Characteristics of Early-Onset vs Late-Onset Colorectal Cancer: A Review.

The incidence of early-onset colorectal cancer (younger than 50 years) is rising globally, the reasons for which are unclear. It appears to represent a unique disease process with different clinical, pathological, and molecular characteristics compared with late-onset colorectal cancer. Data on oncological outcomes are limited, and sensitivity to conventional neoadjuvant and adjuvant therapy regimens appear to be unknown. The purpose of this review is to summarize the available literature on early-onset colorectal cancer. Within the next decade, it is estimated that 1 in 10 colon cancers and 1 in 4 rectal cancers will be diagnosed in adults younger than 50 years. Potential risk factors include a Westernized diet, obesity, antibiotic usage, and alterations in the gut microbiome. Although genetic predisposition plays a role, most cases are sporadic. The full spectrum of germline and somatic sequence variations implicated remains unknown. Younger patients typically present with descending colonic or rectal cancer, advanced disease stage, and unfavorable histopathological features. Despite being more likely to receive neoadjuvant and adjuvant therapy, patients with early-onset disease demonstrate comparable oncological outcomes with their older counterparts. The clinicopathological features, underlying molecular profiles, and drivers of early-onset colorectal cancer differ from those of late-onset disease. Standardized, age-specific preventive, screening, diagnostic, and therapeutic strategies are required to optimize outcomes

Post-Operative Functional Outcomes in Early Age Onset Rectal Cancer

Background: Impairment of bowel, urogenital and fertility-related function in patients treated for rectal cancer is common. While the rate of rectal cancer in the young (<50 years) is rising, there is little data on functional outcomes in this group. Methods: The REACCT international collaborative database was reviewed and data on eligible patients analysed. Inclusion criteria comprised patients with a histologically confirmed rectal cancer, <50 years of age at time of diagnosis and with documented follow-up including functional outcomes. Results: A total of 1428 (n=1428) patients met the eligibility criteria and were included in the final analysis. Metastatic disease was present at diagnosis in 13%. Of these, 40% received neoadjuvant therapy and 50% adjuvant chemotherapy. The incidence of post-operative major morbidity was 10%. A defunctioning stoma was placed for 621 patients (43%); 534 of these proceeded to elective restoration of bowel continuity. The median follow-up time was 42 months. Of this cohort, a total of 415 (29%) reported persistent impairment of functional outcomes, the most frequent of which was bowel dysfunction (16%), followed by bladder dysfunction (7%), sexual dysfunction (4.5%) and infertility (1%). Conclusion: A substantial proportion of patients with early-onset rectal cancer who undergo surgery report persistent impairment of functional status. Patients should be involved in the discussion regarding their treatment options and potential impact on quality of life. Functional outcomes should be routinely recorded as part of follow up alongside oncological parameters

Porast incidencije raka debelog crijeva kod osoba <50 godina – populacijska studija

