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Introduction: Surgical treatment of rectal cancer depends on clinical stage, size and location of primary tumor. A sphincter preserving technique such as low anterior resection (LAR) is the preferred method if negative distal margin can be achieved. If an adequate distal margin cannot be obtained, an abdominoperineal resection (APR) is required. A proctosigmoidectomy (Hartmann's procedure) is performed in patients with potentially curable obstructing rectal cancer after neoadjuvant chemoradiotherapy, or as a palliative treatment for locally advanced rectal cancer. Aim(s): The aim of this retrospective study was to investigate the impact of COVID 19 pandemic on the number and type of surgeries performed for the treatment of rectal cancer in UHC Zagreb, Department of Surgery. Material(s) and Method(s): Collected data were extracted from medical records of the patients who underwent surgery at the Department of Surgery from 1st of January 2016 to 31st of December 2022 with prior Ethics Committee approval. Total of 688 patients were included. Retrospective analysis of number and type of surgery was done consecutively by years for the period of interest. Result(s): In 2016 total of 75 patients underwent elective surgery for rectal cancer. LAR was performed in 64% (N=48) of patients, Hartmann's procedure in 20% (N=15), and APR in 16% (N=12). In 2017, 94 surgeries were performed. LAR accounted for 64% (N=60), Hartmann's procedure 17% (N=16), and APR 19% (N=18). In 2018, 115 surgeries were performed. LAR accounted for 69% (N=79), Hartmann's procedure 10% (N=12), and APR 21% (N=24). In 2019, 80 surgeries were performed. LAR accounted for 67% (N=54), Hartmann's procedure 9% (N=80), and APR 24%. In 2020, 78 surgeries were performed. LAR accounted for 59% (N=46), Hartmann's procedure 14% (N=11), and APR 27% (N=21). In 2021, 124 surgeries were performed. LAR accounted for 66% (N=82), Hartmann's procedure 14% (N=17), and APR 20% (N=25). In 2022, 122 surgeries were performed. LAR accounted for 64% (N=78), Hartmann's procedure 15% (N=18), and APR 21% (N=26). Conclusion(s): Our results show steady growth in numbers of performed surgeries in the years prior to the pandemic, with exception of the year 2019 when our department underwent organizational changes. In 2020, significant decrease in number of surgeries was observed as a result of restrictive epidemiological measures established to reduce the spread of COVID 19 infection. COVID 19 pandemic measures also resulted in delayed diagnosis and treatment of rectal cancer which is indirectly shown through the increasing share of Hartmann's procedure. In the years following the relaxation of measures, significant increase in number of performed surgeries that exceeded all the pre-pandemic years was recorded. Constant elevated share of Hartmann's procedure was noted as possible consequence of post COVID delay in diagnosis and confirmation of rectal cancer in more advanced stages of disease.
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Lung cancer is the most common cancer in males and the second most common among females both in Europe and worldwide. Moreover, lung cancer is the leading cause of death due to cancer in males. The European region accounts for 23% of total cancer cases and 20% of cancer-related deaths. Relationships have been described between a number of infectious agents and cancers, but our knowledge of the role of viruses, both respiratory and systemic, in the pathogenesis of lung cancer is still rudimentary and has been poorly disseminated. In this chapter, we review the available evidence on the involvement of HPV, Epstein-Barr virus, HIV, cytomegalovirus and measles virus in the epidemiology and pathogenesis of lung cancer.Copyright © ERS 2021.
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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.
