Introduction

Health insurance is a strong and potentially modifiable determinant of access to care and health outcomes in the United States. Lack of health insurance is linked to advanced stage at cancer diagnosis and worse survival. Individuals without insurance are less likely to receive recommended screening and timely, if any, follow-up of abnormal screening results. In this study, we estimate the effects of health insurance coverage gains for uninsured individuals on colorectal cancer (CRC) outcomes.

Aims & Methods

The MISCAN-Colon model was used to simulate the effects of health insurance coverage gains for uninsured individuals. Model inputs of CRC screening, stage distribution, and survival were estimated by age and health insurance status from the National Health Interview Survey and National Cancer Database. We evaluated the effects on CRC outcomes if cohorts of uninsured individuals gained health insurance coverage at different ages (45, 50, 55, 60 years) compared with a cohort remaining uninsured until age 65, and then becoming age-eligible for Medicare coverage. CRC outcomes included incidence, mortality and costs per 1,000 45-year old individuals.

Results

In an uninsured population, the model predicted 59 CRC cases and 23 CRC deaths per 1,000 individuals, with a total cost of $5.6 million. If individuals gained health insurance coverage at age 45, 5.0% and 16.0% of CRC cases and deaths could be prevented, respectively. Although cancer treatment costs would decrease (-3.9%), total costs would increase by 5.0%, as a result of increased screening costs (+36.7%). Increasing the age of insurance gain would lower these benefits and costs (Table 1). Gaining health insurance coverage at age 60 would only prevent 1 CRC death and 2 CRC cases per 1,000 individuals, compared with a cohort that remained uninsured until gaining Medicare coverage at age 65 years.

Conclusion

If uninsured individuals gain health insurance at an early age, up to 5% and 16% of CRC cases and deaths could be prevented, respectively, because of more screening, earlier diagnosis, and better survival. However, increased use of screening, and recommended cancer treatment would also increase costs of care.

Introduction

Reductions in cancer mortality rates are the result of better screening and the use of improved treatments¹. Whilst there has been a longstanding awareness of the psychological and social impact of cancer therapy, there has been little emphasis on dealing with the physical symptoms that are a frequent complication of treatment². This can include living with chronic and debilitating bowel symptoms as well as problems with sexual and urinary function³. In our hospital, over 400 patients are diagnosed and treated for colorectal cancer annually. Data suggest that up to half, depending on the treatment(s) received, will develop chronic symptoms.

Aims & Methods

A virtual telephone clinic was set up in October 2020. Patients requiring gastroenterology review were identified at follow-up by colorectal cancer nurse specialists, colorectal surgeons or oncology specialists. Patients were reviewed by a Gastroenterology Research Fellow via a telephone consultation and investigations requested following a predefined, structured checklist according to their symptoms.

Results

66 patients (30 male, 36 female), median age 71 (range 40-89) were reviewed between October 2020 to September 2022. The mean duration of symptoms was 33 months (range 4 to 108). All had been diagnosed with colorectal cancer (20 right colon, 10 left colon and 36 rectum). Previous treatment included surgery (n=31), surgery + chemotherapy (n=13), surgery + radiotherapy (n=4), surgery + radiotherapy + chemotherapy (n=13) and radiotherapy + chemotherapy (n=5).
Patients’ symptoms pre-referral and after treatment were assessed objectively using the gastrointestinal symptoms rating scale (GSRS), with a mean GSRS on referral of 25, improving to 16 following investigation and treatment. 10 different symptoms were identified in patients (loose stool (n=45), bloating/wind (n=31), frequency (n=31), urge (n=28), incontinence (n=19), constipation (n=14), abdominal/rectal pain (n=13), mucous discharge (n=6), nocturnal symptoms (n=6) and rectal bleeding (n=1)). Outcomes of investigations are shown in Table 1. The mean overall package of care cost £803.53 (range £86.83 - £1778.49) / patient.

Table 1 showing the outcomes of investigations in patients

Conclusion

In most patients referred to our specialist clinic, one or more causes for their symptoms were identified. Treatment frequently lead to a dramatic improvement in symptoms. Future recommendations include earlier recognition of patients in need of specialist referral through the use of objective questionnaires. Results from a virtual clinic are consistent with previously reported data from face-to-face consultations.

References

1. Schreuders, E.H., et al., Colorectal cancer screening: a global overview of existing programmes. Gut, 2015. 64(10): p. 1637-49.
2. Andreyev, H.J., et al., Algorithm-based management of patients with gastrointestinal symptoms in patients after pelvic radiation treatment (ORBIT): a randomised controlled trial. Lancet, 2013. 382(9910): p. 2084-92.
3. Andreyev, J., Gastrointestinal symptoms after pelvic radiotherapy: a new understanding to improve management of symptomatic patients. Lancet Oncol, 2007. 8(11): p. 1007-17.

