NCPR CC Registry Report 2008 2013

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December 2014

Jointly published by:

National Cancer Patient Registry-Colorectal Cancer and Clinical Research Centre (CRC)

Contact: editors and do not reflect the official policy of the publisher or the authors’ affiliated institutions. The data represents absolute numbers and not rates. Caution is advised before drawing conclusions from the data. The registry is dynamic; numbers may vary between this report and real time data as the registry continues to be updated.

This report is copyrighted. Reproduction and dissemination of this report in part or in whole for research, educational or other non-commercial purposes are authorized without any prior written permission from the copyright holders provided the source is fully acknowledged.

Suggested citation is:

Muhammad Radzi Abu Hassan, Wan Khamizar Wan Khazim, Zabedah Othman, Nik Raihan Nik Mustapha, Rosaida Mohd Said, Tan Wei Leong, Mohd Azri Mohd Suan, Shahrul Aiman Soelar (eds), The Second Report of the National Cancer Patient Registry-Colorectal Cancer, 2008-2013, Kuala Lumpur, Malaysia 2014.

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ACKNOWLEDGEMENT

We would like to thank all contributing parties for their support and encouragement in making this registry report a reality.

We would especially like to thank the following:

 Director-General of Health, Ministry of Health Malaysia for support for the registry and approval to publish this report.

 Ministry of Health, Malaysia for the research grants to fund the registry.

 The members of our steering committee for their expertise, time and effort dedicated to the registry.

 National Clinical Research Centre for its leadership, guidance and technical support.

 Our source data providers from Ministry of Health Malaysia, University Hospitals and private hospitals, without whose commitment, hard work and timely data collection and submission, this report would not be possible.

 Head of Pathology, Gastroenterogy, Oncology and Colorectal Surgery services.

 Head of Anatomic Pathology and all Histopathologists involved.

 All Hospital Directors, Clinicians and Surgeons of participating centers.

 State epidemiologists involved.

 The registry coordinating centre team and technical support team, for their continuous commitment and contribution.

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The Second Report of the NCPR-Colorectal Cancer 2008 - 2013|

1 About National Colorectal Cancer Registry in Malaysia

Introduction

The National Colorectal Cancer Registry started back in October 2007 involving nine hospitals throughout Malaysia. The National Cancer Patients Registry is a multi-centre and multidisciplinary project involving gastroenterologists, colorectal surgeons, pathologists and oncologists. The registry has expanded from involvement of nine hospitals to 34 hospitals throughout Malaysia from 2007 until 2013.

Furthermore, the registry is fully funded by a Ministry of Health grant disbursed through the Clinical Research Centre (CRC) since its establishment as the registry is crucial to our understanding of colorectal carcinoma in Malaysia. The registry coordinating centre/office is based in Clinical Research Centre, Hospital Sultanah Bahiyah, Alor Setar, Kedah.

Rationale

The registry is mainly collecting data on prevalence, incidence, clinical aspects and treatment modalities of colorectal cancer in Malaysia.

The main reason of the establishment of this National Colorectal Registry is to systematically collect data on all aspects of colorectal cancer relevant to its prevention, management and treatment evaluation in Malaysia. This registry will be able to function as guidance for Ministry of Health, Malaysia in formulating policy to improve colorectal cancer prevention, management and control. On top of that, the registry will be beneficial for Non-Governmental Organizations (NGO), private healthcare providers and healthcare industry in program planning and evaluation.

Objectives

Objectives of the registry are:

1. To estimate the incidence and mortality rate of colorectal cancer in Malaysia.

2. To determine the socio-demographic profiles of patients with colorectal cancer in Malaysia.

3. To identify the risk factors of patients with colorectal cancer.

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| The Second Report of the NCPR-Colorectal Cancer 2008 - 2013

ORGANIZATION:

Steering Committee

NCPR-CC Office Expert Panel

User / Target Group Source Data

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3 SOURCE DATA PROVIDERS / SDP:

Comprehensive cancer registration was achieved through data obtained from a combination of sources, viz.:

(a) Notifications by the medical profession, (b) Pathology records, and

(c) Hospital records

Histopathologists were the key persons in providing primary information on colorectal cancer cases. For cancer cases obtained from sources other than physician’s notifications, the data were checked against known registered cases in the registry. For missed notifications, the doctors-in-charge would be informed and reminded to notify. Until year 2013, we have 34

SDP’s that tirelessly providing the valuable data on colorectal cancer. The list of all SDP’s

involved is as below;

 Hospital Sultan Abdul Halim, Sg. Petani

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4 STEERING COMMITTEE

NAME INSTITUTION

Dato’ Dr Muhammad Radzi Abu Hassan Department of Internal Medicine, Hospital Sultanah Bahiyah Alor Setar, Kedah

Dr Wendy Lim Wan Dee Department of Internal Medicine,

Prince Court Hospital

Datin Dr Nik Raihan Nik Mustapha Department of Pathology, Hospital Sultanah Bahiyah Alor Setar, Kedah

Dato’ Dr Wan Khamizar Wan Khazim Department of Surgery, Hospital Sultanah Bahiyah Alor Setar, Kedah