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Background: During the COVID-19 pandemic, Twitter has been instrumental in accelerating knowledge dissemination and forging collaborations within the medical community and amongst patient advocates. Tweetchats within Twitter are scheduled conversations on a specific topic. In oncology, Tweetchats have been used by cancer advocates to spread awareness and for patient and caregiver education. A colorectal cancer (CRC) specific tweetchat did not previously exist. This describes the creation, and experiences with a CRC specific tweetchat. Method(s): The #CRCTrialsChat tweetchat was created by a patient advocate for colorectal cancer patients, caregivers and clinicians to meet and exchange clinical trial-related information. Two gastrointestinal (GI) medical oncologists and two radiation oncologists were enlisted as moderators. The topic for each session is chosen by the patient advocate, who creates an outline and divides the content, which is designed to last a one hour session. The idea is to create engaging, technical, but easy to understand content. Each moderator then works on the answers to their assigned section, which is edited to fit tweet character limit. Sessions may also have guest moderators with expertise on a specific topic. Through tweeting, moderators answer specific questions that come up during the session and later. Result(s): To date, we have had four sessions covering the following topics: Clinical trial basics, CRC Updates from ASCO22, ClinicalTrialFinders and BRAF-mutated tumors. The content created has been simple and engaging, the format has functioned smoothly, and the reach of #CRCTrialsChat has been steadily increasing. After the most recent session on BRAF in September 2022, the @CRCTrialsChat has 281 followers, 17K impressions and 14.6K profile visits, a reflection of its excellent content. From a clinician perspective, this is a great format to interact with colleagues, discuss enrolling trials and also become familiar with using Twitter. Conclusion(s): A CRC clinical trial focused tweetchat is an engaging way to deliver trial-related content to an audience of clinicians, patients and caregivers. The current format appears to be an effective way to create and disseminate information. Future sessions will focus on ctDNA, molecular markers such as KRAS and HER2, and rectal cancer trials. Our hope is that #CRCTrialsChat will stimulate continued patient and clinician engagement, increase awareness of clinical trials, enhance trial participation and initiate patient-centric research and collaborations.
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Background. During the COVID-19 pandemic, annual adult check-ups have been postponed, resulting in cancer screening disruption. The aim of the study was to evaluate changes in the incidence and stage distribution of malignancies included in the screening program during the COVID-19 pandemic using the Arkhangelsk Regional Cancer Registry (ARRC). Material and Methods. We assessed the changes of the incidence rates and stage distribution for the colon, rectum, lung, breast, cervix, uterine body, ovary, prostate and kidney cancers over the periods 2018-19 and 2020-21. Results. A total of 12354 cases with 9 cancers were selected: 6680 for the period 2018-19 and 5674 (-15.1 %) for the period 2020-21. The most significant decrease in crude and age-standardized incidence rates was registered in patients with lung (-18.0-18.1 %), rectum (-25.1-25.9 %) and cervix (-33.6-36.9 %) cancers, p<0.001. The decrease was not significant in patients with breast, uterine body, and kidney cancers. The proportion of patients with stage I decreased in lung cancer (-20.0 %, from 14.8 % to 11.8 %), rectum (-20.2 %, from 20.9 % to 16.7 %), and uterine cervix (-37.1 %, from 53.2 % to 33.5 %). In prostate and kidney cancers, the proportion of patients with stage I increased by 30 % (from 19.5 % to 25.4 %) and 17.6 % (from 45.9 % to 54.0 %), respectively. A significant reduction in the proportion of early stages during the COVID-19 pandemic was observed in lung and cervical cancer. Conclusion Postponed health checkups due to COVID-19 pandemic disruptions have led to substantial reductions in new cancers being diagnosed, mainly for cervical, lung, colon and rectal cancers. No significant changes were observed for other cancers. Further analysis of mortality and survival of cancer patients is required.Copyright © 2022, Tomsk National Research Medical Center of the Russian Academy of Sciences. All rights reserved.
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Background: Interest in organ preservation (OP) strategies for rectal cancer (RC) patients persists. The efficacy of long course chemoradiation (LCRT) vs. short course radiation therapy (SCRT) relative to OP is unknown. We compared OP rates between SCRT and LCRT total neoadjuvant therapy (TNT) strategies. Method(s): During the COVID-19 pandemic we established an institutional SCRT mandate with no exceptions. For comparison, we identified RC patients treated with LCRT immediately before and after the mandate period. After completion of TNT, patients were restaged by clinical exam, endoscopy, and MRI. A watch and wait (WW) approach was recommended for patients with a clinical complete response (cCR), defined by the MSK regression schema. Total mesorectal excision (TME) was recommended for non-cCR patients. OP was defined as alive, TME-free, and with no evidence of disease in the pelvis. We performed survival analysis for: local regrowth rate, OP, disease-free survival (DFS), and overall survival (OS). Result(s): We identified 563 consecutive patients with RC treated with TNT, of whom 231 were excluded due to either metastatic disease, synchronous/metachronous malignancies, or non-adenocarcinoma histology (Jan. 2018-Jan. 2021). Patient and tumor characteristics were similar in the LCRT (n = 256) and SCRT (n = 76) cohorts. No significant differences in high-risk features were noted. Most patients had clinical stage III disease (82% in LCRT vs. 83% in SCRT). Induction chemotherapy followed by consolidative radiation was the most common treatment order (78% (LCRT) vs. 70% (SCRT)). The median interval from end of TNT to clinical restaging was 8 weeks (LCRT) and 9 weeks (SCRT). The cCR rate was 46% in both cohorts. The cCR rate was numerically higher in patients treated with radiation first, as compared to chemotherapy first (53% vs. 44% (LCRT) and 52% vs. 43% (SCRT)). Among patients with a cCR, the likelihood of WW management was similar (98% (LCRT) vs. 94% (SCRT)). From start of TNT, the median follow-up was 32 and 28 months respectively for LCRT and SCRT. The 2-year OS (95% vs. 92%), DFS (78% vs 70%), and distant recurrence (20% vs. 21%) rates were similar. Among all patients, the 2-year OP rate was 40% (95% CI 35-47%) for LCRT and 29% (95% CI 20-42%) with SCRT. In those patients managed by WW, the 2-year local regrowth rate was 20% (95% CI 12-27%) with LCRT vs. 36% (95% CI 16-52%) with SCRT. Conclusion(s): In this nonrandomized comparison, while cCR rates were similar, we observed a numerically higher OP rate with LCRT-TNT than with SCRT-TNT. The ongoing ACO/ARO/AIO-18.1 trial, hypothesizing that LCRT-TNT will increase OP rates relative to SCRT-TNT, should definitively answer this question.
