december 2014 - crc...acknowledgement we would like to thank all contributing parties for their...

December 2014

© National Cancer Patient Registry-Colorectal Cancer

Jointly published by:

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

Contact:

National Cancer Patient Registry-Colorectal Cancer

Registry Coordinating Centre

c/o Clinical Research Centre

Hospital Sultanah Bahiyah

KM 6, Jalan Langgar

05460 Alor Setar, Kedah

Malaysia

General line: 604-7407391

Fax: 604-7407373

Website: https://app.acrm.org.my/CCD

Disclaimer

Data reported were supplied by NCPR-CC. Interpretation and reporting is the responsibility of the

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.

The electronic version of this report can be downloaded at https://app.acrm.org.my/CCD

https://app.acrm.org.my/CCD

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.

Health Informatics Centre for funding the reports’ printing.

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.

4. To study the stage at diagnosis and histological types of colorectal cancer patients

5. To evaluate the treatment modalities for colorectal cancer.

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

ORGANIZATION:

Steering Committee

NCPR-CC Office

Expert Panel

User / Target Group Source Data

Providers


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 Ampang

Hospital Duchess of Kent, Sandakan

Hospital Kepala Batas, Pulau Pinang

Hospital Kuala Lumpur

Hospital Kulim

Hospital Melaka

Hospital Miri

Hospital Pulau Pinang

Hospital Putrajaya

Hospital Queen Elizabeth, K. Kinabalu

Hospital Raja Perempuan Zainab II,

Kelantan

Hospital Raja Permaisuri Bainun, Ipoh

Hospital Seberang Jaya, P. Pinang

Hospital Selayang, Selangor

Hospital Serdang, Selangor

Hospital Sibu, Sarawak

Hospital Sultan Abdul Halim, Sg. Petani

Hospital Sultan Ismail, Johor Bahru

Hospital Sultanah Aminah, Johor Bahru

Hospital Sultanah Bahiyah, Alor Star

Hospital Sultanah Nur Zahirah, Kuala

Terengganu

Hospital Taiping

Hospital Tengku Ampuan Afzan,

Kuantan

Hospital Tengku Ampuan Rahimah,

Klang

Hospital Tuanku Fauziah, Kangar

Hospital Tuanku Jaafar, Seremban

Hospital Umum Sarawak, Kuching

Hospital Universiti Sains Malaysia,

Kelantan

Pusat Perubatan Universiti Malaya

Kedah Medical Centre, Alor Setar

Mawar Medical Centre, Seremban

Metro Specialist Hospital, Sg. Petani

Hospital Pantai, Sg. Petani

Putra Medical Centre, Alor Setar


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,


Dato’ Dr Wan Khamizar Wan Khazim Department of Surgery,


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,


Dr Hajjah Zabedah Hj Othman Department of Radiotherapy and Oncology,


Datuk Dr Fitjerald Henry Department of Surgery,


Prof. Dr April Roslani

Department of Surgery,

Univerity of Malaya Medical Center,

Kuala Lumpur


Prof Dr Nor Hayati Othman Department of Pathology,

Hospital Universiti Sains Malaysia, Kelantan

Miss Jasiah Zakaria


Hospital Tuanku Jaafar, Seremban,

Negeri Sembilan

Mr Chan Koon Khee


Hospital Sultanah Aminah, Johor Bahru,

Johor

Dr Mohd Roslan bin Haron Oncology Treatment Center,

Hospital Sultan Ismail, Johor Bahru, Johor

Dr Ahmad Shanwani Bin Mohamed Sidek Department of Surgery,

Hospital Raja Perempuan Zainab II, Kelantan

Mr Nik Azim Nik Abdullah Department of Surgery,

Hospital Umum Sarawak

Datuk Dr Jayaram Menon

Department of Internal Medicine,

Hospital Queen Elizabeth, K. Kinabalu,

Sabah

Dr Noor Laili Mokhtar Department of Pathology,

Hospital Serdang, Selangor

Dr Mukarramah bt Che Ayub Department of Pathology,

Hospital Raja Perempuan Zainab II, Kelantan

Assoc. Prof. Dr Gurjeet Kaur

A/P Chatar Singh

Department of Pathology,

Advanced Medical & Dental Institute,

Universiti Sains Malaysia, Penang

Dr Andee Dzulkarnaen Zakaria Department of Surgery,

Hospital Universiti Sains Malaysia

Prof Datuk Dr Ismail Sagap Department of Surgery,

Hospital Universiti Kebangsaan Malaysia


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

Miss Teo Jau Shya ClinData Consulting Sdn Bhd


MEDICAL WRITING COMMITTEE

NAME INSTITUTION

Dato’ Dr Muhammad Radzi Abu Hassan Department of Internal Medicine,


Datin Dr Nik Raihan Nik Mustapha Department of Pathology,


Dato’ Dr Wan Khamizar Wan Khazim Department of Surgery,


Dr Hajjah Rosaida Hj Mohd Said Department of Internal Medicine,

Hospital Ampang, Kuala Lumpur

Datuk Dr Fitjerald Henry Department of Surgery,


Dr Hajjah Zabedah Hj Othman Department of Radiotherapy and Oncology,


Dr Tan Wei Leong

Medical Officer,

Clinical Research Center,


Dr Mohd Azri Mohd Suan

Medical Officer,



Mr Shahrul Aiman Soelar

Statistician,




National Colorectal Cancer Registry Coordinating Centre / Secretariat

NAME INSTITUTION

Dr Madihah Ahmad

Medical Officer,

Clinical Research Centre,


Miss Faizah Ahmad

Manager,

Research Officer,



Miss Ibtisam Ismail

Research Officer,



Mr Shahrul Aiman Soelar

Statistician,



Miss Siti Rohani Suddin Clinical Research Centre,


Miss Aliah Mat Ali Clinical Research Centre,


Miss Jambi Md Hussain Clinical Research Centre,


Miss Neoh Poh Tiew Clinical Research Centre,


Miss Nor Hafiza Johari Clinical Research Centre,


Miss Zainab Shafie Clinical Research Centre,


Miss Wan Muhana Abdullah Clinical Research Centre,


Miss Siti Aishah Aris Clinical Research Centre,


Miss Siti Ertina Asli Clinical Research Centre,



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.

Dato’ Dr Muhammad Radzi Abu Hassan

Principal Investigator


TABLE OF CONTENTS

Acknowledgement

About NCPR-Colorectal Cancer In Malaysia 1

Organization 2

Source Data Providers 3

Steering Committee 4

Medical Writing Committee 7

National Colorectal Cancer Registry Coordinating Centre 8

Letter from The Principal Investigator 9

Table of Contents 10

List of Tables 11

List of Figures 13

Executive Summary 15

Chapter 1: Demographics 19

Chapter 2: Risk Factor and Clinical Presentation 27

Chapter 3: Primary Diagnosis and Final Staging 37

Chapter 4: Pathology 43

Chapter 5: Treatment Modalities 55

Chapter 6: Incidence and Mortality Rate 63

Appendix 69


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 NCPR-


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 NCPR-


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 NCPR-


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 NCPR-



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

44

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

44

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 NCPR-


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 NCPR-


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 NCPR-


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

NCPR-Colorectal Cancer, 2008-2013 58

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 NCPR-


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


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



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 NCPR-


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



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.

The proportion of colorectal cancer increased with age for both men and

women in the six-year duration.


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

(pT3 and pT4). In addition, more than half had nodal metastasis.


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.

The data on chemotherapy and radiotherapy are still insufficient for

analysis.


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.

Figure 1.0: Data flow


CHAPTER 1

DEMOGRAPHICS


DEMOGRAPHICS

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

Participating

Hospitals

Year

Overall 2008 2009 2010 2011 2012 2013

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

1 67 1 (0.2) 25 (2.5) 22 (2.2) 13 (1.7) 6 (0.8) 0 (0.0)

2 36 7 (1.1) 16 (1.6) 12 (1.2) 1 (0.1) 0 (0.0) 0 (0.0)

3 132 2 (0.3) 21 (2.1) 24 (2.5) 26 (3.5) 39 (5.2) 20 (5.4)

4 353 99 (15.0) 61 (6.1) 84 (8.6) 69 (9.2) 39 (5.2) 1 (0.3)

5 20 0 (0.0) 4 (0.4) 5 (0.5) 1 (0.1) 7 (0.9) 3 (0.8)

6 112 1 (0.2) 22 (2.2) 39 (4.0) 31 (4.2) 19 (2.5) 0 (0.0)

7 29 1 (0.2) 19 (1.9) 8 (0.8) 1 (0.1) 0 (0.0) 0 (0.0)

8 276 17 (2.6) 95 (9.6) 88 (9.0) 50 (6.7) 17 (2.2) 9 (2.4)

9 40 4 (0.6) 7 (0.7) 17 (1.7) 4 (0.5) 4 (0.5) 4 (1.1)

10 321 69 (10.5) 50 (5.0) 54 (5.5) 65 (8.7) 53 (7.0) 30 (8.1)

11 175 40 (6.1) 28 (2.8) 35 (3.6) 36 (4.8) 20 (2.6) 16 (4.3)

