Outcomes following a diagnosis of colorectal cancer · Outcomes following a diagnosis of colorectal cancer ... chronic ulcerative colitis and ... cancer in patients with Crohn's disease:

Outcomes following a diagnosis of colorectal cancer

Structure of talk

Present and critically review studies available in the literature

•Incidence by ethnic group

•Stage at presentation

•Survival

•Outcomes in the context of inflammatory bowel disease

Current SEER data for CRC (Archie Bleyer)

Outcomes and age

Br J Surg. 2003 Feb;90(2):205-14. Clinicopathological and molecular biological features of colorectal cancer in patients less than 40 years of age.Br J Surg. 1998 Sep;85(9):1255-9. Young age is not a poor prognostic marker in colorectal cancer.

138 CRC patients <40 years compared to 339 patients >60 years (Taiwan)•14.5% mucin producing (cf 4.7%)•7.2% poorly differentiated (cf 3.3%)•More advanced stage•Operative mortality lower (0.7% vs 5%)•Cancer specific survival reported to be similar in Stages I-III, better in stage IV

110 Singaporean patients <40 years (5.1%) compared to 2064 >40 years•Predisposing conditions and genetic factors in 21% vs 2%•No difference in stage or site at presentation•No difference in characteristics (mucinous &c)•Mean follow up of 32 months•5YOS 55% vs 54%

Outcomes and age

Dis Colon Rectum. 2006;49(7):993-1001. Rectal cancer in the young patient.

Norwegian Rectal Cancer Project

1,354 patients younger than aged 70 years treated for cure•45 patients younger than aged 40 years (3%)•significantly higher frequencies of poorly differentiated tumors (27 vs. 12-16 percent; P = 0.014)•N2-stage (37 vs. 13-18 percent; P = 0.001)

Metastasis 5YOS

Under 40 years 38% 54%

Over 40 years 20-26% 71-88%

Outcomes and age

Hepatogastroenterology. 2004 Jan-Feb;51(55):118-20. Colorectal cancers under 45 years of age.Int J Cancer. 1997 Mar 28;71(1):26-30. Colorectal cancer in Egyptian patients under 40 years of age.

Turkey136 patients under 45 years (20%) among 680 total

•10 patients with family history•Of patients considered resectable (118), 61 (45%) were found to be metastatic at operation

Egypt1608 CRC in 4 hospitals (85% of national burden)

•35.6% under 40 years, constant over time and site•>50% rectal cancers•30.6% mucin producing (cf 14% over 40 years)

http://www.ncbi.nlm.nih.gov/pubmed/9096661?ordinalpos=32&itool=Email.EmailReport.Pubmed_ReportSelector.Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/pubmed/9096661?ordinalpos=32&itool=Email.EmailReport.Pubmed_ReportSelector.Pubmed_RVDocSum

Outcomes and age

J Am Coll Surg. 1996 Aug;183(2):105-12. Survival factors in 186 patients younger than 40 years old with colorectal adenocarcinoma.Am Surg. 1994 Aug;60(8):607-12. Colorectal cancer in young patients: characteristics and outcome.

Retrospective review of 186 patients younger than 40 years at MDACC•median age 34.3 years, median follow-up 9.4 years•Stage III-IV 66% •Histopathologic indicators of more aggressive tumor biology were present at a significantly higher frequency in young patients compared with patients older than 40 years (p < 0.001).

•Poorly differentiated tumor grade 41%•signet-ring cell tumors 11%•infiltrating tumor leading edges 69%

Retrospective review of 62 patients OHSU•3.1% of total CRC population•48% metastatic at diagnosis•Stage for stage, similar survival

Outcomes and age

Dis Colon Rectum. 1989 Oct;32(10):843-6. Colorectal cancer in patients younger than 40 years of age.Dis Colon Rectum. 2001 Mar;44(3):380-7. Colorectal adenocarcinoma in patients under 45 years of age: comparison with older patients in a well-defined French population.

