Xuejiao Wei

Management and Outcome of Colorectal Cancer Liver Metastases in Elderly Patients: A Population-Based Study

IMPORTANCE Surgical resection is standard treatment for patients with colorectal cancer (CRC) liver metastases (LM). Limited data describe practice and outcomes among elderly patients. OBJECTIVE To describe management and outcomes of surgical resection of CRC LM in elderly patients in routine practice. DESIGN, SETTING, AND PARTICIPANTS Population-based retrospective cohort study of routine clinical practices in the Canadian province of Ontario. All cases of CRC in Ontario who underwent resection of LM between January 1, 2002, and December 31, 2009, were identified using the population-based Ontario Cancer Registry and included in this study. Complete information about vital status in the Ontario Cancer Registry was available up to December 31, 2012; cause of death was available up to December 31, 2010. Final study analyses were performed March 13, 2015. Surgical resections of CRC LM were identified from hospital admission records. Pathology reports provided details regarding extent of disease and surgical procedure. Patients were classified into 3 age groups: younger than 65 years, 65 to 74 years, and 75 years or older. We describe volume of resected CRC LM as a ratio of incident cases per CRC LM resection. Use of perioperative chemotherapy was identified through linked electronic treatment and physician billing records. Preoperative and postoperative chemotherapy was defined as chemotherapy given within 16 weeks of surgery. MAIN OUTCOMES AND MEASURES Overall survival and cancer-specific survival measured from time of LM resection. RESULTS We identified 1310 patients: 710 (54%) younger than 65 years; 414 (32%) 65 to 74 years; and 186 (14%) 75 years or older. Case volumes of CRC LM resection varied substantially across age groups. For patients younger than 65 years, there was 1 resection per 26 incident cases; 65 to 74 years, 1 per 38; and 75 years or older, 1 per 101 (P<.001). Patients less than 65 years of age had a mean of 2.3 lesions; 65 to 74 years, 2.0; and 75 years or older, 1.6 (P<.001). For patients younger than 65 years, mean size of the largest lesion was 4.0 cm; patients 65 to 74 years, 4.4 cm; and 75 years or older, 4.5 cm (P=.04). The likelihood patients younger than 65 years were to undergo a major liver resection of more than 3 segments was 65%; 65 to 74 years, 65%; and 75 years or older, 42% (P=.04). The percentage of patients younger than 65 years who underwent perioperative chemotherapy was 71% (501 of 710); 65 to 74 years, 57% (237 of 414); and 75 years or older, 41% (77 of 186) (P<.001). The incidence of 90-day mortality for patients younger than 65 years was 2% (11 of 710); 65 to 74 years, 5% (20 of 414); and 75 years or older, 8% (14 of 186) (P<.001). Cancer-specific survival at 5 years for patients younger than 65 years of age was 49%; 65 to 74 years, 47%; and 75 years or older, 35% (P<.001). Overall survival for patients younger than 65 years was 49%; 65 to 74 years, 44%; and 75 years or older, 28% (P<.001). CONCLUSIONS AND RELEVANCE Resection of CRC LM is associated with greater risk of postoperative mortality among elderly patients despite less aggressive treatment. Although the long-term outcomes are inferior to younger patients, a substantial proportion of elderly patients will have long-term survival.

Outcomes of squamous histology in bladder cancer: A population-based study

OBJECTIVES Squamous cell carcinoma (SCC) of the bladder is an uncommon form of bladder cancer. Using a large population-based sample we sought to describe the outcomes of patients with squamous histology and to define the factors that influence prognosis in these patients. METHODS All incident cases of bladder cancer in Ontario undergoing cystectomy from 1994 to 2008 were identified. Electronic treatment records and detailed pathologic information were linked to the study data set. Patients were divided into 3 cohorts: pure SCC, urothelial carcinoma (UC) with squamous differentiation (UCSD), and pure UC. Cox modeling was performed to evaluate factors associated with overall survival (OS) and cancer-specific survival (CSS). RESULTS There were identified 178, 325, and 2,884 cases of SCC, UCSD, and UC, respectively. The unadjusted 5-year OS for these groups were 33%, 28%, and 34%, respectively. Patients had higher rates of T3/4 disease with SCC (72%) and UCSD (73%) than those with UC (61%, P<0.001). There was no difference in node positivity among groups (20%, 27%, and 25%, P = 0.519). After adjusting for covariates, SCC did not portend a worse survival, at 5 years. However, SCC did result in a more rapid disease trajectory, with survival curves of SCC and UC crossing at the 5-year mark. Adjusted CSS/OS of UCSD was also not significantly different from UC. Among those patients with SCC, factors associated with CSS included age>70 (hazard ratio [HR] = 1.96, 95% CI: 1.16-3.30), T category≥3 (HR = 2.09, 95% CI: 1.24-3.50), N positive disease (HR = 2.59, 95% CI: 1.55-4.32), lymphovascular invasion (HR = 1.98, 95% CI: 1.13-3.47), and positive surgical margins (HR = 2.95, 95% CI: 1.47-5.93). CONCLUSIONS After adjusting for patient and disease characteristics, we have found that SCC leads to a more rapid disease course with survival that is equivalent to UC by 5 years.

