Colorectal Cancer Survivorship Care Research Articles

Efficacy of Traditional Chinese Medicine Combined Online Group Psychotherapy (TCM-eRhab) on improving quality of life and relieving psychological burden for colorectal cancer survivors: a study protocol for a phase-II randomized controlled trial

BackgroundMore than 50% of colorectal cancer(CRC) patients experience cancer-related psychological burden after radical surgery, which can seriously affect their physical wellness, quality of life and even survival outcomes. Our research team developed a six-week Traditional Chinese Medicine Combined Online Group Psychotherapy (TCM-eRhab) and proved its efficacy on relieving cancer-related anxiety, depression and fear of cancer recurrence though phase I single arm clinical trial (n = 40). Large sample size randomized controlled clinical trial(RCT) is necessary to further evaluate TCM-eRhab’s role on improving quality of life and survival outcomes among this population. MethodsWe design a phase II RCT study, in which 210 CRC patients who have received radical surgery (stage I-III) will be recruited. Eligible patients will be randomly assigned to TCM-eRhab group or usual care group by 2:1 ratio. Patients in the intervention group will receive the structured TCM-eRhab program for six weeks, while patients in control group will receive usual care only. The primary outcomes are quality of life, severity of anxiety, depression and fear of cancer recurrence. Cancer recurrence rate will also be calculated according to long term follow-up data.DiscussionAs one of the first RCTs to evaluate the impacts of TCM combined psychological therapy to improve CRC patients’ quality of life after surgery, the results from this study will provide innovative knowledge and evidence on integrating TCM into CRC survivorship care and mind–body intervention model.

Abstract 28: New onset of type 2 diabetes after colorectal cancer diagnosis: Results from three prospective US cohort studies, systematic review, and meta-analysis

Abstract Background: Limited data indicate that patients with colorectal cancer (CRC) are at higher risk of developing type 2 diabetes (T2D). We prospectively examined the risk of T2D between individuals with and without CRC in three large cohorts and conducted a meta-analysis. Methods: We assessed the diagnosis of CRC and T2D among 111 485 women from the Nurses' Health Study, 112 958 women from the Nurses' Health Study II, and 46 581 men from the Health Professionals Follow-up Study. We used multivariable Cox regression with time-varying covariates to calculate the hazard ratio (HR) of T2D in relation to CRC diagnosis. We further performed a systematic review and meta-analysis of cohort studies. Findings: Up to 36 years of follow-up (6.9 million person-years), we documented 3402 incident CRC cases and 26 469 T2D cases. Compared to non-CRC individuals, those with CRC were more likely to develop T2D (multivariable-adjusted HR 1.20, 95% CI 1.05-1.38). The association was most evident for individuals with fewer risk factors for T2D. In the meta-analysis of seven cohort studies (1 061 744 participants), CRC was associated with higher T2D risk (meta-analysis HR 1.21, 95% CI 1.11-1.31, I2=57.9%). By CRC duration, a statistically significant association was observed in the first 10 years but not after 10 years of CRC diagnosis (≤5 years, meta-analysis HR 1.32, 95% CI 1.27-1.36; 5.1-10 years, 1.14 [1.04-1.25]; >10 years, 1.14 [0.91-1.37]). Interpretations: CRC was associated with increased T2D risk, especially in the first ten years after CRC diagnosis. Our findings highlight the importance of T2D prevention for CRC survivorship care. Citation Format: Hongmei Zeng, Chen Yuan, Jakub Morze, Ruiying Fu, Kai Wang, Liang Wang, Feng Sun, John S. Ji, Edward L. Giovannucci, Mingyang Song. New onset of type 2 diabetes after colorectal cancer diagnosis: Results from three prospective US cohort studies, systematic review, and meta-analysis [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 28.

Colorectal cancer survivorship care plans: Variations in documentation and posttreatment surveillance recommendations.

