Effectiveness of Standard Treatment for Stage 4 Colorectal Cancer: Traditional Management with Surgery, Radiation, and Chemotherapy.

Colorectal cancer (CRC) is the second most common cause of cancer-related death in the United States comprising 7.9% of all new cancer diagnoses and 8.6% of all cancer deaths. The combined 5-year relative survival rate for all stages is 65.1% but in its most aggressive form, stage 4 CRC has a 5-year relative survival rate of just 15.1%. For most with stage 4 CRC, treatment is palliative not curative, with the goal to prolong overall survival and maintain an acceptable quality of life. The identification of unique cancer genomic and biologic markers allows patient-specific treatment options. Treatment of stage 4 CRC consists of systemic therapy with chemotherapeutic agents, surgical resection if feasible, potentially including resection of metastasis, palliative radiation in select settings, and targeted therapy toward growth factors. Despite advances in surgical and medical management, metastatic CRC remains a challenging clinical problem associated with poor prognosis and low overall survival.

Effect of "Residents as Teachers" Workshop on Learner Perception of Trainee Teaching Skill.

BACKGROUND: Surgical residencies use variable structures for formal training in education. We hypothesized that a one-day workshop intervention would improve resident teaching ability measured by self-assessment and learner evaluation. MATERIALS AND METHODS: Faculty educators delivered a Residents as Teachers (RAT) workshop to general surgery residents on setting expectations, positive learning environment, difficult feedback and the 1-min preceptor model. For three months before and after the workshop, junior residents and medical students evaluated their supervising residents' teaching skill monthly using a Likert scale questionnaire. Pre- and postworkshop surveys were administered to resident participants to assess their knowledge of the material and teaching confidence. Results were analyzed using Wilcoxon rank sum tests. This study was conducted at a tertiary academic center with a large surgical residency program. RESULTS: Thirty-nine PGY 1-5 residents participated in the Residents as Teachers workshop and were included in the study. Pre- and post- workshop survey results demonstrated significant improvements in participants' knowledge and teaching confidence. On monthly assessments of seniors by junior residents, significant improvements were noted in three domains. Medical student ratings did not reflect significant improvements in resident teaching skill. CONCLUSIONS: This is the first study using learner evaluation of a comprehensive surgical RAT program. Despite a significant increase in surgery residents' self-assessment following participation in an education workshop, no improvement was seen in resident teaching skill as perceived by medical students.

Colorectal Cancer Safety Net: Is It Catching Patients Appropriately?

BACKGROUND: Disparities in access to colorectal cancer care are multifactorial and are affected by socioeconomic elements. Uninsured and Medicaid patients present with advanced stage disease and have worse outcomes compared with similar privately insured patients. Safety net hospitals are a major care provider to this vulnerable population. Few studies have evaluated outcomes for safety net hospitals compared with private institutions in colorectal cancer. OBJECTIVE: The purpose of this study was to compare demographics, screening rates, presentation stage, and survival rates between a safety net hospital and a tertiary care center. DESIGN: Comparative review of patients at 2 institutions in the same metropolitan area were conducted. SETTINGS: The study included colorectal cancer care delivered either at 1 safety net hospital or 1 private tertiary care center in the same city from 2010 to 2016. PATIENTS: A total of 350 patients with colorectal cancer from each hospital were evaluated. MAIN OUTCOME MEASURES: Overall survival across hospital systems was measured. RESULTS: The safety net hospital had significantly more uninsured and Medicaid patients (46% vs 13%; p < 0.001) and a significantly lower median household income than the tertiary care center ($39,299 vs $49,741; p < 0.0001). At initial presentation, a similar percentage of patients at each hospital presented with stage IV disease (26% vs 20%; p = 0.06). For those undergoing resection, final pathologic stage distribution was similar across groups (p = 0.10). After a comparable median follow-up period (26.6 mo for safety net hospital vs 29.2 mo for tertiary care center), log-rank test for overall survival favored the safety net hospital (p = 0.05); disease-free survival was similar between hospitals (p = 0.40). LIMITATIONS: This was a retrospective review, reporting from medical charts. CONCLUSIONS: Our results support the value of safety net hospitals for providing quality colorectal cancer care, with survival and recurrence outcomes equivalent or improved compared with a local tertiary care center. Because safety net hospitals can provide equivalent outcomes despite socioeconomic inequalities and financial constraints, emphasis should be focused on ensuring that adequate funding for these institutions continues. See Video Abstract at http://links.lww.com/DCR/A454.

Are we catching women in the safety net? Colorectal cancer outcomes by gender at a safety net hospital.

BACKGROUND: Our goal was to evaluate presentation and outcomes for colorectal cancer across gender in a safety net hospital (SNH). METHODS: An institutional Tumor Registry was reviewed for colorectal cancer resections 12/2009-2/2016. Patients were stratified into male and female cohorts. The main outcome measures were stage at presentation and oncologic outcomes across gender. RESULTS: 170 women (48.6%) and 180 men (51.4%) were evaluated; 129 (84.1%) females and 143 (79.4%) males underwent curative resection. There were no significant differences in prior colorectal cancer screening. On presentation, there were similar rates of stage IV disease across genders (p = 0.3). After median follow-up of 26.5 months (female) and 29.9 months (male), there were no significant differences in overall survival, survival by stage, or disease-free survival by gender (all p = 0.7). The local (1.4% females vs. 2.6% males, p = 0.7) and distant recurrence (16.6% females vs. 14.9% males, p = 0.7) were similar across gender. CONCLUSION: With equal access to treatment, there were no significant differences in overall survival, survival by stage, or local or distant recurrence rates by gender. These findings stress the importance of the SNH system, and need for continued support.