Datuk Dr Yunus Gul Alif Gul Department of Surgery,

Datuk Dr Ryan Ponnudurai Department of Surgery,

Dr Hajjah Rosaida Hj Mohd Said Department of Internal Medicine,

Hospital Ampang, Kuala Lumpur

Dr Arjunan Saravanan Department of Internal Medicine,

Hospital Kuala Lumpur

Dr Hajjah Zabedah Hj Othman Department of Radiotherapy and Oncology,

Datuk Dr Fitjerald Henry Department of Surgery,

Hospital Selayang, Selangor

Prof. Dr April Roslani

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Assoc. Prof. Dr Raja Affendi Raja Ali Department of Internal Medicine, Hospital Universiti Kebangsaan Malaysia

Dr Gerald Lim Chin Chye Department Of Radiotherapy & Oncology,

Dr Goh Pik Pin Director,

National Clinical Research Center

Dr Jamaiyah Haniff National Registry Unit,

Ministry of Health Malaysia

Mr Patrick Lum See Kai Precision Soft Sdn Bhd

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7 MEDICAL WRITING COMMITTEE

NAME INSTITUTION

Dato’ Dr Muhammad Radzi Abu Hassan Department of Internal Medicine, Hospital Sultanah Bahiyah Alor Setar, Kedah

Datin Dr Nik Raihan Nik Mustapha Department of Pathology, Hospital Sultanah Bahiyah Alor Setar, Kedah

Dato’ Dr Wan Khamizar Wan Khazim Department of Surgery, Hospital Sultanah Bahiyah Alor Setar, Kedah

Dr Hajjah Rosaida Hj Mohd Said Department of Internal Medicine,

Hospital Ampang, Kuala Lumpur

Datuk Dr Fitjerald Henry Department of Surgery,

Hospital Selayang, Selangor

Dr Hajjah Zabedah Hj Othman Department of Radiotherapy and Oncology,

Dr Tan Wei Leong

Medical Officer, Clinical Research Center,

Hospital Sultanah Bahiyah Alor Setar, Kedah

Dr Mohd Azri Mohd Suan

Medical Officer, Clinical Research Center,

Hospital Sultanah Bahiyah Alor Setar, Kedah

Mr Shahrul Aiman Soelar

Statistician, Clinical Research Center,

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8 National Colorectal Cancer Registry Coordinating Centre / Secretariat

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9 LETTER FROM THE PRINCIPAL INVESTIGATOR

The National Cancer Patient Registry-Colorectal Cancer is proud to present its second report which incorporates results from 2008-2013.

The total data captured from the 34 Site Data Providers in six-year period was 4501. Analyzing and coming out with this report was not an easy task. I take this opportunity to congratulate the entire team involved from the data collection to data entry and finally to the actual writing of this report. National Colorectal Cancer Registry is important, not just because its’ valuable epidemiological data, but also management and outcome data which will be a source of information for a national plan to combat this dreadful disease. This information will be important for us when we formulate screening policies. This is especially critical as colorectal cancer can be easily identified and treated if detected early. Hence, prevention will be the most important tenet and strategy employed in the management of colorectal cancer.

In addition, it is also a platform that will be used to develop more research with other stakeholders. This is of paramount importance because combating such a prevalent disease will involve multidisciplinary cooperation and effort that this registry can provide. Needless to say, we hope that the availability of this database allows us to do more than formulating policies. The possibilities in research and investigations in other aspects of colon cancer are endless and hopefully with more data from more centers, this will be realized.

We want to thank all the source data providers for their support in making this report possible. Furthermore, I would like to extend our gratitude to the Director General of Health and Clinical Research Centre, Malaysia for their continuous support for the National Colorectal Cancer Registry.

Thank you.

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11 LIST OF TABLES

Table 1.1: Total patients enrolled in the NCPR-Colorectal Cancer by centre,

2008-2013 20

Table 1.2: Demographics of patients enrolled in the NCPR-Colorectal Cancer,

2008-2013 22

Table 1.3: Age groups by gender and ethnicity of patients enrolled in the

NCPR-Colorectal Cancer, 2008-2013 24

Table 1.4: Gender by ethnicity and education level of patients enrolled in the

Table 2.1: Status of diabetes mellitus for patients enrolled in the NCPR-Colorectal

Cancer, 2008-2013 28

Table 2.2: Diabetes mellitus by age groups, ethnic and education level of patients

enrolled in the NCPR-Colorectal Cancer, 2008-2013 28

Table 2.3: Smoking status of patients enrolled in the NCPR-Colorectal Cancer,

2008-2013 30

Table 2.4: Smoking status by age groups, ethnic and education level of patients

Table 2.5: Family history of patients enrolled in the NCPR-Colorectal Cancer,

2008-2013 32

Table 2.6: Family history by age groups, ethnic and education level of patients

Table 2.7: Past medical history of other cancers of patients enrolled in the

Table 2.8: Symptom of patients enrolled in the NCPR-Colorectal Cancer, 2008-2013 35 Table 3.1: Primary cancer site of patients enrolled in the NCPR-Colorectal Cancer,

2008-2013 38

Table 3.2: Primary cancer site by age groups of patients enrolled in the

Table 3.3: Final TNM staging of patients enrolled in the NCPR-Colorectal Cancer,

2008-2013 40

Table 3.4: Final TNM staging by age groups, ethnic and education level of patients

Table 3.5: Final TNM staging by family history of patients enrolled in the

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Table 4.1: Number of lymph nodes, tumour size, angiolymphatic invasion and venous lymphocytes of patients resected specimen enrolled in the NCPR-Colorectal Cancer, 2008-2013