12 133 1 (0.2) 42 (4.2) 33 (3.4) 27 (3.6) 30 (4.0) 0 (0.0)

13 85 8 (1.2) 22 (2.2) 27 (2.8) 12 (1.6) 10 (1.3) 6 (1.6)

14 282 86 (13.1) 75 (7.6) 69 (7.1) 4 (0.5) 7 (0.9) 41 (11.1)

15 22 20 (3.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.1) 1 (0.3)

16 31 2 (0.3) 19 (1.9) 10 (1.0) 0 (0.0) 0 (0.0) 0 (0.0)

17 27 1 (0.2) 3 (0.3) 6 (0.6) 5 (0.7) 11 (1.5) 1 (0.3)

18 179 3 (0.5) 4 (0.4) 5 (0.5) 19 (2.5) 110 (14.6) 38 (10.3)

19 210 70 (10.6) 61 (6.1) 42 (4.3) 29 (3.9) 5 (0.7) 3 (0.8)

20 403 85 (12.9) 80 (8.1) 76 (7.8) 62 (8.3) 65 (8.6) 35 (9.5)

21 146 7 (1.1) 33 (3.3) 35 (3.6) 30 (4.0) 29 (3.8) 12 (3.3)

22 68 5 (0.8) 16 (1.6) 11 (1.1) 19 (2.5) 9 (1.2) 8 (2.2)

23 54 0 (0.0) 0 (0.0) 0 (0.0) 15 (2.0) 9 (1.2) 30 (8.1)

24 223 5 (0.8) 29 (2.9) 27 (2.8) 41 (5.5) 73 (9.7) 48 (13.0)

25 54 0 (0.0) 17 (1.7) 6 (0.6) 10 (1.3) 18 (2.4) 3 (0.8)

26 194 5 (0.8) 42 (4.2) 45 (4.6) 42 (5.6) 59 (7.8) 1 (0.3)

27 560 75 (11.4) 123 (12.4) 121 (12.4) 110 (14.7) 83 (11.0) 48 (13.0)

28 128 34 (5.2) 38 (3.8) 48 (4.9) 5 (0.7) 2 (0.3) 1 (0.3)

29 42 2 (0.3) 8 (0.8) 12 (1.2) 6 (0.8) 10 (1.3) 4 (1.1)

30 8 0 (0.0) 1 (0.1) 3 (0.3) 2 (0.3) 2 (0.3) 0 (0.0)

31 15 0 (0.0) 7 (0.7) 3 (0.3) 1 (0.1) 1 (0.1) 3 (0.8)

32 2 0 (0.0) 1 (0.1) 1 (0.1) 0 (0.0) 0 (0.0) 0 (0.0)

33 38 4 (0.6) 13 (1.3) 1 (0.1) 4 (0.5) 13 (1.7) 3 (0.8)

34 36 5 (0.8) 11 (1.1) 9 (0.9) 6 (0.8) 5 (0.7) 0 (0.0)

Overall 4501 659 (100.0) 993 (100.0) 978 (100.0) 746 (100.0) 756 (100.0) 369 (100.0)


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

number of colorectal cancer patients encountered in their setting.


Table 1.2: Demographics of 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 (%)

Age (years)

n 4458 654 975 975 739 751 364

Mean 61.6 61.2 62.1 61.6 61.3 61.7 61.4

Standard Deviation 12.72 12.21 12.32 12.84 12.94 12.55 12.54

Age groups (years)

<19 11 1 (9.1) 0 (0.0) 2 (18.2) 4 (36.4) 3 (27.3) 1 (9.1)

20-24 17 3 (17.6) 2 (11.8) 6 (35.3) 2 (11.8) 1 (5.9) 3 (17.6)

25-29 47 6 (12.8) 10 (21.3) 13 (27.7) 7 (14.9) 8 (17.0) 3 (6.4)

30-34 65 9 (13.8) 11 (16.9) 16 (24.6) 14 (21.5) 10 (15.4) 5 (7.7)

35-39 112 20 (17.9) 25 (22.3) 19 (17.0) 22 (19.6) 12 (10.7) 14 (12.5)

40-44 194 36 (18.6) 42 (21.6) 36 (18.6) 28 (14.4) 44 (22.7) 8 (4.1)

45-49 328 55 (16.8) 70 (21.3) 73 (22.3) 52 (15.9) 49 (14.9) 29 (8.8)

50-54 465 66 (14.2) 99 (21.3) 108 (23.2) 76 (16.3) 82 (17.6) 34 (7.3)

55-59 627 95 (15.2) 131 (20.9) 137 (21.9) 114 (18.2) 104 (16.6) 46 (7.3)

60-64 713 91 (12.8) 161 (22.6) 152 (21.3) 119 (16.7) 118 (16.5) 72 (10.1)

65-69 650 95 (14.6) 148 (22.8) 141 (21.7) 105 (16.2) 104 (16.0) 57 (8.8)

70-74 616 79 (12.8) 138 (22.4) 135 (21.9) 92 (14.9) 121 (19.6) 51 (8.3)

75-79 348 56 (16.1) 80 (23.0) 74 (21.3) 61 (17.5) 54 (15.5) 23 (6.6)

>80 265 42 (15.8) 58 (21.9) 63 (23.8) 43 (16.2) 41 (15.5) 18 (6.8)

Missing 43 5 (11.6) 18 (41.9) 3 (7.0) 7 (16.3) 5 (11.6) 5 (11.6)

Gender

Male 2518 393 (15.6) 546 (21.7) 569 (22.6) 387 (15.4) 422 (16.8) 201 (8.0)

Female 1933 264 (13.7) 444 (23.0) 405 (21.0) 355 (18.4) 310 (16.0) 155 (8.0)

Missing 50 2 (4.0) 3 (6.0) 4 (8.0) 4 (8.0) 24 (48.0) 13 (26.0)

Ethnic

Malay 1922 266 (13.8) 394 (20.5) 432 (22.5) 322 (16.8) 334 (17.4) 174 (9.1)

Chinese 1814 265 (14.6) 426 (23.5) 386 (21.3) 296 (16.3) 307 (16.9) 134 (7.4)

Indian 259 36 (13.9) 63 (24.3) 58 (22.4) 45 (17.4) 35 (13.5) 22 (8.5)

Others 484 90 (18.6) 108 (22.3) 101 (20.9) 79 (16.3) 71 (14.7) 35 (7.2)

Missing 22 2 (9.1) 2 (9.1) 1 (4.5) 4 (18.2) 9 (40.9) 4 (18.2)

Education level

No formal education 417 115 (27.6) 83 (19.9) 80 (19.2) 45 (10.8) 64 (15.3) 30 (7.2)

Primary 576 96 (16.7) 146 (25.3) 132 (22.9) 103 (17.9) 64 (11.1) 35 (6.1)

Secondary 672 91 (13.5) 165 (24.6) 174 (25.9) 99 (14.7) 94 (14.0) 49 (7.3)

Tertiary 201 27 (13.4) 43 (21.4) 59 (29.4) 30 (14.9) 26 (12.9) 16 (8.0)

Missing 2635 330 (12.5) 556 (21.1) 533 (20.2) 469 (17.8) 508 (19.3) 239 (9.1)


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

female. For male, the rate decreased from 15.6% to 8.0 % while the rate decreased

from 13.7 to 8.0% for female.


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)


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%).

The patterns of colorectal cancer proportion by age group were similar in all ethnicity.


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.

In term of educational level, majority of male patients achieved at least secondary or

tertiary education. On the other hand, more than half of female patients were without

formal education.


CHAPTER 2

RISK FACTOR & CLINICAL PRESENTATION


RISK FACTOR & CLINICAL PRESENTATION

Table 2.1: Status of diabetes mellitus for 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 (%)

Diabetes Mellitus

No 3110 471 (71.5) 696 (70.1) 680 (69.5) 511 (68.5) 500 (66.1) 252 (68.3)

Yes 1005 127 (19.3) 221 (22.3) 196 (20.0) 191 (25.6) 181 (23.9) 89 (24.1)

Missing 386 61 (9.3) 76 (7.7) 102 (10.4) 44 (5.9) 75 (9.9) 28 (7.6)

Overall 4501 659 (100.0) 993 (100.0) 978 (100.0) 746 (100.0) 756 (100.0) 369 (100.0)

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

the NCPR-Colorectal Cancer, 2008-2013

Characteristics

Diabetes Mellitus

Overall No Yes

n n (%) n (%)

Age group (years)

<19 10 10 (100.0) 0 (0.0)

20-24 14 14 (100.0) 0 (0.0)

25-29 42 42 (100.0) 0 (0.0)

30-34 61 61 (100.0) 0 (0.0)

35-39 102 98 (96.1) 4 (3.9)

40-44 186 168 (90.3) 18 (9.7)

45-49 302 253 (83.8) 49 (16.2)

50-54 431 347 (80.5) 84 (19.5)

55-59 577 420 (72.8) 157 (27.2)

60-64 643 462 (71.9) 181 (28.1)

65-69 595 427 (71.8) 168 (28.2)

70-74 572 388 (67.8) 184 (32.2)

75-79 311 211 (67.8) 100 (32.2)

>80 239 182 (76.2) 57 (23.8)


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

prominent after the age of 55. Otherwise, there was no obvious difference in the

proportion of diabetes mellitus by gender, ethnicity and educational level.


