Background: Genetic and environmental factors have been associated with colorectal cancer (CRC) risk. However, their association with prognosis has been less studied. Methods: Path analysis was employed to examine causal pathways from education to environmental (diet, alcohol, smoking, physical activity) and personal factors (screening), and then to obesity and ultimately to tumour characteristics (stage, grade, microsatellite instability (MSI), and site) that are associated with CRC prognosis. Data came from the Ontario Familial Colon Cancer Registry. Pathways were evaluated for effect modification by sex and two indicators of CRC genetic susceptibility (Bethesda criteria and newly identified familial cancer clusters). Results: Four food patterns (healthy foods, high-fat foods, sweet and processed foods, and oriental foods) and four nutrient patterns (total macronutrient, fat vs. carbohydrate, and micronutrients from supplements and from foods) were identified. Education was associated positively with healthy lifestyle factors (e.g. healthy foods factor) and negatively with unhealthy factors (e.g. smoking). As expected, high body mass index (BMI) was associated with lower physical activity and higher fat vs. carbohydrate factor. Unexpectedly, BMI was positively associated with the healthy foods factor among Bethesda positive patients and men. An association between education and BMI was mediated by the healthy foods factor and by physical activity. Important poor prognostic factors, higher grade and stage, were associated with smoking and not being screened. However, unexpected associations included a positive association of physical activity with tumour grade among Bethesda positive patients and a positive association of healthy foods with stage among Bethesda negative patients. Patients with right-sided tumours were more likely to receive micronutrients from supplements, and screening and less likely to smoke, and for men, to have a high BMI, high fat diet and healthy food diet. Conclusion: Some unhealthy lifestyle factors, such as smoking and a high fat food dietary pattern, are associated with adverse CRC tumour characteristics and so may affect the prognosis. Family history may modify some associations though the findings require independent confirmation.

We first studied factors associated with the rate of colonoscopy by primary care physicians (PCPs) in Ontario between the years 1996 and 2005. Next, we conducted an Instrumental Variable Analysis (IVA) to estimate the effect of colonoscopy on colorectal cancer (CRC) incidence and mortality on average-risk subjects aged 50-74 years. Finally, we explored two study cohorts, one by including subjects who had the outcomes during the exposure period (unselected cohort) and the other cohort by excluding those subjects (restricted cohort). We estimated the absolute risk reduction associated with colonoscopy in preventing CRC incidence and mortality using traditional regression analysis, propensity score analysis and IVA. PCPs who were Canadian medical graduates and with more years of experience were more likely to use colonoscopy. PCPs were more likely to use colonoscopy if their patient populations were predominantly women, older, had more illnesses, and if their patients resided in less marginalized neighborhoods (lower unemployment, fewer immigrants, higher income, higher education, and higher English/French fluency). Using PCP rate of discretionary colonoscopy as an instrumental variable, receipt of colonoscopy was associated with a 0.60% absolute reduction in 7-year CRC incidence and a 0.17% absolute reduction in 5-year risk of death due to CRC. The unselected cohort showed an increase in CRC incidence and mortality associated with colonoscopy, whereas the restricted cohort showed a reduction in CRC incidence and mortality associated with colonoscopy. In the restricted cohort, using different statistical models, the absolute risk reduction varied from 0.52-0.60% for CRC incidence and 0.08-0.17% for CRC mortality. There were social disparities in the use of colonoscopy by PCPs and this disparity increased as the overall use of colonoscopy increased over time. Colonoscopy is effective in reducing incidence and mortality due to CRC. Different methods of subject selection and statistical analysis provided different estimates of colonoscopy effectiveness.

We first studied factors associated with the rate of colonoscopy by primary care physicians (PCPs) in Ontario between the years 1996 and 2005. Next, we conducted an Instrumental Variable Analysis (IVA) to estimate the effect of colonoscopy on colorectal cancer (CRC) incidence and mortality on average-risk subjects aged 50-74 years. Finally, we explored two study cohorts, one by including subjects who had the outcomes during the exposure period (unselected cohort) and the other cohort by excluding those subjects (restricted cohort). We estimated the absolute risk reduction associated with colonoscopy in preventing CRC incidence and mortality using traditional regression analysis, propensity score analysis and IVA. PCPs who were Canadian medical graduates and with more years of experience were more likely to use colonoscopy. PCPs were more likely to use colonoscopy if their patient populations were predominantly women, older, had more illnesses, and if their patients resided in less marginalized neighborhoods (lower unemployment, fewer immigrants, higher income, higher education, and higher English/French fluency). Using PCP rate of discretionary colonoscopy as an instrumental variable, receipt of colonoscopy was associated with a 0.60% absolute reduction in 7-year CRC incidence and a 0.17% absolute reduction in 5-year risk of death due to CRC. The unselected cohort showed an increase in CRC incidence and mortality associated with colonoscopy, whereas the restricted cohort showed a reduction in CRC incidence and mortality associated with colonoscopy. In the restricted cohort, using different statistical models, the absolute risk reduction varied from 0.52-0.60% for CRC incidence and 0.08-0.17% for CRC mortality. There were social disparities in the use of colonoscopy by PCPs and this disparity increased as the overall use of colonoscopy increased over time. Colonoscopy is effective in reducing incidence and mortality due to CRC. Different methods of subject selection and statistical analysis provided different estimates of colonoscopy effectiveness.