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Background. During the COVID-19 pandemic, annual adult check-ups have been postponed, resulting in cancer screening disruption. The aim of the study was to evaluate changes in the incidence and stage distribution of malignancies included in the screening program during the COVID-19 pandemic using the Arkhangelsk Regional Cancer Registry (ARRC). Material and Methods. We assessed the changes of the incidence rates and stage distribution for the colon, rectum, lung, breast, cervix, uterine body, ovary, prostate and kidney cancers over the periods 2018–19 and 2020–21. Results. A total of 12354 cases with 9 cancers were selected: 6680 for the period 2018–19 and 5674 (-15.1 %) for the period 2020-21. The most significant decrease in crude and age-standardized incidence rates was registered in patients with lung (-18.0–18.1 %), rectum (-25.1–25.9 %) and cervix (-33.6–36.9 %) cancers, p<0.001. The decrease was not significant in patients with breast, uterine body, and kidney cancers. The proportion of patients with stage I decreased in lung cancer (-20.0 %, from 14.8 % to 11.8 %), rectum (-20.2 %, from 20.9 % to 16.7 %), and uterine cervix (-37.1 %, from 53.2 % to 33.5 %). In prostate and kidney cancers, the proportion of patients with stage I increased by 30 % (from 19.5 % to 25.4 %) and 17.6 % (from 45.9 % to 54.0 %), respectively. A significant reduction in the proportion of early stages during the COVID-19 pandemic was observed in lung and cervical cancer. Conclusion Postponed health checkups due to COVID-19 pandemic disruptions have led to substantial reductions in new cancers being diagnosed, mainly for cervical, lung, colon and rectal cancers. No significant changes were observed for other cancers. Further analysis of mortality and survival of cancer patients is required.
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Background: Patient satisfaction is a goal that is part of the Swedish initiative for cancer care pathway (CCP). A questionnaire has been developed specifically to request patients‘ experiences (PREM) of care and an overall goal is that the patient perspective has a clear influence in the follow-up and evaluation of CCP. The purpose of this project is to describe patient reported experiences from CCP in the Stockholm-Gotland Region, during the period 2017 to q1 2021. It includes patients’ experiences from CCP, comparisons between groups and whether it differs before and during the COVID-19 pandemic. Methods: An invitation letter to complete a validated PREM questionnaire consisting of 34 questions, is sent to patients 8-10 weeks after CCP has ended. The main questions consist of seven dimensions and own comments can be shared. Results: A total of 14,141 persons responded to the questionnaire with an average response rate of 57%. Representativeness is good for patients where the investigation led to a cancer diagnosis, among the elderly and among patients who have undergone care processes for breast cancer, colon and rectal cancer, prostate cancer, bladder cancer or skin melanoma. Most of the patients are satisfied with CCP regarding overall impression, respect & treatment, continuation & coordination, information & knowledge, and availability. However, areas that can be improved are emotional support as well as participation & involvement. Where the investigation did not lead to a cancer diagnosis and during the COVID-19 pandemic has affected the relative’s situation negatively, both in terms of relatives' opportunity to participate in care and the relative's opportunity to get in touch with health care regarding their own issues or need of support. Conclusions: Most of the patients are satisfied with CCP. Areas that might be improved are emotional support as well as participation & involvement. The COVID-19 pandemic has affected the relatives' situation negatively. Legal entity responsible for the study: Region Stockholm-Gotland. Funding: Has not received any funding. Disclosure: All authors have declared no conflicts of interest.