Table 2.3: Smoking status of 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 (%)

Smoking Status

Non-smoker 1728 247 (37.5) 395 (39.8) 400 (40.9) 282 (37.8) 269 (35.6) 135 (36.6)

Former smoker

(quit > 30 days) 594 96 (14.6) 131 (13.2) 141 (14.4) 88 (11.8) 90 (11.9) 48 (13.0)

Active smoker 430 78 (11.8) 91 (9.2) 105 (10.7) 74 (9.9) 54 (7.1) 28 (7.6)

Missing 1749 238 (36.1) 376 (37.9) 332 (33.9) 302 (40.5) 343 (45.4) 158 (42.8)

Overall 4501 659 (100.0) 993 (100.0) 978 (100.0) 746 (100.0) 756 (100.0) 369 (100.0)

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


Characteristics

Smoking Status

Overall Non-smoker Former smoker

(quit > 30 days) Active smoker

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

Age group (years)

<19 6 5 (83.3) 1 (16.7) 0 (0.0)

20-24 8 7 (87.5) 1 (12.5) 0 (0.0)

25-29 32 18 (56.3) 3 (9.4) 11 (34.4)

30-34 43 26 (60.5) 6 (14.0) 11 (25.6)

35-39 69 43 (62.3) 12 (17.4) 14 (20.3)

40-44 121 76 (62.8) 18 (14.9) 27 (22.3)

45-49 208 125 (60.1) 43 (20.7) 40 (19.2)

50-54 306 214 (69.9) 48 (15.7) 44 (14.4)

55-59 389 261 (67.1) 67 (17.2) 61 (15.7)

60-64 437 255 (58.4) 111 (25.4) 71 (16.2)

65-69 398 237 (59.5) 104 (26.1) 57 (14.3)

70-74 369 232 (62.9) 83 (22.5) 54 (14.6)

75-79 193 124 (64.2) 47 (24.4) 22 (11.4)

>80 158 98 (62.0) 44 (27.8) 16 (10.1)

Gender

Male 1521 595 (39.1) 532 (35.0) 394 (25.9)

Female 1206 1118 (92.7) 55 (4.6) 33 (2.7)


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.

Percentage of active smoker among colorectal cancer patients was noted to be higher

in male and age group between 25 and 44. There was no noticeable difference in

cigarette smoking status by ethnicity and educational level.


Table 2.5: Family history of 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 (%)

Family history of Colorectal Cancer

Yes 288 42 (6.4) 58 (5.8) 64 (6.5) 50 (6.7) 56 (7.4) 18 (4.9)

No 3424 547 (83.0) 800 (80.6) 732 (74.8) 545 (73.1) 517 (68.4) 283 (76.7)

Missing 789 70 (10.6) 135 (13.6) 182 (18.6) 151 (20.2) 183 (24.2) 68 (18.4)

Overall 4501 659 (100.0) 993 (100.0) 978 (100.0) 746 (100.0) 756 (100.0) 369 (100.0)

Family history of Other Cancer

Yes 343 54 (8.2) 71 (7.2) 65 (6.6) 53 (7.1) 61 (8.1) 39 (10.6)

No 2887 445 (67.5) 636 (64.0) 621 (63.5) 467 (62.6) 486 (64.3) 232 (62.9)

Missing 1271 160 (24.3) 286 (28.8) 292 (29.9) 226 (30.3) 209 (27.6) 98 (26.6)

Overall 4501 659 (100.0) 993 (100.0) 978 (100.0) 746 (100.0) 756 (100.0) 369 (100.0)

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


Characteristics

Family history of Colorectal Cancer Family history of Other Cancer

Overall No Yes No Yes

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

Age group (years)

<19 11 8 (72.7) 2 (18.2) 9 (81.8) 0 (0.0)

20-24 17 13 (76.5) 1 (5.9) 11 (64.7) 1 (5.9)

25-29 47 40 (85.1) 3 (6.4) 25 (53.2) 7 (14.9)

30-34 65 49 (75.4) 8 (12.3) 46 (70.8) 5 (7.7)

35-39 112 79 (70.5) 16 (14.3) 69 (61.6) 14 (12.5)

40-44 194 156 (80.4) 17 (8.8) 139 (71.6) 12 (6.2)

45-49 328 247 (75.3) 30 (9.1) 217 (66.2) 23 (7.0)

50-54 465 352 (75.7) 35 (7.5) 287 (61.7) 50 (10.8)

55-59 627 489 (78.0) 41 (6.5) 411 (65.6) 54 (8.6)

60-64 713 531 (74.5) 38 (5.3) 436 (61.2) 51 (7.2)

65-69 650 499 (76.8) 41 (6.3) 428 (65.8) 50 (7.7)

70-74 616 473 (76.8) 30 (4.9) 399 (64.8) 39 (6.3)

75-79 348 256 (73.6) 17 (4.9) 217 (62.4) 22 (6.3)

>80 265 206 (77.7) 7 (2.6) 169 (63.8) 13 (4.9)


Characteristics

Family history of Colorectal Cancer Family history of Other Cancer

Overall No Yes No Yes

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

Gender

Male 2518 1929 (76.6) 162 (6.4) 1623 (64.5) 182 (7.2)

Female 1933 1456 (75.3) 125 (6.5) 1232 (63.7) 159 (8.2)

Ethnic

Malay 1922 1453 (75.6) 117 (6.1) 1299 (67.6) 123 (6.4)

Chinese 1814 1319 (72.7) 144 (7.9) 1052 (58.0) 175 (9.6)

Indian 259 196 (75.7) 10 (3.9) 160 (61.8) 12 (4.6)

Others 484 438 (90.5) 16 (3.3) 363 (75.0) 30 (6.2)

Education level

No formal education 417 367 (88.0) 18 (4.3) 322 (77.2) 20 (4.8)

Primary 576 510 (88.5) 45 (7.8) 447 (77.6) 46 (8.0)

Secondary 672 591 (87.9) 50 (7.4) 488 (72.6) 71 (10.6)

Tertiary 201 160 (79.6) 26 (12.9) 145 (72.1) 36 (17.9)

Table 2.7: Past medical history of other cancers of 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 (%)

Endometrial

Yes 8

3 (0.3) 2 (0.2) 2 (0.3) 1 (0.1) 0 (0.0)

No 3834

990 (99.7) 976 (99.8) 744 (99.7) 755 (99.9) 369 (100.0)

Overall 3842

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

Gastric

Yes 6

1 (0.1) 2 (0.2) 3 (0.4) 0 (0.0) 0 (0.0)

No 3836

992 (99.9) 976 (99.8) 743 (99.6) 756 (100.0) 369 (100.0)

Overall 3842

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

Small bowel

Yes 2

2 (0.2) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)

No 3840

991 (99.8) 978 (100.0) 746 (100.0) 756 (100.0) 369 (100.0)

Overall 3842

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


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.

However the proportion of family history of other malignancies was higher (7.6%).


Table 2.8: Symptom of 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 (%)

Blood in the stool

Yes 444 77 (42.5) 65 (38.2) 85 (40.5) 50 (33.8) 104 (36.2) 63 (24.9)

No 805 104 (57.5) 105 (61.8) 125 (59.5) 98 (66.2) 183 (63.8) 190 (75.1)

Overall 1249 181 (100.0) 170 (100.0) 210 (100.0) 148 (100.0) 287 (100.0) 253 (100.0)

Anemia

Yes 122 18 (9.9) 24 (14.1) 23 (11.0) 12 (8.1) 34 (11.8) 11 (4.3)

No 1127 163 (90.1) 146 (85.9) 187 (89.0) 136 (91.9) 253 (88.2) 242 (95.7)

Overall 1249 181 (100.0) 170 (100.0) 210 (100.0) 148 (100.0) 287 (100.0) 253 (100.0)

Weight loss

Yes 387 72 (39.8) 72 (42.4) 79 (37.6) 41 (27.7) 82 (28.6) 41 (16.2)

No 862 109 (60.2) 98 (57.6) 131 (62.4) 107 (72.3) 205 (71.4) 212 (83.8)

Overall 1249 181 (100.0) 170 (100.0) 210 (100.0) 148 (100.0) 287 (100.0) 253 (100.0)

Intestinal obstruction

Yes 116 17 (9.4) 17 (10.0) 21 (10.0) 17 (11.5) 29 (10.1) 15 (5.9)

No 1133 164 (90.6) 153 (90.0) 189 (90.0) 131 (88.5) 258 (89.9) 238 (94.1)

Overall 1249 181 (100.0) 170 (100.0) 210 (100.0) 148 (100.0) 287 (100.0) 253 (100.0)

Abdominal pain

Yes 393 68 (37.6) 65 (38.2) 81 (38.6) 47 (31.8) 86 (30.0) 46 (18.2)

No 856 113 (62.4) 105 (61.8) 129 (61.4) 101 (68.2) 201 (70.0) 207 (81.8)

Overall 1249 181 (100.0) 170 (100.0) 210 (100.0) 148 (100.0) 287 (100.0) 253 (100.0)

Others

Yes 295 77 (42.5) 55 (32.4) 45 (21.4) 28 (18.9) 45 (15.7) 45 (17.8)

No 954 104 (57.5) 115 (67.6) 165 (78.6) 120 (81.1) 242 (84.3) 208 (82.2)

Overall 1249 181 (100.0) 170 (100.0) 210 (100.0) 148 (100.0) 287 (100.0) 253 (100.0)

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)

No 728 83 (45.9) 80 (47.1) 99 (47.1) 90 (60.8) 193 (67.2) 183 (72.3)

Overall 1249 181 (100.0) 170 (100.0) 210 (100.0) 148 (100.0) 287 (100.0) 253 (100.0)

Not applicable / Unknown

Yes 9 2 (1.1) 0 (0.0) 2 (1.0) 2 (1.4) 2 (0.7) 1 (0.4)

No 1240 179 (98.9) 170 (100.0) 208 (99.0) 146 (98.6) 285 (99.3) 252 (99.6)

Overall 1249 181 (100.0) 170 (100.0) 210 (100.0) 148 (100.0) 287 (100.0) 253 (100.0)

* Information on symptoms was only available for 1249 patients.


