Changing site distribution patterns of colorectal cancer at Thomas Jefferson University Hospital
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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 of 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 flexible s igmoidoscopy is the preferred diagnostic tool. [Key words: Cancer, colorectal , inc idence; Colorectum; Fiberoptic; Sigmoidoscopy]
COLORECTAL CANCER INCIDENCE ill tile United States, estimated for the total population, is higher than that of any other cancer except skin cancer. As outlined in the excellent monograph by Silverberg, t approxi - mately 4 per cent of all newborn boys and 4 !z2 per cent of all newborn girls might be expected to develop cancer of tile colon and rectum at some point in their lives. Thus, one in 25 men and one in 22 women will develop cancer of the colon and rectum.
The colorectal cancer death rate for both men and women has been fairly level since 1930 when reliable age-adjusted mortality report ing began. Despite a profusion of new diagnostic tools the percentages of patients discovered in various stages of colonic and rectal cancer have remained constant. Recently de- veloped cotonoscopic methods may reveal a larger percentage of patients with early and localized can- cers. In all time periods studied, surgery has been the preferred method of treatment, used for more than 80 per cent of those patients with localized or regional disease.
Heretofore, careful physical exantination, includ- ing digital rectal examination and rigid sigmoidos- copy has been the principal tool of diagnosis. Tradi- tional teaching has emphasized that two-thirds of all cotorectal cancers are within reach of 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,
moidoscope and that 50 per cent can be felt digitally. But Rhodes et al. 2 pointed out a statistically significant decrease in the percentage of'distal and an increase in the percentage of proximal colorectal tumors. Axtell and Chiazze a described this phenonlenon in 1966 when they reported a changed ratio of colonic to rec- tal cancers with relatively more colonic tumors ap- pear ing in both men and women. Cut le r and Latourette, 4 reviewing the same data, concluded that the changing ratio was probably the result of a true increase in the incidence of colonic cancer and a de- crease in rectal cancer.
Sensing the important practical implications of what appears to be a significant trend in tile site dis- tribution of colorectal cancer , we were prompted to compare data related to experience with over 2,300 cases of colorectal cancer at the Thomas Jef ferson University ttospital dur ing two periods, 1939 to 1953, and 1959 to 1977.
Resu l ts
The clinical evaluation of 750 patients with colorec- tal cancer treated at the Thomas Jef ferson University Hospital in the 15 years from 1939 to 1953 was re- por ted by Shallow, Wagner , and Colcher. 5 The American College of Surgeons' Long-Term Colon Cancer Study ~ defines the cutoff between rectum and sigmoid at 15 cm. It was possible to apply this criter- ion to Shallow's series since the investigators bad spe- cifically listed each case in terms of distance f rom the anal verge. The data obtained for the years 1959 through 1977 were from the Thomas Jef ferson Uni- versity Hospital Tumor Registry. A comparison of the site distribution over varying periods of time is pre- sented in Table 1, which details both the absolute number of cases and the percentage of cases in each
0012-3706/8150300/0093/$00.65 ~',, American Society of Colon and Rectat Surgeons
r~, i D is . Co l & Rect . ROSATO AND MARKS March 1981
Fro. 1. Graph depicting the change in distribution of cancers of the colorectum, 1939-1977.
i 00 -
k3 75 50
= I u ai5 '.2
~L: -t 2 ) "4
39- 57 59!64
T r - , .~1 ,,,,b:fs~ v . . . .
I i - - - - - !
65 - 69 '70 -74 75 -'77 (Oc !.i
site of the colon. These data have been p lot ted on a graph (Fig. 1), which c lear ly point out the gradua l decrease in the inc idence of rectal cancer and a pro- gressive increase in colonic cancer in o ther locations, most notab ly the s igmoid co lon . The changes documented are such that the 60-cm f iberopt ic flexi- ble s igmoidoscope is now clearly seen as a major case- f ind ing tool.
The not iceable change in the pat tern of d istr ibu- t ion o f co lo recta l cancer repor ted here and e lsewhere r raises impor tant quest ions with s igni f icant d iagnost ic impl icat ions.
The first quest ion involves the in terpretat ion o f these data. Is there a real change in the pat tern o f
colorectal cancer or has an improvement and re f ine- ment o f d iagnost ic techn iques revea led the prev ious ly recogn ized true d is t r ibut ion? In the Amer ican Col- lege of Surgeons ' shor t - te rm s tudy on colonic cancer , ~ an improvement in d iagnost ic techn iques would be ru led out, because less than a th i rd o f all cases were detected at an ear ly and potent ia l ly curab le stage, with the tumor still l imi ted to the wall o f the colon. Of even more concern was the fact that digital rectal examinat ions were not repor ted in 20 per cent o f the charts o f pat ients with co lorecta l cancer, proctos ig- rno idoscopy was per fo rmed in less than 60 per cent o f the pat ients, and bar ium-enema studies were not ob- ta ined in 15 per cent . These f ind ings ser ious ly weaken the assumpt ion that to some extent the change in d is t r ibut ion results f rom more rel iable and ass iduously app l ied d iagnost ic tests.
T?,m.~ 1. Colorectal Cancer Dist~ibution--T*~mor Registry' Th~masJefferson Uns Hospitcl
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
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 , lqmc 24 xumbe~_9 SITE DISTRIBU'FION PAF'I-ERNS tJD
,! ' 7
~ft r " ::. ,4~.
13% , ; / ," i I /~
# , /
FIc. _.'.' C;hancqng~ , site distribution of colorectal cancer sigrnoidc, scope in colorectal cancer
> 90 - i
'70=77 '~ 3].~
, 30 i
! 10 ~
and changing diagnostic capabilities of rigid sigmoMo~cope and flexible
Another a rgument is that increasing excision of benign polyps within reach of the rigid sigmoidos- cope reduced the number of potential ly ma l ignant growths in this region. This assumpt ion is purely speculative since data are not available to support the not ion that most excised polyps are from an area which can be surveyed by the rigid sigmoidoscope.
Certainly, as seen in Fig. 2. digital examinat ion and proctosigmoidoscopy with the 25-cm ins t rument are not as reliable as they had been previously consid- ered. The percentage of lesions within reach of the examin ing f inger or proctoscope was 69 per cent in the series reported by Shallow et al. "~ In the more re- cent d i s t r ibut ion pat tern , the comparab le f igure would be only -t5 per cent. In o rder to achieve op- t imum discovery of colorectal cancer, it would seem obvious that extended studies must be per formed. The major case-f inding tool at this point would be the flexible f iberoptic s igmoidoscope which, in our series. ~..ould have visualized 67 per cent of the lesions. In those situations where problems were suspected and
flexible s igmoidoscopy yielded no evidence of disease. then colonoscopy and bar ium-enema studies would be mandated .
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 co