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Original Investigation |

Incidence and Predictors of Bowel Obstruction in Elderly Patients With Stage IV Colon Cancer:  A Population-Based Cohort Study

Megan Winner, MD, MS1,4; Stephen J. Mooney, MS4; Dawn L. Hershman, MD2,4; Daniel L. Feingold, MD1; John D. Allendorf, MD1; Jason D. Wright, MD3; Alfred I. Neugut, MD, PhD2,4
[+] Author Affiliations
1Department of Surgery, Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University, New York, New York
2Department of Medicine, Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University, New York, New York
3Department of Obstetrics and Gynecology, Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University, New York, New York
4Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
JAMA Surg. 2013;148(8):715-722. doi:10.1001/jamasurg.2013.1.
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Importance  Research has been limited on the incidence, mechanisms, etiology, and treatment of symptoms that require palliation in patients with terminal cancer. Bowel obstruction (BO) is a common complication of advanced abdominal cancer, including colon cancer, for which small, single-institution studies have suggested an incidence rate of 15% to 29%. Large population-based studies examining the incidence or risk factors associated with BO in cancer are lacking.

Objective  To investigate the incidence and risk factors associated with BO in patients with stage IV colon cancer.

Design and Setting  Retrospective cohort, population-based study of patients in the Surveillance, Epidemiology, and End Results and Medicare claims linked databases who were diagnosed as having stage IV colon cancer from January 1, 1991, through December 31, 2005.

Patients  Patients 65 years or older with stage IV colon cancer (n = 12 553).

Main Outcomes and Measures  Time to BO, defined by inpatient hospitalization for BO. We used Cox proportional hazards regression models to determine associations between BO and patient, prior treatment, and tumor features.

Results  We identified 1004 patients with stage IV colon cancer subsequently hospitalized with BO (8.0%). In multivariable analysis, proximal tumor site (hazard ratio, 1.22 [95% CI, 1.07-1.40]), high tumor grade (1.34 [1.16-1.55]), mucinous histological type (1.27 [1.08-1.50]), and nodal stage N2 (1.52 [1.26-1.84]) were associated with increased risk of BO, as was the presence of obstruction at cancer diagnosis (1.75 [1.47-2.04]). A more recent diagnosis was associated with decreased risk of subsequent obstruction (hazard ratio, 0.84 [95% CI, 0.72-0.98]).

Conclusions and Relevance  In this large population of patients with stage IV colon cancer, BO after diagnosis was less common (8.0%) than previously reported. Risk was associated with site and histological type of the primary tumor. Future studies will explore management and outcomes in this serious, common complication.

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Figure.
Cumulative Incidence of Hospitalization for Bowel Obstruction Over Time

Cumulative incidence of hospitalization for bowel obstruction over time in the baseline cohort of 12 553 patients with stage IV colon cancer in the Surveillance, Epidemiology, and End Results and Medicare claims linked databases for January 1, 1991, through December 31, 2005, stratified by tumor histological type. For reference, the median survival of each group is given. We found no significant difference in survival experience by histological type (P = .29) in a multivariable model of survival since the cancer diagnosis that included age at and year of diagnosis, sex, marital status, patient comorbidity score, primary tumor surgery, chemotherapy after diagnosis, tumor site and grade, and lymph node status. IQR indicates interquartile range.

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incidence and predictors of bowel obstruction in elderly patients with stage IVcolon cancers: a population based. cohort study
Posted on June 7, 2013
basil b fadipe
justin fadipe centre. mero heights. dominica. west Indies
Conflict of Interest: None Declared
Interesting study; its observational nature may however not invest it with a power to determine causalities regarding its conclusions, particularly that these are at variance with what is generally known of colonic cancers;1. More cancers are found on the left than right hemicolons 2. The phenotypes on the left are more of the constrictive/annular types than is the case on the right. 3. Luminal capacity is anatomically less on the left than on the right. 4. Faecal consistency on the left is harder than on the right. 5. Nodal invasion comes sooner on the left than on the right cos of its more infiltrative phenotypes. Therefore by virtue of 2,3,4 and 5, MBOs are to be expected more frequently on the left/distal than right/proximal.And the more the tumour progression, the more this difference is expected. What will explain the different observation in this study.?A. Is the mucinous nature of the growth with effect on intraluminal viscosity important determinant/segregant between left and right?B. How do tumour stage and grade affect mesenteric/peritoneal invasion(direct or metastatic) with regards to mucosal oedema and luminal capacity. C. Is nodal status an independent variable or an index of tumour grade .by another measure. D. In the series reviewed, were there instances of synchronous or metachronous lesions with prospects for affecting the observed resultsE. How does the review adjust for intra-grade differences in morphologic types on both sides of colonF. How does the review adjust for size heterogeneities within same nodal group on both sides given the possible and direct relationship between size and mechanical obstruction. G. Was there any attempt to consider non mechanical BOs in the series studied particularly that the cohort studied is advanced cancers(grade IV) with possible implication for peritoneal/mesenteric/neural impairments. Answers to some of these questions may clarify further the predictors in this cohort.
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