Ongoing Challenge of Stage II Colon Cancer

University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH.
Journal of Clinical Oncology (Impact Factor: 18.43). 07/2011; 29(25):3346-8. DOI: 10.1200/JCO.2011.35.4571
Source: PubMed

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    • "There is a trend in costs by stage at diagnosis in the initial phase in all age classes: more advanced stages correspond to higher average costs, patients in stage IV cost about 70% more than patients in early stages I and II (Figure 2a). This result is consistent with the clinical guidelines and recommendations, which suggest different treatment strategies according to the tumor stage: typically, patients with tumor in Stage I are followed up without adjuvant therapy, while for a portion of high risk Stage II patients (about 20%) adjuvant therapy after surgery could be considered [32,33]; Stage III patients are treated with a curative surgical resection (possibly with transient colic anastomosis) and postoperative chemotherapy is mandatory; standard treatments for Stage IV patients have primarily palliative intent, and consist of surgical resection of bowel and/or metastasis, palliative anastomosis, chemotherapy (possibly in association with biological therapy) and radiation therapy to the primary rectal tumor to palliate bleeding, or to disease metastasis to palliate pain [34,35]. In this analysis, the decision to combine Stages I and II, in order to obtain more robust estimates comparable between the two cancer registries, is justified by the similarity between cost profiles observed in Stage I and Stage II separately (data not shown). "
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    ABSTRACT: Due to changes in cancer-related risk factors, improvements in diagnostic procedures and treatments, and the aging of the population, in most developed countries cancer accounts for an increasing proportion of health care expenditures. The analysis of cancer-related costs is a topic of several economic and epidemiological studies and represents a research area of great interest to public health planners and policy makers. In Italy studies are limited either to some specific types of expenditures or to specific groups of cancer patients. Aim of the paper is to estimate the distribution of cancer survivors and associated health care expenditures according to a disease pathway which identifies three clinically relevant phases: initial (one year following diagnosis), continuing (between initial and final) and final (one year before death). The methodology proposed is based on the reconstruction of patterns of care at individual level by combining different data sources, surveillance data and administrative data, in areas covered by cancer registration. A total colorectal cancer-related expenditure of 77.8 million Euros for 18012 patients (corresponding to about 4300 Euros per capita) is estimated in 2006 in two Italian areas located in Tuscany and Veneto regions, respectively. Cost of care varies according to the care pathway: 11% of patients were in the initial phase, and consumed 34% of total expenditure; patients in the final (6%) and in the continuing (83%) phase consumed 23% and 43% of the budget, respectively. There is an association between patterns of care/costs and patients characteristics such as stage and age at diagnosis. This paper represents the first attempt to attribute health care expenditures in Italy to specific phases of disease, according to varying treatment approaches, surveillance strategies and management of relapses, palliative care. The association between stage at diagnosis, profile of therapies and costs supports the idea that primary prevention and early detection play an important role in a public health perspective. Results from this pilot study encourage the use of such analyses in a public health perspective, to increase understanding of patient outcomes and economic consequences of differences in policies related to cancer screening, treatment, and programs of care.
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    ABSTRACT: Tumor staging of colorectal cancer is typically based on conventional TNM and Dukes classifications. However, additional information could be useful, and there is a significant interest in identifying molecular markers that are related to genetic or epigenetic processes. Using immunohistochemistry, we analyzed the expression of the high-mobility group A2 (previously high-mobility group 1-C [HMGI-C]) protein in 103 colorectal cancer cases to determine its use as a biomarker in colorectal cancer to integrate morphological staging. We found a progressive increase of the high-mobility group A2 protein expression in colorectal cancer tumor samples from cases in which all of the tumor cells were negative up to cases in which all of the tumor cells stained positive. Increased high-mobility group A2 expression is strongly associated with an increase in tumor invasiveness, which was measured through both budding and vascular invasion (P < .0001). Kaplan-Meier estimates showed a decrease in overall survival when vascular invasion is present (P = .023). Moreover, a fraction of the analyzed samples showed high-mobility group A2-positive stromal fibroblasts. Although high-mobility group A2-positive tumors were associated with cell invasiveness, high-mobility group A2-positive stromal fibroblasts were correlated with less invasive tumors. High-mobility group A2 protein expression could be used as a prognostic marker to provide prospective information on patient outcome, complementing the data obtained using conventional pathologic staging systems.
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