Patterns of Prescription Medication Use Before Diagnosis of Early Age-Onset Colorectal Cancer: Population-Based Descriptive Study.

BACKGROUND: Colorectal cancer (CRC) is estimated to be the fourth most common cancer diagnosis in Canada (except for nonmelanoma skin cancers) and the second and third leading cause of cancer-related death in male and female individuals, respectively. OBJECTIVE: The rising incidence of early age-onset colorectal cancer (EAO-CRC; diagnosis at less than 50 years) calls for a better understanding of patients' pathway to diagnosis. Therefore, we evaluated patterns of prescription medication use before EAO-CRC diagnosis. METHODS: We used linked administrative health databases in British Columbia (BC), Canada, to identify individuals diagnosed with EAO-CRC between January 1, 2010, and December 31, 2016 (hereinafter referred to as "cases"), along with cancer-free controls (1:10), matched by age and sex. We identified all prescriptions dispensed from community pharmacies during the year prior to diagnosis and used the Anatomical Therapeutic Chemical Classification system Level 3 to group prescriptions according to the drug class. A parallel assessment was conducted for individuals diagnosed with average age-onset CRC (diagnosis at age 50 years and older). RESULTS: We included 1001 EAO-CRC cases (n=450, 45% female participants; mean 41.0, SD 6.1 years), and 12,989 prescriptions were filled in the year before diagnosis by 797 (79.7%) individuals. Top-filled drugs were antidepressants (first; n=1698, 13.1%). Drugs for peptic ulcer disease and gastroesophageal reflux disease (third; n=795, 6.1%) were more likely filled by EAO-CRC cases than controls (odds ratio [OR] 1.4, 95% CI 1.2-1.7) and with more frequent fills (OR 1.8, 95% CI 1.7-1.9). We noted similar patterns for topical agents for hemorrhoids and anal fissures, which were more likely filled by EAO-CRC cases than controls (OR 7.4, 95% CI 5.8-9.4) and with more frequent fills (OR 15.6, 95% CI 13.1-18.6). CONCLUSIONS: We observed frequent prescription medication use in the year before diagnosis of EAO-CRC, including for drugs to treat commonly reported symptoms of EAO-CRC.

PReoperative very low-Energy diets for obese PAtients undergoing non-bariatric surgery Randomized Evaluation (PREPARE): a protocol for a pilot randomized controlled trial.

BACKGROUND: Patients with obesity presenting in need of surgical intervention are at 2-to-sixfold higher risk of prolonged hospitalization, infectious morbidity, venous thromboembolism, and more. To mitigate some of these concerns, prescribed preoperative weight loss via very low-energy diets (VLEDs) has become a standard of care for patients with obesity undergoing bariatric surgery. While VLEDs have become standard prior to bariatric surgery, their application in other surgical settings remains limited. A large, definitive trial is required to resolve the uncertainty surrounding their use in these patients. Prior to a definitive trial to compare the efficacy of VLEDs in patients with obesity undergoing major non-bariatric surgery, we require a pilot trial. We argue a pilot trial will provide the following critical feasibility insights: (1) assessment of recruitment ability, (2) evaluation of adherence to VLED regimens, and (3) assessment of our ability follow patients completely. METHODS: The proposed trial will be a multi-center, surgeon, outcome assessor, and data-analyst blinded, parallel pilot randomized controlled trial (RCT). Patients older than 18 years of age with a body mass index (BMI) of greater than 30 kg/m2 undergoing major elective non-bariatric surgery will be eligible for inclusion. Consecutive patients will be allocated 1:1 according to a computer-generated randomization schedule. Randomization will be stratified by center and will employ randomly permutated blocks. All patients in the intervention group will receive standard patient counseling on weight loss and an active VLED protocol. The preoperative VLED protocol will utilize commercially available weight loss products for three weeks preoperatively. The primary outcomes (randomization percentage, recruitment rate, intervention adherence, follow-up completion, network development) will assess feasibility. Descriptive statistics will be used to characterize the study sample. DISCUSSION: The PREPARE pilot RCT will aim to provide feasibility and safety data that will allow for the successful completion of the definitive PREPARE trial that has the potential to provide practice changing data pertaining to the regular use of VLEDs as a means of pre-habilitation for patients with obesity undergoing major non-bariatric surgery. TRIAL REGISTRATION: This study was registered on ClinicalTrials.gov (reference #NCT05918471) on June 23, 2023.

Applying the fragility index to randomized controlled trials evaluating total neoadjuvant therapy for rectal cancer: A methodological survey.

