Determinants of Physical Activity among Patients with Colorectal Cancer: From Diagnosis to Five Years after Diagnosis.

INTRODUCTION: Physical activity (PA) is associated with higher quality of life and probably better prognosis among colorectal cancer (CRC) patients. This study focuses on determinants of PA among CRC patients from diagnosis until five years post-diagnosis. METHODS: Sociodemographic and disease-related factors of participants of two large CRC cohort studies were combined. Moderate-to-vigorous PA during sport and leisure time (MVPA-SL) was measured at diagnosis (T0) and six, twelve, twenty-four, and sixty (T6 to T60) months post-diagnosis, using the SQUASH questionnaire. Mixed-effects models were performed to identify sociodemographic and disease-related determinants of MVPA-SL, separately for stage I-III colon (CC), stage I-III rectal cancer (RC), and stage IV CRC (T0 and T6 only). Associations were defined as consistently present when significant at ≥4 timepoints for the stage I-III subsets. MVPA-SL levels were compared with an age- and sex-matched sample of the general Dutch population. RESULTS: In total, 2905 CC, 1459 RC and 436 stage IV CRC patients were included. Patients with higher fatigue scores, and women compared to men had consistently lower MVPA-SL levels over time, regardless of tumor type and stage. At T6, having a stoma was significantly associated with lower MVPA-SL among stage I-III RC patients. Systemic therapy and radiotherapy were not significantly associated with MVPA-SL changes at T6. Compared to the general population, MVPA-SL levels of CRC patients were lower at all timepoints, most notably at T6. CONCLUSIONS: Female sex and higher fatigue scores were consistent determinants of lower MVPA-SL levels among all CRC patients, and MVPA-SL levels were lowest at six months post-diagnosis. Our results can inform the design of intervention studies aimed at improving PA, and guide healthcare professionals in optimizing individualized support.

Diagnostic Accuracy of Radioactive Iodine Seed Placement in the Axilla With Sentinel Lymph Node Biopsy After Neoadjuvant Chemotherapy in Node-Positive Breast Cancer.

Importance: Several less-invasive staging procedures have been proposed to replace axillary lymph node dissection (ALND) after neoadjuvant chemotherapy (NAC) in patients with initially clinically node-positive (cN+) breast cancer, but these procedures may fail to detect residual disease. Owing to the lack of high-level evidence, it is not yet clear which procedure is most optimal to replace ALND. Objective: To determine the diagnostic accuracy of radioactive iodine seed placement in the axilla with sentinel lymph node biopsy (RISAS), a targeted axillary dissection procedure. Design, Setting, and Participants: This was a prospective, multicenter, noninferiority, diagnostic accuracy trial conducted from March 1, 2017, to December 31, 2019. Patients were included within 14 institutions (general, teaching, and academic) throughout the Netherlands. Patients with breast cancer clinical tumor categories 1 through 4 (cT1-4; tumor diameter <2 cm and up to >5 cm or extension to the chest wall or skin) and pathologically proven positive axillary lymph nodes (ie, clinical node categories cN1, metastases to movable ipsilateral level I and/or level II axillary nodes; cN2, metastases to fixed or matted ipsilateral level I and/or level II axillary nodes; cN3b, metastases to ipsilateral level I and/or level II axillary nodes with metastases to internal mammary nodes) who were treated with NAC were eligible for inclusion. Data were analyzed from July 2020 to December 2021. Intervention: Pre-NAC, the marking of a pathologically confirmed positive axillary lymph node with radioactive iodine seed (MARI) procedure, was performed and after NAC, sentinel lymph node biopsy (SLNB) combined with excision of the marked lymph node (ie, RISAS procedure) was performed, followed by ALND. Main Outcomes and Measures: The identification rate, false-negative rate (FNR), and negative predictive value (NPV) were calculated for all 3 procedures: RISAS, SLNB, and MARI. The noninferiority margin of the observed FNR was 6.25% for the RISAS procedure. Results: A total of 212 patients (median [range] age, 52 [22-77] years) who had cN+ breast cancer underwent the RISAS procedure and ALND. The identification rate of the RISAS procedure was 98.2% (223 of 227). The identification rates of SLNB and MARI were 86.4% (197 of 228) and 94.1% (224 of 238), respectively. FNR of the RISAS procedure was 3.5% (5 of 144; 90% CI, 1.38-7.16), and NPV was 92.8% (64 of 69; 90% CI, 85.37-97.10), compared with an FNR of 17.9% (22 of 123; 90% CI, 12.4%-24.5%) and NPV of 72.8% (59 of 81; 90% CI, 63.5%-80.8%) for SLNB and an FNR of 7.0% (10 of 143; 90% CI, 3.8%-11.6%) and NPV of 86.3% (63 of 73; 90% CI, 77.9%-92.4%) for the MARI procedure. In a subgroup of 174 patients in whom SLNB and the MARI procedure were successful and ALND was performed, FNR of the RISAS procedure was 2.5% (3 of 118; 90% CI, 0.7%-6.4%), compared with 18.6% (22 of 118; 90% CI, 13.0%-25.5%) for SLNB (P < .001) and 6.8% (8 of 118; 90% CI, 3.4%-11.9%) for the MARI procedure (P = .03). Conclusions and Relevance: Results of this diagnostic study suggest that the RISAS procedure was the most feasible and accurate less-invasive procedure for axillary staging after NAC in patients with cN+ breast cancer.

