Colorectal Carcinoma: Review of the Experiences at Hubbard Hospital Alphonso Pasipanodya, MD Nashville, Tennessee
The records of 112 patients treated for carcinoma of the colon at Hubbard Hospital between 1956 and 1971 were reviewed. The mean age was 64.4 years and 64.9 percent were females. Only 27 percent presented with Duke's A lesions. The delay in seeking medical therapy averaged 4.48 months from onset of symptoms. Most patients presented with complications of their disease and the majority had other concurrent diseases which contributed significantly to the poor overall five-year survival figures. Colorectal carcinoma is now the leading visceral cancer in the United States. For the year 1977, the American Cancer Society projected that 101,000 Americans would be found to have colorectal carcinoma and that 51,000 would succumb to it. Although carcinoma of the lung is a close second, with a predicted occurrence in 98,000 Americans, it still causes more annual deaths (89,000) than colorectal carcinoma." 2 The increasing significance of colon carcinoma has prompted a review of the records of Hubbard Hospital to assess our experience with this disease.
Materials and Methods The records of patients treated for colon carcinoma between 1956 and 1971 were reviewed. Follow-up information was obtained from the Tumor Clinic records. One hundred twelve patients with an average age of 64.5 years (a range of 27 to 93 years) met the criteria for inclusion in the study. All patients were black and 73 percent had lived in the North Nashville area for a minimum of five years; 64.9 percent were females and the majority From the Department of Surgery, Meharry Medical College, Nashville, Tennessee. Requests for reprints should be addressed to Dr. Alphonso Pasipanodya, Department of Surgery, Meharry Medical College, 1005 18th Avenue North, Nashville, TN 37208.
were indigent at the time of diagnosis and treatment. Four patients refused surgical treatment of their lesions and received chemotherapy. All the patients included in this study were treated either by curative or palliative resection. Those who had palliative resection subsequently received chemotherapy and/or radiation therapy for further relief.
with the remaining diagnoses established by barium enema examination. The distribution of the lesions and the extent of their involvement are shown in Table 2. The lesions of the right colon (both flexures) and the transverse colon were more likely to be far advanced in this series. The overall five-year survival figures are shown in Table 3. Thirteen percent of the patients required diverting colostomies because of complete obstruction and marked proximal distention and edema of the bowel. The majority of these patients had a variable combination of concurrent diseases of old age, the more common ones being arteriosclerosis, hypertensive cardiovascular disease, and diabetes.
Results
Discussion
This series is too small to derive firm statistical conclusions. The majority of the patients presented because of some late complication of their disease. Table 1 summarizes the signs and symptoms that caused these patients to seek medical attention. The majority of patients presented with symptoms of partial mechanical obstruction and gastrointestinal bleeding. Sixty-one percent had abdominal fullness; 50.6 percent had constipation; and 44.15 percent had a variable combination of nausea, vomiting, and anorexia. Diarrhea was the presenting complaint in 14 percent and gross rectal bleeding was noted in 29 percent. Some form of change in bowel habits was present in 54.5 percent of the patients. Anemia, defined in this series as Hgbs12 gm/100 ml, was present in 63 percent. Diagnosis of the lesions was established by rectal examination and protosigmoidoscopy in 50.6 percent,
The advanced state of the disease at initial diagnosis and the associated illnesses in these patients account in part for the poor survival figures. In this series, Duke's A lesions yielded a five-year survival rate of only 40 percent. The poor results can be partly explained when one notes that 33.3 percent of those Duke's A patients died of concurrent illnesses after leaving the hospital free of disease. The advanced state of the disease at initial presentation is shown by the fact that only 26.8 percent were considered to be Duke's A lesions at surgery. While the mean period from the point when the patient becomes aware of his symptoms to the point that he seeks medical assistance varied from two to six months,3 we find that in our series, which is composed of elderly and indigent blacks, the average duration of symptoms remains prolonged at 4.48 months. The commonplace nature
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 5, 1979
491
Table 1. Summary of Signs and Symptoms
Signs and Symptoms Frequency
(%)
61 50.6 44.15
Abdominal fullness
Constipation Nausea, vomiting, anorexia Change in bowel habits Rectal bleeding Anemia Diarrhea
54.5 29 63 14
Table 2. Distribution of Lesions Frequency