BACKGROUND: Recently, there has been significant interest in, and adoption of, total neoadjuvant therapy (TNT) for locally advanced rectal cancer (LARC). We designed the present study to assess the robustness of the randomized controlled trials (RCTs) evaluating contemporary TNTs for LARC using the fragility index (FI). MATERIALS AND METHODS: Relevant articles were identified through a review article by Johnson et al. in the Canadian Journal of Surgery. Dichotomous outcomes within these RCTs were eligible for inclusion if the reported effect size had a p-value < 0.05. The main outcome was FI for each included outcome. Walsh et al.'s method of calculating FI was utilized. Correlations between FI and research characteristics were assessed using the Spearman's rank correlation coefficients. Risk of bias was assessed using Cochrane recommended tools. RESULTS: Ten RCTs were identified with 25 outcomes having statistically significant differences between groups. Eleven outcomes were time-to-event outcomes, while the remainder were dichotomous outcomes. Approximately half (n = 13) were oncologic outcomes. The median FI was 2 (interquartile range [IQR] 1-16). The number of patients lost to follow-up exceeded the FI in 17 outcomes (68.0 %) and thus these results were considered "fragile". Lower FI was associated with high risk of bias (rho = -0.5594) and greater loss to follow-up (rho = -0.4394), while higher FI was associated with large study size (rho = 0.5120). CONCLUSIONS: The robustness of outcomes from trials assessing TNT for LARC was found to be questionable. Most outcomes were fragile, as determined by the FI. This survey is limited by the number of included studies.

Transanal Total Mesorectal Excision for Rectal Cancer.

Transanal total mesorectal excision (taTME) is a technique where rectal dissection is begun transanally in a "bottom-up" fashion. This technique facilitates dissection of the most distal part of the rectum and allows the establishment of the distal margin for rectal cancer. TaTME has proven its utility in facilitating low rectal dissection with significantly lower conversion rates and acceptable perioperative, oncological, and functional outcomes. However, taTME remains a challenging technique to learn and adopt. This article describes the technique, indications, and outcomes of taTME in rectal cancer during the last decade.

Patient and disease characteristics, treatment practices and oncologic outcomes among patients with colorectal cancer: a population-based analysis.

BACKGROUND: The incidence of colorectal cancer (CRC) is increasing among young adults. We sought to report on patient and disease characteristics, treatment practice patterns and outcomes in this population. METHODS: We conducted a retrospective cohort study using administrative health data from the Alberta Cancer Registry (2004-2015), including demographic and tumour characteristics, and treatment received. Outcome measures included overall and cancer-specific deaths. We used Cox regression and Kaplan-Meier curves to assess for factors associated with survival. RESULTS: We included 18 070 patients with CRC (n = 1583 [8.8%] < 50 yr, n = 16 487 [91.2 %] ≥ 50 yr). Younger patients were more likely to present with locally advanced disease (21.0% v. 18.0%, p < 0.0001), stage III (16.4 % v. 14.6%, p < 0.0001) or metastatic (16.7% v. 13.8%, p < 0.0001) involvement. Younger patients were more likely to receive surgery (87.2% v. 80.9%, p < 0.0001), chemotherapy (59.6% v. 34.1%, p < 0.0001) or radiation therapy (49.5% v. 37.2%, p < 0.001). At 5 years, overall and cancer-specific survival was better among younger patients than older patients (30.6% v. 51.5% overall deaths, 27.5% v. 38.4% cancer-specific deaths, p < 0.0001). CONCLUSION: Despite higher stage and higher grade disease, young patients with CRC had more favourable oncologic outcomes than stage-matched older patients, which may be related to younger patients receiving more aggressive treatment. Further investigation should focus on optimal treatment patterns for young patients with CRC.

Patterns of Healthcare Utilization Leading to Diagnosis of Young-Onset Colorectal Cancer (yCRC): Population-Based Case-Control Study.

