient's stool blood test is negative. Patient fear, discomfort, and the cost of testing influence physician decisions against proctoscopic examination. However, the growing interest in flexible sigmoidoscopy may change attitudes and influence practice toward more general use of proctoscopy. Primary care physicians widely support cancer education, both for the public and with patients in their own practice.

Experience with a one-stop colorectal clinic.

BACKGROUND AND OBJECTIVE: Colorectal services have traditionally been arranged for the convenience of hospitals rather than patients. This model is not ideal, particularly for minor interventions and diagnostic procedures. In order to address this a one-stop colorectal clinic was set up. PATIENTS AND METHODS: Weekly clinics ran from 6.00 to 9.30 p.m. on Wednesdays for a period of 6 months. Patients with rectal bleeding, altered bowel habit, anorectal symptoms and those requesting screening advice were seen by a consultant or specialist registrar. Patients were asked to fill in a questionnaire at the end of their clinic attendance. RESULTS: 197 patients were seen in 17 clinics; 134 underwent proctoscopy, 72 had a rigid sigmoidoscopy and 85 had a flexible sigmoidoscopy carried out. Twenty-four patients subsequently had a barium enema and 3 were listed for colonoscopy. The main diagnosis was haemorrhoids (n = 104); 14 colorectal neoplasms were discovered (5 cancers and 9 polyps). During the study period the number of patients waiting for lower gastrointestinal endoscopy fell from 119 to 63; 2 months after ending the pilot scheme, the number had risen to 108. CONCLUSION: The clinic was found to have significantly improved patient care. The majority of patients were satisfied with an evening clinic. Flexible sigmoidoscopy without sedation was well tolerated and the ability to perform this at initial assessment had a marked effect on the number of patients awaiting lower gastrointestinal endoscopy.

Sigmoidoscopy/proctoscopy service with open access to general practitioners.

Many hospitals now offer barium enema examinations to general practitioners on an open access basis, so bypassing the traditional sequence of first carrying out a sigmoidoscopy. An open access sigmoidoscopy/proctoscopy service was therefore opened with requests for a barium enema being denied unless preceded by sigmoidoscopy. During the first three and a half years 1458 patients referred direct from their general practitioners were examined using a rigid sigmoidoscope. Patients were also examined with a proctoscope if thought appropriate. After the first year of the service a subsequent examination with a fibreoptic sigmoidoscope was also carried out if the presenting symptom was bleeding for which no cause could be found with the rigid instruments. A total of 516 abnormalities were found to account for symptoms in 506 patients giving a diagnostic rate of 35%. The most common lesion was piles (307 cases). Other relatively common disorders included inflammatory bowel disease (107 cases), benign tumours (44), and malignant tumours (38). Of 41 patients subsequently undergoing fibreoptic sigmoidoscopy a cause for the bleeding was found in 32, the most common being a malignant tumour (16). Most general practitioners in the district used the service and a questionnaire survey indicated that most found it very helpful. Requests from general practitioners for a barium enema fell substantially over the period.

Overall use of proctoscopy in general practice and possible relation to the stage of rectal cancer.

Data from the Danish National Health Service records on activities of each of 146 general practices in the county of North Jutland, Denmark, were studied to determine whether the use of proctoscopy influenced the stage at which cancer of the rectum was recognized. Information for all patients in the county who received the diagnosis of cancer of the rectum was obtained from the Danish Cancer Registry. Proctoscopy was performed significantly more often in partnership practices (96%) than in single practices (81%). The frequency with which the test was used varied from 1 to 107 proctoscopies per general practitioner per year. In the 95 patients with cancer of the rectum, no relationship was found between the stage (Dukes') at the time of diagnosis and work-load, size and activity of practice, or use of proctoscopy.

Differences in rates of cancer screening by usual source of medical care. Data from the 1987 National Health Interview Survey.

Data from the Cancer Control Supplement of the 1987 Health Interview Survey (NHIS), a nationally representative sample of the United States population, was used to examine rates of six screening tests for cancer. The rates of screening were compared for people who receive their usual source of medical care in an HMO or prepaid group practice versus those who receive it in the fee-for-service sector. The purpose of this article is to determine whether HMOs remain more likely to offer cancer screening examinations than the fee-for-service sector. Results indicate that for five of six screening tests examined (Pap smear, mammography, breast physical examination, digital rectal examination, and blood stool test), members of HMOs are significantly more likely to have received the test within the last 3-year period. These results hold in a multivariate analysis when many factors correlated with selection into HMOs, health status, and use of medical services are controlled for, although results are only generalizable to whites. Future research should focus on why the rates for five of the six cancer screening tests examined are higher in HMO settings, and how we can use the HMO experience to improve consensus as to the usefulness of the tests in the non-HMO physician pool, and ultimately increase rates of screening tests in the non-HMO population.