Colorectal Carcinoma: A Decade of Experience at the Lahey Clinic* MARVIN L. COR~IAN, M.D., MALCOLM C. VEIDENHEIMER, M.D., JoHN A. COH_ER, M.D.
PERIODIC STUDIES have been r e p o r t e d on the exp e r i e n c e at the L a h e y Clinic with colorectal carcinoma, the last published in 1973 t and covering the period f r o m 1962 t h r o u g h 1966 inclusive. In o u r current five-year review the results o f the earlier series are i n c o r p o r a t e d with those o f the r e c e n t p e r i o d (1967 t h r o u g h 1971 inclusive). F r o m 1962 t h r o u g h 1971, 1,008 patients at the Lahey Clinic u n d e r w e n t definitive t r e a t m e n t for carcinoma o f the colon and r e c t u m . E x c l u d e d f r o m study were patients who did not u n d e r g o their complete surgical t r e a t m e n t at the Lahey Clinic or who were r e f e r r e d for medical m a n a g e m e n t (i.e., chemotherapy and radiotherapy). Fifteen patients (1.5 per cent) did not u n d e r g o operation. Thirty-nine operative deaths occurred, a mortality rate of 3.9 per cent. Operative mortality in patients o p e r a t e d on for cure was 1.8 per cent. T h e s e data are summarized in Table 1, and mortality, operability, and resectability for the two five-year periods are c o m p a r e d . T a b l e 1 also demonstrates the sex and age distribution o f patients in the previously r e p o r t e d series and in the c u r r e n t series. T h e m e a n age o f patients u n d e r g o i n g resection for colorectal carcinoma is 63 years. No difference exists between m e a n ages and sexes o f patients in both series. Table 2 summarizes the location o f the tumors. Alt h o u g h recent reports have noted a change in distribution o f colorectal carcinoma in that tumors develop m o r e proximally than had been seen previously, 2-4 we have noted no change over the past decade. Rectal a n d sigmoid lesions t o g e t h e r e n c o m passed 67 per cent in the previous five-year study and 69 per cent in the c u r r e n t report. Ascending colonic lesions were present in 18 p e r cent o f the patients in each group.
In Table 3 the survival rate is listed according to Dukes' classification. This classification is schematically illustrated in Figure 1. For patients with Dukes' * Received for publication April 26, 1979. Address reprint requests to Dr. Corman: Section of Colon and Rectal Surgery, Lahey Clinic Foundation, 605 Commonwealth Avenue, Boston, Massachusetts 02215.
From the Section of Colon and Rectal SurgeU , Lahey Clinic Foundation, Boston, Massachusetts
A lesions, the u n c o r r e c t e d five-year survival rate for the c o m b i n e d previous and c u r r e n t series was 81 per cent. For patients with Dukes' B and C lesions, the survival rate falls to 62 and 35 per cent respectively. Only one patient survived with metastatic disease (Dukes' D) for m o r e than five years. No statistically significant d i f f e r e n c e exists between these resnlts and survival rates r e p o r t e d in the previous serics. Uncorrected survival rates for the two series are virtually identical. T h e 10-year study reveals a corrected fiveyear survival o f 95 per cent for patients with Dukes' A lesions, 90 per cent for those with Dukes' B lesions, and 55 per cent for those with Dukes' C lesions. Survival rates generally fall with increasing lymph node involvement. Table 4 illustrates the survival rate versus the n u m b e r o f positive lymph nodes. I f m o r e than three nodes were positive the overall survival rate was 18 p e r cent. Carcinoma o f the colon and rectum is the co,nrnonest visceral malignancy in the United States with 112,000 new cases expected in 1979. 5 And yet, in spite o f advances in surgical technique reducing operative mortality, survival figures have not significantly imp r o v e d in the past 30 years. Adjunctive t h e r a p y with p r e o p e r a t i v e a n d p o s t o p e r a t i v e radiation f o r carcinoma o f the r e c t u m may i m p r o v e survival rates, but the results o f carefully controlled, r a n d o m i z e d studies await evaluation. C h e m o t h e r a p y for Dukes' B and C tumors is being p e r f o r m e d in clinical trials, but preliminary reports are less than enthusiastic. T h e best h o p e for increasing survival rates in the immediate f u t u r e is to bring the patient to o p e r a t i o n with an earlier stage o f t u m o r . Many patients u n f o r tunately continue to be seen the first time having had a relatively l o n g history o f s y m p t o m s o f colonic cancer. One third o f o u r patients have symptoms for longer than six months. Screening techniques including occult blood testing o f the stool, proctosigmoidoscopy, and possibly fiberoptic colonoscopy in the high risk patient, deserve m o r e aggressive application.
