Changing Site Distribution Patterns of Colorectal Cancer at

Thomas Jefferson University Hospital*

FRANCIS E. Ros.~cro, M.D., GERALD MARKS, M.D.

Rosato F E, Marks G. Changing site distribution patterns o f co- lorectal cancer at Thomas Jefferson University Hospital. Dis Colon Rectum 1981;24:93-95.

Analyzed data from an earlier reported experience with colorec- tal cancer at Thomas Jefferson University Hospital, compared with findings observed and analyzed from 1959 to 1977 indicate a changing pattern of distribution of colorectal cancers. These changes lead to therapeutic conclusion that fiberoptic f lexible s igmoidoscopy is the preferred diagnostic tool. [Key words: Cancer, co lorec ta l , i n c i d e n c e ; Co lorec tum; Fiberopt ic ; Sigmoidoscopy]

COLORECTAL CANCER INCIDENCE ill tile United States, estimated for the total population, is higher than tha t

of any o the r cancer except skin cancer. As out l ined in the excellent m o n o g r a p h by Silverberg, t app rox i - mately 4 per cent of all newborn boys and 4 !z2 per cent of all newborn girls might be expected to develop cancer o f tile colon and rec tum at some point in their lives. Thus , one in 25 men and one in 22 women will develop cancer of the colon and rectum.

T h e colorectal cancer death rate for both men and women has been fairly level since 1930 when reliable age-adjus ted morta l i ty r epo r t i ng began. Despite a profusion of new diagnostic tools the percentages o f patients discovered in various stages of colonic and rectal cancer have r ema ined constant. Recently de- veloped cotonoscopic methods may reveal a larger percentage o f patients with early and localized can- cers. In all t ime periods studied, surgery has been the p r e f e r r e d me thod of t rea tment , used for more than 80 per cent o f those patients with localized or regional disease.

Here to fore , careful physical exant inat ion, includ- ing digital rectal examinat ion and rigid sigmoidos- copy has been the principal tool o f diagnosis. Trad i - tional teaching has emphas ized that two-thirds of all cotorectal cancers are within reach o f the 25-cm sig-

" Read at the meeting of the American Socict~ of Colon and Rectal Surgeons, Hollywood Florida. May 11 to 16, 1981).

Supported in part bv the Kapnek Charitable Trust. Address reprint requests to Dr. Rosato: Suite 605. Jefferson

Medical College, 1025 Walnut Street, Philadelphia, Pennsylvania lU!07.

From the Department oJ Surger2,;, Thomas Jefjerson Universi(~ ttospital,

Philadelphia, Pe'nnsylvania

moidoscope and that 50 per cent can be felt digitally. But Rhodes et al. 2 poin ted out a statistically significant decrease in the pe rcen tage of 'distal and an increase in the percentage o f p rox imal colorectal tumors . Axtell and Chiazze a descr ibed this p h e n o n l e n o n in 1966 when they r epo r t ed a changed ratio of colonic to rec- tal cancers with relatively more colonic tumors ap- p e a r i n g in b o t h m e n a n d w o m e n . C u t l e r a n d Latouret te , 4 reviewing the same data, conc luded t h a t

the changing ratio was probably the result o f a t rue increase in the incidence o f colonic cancer and a de- crease in rectal cancer.

Sensing the i m p o r t a n t practical impl ica t ions o f what appears to be a significant t rend in tile site dis- tr ibution of colorectal c a n c e r , we were p r o m p t e d to compa re da ta re la ted to exper ience with over 2,300 cases of colorectal cancer at the T h o m a s J e f f e r s o n University t tospi ta l du r ing two periods, 1939 to 1953, and 1959 to 1977.

