Safiya Karim

Association Between Prognosis and Tumor Laterality in Early-Stage Colon Cancer

Importance Recent data have suggested that disease biology and outcome of colon cancer may differ between right-sided and left-sided tumors. However, the literature on the prognostic value of tumor laterality is conflicting. Objective To explore differences in laterality based on disease characteristics and outcomes in a population-based cohort of early-stage colon cancer. Design, Setting, and Participants This investigation was a population-based retrospective cohort study of patients with early-stage colon cancer from the province of Ontario, Canada. Electronic records of treatment were linked to the Ontario Cancer Registry to identify all patients with colon cancer who underwent resection between January 1, 2002, and December 31, 2008. The date of the final analysis was October 20, 2016. The study population included a 25% random sample of all patients with resected stage I to III disease. Right-sided colon cancer was defined as any tumor arising in the cecum, ascending colon, hepatic flexure, or transverse colon. Left-sided colon cancer was defined as any tumor arising in the splenic flexure, descending colon, sigmoid colon, or rectosigmoid colon. Main Outcomes and Measures Overall survival (OS) and cancer-specific survival (CSS) measured from the time of resection. Results This study identified 6365 patients with early-stage colon cancer (48.7% [3098 of 6365] female). Their median age was 72 years, and 51.7% (3291 of 6365) had right-sided disease. Stage distribution was 18.3% (1163 of 6365) stage I, 38.4% (2446 of 6365) stage II, and 43.3% (2756 of 6365) stage III. Patients with right-sided colon cancer were more likely to be older (median age, 73 vs 70 years; Pu2009<u2009.001) and female (54.4% [1790 of 3291] vs 42.6% [1308 of 3074], Pu2009<u2009.001) and have greater comorbidity. Right-sided cancers were more likely to be T4 (19.2% [631 of 3291] vs 15.9% [490 of 3074], Pu2009<u2009.001) and poorly differentiated (21.1% [695 of 3291] vs 9.6% [295 of 3074], Pu2009<u2009.001) but less likely to be node positive (42.0% [1383 of 3291] vs 44.7% [1373 of 3074], Pu2009=u2009.03) compared with left-sided disease. In adjusted analyses, there was no difference in long-term survival for right-sided compared with left-sided colon cancer: the hazard ratios were 1.00 (95% CI, 0.92-1.08) for OS and 1.00 (95% CI, 0.91-1.10) for CSS. These results were consistent when the survival analyses were restricted to stage III disease: the hazard ratios were 1.03 (95% CI, 0.93-1.14) for OS and 1.10 (95% CI, 0.97-1.24) for CSS. Conclusions and Relevance In this population-based cohort of early-stage resected colon cancer, disease laterality was not associated with long-term OS or CSS.

Radical Treatment of the Primary Tumor in Metastatic Bladder Cancer: Potentially Dangerous Findings From Observational Data

Population-based observational studies allow investigators to evaluate the adoption of new therapies and to determine whether benefits seen in clinical trials are realized in the real world. These studies also provide rich insights into factors that affect access and quality of cancer care in the general population. However, except in a few specific circumstances, real-world data are much less useful in establishing treatment efficacy. Studies that compare outcomes between nonrandomized groups of patients are fundamentally problematic because the patients may also differ with respect to other prognostic factors. This is just as true for modern population-based studies of electronic records as it was for the traditional nonrandomized institution-based reviews of paper charts that were popular 50 years ago before the widespread adoption of hierarchies of evidence raised awareness of the relative weakness of observational study designs. Population-based studies may have greater external validity than institution-based studies, but there is no reason to believe they have any greater internal validity; both are therefore classified as level-3 evidence in Sackett’s original hierarchy.

Management of stage III colon cancer in the elderly: Practice patterns and outcomes in the general population

Clinical trials have established surgical resection and adjuvant chemotherapy (ACT) as the standard management for stage III colon cancer; however, the extent to which these results apply to elderly patients in routine practice is unclear. This article describes the management and outcomes of elderly patients with stage III colon cancer.

Pulmonary Metastasectomy for Colorectal Cancer: Predictors of Survival in Routine Surgical Practice