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

registry. In 2013, altered bowel habit remained the most common presentation,

followed by blood in stool, abdominal pain, weight, intestinal obstruction and anemia.


CHAPTER 3

PRIMARY DIAGNOSIS & FINAL STAGING


PRIMARY DIAGNOSIS & FINAL STAGING

Table 3.1: Primary cancer site of 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 (%)

Malignant Neoplasms based on ICD10

C18 Colon 2409 353 (53.6) 477 (48.0) 538 (55.0) 423 (56.7) 421 (55.7) 197 (53.4)

C19 Rectosigmoid junction 648 98 (14.9) 170 (17.1) 137 (14.0) 89 (11.9) 112 (14.8) 42 (11.4)

C20 Rectum 1407 205 (31.1) 338 (34.0) 296 (30.3) 228 (30.6) 217 (28.7) 123 (33.3)

Missing 37 3 (0.5) 8 (0.8) 7 (0.7) 6 (0.8) 6 (0.8) 7 (1.9)

Overall 4501 659 (100.0) 993 (100.0) 978 (100.0) 746 (100.0) 756 (100.0) 369 (100.0)

Primary Cancer Site

Caecum 223 36 (5.5) 41 (4.1) 62 (6.3) 38 (5.1) 30 (4.0) 16 (4.3)

Hepatic flexure 160 25 (3.8) 35 (3.5) 39 (4.0) 22 (2.9) 30 (4.0) 9 (2.4)

Ascending colon 206 39 (5.9) 47 (4.7) 46 (4.7) 32 (4.3) 28 (3.7) 14 (3.8)

Transverse colon 181 24 (3.6) 43 (4.3) 40 (4.1) 28 (3.8) 24 (3.2) 22 (6.0)

Splenic flexure 103 22 (3.3) 15 (1.5) 30 (3.1) 10 (1.3) 19 (2.5) 7 (1.9)

Descending colon 179 24 (3.6) 37 (3.7) 45 (4.6) 35 (4.7) 22 (2.9) 16 (4.3)

Sigmoid colon 915 132 (20.0) 195 (19.6) 218 (22.3) 161 (21.6) 142 (18.8) 67 (18.2)

Rectosigmoid 729 109 (16.5) 187 (18.8) 148 (15.1) 103 (13.8) 126 (16.7) 56 (15.2)

Rectum 1456 218 (33.1) 336 (33.8) 307 (31.4) 240 (32.2) 223 (29.5) 132 (35.8)

Anorectal 98 7 (1.1) 28 (2.8) 16 (1.6) 20 (2.7) 19 (2.5) 8 (2.2)

Colon 98 12 (1.8) 16 (1.6) 13 (1.3) 24 (3.2) 31 (4.1) 2 (0.5)

Others 16 3 (0.5) 3 (0.3) 4 (0.4) 3 (0.4) 2 (0.3) 1 (0.3)

Not available 17 2 (0.3) 3 (0.3) 1 (0.1) 4 (0.5) 7 (0.9) 0 (0.0)

Missing 120 6 (0.9) 7 (0.7) 9 (0.9) 26 (3.5) 53 (7.0) 19 (5.1)

Overall 4501 659 (100.0) 993 (100.0) 978 (100.0) 746 (100.0) 756 (100.0) 369 (100.0)


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

malignancy throughout the six year period. The proportion ranged from 29.5% to

35.8%. The major primary site of malignancy is different from ICD 10 as colon is

divided into specific segment as indicated in the table.


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 (%)

Age group (years)

<19 10 5 (50.0) 5 (50.0)

20-24 17 14 (82.4) 3 (17.6)

25-29 42 28 (66.7) 14 (33.3)

30-34 64 50 (78.1) 14 (21.9)

35-39 103 82 (79.6) 21 (20.4)

40-44 186 149 (80.1) 37 (19.9)

45-49 308 251 (81.5) 57 (18.5)

50-54 440 366 (83.2) 74 (16.8)

55-59 588 496 (84.4) 92 (15.6)

60-64 676 570 (84.3) 106 (15.7)

65-69 622 502 (80.7) 120 (19.3)

70-74 583 477 (81.8) 106 (18.2)

75-79 327 258 (78.9) 69 (21.1)

>80 246 197 (80.1) 49 (19.9)

Table 3.3: Final TNM staging of 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 (%)

TNM Staging

I 378 52 (7.9) 87 (8.8) 77 (7.9) 67 (9.0) 53 (7.0) 42 (11.4)

II 947 152 (23.1) 212 (21.3) 198 (20.2) 156 (20.9) 154 (20.4) 75 (20.3)

III 1228 167 (25.3) 249 (25.1) 335 (34.3) 206 (27.6) 189 (25.0) 82 (22.2)

IV 909 119 (18.1) 176 (17.7) 173 (17.7) 164 (22.0) 201 (26.6) 76 (20.6)

Not staged 471 66 (10.0) 126 (12.7) 85 (8.7) 73 (9.8) 72 (9.5) 49 (13.3)

Missing 568 103 (15.6) 143 (14.4) 110 (11.2) 80 (10.7) 87 (11.5) 45 (12.2)

Overall 4501 659 (100.0) 993 (100.0) 978 (100.0) 746 (100.0) 756 (100.0) 369 (100.0)


Table 3.4: Final TNM staging by age groups, ethnic and education level 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 (%)

Age group (years)

<19 10 0 (0.0) 1 (10.0) 3 (30.0) 2 (20.0) 4 (40.0)

20-24 15 0 (0.0) 1 (6.7) 5 (33.3) 7 (46.7) 2 (13.3)

25-29 35 6 (17.1) 4 (11.4) 11 (31.4) 9 (25.7) 5 (14.3)

30-34 56 6 (10.7) 11 (19.6) 26 (46.4) 7 (12.5) 6 (10.7)

35-39 95 4 (4.2) 26 (27.4) 37 (38.9) 15 (15.8) 13 (13.7)

40-44 173 14 (8.1) 42 (24.3) 59 (34.1) 42 (24.3) 16 (9.2)

45-49 290 19 (6.6) 66 (22.8) 95 (32.8) 76 (26.2) 34 (11.7)

50-54 404 36 (8.9) 102 (25.2) 136 (33.7) 94 (23.3) 36 (8.9)

55-59 582 40 (6.9) 152 (26.1) 196 (33.7) 135 (23.2) 59 (10.1)

60-64 619 70 (11.3) 147 (23.7) 199 (32.1) 139 (22.5) 64 (10.3)

65-69 576 56 (9.7) 152 (26.4) 162 (28.1) 137 (23.8) 69 (12.0)

70-74 533 62 (11.6) 122 (22.9) 153 (28.7) 128 (24.0) 68 (12.8)

75-79 308 39 (12.7) 68 (22.1) 77 (25.0) 77 (25.0) 47 (15.3)

>80 215 25 (11.6) 48 (22.3) 62 (28.8) 37 (17.2) 43 (20.0)

Ethnic

Malay 1683 129 (7.7) 395 (23.5) 520 (30.9) 411 (24.4) 228 (13.5)

Chinese 1601 178 (11.1) 394 (24.6) 504 (31.5) 361 (22.5) 164 (10.2)

Indian 234 40 (17.1) 63 (26.9) 69 (29.5) 45 (19.2) 17 (7.3)

Others 398 29 (7.3) 92 (23.1) 130 (32.7) 87 (21.9) 60 (15.1)

Education level

No formal education 354 34 (9.6) 88 (24.9) 105 (29.7) 74 (20.9) 53 (15.0)

Primary 520 45 (8.7) 131 (25.2) 167 (32.1) 117 (22.5) 60 (11.5)

Secondary 609 62 (10.2) 155 (25.5) 204 (33.5) 132 (21.7) 56 (9.2)

Tertiary 177 16 (9.0) 42 (23.7) 63 (35.6) 43 (24.3) 13 (7.3)


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


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

family history of colorectal cancer as well as other cancer.