Disclosure

There is no conflict of interest to declare.

Introduction

There is growing evidence that the balance of harms and benefits of colorectal cancer (CRC) screening can be improved by risk stratification. One way to stratify participants is to assign a personalized invitation interval based on prior screening test results. Previous studies have shown that prior hemoglobin (Hb) concentrations determined by fecal immunochemical test (FIT), have greater predictive power for the detection of CRC in the next screening round than age and sex (1-3). Therefore, a randomized controlled trial, the PERFECT-FIT study (4), was initiated within the Dutch national CRC screening program in which participants with a prior negative FIT are invited using tailored invitation intervals (1,2 or 3 years) based on prior Hb concentrations. We aimed to investigate long-term outcomes of such personalized CRC screening based on prior Hb concentrations and to compare those to uniform CRC screening.

Aims & Methods

We simulated the Dutch national CRC screening program using a microsimulation model, MISCAN-Colon, to mimic the natural history of CRC and long-term outcomes of CRC screening interventions. We added a module to MISCAN-Colon that explicitly simulates a Hb concentration for every participant based on their age, sex, CRC state and an individual risk factor. Next, to mimic the PERFECT-FIT study, all participants with a negative FIT got assigned to either the low (0 µg Hb/g), intermediate (>0-15 µg Hb/g) or high (>15-<47 µg Hb/g) risk category. We evaluated different invitation intervals (ranging between 0.5 and 4 years) for each risk category and estimated short- and long-term effects of the different screening strategies. We compared each personalized screening strategy to uniform biennial screening. Using cost-effectiveness analysis with a willingness-to-pay threshold per QALY gained of €20,000,-, we determined optimal invitation intervals for each risk category, assuming (i) unlimited colonoscopy capacity and (ii) current colonoscopy capacity levels.

Results

Uniform biennial screening resulted in 177 QALYs gained and €101,852 saved compared to no screening per 1,000 individuals (Table 1). The PERFECT-FIT strategy resulted in 162 QALYs gained and €111,248 saved. The optimal invitation interval was 1 year for the low-risk group and 6 months for the intermediate and high-risk groups with 209 QALYs gained and €19,828 saved. With limited colonoscopy capacity, the optimal invitation interval changed to 2.5 years for the low-risk group, 1 year for the intermediate-risk group and 6 months for the high-risk group with 180 QALYs gained and €124,640 saved.

Table 1 Model outcomes per 1,000 individuals.

Conclusion

The optimal personalized CRC screening strategy is more cost-effective than uniform biennial screening, both with unrestricted and restricted colonoscopy capacity. Consequently, personalizing CRC screening invitation intervals based on prior FIT results may be an important next step to improve the balance between the harms and benefits of screening.

References

1. Grobbee EJ, Schreuders EH, Hansen BE, Bruno MJ, Lansdorp-Vogelaar I, Spaander MCW, et al. Association Between Concentrations of Hemoglobin Determined by Fecal Immunochemical Tests and Long-term Development of Advanced Colorectal Neoplasia. Gastroenterology. 2017;153(5):1251-9.e2.
2. Senore C, Zappa M, Campari C, Crotta S, Armaroli P, Arrigoni A, et al. Faecal haemoglobin concentration among subjects with negative FIT results is associated with the detection rate of neoplasia at subsequent rounds: a prospective study in the context of population based screening programmes in Italy. Gut. 2020;69(3):523-30.
3. Chen LS, Yen AMF, Chiu SYH, Liao CS, Chen HH. Baseline faecal occult blood concentration as a predictor of incident colorectal neoplasia: Longitudinal follow-up of a Taiwanese population-based colorectal cancer screening cohort. Lancet Oncol. 2011;12(6):551-8.
4. Breekveldt ECH, Toes-Zoutendijk E, de Jonge L, Spaander MCW, Dekker E, van Kemenade FJ, et al. Personalized colorectal cancer screening: study protocol of a mixed-methods study on the effectiveness of tailored intervals based on prior f-Hb concentration in a fit-based colorectal cancer screening program (PERFECT-FIT). Bmc Gastroenterology. 2023;23(1):1-10.

Introduction

Malnutrition is a highly prevalent condition in patients with cancer that has a negative impact on clinical outcomes. The GLIM criteria for malnutrition aim to standardize its diagnosis. In colorectal cancer, poor nutritional status is associated with increased morbidity and mortality and reduce tolerance to treatment.