Site Cecum and ascending colon Transverse colon and hepatic and splenic flexure Descending colon Rectosigmoid Simultaneous sites
Duke's Lesions (%) C B
Distant (%)
Unclassified (%)
(%)
A
27.7
22.6
22.6
29
25.8
20.53
4.3
30.4
26.1
34.8
4.3
10.7 36.6 4.46
50 39.02
25 19.5
0
25 19.02
4.9
17.7
Table 3. Five-Year Survivals Cases
Five-Year Survival (%)
Death Due to Other Causes (%)
26.8 24.1 21.4 25.0 2.7
40 25.9 20.8
33.33 29.63
(%)
Duke's A B C Stage IV
Unclassified
of the early symptoms of colon carcinoma may account for the delay in seeking medical attention. Thirteen percent required colostomy for decompression before definitive surgery could be undertaken. More radical resections beyond the limits of presently acceptable dissections for achieving a cure are not likely to improve survival rates.4 The longrange solution will lie in prevention, but a more realistic goal probably would be intensified concentration on early detection of these lesions.5 This requires 492
7.14
increased physician and patient awareness of the presentation of these lesions. Aggressive follow-up of patients in the target age groups, and those with premalignant lesions such as familial polyposis, villous adenomas, ulcerative colitis, Gardner syndrome, and Turcot syndrome,2'4'5 may increase the detection of early lesions and consequently improve overall prognosis. Survival figures may further be improved by diligent management of concurrent diseases, which accounted for the demise of a significant number of our patients.
Literature Cited 1. Valdivieso M, Mavligit SM: Chemotherapy and chemoimmunotherapy of colorectal cancer. Surg Clin North Am 58(3):619, 1978 2. Storer EH, Goldberg SM, Nivatvongs S: Colon, rectum and anus. In Schwartz IS (ed): Principles of Surgery, ed 3. New York, McGraw-Hill, 1979, pp 1217-1226. 3. Cole WH: Cancer of the colon and rectum. Symposium on Diseases of the Colon and Anorectum. Surg Clin North Am 52(4): 871-882, 1972 4. Stearns MW Jr: Benign and malignant neoplasms of colon and rectum:,Diagnosis and management. Symposium on Colon and Anorectal Surgery. Surg Clin North Am 58(3):605-608, 1978 5. Winawer SJ, Sherlock P: Detecting early colon cancer. Hosp Pract 12(3):49-53, 1976
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 5, 1979
The records of 112 patients treated for carcinoma of the colon at Hubbard Hospital between 1956 and 1971 were reviewed. The mean age was 64.4 years and 64.9 percent were females. Only 27 percent presented with Duke's A lesions. The delay in seeking medical therapy averaged 4.48 months from onset of symptoms. Most patients presented with complications of their disease and the majority had other concurrent diseases which contributed significantly to the poor overall five-year survival figures. Colorectal carcinoma is now the leading visceral cancer in the United States. For the year 1977, the American Cancer Society projected that 101,000 Americans would be found to have colorectal carcinoma and that 51,000 would succumb to it. Although carcinoma of the lung is a close second, with a predicted occurrence in 98,000 Americans, it still causes more annual deaths (89,000) than colorectal carcinoma." 2 The increasing significance of colon carcinoma has prompted a review of the records of Hubbard Hospital to assess our experience with this disease.
Materials and Methods The records of patients treated for colon carcinoma between 1956 and 1971 were reviewed. Follow-up information was obtained from the Tumor Clinic records. One hundred twelve patients with an average age of 64.5 years (a range of 27 to 93 years) met the criteria for inclusion in the study. All patients were black and 73 percent had lived in the North Nashville area for a minimum of five years; 64.9 percent were females and the majority From the Department of Surgery, Meharry Medical College, Nashville, Tennessee. Requests for reprints should be addressed to Dr. Alphonso Pasipanodya, Department of Surgery, Meharry Medical College, 1005 18th Avenue North, Nashville, TN 37208.
were indigent at the time of diagnosis and treatment. Four patients refused surgical treatment of their lesions and received chemotherapy. All the patients included in this study were treated either by curative or palliative resection. Those who had palliative resection subsequently received chemotherapy and/or radiation therapy for further relief.
with the remaining diagnoses established by barium enema examination. The distribution of the lesions and the extent of their involvement are shown in Table 2. The lesions of the right colon (both flexures) and the transverse colon were more likely to be far advanced in this series. The overall five-year survival figures are shown in Table 3. Thirteen percent of the patients required diverting colostomies because of complete obstruction and marked proximal distention and edema of the bowel. The majority of these patients had a variable combination of concurrent diseases of old age, the more common ones being arteriosclerosis, hypertensive cardiovascular disease, and diabetes.
