Ian Hastie

Sacral nerve stimulation for fecal incontinence: long-term outcomes.

BACKGROUND: Numerous studies advocate the short-term benefits of sacral nerve stimulation for fecal incontinence, but there has been a paucity of studies on longer-term outcomes. OBJECTIVE: The objective of this study was to report the long-term outcome of sacral nerve stimulation performed for fecal incontinence at a single institution. PATIENTS AND DESIGN: Between January 2004 and May 2007, 53 patients underwent definitive sacral nerve stimulation for fecal incontinence at our institution. Prospectively recorded baseline information, including Wexner incontinence scores and standard short-form (SF-12) health survey scores, were compared with scores at follow-up. RESULTS: Forty-one patients were available for long-term follow-up with a mean duration of 51 months. The median Wexner score decreased from a baseline of 11.5 (range, 3.0–18.0) to 8.0 (range, 0.0–18.0) at follow-up. The mean difference in Wexner score was 2.7 (P < .001). There was no statistically significant change in SF-12 physical scores, but a small but highly significant change occurred in SF-12 mental scores. The median SF-12 mental domain score was 49.5 (range, 15.0–62.1) at baseline, and 57.0 (range, 20.0–64.0) at follow-up, with a mean difference of 4.5 (P = .006). Subgroup analysis performed comparing patients with or without prior intersphincteric silicon biomaterial implants demonstrated a mean difference in Wexner score of −3.5 (no implant) vs 0.0 (previous implant), with P < .09 (not statistically significant). CONCLUSIONS: Sacral nerve stimulation results in a statistically significant improvement in fecal incontinence scores in the long term.

Comparing oncological outcomes of laparoscopic versus open surgery for colon cancer: Analysis of a large prospective clinical database.

Oncological outcomes of laparoscopic colon cancer surgery have been shown to be equivalent to those of open surgery, but only in the setting of randomized controlled trials on highly selected patients. The aim of this study is to investigate whether this finding is generalizable to real world practice.

Linking data from hospital and cancer registry databases: should this be standard practice?

Background: Varying amounts of data related to cancer diagnosis, treatment and/or outcome are routinely collected by many disparate groups. Routinely combining data from these sources could improve data quality and utility for audit and research purposes. The aim of this study is to demonstrate the benefits of linkage between oncology databases.

Patient comorbidities and behaviour once diagnosed are major contributors to disparities in cancer health outcomes.

TO THE EDITOR: As broad progress is made in the treatment and outcomes of cancer, it becomes increasingly important that all patients have the opportunity to benefit from these advances, so we commend the American Society of Clinical Oncology (ASCO) for highlighting the significant issue of disparities in outcomes. The main focus of the policy statement, however, is the presumed major contributions of poor quality of care and limited access to treatment. While this is consistent with the available data, we believe too little attention is paid to the potential impact of differences in patient comorbidities and/or behavior on cancer outcomes. Based on our own data, we would argue that further study of attitudes to disease and treatment may permit tailored intervention that will reduce some of the observed differences between advantaged and disadvantaged populations. The Australian model of healthcare differs markedly from the United States in that there are parallel systems—a publicly funded universal health care system, known as Medicare, and a private system. Many Australians choose to pay private health insurance to enable choice of doctor and treatment location and to avoid long waiting lists for elective procedures. Of note, there are many instances where the public and private hospital systems are closely affiliated, with the same surgeons and medical oncologists providing care in both settings. For patients presenting with cancer, the same range of treatment options is available, with all standard therapy made available in both systems through the government-funded pharmaceutical benefits scheme. Thus the Australian model provides a unique opportunity to contrast the outcomes of privately insured patients (an advantaged population), with that of public patients (a more disadvantaged population), where any disparity in outcome is unlikely to be because of issues such as the quality of care received or a difference in access to care. To explore the differences between private and public patients, and how these could impact on the presentation, treatment, and outcome of cancer, we examined data from four hospitals, consisting of two sets of affiliated public and private centers. We identified 1,930 patients diagnosed with colorectal cancer between January 2000 (when prospective comprehensive data collection was initiated) and December 2007, 1,568 (81%) of whom were treated in the public system and 362 (19%) in the private sector. Table 1 illustrates some of the differences in patient characteristics between the two populations. The public patients are a median of 3 years older than the private patients (P .001). As expected, they have a greater degree of social disadvantage measured by the Index of Relative Social Advantage/Disadvantage score, which is calculated on a postcode basis using indicators such as education, level of unemployment, and median income. There are also clear differences between the two populations with respect to specific comorbidities (diabetes) and lifestyle choices (smoking). Both smoking and diabetes are significantly associated with premature death unrelated to cancer diagnosis, and in the case of diabetes, worse cancer-specific survival outcomes. Inferior overall scores for the public patients when assessed by the general measure of operative risk, the American Society of Anaesthesiology score, are also consistent with an excess of comorbidities and poorer general health among the public patients. Features related to the cancer diagnosis are presented in Table 2. The marked excess of emergency presentations in the public patients suggests these patients may delay seeking medical attention for their symptoms, and the overall differences in stage at presentation are consistent with this, including an excess of public patients presenting with metastatic disease. Adjuvant treatment data is also presented in Table 2. For the 623 patients with stage II (n 200) or III colon cancer (n 423), the medical oncologist recommended adjuvant treatment in a greater percentage of private patients than public (63% v 54%; P .003). A significantly greater proportion of the public patients (52 of 482; 10.79%) compared with private patients (seven of 141; 4.96%) decided not to pursue treatment against medical advice (P .0001). The greater number of private patients offered treatment is consistent with differences in the age and comorbidity profile of the two groups, whereas the lower acceptance of treatment advice may represent differences in knowledge, attitudes, and/or beliefs about cancer. Table 1. Patient and Tumor Characteristics