0012-3706/79/1000/0477/$00.65 9 American Society of Colon and Rectal Surgeons
477
478
Dis. Col. & Rect. October 1979
C O R M A N E T AL.
Fro. 1. Dukes' classification. A, T u m o r confined to the bowel wall. B, T u m o r b r e a c h e s the s e r o m u s c u l a r s u r f a c e o f the bowel wall. C, Inv o l v e m e n t of l y m p h n o d e s in t u m o r - b e a r i n g segment. T u m o r m a y or m a y not be t h r o u g h the bowel wail. D, T u m o r is beyond surgicaI curability. (From C o r m a n ML, V e i d e n h e i m e r MC, CollerJA: C o l o n a n d Rectal S u r g e r y . P h i l a d e l p h i a , W B S a u n d e r s C o m p a n y , in press. R e p r i n t e d with permission.)
TABLE 1.
Ten-Year Results of Operationfor Co&rectal Carcinoma
Data N u m b e r o f patients
1962-1966 .
1967-1971
513
495
Men Women
267 246
Mean Age
1,008 281 214
62
63
62 62
Number operated
548 460
64
Men Women Not o p e r a t e d
1962-1971
64 63
63 62
8
7
15
505
488
993
Not resected
30
21
51
Resectability, per cent
94
96
95
Operative d e a t h s
23
16
39
Operative mortality, p e r cent
4.5
3.3
TABLE 2.
Locations of Tumors
1962-1966 Site
1967-1971 Per Cent
47
199
40
438
43
20
143
29
248
25
93
18
89
18
182
18
44
8
45
9
89
9
6
19
4
51
5
Per Cent
Rectum
239
Sigmoid colon
105
A s c e n d i n g colon T r a n s v e r s e colon (including flexures)
TOTAL
1962-1971
Number
Number
D e s c e n d i n g colon
3.9
32 513
495
Number
t,008
Per Cent
Volume 22
Number 7
479
COLORECTAL CANCER REVIEW
TABLE 3. Survival Rate by Dukes' Classification Uncorrected 1962-1966 Dukes' Classification
Per Cent
A B C D
84 65 36 0
Number 103 175 118 117
Corrected*
1967-1971 Per Cent 78 60 34 1
513
1962-1971
Number 122 157 86 130
Per Cent
Number
81 62 35 0
495
1962-1966
1967-1971
1962-1971
Per Cent
Per Cent
Per Cent
98 88 56 0
96 90 56 1
95 90 55 t
225 332 204 247 1,008
* Table of Expectation of Life and Mortality Rates from Vital Statistics for the United States (1974), vol 2, section 5, Life Tables. United States National Center for Health Statistics, Washington, D.C., Government Printing Office, 1976.
TABLE 4.
Survival vs. Number of Lymph Nodes lnvoh,ed (1962.-1971) Survival
Number of Positive L}mph Nodes
Five-Year Total
Deaths
Number
Per Cent
1
71
39
32
45
2 3 4 5 6 7 8 ormore
47 30 20 11 8 7 9
33 15 16 9 6 6 8
14 15 4 2 2 1 1
30 50 20 18 25 14 ll
203
132
71
35
Summary Carcinoma o f t h e c o l o n a n d r e c t u m is t h e c o m monest visceral malignancy in this country today. Uncorrected five-year survival rates (1967-1971) for D u k e s ' A , B, a n d C l e s i o n s w e r e 81 p e r c e n t , 6 2 p e r cent, and 33 per cent respectively, and are essentially t h e s a m e as t h o s e o b s e r v e d i n t h e p r e v i o u s f i v e - y e a r period (1962-1966). The actuarially corrected fiveyear survival rates for Dukes' A, B, and C lesions for the ten-year period (1962-1971) were 95 per cent, 90 per cent, and 55 per cent. Further improvement in these statistics depends on bringing the patient to ope r a t i o n w i t h less a d v a n c e d d i s e a s e a n d p o s s i b l y o n supplementing resection with other modalities of therapy.
Overall Per Cent
41
18
Acknowledgment We are i n d e b t e d to Mr. William A. Curby, Head, Sias Biophysics Research Unit, Lahey Clinic Foundation, for his statistical help in the preparation of this manuscript.