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Background: We illustrate a clinical application of Covid-Death Mean-Imputation (CoDMI) algorithm in survival analysis. CoDMI algorithm is a new statistical tool that allows to adjust, through mean imputation based on the Kaplan-Meier model, Covid-19 death events in oncologic clinical trials, providing a complete sample of observations to which any statistical method in survival analysis can be applied. Methods: We analyzed a group of patients who received trimodal treatment - neoadjuvant chemoradiotherapy, followed by surgery and adjuvant chemotherapy - for primary locally advanced rectal cancer (LARC). Overall survival (OS) was calculated in months from the date of diagnosis to the first event, including date of last follow-up or death. Because Covid-19 death events potentially bias survival estimation, to eliminate skewed data due to Covid-19 death events the observed lifetime of Covid-19 cases was replaced by its corresponding expected lifetime in absence of the Covid-19 event using CoDMI algorithm. In a traditional Kaplan-Meier approach, patient died of Covid-19 (DoC) can be: i) excluded to the cohort;ii) counted as censored (Cen);iii) considered as died of disease (DoD). CoDMI algorithm offers an additional, more satisfactory option: iv) DoC events are mean-imputed as no-DoC cases at later follow-up times. With this approach, the observed lifetime of each DoC patient is considered as an “incomplete data” and is extended by an additional expected lifetime computed using the classical Kaplan-Meyer model. Results: In total 94 patient records were collected. At the time of the analysis, there were 16 DoD cases, 1 DoC patient and 77 Cen cases. The DoC patient died due to Covid-19 52 months after diagnosis. CoDMI algorithm computed the expected future lifetime (beyond the DoC time of occurrence) provided by the Kaplan-Meier estimator applied to the no-DoC observations as well as to the DoC data itself. Given the DoC event at 52 months, CoDMI algorithm (applied in its standard form: DoC as virtual DoD) estimated that this patient would be died after 79.5 months of follow-up. Table summarizes the 2-year OS and the 5-year OS rates for the different treatment of DoC event. Since our sample contains only one DoC case, the effects on the estimates of the options considered differ very little. In this situation, however, one can better understand how CoDMI algorithm works. Conclusions: CoDMI algorithm leads to the “unbiased” (appropriately adjusted) OS probability in LARC patients with Covid-19 infection, compared with that provided by a naïve application of the Kaplan-Meier approach. This allows a proper interpretation of Covid-19 events in survival analysis. A user-friendly version of CoDMI is available at https://github.com/alef-innovation/codmi.
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Background: The coronavirus (COVID-19) pandemic has resulted in an abrupt transition to virtual oncology care at most cancer centres worldwide. A pillar of the American Medical Association's proposed framework for digitally enabled care is assessing clinical quality, safety, and outcomes. This study's objective is to evaluate chemotherapy quality and clinical outcomes in patients receiving intravenous chemotherapy for colorectal cancer before and during the COVID-19 pandemic. Methods: This is an observational study assessing patients treated with intravenous chemotherapy for colorectal cancer consecutively at the Ottawa Hospital Cancer Centre from June 2019 to September 2021. Patients with non-metastatic rectal cancer were excluded. Patient were stratified by whether they were started on chemotherapy pre-pandemic (June 2019 - Jan 2020) versus intra-pandemic (Feb 2020 - Sept 2021). Baseline characteristics and treatment data were collected from the electronic medical records. Outcomes of interest included chemotherapy delays, dose reductions, emergency department (ED) visits and hospitalizations. We used generalized linear and binary logistic regression modelling to compare outcomes between pre- and intra-pandemic periods. Results: There were 220 patients included in this study with 108 (49%) diagnosed with metastatic disease. In total, there were 66 (30%) patients treated in the pre-pandemic and 154 (70%) in the intra-pandemic period. As expected, virtual care consultations increased during the pandemic from 1.5% to 43.5% (p < 0.001). Likewise, the proportion of follow-up visits also increased from 37% to 84% (p < 0.001). There was no difference in the incidence of treatment delays (odds ratio [OR] = 1.01, p = 0.78), dose reductions (OR = 0.99, p = 0.69), ED visits (OR = 1.23, p = 0.37), hospitalizations (OR = 0.73, p = 0.43) or the total length of time off treatment (OR = 0.85, p = 0.17) between the pre- and intra-pandemic periods by multivariable analysis. A subgroup analysis was performed based on stage, which showed no difference in outcomes independent of the presence of metastases. Conclusions: This study demonstrates no significant difference in chemotherapy interruptions, dose intensity, or clinical outcomes in patients treated for colorectal cancer during the COVID-19 pandemic. These findings serve as an important quality-care indictor and demonstrate that virtual oncology care appears safe in a cohort of high-risk colorectal cancer patients. Future work dedicated to other tumor sites would allow for broader application of these findings.