Background: The increasing risk of young-onset colorectal cancer (yCRC) in adults < 50 years has called for better understanding of patients' pathways to diagnosis. This study evaluated patterns of healthcare utilization before diagnosis of yCRC. Methods: Using linked administrative health databases in British Columbia, Canada, we identified yCRC cases and cancer-free controls matched (1:10) on age, sex, and healthcare utilization. The index date was the date of diagnosis for yCRC cases and matched date for controls. Outpatient visits, emergency department visits, and hospitalizations over a 5-year prediagnosis period (e.g., year-1 to year-5) were compared using descriptive statistics and Poisson regression models. Results: The study included 2567 yCRC cases (49.6% females, 43.0 ± 5.8 years) and 25,455 controls (48.6% females, 43.0 ± 5.8 years). We observed an increasing number of outpatient visits from prediagnosis year-5 (median = 3) to year-1 (median = 8) for yCRC cases. Among controls, outpatient visits were stable and did not have a pattern of increase. Poisson regression models indicated higher adjusted count ratios for outpatient visits for yCRC cases compared to controls in the year before diagnosis (1.11; 95% CI, 1.07 to 1.15). In the year before diagnosis, 35.1% of yCRC cases had potentially related visits to CRC (e.g., nausea, vomiting) and 16.9% had potentially red flag visits (e.g., gastrointestinal hemorrhage or iron deficiency anemia). Conclusions: Using population-based data, we found that individuals with yCRC did not have higher healthcare utilization than individuals without in the prediagnosis period except for the year before diagnosis.

Indications and Technical Considerations for Transanal Total Mesorectal Excision.

CASE SUMMARY: A 53-year-old man presented after noting bright red blood from his rectum. On examination, he was found to have a mass 1 cm above the anal sphincter complex. He had a BMI of 40 kg/m2 and was otherwise healthy. MRI revealed a T2/early T3 lesion with extramural venous invasion and suspicious perirectal lymph nodes. Low rectal cancer was diagnosed. He underwent long-course neoadjuvant chemoradiation with good but not complete clinical response. Given his obesity and the low nature of his rectal cancer, a transanal total mesorectal excision (taTME) was planned.

The Digital Divide: A Retrospective Survey of Digital Rectal Examinations during the Workup of Rectal Cancers.

Background: Digital rectal examination (DRE) is considered an important part of the physical examination. However, it is unclear how many patients have a DRE performed at the primary care level in the work-up of rectal cancer, and if the absence of a DRE causes a delay to consultation with a specialist. Methods: A retrospective patient questionnaire was sent to 1000 consecutive patients with stage II or stage III rectal cancer. The questionnaire asked patients to recall if they had a DRE performed by their general practitioner (GP) when they first presented with symptoms or a positive FIT test. Demographic data, staging data, and time to consultation with a specialist were also collected. Results: A thousand surveys were mailed out, and a total of 262 patients responded. Of the respondents, 46.2% did not recall undergoing a digital rectal examination by their primary care provider. Women were less likely to undergo a DRE than men (28.6% vs. 44.3%, p = 0.019). While there was a trend towards longer times to specialist consultation in patients who did not undergo a DRE (27.0 vs. 12.2 weeks), this was not statistically significant (p = 0.121). Conclusion: A significant proportion of patients who are FIT positive or have symptomatic rectal bleeding do not recall having a DRE by their primary care provider. Barriers may include lack of comfort with performing DRE or lack of time. Clearer guidelines and more support for GP's may increase uptake of DRE.

Trends in the Incidence of Young-Onset Colorectal Cancer With a Focus on Years Approaching Screening Age: A Population-Based Longitudinal Study.

BACKGROUND: With recent evidence for the increasing risk of young-onset colorectal cancer (yCRC), we had the objective to evaluate the incidence of yCRC in 1-year age increments, particularly focusing around the screening age of 50 years. METHODS: We conducted a longitudinal study using linked administrative health databases in British Columbia, Canada, including a provincial cancer registry, inpatient and outpatient visits, and vital statistics from January 1, 1986, to December 31, 2016. We calculated incidence rates per 100 000 at every age from 20 to 60 years and estimated annual percent change in incidence (APCi) of yCRC using joinpoint regression analysis. RESULTS: We identified 3614 individuals with yCRC (49.9% women). The incidence of CRC steadily increased from 20 to 60 years, with a marked increase from 49 to 50 years (incidence rate ratio = 1.19, 95% confidence interval [CI] = 1.04 to 1.34). Furthermore, there was a trend of increased incidence of yCRC among women (APCi = 0.79%, 95% CI = 0.22% to 1.36%) and men (APCi = 2.17%, 95% CI = 1.59% to 2.76%). Analyses stratified by age yielded APCis of 2.49% (95% CI = 1.36% to 3.63%) and 0.12% (95% CI = -0.54% to 0.79%) for women aged 30-39 years and 40-49 years, respectively, and 2.97% (95% CI = 1.65% to 4.31%) and 1.86% (95% CI = 1.19% to 2.53%) for men. CONCLUSIONS: Our findings indicate a steady increase over 1-year age increments in the risk of yCRC during the years approaching and beyond screening age. These findings highlight the need to raise awareness as well as continue discussions regarding considerations of lowering the screening age.