References 1. Corman ML, Swinton NW, O'Keefe DD, et al: Colorectal carcinoma at the Lahey Clinic, 1962 to 1966. Am J Surg 125: 424, 1973 2. Cady B, Persson AV, Monson DO, et al: Changing patterns of colorectal carcinoma. Cancer 33: 422, 1974 3. Abrams JS, Reines HD: Increasing incidence of right-sided lesions in colorectal cancer. Am J Surg 137: 522, 1979 4. Haenszel W, Correa P: Cancer of the colon and rectum and adenomatous polyps. A review of epidemiologic findings. Cancer 28: 14, 1971 5. Cancer Facts and Figures, 1979. New York, American Cancer Society, Inc, 1979, p 9
PERIODIC STUDIES have been r e p o r t e d on the exp e r i e n c e at the L a h e y Clinic with colorectal carcinoma, the last published in 1973 t and covering the period f r o m 1962 t h r o u g h 1966 inclusive. In o u r current five-year review the results o f the earlier series are i n c o r p o r a t e d with those o f the r e c e n t p e r i o d (1967 t h r o u g h 1971 inclusive). F r o m 1962 t h r o u g h 1971, 1,008 patients at the Lahey Clinic u n d e r w e n t definitive t r e a t m e n t for carcinoma o f the colon and r e c t u m . E x c l u d e d f r o m study were patients who did not u n d e r g o their complete surgical t r e a t m e n t at the Lahey Clinic or who were r e f e r r e d for medical m a n a g e m e n t (i.e., chemotherapy and radiotherapy). Fifteen patients (1.5 per cent) did not u n d e r g o operation. Thirty-nine operative deaths occurred, a mortality rate of 3.9 per cent. Operative mortality in patients o p e r a t e d on for cure was 1.8 per cent. T h e s e data are summarized in Table 1, and mortality, operability, and resectability for the two five-year periods are c o m p a r e d . T a b l e 1 also demonstrates the sex and age distribution o f patients in the previously r e p o r t e d series and in the c u r r e n t series. T h e m e a n age o f patients u n d e r g o i n g resection for colorectal carcinoma is 63 years. No difference exists between m e a n ages and sexes o f patients in both series. Table 2 summarizes the location o f the tumors. Alt h o u g h recent reports have noted a change in distribution o f colorectal carcinoma in that tumors develop m o r e proximally than had been seen previously, 2-4 we have noted no change over the past decade. Rectal a n d sigmoid lesions t o g e t h e r e n c o m passed 67 per cent in the previous five-year study and 69 per cent in the c u r r e n t report. Ascending colonic lesions were present in 18 p e r cent o f the patients in each group.
In Table 3 the survival rate is listed according to Dukes' classification. This classification is schematically illustrated in Figure 1. For patients with Dukes' * Received for publication April 26, 1979. Address reprint requests to Dr. Corman: Section of Colon and Rectal Surgery, Lahey Clinic Foundation, 605 Commonwealth Avenue, Boston, Massachusetts 02215.
From the Section of Colon and Rectal SurgeU , Lahey Clinic Foundation, Boston, Massachusetts
A lesions, the u n c o r r e c t e d five-year survival rate for the c o m b i n e d previous and c u r r e n t series was 81 per cent. For patients with Dukes' B and C lesions, the survival rate falls to 62 and 35 per cent respectively. Only one patient survived with metastatic disease (Dukes' D) for m o r e than five years. No statistically significant d i f f e r e n c e exists between these resnlts and survival rates r e p o r t e d in the previous serics. Uncorrected survival rates for the two series are virtually identical. T h e 10-year study reveals a corrected fiveyear survival o f 95 per cent for patients with Dukes' A lesions, 90 per cent for those with Dukes' B lesions, and 55 per cent for those with Dukes' C lesions. Survival rates generally fall with increasing lymph node involvement. Table 4 illustrates the survival rate versus the n u m b e r o f positive lymph nodes. I f m o r e than three nodes were positive the overall survival rate was 18 p e r cent. Carcinoma o f the colon and rectum is the co,nrnonest visceral malignancy in the United States with 112,000 new cases expected in 1979. 5 And yet, in spite o f advances in surgical technique reducing operative mortality, survival figures have not significantly imp r o v e d in the past 30 years. Adjunctive t h e r a p y with p r e o p e r a t i v e a n d p o s t o p e r a t i v e radiation f o r carcinoma o f the r e c t u m may i m p r o v e survival rates, but the results o f carefully controlled, r a n d o m i z e d studies await evaluation. C h e m o t h e r a p y for Dukes' B and C tumors is being p e r f o r m e d in clinical trials, but preliminary reports are less than enthusiastic. T h e best h o p e for increasing survival rates in the immediate f u t u r e is to bring the patient to o p e r a t i o n with an earlier stage o f t u m o r . Many patients u n f o r tunately continue to be seen the first time having had a relatively l o n g history o f s y m p t o m s o f colonic cancer. One third o f o u r patients have symptoms for longer than six months. Screening techniques including occult blood testing o f the stool, proctosigmoidoscopy, and possibly fiberoptic colonoscopy in the high risk patient, deserve m o r e aggressive application.
0012-3706/79/1000/0477/$00.65 9 American Society of Colon and Rectal Surgeons
477
478
Dis. Col. & Rect. October 1979
C O R M A N E T AL.