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Purpose or Objective To illustrate a clinical application of Covid-Death Mean-Imputation (CoDMI) algorithm in survival analysis. CoDMI algorithm is a new statistical tool that allows to adjust, through mean imputation based on the Kaplan-Meier model, Covid-19 death events in oncologic clinical trials, providing a complete sample of observations to which any statistical method in survival analysis can be applied. Materials and Methods We analyzed a group of patients who received trimodal treatment – neoadjuvant chemoradiotherapy, followed by surgery and adjuvant chemotherapy – for primary locally advanced rectal cancer. Overall survival was calculated in months from the date of diagnosis to the first event, including date of the last follow-up or death. Because Covid-19 death events potentially bias survival estimation, to eliminate skewed data due to Covid-19 death events the observed lifetime of Covid-19 cases was replaced by its corresponding expected lifetime in absence of the Covid-19 event using CoDMI algorithm. In a traditional Kaplan-Meier approach, patient died of Covid-19 (DoC) can be: i) excluded to the cohort (but this would represent a loss of data), or ii) counted as censored (Cen) (but actually, due to its informative nature, Covid-19 death in a cancer patient cannot be censored as death from other causes), or iii) considered as died of disease (DoD) (but this provides an inappropriate exit cause). CoDMI algorithm offers an additional, more satisfactory option: iv) DoC events are mean-imputed as no-DoC cases at later follow-up times. With this approach, the observed lifetime of each DoC patient is considered as an “incomplete data” and is extended by an additional expected lifetime computed using the classical Kaplan-Meyer model. Results A total of 94 patient records were collected. At the time of the analysis, 16 patients died of disease (DoD), 1 patient died of Covid-19 (DoC) and 77 cases were censored (Cen). The DoC patient died due to Covid-19 52 months after diagnosis. CoDMI algorithm computed the expected future lifetime (beyond the DoC time of occurrence) provided by the Kaplan-Meier estimator applied to the no-DoC observations as well as to the DoC data itself. Given the DoC event at 52 months (red triangle in Figure 1), CoDMI algorithm (applied in its standard form) estimated that this patient would be died after 79.5 months of follow-up. The blue line in Figure 1 represents the newly estimated survival curve, where the additional DoD event is denoted by a circle. (Figure Presented) Conclusion CoDMI algorithm leads to the “unbiased” (appropriately adjusted) probability of overall survival in locally advanced rectal cancer patients with Covid-19 infection, compared with that provided by a naïve application of the Kaplan-Meier approach. This allows a proper interpretation/use of Covid-19 events in survival analysis. A user-friendly version of CoDMI is freely available at https://github.com/alef-innovation/codmi.