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Table 4.2: Final TNM staging by number of lymph nodes, tumour size,

angiolymphatic invasion and venous lymphocytes of patients resected specimen enrolled in the NCPR-Colorectal Cancer, 2008-2013

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Table 4.3: Proximal , distal and circumferential of patients resected specimen enrolled

in the NCPR-Colorectal Cancer, 2008-2013 46

Table 4.4: ypTNM staging of patients with resected specimen enrolled in the

Table 4.5: pTNM staging of patients enrolled in the NCPR-Colorectal Cancer,

2008-2013 49

Table 4.6: Tumour differentiation by TNM staging of patients enrolled in the

Table 4.7: Polyps of patients enrolled in the NCPR-Colorectal Cancer, 2008-2013 51 Table 4.8: Synchronous tumour present of patients enrolled in the NCPR-Colorectal

Cancer, 2008-2013 52

Table 4.9: Synchronous tumour in patients enrolled in the NCPR-Colorectal Cancer,

2008-2013 53

Table 5.1: Treatment modalities of patients enrolled in the NCPR-Colorectal Cancer,

2008-2013 56

Table 5.2: Treatment modalities of patients resected specimen enrolled in the

Table 5.3: Final TNM staging by treatment modalities of patients enrolled in the

Table 5.4: Surgery method, operation performed and protocol/regimen of patients

Table 5.5: Final TNM staging by treatment modalities of patients enrolled in the

NCPR-Colorectal Cancer, 2008-2013. 61

Table 6.1: Status of patients enrolled in the NCPR-Colorectal Cancer, 2008-2013 64

Table 6.2: Age-adjusted rates (per 100,000) by gender of patiens in the

Table 6.3: Age-adjusted rates (per 100,000) by ethnic of patiens in the

Table 6.4: Patient status by final TNM staging of patients enrolled in the

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13 LIST OF FIGURES

Figure 1.0 : Data flow 18

Figure 1.1: Distributions of gender and ethnicity by age groups 24

Figure 1.2: Trends in the incidence and mortality of patients in the

Figure 1.3: Trends in the incidence and mortality by ethnic of patiens in the

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EXECUTIVE SUMMARY

Incidence and mortality

 From 2008 to 2013, overall incidence rate for colorectal cancer was 21.3

cases per 100, 000 populations in Malaysia. Age-adjusted incidence rate of colorectal cancer was 1.33 times higher among male than female. The incidence rate of colorectal cancer per 100,000 population by ethnicity was highest in Chinese (27.4 cases per 100,00 population).

 From 2008 to 2013, overall mortality rate for colorectal cancer was 9.8

cases per 100,000 populations. Likewise, age-adjusted mortality rate of colorectal cancer was about 1.42 times higher among male than female.

International comparisons in incidence and mortality:

 From 2007 to 2011, incidence rate for colorectal cancer in United States

of America was 43.7 per 100,000 populations annually and their mortality rate was 15.9 per 100,000 populations annually.

 In Asia, Japan had incidence rate of 41.7 per 100,000 populations and

22.8 per 100,000 populations for female in 2008. As for the mortality rate, male was 15.2 per 100,000 populations while female was 8.9 per 100,000 populations (2008, U.S National Institute of Health).

 In Malaysia, our overall incidence rate was 21.3 cases per 100,000

populations from 2008 until 2013. Our mortality rate for the same duration was 9.8 cases per 100,000 populations.

Demographics

 In the six-year period between 2008 and 2013, mean age for colorectal

cancer patients was 61.6 year old (standard deviation of 12.7).

 Registered colorectal cancer was more dominant among male than female

for the entire period from 2008 to 2013.

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Risk factors and clinical presentation

 In this registry, there were 22.3% of colorectal cancer patient with diabetes mellitus. The trend of diabetes mellitus was persistent between 19.3% and 25.6%.

 For these six-year duration, there were 9.6% of active smoker, 13.2% of

former smoker and 38.4% were non-smoker.

 Even though family history is a known risk factor for colorectal cancer,

there were merely 6.4% patients with positive family history.

 The most common presentation of colorectal cancer was altered bowel

habits (41.7%).

Primary diagnosis and final staging

 The commonest site of colorectal cancer was at colon according to ICD

10 from 2008 until 2013. However, rectum and rectosigmoid were the commonest site of colorectal cancer when colon is specifically divided into small segment.

 Left sided tumour constitutes more than three quarter of the colorectal

cancer notified.

 Over the past six-year period, majority of our patient were diagnosed at

stage III according to final TNM staging.

Pathology of colorectal cancer

 The most common histologic tumour type seen in colorectal cancer

patients in Malaysia is adenocarcinoma of usual-type (95.5%), most of which were moderately-differentiated.

 The majority of our patients were presented with locally advanced tumour

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Treatment modalities

 There was 70.8% of colorectal cancer patients had surgery performed and 35.9% of colorectal patients had chemotherapy. For rectal cancer, 26.3% of our patients received radiotherapy.

 As for complimentary or alternative treatment, 5.5% of our patients

received the care while there was merely 1.6% of colorectal cancer patients received palliative care in this registry.

