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AbstractObjectivesTo quantify post-colonoscopy colorectal cancer (PCCRC) rates in England by using recent World Endoscopy Organisation guidelines, compare incidence among colonoscopy providers, and explore associated factors that could benefit from quality improvement initiatives.DesignPopulation based cohort study.SettingNational Health Service in England between 2005 and 2013.PopulationAll people undergoing colonoscopy and subsequently diagnosed as having colorectal cancer up to three years after their investigation (PCCRC-3yr).Main outcome measuresNational trends in incidence of PCCRC (within 6-36 months of colonoscopy), univariable and multivariable analyses to explore factors associated with occurrence, and funnel plots to measure variation among providers.ResultsThe overall unadjusted PCCRC-3yr rate was 7.4% (9317/126 152), which decreased from 9.0% in 2005 to 6.5% in 2013 (P<0.01). Rates were lower for colonoscopies performed under the NHS bowel cancer screening programme (593/16 640, 3.6%), while they were higher for those conducted by non-NHS providers (187/2009, 9.3%). Rates were higher in women, in older age groups, and in people with inflammatory bowel disease or diverticular disease, in those with higher comorbidity scores, and in people with previous cancers. Substantial variation in rates among colonoscopy providers remained after adjustment for case mix.ConclusionsWide variation exists in PCCRC-3yr rates across NHS colonoscopy providers in England. The lowest incidence was seen in colonoscopies performed under the NHS bowel cancer screening programme. Quality improvement initiatives are needed to address this variation in rates and prevent colorectal cancer by enabling earlier diagnosis, removing premalignant polyps, and therefore improving outcomes.

ObjectiveIn 2001, the National Institute for Health Research Cancer Research Network (NCRN) was established, leading to a rapid increase in clinical research activity across the English NHS. Using colorectal cancer (CRC) as an example, we test the hypothesis that high, sustained hospital-level participation in interventional clinical trials improves outcomes for all patients with CRC managed in those research-intensive hospitals.DesignData for patients diagnosed with CRC in England in 2001–2008 (n=209 968) were linked with data on accrual to NCRN CRC studies (n=30 998). Hospital Trusts were categorised by the proportion of patients accrued to interventional studies annually. Multivariable models investigated the relationship between 30-day postoperative mortality and 5-year survival and the level and duration of study participation.ResultsMost of the Trusts achieving high participation were district general hospitals and the effects were not limited to cancer ‘centres of excellence’, although such centres do make substantial contributions. Patients treated in Trusts with high research participation (≥16%) in their year of diagnosis had lower postoperative mortality (p<0.001) and improved survival (p<0.001) after adjustment for casemix and hospital-level variables. The effects increased with sustained research participation, with a reduction in postoperative mortality of 1.5% (6.5%–5%, p<2.2×10−6) and an improvement in survival (p<10−19; 5-year difference: 3.8% (41.0%–44.8%)) comparing high participation for ≥4 years with 0 years.ConclusionsThere is a strong independent association between survival and participation in interventional clinical studies for all patients with CRC treated in the hospital study participants. Improvement precedes and increases with the level and years of sustained participation.

Background Colorectal cancer prognosis varies substantially with socioeconomic status. We investigated differences in life expectancy between socioeconomic groups and estimated the potential gain in life-years if cancer-related survival differences could be eliminated. Methods This population-based study included 470,000 individuals diagnosed with colon and rectal cancers between 1998 and 2013 in England. Using flexible parametric survival models, we obtained a range of life expectancy measures by deprivation status. The number of life-years that could be gained if differences in cancer-related survival between the least and most deprived groups were removed was also estimated. Results We observed up to 10% points differences in 5-year relative survival between the least and most deprived. If these differences had been eliminated for colon and rectal cancers diagnosed in 2013 then almost 8231 and 7295 life-years would have been gained respectively. This results for instance in more than 1-year gain for each colon cancer male patient in the most deprived group on average. Cancer-related differences are more profound earlier on, as conditioning on 1-year survival the main reason for socioeconomic differences were factors other than cancer. Conclusion This study highlights the importance of policies to eliminate socioeconomic differences in cancer survival as in this way many life-years could be gained.