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Introduction Faecal immunochemical test (FIT) has been introduced as an effective screening test for colorectal cancer in the general population and colonoscopy is the gold standard test for confirmation of colon cancer. Due to the emergence of the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) pandemic, endoscopy services were severely reduced to emergency only in order to minimise COVID-19 infection spread throughout the world. Subsequently, FIT has been used as a triage tool to refer urgently (2 week wait cancer pathway) along with other alarm symptoms, e.g. anaemia, weight loss and change in bowel habit;to endoscopy services in the UK. The aim of this study was to determine the diagnostic efficacy of FIT in colorectal disease within a London based district general hospital. Secondary aims including assessing whether FIT has any diagnostic efficacy in inflammatory bowel disease (IBD). Methods From March to December 2020 all cases referred to the 2 week wait cancer pathway were analysed. The FIT score as well as well as presenting alarm symptoms were recorded prior to further investigation. The post colonoscopy outcome was also recorded to assess which patients were diagnosed with Colo-rectal cancer. Results There were 386 cases referred under 2 weeks wait cancer pathway. Of them 137 had positive FIT (>10 microgram/gram). Only 12 of those had colorectal cancer diagnosed on colonoscopy (8.8%). Median age of 68.5 (the range 44- 90 years), 58 % female and 42% were male respectively. The sensitivity of FIT in colorectal cancer diagnosis was 90% with a specificity of 48%, positive predictive value (PPV) was 6% and negative predictive value (NPV) 99%, However, out of 137 FIT positivity, there were 14 cases diagnosed inflammatory bowel disease (IBD, 13 Ulcerative colitis and 1 Crohn's disease). The sensitivity of FIT in diagnosing IBD was 93%, and specificity was 49% The PPV is 8% and NPV 99%. The Median age 56 (range 25-82 years), 57% were male and 43% were female. Those with a positive FIT and new IBD diagnosis appeared to be a younger, male dominant group. Conclusion FIT is a useful Colo-rectal cancer screening tool within the general population though its diagnostic yield is low. Its use has dramatically increased throughout the pandemic allowing a release of pressure off 2 week wait services with fewer referrals in FIT negative patients. Using FIT as a rule out method should be approached with caution as it is clear some Colo-rectal malignancies can present as FIT negative. FIT may also have a potential in assisting the diagnosis of IBD, in particular ulcerative colitis, within a younger group of the population though remains inferior to faecal calprotectin. Judicious use of the FIT in specific age groups is recommended in order to minimise both patient and practitioner anxiety and unnecessary referral.
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Purpose/Background: Bowel dysfunction following rectal cancer surgery changes with time and patients adapt to symptoms. The impact of bowel dysfunction on quality of life (QOL) over time is uncertain. Hypothesis/Aim: To evaluate the change in QOL due to bowel dysfunction over time. Methods/Interventions: A prospective database starting in July 2017 of adult patients who had undergone sphincter preserving rectal cancer surgery at a single university-affiliated colorectal cancer referral centre was queried. Patients were excluded if they had local recurrence, metastasis, or persistent stoma beyond 1-year follow-up. Follow-ups were arranged according to current guidelines. Main outcomes were QOL measured by the Short Form-36 survey (8 scales and 2 summary scores), bowel dysfunction was classified using the Low Anterior Resection Syndrome (LARS) score (no LARS, minor LARS and Major LARS), and bowel-related quality of life was evaluated using the single-item Bowel-Related Quality of Life (BQOL) survey. The SF-36 and LARS scores were collected as part of the ongoing registry. Eligible patients were then called at 3 months after their last in-person follow-up and administered the SF-36, LARS score and BQOL. Patients were also asked how they would have answered the BQOL 3-months prior. Changes in LARS and BQOL scores were noted and compared to SF-36 scores. Results/Outcome(s): Overall, 136 patients were included (75% response rate). Mean age 61.8 (+/-10.6 years), 71% male, mean distance from the anal verge was 8.7 cm (+/-4), 54% underwent neoadjuvant radiotherapy, 51% had a diverting loop ileostomy, 87% were laparoscopic, and median follow-up was 35.4 months [23.5-64.3]. There was no significant change in 3-month BQOL (96% of patients had no change, 3% improved, and 1% deteriorated. In patients who reported no change in BQOL, 54% (72/131) had no change in their LARS score, 31% (41/131) scored worse, and 27% (31/131) improved. Patients that showed improvement in their LARS score had an associated increase in their physical component summary, role emotional, role physical, physical functioning and bodily pain. Whereas patients with a deterioration of their LARS score had an associated decrease in their general health, vitality, and mental health. Interestingly, patients with no change in their LARS score reported increases in physical functioning and role emotional, but decreases in their scores for vitality and mental health (Table). Limitations: Recall bias, Covid-19, and volunteer bias. Conclusions/Discussion: Assessment of patients' bowel related QOL is complex. Improvements in bowel dysfunction appears to be associated with improved QOL. Whereas patients with worsening bowel dysfunction had an associated deterioration in QOL. Of note, BQOL scores did not change significantly over the study period. There is currently a paucity of instruments with sensitivity to detect changes specific to bowel dysfunction- related QOL.