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SELECTION OF THE PATIENTS

The figures produced in this report are based on National Cancer Patient Registry – Colorectal data. 316 cases were requested the case to delete. The resulting sample of 6971 cases was then restricted to year of diagnosis between 2008 and 2013. Duplicate records were identified on the Patient ID.

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CHAPTER 1

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DEMOGRAPHICS

Table 1.1: Total patients enrolled in the NCPR-Colorectal Cancer by centre, 2008-2013

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 There were 34 hospitals throughout Malaysia in this registry with a total of 4501

colorectal cancer patients registered over six-year period (2008-2013).

 The number of colorectal cancer patients captured in the registry was consistent

throughout this six-year period except slight reduction in 2013 (range between 369 and 978 cases per annum).

 The number of patients registered in each hospital or medical centre depends on the

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Table 1.2: Demographics of patients enrolled in the NCPR-Colorectal Cancer, 2008-2013

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 In the six-year period between 2008 and 2013, the mean age for total colorectal

patients was 61.6 year old (standard deviation 12.7).

 The registered colorectal cancer was more dominant among male than female for the

entire period from 2008 to 2013.

 From 2008 to 2013, the registered colorectal cancer decreased for both male and

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Figure 1.1: Distributions of gender and ethnicity by age groups

Table 1.3: Age groups by gender and ethnicity of patients enrolled in the NCPR-Colorectal Cancer, 2008-2013

Characteristics

Gender Ethnic

Male Female Malay Chinese Indian Others

n (%) n (%) n (%) n (%) n (%) n (%)

Age groups (years)

<19 7 (0.3) 4 (0.2) 5 (0.3) 2 (0.1) 0 (0.0) 4 (0.9)

20-24 9 (0.4) 8 (0.4) 10 (0.5) 2 (0.1) 1 (0.4) 4 (0.9)

25-29 27 (1.1) 20 (1.0) 31 (1.6) 2 (0.1) 1 (0.4) 13 (2.8)

30-34 32 (1.3) 33 (1.7) 42 (2.2) 7 (0.4) 5 (1.9) 10 (2.1)

35-39 61 (2.4) 51 (2.7) 54 (2.8) 25 (1.4) 10 (3.9) 23 (4.9)

40-44 106 (4.2) 86 (4.5) 105 (5.5) 39 (2.2) 14 (5.4) 36 (7.7)

45-49 175 (7.0) 149 (7.8) 172 (9.0) 92 (5.1) 20 (7.7) 42 (9.0)

50-54 250 (10.0) 212 (11.1) 229 (12.0) 139 (7.7) 33 (12.7) 61 (13.1)

55-59 330 (13.2) 289 (15.1) 282 (14.8) 241 (13.4) 34 (13.1) 69 (14.8)

60-64 433 (17.3) 273 (14.3) 302 (15.8) 300 (16.6) 45 (17.4) 63 (13.5)

65-69 397 (15.9) 246 (12.9) 257 (13.5) 310 (17.2) 31 (12.0) 47 (10.1)

70-74 346 (13.9) 260 (13.6) 232 (12.2) 307 (17.0) 36 (13.9) 39 (8.4)

75-79 189 (7.6) 157 (8.2) 99 (5.2) 192 (10.6) 18 (6.9) 36 (7.7)

>80 136 (5.4) 126 (6.6) 89 (4.7) 145 (8.0) 11 (4.2) 20 (4.3)

Overall 2498 (100.0) 1914 (100.0) 1909 (100.0) 1803 (100.0) 259 (100.0) 467 (100.0)

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 The proportion of colorectal cancer increased with age for both male and female. The

increases were peak between age 60 and 64 for male and between 55 and 59 for female.

 Malay ethnicity (42.7%) had more colorectal cancer cases reported, followed by

Chinese (40.3%), others (10.8%) and Indian (5.8%).

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Table 1.4: Gender by ethnicity and education level of patients enrolled in the NCPR-Colorectal Cancer, 2008-2013

Characteristics

Overall Male Female

n n (%) n (%)

Ethnic

Malay 1908 1064 (55.8) 844 (44.2)

Chinese 1794 1039 (57.9) 755 (42.1)

Indian 255 149 (58.4) 106 (41.6)

Others 479 258 (53.9) 221 (46.1)

Education level

No formal education 409 184 (45.0) 225 (55.0)

Primary 571 329 (57.6) 242 (42.4)

Secondary 667 412 (61.8) 255 (38.2)

Tertiary 201 133 (66.2) 68 (33.8)

 From 2008 to 2013, among male populations, the proportion of colorectal cancer was similar among Malay and Chinese, but lower in Indian and other ethnicity. The same pattern was also seen among female populations.

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CHAPTER 2

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RISK FACTOR & CLINICAL PRESENTATION

Table 2.1: Status of diabetes mellitus for patients enrolled in the NCPR-Colorectal Cancer, 2008-2013

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Characteristics

Diabetes Mellitus

Overall No Yes

n n (%) n (%)

Gender

Male 2293 1765 (77.0) 528 (23.0)

Female 1776 1315 (74.0) 461 (26.0)

Ethnic

Malay 1759 1319 (75.0) 440 (25.0)

Chinese 1636 1222 (74.7) 414 (25.3)

Indian 232 145 (62.5) 87 (37.5)

Others 470 409 (87.0) 61 (13.0)

Education level

No formal education 404 323 (80.0) 81 (20.0)

Primary 564 432 (76.6) 132 (23.4)

Secondary 660 507 (76.8) 153 (23.2)

Tertiary 199 155 (77.9) 44 (22.1)

 Diabetes mellitus is a chronic disease with multiple macro and micro complications.