R e s u l t s

T h e clinical evaluation of 750 patients with colorec- tal cancer t rea ted at the T h o m a s J e f f e r son University Hospital in the 15 years f rom 1939 to 1953 was re- p o r t e d by Shal low, W a g n e r , and Colcher . 5 T h e Amer ican College o f Surgeons ' L o n g - T e r m Colon Cancer Study ~ def ines the cu to f f between rec tum and sigmoid at 15 cm. I t was possible to app ly this cri ter- ion to Shallow's series since the investigators bad spe- cifically listed each case in te rms o f distance f r o m the anal verge. T h e data ob ta ined for the years 1959 th rough 1977 were f rom the T h o m a s J e f f e r son Uni- versity Hospital T u m o r Registry. A compar i son o f the site distr ibution over varying periods o f t ime is pre- sented in Table 1, which details both the absolute n u m b e r of cases and the percen tage of cases in each

0012-3706/8150300/0093/$00.65 ~',, American Society of Colon and Rectat Surgeons

93

r ~ , i D i s . C o l & R e c t . ROSATO AND MARKS M a r c h 1 9 8 1

Fro. 1. Graph depicting the change in distribution of cancers of the colorectum, 1939-1977.

i 0 0 -

90

80

70

;,5 ~r

k3 75 50

= I u ai5 ' .2

c 1

~L: -t 2 ) "4

i(5 -{

i 1

39- 57 59!64

T r - , .~1 , , , ,b:fs~ v . . . .

I i - - - - - !

65 - 69 '70 -74 75 -'77 (Oc !.i

site o f the colon . T h e s e da t a have b e e n p l o t t e d on a g r a p h (Fig. 1), wh ich c l ea r ly po in t o u t the g r a d u a l d e c r e a s e in the i n c i d e n c e o f rec ta l c a n c e r a n d a p r o - g ress ive inc rease in co lon ic c a n c e r in o t h e r loca t ions , m o s t n o t a b l y t h e s i g m o i d c o l o n . T h e c h a n g e s d o c u m e n t e d are such tha t the 60-cm f i b e r o p t i c f lexi- ble s i g m o i d o s c o p e is now c lear ly seen as a m a j o r case- f i n d i n g tool.

D i s c u s s i o n

T h e no t i ceab l e c h a n g e in the p a t t e r n o f d i s t r i bu - t i o n o f c o l o r e c t a l c a n c e r r e p o r t e d h e r e a n d e l s e w h e r e r ra ises i m p o r t a n t ques t ions with s ign i f i can t d i a gnos t i c impl i ca t ions .

T h e first q u e s t i o n involves the i n t e r p r e t a t i o n o f these da ta . Is t h e r e a rea l c h a n g e in the p a t t e r n o f

co lo rec ta l c a n c e r o r has an i m p r o v e m e n t a n d r e f i n e - m e n t o f d i a gnos t i c t e c h n i q u e s r e v e a l e d the p r e v i o u s l y r e c o g n i z e d t rue d i s t r i b u t i o n ? I n t he A m e r i c a n Col- lege o f S u r g e o n s ' s h o r t - t e r m s t u d y on co lonic c a nce r , ~ an i m p r o v e m e n t in d i a g n o s t i c t e c h n i q u e s w o u l d be r u l e d ou t , b e c a u s e less t han a t h i r d o f all cases we re d e t e c t e d at an ea r ly a n d p o t e n t i a l l y c u r a b l e s tage , with the t u m o r still l i m i t e d to the wall o f the co lon . O f even m o r e c o n c e r n was the fac t t ha t d ig i ta l r ec ta l e x a m i n a t i o n s were n o t r e p o r t e d in 20 p e r c en t o f the cha r t s o f pa t i en t s with c o lo r e c t a l cance r , p r o c t o s i g - r n o i d o s c o p y was p e r f o r m e d in less t h a n 60 p e r cen t o f t he pa t i en t s , a n d b a r i u m - e n e m a s t u d i e s we re no t ob- t a i n e d in 15 p e r c e n t . T h e s e f i n d i n g s s e r i o u s l y w e a k e n the a s s u m p t i o n t h a t to s o m e e x t e n t t h e c h a n g e in d i s t r i b u t i o n resu l t s f r o m m o r e re l i ab le a n d a s s iduous ly a p p l i e d d i a g n o s t i c tests.

