ABSTRACT
INTRODUCTION: Patient often experience delays in operative care due to access issues, comorbidities, and other personal reasons. However, during the recent COVID pandemic, hospital resources were severely limited and all patients were forced to endure unprecedented delays, including colon and rectal cancer patients. The oncologic implications of these delays are unknown. METHOD(S): Adult patients who underwent surgery for colon and rectal cancer between January and September of 2020 were retrospectively reviewed. Patients with stage 4 disease were excluded. Patients were categorized as regular or extended interval if time to operation was less than or greater than 40 days for colon cancer and 80 days for rectal cancer. RESULT(S): A total of 186 patients were included, 123 colon cancer and 63 rectal cancer. In the colon cancer group, there were 65 regular interval and 58 prolonged interval patients. There were no significant differences in post-operative, 30-day, or 90-day post-operative outcomes between the two interval groups. During the follow up period (regular vs prolonged: 468.7 +/- 238.3 vs 414.2 +/- 235.5, p = 0.005) there was a higher rate of recurrence in the prolonged group (4.6% vs 17.2%, p = 0.023). Cox regression controlling for disease stage, procedure performed, and resection score demonstrated a significant difference in recurrence-free survival (HR = 7.544, p = 0.007). In the rectal cancer group, there were 48 regular interval and 15 prolonged interval patients. There were no significant differences in postoperative, 30-day, or 90-day outcomes between the two interval groups. During the follow up period (regular vs prolonged: 574.0 +/- 237.3 vs 569.3 +/- 252.2, p = 0.687) there was no difference in recurrence (16.7% vs 26.7%, p = 0.389), but recurrence-free survival was significantly longer in the regular interval group (543.9 +/- 241.6 vs 493.1 +/- 237.4, p = 0.009). However, Cox regression controlling for disease stage, neoadjuvant chemotherapy, procedure performed, resection score demonstrated no difference in recurrence-free survival (HR = 1.403, p = 0.662). CONCLUSION(S): A prolonged time to surgery, greater than 40 days, was associated with decreased recurrence-free survival for color cancer patients. In rectal cancer, no significant reduction in recurrence-free survival was observed despite a longer time to surgery interval in the prolonged group. In events when resources are limited, colon cancer patients may benefit from prioritized treatment and rectal cancer patients may be able to tolerate longer delays without significant impacts on recurrence-free survival.
ABSTRACT
5-Fluorouracil (Efudix) cream is established as a topical treatment for superficial malignant and premalignant skin lesions. Its method of action involves the irreversible binding of the pyrimidine analogue fluorouracil to thymidylate synthetase within a cell. This prevents the incorporation of uracil into nuclear RNA, which destroys abnormal cancer cells (https://dermnetnz.org/topics/5-fluorouracil-cream). The expected sequelae of its use involves the development of a marked inflammatory response. We present a case of a severe, disproportionate reaction to Efudix cream, secondary to contact allergy to the excipients. A 61-year-old man attended the cutaneous allergy clinic with a history of severe, florid, inflammatory and ulcerative skin reactions affecting the lower limbs at sites of application of Efudix cream. This had been used as directed, to treat areas of Bowen disease, at intervals between December 2019 and February 2021. Contact allergy to Efudix cream was suspected and patch testing was performed to the British Standard and Cosmetic series, as well as the excipients of Efudix cream, including stearyl alcohol, propylene glycol (PG), methylparahydroxybenzoate, propylparahydroxybenzoate and white soft paraffin. While the patch tests were applied in the department on day 0, subsequent appointments on days 2, 4 and 7 were performed virtually with photographs as the patient developed COVID-19 symptoms, with positive lateral flow and polymerase chain reaction tests. He was patch test positive on days 4 and 7 to stearyl alcohol and propylene glycol, both being excipients of Efudix cream. A review of our database over a period of 17 years revealed 53 other cases with positive patch test to PG (n = 53/8000;0.66%), none of which were attributable to the use of Efudix cream, and only six cases of a positive patch test to stearyl alcohol (n = 6/8000;0.075%), of which one was attributable to the use of Efudix cream. Allergic contact dermatitis to Efudix cream and its excipients stearyl alcohol and propylene glycol is rare, although it has previously been described in the literature with the earliest reports in 1992, and the most recent being 15 years ago [Meijer B, de Waardvan der Spek F. Allergic contact dermatitis because of topical use of 5-fluorouracil (Efudix cream). Contact Dermatitis 2007;57: 58-60]. This case adds to the existing literature and is a reminder to clinicians that, although inflammation is expected with the use of Efudix cream, severe or disproportionate reactions should raise suspicion of possible contact allergy. Furthermore, this case highlights the challenges of patch testing in the current COVID-19 climate and highlights the importance of teledermatology as a novel option for assessment in cutaneous allergy services facing these conditions.