50 patients Harbor-UCLA medical centre 1956-85•7-39 years of age•2 inflammatory bowel disease, 3 FAP•45% Dukes C, 23% Dukes D•5YOS 28%

French retrospective survey•4643 cases of CRC 1976-96•146 under 45 years (3%)•Stage III patients more frequent in younger patients•Post-operative mortality lower under 45 years (2.1% vs 8.4%)•Stage for stage, survival better for under 45 years compared to over 45 years•Gender prognostic in multivariate analyses

Outcomes and age

Pediatr Blood Cancer. 2008;50(3):588-93. Colorectal carcinoma in children and adolescents: the experience of the Istituto Nazionale Tumori of Milan, Italy. Colorectal Dis. 2004 May;6(3):191-4. Colorectal cancer in the young: a 12-year review of patients 30 years or less.

NCI in Milan•27 patients <30 years, 7 patients <18 years•Under 18 years

•5/7 unfavourable histology•6/7 advanced disease at diagnosis•6/7 relapsed/progressed•5 died•23% 5YOS

•19-29 years•72% 5YOS

39 patients under 30 years of age•6 had Family history, 4 index cases of FAP•Rectal cancers in 43%•70% at advanced stage•11 deaths, 3 alive with disease, 14 no evidence of disease (of 29 curative resections attempted)

Outcomes and age

Hepatogastroenterology. 1997 Mar-Apr;44(14):441-4. Cancer of the colon and rectum in the first three decades of life.

South Korean 28 CRC patients under 20 years

•Location evenly distributed•Mucinous cancers more common•22/28 stage III or IV•5YOS 21%

Malaysia21 patients under 30 years

•Ethnic Chinese>Malay>Indian•25% caecal, mucinous and advanced stage dominated•5YOS 25%

Outcomes and age

Surgical outcomes

53 patients with FAP treated with ileal pouch-anal anastamosis (IPAA)•31 under 40 years, 22 over 40 years•No difference in functional outcomes and QoL•Less nocturnal bowel movements in younger patients at 1 and 3 years•Fewer bowel movements/day than older patients at all stages of follow up

J Gastroenterol Hepatol. 2007;22(5):710-4. Age-related analysis of functional outcome and quality of life after restorative proctocolectomy and ileal pouch-anal anastomosis for familial adenomatous polyposis.

Outcomes and age

Clin Gastroenterol Hepatol. 2006;4(3):335-42. Colorectal cancer prognosis among patients with inflammatory bowel disease.

Inflammatory bowel disease and cancer

290 patients with IBD-associated CRC (241 with chronic ulcerative colitis and 49 with Crohn's disease) compared to sporadic CRC patients at the Mayo Clinic •The median age at diagnosis of IBD-related CRC was 48 years •55% of IBD-related tumors were distal to the splenic flexure compared with 78% of sporadic tumors•5YS

•163 IBD-associated CRC patients=54%, •164 sporadic CRC patients=53%

Outcomes and age

Am J Gastroenterol. 2007 102(1):163-7. Survival after colorectal cancer in patients with Crohn's disease: A nationwide population-based Danish follow-up study.Am J Gastroenterol. 2006 101(6):1283-7. Survival after colorectal cancer in patients with ulcerative colitis: a nationwide population-based Danish study.

Inflammatory bowel disease and cancer

Danish population-based registry•279 patients with UC-associated CRC

•Younger (median age of onset 63 vs 71 years)•Stage similar to overall CRC•Mortality rate ratios higher

•1.24 (95% CI 1.02-1.51)•100 patients with CD-associated CRC

•Younger age of onset•Stage similar•Hazard ratio higher

•1.82 (95% CI 1.36-2.43)

•COMPLIANCE WITH SCREENING PROGRAMMES NOT REPORTED

Summary

Age Number Stage Survival (5YS)

<40 186 More advanced NA

<45 146 More advanced No effect (corr. for stage)

