Impact of age on the use of adjuvant treatments in patients undergoing surgery for colorectal cancer: patients with stage III colon or stage II/III rectal cancer.

BACKGROUND: Many older patients don't receive appropriate oncological treatment. Our aim was to analyse whether there are age differences in the use of adjuvant chemotherapy and preoperative radiotherapy in patients with colorectal cancer. METHODS: A prospective cohort study was conducted in 22 hospitals including 1157 patients with stage III colon or stage II/III rectal cancer who underwent surgery. Primary outcomes were the use of adjuvant chemotherapy for stage III colon cancer and preoperative radiotherapy for stage II/III rectal cancer. Generalised estimating equations were used to adjust for education, living arrangements, area deprivation, comorbidity and clinical tumour characteristics. RESULTS: In colon cancer 92% of patients aged under 65 years, 77% of those aged 65 to 80 years and 27% of those aged over 80 years received adjuvant chemotherapy (χ2trends < 0.001). In rectal cancer preoperative radiotherapy was used in 68% of patients aged under 65 years, 60% of those aged 65 to 80 years, and 42% of those aged over 80 years (χ2trends < 0.001). Adjusting by comorbidity level, tumour characteristics and socioeconomic level, the odds ratio of use of chemotherapy compared with those under age 65, was 0.3 (0.1-0.6) and 0.04 (0.02-0.09) for those aged 65 to 80 and those aged over 80, respectively; similarly, the odds ratio of use of preoperative radiotherapy was 0.9 (0.6-1.4) and 0.5 (0.3-0.8) compared with those under 65 years of age. CONCLUSIONS: The probability of older patients with colorectal cancer receiving adjuvant chemotherapy and preoperative radiotherapy is lower than that of younger patients; many of them are not receiving the treatments recommended by clinical practice guidelines. Differences in comorbidity, tumour characteristics, curative resection, and socioeconomic factors do not explain this lower probability of treatment. Research is needed to identify the role of physical and cognitive functional status, doctors' attitudes, and preferences of patients and their relatives, in the use of adjuvant therapies.

CCR-CARESS score for predicting operative mortality in patients with colorectal cancer.

BACKGROUND: The aim of this study was to assess factors associated with outcomes after surgery for colorectal cancer and to design and internally validate a simple score for predicting perioperative mortality. METHODS: Patients undergoing surgery for primary invasive colorectal cancer in 22 centres in Spain between June 2010 and December 2012 were included. Clinical variables up to 30 days were collected prospectively. Multiple logistic regression techniques were applied and a risk score was developed. The Hosmer-Lemeshow test was applied and the area under the receiver operating characteristic (ROC) curve (AUC, with 95 per cent c.i.) was estimated. RESULTS: A total of 2749 patients with a median age of 68·5 (range 24-97) years were included; the male : female ratio was approximately 2 : 1. Stage III tumours were diagnosed in 32·6 per cent and stage IV in 9·5 per cent. Open surgery was used in 39·3 per cent, and 3·6 per cent of interventions were urgent. Complications were most commonly infectious or surgical, and 25·5 per cent of patients had a transfusion during the hospital stay. The 30-day postoperative mortality rate was 1·9 (95 per cent c.i. 1·4 to 2·4) per cent. Predictive factors independently associated with mortality were: age 80 years or above (odds ratio (OR) 2·76), chronic obstructive pulmonary disease (COPD) (OR 3·62) and palliative surgery (OR 10·46). According to the categorical risk score, a patient aged 80 years or more, with COPD, and who underwent palliative surgery would have a 23·5 per cent risk of death within 30 days of the intervention. CONCLUSION: Elderly patients with co-morbidity and palliative intention of surgery have an unacceptably high risk of death.

Predictors of 1- and 2-year mortality in patients with rectal cancer.

AIM: Tools are needed to aid in the assessment of the prognosis of patients with rectal cancer regarding the risk of medium-term mortality. The aim of this study was to develop and validate clinical prediction rules for 1- and 2-year mortality in patients undergoing surgery for rectal cancer. METHOD: A prospective cohort study of patients diagnosed with rectal cancer who underwent surgery was carried out. The main outcomes were mortality at 1 and 2 years after surgery. Background, clinical parameters and diagnostic test findings were evaluated as possible predictors. Multivariable survival models were used in the statistical analyses. RESULTS: Predictors of 1-year mortality were being a current smoker [hazard ratio (HR) 4.98], having a Charlson index adjusted by age > 5 (HR 2.61), the presence of vascular, perineural or lymphatic invasion (HR 3.30), the presence of residual tumour at the operation (R-stage) (HR 8.64) and TNM stage (HR for TNM IV 5.10) [concordance index (C-index) 0.799 (95% CI: 0.71-0.89)]. Age greater than 80 years (HR 2.19), being a current smoker (HR 2.20), the pre-intervention haemoglobin level (HR 2.02), need for blood transfusion (HR 2.12), vascular, perineural or lymphatic invasion (HR 2.59), R-stage of the operation (HR 6.13) and TNM stage (HR for TNM IV 4.43) were predictors of 2-year mortality [C-index 0.779 (0.718-0.840)]. Adjuvant chemotherapy was an additional predictor at both outcome durations. CONCLUSION: These clinical parameters show good predictive values and are easy and quick-to-use tools to help in clinical decision making.

Profilaxis antimicrobiana de la infección de localización quirúrgica: monodosis versus multidosis. Revisión sistemática de Ensayos Clínicos aleatorizados / No disponible

Objetivo: Valorar la evidencia científica acerca de la duración óptima de la profilaxis antimicrobiana quirúrgica. Material y Métodos: Revisión sistemática que incluye ensayos clínicos aleatorizados (ECAs) que comparan profilaxis antimicrobiana con monodosis prequirúrgica frente a profilaxis multidosis, publicados hasta Septiembre de 2004. Resultados: Se localizó una revisión sistemática publicada en 1998 que obtiene un OR de 1'04 con un Intervalo de Confianza (IC) al 95% [0'86-1'27] al comparar frecuencia de infección de localización quirúrgica en pacientes que reciben monodosis y multidosis. Tras esta revisión, se publicaron cuatro ECAs con los siguientes RR e IC al 95%: 2 [1'02-3'92], 0'51[0'10-2'65], 0'46[0'21-1'02] y 1'18[0'33-4'24]. Conclusiones: La administración de dosis adicionales de antimicrobiano posquirúrgicas no reduce la incidencia de infección de localización quirúrgica. No obstante, es preciso realizar nuevos ensayos clínicos para asentar esta evidencia en aquellas especialidades quirúrgicas con poca representación en los estudios realizados hasta ahora

Objective: To assess the scientific evidence about the optimum length for the antimicrobial prophylaxis in surgery. Methods: Systematic review including randomized clinical trials comparing single-dose preoperative prophylaxis with multiple-dose surgical prophylaxis, published until September 2004. Results: A systematic review published in 1998 was identified. The combined OR of surgical site infection for single versus multiple-dose prophylaxis was 1'04, 95% CI [0'86,1'27]. After this review another four trials were published with the following RR and CI 95%: 2 [1'02-3'92], 0'51 [0'10-2'65], 0'46 [0'21-l'02] and l'18[0'33-4'24]. Conclusions: Administration of postsurgery doses don't reduce the surgical site infection incidence. However, new trials are necessary to support this evidence in surgical disciplines with little participation in previous trials