PURPOSE: Data on the incidence of colorectal cancer (CRC) is conflicting, and it is unknown if the incidence is constant, declining, or increasing. Proximal colon cancer is considered to be more common among older individuals, but recent data have shown that rectal cancer and distal colon cancer have been increasing in the younger population. The aim of this study was to determine the trends regarding CRC incidence and tumour location in Sweden. ----- METHODS: CRC statistics from the National Board of Health and Welfare 1995–2015 were used. CRC incidence rates by age group (<50 years, 50–79 years, ≥80 years), sex, and tumour localisation (proximal colon, distal colon, or rectum) were calculated and analysed using Poisson regression. ----- RESULTS: The age-standardised incidence of CRC increased in Sweden during the study period. This increase was significant (P<0.0001) for colon cancer during the study period for all age groups regardless of tumour localisation. The greatest increase (27–52% per decade) in the colon cancer incidence rate was seen among men and women <50 years of age. The incidence rate for rectal cancer increased for men <50 years (P<0.0001), decreased for both men and women aged ≥80 years (P<0.005), and did not change for the remaining groups. ----- CONCLUSIONS: The CRC incidence in Sweden, in particular colon cancer, is increasing regardless of tumour localisation for individuals <50 years of age. This paper supports the implementation of population-based colorectal cancer screening. A diagnostic workup should be performed in symptomatic individuals <50 years of age.SVRHA: Podaci o incidenciji kolorektalnog raka su proturiječni i nije poznato je li incidencija konstantna, opadajuća ili rastuća. Rak proksimalnog debelog crijeva smatra se češćim među starijim osobama ali nedavni podaci pokazuju da se rak stražnjeg debelog crijeva i rak distalnog debelog crijeva povećavaju u mlađoj populaciji. Svrha ovog istraživanja je bila odrediti trendove što se tiče incidencije kolorektalnog raka i lokacije tumora u Švedskoj. ----- METODE: Korišteni su statistički podaci kolorektalnog raka iz Naciolnalnog ministarstva za zdravlje i socijalnu skrb 1995-2015. Stopa incidencije kolorektalnog raka prema dobnoj skupini (<50 godina, 50-79 godina, ≥80 godina), spolu i lokaciji tumora (proksimalno debelo crijevo, distalno debelo crijevo ili stražnje debelo crijevo) su izračunati i analizirani pomoću Poissonove regresije. ----- REZULTATI: Dobna standardizirana incidencija kolorektalnog raka povećala se u Švedskoj tijekom razdoblja istraživanja. Ovaj porast bio je signifikantan (P<0.0001) za rak debelog crijeva tijekom istraživanog razdoblja za sve dobne skupine bez obzira na lokaciju tumora. Najveći porast (27-52% /desetljeće) stope incidencije raka debelog crijeva viđen je među muškarcima i ženama mlađim od 50 godina. Stopa incidencije raka stražnjeg debelog crijeva porasla je za muškarce <50 godina (P<0.0001), smanjila se i za muškarce i za žene u dobi ≥80 godina (P<0.005) i nije se promijenila za preostale skupine. ----- ZAKLJUČAK: Incidencija kolorektalnog raka u Švedskoj, posebno raka debelog crijeva, raste bez obzira na lokaciju tumora za osobe mlađe od 50 godina. Ova studija podržava uvođenje populacijski baziranog probira za kolorektalni rak. Diagnostičku obradu treba vršiti kod simptomatskih osoba mlađih od 50 godina

Porast incidencije raka debelog crijeva kod osoba <50 godina – populacijska studija

PURPOSE: Data on the incidence of colorectal cancer (CRC) is conflicting, and it is unknown if the incidence is constant, declining, or increasing. Proximal colon cancer is considered to be more common among older individuals, but recent data have shown that rectal cancer and distal colon cancer have been increasing in the younger population. The aim of this study was to determine the trends regarding CRC incidence and tumour location in Sweden. ----- METHODS: CRC statistics from the National Board of Health and Welfare 1995–2015 were used. CRC incidence rates by age group (<50 years, 50–79 years, ≥80 years), sex, and tumour localisation (proximal colon, distal colon, or rectum) were calculated and analysed using Poisson regression. ----- RESULTS: The age-standardised incidence of CRC increased in Sweden during the study period. This increase was significant (P<0.0001) for colon cancer during the study period for all age groups regardless of tumour localisation. The greatest increase (27–52% per decade) in the colon cancer incidence rate was seen among men and women <50 years of age. The incidence rate for rectal cancer increased for men <50 years (P<0.0001), decreased for both men and women aged ≥80 years (P<0.005), and did not change for the remaining groups. ----- CONCLUSIONS: The CRC incidence in Sweden, in particular colon cancer, is increasing regardless of tumour localisation for individuals <50 years of age. This paper supports the implementation of population-based colorectal cancer screening. A diagnostic workup should be performed in symptomatic individuals <50 years of age.SVRHA: Podaci o incidenciji kolorektalnog raka su proturiječni i nije poznato je li incidencija konstantna, opadajuća ili rastuća. Rak proksimalnog debelog crijeva smatra se češćim među starijim osobama ali nedavni podaci pokazuju da se rak stražnjeg debelog crijeva i rak distalnog debelog crijeva povećavaju u mlađoj populaciji. Svrha ovog istraživanja je bila odrediti trendove što se tiče incidencije kolorektalnog raka i lokacije tumora u Švedskoj. ----- METODE: Korišteni su statistički podaci kolorektalnog raka iz Naciolnalnog ministarstva za zdravlje i socijalnu skrb 1995-2015. Stopa incidencije kolorektalnog raka prema dobnoj skupini (<50 godina, 50-79 godina, ≥80 godina), spolu i lokaciji tumora (proksimalno debelo crijevo, distalno debelo crijevo ili stražnje debelo crijevo) su izračunati i analizirani pomoću Poissonove regresije. ----- REZULTATI: Dobna standardizirana incidencija kolorektalnog raka povećala se u Švedskoj tijekom razdoblja istraživanja. Ovaj porast bio je signifikantan (P<0.0001) za rak debelog crijeva tijekom istraživanog razdoblja za sve dobne skupine bez obzira na lokaciju tumora. Najveći porast (27-52% /desetljeće) stope incidencije raka debelog crijeva viđen je među muškarcima i ženama mlađim od 50 godina. Stopa incidencije raka stražnjeg debelog crijeva porasla je za muškarce <50 godina (P<0.0001), smanjila se i za muškarce i za žene u dobi ≥80 godina (P<0.005) i nije se promijenila za preostale skupine. ----- ZAKLJUČAK: Incidencija kolorektalnog raka u Švedskoj, posebno raka debelog crijeva, raste bez obzira na lokaciju tumora za osobe mlađe od 50 godina. Ova studija podržava uvođenje populacijski baziranog probira za kolorektalni rak. Diagnostičku obradu treba vršiti kod simptomatskih osoba mlađih od 50 godina