Survivorship care plans (SCP) should outline pertinent information about cancer treatment and follow-up. We descriptively analyzed the content of 74 colorectal cancer SCPs completed as part of a randomized, controlled trial of SCPs at an academic and community cancer center. Surveillance recommendations were compared with American Cancer Society, American Society of Clinical Oncology and National Comprehensive Cancer Network guidelines. SCP information provided in >80% of the plans included participant age, cancer diagnosis, details, and side-effects of treatment (surgery, chemotherapy, radiation) and health promotion recommendations. SCP content documented less frequently included predisposing conditions, genetic counseling/testing information and staging. Posttreatment surveillance recommendations were documented in >90% SCPs. For stage 2-3 cancer, rates of guideline concordant recommendations were 100% for colonoscopy surveillance (Year 1 only), 87% for imaging surveillance, 65% for carcinoembryonic antigen surveillance, and 33% for follow-up visits. Excluding colonoscopy, >15 unique recommendations were listed for each modality across stages and sites, with more variation at the academic site. SCPs consistently recorded information about cancer diagnosis and treatment but omitted critical information about cancer-specific details denoting risk. Surveillance recommendations varied considerably between cancer centers. Future work to improve the consistency of surveillance recommendations documented in SCPs may be needed.

Perspectives and practices regarding colorectal cancer survivorship care: Online survey results from oncology nurses in Thailand.

Limited research has highlighted disparities in survivorship care in low- and middle-income countries. However, such care for colorectal cancer (CRC) survivors remains unexplored, especially in Thailand. This study examined Thai oncology nurses' perceptions of responsibility, confidence levels, and frequency of survivorship care practice for CRC survivors and identified factors impeding such care. A cross-sectional study utilizing an online survey approach was conducted between October and November 2020. Thai oncology nurses (N=155) completed the survey's demographic questionnaire, 29-item survivorship care scale, and 16-item impeding factor scale. Oncology nurses had high levels of perceived responsibility (mean=73.37, SD=12.12) and confidence (mean=65.09, SD=14.89) for providing CRC survivorship care. However, they reported less frequency of practice (mean=47.60, SD=21.03), especially concerning sexual, fertility, employment, and financial issues. Nurses with higher education had significantly higher responsibility perceptions, confidence levels, and frequency of practice (all p<.05). Also, nurses with specialty training in cancer care reported higher frequency of practice (p=.013). Common factors impeding survivorship care were lack of physical facilities (60.4%), knowledge/skills (57.4%), and educational resources for family members (52.3%) and survivors (51.6%). This study revealed inconsistencies between oncology nurses' responsibility perceptions, confidence levels, and frequency of survivorship care practice. The results can guide nurse researchers, educators, leaders, and policymakers in enhancing the quality of CRC survivorship care in low- and middle-income countries such as Thailand. Future efforts should focus on developing educational resources and training programs for survivorship care for oncology nurses and addressing factors impeding such care during healthcare service planning.

Variations in recommended surveillance in colorectal cancer survivorship care plans.

13 Background: Survivorship care plans (SCPs) outline pertinent information about a cancer survivor’s treatment and follow-up care. We describe the content of colorectal cancer (CRC) SCPs, completed as part of a randomized controlled trial of SCPs, and evaluate whether follow-up recommendations are guideline concordant. Methods: We analyzed 74 CRC SCPs from an academic and community cancer center. Frequency distributions and descriptive statistics were calculated for the entire cohort and separately by recruiting site. Follow-up recommendations were compared to American Cancer Society (ACS), American Society of Clinical Oncology (ASCO) and National Comprehensive Cancer Network (NCCN) guidelines (Table). Results: Content routinely provided in SCPs (&gt;80%) included patient demographics, cancer diagnosis, treatment details (surgery, chemotherapy, radiation therapy) as well as treatment-related side effects. SCP content specified less frequently included cancer stage, cancer risk (predisposing conditions), and recommendations for genetic counseling/testing and health promotion. Nearly all SCPs from the community site provided uniform, guideline-concordant follow-up. At the academic site, on average, more than 15 follow-up recommendations were listed for each surveillance modality, except colonoscopy. Among the SCPs that specified the frequency of follow-up care, the rate of guideline-concordant recommendations was 15/42 (36%) for follow-up visits, 29/43 (67%) for imaging, 12/45 (27%) for laboratory and 39/39 (100%) for colonoscopy. Conclusions: SCPs consistently provided information about CRC diagnosis and treatment, but often omitted information about cancer risk, staging and prognosis. There was considerable variation between cancer centers in the follow-up recommendations suggested for CRC survivors. Future work to improve the consistency of SCP follow-up recommendations with guidelines may be needed. Clinical trial information: NCT03035773 . [Table: see text]

Correlates of Physical Activity in Colorectal Cancer Patients Based on Health Promotion Model.

