Search

Background:Physical activity and obesity are well-established factors of colorectal cancer risk and prognosis. Here, we investigate associations of individual and combined physical activity and body mass index (BMI) groups with proinflammatory biomarkers in colorectal cancer patients.Methods:Self-reported physical activity levels were classified as “active” (≥8.75 MET-hours/week) versus “inactive” (n = 579 stage I–IV colorectal cancer patients enrolled in the ColoCare Study. BMI [normal weight (≥18.5–2), overweight (≥25–2), and obese (≥30 kg/m2)] was abstracted from medical records. Patients were classified into four combinations of physical activity levels and BMI. Biomarkers [C-reactive protein (CRP), SAA, IL6, IL8, and TNFα] in presurgery serum samples were measured using the Mesoscale Discovery Platform. Regression models were used to compute relative percent differences in biomarker levels by physical activity and BMI groups.Results:“Inactive” patients had non-statistically significant higher IL6 levels compared with “active” patients (+36%, P = 0.10). “Obese” patients had 88% and 17% higher CRP and TNFα levels compared with “normal weight” patients (P = 0.03 and 0.02, respectively). Highest CRP levels were observed among “overweight or obese/inactive” compared with “normal weight/active” patients (P = 0.03).Conclusions:We provide evidence of associations between individual and combined physical activity and BMI groups with proinflammatory biomarkers. Although BMI was identified as the key driver of inflammation, biomarker levels were higher among “inactive” patients across BMI groups.Impact:This is the largest study in colorectal cancer patients investigating associations of energy balance components with inflammatory biomarkers. Our results suggest that physical activity may reduce obesity-induced inflammation in colorectal cancer patients and support the design of randomized controlled trials testing this hypothesis.

Supplementary Data from Associations of Individual and Combined Physical Activity and Body Mass Index Groups with Proinflammatory Biomarkers among Colorectal Cancer Patients

Background Patients rarely dispose of left-over opioids after surgery. Disposal serves as a primary prevention against misuse, overdose, and diversion. However, current interventions promoting disposal have mixed efficacy. Increasing disposal in rural communities could prevent or reduce the harms caused by prescription opioids. Aims Identify barriers and facilitators to disposal in the rural communities of the United States Mountain West region. Methods We conducted a qualitative description study with 30 participants from Arizona, Idaho, Montana, Nevada, Oregon, Utah, and Wyoming. We used a phronetic iterative approach combining inductive content and thematic analysis with deductive interpretation through the Precaution Adoption Process Model (PAPM). Results We identified four broad themes: (a) awareness, engagement, and education; (b) low perceived risk associated with nondisposal; (c) deciding to keep left-over opioids for future use; and (d) converting decisions into action. Most participants were aware of the importance of disposal but perceived the risks of nondisposal as low. Participants kept opioids for future use due to uncertainty about their recovery and future treatments, breakdowns in the patient–provider relationship, chronic illness or pain, or potential future injury. The rural context, particularly convenience, cost, and environmental contamination, contributes to decisional burden. Conclusions We identified PAPM stage-specific barriers to disposal of left-over opioids. Future interventions should account for where patients are along the spectrum of deciding to dispose or not dispose as well as promoting harm-reduction strategies for those who choose not to dispose.

Background: Physical activity and obesity are well-established factors of colorectal cancer risk and prognosis. Here, we investigate associations of individual and combined physical activity and body mass index (BMI) groups with proinflammatory biomarkers in colorectal cancer patients. Methods: Self-reported physical activity levels were classified as “active” (≥8.75 MET-hours/week) versus “inactive” ( Results: “Inactive” patients had non-statistically significant higher IL6 levels compared with “active” patients (+36%, P = 0.10). “Obese” patients had 88% and 17% higher CRP and TNFα levels compared with “normal weight” patients (P = 0.03 and 0.02, respectively). Highest CRP levels were observed among “overweight or obese/inactive” compared with “normal weight/active” patients (P = 0.03). Conclusions: We provide evidence of associations between individual and combined physical activity and BMI groups with proinflammatory biomarkers. Although BMI was identified as the key driver of inflammation, biomarker levels were higher among “inactive” patients across BMI groups. Impact: This is the largest study in colorectal cancer patients investigating associations of energy balance components with inflammatory biomarkers. Our results suggest that physical activity may reduce obesity-induced inflammation in colorectal cancer patients and support the design of randomized controlled trials testing this hypothesis.

Background Up to 30% of patients with ulcerative colitis will undergo surgery resulting in an ileal pouch-anal anastomosis (IPAA) or permanent end ileostomy (EI). We aimed to understand how patients decide between these two options. Methods We performed semi-structured interviews with ulcerative colitis patients who underwent surgery. Areas of questioning included the degree to which patients participated in decision-making, challenges experienced, and suggestions for improving the decision-making process. We analyzed the data using a directed content and thematic approach. Results We interviewed 16 patients ranging in age from 28 to 68 years. Nine were male, 10 underwent IPAA, and 6 underwent EI. When it came to participation in decision-making, 11 patients felt independently responsible for decision-making, 3 shared decision-making with the surgeon, and 2 experienced surgeon-led decision-making. Themes regarding challenges during decision-making included lack of support from family, lack of time to discuss options with the surgeon, and the overwhelming complexity of the decision. Themes for ways to improve decision-making included the need for additional information, the desire for peer education, and earlier consultation with a surgeon. Only 3 patients were content with the information used to decide about surgery. Conclusions Patients with ulcerative colitis who need surgery largely experience independence when deciding between IPAA and EI, but struggle with inadequate educational information and social support. Patients may benefit from early access to surgeons and peer guidance to enhance independence in decision-making. Preoperative educational materials describing surgical complications and postoperative lifestyle could improve decision-making and facilitate discussions with loved ones.