Randomized clinical trial comparing total extraperitoneal with Lichtenstein inguinal hernia repair (TEPLICH trial)

Background: Chronic pain is reported after 10–35 per cent of inguinal hernia operations. The aim was to compare quality of life (QoL) after total extraperitoneal (TEP) and Lichtenstein hernia repairs in the setting of an RCT with operations performed by department-certified hernia surgeons. Methods: Men aged 30–75 years with an ASA grade I–II primary inguinal hernia were randomized to TEP or Lichtenstein repair. Primary endpoint was pain at 1 year assessed with the Inguinal Pain Questionnaire (IPQ). Clinical examination, IPQ, SF-36® and study-specific questions were recorded before surgery, and at 1 and 3 years. Results: Some 416 patients (202 TEP and 214 Lichtenstein) had surgery; 95·2 per cent completed 1-year and 89·9 per cent 3-year follow-up. At 1 year ‘pain during last week’ was reported by 6·9 per cent after TEP and by 9·8 per cent after Lichtenstein repair (P = 0·303), and ‘pain right now’ by 3·7 and 5·9 per cent respectively (P = 0·315). Favourable outcomes for TEP were duration of operation, 30-day complications, time to full recovery, foreign body sensation and sick leave. Groin sensory changes diminished after TEP but increased after Lichtenstein repair. Preoperative QoL was affected, especially in the physical subscales, but was restored to normal after surgery. At 1 and 3 years, 98·3 and 97·4 per cent respectively of the patients were satisfied; 1·6 per cent (6 of 374) suffered a recurrence at 3 years, four after TEP and two after Lichtenstein repair. Conclusion: In the medium term, both TEP and Lichtenstein hernia repair had similar outcomes after 1 year, with high rates of patient satisfaction and low rates of chronic pain and recurrence. There were short-term advantages for pain and recovery rate after TEP repair. Registration number: NCT00803985 (www.clinicaltrials.gov)

Pain with sexual activity at 1 and 3 years : Comparing total extraperitoneal with Lichtenstein inguinal hernia repair in a randomized setting (TEPLICH trial)

Background: Pain at sexual activity induced by an inguinal hernia or as a cause of its repair is not thoroughly studied. Reported frequencies are between 25% and 30% preoperatively and 10% and 15% postoperatively. The primary aim was to analyze pain at sexual activity at 1 year comparing total extraperitoneal with Lichtenstein repair in a randomized setting. Methods: Men, 30 to 60 years old, with a primary inguinal hernia were randomized to total extraperitoneal without mesh fixation or Lichtenstein repair. A questionnaire on pain prevalence, frequency, intensity, and impairment of sexual functions caused by pain at sexual activity was introduced. Clinical examination, a questionnaire on sexual function, and the 36-Item Short Form Survey were performed preoperatively and at 1 and 3 years postoperatively. A risk factor analysis for pain at sexual activity as performed. Results: A total of 243 patients (111 total extraperitoneal and 132 Lichtenstein) were included between 2008 and 2014; 97% remained for 1-year and 90% for 3-year analysis. Preoperative pain at sexual activity was reported in 35%, with a reduction to 5.9% in total extraperitoneal and 12.5% in Lichtenstein (P = .098) at 1 year and 7.0% in total extraperitoneal and 9.3% in Lichtenstein (P = .566) at 3 years. Quality of life preoperatively was markedly reduced in patients with pain at sexual activity but restored almost to norm levels at 1 and 3 years. New pain at sexual activity (harm) was seen in 8 patients (3.6%) at 1 year. Risk factors for having postoperative pain at sexual activity were preoperative pain and Lichtenstein technique. Conclusion: Pain at sexual activity in inguinal hernia patients is more common than suspected and reduces quality of life. Repair will markedly reduce pain at sexual activity and restore quality of life in most patients without difference between techniques. Patients should be informed on a potential relation between having an inguinal hernia and sexual impairment

