Colon

—Jessup JM, Stewart AK, Greene FL, Minsky BD.  Adjuvant Chemotherapy for Stage III Colon Cancer: Implications of Ethnicity, Age and Differentiation.  JAMA 294, no. 21 (December 7 2005): 2703-11.

—Swanson RS, Compton C, Stewart AK, Bland KI. The prognosis of T3NO colon cancer is dependent upon the number of regional lymph nodes examined. A Surg Onc 2003; 10:65-71. (!)

—Jessup JM, Menck HR, Fremgen AM, Winchester DP. Diagnosing colorectal carcinoma: Clinical and molecular approaches. CA 1997; 47:70-92. (!)

This review assesses the common patterns of presentation of colorectal carcinoma, summarizes the current status of clinical diagnostic methodology, and outlines the future potential of molecular diagnostic tests. Age and ethnicity arise as important diagnostic factors. Presenting symptoms and signs such as bleeding, abdominal pain, obstruction and perforation, and inflammatory bowel disease are discussed as to their role in diagnosis. The relationship between the formation of adenomatous polyps and invasive carcinomas, as well as molecular pathways (FAP, HNPCC, and de novo carcinomas) are explored in the diagnosis of the asymptomatic patient. The goal of the study was to increase the proportion of patients diagnosed while still asymptomatic because these patients present at an earlier stage this is more amenable to cure.

—Jessup JM, McGinnis LS, Steele GD, Menck HR, Winchester DP. The National Cancer Data Base report on colon cancer. Cancer 1996; 78:918-926. (!)

Five calls for data yielded 3,700,000 cases of cancer for the years 1985 through 1993 from hospital cancer registries across the U.S., including 36,937 cases of colon cancer from 1988 and 44,812 from 1993. The following trends were observed: 1) patients older than 80 years presented with earlier stage disease than younger patients; 2) all ethnic groups have similar stages of disease at presentation, except for African-Americans, who have a slightly higher incidence of stage IV disease; 3) the proximal migration of the primary cancer resulted in 54.7% of primary colon cancer arising in the right colon in 1993, compared with 50.9% in 1988; 4) there is a correlation between grade and stage, indicating an important biologic role for grade of cancer; 5) patients with stage II colon cancer who receive adjuvant chemotherapy had a 5% improvement in 5-year survival.

—Beart RW, Steele GD, Menck HR, Chmiel JS, Zuber-Ocwieja KE, Winchester DP. Management and survival of patients with adenocarcinoma of the colon and rectum: A national survey of the Commission on Cancer. J Am Coll Surg 1995; 181:225-236. (*) (!)

A total of 39,502 reports from 943 hospitals were analyzed, including those for 12,682 patients with carcinoma of the colon diagnosed in 1983, 16,527 patients with carcinoma of the colon diagnosed in 1988, 4,597 patients with carcinoma of the rectum diagnosed in 1983, and 5,696 patients with carcinoma of the rectum diagnosed in 1988. Patterns of care, including changes in presentation, diagnostic and therapeutic management, and survival rates, are presented. Specific data showing results for various ethnic groups are also included. The distribution of cases by anatomic site was consistent with a hypothesis of rightward migration of colon carcinoma. Colon and rectal carcinomas in African-Americans were reported in more advanced stages and with corresponding decreases in survival rates. Some patterns of non-optimal diagnostic use were noted. The increasing use of sphincter-sparing surgical alternatives for carcinoma of the rectum was evident. Adjuvant therapy was not widely used during this period. This study suggests that evolving patterns of evaluation, increased preservation of continence, and improved, but varying survival, among ethnic groups. It further suggests that survival as measured across these 943 hospitals may be lower than that attained at some individual centers.

—Steele GD, Jessup JM. Colorectal cancer. In: Steele GD, Jessup JM, Winchester DP, Menck HR, Murphy GP: eds. National Cancer Data Base: Annual review of patient care, 1995. Atlanta, GA: American Cancer Society, 1995; 66-83.

Significant points include the continued trend toward more colon cancers being found in the proximal bowel. Tumors found in the proximal colon (cecum and ascending colon) are still associated with later stage at presentation. In addition, the increased use of multimodal therapy continues for both stage II and III colon and rectal carcinomas, a trend that has been noted previously. Compared with higher-income groups, lower-income patients show a predisposition for higher-stage disease at presentation. African-American patients continue to present with higher stage colon and rectal cancers than do other ethnic groups. African-Americans also have the lowest survival rates of all ethnic groups for colon and rectal cancer, although higher survival rates for those with tumors of the descending and sigmoid colon were reported. Staging accuracy continues to improve for both colon and rectal cancer. This trend obviously is of direct benefit to patients, who are assured of access to appropriate diagnosis and therapy in the majority of hospitals participating in the NCDB. Any impact of multimodality therapy on survival rates for colon and rectal cancer patients had their cancers diagnosed and were treated in 1986- 1987, several years before the National Institutes of Health Consensus Conference of 1990, which set forth guidelines for adjuvant therapy. Nonetheless, the present data suggest that the NCDB is in an excellent position to monitor the effects of multimodality therapy on outcome.

—Steele GD. Colorectal cancer. In: Steele GD, Winchester DP, Osteen RT, Menck HR, Murphy GP: eds. National Cancer Data Base: Annual review of patient care, 1994. Atlanta, GA: American Cancer Society, 1994; 24-42.

