Metastatic spread pattern after curative colorectal cancer surgery. A retrospective, longitudinal analysis.

OBJECTIVE: The most common sites of colorectal cancer (CRC) recurrence are the local tissues, liver or lungs. The objective was to identify risk factors associated with the primary CRC tumor and cancer recurrence in these anatomical sites. METHODS: Retrospective, longitudinal analyses of data on CRC survivors. Multivariable Cox regression analysis was performed to examine the association between possible cofounders with recurrence to various anatomical sites. RESULTS: Data for 10,398CRC survivors (tumor location right colon=3870, left colon=2898, high rectum=2569, low rectum=1061) were analyzed; follow up time was up to five years. Mean age at curative surgery was 71.5 (SD 11.8) years, 20.2% received radio-chemotherapy, stage T3 (64.4%) and N0 (65.1%) were most common. Overall 1632 (15.7%) had cancer recurrence (Isolated liver n=412, 3,8%; isolated lung n=252, 2,4%; isolated local n=223, 2.1%). Risk factors associated with recurrent CRC were identified, i.e. isolated liver metastases (male: Adjusted Hazard Ratio (AHR) 1,45; colon left: AHR 1,63; N2 disease: AHR 3,35; T2 disease: AHR 2,82), isolated lung metastases (colon left: AHR 1,53; rectum high: AHR 2,48; rectum low: AHR 2,65; N2 disease 3,76), and local recurrence (glands examined<12: AHR 1,51; CRM <3mm: AHR 1,60; rectum high: AHR 2,15; N2 disease: AHR 2,58) (all p values <0001). CONCLUSION: Our study finds that the site of the primary CRC tumor is associated with location of subsequent metastasis. Left sided colon cancers have increased risk of metastatic spread to the liver, whereas rectal cancers have increased risk of local recurrence and metastatic spread to the lungs. These results, in combination with other risk factors for CRC recurrence, should be taken into consideration when designing risk adapted post-treatment CRC surveillance programs.

Comparison of cesarean section rates in fee-for-service versus managed care patients in the Ohio Medicaid population, 1992-1997.

OBJECTIVE: To examine changes over time in the cesarean section rates for fee-for-service (FFS) beneficiaries versus enrollees of managed care programs (MCPs) in the Ohio Medicaid population. STUDY DESIGN: Cross-sectional study using linked Ohio birth certificates and Medicaid files. PATIENTS AND METHODS: Study patients were Medicaid-enrolled residents of urban counties who had singleton, live births from 1992 through 1997 (n = 86,459). Changes in primary and repeat cesarean section rates were analyzed in the FFS and MCP groups. The test of homogeneity of odds ratios was used to measure the statistical difference between unadjusted odds ratios. Logistic regression analysis was conducted to adjust for risk factors. RESULTS: From 1992 to 1997, the difference in the rates of primary and repeat cesarean sections between FFS and MCP patients decreased. The unadjusted odds ratio (OR) increased from 0.66 to 0.81 (P = .06) for primary cesarean sections and from 0.67 to 1.04 (P = .03) for repeat cesarean sections; this indicated that the likelihood of undergoing a cesarean section increased over time for MCP enrollees compared with FFS beneficiaries. The results of the multivariate analysis indicated that the interaction term of payment source by year was not significant for primary cesarean sections (adjusted OR = 0.93; 95% confidence interval = 0.83, 1.04), but was highly significant for repeat cesarean sections (adjusted OR = 0.53; 95% confidence interval = 0.44, 0.64). CONCLUSION: We observed a reduction in the difference between the rates of both primary and repeat cesarean sections in FFS and MCP patients over time. The reduction was not statistically significant for primary cesarean sections. For repeat cesarean sections, however, we observed a convergence of the rates for FFS and MCP patients.

Declining trends in cesarean deliveries, Ohio 1989-1996: an analysis by indications.

BACKGROUND: Similar to trends observed nationwide, the rates of cesarean deliveries declined in Ohio during the late 1980s and the early 1990s. This study examined the trends in cesarean deliveries in Ohio from 1989 through 1996, in the presence or absence of indications, and in relation to the use of obstetric procedures. METHODS: Birth certificate data for all singleton, liveborn infants in Ohio (n = 1,204,859) were used to analyze temporal trends in cesarean sections. RESULTS: The rates of primary and repeat cesarean deliveries declined, respectively, from 15.7 to 12.4 percent and from 83 to 63.3 percent during the 8-year study period. Significant declines in repeat cesarean deliveries were observed both in the presence and absence of documented medical conditions that could present a potential indication for the procedure. The rates of repeat cesareans remained comparable among women with and without documented indications for cesarean section (64% and 61%, respectively). In addition, 45 and 30 percent of repeat cesareans in 1989 and 1996, respectively, were performed in the absence of any documented indications, or on an elective basis. The declines in cesarean delivery rates during the 8-year study period occurred simultaneously with an increase in the use of electronic fetal monitoring, induction, and stimulation of labor. CONCLUSIONS: The findings suggest that a sizable proportion of repeat cesarean deliveries in 1996 may be unnecessary, even though a marked decline in the procedure has occurred between 1989 and 1996.

Estimating the proportion of unnecessary Cesarean sections in Ohio using birth certificate data.

The main objective of the study is to present a method that estimates the proportion of unnecessary Cesarean sections (C-sections) using birth certificate data. This population-based cross-sectional study uses two major databases--Ohio birth certificates and Medicaid eligibility files--and includes singleton infants born during the period July 1991 through June 1993 (n = 262,013). A total of 57 variables indicative of adverse events, including maternal medical risk factors, complications of labor and delivery, and congenital anomalies that are available on the birth certificate, are examined to estimate the rate of unnecessary C-sections. The results obtained through this method indicate that nearly 40% of the repeat C-sections had no documented abnormalities on the birth certificate to justify a C-section. Because studies using medical records have yielded similar results, we believe that using birth certificate data may be a reliable method to measure and monitor the rate of unnecessary C-sections.