Inguinal Hernia Surgery in Men - Chronic Pain and Sexual Dysfunction

Life time occurrence of inguinal hernia is 30% of men. Most are symptomatic and will require surgical treatment. Operation will commonly cure the hernia but remaining chronic pain or new pain is seen in 10–15%. Groin pain due to an inguinal hernia can cause impairment of sexual functions. This is sparsely studied. The aim was to analyse postoperative long term chronic pain and sexual impairment in a large cohort of endoscopically (TEP) operated men registered in the Swedish Hernia Register (SHR) were all levels of surgical skills were present. Secondly to analyse within an RCT, using highly standardized techniques for open Lichtenstein (Lich) and TEP repairs, the influence of chronic pain and sexual impairment.PAPER I: a mail enquiry based study on 1110 patients retrieved from SHR comparing mechanically fixated to unfixed mesh in consecutive TEP operated men 30-75 years with a primary hernia during a 5 year time period. Chronic pain was seen in 7.7% with no long term difference (median 33 months). Pain did not attenuate over time. A recurrent operation was low (1.4%) without difference between fixated and unfixed mesh at median 7.5 years follow up. Quality of life was excellent. A postop complication was a risk factor for chronic pain.PAPER II: a RCT including 482 patients comparing Lich to TEP in men 30–75 years with a primary inguinal hernia. Pain was reported preoperatively in 73% and postop “pain past week” by 7.4% after TEP and 9.8% after Lich (ns) and “pain right now” by 4.2% after TEP and 5.9% after Lich (ns) at one year. Patients restored QoL to above norm levels. All short term outcomes favoured TEP. Postoperative sensory disturbances increased markedly at one year after Lich. Low rates for both chronic pain and recurrence can be explained by operations performed in a highly standardized setting by specialists.PAPER III: a cohort of 538 patients within the register-based TEP study in sexually active men, 30–60 years old. A new short form questionnaire (SexIHQ) was developed to assess sexual dysfunction due to groin pain after inguinal hernia repair to be used in large cohorts. Pain during sexual activity showed a surprisingly high incidences of 8.2%. A postoperative complication was a risk factor for pain during sexual activity.PAPER IV: a cohort of 243 patients from the RCT, men 30–60 years old were included. A questionnaire of sexual function was distributed. 35% reported pain at sexual activity preoperatively. At one year 5.8% in TEP and 12.3% in Lich (ns) and after three years 6.8% vs 9.1% (ns). Hernia repair reduce pain at sexual activity and restore QoL in most patients. New pain at sexual activity (harms) was though seen in 3.5% at one year. Risk factors for postoperative pain at sexual activity are Lich technique and preoperative pain.CONCLUSIONS: Both TEP and Lichtenstein repair result in low rates of chronic pain and recurrence without differences between groups. Both techniques reduces symptom and restore QoL in most patients. TEP has short term advantages. Sexual dysfunction due to groin pain in inguinal hernia patients is surprisingly high and reduces the QoL in these patients. Hernia repair by both TEP and Lichtenstein markedly reduce the preoperative sexual dysfunction and restore QoL in most patients. The Lichtenstein technique is through a risk factor for pain at sexual activity

To lead through resistance to change : A qualitative study on leadership at Försäkringskassan

