Evaluating clinical practice guidelines for the management of rectal cancer: Did they get it RIGHT?

BACKGROUND AND OBJECTIVES: Clinical Practice Guidelines (CPGs) are crucial tools for clinicians seeking to deliver evidence-based patient care. We utilized the Reporting Items for practice Guidelines in HealThcare (RIGHT) checklist to assess the reporting quality of CPGs addressing the management of rectal cancer. METHODS: Four multidisciplinary rectal cancer CPGs published 2017-2022 were evaluated: American Society of Colon and Rectal Surgeons (ASCRS), European Society for Medical Oncology (ESMO), National Comprehensive Cancer Network (NCCN), and National Institute for Health and Care Excellence (NICE). We quantitatively assessed each CPG using the RIGHT checklist and qualitative analysis was performed to generate common themes. RESULTS: RIGHT checklist items fulfilled by each CPG ranged from 12 to 17 (out of 22). Each guideline demonstrated unique categories of weakness: ASCRS in Basic Information (1 of 4 items), ESMO in Evidence (1 of 3), NCCN in Recommendations (1 of 3), and NICE in Review and Quality Assurance (0 of 2). Common themes that emerged included sprase discussion on the financial aspects of rectal cancer management and lack of transparency in formulating recommendations. CONCLUSIONS: Despite their variability, each of the 22 checklist elements are present in contemporary CPGs. Utilizing the RIGHT checklist would allow experts to create guidelines adhering to high-quality reporting standards.

Electronic health record-integrated questionnaires in colorectal surgery patients as a new standard: Could preoperative bowel function be used to predict postoperative patient-reported outcomes?

BACKGROUND AND OBJECTIVES: Patient-reported bowel function has been previously shown to correlate with quality of life and patient-reported outcomes (PROs) after colorectal surgery. We examined the relationship between preoperative patient-reported bowel function and postoperative symptom reporting using an electronic health record-integrated symptom management (eSyM). METHODS: Patients who underwent major abdominal surgery for colorectal cancer at a single institution were included. Preoperative bowel function was assessed prospectively using the validated colorectal functional outcome (COREFO) questionnaire. Patients with electronic portal access received automated eSyM questionnaires after discharge. Logistic regression was used to analyze the association between COREFO scores and eSyM use. RESULTS: 169 patients underwent surgery between April 2020 and June 2022 (median age 64, 46.7% female). 148 completed COREFO questionnaires preoperatively; 54 (36.5%) had scores ≥15. Of the 108 patients with portal access, 67.6% used eSyM postoperatively. Among users, 72.3% (47/73) reported severe symptoms. Those with COREFO scores ≥15 were more likely to use eSyM (80.0% vs. 62.7%) though this difference was not significant (p = 0.079). CONCLUSIONS: We found that eSyM utilization regardless of preoperative baseline bowel function was high in this cohort of colorectal surgery patients. This suggests that electronically captured PROs is an effective way for patients to communicate symptoms to their care teams in a postsurgical setting.

Understanding the Effect of Bias on the Experience of Women Surgeons: A Qualitative Study.

BACKGROUND: Exploring the lived experiences of surgeons is necessary to understand the changing culture of surgery and the unique challenges of being a woman in surgery. Surgeons have significant experiences and observations best discovered through qualitative study. The purpose of this study is to identify the similarities and differences between the experiences of men and women surgeons after initiation of mandatory microaggression training. STUDY DESIGN: Qualitative semi-structured interviews with female and male surgeons and residents were done following a year-long series of training sessions on the detrimental effects of microaggression. Participants were selected using a convenience sampling method. MAXQDA coding software (Verbi) was used to evaluate interview transcripts with thematic analysis. RESULTS: Nineteen surgeons and surgical residents were interviewed. The participants were of equal gender identification, with the majority being attending surgeons. Multiple themes highlighted similarities and differences between male and female participants. Differences were noted in identification of a sensitive personality, family planning considerations, and experiences of bias. Similarities were related to the personality traits required to be successful in surgery, the sacrifice inherent to a surgical career, and the war rhetoric used to describe the comradery of residency. CONCLUSION: The challenges and rewards of surgery are similar for women and men, but women have additional stressors, including gender-based bias, microaggression, and family planning. These stressors take up energy, decreasing the mental space available for additional roles and affecting the work environment. Microaggression education can incite necessary discussions of bias and provide women with an opportunity to reflect on and share their experiences.