T?,m.~ 1. Colorectal Cancer Dist~ibution--T*~mor Registry' Th~masJefferson Uns Hospitcl

Site

1939-1957 t959-1964 t965-1969 t970-1974 1975-1977 (Oct.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Number Per Cent Number Per Cent Number Per Cent Number Per Cent Number Per Cent

Right colon 89 -1- ransverse 27 Descending 149 Sigmoid colon 99 Rectum 375 Anal [ 1 Site unspecified 0

750

11.9 74 t 6.4 62 15.4 53 14.6 43 18.0 36 44 9.8 29 7.2 47 13.0 29 12.0

19.8 t8 4.0 26 6.5 13 3.6 19 8.0 13.2 146 32.4 124 30.8 109 30,1 77 32.1 50.0 156 34.6 148 36.8 128 35,4 60 25,0

1.5 5 1.1 fi 2.0 3 .8 3 1,3 0 8 1.8 5 1.2 9 2.5 9 3.8

151 402 362 240

\ i , l q m c 24 xumbe~_9 SITE DISTRIBU'FION PAF'I-ERNS tJD

129,;

1939-'57

,!

' 7

i

~ft r " ::. ,4~.

13% , ; / ," i I / ~

i-51%

# , /

' I

-2O%

'39 -'57

FIc. _.'.' C;hancqng~ , site distribution of colorectal cancer sigrnoidc, scope in colorectal cancer

16~

1970-'77

"-;'> 5%

> 90 - i

F

c 70-

I

50 -

L

'70=77 '~ 3].~

--32~0

, 30 i

! 10 ~

and changing diagnostic capabilities of rigid sigmoMo~cope and flexible

A n o t h e r a r g u m e n t is that i nc r ea s ing excision o f b e n i g n polyps within reach of the r igid s igmoidos- cope r e d u c e d the n u m b e r of potent ia l ly m a l i g n a n t g rowths in this reg ion . Th i s a s s u m p t i o n is pu re ly speculat ive since data are not available to s u p p o r t the no t ion that most excised polyps are f rom an area which can be su rveyed by the r igid s igmoidoscope .

Cer ta in ly , as seen in Fig. 2. digital e x a m i n a t i o n and p roc tos igmoidoscopy with the 25-cm i n s t r u m e n t are not as rel iable as they had been previous ly cons id- ered. T h e pe rcen t age of lesions wi th in reach of the e x a m i n i n g f inger or proc toscope was 69 per cen t in the series r e p o r t e d by Shallow et al . "~ In the more re- cen t d i s t r i b u t i o n p a t t e r n , the c o m p a r a b l e f i g u r e would be only -t5 pe r cent . In o r d e r to achieve op- t i m u m discovery of colorectal cancer , it wou ld seem obvious that e x t e n d e d s tudies mus t be p e r f o r m e d . The ma jo r ca se - f ind ing tool at this po in t wou ld be the

flexible f iberopt ic s igmoidoscope which, in o u r series. ~..ould have visualized 67 per cent o f the lesions. In those s i tua t ions where p rob l ems were suspec ted a n d

flexible s igmoidoscopy y ie lded no ev idence of disease. t h e n co lonoscopy a n d b a r i u m - e n e m a s tudies would be m a n d a t e d .

R e f e r e n c e s

1. Sllverberg E. Cancer of the colon and rectum. American Cancer Society Professional Education Publication. p 5.

'2. Rhodes JB, ftolme~ FF, Clark GM. Changing distribution of primar,," cancers in the large tx)wel. J:LMA 1977:238: 1641-3.

3. Axtell I.M. Chiazze L Jr. Changing reladve frequency of" can- cers of the colon arid rectum in the United States. Cancer 1966;19:50--4.

4. Curler SJ, l.atourette HB. Quoted by Axtell LM, Chiaz~,e I. Jr? 5 Shallow "fA Wagner FB Jr, Colche[" RE. Clinical evaluation of

750 patients with colon cancer: diagnostic survey and follow-up covering a fifteen-)ear period. Ann Surg 1955; 1 .t2:164-75.

6. Murphy G. Long-term patient care evaluation study of cancer of the colon. Prepared tor the American College of Sur- geons Commission on Cancer. 1977:Oct 15.

7. Berg .IW, Howell MA. The geographic patholog~ of bowel cancer. Cancer 1974;3-t :SO 7 - ] 4.

6. Murphy G. Short-term patient care evaluation study of cancer of the colon. Prepared for tI:e American College of Sur- geons Commission on Cancer. 1977:Oct 15.