|Year : 2019 | Volume
| Issue : 4 | Page : 297-301
Management of colon cancer at a tertiary referral center in India - Patterns of presentation, treatment, and survival outcomes
Jarin Noronha, Ashwin deSouza, Prachi Patil, Shaesta Mehta, Reena Engineer, Vikas Ostwal, Anant Ramaswamy, Suman K Ankathi, Mukta Ramadwar, Avanish Saklani
Department of GI and HPB Oncology, Tata Memorial Hospital and Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
|Date of Web Publication||11-Oct-2019|
Department of GI and HPB Oncology, Tata Memorial Hospital and Homi Bhabha National Institute, Parel, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
AIM: To define the patterns of disease presentation, treatment strategies, and outcomes for patients with colon cancer at a tertiary referral center in India over 1 year period.
MATERIALS AND METHODS: This is a retrospective analysis of a prospectively maintained database. All consecutive patients with proven or suspected colonic adenocarcinoma between July 2013 and July 2014 were evaluated in a dedicated analysed multidisciplinary clinic at the Tata Memorial Hospital, Mumbai. The demography, treatment plan, pathology, stage, and survival data were examined.
RESULTS: The median age of presentation was 49 years with 60.1% male patients. In total, 151 cases (57.4%) underwent treatment with curative intent consisting of surgery with adjuvant chemotherapy as indicated. The rest were offered either palliative chemotherapy (36.9%) or best supportive care (5.7%). Approximately, 70% patients had advanced stage disease (Stage III/IV) at presentation and 41.8% presented with metastatic disease with the liver being the most common site of disease dissemination. With a median follow-up of 29 months, the estimated 3-year disease free survival for patients treated with curative intent was 67.1%. The median progression free survival was 12.3 months for patients treated with palliative intent. The estimated 3-year overall survival was 89.7%, 65.5%, and 22.8% for Stage I/II, Stage III, and Stage IV, respectively.
CONCLUSION: Indian patients with colon cancer, at a tertiary referral center, tend to present at more advanced stages of the disease as compared to the West. However, curative treatment with surgery and chemotherapy offers similar survival outcomes when compared stage for stage.
Keywords: Cancer, colon, India, survival
|How to cite this article:|
Noronha J, deSouza A, Patil P, Mehta S, Engineer R, Ostwal V, Ramaswamy A, Ankathi SK, Ramadwar M, Saklani A. Management of colon cancer at a tertiary referral center in India - Patterns of presentation, treatment, and survival outcomes. Indian J Cancer 2019;56:297-301
|How to cite this URL:|
Noronha J, deSouza A, Patil P, Mehta S, Engineer R, Ostwal V, Ramaswamy A, Ankathi SK, Ramadwar M, Saklani A. Management of colon cancer at a tertiary referral center in India - Patterns of presentation, treatment, and survival outcomes. Indian J Cancer [serial online] 2019 [cited 2020 Apr 10];56:297-301. Available from: http://www.indianjcancer.com/text.asp?2019/56/4/297/268959
| » Background and Introduction|| |
In India, the annual incidence rate of colon cancer in men and women is 4.4 and 3.9 per 100,000. It is the eight most common cancer in men, whereas for women, colon cancer ranks ninth. Western literature reports colorectal cancer to be the third most commonly occurring cancer in men and second most commonly occurring cancer in women. The higher frequency of colorectal cancer in America, Europe, and Oceania in comparison to Africa and Asia has been attributed to higher indices of development and/or income. By virtue of a population of over one billion and underreporting of the disease, the absolute number of colorectal cancer patients in India still remains high despite its low incidence. An increased frequency of colon cancer in the urban Indian population as well as Indian migrants abroad is known.,, The rapid increase in urbanization of the subcontinent with accompanying diet and lifestyle changes will, in all probability, increase the incidence of colon cancer in India in the coming decade.