Increasing attention is being given to physical activity in colorectal cancer patients. Some studies have explored a few correlates of physical activity separately. A contemporary study based on the Health Promotion Model may systematically broaden the understanding of physical activity in colorectal cancer patients. To understand the status of physical activity in Chinese colorectal cancer patients and to explore the correlated factors. A total of 168 adults with colorectal cancer were recruited at 3 tertiary hospitals in China. Participant data were collected on demographics, physical activity, biological factors, anxiety and depression, benefits/barriers to physical activity, self-efficacy, and social support. SAS 8.2 was used for statistical analysis, including descriptive analysis, correlation analysis, single factor analysis, and multiple stepwise regression analysis. Only 25.60% of colorectal cancer survivors reached the requirements of the Colorectal Cancer Survivorship Care Guidelines. Employment states, number of complications, fatigue, body image, depression, perception of benefits/barriers, and self-efficacy were closely correlated with physical activity in Chinese colorectal cancer patients. The physical activity status of patients with colorectal cancer is not optimal. The correlated factors that nurses can take measures to improve are fatigue, body image, depression, perception of benefits/barriers, and self-efficacy, which may improve physical activity in colorectal cancer patients in China. Additional research is needed to determine if improving factors correlated with physical activity will assist with directly increasing physical activity. Nurses should evaluate physical activity of colorectal cancer patients timely and play an active role in health promotion programs to improve colorectal cancer patients' physical activity.

Integration of Ongoing Quality Assurance Measures in Colorectal Cancer Survivorship Care Plans

e18858Background: A follow up program for patients with stages II or III colorectal cancer (CRC) after treatment completion was initiated in 2014 at the Cancer Centre of South Eastern Ontario (CCSE...

Integration of ongoing quality assurance measures in colorectal cancer survivorship care plans.

e18858Background: A follow up program for patients with stages II or III colorectal cancer (CRC) after treatment completion was initiated in 2014 at the Cancer Centre of South Eastern Ontario (CCSE...

Surveillance for colorectal cancer survivors in an integrated safety-net health system in the United States.

Guideline-recommended surveillance reduces likelihood of colorectal cancer (CRC) recurrence, yet surveillance rates are low in the United States (US). Little is known about CRC surveillance rates among patients without health insurance and their primary care clinicians/oncologists' attitudes towards surveillance care. A retrospective study of 205 patients diagnosed with Stage I-III CRC from 2008-2010 was conducted in an integrated system with a network of providers delivering care to patients lacking health insurance coverage. Surveillance patterns were characterized from medical records and logistic regression models examined correlates of guideline-concordant surveillance. 41 Parkland primary care physicians (PCPs) and 24 oncologists completed surveys to assess their attitudes and practices regarding CRC surveillance. 38% of CRC patients received guideline-concordant surveillance; those with early stage cancers were less likely to receive surveillance (OR=0.35; 95 CI: 0.14, 0.87). PCPs and oncologists differed markedly on who is responsible for cancer surveillance care. 77% of oncologists responded that PCPs evaluated patients for cancer recurrence while 76% of PCPs responded that these services were either ordered by oncologists or shared with PCPs. 67% of oncologists said they rarely provide a treatment and surveillance care plan to survivors and over half said that they infrequently communicate with patients' other physicians about who will follow patients for their cancer and other medical issues. Care coordination between PCP and oncologist is needed to improve CRC surveillance. New models of shared care clearly delineating roles for oncologists and PCPs are needed to improve CRC survivorship care.