<45 136 45% Advanced NA

<40 110 No age effect 55%


<40 138 No age effect No effect (corr. for stage)

<40 45 38% 54% (cf 71-88%)

<40 50 28% 28%

<30 21 NA 25%


<20 28 NA 21%

<20 7 84% 23%

Data is •Heterogeneous•Retrospective, historical•Often uncontrolled

Summary


Age and stage•Consistently more advanced disease in younger populations

Summary



Age and survival•Under 45 years, little consistent effect independent of stage•Under 30 years of age, ? survival may be worse allowing for stage

Summary




Age and surgical outcomes•The young do better

Summary




Age and surgical outcomes•The young do better

Inflammatory bowel disease and outcomes•Suggestion that hazard ratio for death from CRC is increased•No data on psychosocial factors and adherence to surveillance

Summary

The ABCs of Acute Lymphoblastic Leukema,

Breast Cancer and Colon Cancer

in Adolescent and Young Adult (AYA) Americans

NCI AYA Cancer Biology Workshop, June 9-10, 2009

Archie Bleyer, MD

in recognition of the 10th anniversary of the 1st NCI AYAO Workshop (June 1999)

Bleyer

Incidencesince 2000


• Colon Cancer

ALL, Colon Cancer, Breast Cancer

Colon Cancer

Incidence, 2000-2006, SEER17*

1

100

Incid

en

ce p

er

Millio

n p

er

Year

Age at Diagnosis (Years)

0 10 20 30 40 50 60 70 80

10

1000

Age 15-39

Log Scale

Breast Cancerin Females

ALL

19%

17%

11%

7%

6%

6%

5%

3%3%3%

2%

1%2%

26%

15%

11%

9%

9%

4%4%3%3%

3%

0%

20%

40%

60%

80%

100%

Relative Incidence of Top 12 Most Frequent Types of CancerAge 15-39, 2000-2004, SEER17

Other

CNS Cancer

Endometrial Cancer

Ovary Cancer

Colorectal Cancer

Lymphoma

Thyroid Cancer

Melanoma

Uterine Cervix Cancer

Breast Cancer

Leukemia

Oropharyneal Cancer

Soft Tissue Sarcoma

Testis Cancer

Kidney Cancer

Females Males

2%

Urinary Bladder

Lung

Other

Relative Incidence of Top 10 Most Frequent Types of Cancer

in Males <40 Years of Age, by 5 Year IntervalsICD, 2000-2004 SEER17


35-3930-3425-2920-2415-19

CNS

Lung

Colorectal

Lymphoma

Melanoma

Leukemia

Mouth/Throat

Thyroid

Kidney

excluding KaposiSarcoma

Testis Cancer

0%

20%

40%

60%

80%

100%

13%

2%2%

4%

5%

5%

6%

7%

11%

18%

27%

9%

1%2%2%

3%

8%

8%

8%

9%

21%

29%

8%

1%1%2%

3%

6%

10%

15%

15%

16%

23%

18%

3%3%4%

5%

6%

6%

7%

12%

16%

21%

24%

4%4%

5%

5%

5%

5%

9%

12%

13%

14%

Relative Incidence of Top 10 Most Frequent Types of Cancer

in Females 15-39 Years of Age by 5-Year Intervals


Other

CNS

Lung

Endometrium

Ovary

Colorectal

Lymphoma

Thyroid

Melanoma

Uterine Cervix

Breast

Leukemia

Oropharynx

35-390%

20%

40%

60%

80%

100%

30-3425-2920-24

39%

10%

9%

8%

5%4%4%4%2%2%

28%

13%

13%

12%

7%

4%4%3%

3%

2%16%

15%

15%

14%

12%

4%

3%

3%3%

2%

20%

20%

15%

7%

6%

5%

5%

4%

3%2%

25%

14%

10%

9%

9%

8%

5%

5%2%

1%

15-19

ICD, 2000-2004 SEER17


Survival2000-2006

• Colon Cancer

5-Year Relative Survival, 2000-2006, SEER 17


0

20

40

60

80

100

0 10 20 30 40 50 60 70 80

Colon Cancer

Breast Cancer in Females

ALL

Survival

(%)