High-quality rectal cancer surgery is known to improve patient outcome. We aimed to assess the quality of colon cancer surgery by studying the extent of variation in the plane of surgical resection, the amount of tissue removed, and its association with survival. All resections for primary colon adenocarcinoma done at Leeds General Infirmary (Leeds, UK) between Jan 1, 1997, and June 30, 2002, were identified. The specimens were photographed and graded according to the plane of mesocolic dissection. Tissue morphometry was done on 253 tumours. Univariate and multivariate models were used to ascertain whether there was an association with 5-year survival. The primary outcome measure was overall survival defined as death from any cause. 521 cancers were identified, 122 were excluded because of either no photographic images or insufficient images to allow retrospective grading, leaving 399 specimens for analysis. There was marked variation in the proportion of each plane of surgery: muscularis propria in 95 of 399 (24%) specimens, intramesocolic in 177 of 399 (44%) specimens, and mesocolic in 127 of 399 (32%) specimens. Mean cross-sectional tissue area outside the muscularis propria was significantly higher with mesocolic plane surgery (mean 2181 [SD 895] mm 2) compared with intramesocolic (mean 2109 [1273] mm 2) and muscularis propria plane (mean 1447 [913] mm 2) surgery (p=0·0003). There was also a significant increase in the distance from the muscularis propria to the mesocolic resection margin with mesocolic plane surgery (mean 44 [21] mm) compared with intramesocolic (mean 30 [16] mm) and muscularis propria plane (mean 21 [12] mm) surgery, which was independent of tumour site (all excisions p<0·0001). We noted a 15% (95% CI) overall survival advantage at 5 years with mesocolic plane surgery compared with surgery in the muscularis propria plane (HR 0·57 [0·38–0·85], p=0·006) in univariate analysis. However, this association was no longer significant in the multivariate model (HR 0·86 [95% CI 0·56–1·31], p=0·472), but was especially noted in patients with stage III cancers (HR 0·45 [95% CI 0·24–0·85], p=0·014; multivariate analysis). The plane of surgery and amount of mesocolon removed varied between the different sites with better planes in left-sided resections than right-sided ones, which were better than transverse resection (p<0·0001). As previously shown in the rectum, we have now shown there is marked variability in the plane of surgery achieved in colon cancer. Improving the plane of dissection might improve survival, especially in patients with stage III disease. If confirmed by clinical trial data, such as from the ongoing National Cancer Research Institute Fluoropyrimidine, Oxaliplatin and Targeted Receptor pre-Operative Therapy for colon cancer (FOxTROT) trial of neoadjuvant chemotherapy in advanced resectable colon cancer, improvement of the plane of dissection might be a new cost-effective method of decreasing morbidity and mortality in patients with colon cancer. National Institute for Health Research Academic Clinical Fellowship Programme, Experimental Cancer Medicine Centre programme (both Department of Health, London, UK), Yorkshire Cancer Research (Harrogate, UK), and the Pelican Trust (Basingstoke, UK).

ObjectivePost-colonoscopy colorectal cancer (PCCRC) is a key quality indicator of colonoscopy. This study compares methods for defining PCCRC rates, proposes a new method of calculating them and quantifies them across the English National Health Service (NHS).DesignThis retrospective observational population-based study involved all individuals with a first primary diagnosis of colorectal cancer made between 2001 and 2010 and treated in the English NHS. Previously published methods for deriving PCCRC rates were applied to the linked routine health data for this population to investigate the effect on the rate. A new method, based on the year of the colonoscopy rather than colorectal cancer diagnosis, was then used to calculate PCCRC rates.ResultsOf 297 956 individuals diagnosed with colorectal cancer, a total of 94 648 underwent a colonoscopy in the 3 years prior to their diagnosis. The application of the published methods and exclusion criteria to the dataset produced significantly different PCCRC rates from 2.5% to 7.7%. The new method demonstrates that PCCRC rates within 3 years of colonoscopy (without exclusions) decreased in the English NHS over 8 years, falling from 10.6% to 7.3% for colonoscopies performed in 2001 and 2007 respectively.ConclusionsThe method used to determine PCCRC rates significantly affects findings with potential to substantially underestimate rates. To enable international benchmarking there needs to be a standardised method for defining PCCRC. This study proposes a new methodology using colonoscopy as a denominator and between 2001 and 2007 this method indicated an 8.6% PCCRC rate across the English NHS. It also demonstrated PCCRC rates have fallen over time.

