Linda C. Cummings

Survival after hepatic resection in metastatic colorectal cancer: A population-based study

Hepatectomy is the standard of care for patients with colorectal cancer who have isolated hepatic metastases; however, the long‐term survival benefits of hepatectomy in this population have not been characterized well outside of case series. For the current study, a population‐based database was used to compare the survival of patients with liver metastases from colorectal cancer who did and did not undergo hepatectomy.

A comparison of epidural analgesia and traditional pain management effects on survival and cancer recurrence after colectomy: a population-based study.

Background: Cancer recurrence after surgery may be affected by immunosuppressive factors such as surgical stress, anesthetic drugs, and opioids. By limiting exposure to these, epidural analgesia may enhance tumor surveillance. This study compared survival and cancer recurrence rates for resection of colorectal cancer between patients who received perioperative epidurals and those who did not. Methods: The linked Medicare-Surveillance, Epidemiology, and End Results database was used to identify patients ages 66 yr or older with nonmetastatic colorectal cancer diagnosed between 1996 and 2005 who underwent open colectomy. Recurrence was defined as chemotherapy 16 months or more after surgery and/or radiation 12 months or more after surgery. Patients were followed for at least 4 yr. To account for hospital effects, overall survival was estimated via marginal Cox regression. Recurrence was estimated by conditional logistic regression. Results: A cohort of 42,151 patients, of whom 22.9% (n = 9,670) had epidurals at the time of resection, was identified. 5-yr survival was 61% in the epidural group and 55% in the nonepidural group. There was a significant association between epidural use and improved survival (adjusted Cox model hazard ratio = 0.91, 95% CI = [0.87, 0.94]). Adjusting for covariates, there was no significant reduction of recurrence in the epidural group (odds ratio = 1.05, 95% CI = [0.95, 1.15]). Several covariates, including blood transfusion, were predictive of mortality and cancer recurrence. Conclusion: This large cohort study found that epidural use is associated with improved survival in patients with nonmetastatic colorectal cancer undergoing resection but does not support an association between epidural use and decreased cancer recurrence.

Laparoscopic versus open colectomy for colon cancer in an older population: a cohort study

BackgroundLaparoscopic colectomy for colon cancer has been compared with open colectomy in randomized controlled trials, but these studies may not be generalizable because of strict enrollment and exclusion criteria which may explicitly or inadvertently exclude older individuals due to associated comorbidities. Previous studies of older patients undergoing laparoscopic colectomy have generally focused on short-term outcomes. The goals of this cohort study were to identify predictors of laparoscopic colectomy in an older population in the United States and to compare short-term and long-term outcomes.MethodsPatients aged 65 years or older with incident colorectal cancer diagnosed 1996-2002 who underwent colectomy within 6 months of cancer diagnosis were identified from the linked Surveillance, Epidemiology, and End Results-Medicare database. Laparoscopic and open colectomy patients were compared with respect to length of stay, blood transfusion requirements, intensive care unit monitoring, complications, 30-day mortality, and long-term survival. We adjusted for potential selection bias in surgical approach with propensity score matching.ResultsLaparoscopic colectomy cases were associated with left-sided tumors; areas with higher population density, income, and education level; areas in the western United States; and National Cancer Institute-designated cancer centers. Laparoscopic colectomy cases had shorter length of stay and less intensive care unit monitoring. Although laparoscopic colectomy patients (n = 424) had fewer complications (21.5% versus 26.3%), lower 30-day mortality (3.3% versus 5.8%), and longer median survival (6.6 versus 4.8 years) compared with open colectomy patients (n = 27,012), after propensity score matching these differences disappeared.ConclusionsIn this older population, laparoscopic colectomy practice patterns were associated with factors which likely correlate with tertiary referral centers. Although short-term and long-term survival are comparable, laparoscopic colectomy offers shorter hospitalizations and less intensive care.

Colorectal cancer screening: update for 2011.

Colorectal cancer is the third most common cancer in the United States. Although mortality and incidence rates are declining in the United States, colorectal cancer screening remains underused. In addition, recent data suggest that colonoscopy, which is often considered the gold standard for colorectal cancer screening, is less protective for right-sided tumors, which are more likely to be flat or depressed and are more affected by an inadequate bowel preparation. Imaging technologies such as chromoendoscopy and narrow band imaging have been developed to improve delineation of suspicious lesions during colonoscopy. In addition, other new modalities such as computed tomography colonography (CTC), capsule endoscopy, fecal immunochemical tests, and fecal DNA tests may offer less invasive screening options for patients who decline colonoscopy.