Su

rviv

al

(%)

5-Year Relative Survival, Colon Cancer, 2000-2006, SEER17with 20 polynomial regressions

15 25 35 45 55 65 75 85

American Indian/Alaska Native

0

20

40

60

80

0

20

40

60

80

15 25 35 45 55 65 75 85

Asian/Pacific Islander



Su

rviv

al

(%)


15 25 35 45 55 65 75 85

Hispanic/Latino

0

20

40

60

80


Su

rviv

al

(%)


15 25 35 45 55 65 75 85

0

20

40

60

80

Black/African American

Non-Hispanic White


Su

rviv

al

(%)

5-Year Relative Survival, 1975-1997 by Calendar Year, SEER9 S

urv

ival

(%)

56 56

50

55

64

49

60

51

57

5049

59

61

57

64

55

52

55 55

62

5860

59

30

40

50

60

70

Age 35-39

30

51

74

59

47

61

44

54

51

60

54 54

62

54

51

60

5553

60

57

53

56

67

64

40

50

60

70

54

64

61

64

70

47

54

64

61

50

59 59

51

6365 66

56 56

60

56

66

57

68

30

40

50

60

70

1975 1980 1985 1990 1995

53

60

5452

5856

65

55

63

59

65

6159 59

62

68

63

56

6465

66

6463

30

40

50

60

70%

Colon Cancer

Age 25-29 Age 40-44

Age 30-34 Age 45-49

1975 1980 1985 1990 1995

Age 20-24

50

60

70

80

6163

43

52

77

44

50

65

75

36

75

60

50

57

70

6263

71

50

57

35

49

82

39

50

59

67

50

72

37

67

63

50

67

60

75

34

50

67 67

50

42

8284

80

2540

50

60

70

80

40

Age 50-54 Age 65-69

Age 55-59 Age 70-74

Age 60-64 Age 75-79

48

56

52

5654

62

5957

56

59

64

60 60

65

61 62

64 64

59

66

58

65

62

30

40

50

60

70

4949

5151

53 53

56 5654

57

6362

65

61

63 64

6765

62

68

63

6665

30

40

50

60

70

52 5249

51

5456

62

54

59

57

60 6061

63

65

62

66

70

57

6162

61

68

30

40

50

60

70

4949

5151

53 53

56 5654

57

6362

65

61

63 64

6765

62

68

63

6665

30

40

50

60

70

5050

55

51 5152

54 54 53

5655

63

59

6163

6462 63

6163

64

60

30

40

50

60

70

Su

rviv

al

(%)

5-Year Relative Survival, 1975-1997 by Calendar Year, SEER9 Colon Cancer

1975 1980 1985 1990 19951975 1980 1985 1990 1995

59

52

54

57

54

58 58

6259 59 59

62 6364

62 63

6665 65

6361

62

66

30

40

50

60

70

62

15-

19

20-

24

25-

29

30-

34

35-

39

40-

44

45-

49

50-

54

55-

59

60-

64

65-

69

70-

74

75-

79

80-

84

85+

-0.43 -0.13

0.26

0.35

0.18

0.74

0.87

1.10

0.78

1.45

1.20 1.19

1.34

1.24

-0.5

0

0.5

1.0

1.5

<-0.5

Average Annual % Change (AAPC) 5-Year Relative Survival

Colon Cancer

1975 to 1997, SEER9

**

*

*p<0.05

*

* *

AAPC

Documents

Outcomes following a diagnosis of colorectal cancer · Outcomes following a diagnosis of colorectal cancer ... chronic ulcerative colitis and ... cancer in patients with Crohn's disease: