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Quality of life after treatment for rectal cancer.

A plain language summary of:
Functional outcomes and health-related quality of life following curative treatment for rectal cancer: A population-level study in EnglandDowning A, Glaser AW, Finan PJ, Wright P, Thomas JD, Gilbert A, Corner J, Richards M, Morris EJ, Sebag-Montefiore D, International Journal of Radiation Oncology • Biology • Physics (2019).

What was the study about?
The number of people surviving cancer has increased significantly in recent years. This leaves many at risk of problems related to their cancer treatment. We used data from a large survey of cancer survivors to look at the problems reported by people treated for rectal cancer.

What did we do?
In 2013, a survey was sent to people in England who had survived 1-3 years after being diagnosed with rectal cancer. The survey asked a wide range of questions about life after cancer. In this study we wanted to look at problems with bowel control, leaking urine and sexual matters. We also looked at problems with general health. To get more information about the type of treatment people had, we linked the survey responses with other datasets. Treatment could be surgery only or radiotherapy followed by surgery. Some patients who had surgery had a stoma formed (an opening in the tummy area connected to a bag).

What did we find?
6,713 people completed a survey (64% response). We looked in detail at the 3,998 people who had surgery and said their cancer had not come back (in remission). Some of these people had radiotherapy before surgery and some did not. People who had radiotherapy before surgery were more likely to say they had problems with bowel control, leaking urine and sexual matters compared to people who had surgery only. Just less than half (44%) of people had a stoma still open at the time of survey. People with a stoma still open were more likely to say they had problems with sexual matters compared to those who did not have a stoma (or had a stoma that had been closed). People with a stoma also said they had more problems with their general health. The results highlight key areas to focus on to improve the care and support of patients treated for rectal cancer.

Acknowledgements
The survey was designed and administered by the Department of Health in England. The survey responses were linked with cancer registration, hospital admissions and radiotherapy data through the National Cancer Registration and Analysis Service. The analysis and linkage work was supported by Cancer Research UK (C23434/A23706).

Does surgery to treat obesity reduce or increase cancer risk?

A plain language summary of:
Obesity surgery and risk of colorectal and other obesity-related cancers: An English population-based cohort study, Ariadni Aravani, Amy Downing, James D. Thomas, Jesper Lagergren, Eva J.A. Morris, Mark A. Hull, Cancer Epidemiology, Volume 53, April 2018, Pages 99-104, ISSN 1877-7821 .

What do we already know?
– People who are heavily over weight (obese) are known to be at increased risk of cancer.
– It seems likely that surgery to treat obesity will also reduce a person’s risk of cancer.
– However, a Swedish study has suggested surgery to treat obesity may increase the risk of bowel cancer.

What did we do in our study?
Our study looked at routine healthcare data from NHS patients to see if surgery to treat obesity made a difference to the risk of developing cancer.

What did we find for bowel, endometrial and kidney cancer?
Over a million obese patients were found and, as expected, they had an increased risk of bowel, endometrial and kidney cancer compared to the non-obese population.

Of the million obese patents:
– 3,280 developed bowel cancer.
– 43 of these cancers were in those who had previously had surgery to treat their obesity. Because only 4% of the obese patients had such surgery we did not have enough patients to detect an effect on the chances of subsequently developing bowel cancer.

What about other cancers?
We did have more definitive answers for other cancers. Our analysis showed that:
– Those who had surgery had a decreased risk of breast cancer, compared to those who did not have surgery.
– Surgery made no difference to the risk of endometrial and kidney cancers.

NHS surgery to treat obesity is becoming more common so, in time, we hope to have more information to answer these questions.

Acknowledgements
This work uses data provided by patients and collected by the NHS as part of their care and support. World Cancer Research Fund International (WCRF) (ref: 2012/596) and Cancer Research UK (C23434/A23706) funded this research. NHS Digital, the National Cancer Registration and Analysis Service (NCRAS) and the Office for National Statistics (ONS) provided the data. We would like to thanks these organisations, and NHS patients, for making this research possible.

Rectal cancer in old age – is it appropriately managed?

A plain language summary of:
Rectal cancer in old age – is it appropriately managed? Evidence from population-based analysis of routine data across the English national health service. Rebecca J. Birch, John C. Taylor, Amy Downing, Katie Spencer, Paul J. Finan, Riccardo A. Audisio, Christopher M. Carrigan, Peter J. Selby, Eva J. A. Morris, European Journal of Surgical Oncology (2019).

What do we already know?
More than a third of rectal cancers are diagnosed in people aged 75 and over. The treatment of older patients is controversial. Older patients are less likely to receive surgery, radiotherapy and chemotherapy than younger patients. This may partly explain why England has a worse survival rate than some other European countries. However, some studies have suggested older patients have worse treatment outcomes than younger patients and so reduced treatment rates in this group are acceptable. The challenge is to neither over treat nor under treat older rectal cancer patients.

What did we do in our study?
This study used routinely collected English healthcare data to examine the use of different treatments for rectal cancer and their associated outcomes. It also assessed how treatment and outcome varied across the English NHS.