Some studies have established significant relationship between diabetes mellitus and colorectal cancer.

 In our registry, there were 22.3% of colorectal cancer patients with diabetes mellitus. The trend of diabetes mellitus among our patient was persistently hovering between 19.3% and 25.6%.

 The proportion of diabetes mellitus among colorectal cancer patients was more

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Table 2.3: Smoking status of patients enrolled in the NCPR-Colorectal Cancer, 2008-2013

Characteristics

Table 2.4: Smoking status by age groups, ethnic and education level of patients enrolled in the NCPR-Colorectal Cancer, 2008-2013

Characteristics

Smoking Status

Overall Non-smoker Former smoker

(quit > 30 days) Active smoker

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Characteristics

Smoking Status

Overall Non-smoker Former smoker

(quit > 30 days) Active smoker

n n (%) n (%) n (%)

Ethnic

Malay 1186 715 (60.3) 263 (22.2) 208 (17.5)

Chinese 1061 697 (65.7) 223 (21.0) 141 (13.3)

Indian 155 106 (68.4) 28 (18.1) 21 (13.5)

Others 338 203 (60.1) 77 (22.8) 58 (17.2)

Education level

No formal education 343 238 (69.4) 64 (18.7) 41 (12.0)

Primary 501 279 (55.7) 139 (27.7) 83 (16.6)

Secondary 614 389 (63.4) 124 (20.2) 101 (16.4)

Tertiary 189 125 (66.1) 45 (23.8) 19 (10.1)

 With the ever increasing number of cigarette smoker worldwide, the research

evaluating linkage between cigarette smoking and colorectal cancer is expanding.

 For six-year duration of this registry, there were 9.6% of active smoker, 13.2% of

former smoker and another 38.4% were non-smoker.

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Table 2.5: Family history of patients enrolled in the NCPR-Colorectal Cancer, 2008-2013

Characteristics

Table 2.6: Family history by age groups, ethnic and education level of patients enrolled in the NCPR-Colorectal Cancer, 2008-2013

Characteristics

Family history of Colorectal Cancer Family history of Other Cancer

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Characteristics

Family history of Colorectal Cancer Family history of Other Cancer

Overall No Yes No Yes

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| The Second Report of the NCPR-Colorectal Cancer 2008 - 2013 Characteristics

Year

Overall 2008 2009 2010 2011 2012 2013

n n (%) n (%) n (%) n (%) n (%) n (%)

Hepatobiliary

Yes 2 1 (0.1) 0 (0.0) 1 (0.1) 0 (0.0) 0 (0.0)

No 3840 992 (99.9) 978 (100.0) 745 (99.9) 756 (100.0) 369 (100.0)

Overall 3842 993 (100.0) 978 (100.0) 746 (100.0) 756 (100.0) 369 (100.0)

Urinary tract

Yes 2 0 (0.0) 1 (0.1) 0 (0.0) 0 (0.0) 1 (0.3)

No 3840 993 (100.0) 977 (99.9) 746 (100.0) 756 (100.0) 368 (99.7)

Overall 3842 993 (100.0) 978 (100.0) 746 (100.0) 756 (100.0) 369 (100.0)

Ovarian

Yes 17 4 (0.4) 5 (0.5) 4 (0.5) 4 (0.5) 0 (0.0)

No 3825 989 (99.6) 973 (99.5) 742 (99.5) 752 (99.5) 369 (100.0)

Overall 3842 993 (100.0) 978 (100.0) 746 (100.0) 756 (100.0) 369 (100.0)

Other

Yes 67 25 (2.5) 16 (1.6) 15 (2.0) 9 (1.2) 2 (0.5)

No 3775 968 (97.5) 962 (98.4) 731 (98.0) 747 (98.8) 367 (99.5)

Overall 3842 993 (100.0) 978 (100.0) 746 (100.0) 756 (100.0) 369 (100.0)

 Even though family history is a known risk factor for colorectal cancer, there were merely 288 (6.4%) patients with positive family history in this registry.

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Table 2.8: Symptom of patients enrolled in the NCPR-Colorectal Cancer, 2008-2013

Characteristics

Diarrhea, constipation, or other change in bowel habits

Yes 521 98 (54.1) 90 (52.9) 111 (52.9) 58 (39.2) 94 (32.8) 70 (27.7)

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 The most common presentations of colorectal cancer captured in the registry were altered bowel habits (41.7%), followed by blood in stool (35.5%), abdominal pain (31.5%), weight loss (31.0%), anemia (9.8%) and intestinal obstruction (9.3%).

 For the six-year period, the pattern of presentation had been very consistent in our

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CHAPTER 3

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PRIMARY DIAGNOSIS & FINAL STAGING

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 According to International Classification of Disease (ICD) 10, colorectal cancer is

classified into 3 main sites, including colon, recto-sigmoid junction and rectum.

 Overall, the most common site of colorectal cancer was at colon from 2008 until

2013. The trend of site according to ICD 10 had been persistently dominated by colon throughout the six-year duration.

 In another classification of primary site, rectum was the highest among all sites of

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Table 3.2: Primary cancer site by age groups of patients enrolled in the NCPR-Colorectal Cancer, 2008-2013

Characteristics

Primary Cancer Site

Overall Left Sided Right Sided

n n (%) n (%)

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 Left sided tumour was commoner among our patients, with the peak after 45 years old.