Die Entwicklung moderner minimal-invasiver Diagnose- und Behandlungsverfahren auf dem Gebiet der kolorektalen Adenome und Karzinome ermöglicht eine effektive Überwachung von Risikopersonen, andererseits erfolgt durch die endoskopische Abtragung oder transanale bzw. TEM-technische Resektion von Adenomen bereits eine erhebliche Karzinomprävention. Die Einführung der laparoskopischen Technik bei der Resektion kolorektaler Tumoren könnte nach Evaluierung der bisherigen Ergebnisse zu einer weiteren Verringerung der Hospitalisierung und operationsassoziierten Morbidität der Patienten bei gleicher Prognose führen. Kennzeichnend für familiäre Formen des kolorektalen Karzinoms ist das hohe Risiko für die Entwicklung kolorektaler Tumoren, jedoch auch für weitere extrakolonische Neoplasien. Dies trifft für das hereditäre Nicht-Polyposis-assoziierte kolorektale Karzinom (HNPCC), die familiäre Polyposis (FAP) und die selteneren Formen wie Peutz-Jeghers-Syndrom und juvenile Polyposis zu. Die Anwendung der molekularen Diagnostik in diesen Familien ermöglicht durch die Identifizierung von Mutationsträgern und Nichtmutationsträgern einerseits die gezielte Eingliederung von Hochrisikopersonen (Mutationsträgern) in spezielle, auf das jeweilige Syndrom zugeschnittene Überwachungs- und Vorsorgeprogramme und erspart andererseits Personen mit durchschnittlichem Risiko (Nichtmutationsträgern) unnötige und teilweise invasive Diagnostik. Bezüglich des chirurgischen Vorgehens bei Patienten mit einer Form des hereditären kolorektalen Karzinoms gibt es bereits etablierte Verfahren, wie die Durchführung einer restaurativen Proktokolektomie bei der FAP, bei anderen Formen, wie bei HNPCC, sind diese noch in der Diskussion. Wesentliche Fortschritte bei der Prävention kolorektaler Tumoren sind in den nächsten Jahren möglicherweise auf dem Gebiet der Chemoprävention zu erwarten. / Development of modern, minimally invasive methods for diagnosis and treatment in the field of colorectal tumours enables an effective surveillance for persons at high risk as well as a distinct cancer prevention by endoscopic, transanal or TEM removal of colorectal adenomas. Introduction of laparoscopic techniques in the resection of colorectal tumours could entail, after evaluation of preliminary results, a decreased duration of hospitalisation and procedure-associated morbidity in patients with the same prognosis. The very high risk for development of colorectal tumours as well as for some extracolonic neoplasia is typical for familial colorectal cancer syndromes. This concerns hereditary nonpolyposis colorectal cancer (HNPCC) syndrome, familial polyposis coli, and the infrequent forms like Peutz-Jeghers syndrome and juvenile polyposis. Molecular diagnostics has the power to identify carriers and noncarriers of a mutated gene in these families and therefore may permit clear-cut decisions regarding inclusion in special surveillance programmes, which is recommended for all persons at risk from affected families. Concerning the surgical approach in patients with hereditary colorectal cancer, well-accepted routine procedures like restorative proctocolectomy in familiar polyposis patients have already been established; in other forms like HNPCC the best surgical modality is still under discussion. Remarkable progress in the prevention of colorectal tumours could be expected from chemoprevention trials in the next years. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Die zytostatische Chemotherapie ist wesentlicher Bestandteil der palliativen Therapie von Patienten mit metastasiertem kolorektalen Karzinom. Gegenüber einer rein supportiven Behandlung verbessert eine auf 5-Fluorouracil (5-FU) basierende Chemotherapie die Lebensqualität und verlängert das Überleben der Patienten. 5- FU-Dauerinfusion moduliert mit Folinsäure ist die beste Grundlage für die Kombination mit Irinotecan oder Oxaliplatin. Randomisierte Studien zum Einsatz von Irinotecan zeigten signifikante Vorteile im Hinblick auf die Remissionsrate, das progressionsfreie Überleben und auch die mediane Überlebenszeit. Randomisierte Studien zum Einsatz von Oxaliplatin zeigten ebenfalls höhere Remissionsraten und ein verlängertes progressionsfreies Überleben ohne eine verlängerte Überlebenszeit nachweisen zu können. Heutzutage sollten alle Patienten mit einer Kombinationschemotherapie behandelt werden und im Verlauf ihrer Erkrankung, soweit möglich, alle zur Verfügung stehenden Medikamente erhalten. Nur dadurch können mediane Überlebenszeiten von über 20 Monaten erreicht werden. Der Einsatz oraler Fluoropyrimidine statt einer 5-FU-Dauerinfusion in Kombination mit Irinotecan und Oxaliplatin ist viel versprechend, jedoch Gegenstand laufender Studien. Monoklonale Antikörper gegen den EGF-Rezeptor bzw. gegen VEGF haben ebenfalls viel versprechende Ergebnisse gezeigt und werden wahrscheinlich die Behandlungsmöglichkeiten in der Zukunft wesentlich verbessern. / Systemic chemotherapy has a key role in the palliative treatment of patients with metastatic colorectal cancer. Compared to best supportive care, 5-fluorouracil (5-FU)-based therapy prolongs survival and improves quality of life. 5-FU continuous infusion modulated by Leukovorin (LV) is the optimal basis for a combination therapy with irinotecan or oxaliplatin. Randomized trials investigating the role of irinotecan in combination with 5-FU/LV relative to 5-FU/LV alone demonstrated a significant improvement in the response rate, progression free survival and overall survival. Randomized studies using oxaliplatin/ 5-FU/LV vs. FU/LV alone resulted in a higher response rate and longer progression-free survival while the overall survival was not significantly different. Today, all patients should receive combination treatment in first line and should be offered all active compounds during the course of their disease. Hereby, median survival times of more than 20 months are achievable. The use of oral fluoropyrimidines as a substitute of infusional 5-FU in combination with irinotecan or oxaliplatin is promising and subject of clinical trials. Monoclonal antibodies directed against the EGF-receptor or against VEGF have demonstrated interesting results and may be a treatment option in the future. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Background: Meat consumption is associated with an elevated risk of colorectal cancer (CRC); exposure to heterocyclic aromatic amines (HAAs), carcinogens produced when meat is cooked at high temperatures, is one hypothesized explanation for this relationship. HAAs form adducts with DNA; left unrepaired, DNA adducts can induce mutations which may initiate and/or promote the development of colorectal adenomas, precursors to the vast majority of CRCs. Along this continuum, genetic differences in the ability to biotransform or metabolize HAAs and repair DNA is postulated to modify the HAA-CRC relationship. Methods: This thesis examined the HAA-CRC relationship in two studies (Phase 1 and 2). In a cross-sectional study of 99 healthy volunteers, Phase 1 investigated the relationship between dietary exposure to HAAs and the levels of bulky DNA adducts in blood leukocytes. In Phase 2, a cross-sectional study examined the relationships between dietary exposures to: a) HAAs and; b) meat mutagenicity, and the prevalence of colorectal adenomas among 342 patients undergoing a screening colonoscopy. Both Phase 1 and 2 examined potential gene-diet interactions between dietary HAAs and genetic factors relevant to the biotransformation of HAAs and DNA repair. Results: In Phase 1, an interaction was observed for dietary HAAs and NAT1 polymorphisms where a positive association between HAA intakes and bulky DNA adduct levels was found among those with the NAT1 slow acetylator genotype, hypothesized to confer a lower ability to biotransform HAAs. In Phase 2, polymorphisms in genes involved in the biotransformation of HAAs (CYP1B1 rs10012 and rs1056827) and DNA repair (XPC rs2228001) were found to determine colorectal adenoma risk. As well, gene-diet interactions were observed for dietary HAAs/meat mutagenicity exposures and polymorphisms in CYP1B1 and XPD (rs13181 and rs1799793). Overall, a higher risk of colorectal adenoma was observed with higher HAA and/or meat mutagenicity exposures among those with polymorphisms which confer a greater activity to biotransform HAAs and/or a lower ability to repair DNA. Conclusion: This research supports the contribution of dietary HAAs and genetic susceptibility to the risk of developing colorectal adenomas and highlighted bulky DNA adduct formation as a potential biologic pathway through which HAAs may influence cancer risk. / Thesis (Ph.D, Community Health & Epidemiology) -- Queen's University, 2014-04-25 11:32:30.392

Background: Laparoscopic surgery for colorectal cancer is a novel healthcare technology, for which much research evidence has been published. The objectives of this work were to compare the oncologic outcomes of this technology across different study types, and to define patterns of adoption on the basis of the literature. Methods: A comprehensive systematic review of the literature was conducted using 1) existing systematic reviews, 2) randomized controlled trials (RCTs), and 3) observational studies. Outcomes of interest were overall survival, and total lymph node harvest. Outcomes were compared for congruence. Adoption was evaluated by means of summary expert opinions in the literature. Results: 1) Existing systematic reviews were of low to moderate quality and displayed evidence of overlap and duplication. 2) Laparoscopy was not inferior to open surgery in terms of oncologic outcomes in any study type. 3) Oncologic outcomes from RCTs and observational studies were congruent. 4) Expert opinion in the literature has been supportive of this technology, paralleling the publication of large RCTs. Conclusions: The evaluation of laparoscopic surgery for colorectal cancer in RCTs and observational studies suggests that it is not inferior to open surgery. Adoption of this technology has paralleled RCT evidence.

In the intestinal epithelium, Wnt signaling drives the expression of the genes encoding tyrosine kinase receptors EphB2 and EphB3 and represses the expression of their membrane-tethered ligands, ephrin-Bs. Eph-ephrin interactions result in cellular repulsion and are involved in boundary formation. The project of this thesis is to understand the mechanism by which EphB−ephrin-B signals restrict cell positioning of cell types (cell sorting) in the normal intestinal epithelium and suppress colorectal cancer (CRC) progression beyond the earliest stages. We have demonstrated that at the onset of CRC EphB receptors impair the expansion of tumor cells through a mechanism dependent on E-cadherin–mediated adhesion. We show that EphB-mediated compartmentalization restricts the spreading of EphB+ tumor cells into ephrin-B1+ territories in vitro and in vivo. Our results indicate that CRC cells must silence EphB expression to avoid repulsive interactions imposed by normal ephrin-B1+ intestinal cells at the onset of tumorigenesis. We have discovered that cell sorting is the outcome of two integrated mechanisms: cell contraction/repulsion and differential cell adhesion. The latter is the driving force to induce EphB/ephrin-B−mediated cell compartmentalization. We have developed in vitro models to analyze the mechanisms that induce E-cadherin remodeling upon EphB activation. We found RhoA, p120-catenin and the metalloproteinase ADAM10 as downstream effectors of EphB signaling involved in the control of cell sorting in CRC cells. / A l'epiteli intestinal, la ruta de senyalització Wnt indueix l'expressió dels gens que codifiquen per als receptors tirosina kinasa EphB2 i EphB3 i reprimeixen la dels seus lligands transmembrana, efrines de tipus B. Les interaccions Eph-efrina causen repulsió cel·lular i estan implicades en la formació de fronteres entre compartiments. La finalitat d'aquesta tesi és entendre el mecanisme pel qual la senyalització per EphB−efrina-B restringeix el posicionament dels diferents tipus cel·lulars a l'epiteli intestinal normal i suprimeix la progressió del càncer colorectal (CRC) en els primer estadis. Hem demostrat que, a l’inici del CRC, els receptors EphB restringeixen l'expansió de les cèl·lules tumorals a través d'un mecanisme depenent d'adhesió intercel·lular a través d’E-cadherina. En aquest treball es mostra in vitro i in vivo que la compartimentalització mitjançada per la senyalització dels receptors EphB restringeix l’invasió de les cèl·lules tumorals EphB+ als territoris efrina-B+. Aquests resultats indiquen que les cèl·lules de CRC han de silenciar l’expressió d'EphB per evitar les interaccions repulsives imposades per les cèl·lules intestinals normals efrina-B+ circumdants al començament del procés de tumorigènesi. Hem pogut discernir que el reordenament cel·lular per senyals EphB−efrina-B és el resultat de dos mecanismes integrats: la contracció/repulsió intercel·lular i l’adhesió diferencial entre diferents poblacions cel·lulars. Aquesta última és la força principal que condueix a la compartimentalització cel·lular mitjançada per EphB−efrina-B. Hem desenvolupat models in vitro per analitzar els mecanismes que provoquen el remodelament de la E-cadherina sota la senyalització per EphB. Presentem RhoA, p120-catenina i ADAM10 com a efectors de la senyalització de la ruta EphB implicats en el control de la compartimentalització cel·lular en el CRC.