What did we find?
The results confirmed that older people were less likely to receive treatment aimed at curing them of rectal cancer. However, those older people who received such treatment had similar outcomes to younger patients. The study suggests that these treatments should be offered to patients of all ages if they are fit enough to receive them. It might be argued that a lower proportion of older people received these treatments because older patients are more likely to have other healthcare conditions and experience complications. The study did find some evidence to support this. However, the study found major differences between hospital Trusts which could not be accounted for by differences in patient characteristics.

Acknowledgements
Cancer Research UK (grants C23434/A23706 and C34080/A16438) funded this research. This work involves patient-level information collected by the NHS that has either been provided by, or derived from, patients as part of their care and support. The data is collated, maintained and quality assured by the National Cancer Registration and Analysis Service, which is part of Public Health England (PHE). Access to the data was facilitated by the PHE Office for Data Release.

Time to surgery following short-course radiotherapy in rectal cancer and its impact on post-operative outcomes.

A plain language summary of:
Time to surgery following short-course radiotherapy in rectal cancer and its impact on post-operative outcomes. A population-based study across the English NHS, 2009-2014. B.A.Levick, A.J.Gilbert, K.L.Spencer, A.Downing, Time to surgeryJ.C.Taylor, P.J.Finan, D.J.Sebag-Montefiore, E.J.A.Morris, Clinical Oncology (2019).

What was the study about?
Short course radiotherapy (SCRT) before an operation is an effective treatment for rectal cancer. Previous studies have shown that it reduces the risk of the disease returning in the same location. The recommended gap between completing SCRT and having surgery varies widely, with some studies suggesting that it should be less than four days. This study examined the time between SCRT and surgery and related it to post-operative outcomes up to a year after surgery.

What did we do?
Information was obtained on all rectal cancer patients who underwent surgery and received SCRT in the English NHS between April 2009-December 2014. Post-operative outcomes such as thirty day post-operative mortality, returns to theatre, length of stay and one year survival were investigated in relation to the amount of time between SCRT and surgery. Patients who had a gap of over 27 days were not included in the study.

What did we find?
The study found that although the majority of patients were operated on within seven days of SCRT, there was huge variation across the English NHS. The study did not find any associations between time to surgery following SCRT and surgical outcome.

Acknowledgements
This work involves patient-level information collected by the NHS that has either been provided by, or derived from, patients as part of their care and support. The data are collated, maintained and quality assured by the National Cancer Registration and Analysis Service, which is part of Public Health England (PHE). Access to the data was facilitated by the PHE Office for Data Release. The data used for this study are available from the National Cancer Registration and Analysis Service via the PHE Office for Data Release, subject to relevant approvals. This work was supported by the Bobby Moore Fund/Cancer Research UK (grant number C23434/A23706) and Yorkshire Cancer Research (grant number L394). It was underpinned by the Leeds MRC Medical Bioinformatics Centre (grant number MR/L01629X/1). This study was approved by the South West – Central Bristol Research Ethics Committee (ref 18/SW/0134).

Variation in the use of resection for colorectal cancer liver metastases across the English NHS.

A plain language summary of:
Variation in the use of resection for colorectal cancer liver metastases across the English NHS’. Hayley Fenton, John Taylor, Peter Lodge, Giles Toogood, Paul Finan, Alastair Young, Eva Morris, Annals of Surgery, 2019.

What was the study about?
Bowel cancer is a common disease in the UK with over 42,000 people diagnosed every year. If at diagnosis the cancer is found to have spread then patient outcomes can be poor. A common site for such spread is the liver. When this happens, it is called secondary liver cancer (the primary cancer being in the bowel). The National Institute for Health and Care Excellence (NICE) recommends surgery to remove the cancer from the liver where possible (the surgery needs to leave enough of the liver to support the patient). Around 25% of people who have such surgery survive for at least ten years. Previous studies, some of which date back 10 years, have shown that use of liver surgery varies significantly across the English NHS. This study looked at more recent data to see whether this variation still exists.

What did we do?
The study identified all patients who underwent bowel cancer surgery in an NHS hospital between 2005-2012. All patients who received liver surgery within three years of their bowel surgery were then identified.

What did we find?
There were significant differences in the rate of liver surgery between NHS Trusts. Also, patients whose bowel surgery took place in a hospital with an onsite liver specialist team were more likely to receive a liver operation. This may mean more patients could be benefiting from surgery for secondary liver cancer.

More information about secondary liver cancer can be found on the Macmillan website.

Variation in bowel cancer rates after colonoscopies in England

A plain language summary of:
Variation in post-colonoscopy colorectal cancer across colonoscopy providers in the English National Health Service Nicholas E Burr, Edmund Derbyshire, John Taylor, Simon Whalley, Venkataraman Subramanian, Paul J Finan, Matthew colonoscopiesD Rutter, Roland Valori, Eva J A Morris, British Medical Journal, 2019.

Background
Around 40,000 people are diagnosed with bowel cancer every year in England. As well as being the main test to detect cancer, colonoscopies can also prevent cancer. Unfortunately, colonoscopies are not perfect and sometimes a person develops bowel cancer after having a colonoscopy. This is referred to as a post-colonoscopy colorectal cancer (PCCRC).