Physical Activity Is Associated with Improved Overall Survival among Patients with Metastatic Colorectal Cancer.

Regular physical activity (PA) is associated with improved overall survival (OS) in stage I-III colorectal cancer (CRC) patients. This association is less defined in patients with metastatic CRC (mCRC). We therefore conducted a study in mCRC patients participating in the Prospective Dutch Colorectal Cancer cohort. PA was assessed with the validated SQUASH questionnaire, filled-in within a maximum of 60 days after diagnosis of mCRC. PA was quantified by calculating Metabolic Equivalent Task (MET) hours per week. American College of Sports and Medicine (ACSM) PA guideline adherence, tertiles of moderate to vigorous PA (MVPA), and sport and leisure time MVPA (MVPA-SL) were assessed as well. Vital status was obtained from the municipal population registry. Cox proportional-hazards models were used to study the association between PA determinants and all-cause mortality adjusted for prognostic patient and treatment-related factors. In total, 293 mCRC patients (mean age 62.9 ± 10.6 years, 67% male) were included in the analysis. Compared to low levels, moderate and high levels of MET-hours were significantly associated with longer OS (fully adjusted hazard ratios: 0.491, (95% CI 0.299-0.807, p value = 0.005) and 0.485 (95% CI 0.303-0.778, p value = 0.003), respectively), as were high levels of MVPA (0.476 (95% CI 0.278-0.816, p value = 0.007)) and MVPA-SL (0.389 (95% CI 0.224-0.677, p value < 0.001)), and adherence to ACSM PA guidelines compared to non-adherence (0.629 (95% CI 0.412-0.961, p value = 0.032)). The present study provides evidence that higher PA levels at diagnosis of mCRC are associated with longer OS.

Impact of low skeletal muscle mass and density on short and long-term outcome after resection of stage I-III colorectal cancer.