Aims & Methods

We aimed to assess the prevalence of malnutrition base on the GLIM criteria and to correlate this with patient outcomes and survival in colorectal cancer.
Patients with colorectal cancer diagnosed from January 2015 to December 2022 were included. All of them were screened for malnutrition using the GLIM criteria.
The relationships between GLIM-malnutrition and suvival were analyzed.

Results

Sixty patients were included. The mean age was 54 years [35 - 82] with a sex ratio of 1.8 (M/F). Tumors were located in the right colon in 20 patients (33%), the left colon in 22 patients (36%), and the rectum in 15 patients (25%). According to TNM classification, patients were predominantly classified in stages II and III. In terms of treatment, 20 patients received neoadjuvant chemotherapy (30%), 15 patients received neoadjuvant radiotherapy (25%), and 45 patients underwent surgery (75%). Malnutrition, according to GLIM criteria, was present in 40% of patients. It was classified as mild, moderate, and severe in 40%, 45%, and 15% of cases, respectively.
Regarding survival, the difference between the two Kaplan-Meier curves of patients fulfilling GLIM malnutrition criteria versus patients without malnutrition was statistically significant (Log-rank test p = 0.001), [HR = 4.35 (95% CI = 2 - 9)], with a mean survival period of 18 ± 4.7 versus 32 ± 5.2 months, respectively (p = 0.028). Mild malnutrition was associated with better survival compared to moderate and severe malnutrition: 20 ± 2.3 versus 17 ± 3.2 months, respectively (p = 0.003).

Conclusion

Pretherapeutic screening for malnutrition seems to be mandatory due to its negative prognostic impact in patients with colorectal cancer, allowing for better pre-therapeutic stratification.

References

Cederholm T, Jensen GL, Correia MITD, et al. GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community. Clin Nutr. 2019;38(1):1-9.

Introduction

Diabetes mellitus affects 6-7% of the population in the United Kingdom (UK), with a consistently increasing prevalence over the last 15 years.^​ The impact of diabetes on outcomes after resectional colorectal surgery have yet to be fully quantified. We aimed to investigate the effect of diabetes mellitus on perioperative outcomes following resectional colorectal surgery using a national cohort.

Aims & Methods

All adult patients undergoing colorectal resections in England registered in the Clinical Practice Research Database (CPRD) with linked Hospital Episode Statistics (HES) data between 2010 and 2020 were included. Data relating to diabetes status and insulin use were extracted using CPRD read codes. Gestational diabetes and type 3c diabetes subtypes were excluded. The primary outcome was all-cause 90-day mortality, whilst secondary outcomes included hospital length of stay and unplanned hospital readmission within 90 days of discharge. Adjusted hazard ratios (HR) were calculated using Cox proportional hazard models for 90-day mortality and 90-day readmission. Length of stay was analysed using an accelerate failure time model, with results presented in the form of adjusted time ratios (TR). The hazard and time ratios resulting from these multivariate models were adjusted for patient age, sex, deprivation, comorbidity burden (excluding diabetes), operative urgency (elective versus emergency), operative indication (benign versus malignant disease) and surgical access (open versus minimally-invasive). P values of <0.05 were considered statistically significant. All data were analysed using STATA v17.

Results

106139 (50% male) patients with a median age of 66 years (Interquartile Range (IQR) 52 to 76) were included. The prevalence of diabetes in this cohort was 10% (n = 10931), including 653 (6%) patients with Type 1 and 10278 (94%) with Type 2 diabetes. 20% of all patients with diabetes had a record of insulin use. The overall unadjusted 90-day mortality risk was 5.7%, with an increased hazard rate for patients with diabetes compared with those without diabetes (adjusted HR 1.28, 95% CI 1.18 to 1.40, p < 0.001). This risk was higher in patients with diabetes with associated insulin use (adjusted HR 1.49, 95% CI 1.23 to 1.78, p < 0.001), and without insulin use (adjusted HR 1.24, 95% CI 1.23 to 1.36, p < 0.001), compared to patients without diabetes. The median length of stay was 8 days (IQR 5 to 15) for the overall cohort. Patients with diabetes experienced a 10% longer hospital length of stay (adjusted TR 1.10, 95% CI 1.08 to 1.11, p < 0.001) compared with those without diabetes. Emergency readmission within 90 days occurred in 23% of those operated for benign disease, versus 18% of patients operated for malignant disease. Patients with diabetes were more likely to experience 90-day readmission (adjusted HR 1.22, 95% CI 1.16 to 1.28, p < 0.001) compared with those without diabetes.

Conclusion

Patients with diabetes undergoing resectional colorectal surgery are at a higher risk of 90-day mortality, prolonged length of stay and 90-day readmissions. Awareness of these increased risks should be considered during perioperative optimisation of the patient, as well as in consent discussions and the patient selection processes.