BACKGROUND: Surgical resection is an integral component of the curative-intent treatment for most patients with non-metastatic rectal cancer. However, some patients refuse surgery for a number of reasons. Utilizing the National Cancer Database (NCDB), we investigated the sociodemographic and clinical factors associated with patients who were coded as having been offered but refused surgery, and the factors affecting overall survival (OS) in these patients. METHODS: Adult patients with adenocarcinoma of the rectum (excluding T1N0M0 and M1 disease) diagnosed from 2004 to 2015 were analyzed in this retrospective cohort study. Logistic regression was performed to identify factors associated with refusal of surgery. OS of patients refusing surgery was compared using Kaplan-Meier estimate, log-rank test, propensity score matching, and proportional hazards regression. RESULTS: A total of 55,704 patients were identified: 54,266 received definitive surgery (97.4%) and 1,438 refused (2.6%). Of patients refusing surgery, 135 (9.4%) were stage I, 709 (49.3%) were stage II, and 594 (41.3%) were stage III. Patients were more likely to refuse surgery as the study period progressed (P

Background: Advance care planning (ACP) is recommended for older patients undergoing surgery. ACP consists of creating advance directives (ADs), identifying surrogate decision makers (SDMs), and documenting goals of care. We identified factors associated with documentation of preoperative ACP to identify opportunities to optimize ACP for older surgical patients. Methods: This was a retrospective study of surgical patients ≥70 years old who underwent elective, high-risk abdominal procedures between 01/2015-08/2019. Clinical data were obtained from our institution’s National Surgical Quality Improvement Project database. ACP metrics were extracted from the electronic medical record. We analyzed the data to identify patient factors associated with ACP metrics. We also analyzed whether ACP was more frequent for patients who experienced postoperative complications or death. Results: 267/1,651 patients were included. 97 patients (36%) had an AD available on the day of surgery, 57 (21%) had an SDM identified, and 31 (12%) had a documented goals of care conversation. On multivariable analysis, older age and white race were associated with an increased likelihood of having an AD available on the day of surgery. Women were 1.7 times more likely to have an SDM (p = 0.02). No patient or surgeon factors were significantly associated with goals of care documentation. ACP was not performed more frequently in patients who experienced postoperative complications or death. Conclusion: In this series, ACP was not routinely documented for older patients undergoing major surgery. ACP was not more frequent in patients who experienced complications or death, demonstrating the importance of universal preoperative ACP in older patients.

Background: More than 10% of US adults are living with type 2 diabetes. The Centers for Disease Control and Prevention established the National Diabetes Prevention Program (National DPP) in 2010 in an effort to delay or prevent this disease among individuals at high risk. Unfortunately, enrollment and retention rates are low. This qualitative study aims to understand barriers and facilitators to enrolling and completing the National DPP among women, and to provide recommendations for improvement. Methods: Semistructured interviews were conducted with the following: (1) women who were eligible for the National DPP, but declined to enroll (n=11); (2) women who enrolled in the National DPP, but did not complete the program (n=12); and (3) clinicians who treat women eligible for the National DPP (n=12). Transcripts of the interviews were coded using content analysis. Results: The 35 interviews (23 patients and 12 clinicians) provided further insight into known barriers, such as the cost of the program, the time that it takes, and inconvenient locations. The study also identified previously undiscovered barriers, including the program not meeting participants' expectations and facilitating referrals. Furthermore, improved communication between clinicians, patients, and National DPP staff could ensure that both clinicians and National DPP staff are aware of patients' goals and their individual barriers to success. Conclusions: Enrollment and retention in the National DPP may be improved with additional communication, more training for National DPP staff to work more closely with participants, adding better incentives to participation, and making the program more accessible through flexibility in time and/or locations.

BACKGROUND: Mechanical bowel preparation with antibiotics is associated with decreased surgical site infections (SSI) after colorectal surgery. However, antibiotics have side effects, such as vomiting. It is unknown how patient willingness to take antibiotics is affected by side effect severity. MATERIALS AND METHODS: This was a single-center study of 86 patients (37 undergoing colorectal surgery) using a modified standard gamble technique. We presented patients with four hypothetical scenarios, holding SSI reduction constant and varying antibiotic side effect severity. Patients reported willingness to take antibiotics using a scale from 0 to 100. Patients also reported the maximum level of side effects they would accept. We examined the association between side effect severity and willingness to take antibiotics with a multivariable mixedeffects regression model and investigated differences in surgical and nonsurgical patients. RESULTS: After adjusting for age, sex, and patient type, willingness scores decreased with increasing side effect severity. No side effects: 92 (CI 86,99), mild: 83 (CI 76,90), moderate: 76 (CI 69,83), and severe: 46 (CI 38,52), P < 0.001. Surgical patients were more willing to take antibiotics at all severity levels compared with nonsurgical patients, P < 0.001. Surgical (57%) and nonsurgical (58%) patients reported that they would accept moderate side effects. Patients with prior SSI (n = 5) would take antibiotics regardless of side effect severity. CONCLUSIONS: Increasing antibiotic side effect severity is associated with decreased willingness to take antibiotics during bowel preparation, despite a reduction in SSI. Adherence may be improved with strategies that increase patient education and decrease side effects during bowel preparation.