CHAPTER 4

PATHOLOGY


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

Year

Overall 2008 2009 2010 2011 2012 2013

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

Specimen type

Biopsy 1411 268 (35.5) 349 (31.4) 268 (24.8) 204 (25.0) 223 (27.1) 99 (25.4)

Resection 2859 433 (57.4) 653 (58.8) 623 (57.7) 487 (59.6) 440 (53.4) 223 (57.3)

Polypectomy 47 18 (2.4) 7 (0.6) 14 (1.3) 4 (0.5) 3 (0.4) 1 (0.3)

Not

specified 657 35 (4.6) 102 (9.2) 174 (16.1) 122 (14.9) 158 (19.2) 66 (17.0)

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

Table 4.2: Tumour histology and differentian in Colorectal Cancer Patients in Malaysia;

NCPR-Colorectal Cancer, 2008-2013

Characteristics

Year

Overall 2008 2009 2010 2011 2012 2013

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

Histologic type

Adenocarcinoma 4039 674 (89.4) 951 (85.6) 833 (77.2) 667 (81.6) 618 (75.0) 296 (76.1)

Others 192 33 (4.4) 44 (4.0) 47 (4.4) 26 (3.2) 27 (3.3) 15 (3.9)

No information* 743 47 (6.2) 116 (10.4) 199 (18.4) 124 (15.2) 179 (21.7) 78 (20.1)

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

Tumour differentiation

Well 393 65 (8.6) 128 (11.5) 68 (6.3) 59 (7.2) 43 (5.2) 30 (7.7)

Moderate 2776 455 (60.3) 632 (56.9) 591 (54.8) 456 (55.8) 432 (52.4) 210 (54.0)

Poor 177 30 (4.0) 39 (3.5) 43 (4.0) 24 (2.9) 26 (3.2) 15 (3.9)

No information* 1628 204 (27.1) 312 (28.1) 377 (34.9) 278 (34.0) 323 (39.2) 134 (34.4)

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

No information* - Tumour differentiation is generally not given/assessed on biopsy specimens.


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

Malaysia is adenocarcinoma of usual-type (95.5%). For the latter, out of 3346 with

information on tumour differentiation, the majority of them (83.0%) were moderately-

differentiated.


Table 4.3: Tumour differentiation in relation to pathologic (pTNM) stage in patients who had

tumour resection; NCPR-Colorectal Cancer, 2008-2013

Characteristics

Tumour differentiation

Overall Well Moderate Poor

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

T

T1 93 31 (33.3) 60 (64.5) 2 (2.2)

T2 370 61 (16.5) 304 (82.2) 5 (1.4)

T3 1690 168 (9.9) 1455 (86.1) 67 (4.0)

T4 431 41 (9.5) 347 (80.5) 43 (10.0)

No Information* 762 92 (12.1) 610 (80.1) 60 (7.9)

N

N0 1210 165 (13.6) 1,014 (83.8) 31 (2.6)

N1 764 92 (12.0) 644 (84.3) 28 (3.7)

N2 573 39 (6.8) 481 (83.9) 53 (9.2)

NX 799 97 (12.1) 637 (79.7) 65 (8.1)

M

M0 558 93 (16.7) 441 (79.0) 24 (4.3)

M1 197 14 (7.1) 167 (84.8) 16 (8.1)

MX 2591 286 (11.0) 2168 (83.7) 137 (5.3)

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

755 cases. Histologically confirmed distant metastasis was observed in 13.1%

(14/107), 27.5% (167/608) and 40.0% (16/40) of well-, moderately- and poorly-

differentiated tumours, respectively.


Table 4.4: Number of lymph nodes, tumour size, intratumoral angiolymphatic invasion and

extramural venous invasion of resected colorectal cancer specimens; NCPR-Colorectal

Cancer, 2008-2013

Characteristics

Year

Overall 2008 2009 2010 2011 2012 2013

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

Number of lymph nodes

n 2673 421 605 588 458 400 201

Mode 12 7 10 12 7 15 12

Median 12 11 11 13 12 13 14

Interquartile Range

9 10 9 9 10 9 11

Tumour Size

n 2395 345 576 555 412 330 177

Median 50 50 50 45 45.5 50 50

Interquartile Range

30 35 30 25 25 35 45

Intratumoral angiolymphatic invasion

Yes 633 98 (13.0) 139 (12.5) 125 (11.6)

12

9 (15.8)

10

4 (12.6) 38 (9.8)

No 1541

249

(33.0) 354 (31.9) 343 (31.8) 25

1 (30.7)

203

(24.6) 14

1 (36.2)

No Information* 2800

40

7 (54.0) 618 (55.6) 611 (56.6)

43

7 (53.5)

51

7 (62.7)

21

0 (54.0)

Overall 4974

75

4

(100.0

)

111

1

(100.0

)

107

9

(100.0

)

81

7

(100.0

)

82

4

(100.0

)

38

9

(100.0

)

Extramural venous invasion

Yes 488 75 (9.9) 102 (9.2) 102 (9.5) 95 (11.6) 79 (9.6) 35 (9.0)

No 1639

26

7 (35.4) 379 (34.1) 362 (33.5)

27

3 (33.4)

21

9 (26.6)

13

9 (35.7)


41

2 (54.6) 630 (56.7) 615 (57.0)

44

9 (55.0)

52

6 (63.8)

21

5 (55.3)

Overall 4974

75

4

(100.0

)

111

1

(100.0

)

107

9

(100.0

)

81

7

(100.0

)

82

4

(100.0

)

38

9

(100.0

)


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

488 out of 2127 cases with such available information (22.9%).


Table 4.5: Proximal, distal and circumferential resection margins of resected colorectal

cancer specimens; NCPR-Colorectal Cancer 2008-2013

Characteristics

Year

Overall 2008 2009 2010 2011 2012 2013

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

Proximal margin (Resection only)

Involved 60 9 (2.1) 15 (2.3) 10 (1.6) 10 (2.1) 9 (2.0) 7 (3.1)

Not involved 2300 364 (84.1) 541 (82.8) 514 (82.5) 391 (80.3) 324 (73.6) 166 (74.4)

Not reported 139 19 (4.4) 33 (5.1) 24 (3.9) 28 (5.7) 25 (5.7) 10 (4.5)

No Information 360 41 (9.5) 64 (9.8) 75 (12.0) 58 (11.9) 82 (18.6) 40 (17.9)

Overall 2859 433 (100.0) 653 (100.0) 623 (100.0) 487 (100.0) 440 (100.0) 223 (100.0)

Distal margin (Resection only)

Involved 84 12 (2.8) 31 (4.7) 16 (2.6) 13 (2.7) 7 (1.6) 5 (2.2)

Not involved 2236 361 (83.4) 510 (78.1) 496 (79.6) 383 (78.6) 318 (72.3) 168 (75.3)

Not reported 138 17 (3.9) 33 (5.1) 24 (3.9) 28 (5.7) 27 (6.1) 9 (4.0)

No Information 401 43 (9.9) 79 (12.1) 87 (14.0) 63 (12.9) 88 (20.0) 41 (18.4)

Overall 2859 433 (100.0) 653 (100.0) 623 (100.0) 487 (100.0) 440 (100.0) 223 (100.0)

Circumferential margin (rectum/anorectum)

Involved 87 19 (7.5) 17 (4.9) 17 (5.7) 15 (6.4) 12 (5.8) 7 (5.8)

Not involved 400 63 (24.8) 110 (31.6) 79 (26.3) 65 (27.7) 49 (23.7) 34 (28.3)

Not reported 103 20 (7.9) 32 (9.2) 20 (6.7) 11 (4.7) 16 (7.7) 4 (3.3)

No Information 874 152 (59.8) 189 (54.3) 184 (61.3) 144 (61.3) 130 (62.8) 75 (62.5)

Overall 1464 254 (100.0) 348 (100.0) 300 (100.0) 235 (100.0) 207 (100.0) 120 (100.0)

Involvement of resection margin implies either presence of residual tumour in the

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.

Out of 487 rectal and anorectal cancers which had information on circumferential

margin, 87 (17.9%) cases were involved by tumour.