There is a dearth of Indian data in reported literature on the patterns of presentation and treatment outcomes for colon cancer. We could come across a single published article  with similar data, but the cohort consisted of right colon cancer cases alone. This audit aims to define the patterns of disease presentation, treatment strategies, and outcomes for patients with colon cancer at a tertiary referral center in India. Such studies provide a foundation on which to draw comparisons with internationally reported data, which aid in the development and improvement of treatment strategies in the management of colon cancer.
| » Materials and Methods|| |
This is a retrospective analysis of a prospectively maintained database of colon cancer patients treated in a dedicated multidisciplinary colorectal cancer clinic between July 2013 and July 2014, at the Tata Memorial Hospital, a tertiary referral center for cancer in India. The aim of this study was to evaluate the demography, stage at presentation, and survival outcomes of colon cancer patients registered at our center over a one-year period. Only tumors of the abdominal colon i.e., with the lower limit above the sacral promontory as determined on imaging/endoscopy were included in this analysis. Tumors with rectosigmoid involvement were excluded, as the management of these lesions is influenced by the location of the epicenter of the mass. Neoadjuvant chemoradiation can be considered for lesions extending into the upper and mid rectum, especially if the circumferential resection margin is involved/threatened, however, this is not suitable for tumors with the epicenter in the sigmoid colon with involvement of the rectosigmoid. In view of the heterogeneity in the management of this patient group, they were excluded from this study. Right colon cancers were defined as tumours proximal to the splenic flexure. Tumors with involvement of the splenic flexure, descending, or sigmoid colon were labeled as left sided tumors. All patients with suspected or proven colon cancer were assessed and treated as per standard prevailing guidelines by a multidisciplinary team (MDT) consisting of at least one surgical oncologist, medical oncologist, radiation oncologist, medical gastroenterologist, and dedicated colorectal radiologist. Patients were staged according to the 8th edition American Joint Committee on Cancer, TNM classification. Surgery for tumors with evidence of intestinal obstruction, perforation, or intraluminal bleeding requiring blood transfusion were labeled as emergency procedures. Such patients were not scheduled on the routine operating list but rather accommodated on the next operating list or operated out of routine hours, each case being decided on an individual basis. Anastomotic leak was defined as feculant drainage in the intraoperatively placed surgical drains or presence of contrast extravasation or perianastomotic collection (with or without contrast extravasation) on post-operative imaging. After completing treatment, patients were followed up with an annual Contrast Enhanced Computed Tomography (CECT) scan of the thorax, abdomen, and pelvis till 5 years, and a complete physical examination and serum Carcinoembryonic antigen (CEA) every 3 months for the first 2 years and then 6 monthly till 5 years. Surveillance colonoscopy was performed at 1 year, and if normal, repeated after 3 years and then 5 yearly. Patients who were symptomatic in the interim were discussed in MDT and treated accordingly. Survival data were collected from follow-up hospital visits and telephonic interviews when possible. Survival time was calculated from the date of surgery and date of registration for patient treated with curative and palliative intent, respectively. Survival analysis was done using Kaplan Meir method. Data were analyzed using SPSS Version 20.0 for Windows. Institutional Ethics Committee approval was obtained for this study.
| » Results|| |
Patterns of presentation
From July 2013 to July 2014, 263 treatment-naïve and previously treated patients with colon adenocarcinoma were evaluated at our dedicated colorectal MDT. At presentation, 223 patients had primary disease (metachronous second primary in 4 patients), whereas 40 patients had recurrent disease after treatment of their primary cancer. Among patients with primary cancers, 68 (30.5%) had prior cancer directed treatment. In total, 80% of these previously treated patients had surgery for the primary cancer before being referred to our institute.
Overall, 158 (60.1%) were male with the median age of presentation in men and women being 50 years and 47 years, respectively. Totally, 133 patients (50.57%) were <50 years, with a third of the patients presenting at <40 years of age [Table 1]. A little more than half of the patients (57.8%) had right sided tumors i.e., in the caecum, appendix, ascending, and transverse colon. The rest (39.9%) had tumors in the left colon with only 6 patients (2.3%) presenting with synchronous colonic cancers [Table 2].
Adenocarcinoma was diagnosed in all patients on endoscopic biopsy. However, tumor differentiation was reported in 72.6% of patients. Moderately differentiated adenocarcinoma formed the bulk of tumours in this series [Table 3]. There were 37 (14.1%) patients with signet ring morphology and 51 (19%) cases reported to have mucinous adenocarcinoma.