BACKGROUND Anorectal melanoma (ARM) is a rare disease with a poor prognosis. Evidence on optimal treatment is limited and surgical management varies widely. We hypothesized that the frequency of abdominoperineal resection used as primary treatment of ARM has decreased over the past several decades. AIM To update our understanding of outcomes for patients with ARM and analyze management trends around the world. METHODS This is a multi-institutional, retrospective study of patients treated for ARM at 7 hospitals. Hospitals included both large, academic, tertiary care centers and smaller, general community hospitals. Using prospectively maintained institutional tumor registries, we identified 24 patients diagnosed with ARM between January 2000 and May 2019. We analyzed factors prognostic for recurrence and survival. We then used Cox regression to measure overall survival (OS) and melanoma-specific survival. We also performed a literature review to assess trends in surgical management and outcomes. RESULTS Of the 24 patients diagnosed with ARM, 12 (50.0%) had local, 8 (33.3%) regional, and 4 (16.7%) distant disease at diagnosis. Median time to recurrence was 10.4 mo [interquartile range (IQR) 7.5-17.2] with only 2 patients (9.3%) not developing recurrence following surgical resection. Median OS was 18.8 mo (IQR 13.5-33.9). One patient is still alive without recurrence at 21.4 mo from diagnosis; no other patient survived 5 years. Primary surgical management with abdominoperineal resection (APR) vs wide excision (WE) did not lead to differences in OS [hazard ratio = 1.4 (95%CI: 0.3-6.8)]. Review of the literature revealed geographic differences in surgical management of ARM, with increased use of WE in the United States and Europe over time and more frequent use of APR in Asia and India. There was no significant improvement in survival over time. CONCLUSION There is wide variation in the management of ARM and survival outcomes remain poor regardless of approach. Surgical management should aim to minimize morbidity.

BackgroundTo increase bed capacity and resources, hospitals have postponed elective surgeries, although the financial impact of this decision is unknown. We sought to report elective surgical case distribution, associated gross hospital earnings and regional hospital and intensive care unit (ICU) bed capacity as elective surgical cases are cancelled and then resumed under simulated trends of COVID-19 incidence.MethodsA retrospective, cohort analysis was performed using insurance claims from 161 million enrollees from the MarketScan database from January 1, 2008 to December 31, 2017. COVID-19 cases were calculated using a generalized Richards model. Centers for Disease Control (CDC) reports on the number of hospitalized and intensive care patients by age were used to estimate the number of cases seen in the ICU, the reduction in elective surgeries and the financial impact of this from historic claims data, using a denominator of all inpatient revenue and outpatient surgeries.ResultsAssuming 5% infection prevalence, cancelling all elective procedures decreases ICU overcapacity from 340% to 270%, but these elective surgical cases contribute 78% (IQR 74, 80) (1.1 trillion (T) US dollars) to inpatient hospital plus outpatient surgical gross earnings per year. Musculoskeletal, circulatory and digestive category elective surgical cases compose 33% ($447B) of total revenue.ConclusionsProcedures involving the musculoskeletal, cardiovascular and digestive system account for the largest loss of hospital gross earnings when elective surgery is postponed. As hospital bed capacity increases following the COVID-19 pandemic, restoring volume of these elective cases will help maintain revenue.DECLARATIONSEthics approval and consent to participateThis study did not meet criteria for IRB review.Consent for publicationNot applicableAvailability of data and materialsTo facilitate research reproducibility, replicability, accuracy and transparency, the associated analytic code is available on the Open Science Foundation [1] (OSF) repository, [DOI 10.17605/OSF.IO/U53M4] at [https://osf.io/u53m4]. The data that support the findings of this study were obtained under license from Truven. Data were received de-identified in accordance with Section 164.514 of the Health Insurance Portability and Accountability Act (HIPAA).Competing interestsJET received modest financial support for speakers fees from LivaNova and from Philips Healthcare, outside of the work. The other authors declare that they have no competing interests.FundingJET is supported by a career development award (K23HL141596) from the National Heart, Lung, And Blood Institute (NHLBI) of the National Institutes of Health (NIH). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. None of the funding sources were involved in the design or conduct of the study, collection, management, analysis or interpretation of the data, or preparation, review or approval of the manuscript.Authors’ contributionsJET, JH had full access to all the data in the study, takes responsibility for the integrity of the data, the accuracy of the data analysis, and the integrity of the submission as a whole, from inception to published article. JET, HH, BSB, JC, MM, JJH, JH conceived study design; JET, HH, BSB, JC, MM, JJH, RD, BK, AJC, JH contributed to data acquisition and analysis; JET, HH, JJH, JH drafted the work; all authors revised the article for important intellectual content, had final approval of the work to be published, and agree to be accountable to for all aspects of the work.AcknowledgementsNot applicable