Table 4.6: Pathologic (pTNM) stage of resected specimens of patients enrolled in the NCPR-


Characteristics

Year

Overall 2008 2009 2010 2011 2012 2013

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

T

T1 65 13 (3.8) 15 (2.9) 12 (2.4) 11 (3.3) 5 (1.8) 9 (6.9)

T2 263 36 (10.5) 64 (12.5) 65 (13.2) 41 (12.5) 36 (12.9) 21 (16.2)

T3 1328 224 (65.5) 314 (61.1) 313 (63.7) 210 (63.8) 181 (64.9) 86 (66.2)

T4 348 50 (14.6) 99 (19.3) 78 (15.9) 57 (17.3) 51 (18.3) 13 (10.0)

No Information 81 19 (5.6) 22 (4.3) 23 (4.7) 10 (3.0) 6 (2.2) 1 (0.8)

Overall 2085 342 (100.0) 514 (100.0) 491 (100.0) 329 (100.0) 279 (100.0) 130 (100.0)

N

N0 931 145 (42.4) 243 (47.3) 192 (39.1) 152 (46.2) 130 (46.6) 69 (53.1)

N1 594 103 (30.1) 135 (26.3) 157 (32.0) 86 (26.1) 83 (29.7) 30 (23.1)

N2 464 71 (20.8) 113 (22.0) 118 (24.0) 80 (24.3) 55 (19.7) 27 (20.8)

NX 26 6 (1.8) 2 (0.4) 8 (1.6) 3 (0.9) 6 (2.2) 1 (0.8)

No Information 70 17 (5.0) 21 (4.1) 16 (3.3) 8 (2.4) 5 (1.8) 3 (2.3)

Overall 2085 342 (100.0) 514 (100.0) 491 (100.0) 329 (100.0) 279 (100.0) 130 (100.0)

M

M0 435 64 (18.7) 128 (24.9) 79 (16.1) 76 (23.1) 56 (20.1) 32 (24.6)

M1 146 20 (5.8) 37 (7.2) 25 (5.1) 28 (8.5) 25 (9.0) 11 (8.5)

MX 1377 218 (63.7) 320 (62.3) 359 (73.1) 213 (64.7) 188 (67.4) 79 (60.8)

No Information 127 40 (11.7) 29 (5.6) 28 (5.7) 12 (3.6) 10 (3.6) 8 (6.2)

Overall 2085 342 (100.0) 514 (100.0) 491 (100.0) 329 (100.0) 279 (100.0) 130 (100.0)

Out of 2004 cases with information on pathologic tumour stage, 1676 (83.6%)

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.

In most instances, pM staging can only be done when suspected metastatic sites

are being sampled for histologic assessment. Therefore final M stage should be

based on findings from other investigations, as well as, intraoperatively.


Table 4.7: Pathologic (ypTNM) stage of resected specimens of patients enrolled in the

NCPR-Colorectal Cancer, 2008-2013

Characteristics

Year

Overal

l 2008 2009 2010 2011 2012 2013

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

T

T1 6 1 (4.2) 1 (3.0) 3 (10.3) 0 (0.0) 0 (0.0) 1 (10.0)

T2 24 6 (25.0) 6 (18.2) 3 (10.3) 2 (15.4) 3 (23.1) 4 (40.0)

T3 60

1

1 (45.8)

1

6 (48.5)

1

6 (55.2) 6 (46.2) 6 (46.2) 5 (50.0)

T4 23 4 (16.7) 8 (24.2) 3 (10.3) 4 (30.8) 4 (30.8) 0 (0.0)

No Information* 9 2 (8.3) 2 (6.1) 4 (13.8) 1 (7.7) 0 (0.0) 0 (0.0)

Overall 122

2

4

(100.0

)

3

3

(100.0

)

2

9

(100.0

)

1

3

(100.0

)

1

3

(100.0

)

1

0

(100.0

)

N

N0 63

1

1 (45.8)

2

1 (63.6)

1

5 (51.7) 4 (30.8) 5 (38.5) 7 (70.0)

N1 29 9 (37.5) 7 (21.2) 6 (20.7) 3 (23.1) 1 (7.7) 3 (30.0)

N2 17 2 (8.3) 2 (6.1) 4 (13.8) 4 (30.8) 5 (38.5) 0 (0.0)

NX 6 0 (0.0) 3 (9.1) 2 (6.9) 0 (0.0) 1 (7.7) 0 (0.0)

No Information* 7 2 (8.3) 0 (0.0) 2 (6.9) 2 (15.4) 1 (7.7) 0 (0.0)

Overall 122

2

4

(100.0

)

3

3

(100.0

)

2

9

(100.0

)

1

3

(100.0

)

1

3

(100.0

)

1

0

(100.0

)

M

M0 14 0 (0.0) 6 (18.2) 6 (20.7) 1 (7.7) 1 (7.7) 0 (0.0)

M1 11 2 (8.3) 3 (9.1) 1 (3.4) 1 (7.7) 3 (23.1) 1 (10.0)

MX 90

2

0 (83.3)

2

4 (72.7)

2

0 (69.0)

1

0 (76.9) 7 (53.8) 9 (90.0)

No Information* 7 2 (8.3) 0 (0.0) 2 (6.9) 1 (7.7) 2 (15.4) 0 (0.0)

Overall 122

2

4

(100.0

)

3

3

(100.0

)

2

9

(100.0

)

1

3

(100.0

)

1

3

(100.0

)

1

0

(100.0

)

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

neoadjuvant therapy.


Table 4.8: Polyps in resected specimens of patients with colorectal cancer cancer; NCPR-


Characteristics

Year

Overal

l 2008 2009 2010 2011 2012 2013

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

Present

Yes 416 74 (17.1)

106

(16.2) 90 (14.4) 66 (13.6) 54 (12.3) 26 (11.7)

No 1853

27

8 (64.2)

45

5 (69.7)

41

3 (66.3)

31

6 (64.9)

25

8 (58.6)

13

3 (59.6)

Not reported 289 50 (11.5) 59 (9.0) 66 (10.6) 48 (9.9) 40 (9.1) 26 (11.7)

No Information* 301 31 (7.2) 33 (5.1) 54 (8.7) 57 (11.7) 88 (20.0) 38 (17.0)

Overall 2859

43

3

(100.0

)

65

3

(100.0

)

62

3

(100.0

)

48

7

(100.0

)

44

0

(100.0

)

22

3

(100.0

)

Number

<100 261 37 (8.5) 82 (12.6) 63 (10.1) 39 (8.0) 30 (6.8) 10 (4.5)

>100 43 6 (1.4) 9 (1.4) 10 (1.6) 12 (2.5) 4 (0.9) 2 (0.9)


390

(90.1) 56

2 (86.1)

550

(88.3) 43

6 (89.5)

406

(92.3) 21

1 (94.6)

Overall 2859

43

3

(100.0

)

65

3

(100.0

)

62

3

(100.0

)

48

7

(100.0

)

44

0

(100.0

)

22

3

(100.0

)

Polyp Histology

Tubular adenoma 147 28 (6.5) 46 (7.0) 29 (4.7) 22 (4.5) 16 (3.6) 6 (2.7)

Villous adenoma 22 5 (1.2) 3 (0.5) 5 (0.8) 2 (0.4) 6 (1.4) 1 (0.4)

Tubulovillous

adenoma 61 2 (0.5) 19 (2.9) 21 (3.4) 6 (1.2) 11 (2.5) 2 (0.9)

Serrated adenoma 10 2 (0.5) 3 (0.5) 2 (0.3) 2 (0.4) 0 (0.0) 1 (0.4)

Hyperplastic polyp 40 10 (2.3) 11 (1.7) 8 (1.3) 5 (1.0) 5 (1.1) 1 (0.4)

Sessile serrated polyp 29 5 (1.2) 6 (0.9) 6 (1.0) 9 (1.8) 3 (0.7) 0 (0.0)

Mixed polyp 4 1 (0.2) 0 (0.0) 1 (0.2) 0 (0.0) 0 (0.0) 2 (0.9)

Other 50 6 (1.4) 7 (1.1) 16 (2.6) 10 (2.1) 6 (1.4) 5 (2.2)

Overall 363 59 (16.3) 95 (26.2) 88 (24.2) 56 (15.4) 47 (12.9) 18 (5.0)

* 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

common types of polyps observed.


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

colorectal cancer patients and was seen in 3.8% of the cases.


CHAPTER 5

TREATMENT MODALITIES


TREATMENT MODALITIES

Table 5.1: Treatment modalities of 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 (%)

Therapy received

Yes 3901 607 (92.1) 890 (89.6) 858 (87.7) 638 (85.5) 618 (81.7) 290 (78.6)

No 208 24 (3.6) 45 (4.5) 49 (5.0) 28 (3.8) 43 (5.7) 19 (5.1)

Missing 392 28 (4.2) 58 (5.8) 71 (7.3) 80 (10.7) 95 (12.6) 60 (16.3)

Overall 4501 659 (100.0) 993 (100.0) 978 (100.0) 746 (100.0) 756 (100.0) 369 (100.0)

Surgery

Yes 3188 525 (79.7) 745 (75.0) 712 (72.8) 519 (69.6) 467 (61.8) 220 (59.6)

No 921 106 (16.1) 190 (19.1) 195 (19.9) 147 (19.7) 194 (25.7) 89 (24.1)

Missing 392 28 (4.2) 58 (5.8) 71 (7.3) 80 (10.7) 95 (12.6) 60 (16.3)

Overall 4501 659 (100.0) 993 (100.0) 978 (100.0) 746 (100.0) 756 (100.0) 369 (100.0)

Radiotherapy

Yes 709 115 (17.5) 152 (15.3) 139 (14.2) 134 (18.0) 130 (17.2) 39 (10.6)

No 3400 516 (78.3) 783 (78.9) 768 (78.5) 532 (71.3) 531 (70.2) 270 (73.2)

Missing 392 28 (4.2) 58 (5.8) 71 (7.3) 80 (10.7) 95 (12.6) 60 (16.3)