BACKGROUNDnResection of lung metastases is considered standard treatment for patients with metastatic colorectal cancer. We describe surgical management, prognostic factors, and outcomes in routine clinical practice.nnnMETHODSnAll cases of colorectal cancer lung metastases in Ontario, Canada, resected during 2002 to 2009 were identified using the Ontario Cancer Registry and linked electronic records. Pathology reports were reviewed to identify extent of disease.nnnRESULTSnThe study population included 420 patients (60% male). Median age was 64 years. A solitary metastasis was present in 61% (256 of 420). Mean size of the largest metastasis was 2.4 cm. Lymph nodes were resected in 63% (263 of 420) of patients. The 5-year cancer-specific survival (CSS) and overall survival (OS) was 42% (95% confidence interval [CI], 37% to 47%) and 40% (95% CI, 35% to 45%), respectively. On adjusted analyses, greater number (p < 0.001) and size (pxa0= 0.001) of lesions and lymph node involvement (p < 0.001) were associated with inferior CSS and OS. Lymph node positivity was strongly associated with survival (adjusted CSS hazard ratio, 2.19 [95% CI, 1.48 to 3.25]; adjusted OS hazard ratio, 2.08 [95% CI, 1.41 to 3.07]). Unadjusted 5-year CSS/OS was 49%/47% for node-negative disease and 19%/19% for node-positive disease. The negative prognostic effect of size (>2 cm) and number (>1) of lesions was additive: 5-year CSS/OS ranged from 57%/55% (single lesion <2 cm) to 24%/20% (multiple lesions, largest lesion>2 cm).nnnCONCLUSIONSnLong-term survival of patients with resected colorectal cancer lung metastases in routine practice is comparable to outcomes reported in institutional case series. Lymph node positivity is strongly associated with reduced survival. Combining size and number of metastatic lesions in advance of the operation may facilitate treatment decision making.

Perioperative chemotherapy for bladder cancer in the general population: Are practice patterns finally changing?

BACKGROUNDnUptake of perioperative chemotherapy for muscle-invasive bladder cancer (MIBC) has been historically poor. We describe contemporary use of neoadjuvant (NACT) and adjuvant chemotherapy (ACT) as well as medical oncology (MO) referral patterns in routine practice.nnnMETHODSnElectronic treatment records were linked to the population-based Ontario Cancer Registry to identify all MIBC patients treated with cystectomy in Ontario 1994 to 2013. Physician billing records were used to identify consultation with MO. Practice patterns in the contemporary era (2009-2013) are compared with data from 1994 to 2008.nnnRESULTSnA total of 5,582 patients had cystectomy for MIBC. Use of NACT increased from 4% in 1994 to 2008 to 19% in 2009 to 2013 (P<0.001); rates continued to rise in the most recent era from 12% in 2009 to 27% in 2013 (P<0.001). ACT was delivered to 20% of patients in 2009 to 2013 (19% in 1994-2008, P = 0.875). Use of any chemotherapy (NACT or ACT) in 2009 to 2013 was 35% compared to 23% in 1994 to 2008 (P<0.001). Preoperative referral rates during 2009 to 2013 to MO were greater than 1994 to 2008 (32% vs. 11%, P<0.001); referral rates continued to increase in recent years from 21% in 2009 to 44% in 2013 (P<0.001). The proportion of referred patients ultimately treated with NACT increased substantially; from 32% in 1994 to 1998 to 54% in 2009 to 2013 (P<0.001).nnnCONCLUSIONSnAfter many years of practice lagging behind evidence, use of NACT in the general population has increased substantially. Our results suggest that increased uptake has been driven by greater preoperative referral to MO as well as greater propensity of MOs to treat referred patients.

Peri-operative blood transfusion for resected colon cancer: Practice patterns and outcomes in a population-based study

BACKGROUND & OBJECTIVESnLiterature suggests that peri-operative blood transfusion among patients with resected colon cancer may be associated with inferior long-term survival. The study objective was to characterize this association in our population.nnnMETHODSnThis is a retrospective cohort study using the population-based Ontario Cancer Registry (2002-2008). Pathology reports were obtained for a 25% random sample of all cases and constituted the study population. Log binomial regression was used to identify factors associated with transfusion. Cox proportional hazards model explored the association between transfusion and cancer specific survival (CSS) and overall survival (OS).nnnRESULTSnThe study population included 7198 patients: 18% stage I, 36% stage II, 40% stage III, and 6% stage IV. Twenty-eight percent of patients were transfused. Factors independently associated with transfusion included advanced age (p<0.001), female sex (p<0.001), greater comorbidity (p<0.001), more advanced disease (p<0.001) and open surgical resection (p<0.001). Transfusion was associated with inferior CSS (HR 1.51, 95% CI 1.38-1.65) and OS (HR 1.52, 95% CI 1.41-1.63), after adjusting for important confounders.nnnCONCLUSIONSnPeri-operative transfusion rates among patients with colon cancer have decreased over time. Transfusion is associated with inferior long-term CSS and OS.