What did we do?
We looked at all individuals who had undergone a colonoscopy in the English NHS between 2005 and 2013 who then went on to be diagnosed with bowel cancer within the three years following the colonoscopy. Cancers diagnosed 6-36 months after a colonoscopy were categorised as PCCRC.

To see if some individuals were more at risk of developing a PCCRC, we looked at the rates in relation to age, sex, socio-economic status and whether they had any pre-existing health conditions, including a history of inflammatory bowel disease or diverticular disease, whether they had ever previously had bowel cancer and whether they had previously undergone a colonoscopy.

The rate of PCCRC was then calculated for each colonoscopy provider in the English NHS.

What did we find? 
The overall rate of PCCRC has fallen from 9% in 2005 to 6.5% in 2013. PCCRCs were more frequent in females, those with pre-existing health conditions, in people with inflammatory bowel disease and diverticular disease, in people who had undergone multiple colonoscopies and in people with a previous diagnosis of bowel cancer. PCCRCs were also more common in older patients.

The lowest rates of PCCRC were found in those performed as part of the Bowel Cancer Screening Programme. Colonoscopies performed at private providers for the NHS had much higher rates.

In the years 2011-2013 the rate of PCCRCs varied substantially across NHS Trusts with rates ranging from 3.3% in the best performing to 13.4% in the worst performing.

If all providers during the eight years of the study period had achieved the same rate of PCCRC as the colonoscopies performed as part of the Bowel Cancer Screening Programme, 3900 cases of colorectal cancer could have been diagnosed earlier or even prevented.

Conclusion
Although the rates of PCCRC are improving, significant difference between providers exists. There is a need for all providers of colonoscopy to examine their cases of PCCRC, and local reasons for them.

From this, providers may be able to identify measures which once put into practice will lead to improved rates and improved outcomes for patients.

The lower rates of PCCRC found in the Bowel Cancer Screening Programme colonoscopies is noteworthy. All colonoscopies performed as part of the Bowel Cancer Screening Programme take place within accredited screening centres by colonoscopists who have undergone an accreditation test and who adhere to strict performance criteria. This shows that where strict standards are applied, quality is better.

Key Findings

  • There is significant variation in the rate of post-colonoscopy colorectal cancers (PCCRCs) in the English NHS from 13.4% in the worst performing to 3.3% in the best.
  • Colonoscopies performed as part of the Bowel Cancer Screening Programme have the lowest rate of PCCRCs.
  • If all providers during the eight years of the study period had achieved the same rate of PCCRC as the colonoscopies performed as part of the Bowel Cancer Screening Programme, 3900 cases of colorectal cancer could have been diagnosed earlier or even prevented.
  • High risk groups were identified: patients with a previous diagnosis of cancer, patients who have had multiple colonoscopies, and patients with inflammatory bowel diseases.

Addressing the variation in adjuvant chemotherapy treatment for colorectal cancer: Can a regional intervention promote national change?

A plain language summary of:
Addressing the variation in adjuvant chemotherapy treatment for colorectal cancer: Can a regional intervention promote national change?  John C. Taylor, Daniel Swinson, Jenny F. Seligmann, Rebecca J. Birch, Alice Dewdney, Victoria Brown, Joanna Dent, Hannah L. Rossington, Philip Quirke, Eva J. A. Morris, YCR BCIP Study Group

Background:
Surgery is the main treatment for bowel cancer. In order to try and reduce the chances of the cancer coming back, some patients are also offered additional treatment either before or after they have surgery. This is usually done by chemotherapy, which is where a patient is given a drug or a combination of drugs over a number of months. When chemotherapy is given after surgery, this is referred to as adjuvant chemotherapy. There are guidelines in place which help doctors decide when to offer this treatment to a patient.

The aim of this study is to identify which patients received adjuvant chemotherapy and look at whether treatment is more common in any particular groups of patients or at any particular hospital. This information could then be used to improve the guidance provided to doctors therefore improving the care of patients.

What did we do?
The differences in the use of adjuvant chemotherapy was investigated using data from all hospitals treating colorectal cancer in England. A more detailed investigation then took place focusing just on the hospitals within the Yorkshire and Humber region.

Alongside the investigation into the data, questionnaires about the uses of adjuvant chemotherapy were sent to the doctors who prescribe the chemotherapy, known as Oncologists, in the Yorkshire and Humber region.

A series of meetings for all Oncologists from the Yorkshire and Humber region were held to address the differences in adjuvant chemotherapy use both at a regional and national level. A further round of questionnaires were then sent to the Oncologists to see if the differences identified in the previous meetings had been addressed.

A final meeting took place during which a new set of guidelines was agreed in order to reduce the differences in treatment across the Yorkshire and Humber region.

What did we find?
The study found that there are large differences in the use of adjuvant chemotherapy for bowel cancer both nationally and regionally. Through bringing this information to the attention of the Oncologists in the Yorkshire and Humber region, all hospitals in the region agreed to a new set of guidelines which aims to reduce the differences in care that patients receive. This process could be copied in other regions in England.