Descriptive epidemiology of esophageal carcinoma in the Ohio Cancer Registry

BACKGROUND Etiologic factors and demographics in esophageal cancer have not been fully characterized at a population-level. This study aimed to compare incidence rates of esophageal adenocarcinoma (EAC) and squamous cell carcinoma (ESCC) by race. Other aims were to evaluate the impact of race, age, gender, and histology on presenting stage, and to describe tobacco use history in EAC as documented in a cancer registry. METHODS Invasive esophageal cancer cases reported to Ohios Cancer Registry 1998-2002 were identified. Incident staged EAC and ESCC cases were analyzed for factors associated with metastatic disease. RESULTS 930 ESCC and 1801 EAC cases were identified. African-Americans had higher ESCC incidence than whites (5.0 versus 1.3 cases/100,000/year). However, whites had higher EAC incidence (3.3 versus 0.8 cases/100,000/year). 77% of EAC cases with available tobacco history were reported in tobacco users. In univariate analyses, race, age, gender, and histology differed significantly by stage. 31% of patients aged > or =65 presented with distant stage, versus 26% of those <65 (p<0.001). 32% of African-Americans had distant stage, versus 34% of whites (p=0.048). In logistic regression modeling, male gender [OR 1.76, CI (1.15, 2.67)] and age <75 [OR 1.95, CI (1.21, 3.15)], but not race, predicted distant stage ESCC. Distant stage EAC was associated with age <56 [OR 1.82, CI (1.39, 2.38)] but not significantly associated with African-American race (p=0.062) for the sample size available. CONCLUSIONS Whites had higher EAC rates, and African-Americans had higher ESCC rates. African-Americans were not more likely than whites to present with metastatic ESCC.

A comparison of the effects of epidural analgesia versus traditional pain management on outcomes after gastric cancer resection: A population-based study

Background and Objectives Epidural analgesia may increase survival after cancer surgery by reducing recurrence. This population-based study compared survival and treated recurrence after gastric cancer resection between patients receiving epidurals and those who did not. Methods We used the linked federal Surveillance, Epidemiology, and End Results Program/Medicare database to identify patients aged 66 years or older with nonmetastatic gastric carcinoma diagnosed 1996 to 2005 who underwent resection. Exclusions included diagnosis at autopsy, no Medicare Part B, familial cancer syndrome, emergency surgery, and laparoscopic procedures. Epidurals were identified by Current Procedural Terminology codes. Treated recurrence was defined as chemotherapy greater than or equal to 16 months and/or radiation greater than or equal to 12 months after surgery. Recurrence was compared by conditional logistic regression. Survival was compared via marginal Cox proportional hazards regression model. Results We identified 2745 patients, 766 of whom had epidural codes. Patients receiving epidurals were more likely to have regional disease, be white, and live in areas with relatively high socioeconomic status. Overall treated recurrence was 25.6% (27.5% epidural and 24.9% nonepidural). In the adjusted logistic regression, there was no difference in recurrence (odds ratio, 1.40; 95% confidence interval [CI], 0.96–2.05). Median survival did not differ: 28.1 months (95% CI, 24.8–32.3) in the epidural versus 27.4 months (95% CI, 24.8–30.0) in the nonepidural groups. The marginal Cox models showed no association between epidural use and mortality (adjusted hazard ratio, 0.93; 95% CI, 0.84–1.03). Conclusions There was no difference between groups regarding treated recurrence or survival. Whether this is true or simply a result of insufficient power is unclear. Prospective studies are needed to provide stronger evidence.

Barrett’s esophagus and the risk of obstructive sleep apnea: a case–control study

BackgroundPrior studies suggest that obstructive sleep apnea may be associated with gastroesophageal reflux disease, a strong risk factor for Barrett’s esophagus. The goals of this pilot case–control study were to determine whether Barrett’s esophagus patients have an increased likelihood of obstructive sleep apnea and to determine whether nocturnal gastroesophageal reflux symptoms affect the relationship between Barrett’s esophagus and obstructive sleep apnea risk.MethodsPatients with Barrett’s esophagus completed the Berlin Questionnaire, a validated survey instrument identifying subjects at high risk for obstructive sleep apnea. Two outpatient control groups were recruited: 1) EGD Group, subjects matched to Barrett’s esophagus cases by age, race, and gender with esophagogastroduodenoscopy negative for Barrett’s esophagus; and 2) Colonoscopy Group, patients getting colonoscopy. Rates of scoring at high risk for obstructive sleep apnea were compared. Respondents were also questioned regarding severity of their typical gastroesophageal reflux symptoms and presence of nocturnal gastroesophageal reflux symptoms.ResultsThe study included 287 patients (54 Barrett’s esophagus, 62 EGD, and 171 colonoscopy subjects). Barrett’s esophagus patients were slightly older than colonoscopy patients and more obese. 56% (n = 30) of Barrett’s esophagus subjects scored at high risk for obstructive sleep apnea, compared with 42% (n = 26) of EGD subjects (OR 1.73, 95% CI [0.83, 3.62]) and 37% (n = 64) of colonoscopy patients (OR 2.08, 95% CI [1.12, 3.88]). The association between Barrett’s esophagus and scoring at high risk for obstructive sleep apnea compared with colonoscopy patients disappeared after adjusting for age. Barrett’s esophagus patients reported more severe typical heartburn and regurgitation symptoms than either control group. Among all subjects, patients with nocturnal reflux symptoms were more likely to score at high risk for obstructive sleep apnea than patients without nocturnal reflux.ConclusionsIn this pilot study, a high proportion of Barrett’s esophagus subjects scored at high risk for obstructive sleep apnea. Having Barrett’s esophagus was associated with more severe gastroesophageal reflux symptoms, and nocturnal reflux symptoms were associated with scoring at high risk for obstructive sleep apnea. The need for obstructive sleep apnea screening in Barrett’s esophagus patients with nocturnal gastroesophageal reflux symptoms should be further evaluated.