Abstract IA27: Understanding more about risk and prognostic factors: Lessons from the Colon Cancer Family Registry

Abstract Background: Colorectal cancer (CRC) is a heterogeneous disease with etiology associated with genetic and epidemiologic factors. Family studies have served as the cornerstone of genetic research on CRC. Studies of multiple-case families led to the discovery of the best characterized CRC susceptibility syndromes: hereditary nonpolyposis colorectal cancer (HNPCC; hereafter called Lynch syndrome) and familial adenomatous polyposis (FAP). The primary genetic bases of these dominant, relatively high-penetrance syndromes were identified. However, somatic and epigenetic alterations in these same genes are involved in sporadic CRC as well. Although these changes are established causes of CRC, many important questions remain, specifically the relation of these genetic and also environmental risk factors in relation to CRC survival. The Colon Cancer Family Registry (CCFR) is an NCI-supported international resource established in 1997 to support interdisciplinary studies on the genetic, somatic, environmental, behavioral, and lifestyle risk factors for CRC. Case subjects with incident colon or rectal cancer were identified via regional, state, and provincial cancer registries in the U.S., Canada and Australasia. Now in its 18th year, the CCFR is the largest registry of colorectal cancers world-wide. In this study, we have now leveraged this cohort to examine the epidemiology, genetics, and molecular characteristics of outcomes after a diagnosis of colorectal cancer. Methods: Over 10,000 participants with incident CRC were recruited into the CCFR between 1998 and 2007 across six international sites; nearly 3,500 deaths have occurred. Each center had slight differences in design and sampling schemes, which ensured a resource that covers the continuum of disease risk for CRC. Risk-factor data, blood and tumor samples, and medical records were collected from participants using standardized protocols. Participants continue to be followed every 5 years for changes in common risk factors, surveillance, and new cancers. Vital status, including cause of death, is recorded. Tumors have been characterized for microsatellite instability (MSI) status, protein expression for mismatch repair mutations (MLH1, MSH2, MSH6 and PMS2), and for point mutations in BRAF V600E and KRAS codons 12 and 13. CpG Island Methylator Phenotype (CIMP) was measured in tumors demonstrating microsatellite instability and the somatic silencing of MLH1 due to DNA methylation was tested in tumors showing loss of MLH1 protein expression. Germline testing was conducted for MutYH mutations in all cases and for MMR gene mutations for all cases showing a loss of gene expression in the respective protein. Genome-wide association studies (GWAS) will soon be completed on all cases. Analyses have been conducted using the CCFR case population as a whole, or using site subsets based on appropriate design and inclusion criteria. Results: Several factors known to be associated with a reduced risk of colorectal cancer, such as physical activity and the use of non-steroidal anti-inflammatory drugs (NSAIDs), were also associated with improved survival, while other such factors, including hormone replacement therapy, were not. Elevated pre-diagnostic BMI was associated with increased risk but modestly elevated post-diagnostic BMI was associated with improved survival. A history of smoking was associated with both increased risk and worse survival. Family history of colorectal cancer, which has consistently been associated with increased risk of disease, was not found to be associated with survival. Similarly, we found in a screen of 18 genetic susceptibility loci, one identified locus in SMAD7 was also associated with survival, but others were not. Tumor microsatellite instability was strongly associated with improved survival. Cases with CIMP positive tumors and/or mutations in BRAF, and/or KRAS were each associated with higher mortality, particularly when those characteristics were combined, where a two-fold increase was observed in cases MSS, CIMP+, and positive for BRAF when compared to cases with MSS tumors and negative for all other markers; a 70% lower mortality was observed in cases with tumors characterized as MSI-high, non-CIMP, and negative for mutations in BRAF and KRAS. Conclusions: The CCFR has shed light on many environmental factors, genetics and tumor characteristics that are related to both incidence and survival. Information gained from studies using this resource provides insight into the biology of this common cancer and importantly may help target messaging on prevention, inform the development of interventions, or tailor recommendations for CRC survivorship care. The greater scientific community has access to this rich resource. Citation Format: Polly A. Newcomb. Understanding more about risk and prognostic factors: Lessons from the Colon Cancer Family Registry. [abstract]. In: Proceedings of the AACR Special Conference on Colorectal Cancer: From Initiation to Outcomes; 2016 Sep 17-20; Tampa, FL. Philadelphia (PA): AACR; Cancer Res 2017;77(3 Suppl):Abstract nr IA27.

American Cancer Society Colorectal Cancer Survivorship Care Guidelines.