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Purpose/Background: The COVID-19 pandemic resulted in major disruptions in surgical care due to limited resources and concerns over in-hospital transmission. Temporary pauses in elective colonoscopies delayed diagnosis for many colorectal diseases. It is unclear how these delays impacted colorectal surgical care. Hypothesis/Aim: We aim to examine changes in patterns of colorectal surgical care during the COVID-19 pandemic. Methods/Interventions: We performed a single-institution retrospective observational study including six surgeons examining changes in the relative proportions of procedures performed for three major surgical disease categories: colorectal cancer, diverticulitis, and inflammatory bowel disease (IBD). We examined case volumes across three large affiliated hospitals from January 1, 2019 to December 31, 2020. Trends in surgical case volume for patients with colorectal cancer, diverticulitis, and IBD were compared. We then examined trends in monthly mean follow-up time measured in days between time of surgical referral to time of surgery. Results/Outcome(s): Our study identified 956 colorectal surgeries over the 2-year period. There were more total procedures done in 2019 relative to 2020 (520 vs 436). Following March 2020, monthly surgical case volume decreased, driven primarily by decreases in diverticulitis and IBD case volume. Trends in cancer case volume remained relatively unchanged throughout the pandemic. See Figure 1. We noted no rise in emergent colorectal surgery case volume. On average, there were 6 emergent cases per month compared to 4 cases per month in the six months before and after March 2020. Average wait time to surgery increased from 77 days to 114 days in the six months immediately before and after March 2020 driven primarily by rectal cancer patients receiving neoadjuvant chemoradiation. Pre-pandemic wait times ranged from 39 days for colon cancer patients to 236 days for rectal cancer patients receiving neoadjuvant therapy. Postpandemic, average wait times ranged from 57 days for colon cancer patients to 282 days for rectal cancer patients requiring neoadjuvant therapy. Limitations: This is a single-institution case series which limits generalizability. However, given the increased availability in resources at a major academic institution, the shifts and potential delays in surgical care noted in this study may be greater at smaller hospitals. Conclusions/Discussion: Surgical case volume decreased following the pandemic, driven primarily by decreases in cases for IBD and diverticulitis. Despite these changes, we noted no large rise in the rates of emergent colorectal surgery suggesting the potential success of medical management of diverticulitis and IBD. Examination of outpatient wait time revealed a rise in the average wait time to surgery. This data may be helpful in better understanding the potential future surgical needs of a large population of patients whose care was deferred during the pandemic.
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Purpose/Background: Perioperative COVID-19 infection is associated with an increase in morbidity and mortality, in addition to the consequences on surgical pathologies due to delays in diagnosis and treatment. Hypothesis/Aim: The aim of this study it is to describe and evaluate the effects of the pandemic on patients undergoing colorectal cancer surgery in the UC-Christus Healthcare Network. Methods/Interventions: A retrospective observational cross-sectional cohort study was made. It was based on the review of the admissions and surgical protocols of patients operated due to colon and rectal cancer diagnosis between 03/18/2019 - 03/17/2021 in the UC-Christus Healthcare Network. Patients with incomplete records and follow-ups, recurrences, or endoscopic treatments were excluded. The results of patients who were operated before the sanitary restrictions were compared with those who were operated afterwards (03/18/2020). The variables of sex, age, date of surgery, procedure, approach, tumor location, TNM, biopsy, pathological stage, presence of neoadjuvant and/or adjuvant, cause of mortality, emergency admission, and ostomy requirement were recorded in a database. The descriptive and analytic statistics of the results were analyzed using the Microsoft SPSS-Statistics21 program. Proportions were compared with the Chi2 test and Fisher's exact test in variables whose frequency was less than 5. Results/Outcome(s): One hundred seven records were included in the first period (79 colon and 28 rectal tumors) and 134 in the second (100 colon and 34 rectal tumors), with no significant differences between the number of patients nor the distribution by sex in both periods. In the colon tumors group, there were no significant differences between the groups of patients with early-stage (17), locally advanced (118), and metastatic (44) tumors between both periods. Nineteen patients (10.6%) underwent emergency surgery, 36 patients (20.1%) required an ostomy to be performed without significant differences in both periods. At the rectum tumor group, there were no significant differences concerning sex, nor pathological stage, where 17 (26.9%) were in the initial stages, 29 (46%) locally advanced, and 17 (26.9%) were metastatic. The laparoscopic approach was preferred in all tumor groups, requiring conversion in 6 (4.65%) colon tumor and 1 (2.17%) rectal tumor cases. No mortalities were recorded 30, 60, nor 90 days after Limitations: Among the limitations of our study is a selection bias, since it was carried out only in one institution, so the results obtained here are not necessarily extrapolated to the general population. Conclusions/Discussion: In patients operated in the oncology program of the Healthcare Network, there were no significant differences regarding the number of operated patients, their pathological stage, mortality, or approach in the compared periods.