Overall 4501 659 (100.0) 993 (100.0) 978 (100.0) 746 (100.0) 756 (100.0) 369 (100.0)

Endoscopy

Yes 67 15 (2.3) 20 (2.0) 13 (1.3) 3 (0.4) 9 (1.2) 7 (1.9)

No 4042 616 (93.5) 915 (92.1) 894 (91.4) 663 (88.9) 652 (86.2) 302 (81.8)

Missing 392 28 (4.2) 58 (5.8) 71 (7.3) 80 (10.7) 95 (12.6) 60 (16.3)

Overall 4501 659 (100.0) 993 (100.0) 978 (100.0) 746 (100.0) 756 (100.0) 369 (100.0)

Chemotherapy and Biological Therapy

Yes 1614 291 (44.2) 353 (35.5) 303 (31.0) 256 (34.3) 298 (39.4) 113 (30.6)

No 2495 340 (51.6) 582 (58.6) 604 (61.8) 410 (55.0) 363 (48.0) 196 (53.1)

Missing 392 28 (4.2) 58 (5.8) 71 (7.3) 80 (10.7) 95 (12.6) 60 (16.3)

Overall 4501 659 (100.0) 993 (100.0) 978 (100.0) 746 (100.0) 756 (100.0) 369 (100.0)

Complementary/Alternative Treatment

Yes 37 7 (1.1) 9 (0.9) 9 (0.9) 6 (0.8) 5 (0.7) 1 (0.3)

No 4072 624 (94.7) 926 (93.3) 898 (91.8) 660 (88.5) 656 (86.8) 308 (83.5)

Missing 392 28 (4.2) 58 (5.8) 71 (7.3) 80 (10.7) 95 (12.6) 60 (16.3)

Overall 4501 659 (100.0) 993 (100.0) 978 (100.0) 746 (100.0) 756 (100.0) 369 (100.0)


Characteristics

Year

Overall 2008 2009 2010 2011 2012 2013

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

Supportive care/Palliative care

Yes 225 28 (4.2) 58 (5.8) 39 (4.0) 38 (5.1) 44 (5.8) 18 (4.9)

No 3884 603 (91.5) 877 (88.3) 868 (88.8) 628 (84.2) 617 (81.6) 291 (78.9)

Missing 392 28 (4.2) 58 (5.8) 71 (7.3) 80 (10.7) 95 (12.6) 60 (16.3)

Overall 4501 659 (100.0) 993 (100.0) 978 (100.0) 746 (100.0) 756 (100.0) 369 (100.0)

Table 5.2: Treatment modalities of patients with rectum as a primary cancer site enrolled in


Characteristics

Year

Overall 2008 2009 2010 2011 2012 2013

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

Radiotherapy

Yes 397 55 (25.2) 86 (25.6) 77 (25.1) 75 (31.3) 76 (34.1) 28 (21.2)

No 910 154 (70.6) 227 (67.6) 203 (66.1) 137 (57.1) 112 (50.2) 77 (58.3)

Missing 149 9 (4.1) 23 (6.8) 27 (8.8) 28 (11.7) 35 (15.7) 27 (20.5)

Overall 1456 218 (100.0) 336 (100.0) 307 (100.0) 240 (100.0) 223 (100.0) 132 (100.0)

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.

For rectal cancer, 26.3% of our patients received radiotherapy.


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


Characteristics

TNM staging


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

Therapy received

Yes 3517 337 (95.2) 871 (97.9) 1149 (98.4) 812 (96.4) 348 (89.5)

No 126 17 (4.8) 19 (2.1) 19 (1.6) 30 (3.6) 41 (10.5)

Overall 3643 354 (100.0) 890 (100.0) 1168 (100.0) 842 (100.0) 389 (100.0)

Surgery

Yes 2962 307 (86.7) 808 (90.8) 1033 (88.4) 624 (74.1) 190 (48.8)

No 681 47 (13.3) 82 (9.2) 135 (11.6) 218 (25.9) 199 (51.2)

Overall 3643 354 (100.0) 890 (100.0) 1168 (100.0) 842 (100.0) 389 (100.0)

Radiotherapy

Yes 631 51 (14.4) 133 (14.9) 226 (19.3) 153 (18.2) 68 (17.5)

No 3012 303 (85.6) 757 (85.1) 942 (80.7) 689 (81.8) 321 (82.5)

Overall 3643 354 (100.0) 890 (100.0) 1168 (100.0) 842 (100.0) 389 (100.0)

Endoscopy

Yes 56 4 (1.1) 13 (1.5) 9 (0.8) 16 (1.9) 14 (3.6)

No 3587 350 (98.9) 877 (98.5) 1159 (99.2) 826 (98.1) 375 (96.4)

Overall 3643 354 (100.0) 890 (100.0) 1168 (100.0) 842 (100.0) 389 (100.0)

Chemotherapy and Biological Therapy

Yes 1465 57 (16.1) 314 (35.3) 561 (48.0) 387 (46.0) 146 (37.5)

No 2178 297 (83.9) 576 (64.7) 607 (52.0) 455 (54.0) 243 (62.5)

Overall 3643 354 (100.0) 890 (100.0) 1168 (100.0) 842 (100.0) 389 (100.0)

Complementary/Alternative Treatment

Yes 31 0 (0.0) 4 (0.4) 8 (0.7) 8 (1.0) 11 (2.8)

No 3612 354 (100.0) 886 (99.6) 1160 (99.3) 834 (99.0) 378 (97.2)

Overall 3643 354 (100.0) 890 (100.0) 1168 (100.0) 842 (100.0) 389 (100.0)

Supportive care/Palliative care

Yes 182 8 (2.3) 19 (2.1) 27 (2.3) 87 (10.3) 41 (10.5)

No 3461 346 (97.7) 871 (97.9) 1141 (97.7) 755 (89.7) 348 (89.5)

Overall 3643 354 (100.0) 890 (100.0) 1168 (100.0) 842 (100.0) 389 (100.0)


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 proportion of 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

palliative care.


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


Characteristics

Year

Overall 2008 2009 2010 2011 2012 2013

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

Surgery method

Open 2261 373 (65.7) 554 (67.9) 515 (63.3) 342 (57.4) 333 (57.0) 144 (50.7)

Laparoscopic 589 84 (14.8) 118 (14.5) 157 (19.3) 118 (19.8) 71 (12.2) 41 (14.4)

Laparoscopic converted 148 14 (2.5) 26 (3.2) 42 (5.2) 19 (3.2) 21 (3.6) 26 (9.2)

Hand assisted 14 0 (0.0) 7 (0.9) 4 (0.5) 0 (0.0) 3 (0.5) 0 (0.0)

Missing 650 97 (17.1) 111 (13.6) 96 (11.8) 117 (19.6) 156 (26.7) 73 (25.7)

Overall 3662 568 (100.0) 816 (100.0) 814 (100.0) 596 (100.0) 584 (100.0) 284 (100.0)

Operation performed

Right Hemicolectomy 455 75 (13.2) 85 (10.4) 124 (15.2) 71 (11.9) 69 (11.8) 31 (10.9)

Extended Right Hemicolectomy 191 31 (5.5) 47 (5.8) 52 (6.4) 21 (3.5) 24 (4.1) 16 (5.6)

Left Hemicolectomy 204 36 (6.3) 41 (5.0) 48 (5.9) 29 (4.9) 30 (5.1) 20 (7.0)

Sigmoid colectomy 265 37 (6.5) 55 (6.7) 68 (8.4) 44 (7.4) 45 (7.7) 16 (5.6)

Proctocolectomy 19 1 (0.2) 3 (0.4) 8 (1.0) 2 (0.3) 3 (0.5) 2 (0.7)

Sub total colectomy 73 8 (1.4) 21 (2.6) 13 (1.6) 11 (1.8) 16 (2.7) 4 (1.4)

Transverse colectomy 32 5 (0.9) 6 (0.7) 6 (0.7) 5 (0.8) 2 (0.3) 8 (2.8)

Loop colostomy 112 22 (3.9) 28 (3.4) 26 (3.2) 24 (4.0) 11 (1.9) 1 (0.4)

APR 276 43 (7.6) 73 (8.9) 54 (6.6) 44 (7.4) 42 (7.2) 20 (7.0)

Hartmann's Procedure 266 35 (6.2) 68 (8.3) 54 (6.6) 49 (8.2) 47 (8.0) 13 (4.6)

Local excision 5 1 (0.2) 2 (0.2) 1 (0.1) 1 (0.2) 0 (0.0) 0 (0.0)

Laparotomy only 74 16 (2.8) 16 (2.0) 15 (1.8) 12 (2.0) 10 (1.7) 5 (1.8)

High AR 356 58 (10.2) 90 (11.0) 86 (10.6) 59 (9.9) 34 (5.8) 29 (10.2)

Low AR 340 57 (10.0) 83 (10.2) 73 (9.0) 51 (8.6) 49 (8.4) 27 (9.5)

Ultra Low AR 107 22 (3.9) 24 (2.9) 22 (2.7) 14 (2.3) 14 (2.4) 11 (3.9)