BACKGROUND The optimal strategy for colonic polyps not amenable to traditional endoscopic polypectomy is unknown. Endoscopic step up is a promising strategy for definitive treatment. OBJECTIVE The purpose of this study was to determine whether endoscopic step up leads to improved outcomes and decreased costs compared with planned colectomy for endoscopically unresectable colon polyps. DESIGN This was a retrospective review of a prospective database. SETTING The study was conducted at a tertiary referral center. PATIENTS Consecutive patients referred for endoscopically unresectable colon polyps 15 to 50 mm in size were included. INTERVENTIONS Patients underwent planned colectomy or endoscopic step up at the surgeon's discretion. Endoscopic step up began with diagnostic colonoscopy in the operating room. If the polyp was amenable to endoscopic removal, endoscopic mucosal resection or endoscopic submucosal dissection was performed with progression to combined endoscopic-laparoscopic surgery or laparoscopic colectomy, as indicated. MAIN OUTCOME MEASURES The primary outcome was 30-day adverse events. We also examined length of stay, hospital charges, insurer payments, and polyp recurrence. RESULTS A total of 52 patients underwent planned colectomy (48 laparoscopic), and 38 underwent endoscopic step up (28 endoscopic mucosal resection, 2 endoscopic submucosal dissection, 6 combined endoscopic-laparoscopic surgery, and 2 colectomy). Compared with planned colectomy, endoscopic step-up patients had fewer complications (13% vs 33%; p = 0.03) and shorter length of stay (median, 0 vs 4 d; p < 0.001). There was 1 readmission in the endoscopic step-up group and 5 in the planned colectomy group. Endoscopic step-up patients had lower hospital costs ($4790 vs $13,004; p < 0.001) and insurer payments ($2431 vs $19,951; p < 0.001). One-year polyp recurrence-free survival was 84% (95% CI, 67%-93%) in endoscopic step-up patients. All of the recurrences were benign

Successful recovery after surgery is complex and highly individual. Rural patients encounter greater barriers to successful surgical recovery than urban patients due to varying healthcare and community factors. Although studies have previously examined the recovery process, rural patients' experiences with recovery have not been well-studied. The rural socioecological context can provide insights into potential barriers or facilitators to rural patient recovery after surgery.We conducted semi-structured qualitative interviews with a purposeful sample of 30 adult general surgery patients from rural areas in the Mountain West region of the United States. We used the socioecological framework to analyze their responses. Interviews focused on rural participants' experiences accessing healthcare and the impact of family and community support during postoperative recovery. Interviews were transcribed verbatim and coded using content and thematic analysis.All participants commented on the quality of their rural healthcare systems and its influence on postoperative care. Some enjoyed the trust developed through long-standing relationships with providers in their communities. However, participants described community providers' lack of money, equipment, and/or knowledge as barriers to care. Following surgery, participants recognized that there are advantages and disadvantages to receiving family and community support. Some participants worried about being stigmatized or judged by their community.Future interventions aimed at improving access to and recovery from surgery for rural patients should take into account the unique perspectives of rural patients. Addressing the socioecological factors surrounding rural surgery patients, such as healthcare, family, and community resources, will be key to improving postoperative recovery.

After initial nonoperative management of diverticulitis, individuals with a family history of diverticulitis may have increased risk of recurrent disease.This study measured the association between family history and recurrent diverticulitis in a population-based cohort.This is a retrospective, population-based cohort study.The cohort was identified from the Utah Population Database, a statewide resource linking hospital and genealogy records.Individuals evaluated in an emergency department or hospitalized 1998-2018 for nonoperatively managed diverticulitis were included.The primary predictor was a positive family history of diverticulitis, defined as diverticulitis in a first-, second-, or third-degree relative.This study measured the adjusted association between family history and the primary outcome of recurrent diverticulitis. A secondary outcome was elective surgery for diverticulitis. Additional analyses evaluated risk by degree of relation of the affected family member.The cohort included 4426 individuals followed for a median of 71 months. Median age was 64 years and 45% were male. 17% had complicated disease, 11% had recurrence, and 15% underwent elective surgery. After adjustment, individuals with a family history of diverticulitis had a similar risk of recurrence when compared to those without a family history (HR 1.0 95% CI 0.8-1.2). However, individuals with a family history of diverticulitis were more likely to undergo elective surgery (HR 1.4 95% CI 1.1-1.6). This effect was most pronounced in those with an affected first-degree family member (HR 1.7 95% CI 1.4-2.2).The use of state-specific data may limit generalizability.In this population-based analysis, individuals with a family history of diverticulitis were more likely to undergo elective surgery than those without a family history, despite similar risks of recurrence and complicated diverticulitis. Further work is necessary to understand the complex social, environmental, and genetic factors that influence diverticulitis treatment and outcomes. See Video Abstract at http://links.lww.com/DCR/B876.

Objective: Interventions aimed at limiting opioid use are widespread. These are most often targeted toward prescribers or health systems. Patients’ perspectives are too often absent during the creation of such interventions. This qualitative study aims to understand patient experiences with education about perioperative pain control, from preoperative expectation-setting to post-operative pain control strategies and ultimately opioid disposal.Design: We performed semistructured interviews focused on patient experiences in the perioperative period. Content from interview transcripts was analyzed using a constant comparative method.Setting: All participants underwent surgery at a single, academic tertiary-care center.Participants: Adult patients who had a general surgery operation in the prior 60 days.Outcome measure: Key themes from interviews about perioperative pain management, specifically related to preoperative expectation-setting and post-operative education.Results: Patients identified gaps in communication and education in three main areas: preoperative expectation setting of post-operative pain; post-operative pain control strategies, including use of opioid medications; and the importance of appropriate opioid disposal. Failure to set expectations led to either significant patient anxiety preoperatively or poor preparation for home discharge. Poor education on pain control strategies led to misinformation on when and how to use opioids. Lack of education on opioid disposal led to most participants failing to properly dispose of leftover medication.Conclusions: Gaps in education surrounding post-operative pain and opioid use can lead to patient anxiety, inappropriate use of opioids, and poor disposal rates of leftover medications. Future interventions aimed at patient education to improve pain management and opioid stewardship should be created with an understanding of patient experiences and perceptions.