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Purpose/Background: The lack of screening and healthcare access during COVID-19 has delayed diagnosis of rectal cancer. Purpose: To determine whether the COVID-19 pandemic influenced sphincter preserving surgery rates. Hypothesis/Aim: The COVID-19 pandemic influenced sphincter preserving surgery rates in rectal cancer. Methods/Interventions: Methods: In this retrospective cross-sectional study patients undergoing surgery for rectal cancer between 2016 and 2021 were divided into two groups. Patients operated during the COVID-19 pandemic (2020 - 2021) and patients operated before the pandemic (2016-2020). Intervention(s): Sphincter preserving surgical interventions included transanal local excision and low anterior resection with restorative proctectomy or coloanal anastomosis. Radical surgery included abdominoperineal resection with a permanent colostomy. Results/Outcome(s): 234 patients were included, 180 patients (76.9 %) in the pre-COVID-19 group, and 54 patients (23.1%) in the COVID-19 era group. There were no differences between the groups in mean patient age (60.0 ± 12.7 vs 60.6 ± 12.7;p = 0.7648), gender (33.3% vs 40.7% females;p = 0.31) and BMI (26.6 ± 4.8 vs. 27.4 ± 4.6;p = 0.2580). The COVID-19 era group had a significantly lower rates of sphincter preserving surgery (73.1% vs. 86%;p=0.028). Patients in the COVID-19 era also presented with a significantly higher rate of locally advanced disease (stage T3/T4 78.8% vs 57.9%;p=0.02) and metastatic disease (9.4% vs. 2.8%;p = 0.05) compared to the pre COVID-19 group. Time from diagnosis to surgery in this group was also significantly longer (median 272 vs. 146 days, p<0.0001). Limitations: Retrospective single center study Conclusions/Discussion: Patients diagnosed with rectal cancer during the COVID-19 era presented at a more advanced oncological stage and underwent sphincter preserving surgery at lower rates.
ABSTRACT
Background: Cancer therapy may put patients at risk of mortality from COVID-19. The impact of abbreviated treatment courses on outcomes in the setting of COVID-19 is unknown. We incorporated COVID-19-associated risks in re-analysis of practice-defining randomized trials in oncology that compared different radiation therapy (RT) regimens. Methods: We extracted individual patient level data (IPLD) from published survival curves from randomized trials in rectal cancer (Dutch TME, TROG 01.04), early stage breast cancer (CALGB 9343, OCOG hypofractionation trial, FAST-Forward, NSABP B-39), and localized prostate cancer (CHHiP, HYPO-RT-PC). Trials were simulated with incorporation of varying risk of SARS-CoV-2 infection and mortality associated with receipt of therapy. Results: IPLD from 14,170 patients were re-analyzed. In scenarios with low COVID-19-associated risks (0.5% infection risk per fraction [IRF], 5% case fatality rate [CFR]), fractionation did not significantly affect outcomes. In locally advanced rectal cancer, short-course RT appeared preferable to long-course chemoradiation (TROG 01.04) or RT omission (Dutch TME) in most settings. While moderate hypofractionation in early stage breast cancer (OCOG hypofractionation trial) and prostate cancer (CHHiP) was not associated with survival benefits in the setting of COVID-19, more aggressive hypofractionation (FAST-Forward, HYPO-RT-PC) and accelerated partial breast irradiation (NSABP B-39) were associated with improved survival in higher risk scenarios (≥5% IRF;≥ 20% CFR). In settings where RT can be omitted, such as favorable early stage breast cancer in the elderly (CALGB 9343), RT was associated with worse survival in higher risk pandemic scenarios (≥5% IRF, ≥ 20% CFR). Conclusions: Our framework, which can be adapted to dynamic changes in COVID-19 risk, provides a flexible, quantitative approach to assess the impact of treatment recommendations across oncology. The magnitude of potential benefit from abbreviated RT courses depends on the degree of hypofractionation and local COVID-19-associated risk. Abbreviated RT courses should be prioritized when possible and are increasingly beneficial in higher risk pandemic settings. With increased understanding and precautions against COVID-19 that can minimize risks for patients, our results support the continued use of evidence-based treatments for cancer patients in the COVID-19 era.