EGFR is a transmembrane tyrosine kinase receptor from the HER family which, upon ligand stimulation, activates different signaling pathways involved in tumorogenesis. EGFR can be targeted by monoclonal antibodies, as cetuximab and panitumumab, which bind to EGFR preventing ligand stimulation of the receptor. Cetuximab and panitumumab are approved for colorectal cancer treatment. However, its clinical success is uniformily limited by the development of acquired drug resistance. We describe a new mechanism of acquired resistance to cetuximab in colorectal cancer that was due to a missense mutation in the EGFR ectodomain (S492R mutation). Upon chronic exposure to cetuximab, colorectal cancer cell lines acquired S492R mutation and became resistant to the treatment. We observed that cetuximab was not able to bind mutant EGFR. Notably, this amino acid change did not affect the ability of panitumumab to bind to EGFR, and panitumumab effectively suppressed growth of mutant cells. EGFRS492R mutation was detected in 2 out of 10 tumor specimens from patients following progression on cetuximab. One of these patients was subsequently treated with single agent panitumumab yielding a partial response. The S492R mutation defines a novel biomarker of resistance to cetuximab but not to panitumumab in colorectal cancer / EGFR és un receptor transmembrana tirosina cinasa de la família HER el qual, després de l’estimulació mitjançant lligands, activa vies de senyalització involucrades en processos tumorogènics. L’EGFR es pot inhibir amb anticossos monoclonals, com cetuximab i panitumumab, que s’uneixen al receptor prevenint-ne l’activació per part dels lligands. Cetuximab i panitumumab estan aprovats per al tractament del càncer colorectal, però el seu ús es veu limitat per el desenvolupament de resistència adquirida al tractament. Nosaltres describim un mecanisme de resistència adquirida a cetuximab en càncer colorectal degut a l’adquisió d’una mutació en el domini extracel•lular de l’EGFR, la mutació S492R. Durant l’exposició crònica a cetuximab, linies cel•lulars de càncer colorectal van adquirir la mutació S492R tornat-se resistents al tractament. Cetuximab no era capaç d’unir-se a l’EGFR mutat. Aquests canvi d’aminoàcid no afectava a l’habilitat que té panitumumab a unir-se al EGFR, pertant, panitumumab suprimia el creixement de les cèl•lules tumorals mutades. Vam detectar la mutació EGFRS492R en 2 de 10 mostres tumorals de pacients que havien recaigut al tractament amb cetuximab. Un d’aquest pacients va ser posteriorment tractat amb panitumumab obtenint-ne una resposta tumoral parcial. La mutació S492R defineix un nou mecanisme de resistència a cetuximab però no a panitumumab en el tractament del càncer colorectal.

In most randomised controlled trials (RCTs), a large number of patients need to be followed over many years, for the clinical benefit of the drug to be accurately quantified (1). Using an early proxy, or a surrogate endpoint, in place of the direct endpoint of overall survival (OS) could theoretically shorten the duration of RCTs and minimise the exposure of patients to ineffective or toxic treatments (2, 3). This thesis examined the relationship between surrogate endpoints and OS in metastatic colorectal cancer (CRC), advanced non-small cell lung cancer (NSCLC) and metastatic breast cancer (MBC). A review of the literature identified 144 RCTs in metastatic CRC, 189 in advanced NSCLC and 133 in MBC. The publications were generally of poor quality with incomplete reporting on many key variables, making comparisons between studies difficult. The introduction of the CONSORT statement was associated with improvements in the quality of reporting. For CRC (337 arms), NSCLC (429 arms) and MBC (290 arms) there were strong relationships between OS and progression free survival (PFS), time to progression (TTP), disease control rate (DCR), response rate (RR) and partial response (PR). Correlation was also demonstrated between OS and complete response (CR) in CRC and duration of response (DOR) in MBC. However, while strong relationships were found, the proportion of variance explained by the models was small. Prediction bands constructed to determine the surrogate threshold effect size indicated that large improvements in the surrogate endpoints were needed to predict overall survival gains. PFS and TTP showed the most promise as surrogates. The gain in PFS and TTP required to predict a significant gain in overall survival was between 1.2 and 7.0 months and 1.8 and 7.7 months respectively, depending on trial size and tumour type. DCR was a better potential predictor of OS than RR. The results of this study could be used to design future clinical trials with particular reference to the selection of surrogate endpoint and trial size.