Impact of Body Mass Index on Colorectal Cancer Treatment and Outcomes: Need for Prospective and Comprehensive Data

TO THE EDITOR: Drs Lorenz and Ganz brought together a stellar group of investigators providing a comprehensive review on quality of care and supportive care in oncology. I commend the authors for stating up front that an examination of quality of care in oncology needs to include not only the supportive and end-of-life aspects, but also the entire spectrum of clinical care. However, having emphasized the multidisciplinary aspects of palliative care, the authors failed to review the progress of supportive care in surgical and radiologic treatments of the cancer patient. One of the most important contributions of health-related quality-of-life research to clinical care is the inclusion of patient and family input into the decision-making process for the treatment of cancer. Whether the decision is to proceed with a major curative operation or embark on several months of systemic chemotherapy, the decision-making process has largely been based on survival and morbidity-mortality rates, performance status, molecular markers, and other clinical end points. The patient may be provided with a detailed explanation of the scientific basis of the treatment options. However, patient and family involvement in the decision-making process has been peripheral. Today, the patient can choose among several treatment options resulting in better quality of life, and sometimes not take advantage of the curative potential of other, more disabling treatment options. For example, neoadjuvant chemotherapy with complete or partial responses can allow organ preservation with minimal compromise in eventual survival rates. The need for additional research in quality of care has been outlined by several authors. In oncologic surgical care, the need for research into quality of care and palliative surgery has been underestimated. Just as quality-of-life measures have been incorporated into several phase III trials, these measures should also be incorporated into newer, minimally invasive surgical treatment evaluations. Lack of awareness and underuse of supportive care services have also been well documented. There is a general consensus about the need to evaluate quality of care. However, there is neither a consensus nor a clinical standard in the measure of quality of care. These measures need to be simple and easily applied at the bedside or clinic. The adopted measure has to be reproducible among different investigators and clinicians across different institutions. The end points from these measures need to be consistent with other clinical standards, and when applied to patient care, the results will indicate improved, cost-effective patient management.

Survival Impact of Adjuvant Chemotherapy for Resected Locally Advanced Rectal Adenocarcinoma

Micro‐Abstract The benefit of adjuvant fluoropyrimidine‐containing chemotherapy following preoperative chemoradiotherapy and surgical resection for locally advanced rectal cancer is uncertain. In this retrospective analysis, no significant relapse‐free or overall survival benefit was associated with adjuvant chemotherapy. However, in the subset of patients who did not achieve a pathologic complete response to preoperative chemoradiotherapy, use of adjuvant chemotherapy resulted in a significant overall survival benefit. Background: Recent data has created uncertainty regarding the benefit of adjuvant fluoropyrimidine‐containing chemotherapy following preoperative chemoradiotherapy and surgical resection for locally advanced rectal cancer (LARC). In particular, patients with a pathologic complete response (pCR) may derive no benefit from adjuvant chemotherapy. Patients and Methods: This is a retrospective analysis of patients with LARC, diagnosed between January 1, 2003 and December 31, 2014 at 3 Melbourne health services. Patients were identified from the Australian Comprehensive Cancer Outcomes and Research Database, where a defined data set is prospectively collected on consecutive patients. Patient demographics, pCR rates, postoperative treatment, recurrence, and survival were analyzed. Results: A total of 717 patients with LARC were identified, of whom 555 (77%) had received preoperative long‐course chemoradiation followed by surgery. Four hundred fifty‐two of 555 patients (81%) subsequently received adjuvant fluoropyrimidine‐based chemotherapy. At a median follow‐up of 45.9 months, 95 (21%) patients in the adjuvant chemotherapy group and 20 (19%) in the surveillance group had relapsed. Five‐year relapse‐free survival was 77% in the adjuvant chemotherapy group and 71% in the surveillance group with no significant difference on univariate analysis (hazard ratio [HR], 0.93; 95% confidence interval [CI], 0.58‐1.51; P = .780). No significant impact on relapse‐free survival was seen for either pCR or non‐pCR patients. Five‐year overall survival (OS) was 85% in the adjuvant chemotherapy group and 74% in the surveillance group with a nonsignificant trend towards OS benefit (HR, 0.62; 95% CI, 0.37‐1.05; P = .074). A significant OS benefit favoring adjuvant chemotherapy was seen in the non‐pCR subset of patients (HR, 0.49; 95% CI, 0.28‐0.86; P = .014). Conclusion: A high proportion of patients in this routine practice cohort received adjuvant chemotherapy following preoperative treatment and surgery for LARC. Adjuvant chemotherapy administration was associated with a significant improvement in 5‐year OS only in the patients with a non‐pCR.