Colorectal carcinoma in pediatric patients: A comparison with adult tumors, treatment and outcomes from the National Cancer Database.

BACKGROUND: Pediatric colorectal cancer (CRC) is rare. Comparison with adult CRC tumors, management, and outcomes may identify opportunities for improvement in pediatric CRC care. STUDY DESIGN: CRC patients in the National Cancer Data Base from 1998 to 2011, were grouped into Pediatric (≤21years), early onset adult (22-50) and older adult (>50) patients. Groups were compared with χ(2) and survival analysis. RESULTS: A total of 918 pediatric (Ped), 157,779 early onset adult (EA), and 1,304,085 older adults (OA) were identified (p<0.01 for all comparisons). Patients ≤50 presented more frequently with stage 3 and 4 disease (Ped: 62.0%, EA: 49.7%, OA: 37.3%) and rectal cancer (Ped: 23.6%, EA: 27.5%, OA: 19.2%). Pediatric histology was more likely signet ring, mucinous, and poorly differentiated. Initial treatment was usually surgery, but patients ≤50 were more likely to have radiation (Ped: 15.1%, EA: 18.6%, and OA: 9.2%) and chemotherapy (Ped: 42.0%, EA: 38.2%, and OA: 22.7%). Children and older adults showed poorer overall survival at 5years when compared to early onset adults. Adjusting for covariates, age ≤21 was a significant predictor of mortality for colon and rectal cancers (colon HR: 1.22, rectal HR: 1.69). CONCLUSIONS: This is the largest cohort of pediatric CRC patients, revealing more aggressive tumor histology and behavior in children, particularly in rectal cancer. Despite standard oncologic treatment, age ≤21 was a significant predictor of mortality. This is likely owing to worse tumor biology rather than treatment disparities and may signal the need for different therapeutic strategies.

Adenocarcinoma of the cervix metastatic from a colon primary and diagnosed from a routine pap smear in a 17-year-old woman: a case report.

BACKGROUND: Carcinoma metastatic to the uterine cervix is very rare. The most frequent nongenital primary sites are the stomach and colon. CASE: A 17-year-old woman presented to the office for an annual gynecologic examination. The Pap smear and cervical biopsy of a 1.5-cm lesion were positive for adenocarcinoma. Subsequent surgery revealed a sigmoid tumor with extensive abdominal and pelvic carcinomatosis. Following 2 cycles of ineffective chemotherapy, the patient died 4 months after her initial visit to the gynecologist. CONCLUSION: To our knowledge, this was the youngest patient in the literature with colon cancer metastatic to the cervix. This case focuses attention on the diagnostic challenge posed by an incidental finding of a cervical adenocarcinoma in the presence of an asymptomatic primary tumor.

Increases in serum estrogen levels during major illness are caused by increased peripheral aromatization.

Although serum testosterone levels decrease acutely in critically ill patients, estrogen levels rise. We hypothesized that increased rates of aromatization of androgens to estrogens underlie the increase in serum estrogen levels. Eleven men and three women (age 42-69 yr) were prospectively studied before and again after elective coronary artery bypass graft surgery (CABG). Each patient received priming doses of [(14)C]androgen and [(3)H]estrogen that were immediately followed by peripheral infusions for 210 min. Eight men and three women received androstenedione (A(4))/estrone (E(1)) and three men received testosterone (T)/estradiol (E(2)). Adipose tissue biopsies were obtained in another six men before and after CABG to evaluate levels of P450 aromatase mRNA. Serum T levels decreased postoperatively in all 17 men (P < 0.001), whereas E(1) levels rose (P = 0.004), with a trend toward a rise in E(2) (P = 0.23). Peripheral aromatization rates of androgens to estrogens rose markedly in all 14 patients (P < 0.0001). Estrogen clearance rates rose (P < 0.002). Mean serum A(4) levels increased slightly postoperatively (P = 0.04), although no increase in A(4) production rates (PRs) was observed. T PRs decreased in two of three men, whereas clearance rates increased in all three. Adipose tissue P450 aromatase mRNA content increased postoperatively (P < 0.001). We conclude that the primary cause of increased estrogen levels in acute illness is increased aromatase P450 gene expression, resulting in enhanced aromatization of androgens to estrogens, a previously undescribed endocrine response to acute illness. Both increased T clearance and decreased T production contribute to decreased serum T levels. Animal studies suggest that these opposing changes in circulating estrogen and androgen levels may be important to reduce morbidity and mortality in critical illness.