A nonrandomized trial of vitamin D supplementation for Barrett’s esophagus

Background Vitamin D deficiency may increase esophageal cancer risk. Vitamin D affects genes regulating proliferation, apoptosis, and differentiation and induces the tumor suppressor 15-hydroxyprostaglandin dehydrogenase (PGDH) in other cancers. This nonrandomized interventional study assessed effects of vitamin D supplementation in Barrett’s esophagus (BE). We hypothesized that vitamin D supplementation may have beneficial effects on gene expression including 15-PGDH in BE. Methods BE subjects with low grade or no dysplasia received vitamin D3 (cholecalciferol) 50,000 international units weekly plus a proton pump inhibitor for 12 weeks. Esophageal biopsies from normal plus metaplastic BE epithelium and blood samples were obtained before and after vitamin D supplementation. Serum 25-hydroxyvitamin D was measured to characterize vitamin D status. Esophageal gene expression was assessed using microarrays. Results 18 study subjects were evaluated. The baseline mean serum 25-hydroxyvitamin D level was 27 ng/mL (normal ≥30 ng/mL). After vitamin D supplementation, 25-hydroxyvitamin D levels rose significantly (median increase of 31.6 ng/mL, p<0.001). There were no significant changes in gene expression from esophageal squamous or Barrett’s epithelium including 15-PGDH after supplementation. Conclusion BE subjects were vitamin D insufficient. Despite improved vitamin D status with supplementation, no significant alterations in gene expression profiles were noted. If vitamin D supplementation benefits BE, a longer duration or higher dose of supplementation may be needed.

Editorial: Detection of small polyps: Much ado about nothing

Computed tomographic (CT) colonography (CTC) represents an alternative to optical colonoscopy for colorectal cancer screening. However, diminutive polyps (≤5 mm) are not routinely reported for CTC. An observational study comparing the rates of recovery of subcentimeter adenomas in average-risk patients between two screening strategies, CTC and optical colonoscopy, found that the colonoscopy group had a four and a half-fold greater recovery rate of diminutive adenomas. Although the study was not randomized, the results highlight the difference between the two screening strategies. Because of incomplete understanding of the natural history of diminutive adenomas, further study is needed to determine the long-term impact of the use of CTC for colorectal cancer screening.

Epidural compared with non-epidural analgesia and cardiopulmonary complications after colectomy: A retrospective cohort study of 20,880 patients using a national quality database

STUDY OBJECTIVE Epidural analgesia may be associated with fewer postoperative complications and is associated with improved survival after colon cancer resection. This study used the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) to assess any association between epidural analgesia (versus non-epidural) and complications after colectomy. DESIGN Retrospective cohort study. SETTING 603 hospitals in the United States reporting data to NSQIP. PATIENTS From 2014-15 data, 4176 patients undergoing colectomy with records indicating epidural analgesia were matched 1:4 via propensity scores to 16,704 patients without. INTERVENTIONS None (observational study). MEASUREMENTS Primarily, we assessed the association between epidural analgesia and a composite of cardiopulmonary complications using an average relative effect generalized estimating equations model. Secondary outcomes included neurologic, renal, and surgical complications and length of hospitalization. Sensitivity analyses repeated the analyses on a subgroup of only open colectomies. MAIN RESULTS We found no association between epidural analgesia and the primary outcome: average relative effect (95% CI) 0.87 (0.68, 1.11); P = 0.25. We found no significant associations with any secondary outcomes. In the 8005 open colectomies, however, there was a significant association between epidural analgesia and fewer cardiopulmonary complications (average relative effect odds ratio [95% CI] of 0.58 [0.35, 0.95]; P = 0.03) and shortened hospital stay (HR for time to discharge [98.75% CI] of 1.10 [1.02, 1.18]; P < 0.001). CONCLUSIONS We found no overall association between epidural analgesia and reduced complications after colectomy. In open colectomies, however, epidural analgesia was associated with fewer cardiopulmonary complications and shorter hospitalization. This may inform analgesic choice when planning open colectomy.