Genom alla år har Försäkringskassan funnits till för människans sociala trygghet. Tanken är att det ska finnas hjälp när det behövs, såsom vid sjukdom och funktionsnedsättning, bidrag till barn etc. Det vill säga att människor fortfarande ska få chansen till trygghet trots att livet väljer att ta en ny vändning. Dock har Försäkringskassan fått mycket kritik mot sig och blivit ifrågasatt många gånger kring ledningens arbete. Vårt syfte med denna kvalitativa studie var att få en större inblick om ledarskapet på Försäkringskassan samt hur den påverkas genom förändring och motstånd. Därmed valde vi att intervjua sex enhetschefer som arbetar på Försäkringskassan, där de fick chansen att yttra sig frivilligt genom en semistrukturerad intervju. Vi ansåg att denna metod var den mest effektiva för att kunna förstå innebörden av ledarskapet under förändringar och motstånd. Med hjälp av vår teori kunde vi genom vår analys komma fram till att enhetscheferna uppfattar sitt ledarskap som transformativt. Vår analys har gett oss svar på att alla enhetschefer på Försäkringskassan uppfattar sig själva som transformativa ledare. Vi har även kommit fram till att deras ledarskapsstil spelar en stor roll i hur de bekämpar motstånd som uppkommer genom förändringar inom organisationer. Det vill säga hur de har valt att hantera förändringarna och motstånden i organisationen. Resultatet försäkrade oss om att enhetschefer hade mycket gemensamt gällande sitt ledarskap. Respondenterna använde sig utav samma begrepp såsom kommunikation, lyhördhet och tillgänglighet för att leda genom motstånd vid förändring.The Swedish Social Insurance Agency (Försäkringskassan) has through the years aimed to support the social security system. The idea is that there should be assistance when needed, such as providing financial security in the event of illness, disability and for families with children. The vision behind this is a society where people can get a chance to feel secure even when life takes an unexpected turn. However, the Social Insurance Agency has received a lot of criticism about their management and their work has been questioned many times. Our aim with this qualitative study is to obtain a greater insight into the leadership of the Swedish Social Insurance Agency and how it is affected by change and resistance. Thus, we chose to interview six head of unit managers who work at the Swedish Social Insurance Agency where they were given the opportunity to speak freely through a semi-structured interview. We felt that this method was the most effective one in order to understand the meaning of leadership during changes and resistance. With the help of our theory, through our analysis, we could find that the managers perceive their leadership as transformative and that they perceive themselves as transformative leaders. We also came to the conclusion that their leadership style plays a major role in how they combat resistance that arises through changes within organizations. That is, how they have chosen to handle the changes and the oppositions in the organization. The result assured us that that unit managers have a lot in common regarding their leadership. The respondents used the same concepts such as communication, responsiveness and accessibility/availability to lead through resistance during change

The Relevance of Sexual Dysfunction Related to Groin Pain After Inguinal Hernia Repair : The SexIHQ Short Form Questionnaire Assessment

Background: Chronic postoperative pain after inguinal hernia surgery can affect sexual function. A new short form questionnaire for inguinal hernia pain related sexual dysfunction (SexIHQ) was introduced and applied to a register based cohort of total extra-peritoneal hernioplasty (TEP) operated patients. Methods: Sexually active men, 30–60 years old, recorded in the Swedish Hernia Register for a primary inguinal hernia TEP operation were included. Two initial questions of the SexIHQ identify patients with pain at sexual activity. Only these patients proceeded to answer the specific questions on pain-induced impairment of sexual activity, pain frequency and intensity, physical functions (erection and ejaculation), and symptoms of depression. SexIHQ, the Short Form-36 (SF-36), the Inguinal Pain Questionnaire (IPQ) were mailed to participants for long term follow up. Results: In 538 included patients, 44 (8.2%) reported pain during sexual activity at mean 33 months after surgery. Sexual dysfunction was seen in 33 of these patients. A postoperative complication was a risk factor for pain during sexual activity; OR 4.89 (95% CI 1.92–12.43; p < 0.001). Quality-of-life was reduced in almost all SF-36 domains in patients with pain during sexual activity. Conclusions: A short form questionnaire, suitable for large cohorts, was developed to assess sexual dysfunction due to groin pain after inguinal hernia repair in male patients. Sexual dysfunction due to groin pain after hernia surgery by TEP is surprisingly common. Patients should preoperatively be informed of the risk of having pain during sexual activity following groin hernia surgery