Lymph node counts are valid indicators of the quality of surgical care in bladder cancer: A population-based study

OBJECTIVE To describe lymph node counts in routine clinical practice and evaluate their association with outcomes to explore its utility as a quality indicator. METHODS AND MATERIALS Electronic records of treatment and surgical pathology reports were linked with the population-based Ontario Cancer Registry to identify all patients who underwent cystectomy between 1994 and 2008. Temporal trends were described over 3 periods: 1994 to 1998, 1999 to 2000, and 2004 to 2008. Multivariate generalized linear regression analysis was used to determine the factors associated with the use of pelvic lymph node dissection (PLND). A Cox proportional hazards regression model was used to explore the associations between PLND and survival. RESULTS The study population included 2,802 patients. Use of PLND (50%, 62%, and 85%, correspondingly), median node yield (5, 6, and 9, correspondingly), and node density (56%, 50%, and 39%, correspondingly) all improved over the study periods, 1994 to 1998, 1999 to 2000, and 2004 to 2008 (P<0.001). In multivariate analysis, factors associated with not having PLND include advanced age, female sex, lower socioeconomic status, low surgeon volume, and partial cystectomy. In adjusted analyses, patients who did not receive a PLND had inferior overall (hazard ratio = 1.26, 95% CI: 1.15-1.38) and cancer-specific (hazard ratio = 1.23, 95% CI: 1.11-1.36) survival. Node yield, as well as density, was also associated with long-term survival. CONCLUSIONS There is significant variation in use and quality of PLND at cystectomy in routine practice. Node counts are independently associated with long-term survival, and this association is persistent despite adjustment for provider-related variables. These results suggest that lymph node counts are a valid quality indicator of surgical care of muscle-invasive bladder cancer.

Surgical resection and peri-operative chemotherapy for colorectal cancer liver metastases: A population-based study

BACKGROUND Most literature describing surgery for colorectal cancer (CRC) liver metastases (LM) comes from high volume centres. Here, we report management and outcomes achieved in routine clinical practice. METHODS All cases of CRC in Ontario who underwent resection of LM in 1994-2009 were identified using the population-based Ontario Cancer Registry. Electronic treatment records identified chemotherapy delivery. Temporal trends are described for 3 periods: 1994-1999, 2000-2004, 2005-2009. We describe volume of resected CRCLM as a ratio of incident cases per CRCLM resection. Overall (OS) and cancer-specific survival (CSS) are measured from time of LM resection. RESULTS 2717 patients underwent resection of CRCLM. Between 1994 and 2009 there was a 78% increase in case volume; from one resection for every 48 incident cases to one resection for every 27 incident cases, p < 0.001. Use of peri-operative chemotherapy increased over study periods from 44% (306/700), to 52% (429/830), to 65% (777/1187, p < 0.001). Chemotherapy utilization rates varied across geographic regions (range 43%-69%, p < 0.001). Post-operative mortality rates at 30 and 90 days were 2.5% and 4.3% respectively. Five year OS during the study periods was 36% (95% CI 32-39%), 40% (95% CI 36-43%), and 46% (95% CI 43-49%) (p < 0.001); CSS was 38% (95% CI 35-42%), 42% (95% CI 38-45%), 49% (95% CI 44-53%) (p < 0.001). The temporal improvement in OS/CSS persisted on adjusted analyses. CONCLUSIONS Outcomes of patients with resected CRCLM in routine practice is comparable to those reported from high volume centres. Survival improved over the study period despite a greater proportion of patients with CRC undergoing liver resection.

Risk factors and timing of venous thromboembolism after radical cystectomy in routine clinical practice: a population-based study.

To describe the risk factors and timing of perioperative venous thromboembolism (VTE) and its association with survival for patients undergoing radical cystectomy (RC) in routine clinical practice.