Results
Discussion
This series is too small to derive firm statistical conclusions. The majority of the patients presented because of some late complication of their disease. Table 1 summarizes the signs and symptoms that caused these patients to seek medical attention. The majority of patients presented with symptoms of partial mechanical obstruction and gastrointestinal bleeding. Sixty-one percent had abdominal fullness; 50.6 percent had constipation; and 44.15 percent had a variable combination of nausea, vomiting, and anorexia. Diarrhea was the presenting complaint in 14 percent and gross rectal bleeding was noted in 29 percent. Some form of change in bowel habits was present in 54.5 percent of the patients. Anemia, defined in this series as Hgbs12 gm/100 ml, was present in 63 percent. Diagnosis of the lesions was established by rectal examination and protosigmoidoscopy in 50.6 percent,
The advanced state of the disease at initial diagnosis and the associated illnesses in these patients account in part for the poor survival figures. In this series, Duke's A lesions yielded a five-year survival rate of only 40 percent. The poor results can be partly explained when one notes that 33.3 percent of those Duke's A patients died of concurrent illnesses after leaving the hospital free of disease. The advanced state of the disease at initial presentation is shown by the fact that only 26.8 percent were considered to be Duke's A lesions at surgery. While the mean period from the point when the patient becomes aware of his symptoms to the point that he seeks medical assistance varied from two to six months,3 we find that in our series, which is composed of elderly and indigent blacks, the average duration of symptoms remains prolonged at 4.48 months. The commonplace nature
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 5, 1979
491
Table 1. Summary of Signs and Symptoms
Signs and Symptoms Frequency
(%)
61 50.6 44.15
Abdominal fullness
Constipation Nausea, vomiting, anorexia Change in bowel habits Rectal bleeding Anemia Diarrhea
54.5 29 63 14
Table 2. Distribution of Lesions Frequency
Site Cecum and ascending colon Transverse colon and hepatic and splenic flexure Descending colon Rectosigmoid Simultaneous sites
Duke's Lesions (%) C B
Distant (%)
Unclassified (%)
(%)
A
27.7
22.6
22.6
29
25.8
20.53
4.3
30.4
26.1
34.8
4.3
10.7 36.6 4.46
50 39.02
25 19.5
0
25 19.02
4.9
17.7
Table 3. Five-Year Survivals Cases
Five-Year Survival (%)
Death Due to Other Causes (%)
26.8 24.1 21.4 25.0 2.7
40 25.9 20.8
33.33 29.63
(%)
Duke's A B C Stage IV
Unclassified
of the early symptoms of colon carcinoma may account for the delay in seeking medical attention. Thirteen percent required colostomy for decompression before definitive surgery could be undertaken. More radical resections beyond the limits of presently acceptable dissections for achieving a cure are not likely to improve survival rates.4 The longrange solution will lie in prevention, but a more realistic goal probably would be intensified concentration on early detection of these lesions.5 This requires 492
7.14
increased physician and patient awareness of the presentation of these lesions. Aggressive follow-up of patients in the target age groups, and those with premalignant lesions such as familial polyposis, villous adenomas, ulcerative colitis, Gardner syndrome, and Turcot syndrome,2'4'5 may increase the detection of early lesions and consequently improve overall prognosis. Survival figures may further be improved by diligent management of concurrent diseases, which accounted for the demise of a significant number of our patients.
Literature Cited 1. Valdivieso M, Mavligit SM: Chemotherapy and chemoimmunotherapy of colorectal cancer. Surg Clin North Am 58(3):619, 1978 2. Storer EH, Goldberg SM, Nivatvongs S: Colon, rectum and anus. In Schwartz IS (ed): Principles of Surgery, ed 3. New York, McGraw-Hill, 1979, pp 1217-1226. 3. Cole WH: Cancer of the colon and rectum. Symposium on Diseases of the Colon and Anorectum. Surg Clin North Am 52(4): 871-882, 1972 4. Stearns MW Jr: Benign and malignant neoplasms of colon and rectum:,Diagnosis and management. Symposium on Colon and Anorectal Surgery. Surg Clin North Am 58(3):605-608, 1978 5. Winawer SJ, Sherlock P: Detecting early colon cancer. Hosp Pract 12(3):49-53, 1976
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 5, 1979