ObjectivesTo assess the variation in risk-adjusted 30-day postoperative mortality for patients with colorectal cancer between hospital trusts within the English NHS.DesignRetrospective cross-sectional population-based study of data extracted from the National Cancer Data Repository.SettingAll providers of major colorectal cancer surgery within the English NHS.ParticipantsAll 160 920 individuals who underwent major resection for colorectal cancer diagnosed between 1998 and 2006 in the English NHS.Main outcome measuresNational patterns of 30-day postoperative mortality were examined and logistic binary regression was used to study factors associated with death within 30 days of surgery. Funnel plots were used to show variation between trusts in risk-adjusted mortality.ResultsOverall 30-day mortality was 6.7% but decreased over time from 6.8% in 1998 to 5.8% in 2006. The largest reduction in mortality was seen in 2005 and 2006. Postoperative mortality increased with age (15.0% (95% CI 14.1% to 15.9%) for those aged >80 years), comorbidity (24.2% (95% CI 22.0% to 26.5%) for those with a Charlson comorbidity score ≥3), stage of disease (9.9% (95% CI 9.3% to 10.6%) for patients with Dukes' D disease), socioeconomic deprivation (7.8% (95% CI 7.2% to 8.4%) for residents of the most deprived quintile) and operative urgency (14.9% (95% CI 14.2% to 15.7%) for patients undergoing emergency resection). Risk-adjusted control charts showed that one trust had consistently significantly better outcomes and three had significantly worse outcomes than the population mean.ConclusionsSignificant variation in 30-day postoperative mortality following major colorectal cancer surgery existed between NHS hospitals in England throughout the period 1998–2006. Understanding the underlying causes of this variation between surgical providers will make it possible to identify and spread best practice, improve outcomes and, ultimately, reduce 30-day postoperative mortality following colorectal cancer surgery.

IntroductionAlthough colorectal cancer outcomes in England are improving, they remain poorer than many comparable countries. Yorkshire Cancer Research has, therefore, established a Bowel Cancer Improvement Programme (YCR BCIP) to improve colorectal cancer outcomes within Yorkshire and Humber, a region representative of the nation. It aims to do this by quantifying variation in practice, engaging with the colorectal multidisciplinary teams (MDTs) to understand this and developing educational interventions to minimise it and improve outcomes.Methods and analysisInitially, routine health datasets will be used to quantify variation in the demographics, management and outcomes of patients across the Yorkshire and Humber region and results presented to MDTs. The YCR BCIP is seeking to supplement these existing data with patient-reported health-related quality of life information (patient-reported outcome measures, PROMs) and tissue sample analysis. Specialty groups (surgery, radiology, pathology, clinical oncology, medical oncology, clinical nurse specialists and anaesthetics) have been established to provide oversight and direction for their clinical area within the programme, to review data and analysis and to develop appropriate educational initiatives.Ethics and disseminationThe YCR BCIP is aiming to address the variation in practice to significantly improve colorectal cancer outcomes across the Yorkshire and Humber region. PROMs and tissue sample collection and analysis will help to capture the information required to fully assess care in the region. Engagement of the region’s MDTs with their data will lead to a range of educational initiatives, studies and clinical audits that aim to optimise practice across the region.

There is variability in clinical outcome for patients with apparently the same stage colorectal cancer (CRC). Single nucleotide polymorphisms (SNPs) mapping to chromosomes 1q41, 3q26.2, 6p21, 8q23.3, 8q24.21, 10p14, 11q13, 11q23.1, 12q13.13, 14q22, 14q22.2, 15q13.3, 16q22.1, 18q21.1, 19q13.11, 20p12, 20p12.3, 20q13.33 and Xp22 have robustly been shown to be associated with the risk of developing CRC. Since germline variation can also influence patient outcome the relationship between these SNPs and patient survivorship from CRC was examined. All enrolled into the National Study of Colorectal Cancer Genetics (NSCCG) were genotyped for 1q41, 3q26.2, 6p21, 8q23.3, 8q24.21, 10p14, 11q13, 11q23.1, 12q13.13, 14q22, 14q22.2, 15q13.3, 16q22.1, 18q21.1, 19q13.11, 20p12, 20p12.3, 20q13.33 and xp22 SNPs. Linking this information to the National Cancer Data Repository allowed patient genotype to be related to survival. The linked dataset consisted of 4,327 individuals. 14q22.22 genotype defined by the SNP rs4444235 showed a significant association with overall survival. Specifically, the C allele was associated with poorer observed survival (per allele hazard ratio 1.13, 95% confidence interval 1.05-1.22, P = 0.0015). The CRC susceptibility SNP rs4444235 also appears to exert an influence in modulating patient survival and warrants further evaluation as a potential prognostic marker.