The stage grouping is listed in [Table 4], with 30.4% early colon cancer (Stage I/II) and 27.8% loco-regional disease (Stage III). The majority of patients in this study (41.8%) had distant metastases at presentation. Stage IV disease at presentation was seen in 35.9% of patients with primary colon cancer (n = 223). In total, 75% of patients with recurrent disease had distant metastasis with only 10 of these patients (25%) presenting with isolated locoregional recurrence [Table 5]. Of the 110 patients with metastatic disease, at the time of registration 37 (33.63%) had liver metastases making it the most common site of disease dissemination followed by the peritoneum (25.45%). The majority of patients with metastatic disease had more than one site of disease spread (58.1%). Isolated lung metastasis in the absence of other systemic metastasis was seen in just 2 patients (1.8%) at presentation [Table 6].
|Table 4: Clinico-radiological stage distribution at presentation (n=263)|
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After MDT evaluation, 151 patients (57.4%) were offered curative treatment with surgery and adjuvant chemotherapy as indicated, 97 patients (36.9%) underwent palliative treatment, and 15 patients (5.7%) were offered best supportive care. Treatment with curative intent was offered to 62.8% of patients with primary cancer but to only 11 patients (27.5%) presenting with recurrent disease [Table 5]. In total, 192 operations were performed for staging, curative, and palliative purposes [Table 7]. Totally, 52 surgical procedures (27.08%) were performed as emergency surgeries for obstruction, perforated, or bleeding tumors. Of the 178 radical colonic resections, 32 patients underwent palliative tumor resections for symptom control. An anastomosis was fashioned for all patients undergoing radical resection, and a covering ileostomy was performed in one of these patients on account of intraoperative hemodynamic instability. Six patients (6/178 anastomoses, 3.4%) had an anastomotic dehiscence that required a return to operation theater. There was no 30-day mortality, and postoperative complications are as listed in [Table 8]. There was no difference in the 30-day morbidity associated with patients undergoing radical colonic resections either with curative or palliative intent (P = 0.106).
|Table 7: Surgical procedure distribution (Staging/curative/palliative; n=192)|
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|Table 8: Clavien-Dindo complications of patients undergoing surgery (n=192)|
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Follow-up data were available for 70% of patients in this study, with a median follow-up duration of 29 months. The estimated 3-year disease free survival (DFS) and overall survival (OS) for patients treated with curative intent was 67.1% and 79.1%, respectively. For patients treated with palliative intent, the median progression free survival and estimated 3-year overall survival was 12.3 months and 19.9%, respectively. When analyzed by stage, the estimated 3-year overall survival was 89.7%, 65.5%, and 22.8% for Stage I/II, Stage III, and Stage IV, respectively. The recurrence patterns have been listed in [Table 9].
|Table 9: Recurrence patterns in patients treated with curative intent (n=151)|
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The estimated 3-year OS and DFS for patients with right colon lesions treated with curative intent was 74.8% and 64.5%, respectively. Similarly, for left colon lesions, these values were 81.2% and 59.6%, respectively. There was no statistical difference in the OS (P = 0.29) and DFS (P = 0.87) when the survival outcomes of right and left sided tumors were compared.
| » Discussion|| |
The incidence of colon cancer in India, like other developing nations, is lower than that reported in the West but is steadily increasing., The median age in our cohort was 49 years with 77 patients (28.5%) presenting with colon cancer under the age of 40. Other Indian studies have reported the incidence in the same age group to range between 12% and 37% that is higher than the 10% observed in the West.,, In the United States of America, >90% colorectal cancers are diagnosed in people above the age of 50.
Patients with early colon cancer (Stage I/II) comprised 30.4% of our cohort, with 41.8% of patients presenting with metastatic disease at registration. Even in patients with primary colon cancer, Stage IV disease at presentation formed the single largest patient group (35.9%). This contrasts with data from the American SEER database, which reports corresponding figures of 39% (Stage I/II) and 21% (Stage IV). Our center serves as a tertiary referral center for cancer for India. This could partly explain the greater proportion of patients with advanced and metastatic disease in our study.