Racial and Socioeconomic Disparities After Surgical Resection for Rectal Cancer.

BACKGROUND: There are various racial, socioeconomic, and tumor-specific factors that can impact rectal cancer outcomes. The current systematic review and meta-analysis evaluate the effect socioeconomic and racial variables on overall survival of rectal cancer patients after surgical resection. METHODS: A literature search was performed via electronic databases according to Systematic Reviews and Meta-Analyses and Meta-analysis Of Observational Studies in Epidemiology guidelines. All studies were evaluated by three authors and validated for data extraction. Predictive variables and survival profiles (1-, 5-, and 10-y survival and overall survival) reported by the studies were recorded for the systematic review. Hazard ratios, odds ratios, and 95% confidence intervals were extracted for meta-analysis. Forest plots were used to interpret the results. The primary outcome was the effect size of the predictive variables on overall survival after surgical resection. RESULTS: Of the 265 articles collected, 22 met inclusion criteria. Sixteen studies were used for the systematic review, and 17 studies were considered for meta-analysis. Overall, 662,053 subjects with rectal cancer were studied (439,766 with race reported), of which 344,193 (78.3%) were White and 60,283 (13.7%) were Black. The median survival was 56.8% for White patients and 47.9% for Black patients. Meta-analysis revealed that race, socioeconomic variables (education level, income level, and insurance status), and facility characteristics (type and volume) were significantly associated with overall survival in rectal cancer. CONCLUSIONS: Racial and socioeconomic disparities are present in outcomes for rectal cancer patients undergoing surgical resection. It is important to consider these disparities in the management of patients with rectal cancer to minimize any consequent disparities in surgical outcomes.

Safety and efficiency of gasless laparoscopy: a systematic review protocol.

BACKGROUND: Gasless laparoscopy, developed in the early 1990s, was a means to minimize the clinical and financial challenges of pneumoperitoneum and general anaesthesia. It has been used in a variety of procedures such as in general surgery and gynecology procedures including diagnostic laparoscopy. There has been increasing evidence of the utility of gasless laparoscopy in resource limited settings where diagnostic imaging is not available. In addition, it may help save costs for hospitals. The aim of this study is to conduct a systematic review of the available evidence surrounding the safety and efficiency of gasless laparoscopy compared to conventional laparoscopy and open techniques and to analyze the benefits that gasless laparoscopy has for low resource setting hospitals. METHODS: This protocol is developed by following the Preferred Reporting Items for Systematic review and Meta-Analysis-Protocols (PRISMA-P). The PRISMA statement guidelines and flowchart will be used to conduct the study itself. MEDLINE (Ovid), Embase, Web of Science, Cochrane Central, and Global Index Medicus (WHO) will be searched and the National Institutes of Health Clinical Trials database. The articles that will be found will be pooled into Covidence article manager software where all the records will be screened for eligibility and duplicates removed. A data extraction spreadsheet will be developed based on variables of interest set a priori. Reviewers will then screen all included studies based on the eligibility criteria. The GRADE tool will be used to assess the quality of the studies and the risk of bias in all the studies will be assessed using the Cochrane Risk assessment tool. The RoB II tool will assed the risk of bias in randomized control studies and the ROBINS I will be used for the non-randomized studies. DISCUSSION: This study will be a comprehensive review on all published articles found using this search strategy on the safety and efficiency of the use of gasless laparoscopy. The systematic review outcomes will include safety and efficiency of gasless laparoscopy compared to the use of conventional laparoscopy or laparotomy. TRIAL REGISTRATION: The study has been registered in PROSPERO under registration number: CRD42017078338.

Instant replay: Evaluation of instant video feedback in surgical novices for a laparoscopic gallbladder dissection.

BACKGROUND: Athletes often use video to improve their technique. We hypothesized that surgical novices given feedback using video-replay would outperform surgical novices given verbal feedback in the performance of a laparoscopic task. METHODS: Our study used a prospective, randomized control design. The surgical task involved the laparoscopic dissection of a pig gallbladder. Our participants performed a dissection, pre- and post-traditional or video feedback. Each recording was independently scored by two staff surgeons using the previously validated rating tools. RESULTS: There was no significant difference between video feedback or traditional feedback groups in their mean overall or task specific scores. Both traditional and video-feedback groups had a trend towards improved performance post-feedback. CONCLUSIONS: No significant difference in performance by both our global assessment metrics or task-specific metrics was observed. Video feedback requires further study to investigate its impact on surgical training.