Colorectal cancer is a common disease with over 41 000 new cases diagnosed every year in the UK, of which around two-thirds occur in the colon. The primary treatment for colon cancer is surgery, though outcomes vary substantially worldwide. Centres in Germany and Japan using complete mesocolic excision with central vascular ligation (CME with CVL) report some of the best outcomes after colon cancer resection in published research. We aimed to identify the optimum surgical technique for colon cancer and determine whether it could be implemented into routine practice. Digital colour photographs of consecutive colon cancer resection specimens were submitted for independent review at the University of Leeds from two UK (n=468), one German (n=136), one Japanese (n=149), and six Danish (n=263) centres. The specimens were subjected to tissue morphometry with Aperio ImageScope and given a quality score according to the plane of resection. The association to 5-year overall survival was calculated with the Kaplan-Meier method and the log rank test. A Cox's proportional hazards regression model was used to determine the independence of prognostic variables. The study was approved by the Northern and Yorkshire Research Ethics Committee. Individual patient consent was not required. Analysis of specimens resected using conventional low tie surgery from Leeds (n=399) showed that only 127 specimens (32%) were resected in the mesocolic plane (intact mesocolon) and 95 (24%) had pronounced defects going down to the muscularis propria. There was a 15% improvement in 5-year overall survival with mesocolic plane surgery compared with muscularis propria plane surgery (hazard ratio 0·57, 95% CI 0·38–0·85; p=0·006). Plane of surgery remained an independent prognostic factor on multivariate analysis in stage III disease (0·45, 0·24–0·85; p=0·014). CME with CVL undertaken in specialist units in Germany and Japan removed more tissue between the tumour and high vascular tie than did standard surgery (median 117 mm [IQR 99–137] vs 90 [67–111], p<0·0001), and was more likely to occur in the mesocolic plane (81% vs 40%, p<0·0001). Laparoscopic CME with CVL specimens from St Mark's Hospital, UK, were not significantly different from open specimens from Germany in mesocolic plane rate and tissue morphometry. After a surgical training programme in Denmark focussing on CME with CVL, the mesocolic plane rate improved (75% after training vs 48% before, p<0·0001), amount of tissue resected between the tumour and high vascular tie increased (median 105 mm [84–129] vs 84 [67–101], p=0·006), and lymph-node yield rose (median number 28 [24–37] vs 18 [14–23], p<0·0001). We have shown that CME with CVL is better than conventional colon cancer surgery with respect to oncological outcomes, can be effectively done laparoscopically, and can be learned through a surgical training programme. Such programmes are easy to implement and cheap compared with the cost of modern chemotherapy. With a move towards better colon cancer surgery, around 5000 lives could potentially be saved every year in the UK and many more worldwide. Yorkshire Cancer Research.

Andrew Shorthouse Department of Coloproctology, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK Honorary Professor to the Faculty of Health and Wellbeing at Sheffield Hallam University, Sheffield, UK E: shorthouse@doctors.org.uk Traditional teaching in colorectal cancer surgery is that splenic flexure mobilisation accompanied by ligation of the inferior mesenteric artery at its origin are mandatory to achieve a satisfactory outcome, judged not only in the short-term by patient recovery but also in the long-term by oncological results. [...]is splenic flexure mobilisation necessary to ensure a well-vascularised anastomosis without tension? Another method of looking at this is the measurement of vascularity during surgery using tissue oxygen tension or laser Doppler techniques.7,8 There is a suggestion of decreased vascularity in the descending colon but there is no clear guidance regarding the optimal proximal site for anastomosis. Rullier and colleagues2 reported a 6-fold increase in the leak rate for anastomoses fashioned below 5 cm from the anal verge, and similar results have been reported by others.3 The height of the anastomosis has been identified as an independent risk factor for leakage in a large prospective study4 and within a multivariate analysis of significant risk factors.5 In stating that I ‘nearly’ always mobilize the splenic flexure in rectal cancer surgery, it is not necessary when the proximal colon has to reach the abdominal wall rather than the pelvic floor (APER or Hartmann's procedure); however, in the remaining cases, I would contest that the additional time spent in the left upper quadrant is time well spent.