 Over the past six-year, majority of our patient were at stage III according to final TNM

staging.

 The trend of late diagnosis was observed in our population throughout the period of

registry. From 4501 patients registered in the registry, there were only 8.4% diagnosed at stage I. On the contrary, a significant proportion of patients were diagnosed at stage III (27.3%).

 Among those diagnosed at stage III, most of the patients were in the age group between

50 and 74 while there was no prominent specific age group for stage I.

Table 3.5: Final TNM staging by family history of patients enrolled in the NCPR-Colorectal Cancer, 2008-2013

Characteristics

TNM Staging

Overall I II III IV Not staged

n n (%) n (%) n (%) n (%) n (%)

Family history of Colorectal Cancer

Yes 265 15 (4.8) 78 (9.8) 92 (8.9) 53 (7.1) 27 (7.2)

No 2996 297 (95.2) 719 (90.2) 939 (91.1) 692 (92.9) 349 (92.8)

Overall 3261 312 (100.0) 797 (100.0) 1031 (100.0) 745 (100.0) 376 (100.0)

Family history of Other Cancer

Yes 306 23 (8.8) 80 (11.6) 91 (10.5) 75 (11.4) 37 (11.3)

No 2505 239 (91.2) 612 (88.4) 778 (89.5) 585 (88.6) 291 (88.7)

Overall 2811 262 (100.0) 692 (100.0) 869 (100.0) 660 (100.0) 328 (100.0)

 There was no obvious difference in final TNM staging among patients with or without

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CHAPTER 4

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PATHOLOGY

Table 4.1: Pathology data obtained from bowel resection, polypectomy and biopsy

specimens of Colorectal Cancer Patients in Malaysia; NCPR-Colorectal Cancer, 2008-2013

Characteristics

Table 4.2: Tumour histology and differentian in Colorectal Cancer Patients in Malaysia; NCPR-Colorectal Cancer, 2008-2013

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 The most common histologic tumour type seen in colorectal cancer patients in

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Table 4.3: Tumour differentiation in relation to pathologic (pTNM) stage in patients who had tumour resection; NCPR-Colorectal Cancer, 2008-2013

 Information on tumour differentiation in relation to pT stage was available for 2584

cases. Collectively, pT3 and pT4 stage were observed in the majority of the moderately-differentiated (1802 out 2166; 83.2%) and poorly-differentiated (110 out of 117; 94.0%) tumours.

 Information on tumour differentiation in relation to pN stage was available for 2547

cases. pN0 stage was observed in 55.7% (165/296) of well-differentiated, 47.4% of (1014/2139) moderately-differentiated and 27.7% (31/112) of poorly-differentiated tumours.

 Information on tumour differentiation in relation to pM stage was only available for

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 Data regarding number of lymph nodes sampled were obtained from 2613 resected specimens. Of these, the median number of lymph nodes harvested by pathologists was 12, with interquartile range of 9. Mode for number of lymph nodes retrieved was 12.

 Information on tumour size was available for 2395 tumours and the median size

observed was 50 mm, with interquartile range of 30 mm.

 Intratumoral angiolymphatic invasion is regarded as an adverse prognostic factor.

This was observed in 633 out of 2174 (29.1%) recorded cases.

 Extramural venous invasion increases the risk for liver metastasis. This was seen in

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Table 4.5: Proximal, distal and circumferential resection margins of resected colorectal cancer specimens; NCPR-Colorectal Cancer 2008-2013

patient or tumour is seen < 1mm away from the margin of the resected specimen.

 Data on proximal and distal resection margins were available for 2360 and 2320 cases

with resected specimens, respectively. Involvement of proximal margin was seen in 60 (2.5%) cases and that of distal margin in 84 (3.6%) cases.

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Table 4.6: Pathologic (pTNM) stage of resected specimens of patients enrolled in the NCPR-Colorectal Cancer, 2008-2013

cases presented with locally advanced tumour (pT3 and pT4).

 Out of 1989 cases with information on pN stage, 1058 (53.2%) cases had nodal metastasis.

 Information on pM is only available for 581 cases and 146 had distant metastasis.

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Table 4.7: Pathologic (ypTNM) stage of resected specimens of patients enrolled in the NCPR-Colorectal Cancer, 2008-2013

 Information on ypT stage (for patients who had received pre-operative neo-adjuvant therapy) was available in 113 cases and ypT1 and ypT2 were observed in 30 of them (26.5%). Additionally, 79.6% (90 out of 113 cases) had been staged as either ypT1, ypT2 or ypT3. yPT4 was observed in 23 specimens (20.4%).

 ypN0 was noted in 63 out of 109 (57.8%) cases that had received pre-operative

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Table 4.8: Polyps in resected specimens of patients with colorectal cancer cancer; NCPR-Colorectal Cancer, 2008-2013

* No information - majority due to data submission based on biopsy specimens (total 1420).

 Information on presence or absence of polyps is available for 2269 specimens and

polyps were noted in 416 (18.3%) of them.

 Out of 2269 specimens with information on polyps, 43 (1.9%) had more than 100

polyps present, suggesting possibility of Familial Adenomatous Polyposis (FAP).