Early-onset colorectal cancer has been on the rise in Western populations. Here, we compare patient characteristics between those with early- (&lt, 50 years) vs. late-onset (≥50 years) disease in a large multinational cohort of colorectal cancer patients (n = 2193). We calculated descriptive statistics and assessed associations of clinicodemographic factors with age of onset using mutually-adjusted logistic regression models. Patients were on average 60 years old, with BMI of 29 kg/m2, 52% colon cancers, 21% early-onset, and presented with stage II or III (60%) disease. Early-onset patients presented with more advanced disease (stages III–IV: 63% vs. 51%, respectively), and received more neo and adjuvant treatment compared to late-onset patients, after controlling for stage (odds ratio (OR) (95% confidence interval (CI)) = 2.30 (1.82–3.83) and 2.00 (1.43–2.81), respectively). Early-onset rectal cancer patients across all stages more commonly received neoadjuvant treatment, even when not indicated as the standard of care, e.g., during stage I disease. The odds of early-onset disease were higher among never smokers and lower among overweight patients (1.55 (1.21–1.98) and 0.56 (0.41–0.76), respectively). Patients with early-onset colorectal cancer were more likely to be diagnosed with advanced stage disease, to have received systemic treatments regardless of stage at diagnosis, and were less likely to be ever smokers or overweight.

Background: Older patients (>65 years) are frequently under-represented in clinical trials that determine cancer treatment guidelines. We sought to characterize treatment patterns among older patients and identify factors for receipt of non-standard of care (SOC) treatment. Methods: The National Cancer Database (NCDB) was queried to describe treatment patterns in stage I-III colorectal cancer patients (2004-2017) over 65 years of age. Patients with metastatic disease and non-adenocarcinoma histology were excluded. SOC therapy was defined as any recommended treatment option listed within site- and stage-specific National Comprehensive Cancer Network guidelines. Clinicodemographic characteristics and treatment patterns were compared between colon and rectal cancer patients by ten-year age-groups. Multivariable logistic regression analysis was used to determine factors associated with receipt of treatment, by tumor site and stage. Results: Of the 498,285 patients who met inclusion criteria, 47% were 65-75 years while 15% were >85 years old (median age: 76 years). The majority were non-Hispanic White (88%), female (52%), Medicare insured (86%), colon cancer patients (76%) with a Charlson comorbidity index (CCI) of 0 (63%). Significant differences in treatment patterns by age were observed; for e.g., 11% of stage I colon cancer patients >85 years of age did not receive SOC surgical treatment but rather received radiation-only treatment compared to only 2% patients 65-75 years of age who received radiation-only treatment. In logistic regression analyses adjusted for diagnosis year, sex, race/ethnicity, CCI, insurance, income, education, hospital type, treatment facility, rurality, and geographic region, older patients were more likely to receive non-SOC treatments for colon cancer stage I [OR(95% CI) for 76-85 years 1.31(1.23,1.40); >85 years 3.41(3.17,3.66)], stage II-III [OR(95% CI) for 76-85 years 1.96(1.92,2.01); >85 years 3.50(3.40,3.60)], rectal cancer stage I [OR(95% CI) for 76-85 years 2.06(1.89,2.24); >85 years 6.36(5.77,7.02)], and stage II-III [OR(95% CI) for 76-85 years 2.14(2.07,2.22); >85 years 9.02(8.33,9.77)] compared to 65-75 year old patients. Other predictors of receiving non-SOC treatments for both colon and rectal cancers included Black race (p3 (p Discussion: Compared to 65-75 year-old stage I-III colorectal cancer patients, older patients at all disease stages are more likely to not receive SOC treatment. Other predictors for receiving non-SOC treatment are Black race, presence of comorbidities, lack of insurance, and treatment at a community cancer clinic. Future observational and randomized studies are needed to define the optimal treatment paradigms in older colorectal cancer patients, identify and address disparities, and better support these patients. Citation Format: Sheetal Hardikar, Christopher R. Weil, Shane Lloyd, Jessica N. Cohan, Mark A. Supiano, Jennifer Ose, Anita R. Peoples, Sumati V. Gupta, Kaitlyn Pelletier, Martine Extermann, Erin M. Siegel, David Shibata, Cornelia M. Ulrich. Treatment patterns in stage I-III colorectal cancer patients over 65 years of age [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 36.