Multi-institutional assessment of sphincter preservation for rectal cancer.

BACKGROUND: Sphincter-preserving surgery (SPS) has been proposed as a quality measure for rectal cancer surgery. However, previous studies on SPS rates lack critical clinical characteristics, rendering it unclear if variation in SPS rates is due to unmeasured case-mix differences or surgeons' selection criteria. In this context, we investigate the variation in SPS rates at various practice settings. METHODS: Ten hospitals in the Michigan Surgical Quality Collaborative collected rectal cancer-specific data, including tumor location and reasons for non-SPS, of patients who underwent rectal cancer surgery from 2007 to 2012. Hospitals were divided into terciles of SPS rates (frequent, average, and infrequent). Patients were categorized as 'definitely SPS eligible' a priori if they did not have any of the following: sphincter involvement, tumor <6 cm from the anal verge, fecal incontinence, stoma preference, or metastatic disease. Fixed-effects logistic regression was used to evaluate for factors associated with SPS. RESULTS: In total, 329 patients underwent rectal cancer surgery at 10 hospitals (5/10 higher volume, and 6/10 major teaching). Overall, 72 % had SPS (range by hospital 47-91 %). Patient and tumor characteristics were similar between hospital terciles. On multivariable analysis, only hospital ID, younger age, and tumor location were associated with SPS, but not sex, race, body mass index, American Joint Committee on Cancer (AJCC) stage, preoperative radiation, or American Society of Anesthesiologists (ASA) class. Analysis of the 181 (55 %) 'definitely-eligible' patients revealed an SPS rate of 90 % (65-100 %). CONCLUSIONS: SPS rates vary by hospital, even after accounting for clinical characteristics using detailed chart review. These data suggest missed opportunities for SPS, and refute the general hypothesis that hospital variation in previous studies is due to unmeasured case-mix differences.

Clostridium difficile of the ileum following total abdominal colectomy, with or without proctectomy: who is at risk?

BACKGROUND: Clostridium difficile enteritis is considered a rare entity, although recent data suggest a significant increase in prevalence and incidence. There is paucity of data evaluating risk factors of C difficile enteritis following total colectomy. OBJECTIVE: The aim of this study was to determine the incidence and risk factors of C difficile enteritis for patients who had undergone total abdominal colectomy with or without proctectomy. DESIGN: This study involves a retrospective chart review of 310 patients. Univariate analysis was performed on potential risk factors (p ≤ 0.05) with the use of a logistic regression model, and a Fisher exact test was used for variables that had no occurrences of C difficile. These groups of variables were then examined in a multiple variate setting with stepwise logistic regression analysis. SETTINGS: This study was conducted at a tertiary referral center. PATIENTS: A data analysis was performed on patients who had undergone total abdominal colectomy with or without proctectomy who were tested for C difficile of the ileum. RESULTS: Twenty-two of 137 patients that were tested (16%) were positive for C difficile of the ileum. Univariate analysis of known risk factors for C difficile demonstrated that black race was a protective factor against C difficile (p = 0.016). The multivariate analysis demonstrated that emergency surgery (p = 0.035), race (p = 0.003), and increasing age by decade (p = 0.033) were risk factors for C difficile. LIMITATIONS: This study was limited by the small patient sample, and it was not a randomized trial. CONCLUSIONS: Black race is protective, and whites are 4 times more likely to acquire C difficile of the ileum after undergoing a total abdominal colectomy with or without proctectomy. The data also demonstrated that an increased age by a decade and emergency surgery are risk factors for C difficile enteritis, whereas the described risk factors of C difficile of the colon and type of colon surgery do not appear to influence the risk of C difficile of the ileum.

Colorectal lymphoma.

Extranodal lymphomas account for a third of all cases of non-Hodgkin lymphoma with the gastrointestinal tract being the most common extranodal site. The most common location is the stomach followed by the small intestine, colon and rectum. Colorectal lymphomas are rare and comprise 10-20% of all gastrointestinal lymphomas and only 1% of all colorectal malignancies. Presenting symptoms include abdominal pain, weight loss, and anorexia. Diagnosis depends on the clinical setting with elective cases being diagnosed with colonoscopy and emergent cases being diagnosed in the operating room. Colonic lymphomas are frequently located proximal to the hepatic flexure. Management depends on the aggressiveness of the lymphoma subtype. Indolent tumors, which are resistant to standard chemotherapeutic regimens, are treated with surgical resection. Aggressive lymphoma subtypes are managed with chemotherapy and surgery with late-stage disease patients being referred to clinical trials.

Functional anorectal disorders.

Functional anorectal disorders include solitary rectal ulcer syndrome, rectocele, nonrelaxing puborectalis syndrome, and descending perineal syndrome. Patients usually present with "constipation," but the clinical picture of these disorders includes rectal pain and bleeding, digitalization, incomplete evacuation, and a feeling of obstruction. Diagnosis is difficult because many findings can be seen in normal patients as well. The diagnosis is made by using a combination of clinical picture, defecography, pathology, and occasionally anometry and pudendal terminal motor nerve latency. These disorders are generally treated medically with dietary changes and biofeedback. Surgical intervention is reserved for patients with intractable symptoms and has not been universally successful.