 Tubular adenoma, tubulovillous adenoma and hyperplastic polyp are the three most

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Table 4.9: Synchronous tumour in patients enrolled in the NCPR-Colorectal Cancer, 2008-2013

Characteristics

Year

Overall 2008 2009 2010 2011 2012 2013

n n (%) n (%) n (%) n (%) n (%) n (%)

Synchronous tumour present

Yes 104 17 (2.3) 19 (1.7) 18 (1.7) 18 (2.2) 20 (2.4) 12 (3.1)

No 2607 492 (65.3) 681 (61.3) 556 (51.5) 406 (49.7) 314 (38.1) 158 (40.6)

No Information* 2263 245 (32.5) 411 (37.0) 505 (46.8) 393 (48.1) 490 (59.5) 219 (56.3)

Overall 4974 754 (100.0) 1111 (100.0) 1079 (100.0) 817 (100.0) 824 (100.0) 389 (100.0)

* Missing - majority due to data submission based on biopsy specimen only (total 1420).

 From the registry, information on synchronous tumour was available for 2711

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CHAPTER 5

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TREATMENT MODALITIES

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Table 5.2: Treatment modalities of patients with rectum as a primary cancer site enrolled in the NCPR-Colorectal Cancer, 2008-2013

 Treatment modalities included in our registry were surgery, radiotherapy,

chemotherapy, complementary or alternative treatment and palliative care.

 For those with treatment modalities recorded, a small proportion of colorectal cancer patients (5.1%) had not received any treatment for their colorectal cancer.

 There was 70.8% of colorectal cancer patients had surgery performed and 35.9% of

colorectal patients had chemotherapy.

 As for complimentary or alternative treatment, 0.8% of our patients received the care.

Lastly, there was merely 5.0% of colorectal cancer patients received palliative care in this registry.

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 The most common treatment modalities for stage III colorectal cancer were surgery

(88.4%), followed by chemotherapy (48.0%) and radiotherapy (19.3%).

 A substantial proportionof colorectal cancer patient in each stage underwent surgical

intervention.

 To complement with surgical treatment, almost half of colorectal cancer patient in

stage III and IV received chemotherapy.

 There was 10.3% of stage IV colorectal cancer patient seeking for supportive or

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 Nearly two-thirds of those with surgical intervention underwent open surgery, followed by laparoscopic surgery (16.1%).

 The 5 most commonly surgery performed were right hemicolectomy (12.7%), high

anterior resection (10%), low anterior resection (9.5%), APR (7.8%) and sigmoid colectomy (7.4%). However, we must remember that there are more procedures available for left sided tumours such as high anterior resection, low anterior resection, sigmoid colectomy and so on. On top of that, left sided tumour is commoner than right sided tumour.

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CHAPTER 6

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INCIDENCE & MORTALITY RATE

Table 6.1: Status of patients enrolled in the NCPR-Colorectal Cancer, 2008-2013

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 During the six-year duration, there were 2011 (44.7%) death recorded out of 4501

colorectal cancer patients. The proportion of death for colorectal cancer patients was hovering from 33.1% to 58.1% from 2008 until 2012; however, there was a drop in 2013 to 14.9%.

 There was a slight difference in the proportion of death by gender [male (46.1%) vs.

female (43.4%)].

 Among the 3 major ethinicities, the highest proportion of death was among Malay

(49.2%), followed by Chinese (42.3%) and Indian (39.4%).

 The incidence rate of colorectal cancer per 100,000 population by ethnicity was

higher among Chinese (27.4), followed by Malay (19.0) and Indian (17.6).

 As for mortality rate per 100,000 population, Chinese had the highest mortality (11.9),

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Figure 1.2: Trends in the incidence and mortality by gender of patients in the NCPR-Colorectal Cancer, 2008-2013

Table 6.2: Age-adjusted rates (per 100,000) by gender of patients in the NCPR-Colorectal Cancer, 2008-2013

Characteristics

Year

Overall 2008 2009 2010 2011 2012 2013

Incidence, overall 21.32 3.12 4.69 4.66 3.52 3.59 1.73

Incidence, male 24.16 3.76 5.28 5.53 3.68 4.00 1.90

Incidence, female 18.14 2.48 4.11 3.79 3.34 2.96 1.45

Mortality, overall 9.79 1.86 2.56 2.34 1.52 1.24 0.27

Mortality, male 11.46 2.35 2.92 2.86 1.57 1.41 0.35

Mortality, female 8.05 1.37 2.20 1.83 1.45 1.01 0.20

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Figure 1.3: Trends in the incidence and mortality by ethnic of patiens in the NCPR-Colorectal Cancer, 2008-2013

Table 6.3: Age-adjusted rates (per 100,000) by ethnic of patiens in the NCPR-Colorectal Cancer, 2008-2013