Background We aimed to identify decision process measures associated with patient decisional regret regarding the decision to pursue elective colectomy or observation for diverticulitis. Materials and methods This was a single-center cross-sectional survey study. We included adult patients treated for diverticulitis between 2014 and 2019 and excluded patients who required urgent or emergent colectomy. The primary outcome was regret regarding the decision to pursue elective surgery or observation for diverticulitis, measured using the Decision Regret Scale. We used multivariable linear regression to examine hypothesized predictors of decision regret, including decisional conflict (Decision Conflict Scale and its subscales), shared decision-making, and decision role concordance. Results Of 923 eligible patients, 133 were included in the analysis. Patients had a median of five episodes of diverticulitis (interquartile range 3-8), occurring a median of 2 y (interquartile range 1-3) before survey administration. Thirty-eight patients (29%) underwent elective surgery for diverticulitis. Decision regret (Decision Regret Scale score ≥25) was present in 42 patients (32%). After controlling for surgery, gender, health status, and years since treatment, decision regret was associated with decisional conflict and inversely associated with values clarity, decision role concordance, shared decision-making, and feeling informed, supported, and effective in decision-making (all P Conclusions Nearly one-third of survey respondents experienced regret regarding the decision between elective surgery and observation for diverticulitis. Decision regret may be reduced through efforts to improve patient knowledge, values clarity, role concordance, and shared decision-making.

Up to 30% of patients who have ulcerative colitis are faced with the complex decision between end ileostomy and IPAA. We developed a decision aid to encourage shared decision making between patients and surgeons.The aim of this study is to determine whether a decision aid is effective and acceptable for surgical patients with ulcerative colitis and their treating surgeons.This was a prospective cohort study.Patients and surgeons were enrolled from 3 colorectal surgery clinics.Consecutive adult patients with ulcerative colitis who were candidates for IPAA and end ileostomy were selected.Patients used a multilingual decision aid before meeting with the surgeon.We measured changes in knowledge, treatment preference, and stage of decision making, as well as preparation for decision making, patient satisfaction, and surgeon satisfaction after using the decision aid.Twenty-five patients were enrolled; 5 had previously undergone subtotal colectomy. After using the decision aid, patients' knowledge scores improved by 39% (p0.006), 6 patients changed their treatment preference, and 8 reported increased certainty in treatment preference. The median for preparation for decision making was 75 of 100. Patient satisfaction with the decision aid (median score, 37/41) and surgeon satisfaction with the clinical encounter (median score, 38/45) were high. Patients who previously underwent subtotal colectomy had lower preparation for decision-making scores (median score, 58 vs 78 for surgery-naïve patients, p = 0.06), and did not report increased certainty in treatment preference after using the decision aid.The study included a small sample with no comparison group.A novel decision aid for surgical patients with ulcerative colitis appears to be effective and acceptable in patients and surgeons from diverse clinical settings. Patients who have not yet initiated surgical treatment seem to benefit most. Future studies to validate the knowledge questionnaire and test the decision aid in a randomized fashion are warranted.

PURPOSE: The ColoCare Study is an international cohort of men and women (>18 years age) newly diagnosed with stage I-IV colorectal cancer from seven centers in the United States and Germany. Study enrollment is currently ongoing. Here, we describe the clinical and demographic characteristics of this large cohort of prospectively followed colorectal cancer patients and describe differences in demographic, lifestyle, and clinical characteristics by age of onset and tumor site. METHODS: Data on demographics (sex, age, race, ethnicity) and lifestyle factors (smoking, body mass index) collected at baseline are included in this analysis, in addition to information on tumor characteristics (tumor stage and site), treatment (neoadjuvant and adjuvant therapy), and clinical outcomes (vital status, recurrence). Patients were categorized into early- ( RESULTS: Data on 1,933 stage I-IV colorectal cancer cases were included in this study, 19% of which were deceased at the time of this analysis. On average, patients were 60 years old, had a BMI of 29 kg/m2, and were predominantly diagnosed with stage II (25%) and stage III (33%) colorectal cancer. Fifty three percent of cases were diagnosed with colon cancer, while 47% were rectal cancer cases. Twenty percent (n=364) of patients were diagnosed before age 50 (i.e. early-onset cases). The early-onset group presented with a higher percentage of rectal cancer (52%) and more advanced disease (64% stage III-IV cancer) compared to late-onset cases (46% and 48%, respectively). Percentages of ever smokers were higher among late-onset compared to early-onset patients (51% vs. 38%), independent of tumor site. Early-onset cancers were more likely to originate in the rectum compared to colon, particularly among women (61% vs. 51%). Early-onset rectal cancer cases were more likely to be female as compared to late-onset rectal cancer cases (61% vs. 36%). Corresponding with national trends, early-onset cases received more aggressive adjuvant therapy after surgical resection compared to late-onset patients (54% vs. 40%). DISCUSSION: Within this large international multi-center cohort, patients with early-onset colorectal cancer were more likely to be diagnosed with rectal cancer and advanced stage disease. The majority of early-onset cases in the ColoCare Study were non-smokers. As expected, more aggressive treatment modalities were used in patients with early-onset disease. Citation Format: Caroline Himbert, Jane Figueiredo, Lyen Huang, Biljana Gigic, Courtney L. Scaife, Bartley Pickron, Laura Lambert, Jessica Cohan, Mary Bronner, Jolanta Jedrzkiewicz, Esther Herpel, Matthias Kloor, Johanna Nattenmueller, Hans-Ulrich Kauczor, Alexis Ulrich, Seth Felder, Julian Sanchez, Sophie Dessureault, Nathan Hinkle, Justin Monroe, Matthew Mutch, Cory Bernadt, Deyali Chatterjee, Mika Sinanan, Stacey Cohen, Ulrik Wallin, Deepti Reddi, Mukta Krane, Afshin E. Gabayan, David M. Hoffman, Yosef Y. Nasseri, Robert W. Decker, Karen Zaghiyan, Zuri A. Murrell, Andrew E. Hendifar, Jun Gong, Eiman Firoozmand, Alexandra Gangi, Beth A. Moore, Kyle G. Cologne, Maryliza El-Masry, William Grady, Martin Schneider, Stephanie L. Schmit, Erin Siegel, David Shibata, Adetunji Toriola, Christopher Li, Cornelia Ulrich, Sheetal Hardikar. Clinical characteristics and outcomes of colorectal cancer in the ColoCare Study: Differences by age of onset [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 2364.