BACKGROUND: Preoperative low skeletal muscle mass and density are associated with increased postoperative morbidity in patients undergoing curative colorectal cancer (CRC) surgery. However, the long-term effects of low skeletal muscle mass and density remain uncertain. METHODS: Patients with stage I-III CRC undergoing surgery, enrolled in a prospective observational cohort study, were included. Skeletal muscle mass and density were measured on CT. Patients with high and low skeletal muscle mass and density were compared regarding postoperative complications, disease-free survival (DFS), overall survival (OS), and cancer-specific survival (CSS). RESULTS: In total, 816 patients (53.9% males, median age 70) were included; 50.4% had low skeletal muscle mass and 64.1% low density. The severe postoperative complication rate was significantly higher in patients with low versus high skeletal muscle and density (20.9% versus 13.6%, p = 0.006; 20.0% versus 11.8%, p = 0.003). Low skeletal muscle mass (OR 1.91, p = 0.018) and density (OR 1.87, p = 0.045) were independently associated with severe postoperative complications. Ninety-day mortality was higher in patients with low skeletal muscle mass and density compared with patients with high skeletal muscle mass and density (3.6% versus 1.7%, p = 0.091; 3.4% versus 1.0%, p = 0.038). No differences in DFS were observed. After adjustment for covariates such as age and comorbidity, univariate differences in OS and CSS diminished. CONCLUSIONS: Low skeletal muscle mass and density are associated with short-term, but not long-term, outcome in patients undergoing CRC surgery. These findings recommend putting more emphasis on preoperative management of patients at risk for surgical complications, but do not support benefit for long-term outcome.

Completeness of pathology reports in stage II colorectal cancer.

INTRODUCTION: The completeness of the pathological examination of resected colon cancer specimens is important for further clinical management. We reviewed the pathological reports of 356 patients regarding the five factors (pT-stage, tumor differentiation grade, lymphovascular invasion, tumor perforation and lymph node metastasis status) that are used to identify high-risk stage II colon cancers, as well as their impact on overall survival (OS). METHODS: All patients with stage II colon cancer who were included in the first five years of the MATCH study (1 July 2007 to 1 July 2012) were selected (n = 356). The hazard ratios of relevant risk factors were calculated using Cox Proportional Hazards analyses. RESULTS: In as many as 69.1% of the pathology reports, the desired information on one or more risk factors was considered incomplete. In multivariable analysis, age (HR: 1.07, 95%CI 1.04-1.10, p < .001), moderately- (HR: 0.35, 95%CI 0.18-0.70, p = .003) and well (HR 0.11, 95%CI 0.01-0.89, p = .038) differentiated tumors were significantly associated with OS. CONCLUSIONS: Pathology reports should better describe the five high-risk factors, in order to enable proper patient selection for further treatment. Chemotherapy may be offered to stage II patients only in select instances, yet a definitive indication is still unavailable.

The fate of research abstracts submitted to a national surgical conference: a cross-sectional study to assess scientific impact.

BACKGROUND: Conference abstracts often lack rigorous peer review, but potentially influence clinical thinking and practice. To evaluate the quality of abstracts submitted to a large surgical conference, presentation and publication rates were investigated to assess scientific impact. METHODS: A Cross-sectional study of abstracts submitted to Dutch Surgical Society meetings from 2007 to 2012 was conducted. Presentation rates, publication rates in MEDLINE-indexed journals using PubMed Central database, and actuarial times to subsequent publication were investigated. RESULTS: Of 2,174 submitted abstracts, 1,305 (60%) abstracts were accepted for presentation. Actuarial 1, 3, and 5-year publication rates were 22.4%, 62.2%, and 68.6% for presented abstracts, compared with 20.9%, 50.3%, and 57.7% for rejected abstracts, respectively (log-rank x(2) 23.728, df1, P < .001). Publications resulting from abstracts presented at the conference had a significantly higher mean (±standard error) impact factor (4.4 ± .2 vs 3.4 ± .1, P < .001), compared with publications from previously rejected abstracts. CONCLUSIONS: We advocate critical appraisal of the use of findings of scientific abstracts and conference presentations. The 5-year abstract-to-publication ratio is proposed as a novel quality indicator to allow objective comparison between scientific meetings.

Prevalence and determinants of disabilities and return to work after major trauma.