Characteristics

Year

Overall 2008 2009 2010 2011 2012 2013

Incidence, Malay 18.95 2.59 3.92 4.27 3.19 3.29 1.70

Incidence, male 21.79 3.14 4.43 4.99 3.44 3.98 1.80

Incidence, female 16.09 2.05 3.45 3.56 2.94 2.54 1.54

Incidence, Chinese 27.35 4.10 6.39 5.83 4.43 4.61 1.98

Incidence, male 30.77 4.92 6.93 7.11 4.66 5.10 2.06

Incidence, Indian 17.55 2.45 4.53 3.84 3.11 2.11 1.51

Incidence, male 21.43 3.52 6.18 4.31 3.10 2.14 2.19

Mortality, Malay 9.56 1.75 2.24 2.34 1.53 1.33 0.38

Mortality, male 11.56 2.24 2.56 2.91 1.79 1.56 0.50

Mortality, female 7.57 1.28 1.94 1.77 1.28 1.02 0.28

Mortality, Chinese 11.85 2.27 3.41 2.80 1.81 1.37 0.19

Mortality, male 13.47 2.85 3.62 3.31 1.81 1.63 0.25

Mortality, Indian 7.08 1.36 2.38 1.52 0.92 0.68 0.23

Mortality, male 9.63 2.20 3.69 2.13 0.42 0.84 0.36

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 The overall incidence rate was 21.3 cases per 100, 000 populations in Malaysia.

 The age-adjusted incidence rate of colorectal cancer was about 1.33 times higher

among male than female (24.2 and 18.1 cases per 100,000 respectively during 2008 – 2013).

 The overall mortality rate for colorectal cancer was 9.8 cases per 100,000 populations.

 Likewise, the age-adjusted mortality rate of colorectal cancer was about 1.42 times

higher among male than female (11.46 and 8.05 cases per 100,000 respectively during 2008 – 2013).

 The incidence rate of colorectal cancer per 100,000 population by ethnicity was

higher among Chinese (27.4 cases), followed by Malay (19.0 cases) and Indian (17.6 cases).

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Table 6.4: Patient status by final TNM staging of patients enrolled in the NCPR-Colorectal Cancer, 2008-2013

Characteristics

Patient status

Overall Alive Death

n n (%) n (%)

TNM staging

I 378 312 (13.9) 66 (3.9)

II 947 718 (32.0) 229 (13.6)

III 1228 704 (31.4) 524 (31.0)

IV 909 324 (14.4) 585 (34.6)

Not staged 471 185 (8.2) 286 (16.9)

Overall 3933 2243 (100.0) 1690 (100.0)

 When the proportion of death was compared by TNM staging, there was an increasing

trend from stage I to stage IV.

 As for the proportion of alive patient, there was no specific trend seen when compared

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1.0 REGISTRY DESIGN

This is a multi-centre, observational cohort study designed to evaluate the health outcomes of patients with colorectal cancer undergoing treatment at participating clinical centres. All confirmed cases of colorectal cancer from the participating sites (source data providers, SDP) that meet the inclusion criteria, will be eligible for enrolment into the registry. The colorectal cancer cases are identified by the gastroenterologists, colorectal surgeons, pathologists and oncologists working in these centers.

The patient registry is designed to observe secular changes in clinical practice as well as to observe long term mortality outcome for colorectal cancer in real world clinical practice. Hence, the registry should operate at least 10 years to meet many of its objectives that require long term patient follow-up to realize.

2.0 REGISTRY STUDY POPULATION AND PATIENT RECRUITMENT

2.1 Selection of subjects

As a patient registry, the eligibility criterion is deliberately broad (any patients undergoing treatment for colorectal cancer at any clinical centres) to reflect real world practice and to ensure the sample is representative of the population at large with colorectal cancer. Patients

are informed of the centre’s participation in the registry through public notices.

2.2 Inclusion criteria

All histologically verified primary colorectal cancer cases from participating sites (irrespective of the staging, histopathology, duration of the disease) reported during the study period.

2.3 Exclusion criteria

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3.0 DATA MANAGEMENT 3.1 Data collection

All data on demographics, clinical history, family history, pathology and treatment details

(including surgical, oncology and palliation treatment) will be extracted from patients’

medical records by designated staff under supervision by site coordinator/investigators.

There are no prescribed study visits. Patient shall attend the clinical site as and when required per the standard of care at the site. Required data shall be collected as they become available. Each participating hospital will notify all new patients to the registry until the termination of the registry. Patients shall be followed-up for up to 36 months.

Data is collected and stored through a customised web-based electronic case report form (eCRF) that is readily available to source data providers. The eCRFs are implemented using third party (Datamed Clinical Computing Services Sdn Bhd) software application that is fully validated and conforms to regulatory requirements for electronic data capture, where applicable.

Where eCRF could not be implemented for technical or resource reason, or as a backup measure, the registry uses paper CRF to record and transfer data collected.

3.2 Database monitoring and data management

Database monitoring and data management will be carried out by the research assistants under the supervision of the principal investigators and the Clinical Research Centre, Hospital Sultanah Bahiyah in compliance with patient data protection.

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NCPR CC Registry Report 2008 2013

ACKNOWLEDGEMENT

1

About National Colorectal Cancer Registry in Malaysia

2

ORGANIZATION:

3

SOURCE DATA PROVIDERS / SDP:

4

STEERING COMMITTEE

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7

MEDICAL WRITING COMMITTEE

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National Colorectal Cancer Registry Coordinating Centre / Secretariat

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LETTER FROM THE PRINCIPAL INVESTIGATOR

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TABLE OF CONTENTS

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LIST OF TABLES

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LIST OF FIGURES

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CHAPTER 1

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CHAPTER 2

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CHAPTER 3

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CHAPTER 4

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CHAPTER 5

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CHAPTER 6

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