Background Although social support is important for quality of life in patients undergoing surgery for ulcerative colitis, the impact of surgery on patient relationships is not known. Objective We examined relationship parameters in patients with ulcerative colitis and their partners before and 6 months after surgery. Design This was a prospective cohort in which we performed an exploratory analysis. Settings Patients were enrolled from an academic medical center. Patients Surgical patients with ulcerative colitis and their partners were invited to participate. Interventions Patients underwent proctocolectomy in 1, 2, or 3 stages. Main outcome measures We measured quality of life and sexual function in patients, as well as relationship quality, empathy, and sexual satisfaction in patients and partners before and 6 months after surgery using validated questionnaires. Results The study sample consisted of 74 participants, including 37 patients (25 men and 12 women) and their opposite-sex partners. Quality of life improved significantly in male and female patients after surgery. Sexual function scores also improved after surgery in male and female patients; however, the changes reached statistical significance in male patients only. Sexual satisfaction scores improved significantly after surgery in female patients and their partners. There was little change in relationship quality or empathy after surgery, with the exception of slightly improved relationship quality reported by male partners. In general, patients and partners reported levels of relationship quality and empathy similar to normative populations. Limitations This study included a small, highly selected sample. Conclusions Male and female patients with ulcerative colitis have high-quality relationships that are not negatively affected by surgical treatment. Changes in sexual function do not necessarily coincide with changes in sexual satisfaction in this patient population. Future studies should evaluate the effect of high-quality relationships on surgical outcomes.

Up to 30% of patients who underwent surgical treatment for rectal prolapse will experience a recurrence. The presentation and evaluation of recurrent rectal prolapse is similar to that of primary rectal prolapse. The options for surgical treatment are the same as those for primary disease, and similarly, there is no widely accepted gold standard. Several factors are considered when choosing an approach, such as the patient׳s previous surgical history, age, functional status, and comorbid pelvic floor disorders such as fecal incontinence and constipation. Abdominal and perineal approaches have been described. The ideal procedure for each patient is that which has the longest durability and best functional outcome while minimizing surgical morbidity. Future prospective studies that critically evaluate outcomes are needed to guide procedure choice.

Background Evidence from single-center studies suggests that ileal pouch-anal anastomosis (IPAA) can be safely performed in selected older patients with ulcerative colitis. The impact of age and frailty on surgical outcomes and hospital length of stay after IPAA has not been examined. Methods We identified all patients with ulcerative colitis who underwent total proctocolectomy or completion proctectomy with IPAA in the National Surgery Quality Improvement Program database from 2005–2012. We examined the associations of age and frailty trait count with length of hospital stay and surgical complications using multivariate regression. Results IPAA was performed in 2493 patients with ulcerative colitis. Thirty-day mortality was 0.2% (n = 6). The majority of patients had no serious postoperative complications (age ≤50 y: 79.5%, age 51–60 y: 80.4%, and age >60 y: 79.1%). After multivariate risk adjustment, patients aged >60 y had a similar mean number of complications as patients aged ≤50 y (0.31 versus 0.35, P = 0.47) and a 0.8-d longer mean length of hospital stay (7.4 versus 8.2 d, P = 0.035). Compared to patients with zero frailty traits, a frailty trait count ≥1 was associated with a similar mean number of complications (0.31 versus 0.34, P = 0.36) and length of hospital stay (7.4 versus 7.7 d, P = 0.25). Conclusions In this analysis of patients undergoing IPAA at National Surgery Quality Improvement Program hospitals, surgical complications were not substantially increased in older patients or those with frailty traits. Older age was associated with a small increase in hospital length of stay. These findings suggest that IPAA is safe in selected older adults with ulcerative colitis.

Aim Little is known about men with faecal incontinence. We compared clinical findings and quality of life in a large cohort of men and women with faecal incontinence to guide its evaluation and treatment in men. Method We analysed men and women presenting to a tertiary referral centre with faecal incontinence between 2005 and 2013. Demographics, physical examination, anorectal physiology testing, symptom severity (Fecal Incontinence Severity Index) and quality of life (Fecal Incontinence Quality of Life Scale) were recorded. We determined differences between men and women and analysed the association between gender and quality of life. Results Data were obtained from 144 men and 897 women. Men with faecal incontinence were slightly younger than women (55.3 vs 57.6 years, P = 0.001), more likely to report coexisting constipation (P = 0.004) and more likely to have normal internal and external sphincter function on physical examination (both P