Other 603 107 (18.8) 128 (15.7) 111 (13.6) 97 (16.3) 106 (18.2) 54 (19.0)

Missing 284 14 (2.5) 46 (5.6) 53 (6.5) 62 (10.4) 82 (14.0) 27 (9.5)

Overall 3662 568 (100.0) 816 (100.0) 814 (100.0) 596 (100.0) 584 (100.0) 284 (100.0)

Protocol/Regimen

MAYO's 482 99 (31.6) 104 (27.7) 87 (24.4) 79 (24.2) 74 (20.8) 39 (27.5)

De Grammont 281 61 (19.5) 73 (19.4) 53 (14.8) 39 (12.0) 45 (12.7) 10 (7.0)

FOLFIRI 42 15 (4.8) 4 (1.1) 5 (1.4) 8 (2.5) 7 (2.0) 3 (2.1)

FOLFOX 352 55 (17.6) 57 (15.2) 64 (17.9) 60 (18.4) 85 (23.9) 31 (21.8)

Capecitabine (Xeloda) 305 43 (13.7) 54 (14.4) 72 (20.2) 63 (19.3) 58 (16.3) 15 (10.6)

Missing 407 40 (12.8) 84 (22.3) 76 (21.3) 77 (23.6) 86 (24.2) 44 (31.0)

Overall 1869 313 (100.0) 376 (100.0) 357 (100.0) 326 (100.0) 355 (100.0) 142 (100.0)


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

Colorectal Cancer, 2008-2013.

Characteristics

TNM Staging


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

Surgery method

Open 2,091 174 (50.4) 602 (66.2) 703 (60.9) 492 (67.1) 120 (50.0)

Laparoscopic 569 101 (29.3) 139 (15.3) 227 (19.7) 74 (10.1) 28 (11.7)

Laparoscopic converted 139 14 (4.1) 41 (4.5) 55 (4.8) 20 (2.7) 9 (3.8)

Hand assisted 13 1 (0.3) 7 (0.8) 3 (0.3) 2 (0.3) 0 (0.0)

Missing 570 55 (15.9) 121 (13.3) 166 (14.4) 145 (19.8) 83 (34.6)

Overall 3,382 345 (100.0) 910 (100.0) 1154 (100.0) 733 (100.0) 240 (100.0)

Operation performed

Right Hemicolectomy 431 32 (9.3) 146 (16.0) 139 (12.0) 86 (11.7) 28 (11.7)

Extended Right Hemicolectomy 181 10 (2.9) 57 (6.3) 62 (5.4) 41 (5.6) 11 (4.6)

Left Hemicolectomy 191 20 (5.8) 65 (7.1) 65 (5.6) 35 (4.8) 6 (2.5)

Sigmoid colectomy 251 33 (9.6) 72 (7.9) 80 (6.9) 49 (6.7) 17 (7.1)

Proctocolectomy 18 6 (1.7) 1 (0.1) 7 (0.6) 2 (0.3) 2 (0.8)

Sub total colectomy 69 4 (1.2) 22 (2.4) 24 (2.1) 17 (2.3) 2 (0.8)

Transverse colectomy 29 2 (0.6) 8 (0.9) 8 (0.7) 8 (1.1) 3 (1.3)

Loop colostomy 100 4 (1.2) 15 (1.6) 30 (2.6) 35 (4.8) 16 (6.7)

APR 264 43 (12.5) 63 (6.9) 96 (8.3) 51 (7.0) 11 (4.6)

Hartmann's Procedure 248 9 (2.6) 72 (7.9) 96 (8.3) 64 (8.7) 7 (2.9)

Local excision 4 3 (0.9) 0 (0.0) 0 (0.0) 1 (0.1) 0 (0.0)

Laparotomy only 60 5 (1.4) 8 (0.9) 14 (1.2) 19 (2.6) 14 (5.8)

High AR 339 46 (13.3) 99 (10.9) 131 (11.4) 47 (6.4) 16 (6.7)

Low AR 321 47 (13.6) 74 (8.1) 137 (11.9) 50 (6.8) 13 (5.4)

Ultra Low AR 99 12 (3.5) 21 (2.3) 40 (3.5) 21 (2.9) 5 (2.1)

Other 520 41 (11.9) 132 (14.5) 157 (13.6) 132 (18.0) 58 (24.2)

Missing 257 28 (8.1) 55 (6.0) 68 (5.9) 75 (10.2) 31 (12.9)

Overall 3,382 345 (100.0) 910 (100.0) 1154 (100.0) 733 (100.0) 240 (100.0)

Protocol/Regimen

MAYO's 438 24 (27.0) 120 (30.6) 185 (29.4) 78 (17.6) 31 (20.1)

De Grammont 262 4 (4.5) 64 (16.3) 103 (16.4) 70 (15.8) 21 (13.6)

FOLFIRI 38 0 (0.0) 7 (1.8) 14 (2.2) 12 (2.7) 5 (3.2)

FOLFOX 315 9 (10.1) 46 (11.7) 113 (18.0) 116 (26.2) 31 (20.1)

Capecitabine (Xeloda) 277 19 (21.3) 70 (17.9) 98 (15.6) 64 (14.4) 26 (16.9)

Missing 377 33 (37.1) 85 (21.7) 116 (18.4) 103 (23.3) 40 (26.0)

Overall 1,707 89 (100.0) 392 (100.0) 629 (100.0) 443 (100.0) 154 (100.0)


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.

The information on chemotherapy was limited partly due to the fact that oncology

services were not available in all participating centers. This had resulted in difficulty

in getting data on chemotherapy regime. Even though the most commonly utilized

chemotherapy regimen was MAYO’s (25.8%), but the number was relatively small to

conclude on the trend of usage.


CHAPTER 6

INCIDENCE & MORTALITY RATE


INCIDENCE & MORTALITY RATE

Table 6.1: Status of 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 (%)

Patient Status

Alive 2490 276 (41.9) 466 (46.9) 498 (50.9) 430 (57.6) 506 (66.9) 314 (85.1)

Death 2011 383 (58.1) 527 (53.1) 480 (49.1) 316 (42.4) 250 (33.1) 55 (14.9)

Overall 4501 659 (100.0) 993 (100.0) 978 (100.0) 746 (100.0) 756 (100.0) 369 (100.0)

Gender

Male

Alive 1358 153 (38.9) 250 (45.8) 284 (49.9) 225 (58.1) 279 (66.1) 167 (83.1)

Death 1160 240 (61.1) 296 (54.2) 285 (50.1) 162 (41.9) 143 (33.9) 34 (16.9)

Overall 2518 393 (100.0) 546 (100.0) 569 (100.0) 387 (100.0) 422 (100.0) 201 (100.0)

Female

Alive 1095 122 (46.2) 215 (48.4) 212 (52.3) 203 (57.2) 209 (67.4) 134 (86.5)

Death 838 142 (53.8) 229 (51.6) 193 (47.7) 152 (42.8) 101 (32.6) 21 (13.5)

Overall 1933 264 (100.0) 444 (100.0) 405 (100.0) 355 (100.0) 310 (100.0) 155 (100.0)

Ethnicity

Malay

Alive 976 89 (33.5) 172 (43.7) 202 (46.8) 169 (52.5) 206 (61.7) 138 (79.3)

Death 946 177 (66.5) 222 (56.3) 230 (53.2) 153 (47.5) 128 (38.3) 36 (20.7)

Overall 1922 266 (100.0) 394 (100.0) 432 (100.0) 322 (100.0) 334 (100.0) 174 (100.0)

Chinese

Alive 1047 120 (45.3) 205 (48.1) 203 (52.6) 178 (60.1) 219 (71.3) 122 (91.0)

Death 767 145 (54.7) 221 (51.9) 183 (47.4) 118 (39.9) 88 (28.7) 12 (9.0)

Overall 1814 265 (100.0) 426 (100.0) 386 (100.0) 296 (100.0) 307 (100.0) 134 (100.0)

Indian

Alive 157 17 (47.2) 29 (46.0) 37 (63.8) 31 (68.9) 25 (71.4) 18 (81.8)

Death 102 19 (52.8) 34 (54.0) 21 (36.2) 14 (31.1) 10 (28.6) 4 (18.2)

Overall 259 36 (100.0) 63 (100.0) 58 (100.0) 45 (100.0) 35 (100.0) 22 (100.0)


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),

followed closely by Malay (9.6) and Indian (7.1).


Figure 1.2: Trends in the incidence and mortality by gender of patients in the NCPR-


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


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


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, 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, 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



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).

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

cases), followed closely by Malay (9.6 cases) and Indian (7.1 cases).


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

by TNM staging.


APPENDIX


APPENDIX 1: METHOD

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

Any patient who received his or her treatment at participating study sites not within the study

period. Anal cancers and metastatic lesions to the colorectum are excluded.


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.

All data captured whether electronically via eCRF or manually via paper CRF is stored in a

third party database. Remote data capture via eCRF and central database management

functions is underpinned by an ICT infrastructure, at the heart of which is the highly secured

data centre (Datamed Clinical Computing Services Sdn Bhd) which hosts the registry

database.

december 2014 - crc...acknowledgement we would like to thank all contributing parties for their...

Documents