Significant points include the continued proximal distribution of colon cancer. The fact is that more proximal distribution of colon cancers (ascending colon, cecum) and more proximal rectal cancers decrease the proclivity for early stage at presentation. In addition, the increased level of multimodality therapy for both stage II and stage III colon and rectal carcinomas that were noted last year has continued. The stage at presentation continues to show a tendency toward higher stage for African-Americans and lower-income groups. Survival trends, which are now available for the first time through the NCDB, are the poorest among African-Americans, particularly for colon cancer. It should be noted that stabilization of mortality in both colon and rectal cancer is not yet apparent, but verification of this should be possible over the next few years. Finally, staging accuracy, which was noted last year to have improved dramatically, continues to improve for both colon and rectal cancer. This obviously is of direct benefit to patients who can be assured of access to the most advanced diagnostic and therapeutic approaches in the majority of hospitals that are included in this survey.

—Steele GD. The National Cancer Data Base Report on colorectal cancer. Cancer 1994; 74:1979-1989. (!)

The 1990 and 1991 Calls for Data yielded 71,560 colon cancer reports and 33,409 rectal cancer reports from hospital registries across the country. For colon cancer, continuation of the time trend toward proximal migration was reported. For both colon and rectal cancer, AJCC staging was used increasingly as the standard of appropriate cancer diagnosis. Increased use of multimodal treatment was reported for both colon and rectal cancers. African-American and non-Hispanic white, low-income patients were reported to have later stages of both colon and rectal cancers.

—Steele, GD. Colorectal cancer. In: Steele GD, Winchester DP, Menck HR, Murphy GP: eds. National Cancer Data Base: Annual review of patient care, 1993. Atlanta, GA: American Cancer Society, 1993; 20-36.

There are several significant points in the 1993 report. There appears to be stability in the age distribution as well as the gender distribution of colon and rectal cancer. There is evidence of a continued trend of proximal migration of large bowel tumors (or, increased access to the proximal colon and subsequent diagnosis of large bowel carcinomas). The data show a gratifying increase in efficiency of staging or at least reporting of staged colon and rectal cancer. Multimodality therapy is increasingly available to patients with colon as well as rectal cancer. Most gratifying, multimodality therapy appears to be appropriately selected for patients who have higher stage disease and are at the greatest risk for recurrence after primary tumor resection. Unfortunately, it appears that certain segments of the population may be at greater risk for disease or at greater risk for disease progression before detection. The data for Hispanics and African-Americans show a trend to higher stage disease at presentation for patients with colon or rectal cancers. Survival trends will not be available through the NCDB until a number of additional annual reports are available. However, the 1985 hospital-based cases provide sufficient evidence to conclude the following: 1) the expected correlation between survival and stage of cancer at presentation is apparent; 2) overall survival is consistent with what has been reported in other databases, and 3) as with other solid tumors reported within the NCDB and in other databases, survival seems to be the poorest among certain population subsets. Specifically, in the NCDB data, African-Americans and non-Hispanic white, low-income patients have the worst survival rates, stage for stage, for both colon and rectal cancer.

—Beart RW. Colon cancer. In: Steele GD, Winchester DP, Menck HR, Murphy GP: eds. National Cancer Data Base: Annual review of patient care, 1992. Atlanta, GA: American Cancer Society, 1992; 40-46.

Data are presented for 9,589 colon cancer patients diagnosed in 1985, and 22,130 patients diagnosed in 1988. The 1988 data in this report represent 21% of the estimated 105,000 cases diagnosed in that year. Of the reported cases, most patients (90.0%) were diagnosed and treated at the reporting hospital; 2.0% were treated elsewhere, and 8.0% were diagnosed elsewhere, but treated at the reporting hospital. It is further reported that females tend to have right-sided disease and males have left-sided disease. Most cases are identified at a favorable stage with little or no difference reported between ethnic and income groups. Left-sided disease is more accessible to local management techniques, and this probably explains why more left-sided disease is managed locally. It is unlikely that this difference in management technique is due to differences in the biology of the disease. These data demonstrate that there are opportunities to identify colon tumors at an earlier stage if detection programs are successfully increased. Local management is used in about 10% of all groups, and with proper staging, it may be possible to see the use of this modality increase. Sexual differences in the site of presentation suggest genetic or perhaps hormonal influences on this disease.

—Evans JT, Vana J, Aronoff BL. Management and survival of carcinoma of the colon: Results of a national survey by the American College of Surgeons. Ann Surg 1978; 188:716-720. (*)

Survey results of long- and short-term audits of colon cancer in participating hospitals with cancer programs conducted during 1976-1977 by the American College of Surgeons are presented. In the long-term audit of 38,621 cases reported by 327 hospitals in 46 states, the overall percentage of cases in localized stage (29.3%) is significantly lower than in the recent series. However, survival approaches the end results for the period 1967-1973. In the short-term audit, the analysis of 11,655 cases diagnosed in 1976 and reported by 491 hospitals in 50 states showed that while 41% of patients had symptoms for less than a month, only 29.5% were diagnosed in the localized stage. Surgery was the predominant treatment modality with an overall resectability rate of 83%. No difference was observed in the stage at diagnosis when the short-term audit (1976) was compared with that found in the long-term audit (1971). The results suggest that the early diagnosis of symptomatic patients may not always substantially improve the cure and survival rate. The screening of asymptomatic patients is suggested as the more promising approach to the substantial improvement of presently less than ideal end results.

Revised May 23, 2007

 

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