OBJECTIVE: The purpose of this study was to assess the prevalence and determinants of disabilities and return to work after severe injury in a Dutch, Level I trauma center. METHODS: We prospectively included 295 patients with an Injury Severity Score > or = 16 treated between January 1996 and January 1999. All survivors received a mailed questionnaire in 2000, at least 1 year after their initial hospital admission. Health status was measured by the EuroQol-5D instrument, and the Glasgow Outcome Scale. Additional questions were asked about cognitive functioning and return-to-work rates. Regression analyses was conducted to explore the associations between these functional outcome measures and patient characteristics. RESULTS: Of the 295 patients included, 99 (34%) died in hospital or during follow-up. From the 196 survivors, a response was obtained from 166 (85%). Of the survivors, 33% had to change their work or daily activity as a result of their injuries. Of the 127 patients of working age (18-65 years), 33 (26%) were unable to work and depended on social security. Problems with mobility, self-care, daily activities, pain/discomfort, anxiety/depression, and cognitive ability were found in 34%, 15%, 51%, 58%, 37%, and 57%, respectively. The EuroQol-5D summary score (0.76) was far below that of the general population norms. The number of body areas affected, injury severity (Injury Severity Score > or = 25), and gender (female) were significant independent predictors of worse long-term functional outcome. CONCLUSION: Severe trauma has a substantial impact on long-term functioning. Empiric quantitative data, as presented in this study, enable us to estimate the burden of injury and to evaluate the quality of trauma care programs.

Pre-hospital trauma care: a proposal for more efficient evaluation.

Although mortality is an important outcome parameter for pre-hospital trauma care, it is influenced by many factors other than pre-hospital trauma care alone. We therefore studied an alternative method to evaluate pre-hospital trauma care by calculating the change in probability of survival (Ps) according to the TRISS methodology, before and directly after the pre-hospital trauma care. Correlations between patient characteristics and a change in Ps were assessed. Further, required sample sizes were calculated for an 80% power to detect a hypothetical 3% reduction in mortality and the corresponding change in Ps. In 140 of 191 patients with an Injury Severity Score > or =16, the Ps did not change. In 36, the Ps increased and in 15 patients, the Ps decreased. Between these three groups, significant differences were found in Revised Trauma Score and age, but no clear differences in Injury Severity Score or mortality. A 3% difference in mortality would require 6800 patients, in contrast to 3500 when the change in Ps was the primary outcome parameter. A change in Ps is a promising outcome parameter for a more efficient evaluation of pre-hospital trauma care. A good collaboration is, however, required between ambulance services and the trauma center for reliable registration.

Consequences of delayed diagnoses in trauma patients: a prospective study.

BACKGROUND: The approach to trauma care has improved in recent decades but delayed diagnoses still occur. This study aimed to analyze the prevalence and consequences of delayed diagnoses in a single European trauma center. The effect of a systematic reexamination of the patient (tertiary survey) and reevaluation of x-rays and CT scans was evaluated. STUDY DESIGN: We prospectively registered complications among all trauma patients admitted to our hospital from January 1, 1996, to January 1, 2000. All relevant trauma and patient-related data were added by the physician to a hospital-wide trauma database with client server architecture. Complications including delay in diagnosis were subsequently added to this database. Admitted trauma patients underwent a tertiary survey and all x-rays and CT scans were reevaluated within 24 hours after admission. RESULTS: A total of 3,879 patients were studied and 1,016 complications were registered. Of all complications 55 concerned delayed diagnoses detected in 49 patients (1.3%). In 28 of these patients (57.1%) the tertiary survey (20 of 49; 40.8%) and reevaluation of x-rays and CT scans (8 of 49; 16.3%) resulted in detection of delayed diagnoses within 24 hours. Detection of the remaining 21 delayed diagnoses occurred after more than 24 hours. Delayed diagnoses resulted in delayed treatment in 27 of the 49 patients (55.1%) and surgery was necessary in 12 patients (24.5%). None of the delayed diagnoses resulted in death. CONCLUSIONS: A prospective trauma and complication registration enables evaluation of the delays in diagnosis. In our study population more than half of the delayed diagnoses could be detected by a tertiary survey and reevaluation of x-rays and CT scans. Attempts to decrease the number of delayed diagnoses should prevent delays in treatment and improve the quality of trauma care.