Complicated colorectal cancer : prevalence in KwaZulu-Natal teaching hospitals.
Mothae, Sibongile Joalane.
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Background Colorectal cancer (CRC) is the third most common +cancer in the world. According to National Cancer Registry in 2004, was listed the 4th most common cancer in South Africa. The average person’s lifetime risk of CRC is 5%. Majority of CRC is sporadic, with only 20% associated with inherited and inflammatory bowel disorders. Incidence increases with increasing age and genetic mutations. CRC incidence higher in people aged 50 and older. Unfortunately the incidence of CRC is escalating in patients younger than 50. Young age is considered a poor prognostic factor, usually presenting in advanced stages, with more aggressive histopathologic features. Other risk factors depend on lifestyle and behaviour (diet, smoking, alcohol, obesity). Survival depends on the stage at diagnosis. Five year survival for localized disease is 90%, 60% for regional disease and 10% for metastatic disease. Due to lack of recognized screening programs in South Africa, a large number of patients with CRC present to surgical units with complications of colorectal cancer. Morbidity and mortality associated with emergency surgery is very high. It is estimated that about 30% of patients with CRC present with complications such as obstruction, perforation, bleeding and fistulas. Of these 8-10% present with obstruction, and approximately 3% with perforation. These complications are associated with the worst prognosis. Aim There is a lack of data on complicated colorectal cancer in South Africa. The study was therefore undertaken in order to establish the prevalence of complicated colorectal cancer among patients presenting to the KwaZulu-Natal teaching hospitals. 8 Methods This is a retrospective analysis of a prospectively collected data. The on-going KwaZulu-Natal colorectal cancer database was established in 2000. The database now comprise 1944 patients with colorectal cancer (CRC). Of these, 448 patients presented with complicated colorectal carcinoma and these patients form the basis of this analysis. Results Four hundred and forty eight patients with complicated colorectal carcinoma were accrued during the period 2000 - 2016. There were 244 (54.5%) males and 204 (45.5%) female. There were 165 Indians, 163 Africans, 92 White and 28 Coloured patients. The mean age at presentation was 56.4± 14.4years. Seventy patients (16.1%) were young patients, presenting at or under the age of 40 years. A total of 382 (20%) patients presented with malignant obstruction, 71 (4%) with perforation and 28 (1.5%) with malignant fistula. Twenty-five patients presented with combined obstruction and perforation and eight had combined malignant obstruction and fistula. The most common sites for malignant obstruction were sigmoid and rectum; the sigmoid colon and caecum were the most common sites for perforation and the rectum and sigmoid colon predominated among patients with malignant fistula. The majority of the patients presented as stages II, III and IV at 26.3%, 26.6% and 29.7% respectively. The median follow up period was 11 months for all three groups of complications (range 1-180 months for malignant obstruction, 1-94 months for perforation and 1-94 months for malignant fistula) 9 Discussion The proportion of patients with complicated colorectal cancer was 23%.The mean age for the cohort was 56.4±14.4 years, considerably less than 63-72 years reported in the world literature. The age at presentation for Blacks was the youngest being about one to two decades younger than the other population groups. Whites were oldest at presentation in comparison to other races and their mean age approximated the world literature. These population differences in age distribution mimic that seen in the general population of patients with CRC in KwaZulu-Natal, where Blacks were a decade younger than the other population groups. The proportion of patients presenting with obstructing CRC in this study was 20%, it fell within the range of published series and did not differ between races or gender. Perforation was the second most common complication (4%) in this study. Contrary to obstruction and fistula, perforation seemed to have an equal sex incidence. The 1.5% fistula rate in this series compares favourably with the literature. In malignant obstruction resection rate was 68% with a five-year survival rate of 70%. Patients with perforation had the highest resection rate at 97% and they achieved the best an overall five-year survival of 85%. Malignant fistula had the lowest resection rate at 32% and the five-year survival was the poorest at 60% compared to the other neoplastic complications in this series. Conclusion The prevalence of complicated colorectal cancer in our setting is similar to that reported in the literature. The prevalence is the same across all population groups and the sex incidence is similar, but the age at presentation is younger in Blacks. The site distribution varied according to the complication, with obstruction associated more frequently with left-sided disease and fistula involving the sigmoid and rectum. 10 The resection rate was dependent on the type of complication. The resection rate was better for malignant perforation and obstruction than malignant fistula. The fistula population also had a worst survival rate. Patients who underwent resection had a zero in-hospital mortality rate. The perforation status did not impact on long-term outcome. Patients with malignant fistula appeared to have the worst outcome. Presentation of CCC (and CRC in general) at a younger age in our setting in Black patients highlights the need for more research in developing countries.