Colorectal cancer (CRC) is the third most common cancer and third leading cause of cancer death in both men and women and second leading cause of cancer death when men and women are combined in the United States (US). Almost two-thirds of CRC survivors are living 5 years after diagnosis. Considering the recent decline in both incidence and mortality, the prevalence of CRC survivors is likely to increase dramatically over the coming decades with the increase in rates of CRC screening, further advances in early detection and treatment and the aging and growth of the US population. Survivors are at risk for a CRC recurrence, a new primary CRC, other cancers, as well as both short-term and long-term adverse effects of the CRC and the modalities used to treat it. CRC survivors may also have psychological, reproductive, genetic, social, and employment concerns after treatment. Communication and coordination of care between the treating oncologist and the primary care clinician is critical to effectively and efficiently manage the long-term care of CRC survivors. The guidelines in this article are intended to assist primary care clinicians in delivering risk-based health care for CRC survivors who have completed active therapy.

Addressing sexual dysfunction in colorectal cancer survivorship care.

Despite the high prevalence of sexual dysfunction in survivors of colorectal cancer, studies have shown that patients and providers rarely discuss how these symptoms may be influencing overall quality of life. The type and severity of symptoms of sexual dysfunction can vary greatly depending on the type of colorectal cancer and treatment, and assessment of sexual dysfunction is key to understanding how patients may be affected by these symptoms. Although patients would like to discuss these issues with their provider, they are often reluctant to ask questions about sexual functioning during appointments. Likewise, health care providers may hesitate to address sexual dysfunction due to time limitations or lack of knowledge regarding treatment of sexual problems. Health care providers can facilitate discussion of sexual dysfunction by (I) assessing sexual functioning throughout treatment; (II) initiating discussions about symptoms of sexual dysfunction at each appointment; and (III) maintaining adequate referral resources for treatment of sexual dysfunction.

Barriers to Breast and Colorectal Cancer Survivorship Care: Perceptions of Primary Care Physicians and Medical Oncologists in the United States

High-quality, well-coordinated cancer survivorship care is needed yet barriers remain owing to fragmentation in the United States health care system. This article is a nationwide survey of barriers perceived by primary care physicians (PCPs) and medical oncologists (MOs) regarding breast and colorectal cancer survivorship care beyond 5 years after treatment. The Survey of Physician Attitudes Regarding the Care of Cancer Survivors was mailed out in 2009 to a nationally-representative sample (n = 3,596) of US PCPs and MOs. Ten physician-perceived cancer survivorship care barriers/concerns were compared between the two provider types. Using weighted multinomial logistic regression, we modeled each barrier, adjusting for physician demographics, reimbursement, training, and practice characteristics. We received responses from 2,202 physicians (1,072 PCPs; 1,130 MOs; 65.1% cooperation rate). In adjusted patient-related barriers models, MOs were more likely than PCPs to report patient language barriers (odds ratio, [OR], 1.72; 95% CI, 1.22 to 2.42), insurance restrictions impeding test/treatment use (OR, 1.42; 95% CI, 1.03 to 1.96), and patients requesting more aggressive testing (OR, 4.08; 95% CI, 2.73 to 6.10). In adjusted physician-related barriers models, PCPs were more likely to report inadequate training (OR, 3.06; 95% CI, 2.03 to 4.61) and ordering additional tests/treatments because of malpractice concerns (OR, 1.87; 95% CI, 1.20 to 2.93). MOs were more likely to report uncertainty regarding general preventive care responsibility (often/always: OR, 1.97; 95% CI, 1.13 to 3.43; sometimes: OR, 2.16; 95% CI, 1.60 to 2.93). MOs and PCPs perceive different cancer follow-up care barriers/concerns to be problematic. Resolving inadequate training, malpractice-driven test ordering, and preventive-care responsibility concerns may require continuing education, explicit guidelines, and survivorship care plans. Reviewing care plans with survivors may also reduce patients' requests for unnecessary testing.