Peri-operative allogeneic blood transfusion and outcomes after radical cystectomy: a population-based study

IntroductionTo describe factors associated with peri-operative blood transfusion (PBT) at radical cystectomy (RC) for patients with bladder cancer and evaluate its association on both early and late outcomes.MethodsElectronic records of treatment and surgical pathology reports were linked to the population-based Ontario Cancer Registry to identify all patients who underwent RC between 2000 and 2008. Modified Poisson regression model was used to determine the factors associated with PBT. A Cox-proportional hazards regression model was used to explore the association between PBT and overall (OS) and cancer-specific (CSS) survival.ResultsAmong 2593 patients identified, 62% received an allogeneic red blood cell transfusion. The frequency of PBT decreased over the study period (from 68 to 54%, p < 0.001). Factors associated with PBT included age, sex, greater co-morbidity, stage, and surgeon volume. PBT was associated with inferior outcomes, including median length of stay (11 vs. 9 days, p < 0.001), 90-day re-admission rate (38 vs. 29%, p < 0.001), and mortality (11 vs. 4%, p < 0.001). OS and CSS at 5 years were lower among patients with PBT on multivariate analysis (OS HR 1.33, 95% CI 1.20–1.48; CSS HR 1.39, 95% CI 1.23–1.56).ConclusionsAlthough rates are decreasing, these data suggest a very high utilization rate of PBT at time of RC in routine clinical practice. PBT is associated with substantially worse early outcomes and long-term survival. This association persists despite adjustment for disease-, patient-, and provider-related factors, suggesting that PBT is an important indicator of surgical care of RC.

Pathological factors associated with survival benefit from adjuvant chemotherapy (ACT): a population‐based study of bladder cancer

To evaluate whether pathological factors are associated with differential effect of adjuvant chemotherapy (ACT).

Is there a sex effect in colon cancer? Disease characteristics, management, and outcomes in routine clinical practice

INTRODUCTION The incidence of colon cancer varies by sex. Whether women and men show differences in extent of disease, treatment, and outcomes is not well described. We used a large population-based cohort to evaluate sex differences in colon cancer. METHODS Using the Ontario Cancer Registry, all cases of colon cancer treated with surgery in Ontario during 2002-2008 were identified. Electronic records of treatment identified use of surgery and adjuvant chemotherapy. Pathology reports for a random 25% sample of all cases were obtained, and disease characteristics, treatment, and outcomes in women and men were compared. A Cox proportional hazards model was used to identify factors associated with overall (os) and cancer-specific survival (css). RESULTS The study population included 7249 patients who underwent resection of colon cancer; 49% (n = 3556) were women. Stage of disease and histologic grade did not vary by sex. Compared with men, women were more likely to have right-sided disease (55% vs. 44%, p ≤ 0.001). Surgical procedure and lymph node yield did not differ by sex. Adjuvant chemotherapy was delivered to 18% of patients with stage ii and 64% of patients with stage iii disease; when adjusted for patient- and disease-related factors, use of adjuvant chemotherapy was similar for women and men [relative risk: 0.99; 95% confidence interval (ci): 0.94 to 1.03]. Adjusted analyses demonstrated that os [hazard ratio (hr): 0.80; 95% ci: 0.75 to 0.86] and css (hr: 0.82; 95% ci: 0.76 to 0.90) were superior for women compared with men. CONCLUSIONS Long-term survival after colon cancer is significantly better for women than for men, which is not explained by any substantial differences in extent of disease or treatment delivered.

Lymph node evaluation for colon cancer in routine clinical practice: a population-based study

BACKGROUND Guidelines recommend that 12 or more lymph nodes (lns) be evaluated during surgical resection of colon cancer. Here, we report ln yield and its association with survival in routine practice. METHODS Electronic records of treatment were linked to the population-based Ontario Cancer Registry to identify all patients with colon cancer treated during 2002-2008. The study population (n = 5508) included a 25% random sample of patients with stage ii or iii disease. Modified Poisson regression was used to identify factors associated with ln yield; Cox models were used to explore the association between ln yield and overall (os) and cancer-specific survival (css). RESULTS During 2002-2008, median ln yield increased to 17 from 11 nodes (p < 0.001), and the proportion of patients with 12 or more nodes evaluated increased to 86% from 45% (p < 0.001). Lymph node positivity did not change over time (to 53% from 54%, p = 0.357). Greater ln yield was associated with younger age (p < 0.001), less comorbidity (p = 0.004), higher socioeconomic status (p = 0.001), right-sided tumours (p < 0.001), and higher hospital volume (p < 0.001). In adjusted analyses, a ln yield of less than 12 nodes was associated with inferior os and css for stages ii and iii disease [stage ii os hazard ratio (hr): 1.36; 95% confidence interval (ci): 1.19 to 1.56; stage ii css hr: 1.52; 95% ci: 1.26 to 1.83; and stage iii os hr: 1.45; 95% ci: 1.30 to 1.61; stage iii css hr: 1.54; 95% ci: 1.36 to 1.75]. CONCLUSIONS Despite a temporal increase in ln yield, the proportion of cases with ln positivity has not changed. Lymph node yield is associated with survival in patients with stages ii and iii colon cancer. The association between ln yield and survival is unlikely to be a result of stage migration.

Population-based study to re-evaluate optimal lymph node yield in colonic cancer

It is well established that lymph node (LN) yield in colonic cancer resection has prognostic significance, although optimal numbers are not clear. Here, LN thresholds associated with both LN positivity and survival were evaluated in a single population‐based data set.