Fro. 1. Dukes' classification. A, T u m o r confined to the bowel wall. B, T u m o r b r e a c h e s the s e r o m u s c u l a r s u r f a c e o f the bowel wall. C, Inv o l v e m e n t of l y m p h n o d e s in t u m o r - b e a r i n g segment. T u m o r m a y or m a y not be t h r o u g h the bowel wail. D, T u m o r is beyond surgicaI curability. (From C o r m a n ML, V e i d e n h e i m e r MC, CollerJA: C o l o n a n d Rectal S u r g e r y . P h i l a d e l p h i a , W B S a u n d e r s C o m p a n y , in press. R e p r i n t e d with permission.)
TABLE 1.
Ten-Year Results of Operationfor Co&rectal Carcinoma
Data N u m b e r o f patients
1962-1966 .
1967-1971
513
495
Men Women
267 246
Mean Age
1,008 281 214
62
63
62 62
Number operated
548 460
64
Men Women Not o p e r a t e d
1962-1971
64 63
63 62
8
7
15
505
488
993
Not resected
30
21
51
Resectability, per cent
94
96
95
Operative d e a t h s
23
16
39
Operative mortality, p e r cent
4.5
3.3
TABLE 2.
Locations of Tumors
1962-1966 Site
1967-1971 Per Cent
47
199
40
438
43
20
143
29
248
25
93
18
89
18
182
18
44
8
45
9
89
9
6
19
4
51
5
Per Cent
Rectum
239
Sigmoid colon
105
A s c e n d i n g colon T r a n s v e r s e colon (including flexures)
TOTAL
1962-1971
Number
Number
D e s c e n d i n g colon
3.9
32 513
495
Number
t,008
Per Cent
Volume 22
Number 7
479
COLORECTAL CANCER REVIEW
TABLE 3. Survival Rate by Dukes' Classification Uncorrected 1962-1966 Dukes' Classification
Per Cent
A B C D
84 65 36 0
Number 103 175 118 117
Corrected*
1967-1971 Per Cent 78 60 34 1
513
1962-1971
Number 122 157 86 130
Per Cent
Number
81 62 35 0
495
1962-1966
1967-1971
1962-1971
Per Cent
Per Cent
Per Cent
98 88 56 0
96 90 56 1
95 90 55 t
225 332 204 247 1,008
* Table of Expectation of Life and Mortality Rates from Vital Statistics for the United States (1974), vol 2, section 5, Life Tables. United States National Center for Health Statistics, Washington, D.C., Government Printing Office, 1976.
TABLE 4.
Survival vs. Number of Lymph Nodes lnvoh,ed (1962.-1971) Survival
Number of Positive L}mph Nodes
Five-Year Total
Deaths
Number
Per Cent
1
71
39
32
45
2 3 4 5 6 7 8 ormore
47 30 20 11 8 7 9
33 15 16 9 6 6 8
14 15 4 2 2 1 1
30 50 20 18 25 14 ll
203
132
71
35
Summary Carcinoma o f t h e c o l o n a n d r e c t u m is t h e c o m monest visceral malignancy in this country today. Uncorrected five-year survival rates (1967-1971) for D u k e s ' A , B, a n d C l e s i o n s w e r e 81 p e r c e n t , 6 2 p e r cent, and 33 per cent respectively, and are essentially t h e s a m e as t h o s e o b s e r v e d i n t h e p r e v i o u s f i v e - y e a r period (1962-1966). The actuarially corrected fiveyear survival rates for Dukes' A, B, and C lesions for the ten-year period (1962-1971) were 95 per cent, 90 per cent, and 55 per cent. Further improvement in these statistics depends on bringing the patient to ope r a t i o n w i t h less a d v a n c e d d i s e a s e a n d p o s s i b l y o n supplementing resection with other modalities of therapy.
Overall Per Cent
41
18
Acknowledgment We are i n d e b t e d to Mr. William A. Curby, Head, Sias Biophysics Research Unit, Lahey Clinic Foundation, for his statistical help in the preparation of this manuscript.
References 1. Corman ML, Swinton NW, O'Keefe DD, et al: Colorectal carcinoma at the Lahey Clinic, 1962 to 1966. Am J Surg 125: 424, 1973 2. Cady B, Persson AV, Monson DO, et al: Changing patterns of colorectal carcinoma. Cancer 33: 422, 1974 3. Abrams JS, Reines HD: Increasing incidence of right-sided lesions in colorectal cancer. Am J Surg 137: 522, 1979 4. Haenszel W, Correa P: Cancer of the colon and rectum and adenomatous polyps. A review of epidemiologic findings. Cancer 28: 14, 1971 5. Cancer Facts and Figures, 1979. New York, American Cancer Society, Inc, 1979, p 9