Object The use of minimally invasive surgical techniques, including microscope-assisted tubular lumbar microdiscectomy (tLMD), has gained increasing popularity in treating lumbar disc herniations (LDHs). This particular procedure has been shown to be both cost-efficient and effective, resulting in outcomes comparable to those of open surgical procedures. Lumbar disc herniation recurrence necessitating reoperation, however, remains an issue following spinal surgery, with an overall reported incidence of approximately 3–13%. The authors' aim in the present study was to report their experience using tLMD for single-level LDH, hoping to provide further insight into the rate of surgical recurrence and to identify potential risk factors leading to this complication. Methods The authors retrospectively reviewed the cases of 217 patients who underwent tLMD for single-level LDH performed identically by 2 surgeons (J.B., R.H.) between 2004 and 2008. Evaluation for LDH recurrence included detailed medical chart review and telephone interview. Recurrent LDH was defined as the return of preoperative signs and symptoms after an interval of postoperative resolution, in conjunction with radiographic demonstration of ipsilateral disc herniation at the same level and pathological confirmation of disc material. A cohort of patients without recurrence was used for comparison to identify possible risk factors for recurrent LDH. Results Of the 147 patients for whom the authors were able to definitively assess symptomatic recurrence status, 14 patients (9.5%) experienced LDH recurrence following single-level tLMD. The most common level involved was L5–S1 (42.9%) and the mean length of time to recurrence was 12 weeks (range 1.5–52 weeks). Sixty-four percent of the patients were male. In a comparison with patients without recurrence, the authors found that relatively lower body mass index was significantly associated with recurrence (p = 0.005), such that LDH in nonobese patients was more likely to recur. Conclusions Recurrence rates following tLMD for LDH compare favorably with those in patients who have undergone open discectomy, lending further support for its effectiveness in treating single-level LDH. Nonobese patients with a relatively lower body mass index, in particular, appear to be at greater risk for recurrence.

Little is known about how obstructive defecation and colonic inertia symptoms contribute to constipation-related quality of life.We sought to characterize the differences in quality of life in patients with severe obstructive defecation and colonic inertia symptoms.This study was a cross-sectional analysis of a prospective database.Patients were enrolled at a single tertiary referral center.We included consecutive adults with severe symptoms of obstructive defecation (n = 115) or colonic inertia (n = 90) as measured by the Constipation Severity Instrument.The primary outcomes measured were the Pelvic Floor Distress Inventory, Constipation-Related Quality of Life instrument, Pelvic Floor Impact Questionnaire, and 12-item Short Form Health Survey.Although physical examination and anorectal physiology testing were similar between groups, patients with severe obstructive defecation symptoms reported worse pain, distress, and constipation-specific quality of life than patients with severe colonic inertia symptoms (all p0.001). Specifically, patients with severe obstructive defecation symptoms showed greater quality-of-life impairment related to eating, bathroom habits, and social functioning (all p ≤ 0.01). Furthermore, patients with severe obstructive defecation symptoms had inferior global quality of life on the 12-item Short Form Health Survey physical component score (p = 0.03) and mental component score (p = 0.06).The use of patient self-report instruments resulted in a proportion of patients with incomplete data.Quality of life was impaired in both groups of patients; however, patients with severe obstructive defecation symptoms were affected to a significantly greater extent. The fact that there were no differences in objective findings on physical examination or anorectal physiology studies highlights the importance of assessing quality of life during the evaluation and treatment of constipated patients.

BACKGROUND Historically, older patients with ulcerative colitis were not considered candidates for ileal pouch-anal anastomosis. However, more recent evidence suggests that this procedure can be performed in older patients with acceptable surgical and functional results. OBJECTIVE The purpose of this work was to determine whether older age is independently associated with surgical procedure type among patients with ulcerative colitis in a large national database. DESIGN This was a cross-sectional analysis of ulcerative colitis patients undergoing end ileostomy or IPAA, grouped by age. SETTINGS This study was conducted in a university teaching hospital. PATIENTS Patients with ulcerative colitis who underwent total proctocolectomy or completion proctectomy with either IPAA or end ileostomy from 2005 to 2012 in the American College of Surgeons National Surgery Quality Improvement Program database were included in this study. MAIN OUTCOME MEASURES The primary outcome was procedure type (end ileostomy or IPAA). Patient factors associated with procedure type, including age and trends over time, were examined using multivariate logistic regression. RESULTS Among 3635 patients with ulcerative colitis, 28.2% underwent end ileostomy and 71.8% underwent IPAA. Older patients were more likely to undergo end ileostomy than patients ≤50 years of age after adjustment for sex, smoking, BMI, frailty trait count, and ASA class (p < 0.001). The odds of end ileostomy decreased by 12% per year between 2005 and 2012 in patients aged 61 to 70 years compared with patients ≤50 years of age (adjusted OR, 0.88 per year; p = 0.021). LIMITATIONS We were unable to analyze other potentially important determinants of procedure type, such as surgeon, patient preference, and anal sphincter integrity. CONCLUSIONS Age remains strongly associated with procedure type. The use of end ileostomy, however, is decreasing over time in patients 61 to 70 years of age as evidence accumulates that IPAA is an acceptable option for older patients with ulcerative colitis (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A191).

Pineal parenchymal tumors comprise a rare group of primary neoplasms of the pineal gland. We describe a case involving a 29-year-old woman who presented with signs and symptoms of hydrocephalus secondary to a pineal region tumor obstructing the third ventricle. Surgical resection was performed and pathological analysis revealed a novel diagnosis consistent with a pineal parenchymal tumor of intermediate differentiation (PPTID) with transition to a papillary tumor of the pineal region (PTPR). To our knowledge, this particular pineal region tumor pathology has not yet been reported in the literature and highlights the continuum with which primary pineal tumors exist. We provide a review of the existing literature on pineal region tumors, specifically PTPR and PPTID, and offer insight into the management of these rare neoplasms.