Of the patients presenting with stage IV disease, 19.1% had metastases confined to the peritoneal cavity that is similar to the 25% reported in literature. Isolated liver metastases has been reported to range between 10% to 25%; we observed 15.4% of such patients in our series. However, 2.3% patients had synchronous lesions which are similar to the overall prevalence of 3.5% published from 39 pooled studies.
Signet ring colon cancer is reported to have a female predominance, a predilection for patients younger than 40 years of age, present with higher stage, have lower survival and higher disease recurrence. There were 38 (14.1%) patients with signet ring morphology in our series. Although most Western series report this as a rare histopathological entity with an incidence of less than 2%, one series from Lebanon found the incidence of more than 10%.,
Mucinous adenocarcinoma is reported to have lower survival after correction for stage. There were 18.1% patients with mucinous histology in our series, which is higher than 5–15% in Western literature., An environmental or genetic basis are possible etiologies for this finding. Further research is required to ascertain the cause of the higher incidence of these specific tumor types in our study population.
Surgical intervention as an emergency procedure is required in 25%–36% of procedures for colon cancer., We performed 52 (27.08%) such emergency procedures in the curative and palliative setting for bowel obstruction, perforation, and bleeding tumors. Radical colectomy is indispensable when offering treatment with curative intent for colon cancer. However, polyagent chemotherapy with or without targeted therapy offers a median survival of 20–30 months even with metastatic disease. A few studies have shown than radical surgery in the presence of metastatic disease may offer a survival advantage though it may be argued that these studies are limited by selection bias., Additionally, surgery may offer excellent palliation for a symptomatic colon primary. There was no statistical difference in the postoperative morbidity for both curative and palliative resections in our study (P = 0.106), suggesting that palliative colonic resection is a feasible option for symptomatic tumors in the metastatic setting, in a select group of patients.
We have adopted a standardized technique both for stapled and hand-sewn anastomoses, the selection of which was dependent on surgeon preference, condition of the bowel wall, clinical presentation of the patient, and competing comorbid factors. However, 3.4% patients had a leak after abdominal colectomy with primary anastomosis, which compares well with reported leak rates of 0.5%–13% for primary anastomoses in large bowel resection for cancer.
Isolated locoregional recurrence following radical colectomy with curative intent was 5.3% in our study, which compares with other contemporary series that report locoregional recurrence rates of 4.4%. While curative treatment could be offered to a large proportion of patients with primary disease (62.8%), 72.5% of patients presenting with recurrent disease could only be offered palliative treatment after discussion in MDT.
Literature on outcomes of right and left colon cancer treated with curative intent shows conflicting results. Survival outcomes favor left colon cancer in the majority of reports.,,,,, However, some reports demonstrate a more favorable outcome for right colon lesions., We did observe a marginally better estimated 3-year OS for left vs. right colon cancers (81.2% vs. 74.8%). However, this did not reach statistical significance.
The population based 5-year survival for colon cancer according to the Mumbai Cancer Registry reported in 2001 was 61.2% for localized colon cancer, 31.9% for regional, and 9.0% for distant metastatic disease, while the 5-year survival reported from the American SEER database was 89.9% for localized colon cancer, 71.3% for regional, and 13.9% for distant metastatic disease., We observed comparable estimated 3-year overall survival rates of 89.7%, 65.5%, and 22.8% for Stage I/II, Stage III, and Stage IV, respectively.
The main drawbacks of this study are its retrospective nature, short follow-up duration, and missing follow-up data. Additionally, the pattern of disease presentation as seen in this study, is probably not representative of the nationwide pattern of colon cancer presentation, as Tata Memorial Hospital serves as a tertiary referral center for cancer in India.
| » Conclusion|| |
Indian patients with colon cancer, at a tertiary referral center, tend to present at more advanced stages of the disease with higher proportions of signet ring and mucinous histology as compared to the West. However, curative treatment with surgery and chemotherapy offers similar survival outcomes when compared stage for stage. Palliative surgery for the symptomatic primary in the metastatic setting is a viable treatment option in a select group of patients.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]