Stomal melanoma—myth or reality?

Dear Editor: Malignant melanoma contributes a large cancer burden to the Australian community. While melanoma of the gastrointestinal (GI) tract has been widely reported in the literature, clarity about primary melanoma of the small bowel remains controversial. It is recognised that these lesions of the small bowel can have the antecedent diagnosis of a cutaneous malignancy, but this is by no means universal. Much conjecture still remains about a true histopathological diagnosis of primary small bowel melanoma. Stomas are relatively common with reasons including GI tract malignancy, colitis (Crohn’s, ulcerative colitis), familial polyposis, and diverticulitis. However, with the high incidence of both stoma and melanoma, there are no reported cases of either primary stomal melanoma or cutaneous melanoma invading a stoma in the literature. We report the first case of malignant melanoma at an ileostomy site. A 92-year-old lady was referred to the colorectal outpatient clinic with a several-month history of an ulcerating lesion around the stoma site. Her stoma had been created 44 years prior, as an end ileostomy in the setting of refractory ulcerative colitis. The lesion had been slowly growing for many years, with an intermittent bleeding tendency. Clinical examination revealed an ileostomy sighted on the right side of her abdomen with a large fungating tumour at its lower edge. Contact bleeding was easily demonstrated at numerous sites around the stoma. A small discrete lymph node was noted in her groin with no further lymphadenopathy demonstrated. Prior review by a dermatologist had suggested a provisional diagnosis of moderately differentiated squamous cell carcinoma. There was no known previous history of cutaneous malignancy. Endoscopy was performed through the ileostomy and revealed only superficial involvement of the stoma. No deeper contiguous spread was noted. A staging CT scan of the chest, abdomen and pelvis revealed no obvious metastases. At operation, a resection of the ileostomy with macroscopically clear margins to 1 cm was performed, including the stoma site. This resection was performed enbloc to include fascia. The fascia was closed partially with 1.0 nylon and an absorbable mesh was used to close the defect. The stoma was resited to the left side of the abdomen. Postoperatively, she progressed well and was discharged after 5 days. No further treatment was offered, given her comorbidities and her age. Macroscopic appearance revealed a large ulcerated tumour extending from the skin edge onto the stoma. The dark pearly appearance of the tumour measured 30×28 mm in area and grew up to 10 m in thickness. It was 7 mm away Contribution of each author Author 1: Principal researcher involved in looking through files and constructing the body of the text. Author 2: 2nd principal researcher. Involved in post operative follow up, coordinating the pathologists role and part writing of the text. Author 3: Pathologist: Involved in looking through the histology and providing appropriate figure legends Author 4: The consultant surgeon involved in this case. The final reviewer of the manuscript.

Triradiate caecal fold: Is it a useful landmark for caecal intubation in colonoscopy?

AIM To determine the frequency of identification of the triradiate fold during colonoscopy and evaluate its reliability as a marker of caecal intubation. METHODS One hundred consecutive patients undergoing colonoscopy in a tertiary hospital colorectal unit from May to September 2013 were studied. Video documentation of the caecum was recorded and shown to consultant colorectal surgeons on the unit. Each reviewer was asked through a series of questions to independently identify the triradiate fold. The main outcome was the frequency of visualisation of the triradiate fold in the caecum. RESULTS The triradiate fold was seen on average in 18% of cases, but inter-observer agreement was poor. There were only four patients (4%) in which all reviewers agreed on the presence of a triradiate fold. In patients who had undergone previous appendicectomy, the appendiceal orifice was less frequently seen compared with patients who had not undergone appendicectomy. CONCLUSION The triradiate fold is infrequently seen during colonoscopy and is therefore an unreliable landmark of caecal intubation.

ORIGINAL ARTICLE: Linking data from hospital and cancer registry databases: should this be standard practice?: Benefits of linking oncology databases

Background: Varying amounts of data related to cancer diagnosis, treatment and/or outcome are routinely collected by many disparate groups. Routinely combining data from these sources could improve data quality and utility for audit and research purposes. The aim of this study is to demonstrate the benefits of linkage between oncology databases.