Patient Satisfaction With Breast and Colorectal Cancer Survivorship Care Plans

Cancer survivors face several challenges following the completion of active treatment, including uncertainty about late effects of treatment and confusion about coordination of follow-up care. The authors evaluated patient satisfaction with personalized survivorship care plans designed to clarify those issues. The authors enrolled 48 patients with breast cancer and 10 patients with colorectal cancer who had completed treatment in the previous two months from an urban academic medical center and a rural community hospital. Patient satisfaction with the care plan was assessed by telephone interview. Overall, about 80% of patients were very or completely satisfied with the care plan, and 90% or more agreed that it was useful, it was easy to understand, and the length was appropriate. Most patients reported that the care plan was very or critically important to understanding an array of survivorship issues. However, only about half felt that it helped them better understand the roles of primary care providers and oncologists in survivorship care. The results provide evidence that patients with cancer find high value in personalized survivorship care plans, but the plans do not eliminate confusion regarding the coordination of follow-up care. Future efforts to improve care plans should focus on better descriptions of how survivorship care will be coordinated.

Primary Care Providers' Needs and Preferences for Information about Colorectal Cancer Survivorship Care

The Institute of Medicine (IOM) proposed that cancer survivors and their primary care providers (PCPs) should receive survivorship care plans to inform ongoing care. We aimed to determine PCPs' preferences for the content of survivorship care plans for colorectal cancer (CRC) survivors. PCPs in 3 practice-based research networks completed a survey regarding 45 topics of CRC information based on the IOM's survivorship care plan framework. One hundred fifty-six PCPs completed the survey. For 35 topics (78%), at least half of respondents felt the topic was very important. Most PCPs reported receiving too little information about problems with chemotherapy (68%) or radiation (60%) and whether the oncologist intended to monitor for other cancers (71%). PCPs widely agreed that they do not have enough information about increased risk of second CRCs, other cancers, and other diseases (78%); long-term effects of chemotherapy (73%) and radiation (67%); and genetic counseling (83%). PCPs endorse the IOM's survivorship care plan framework as relevant and often report needing more information. Survivorship care plans may provide important information to PCPs by communicating patients' cancer histories and making recommendations regarding which aspects of care should be provided by the oncologist or the PCP.

Barriers in providing breast and colorectal cancer survivorship care: Perceptions of U.S. primary care physicians (PCPs) and medical oncologists (MOs).

CRA9006 Background: Increased coordination among clinicians in cancer survivorship care is needed yet the literature suggests barriers remain due to a fragmented healthcare system. This is the first nationwide study of barriers PCPs and MOs perceive regarding breast and colorectal cancer survivorship care. Methods: The Survey of Physician Attitudes Regarding the Care of Cancer Survivors (SPARCCS) was mailed to a nationally representative stratified sample (N=5,275) of eligible American Medical Association member PCPs and MOs (N=3,596) providing care to cancer survivors, to permit comparisons of views regarding follow-up testing, roles, knowledge self-confidence, and perceived barriers. We analyzed physician-based barriers using weighted multinomial logistic regression models adjusted for physician demographics, reimbursement, training, and practice characteristics. Results: 2,202 physicians (1,072 PCPs and 1,130 MOs) responded (57.6% response rate; 65.1% cooperation rate). In weighted univariate analyses, PCPs were significantly more likely to report often/always ordering tests or treatments as malpractice protection, being concerned about missed care, and lacking adequate training to manage patient problems. MOs were more likely to report (often/always and sometimes) concerns about duplicated care and about which physician provides general preventive health care. In multivariate regression models, physician specialty remained significant for 3 of 5 physician-based barriers. MOs were less likely to report inadequate training (OR: 0.33, 95% CI: 0.22-0.49), less likely to often/always order extra tests due to malpractice concerns (OR: 0.53, 95% CI: 0.34-0.84), and more likely to report being often/always (OR: 1.97, 95% CI: 1.13-3.43) and sometimes (OR: 2.16, 95% CI: 1.60-2.93) uncertain who is providing general preventive care, compared to PCPs. Conclusions: MOs perceived different physician-based barriers as problematic in cancer follow-up care compared to PCPs. Alleviation of inadequate training, malpractice-driven test ordering, and preventive care delivery barriers may require education and provision of survivorship care plans.

Barriers in providing breast and colorectal cancer survivorship care: Perceptions of U.S. primary care physicians (PCPs) and medical oncologists (MOs).

Barriers in providing breast and colorectal cancer survivorship care: Perceptions of U.S. primary care physicians (PCPs) and medical oncologists (MOs).