Concurrent chemoradiotherapy for bladder cancer: Practice patterns and outcomes in the general population

BACKGROUNDnClinical trials have shown that chemoradiotherapy (CRT) improves survival compared to radiation therapy (RT) alone in muscle-invasive bladder cancer. We describe uptake of CRT and comparative effectiveness in routine practice.nnnMETHODSnElectronic treatment records were linked to the population-based Ontario Cancer Registry to identify all patients with bladder cancer treated with curative-intent RT in 1999-2013. Modified Poisson regression was used to analyze factors associated with use of CRT. Cox model and propensity score analyses were used to explore factors associated with cancer-specific (CSS) and overall survival (OS).nnnRESULTSn1192 patients underwent RT during 1999-2013; median age was 79. Use of CRT increased over time: 36% (124/341) in 1999-2003, 38% (153/399) in 2004-2008, 48% (217/452) in 2009-2013 (pu202f=u202f0.001). Drug details were available for 82% (402/493) of CRT cases; the most common regimens were single-agent Cisplatin (57%, 230/402), single-agent Carboplatin (31%, 125/402) and 5-FU/Mitomycin (4%, 17/402). Factors associated with CRT include younger age (pu202f<u202f0.001), lower comorbidity (pu202f=u202f0.001), and geographic region (range 14-89%, pu202f<u202f0.001). Five year CSS and OS among CRT cases were 45% (95%CI 39-51%) and 35% (95%CI 30-40%). On adjusted analyses CRT was associated with superior survival compared to RT (CSS HR 0.70, 95%CI 0.59-0.84; OS HR 0.74, 95%CI 0.64-0.85); results were consistent on propensity score analysis. There was significant improvement in survival of all RT-treated cases (irrespective or chemotherapy delivery) in 2009-2013 compared to 1999-2003 (CSS HR 0.77, 95%CI 0.61-0.97; OS HR 0.82, 95%CI 0.69-0.98).nnnCONCLUSIONnCRT is associated with superior survival compared to RT alone and its uptake corresponded to improved survival among all RT-treated cases in the general population. Uptake of CRT varies widely by geographic region.

Documenting Goals of Care Among Patients With Advanced Cancer: Results of a Quality Improvement Initiative

PURPOSEnGuidelines recommend that oncologists discuss goals of care (GOC) with patients who have advanced cancer and that these patients be referred for early palliative care (PC). An audit of practice between 2010 and 2015 at the Cancer Centre of Southeastern Ontario suggested that these rates were suboptimal. We sought to improve the rate of documentation of GOC and referral to PC through the implementation of a quality improvement (QI) initiative.nnnMETHODSnPatients receiving palliative systemic treatment of lung, pancreatic, colorectal, and breast cancer were identified via electronic pharmacy records and the electronic patient care system. Using the Define, Measure, Analyze, Improve, Control QI methodology, we drafted a guideline for GOC documentation and PC referral and designed a standardized documentation system. E-mail reminders were sent to physicians and a QI scorecard was displayed to document overall and individual physician rates of GOC documentation. Data were analyzed monthly and presented on statistical process control P charts.nnnRESULTSnBetween May 2016 and November 2017, a total of 303 unique patients were identified (52%, 21%, 17%, and 10% with lung, breast, colorectal, and pancreatic cancer, respectively). GOC documentation increased significantly over the study period (baseline, 0%; passive phase, 3%; active phase, 31%); this increase was likely because of our intervention. PC referral rates also increased over the study period (baseline, 36%; passive phase, 35%; active phase 48%). We did not identify any patient, physician, or disease factors that were associated with GOC discussion or referral to PC.nnnCONCLUSIONnOur QI initiative was successful in improving rates of GOC documentation in patients with advanced cancer.

Palliative Care Program Development in a Low- to Middle-Income Country: Delivery of Care by a Nongovernmental Organization in India

Purpose Limited data describe the delivery of palliative care services in low- and middle-income countries. We describe delivery of care by the Trivandrum Institute of Palliative Sciences (TIPS) in Trivandrum, India. Methods Administrative records were used to describe case volumes, setting of care, and organizational expenditures. An estimate of cost per clinical encounter was derived by dividing 2016 monthly clinical expenditures by the number of patient visits. Costs are reported in US dollars and are corrected for Organization for Economic Co-operation and Development purchasing power parity (PPP). Results A total of 11,620 new patients were seen at TIPS during 2007 to 2016; 59% had cancer. The average annual growth rate in case volumes was 18% (480 new patients in 2007 and 1,882 in 2016). The proportion of patients with cancer increased over time from 56% in 2014 to 66% in 2016 (P < .001). During 2014 to 2016, outpatient visits increased 26% (from 8,524 to 10,732), inpatient days increased 49% (from 1,763 to 2,625), inpatient visits at other hospitals increased 41% (from 248 to 417), and home visits increased 57% (from 3,951 to 6,186). Total clinical expenditures in 2016 were

Uptake and Effectiveness of FOLFIRINOX for Advanced Pancreatic Cancer: a Population-based Study

288,489 (PPP corrected,