Background Radical resection is the primary treatment for rectal cancer. When anastomosis is possible, a temporary ileostomy is used to decrease morbidity from a poorly healed anastomosis. However, ileostomies are associated with complications, dehydration, and need for a second operation. Our purpose was to evaluate the impact of ileostomy related complications on the treatment of rectal cancer. Methods A retrospective cohort study of patients who underwent sphincter preserving surgery between January 2005 and December 2010 at a tertiary cancer center. The primary outcome was the overall rate of ileostomy related complications. Secondary outcomes included complications related to ileostomy status, ileostomy closure, anastomotic complications at primary resection, rate of stoma closure, and completion of adjuvant chemotherapy. Statistical analyses were performed with STATA 12. Results A total of 294 patients were analyzed, 32% (n=95) were women. Two hundred seventy-one (92%) received neoadjuvant chemoradiation. The median tumor distance from the anal verge was 7 centimeters (interquartile range 5-10). Two hundred eighty-one (96%) underwent stoma closure at a median 7 months (interquartile range 5.4 – 8.3). The most common complication related to readmission was dehydration (n=32, 11%). Readmission within 60 days of primary resection was associated with delay in initiating adjuvant chemotherapy (OR 3.01, 95% CI 1.42-6.38, p=0.004). Conclusion Diverting ileostomies created during surgical treatment of rectal cancers are associated with morbidity; however this is balanced against the risk of anastomosis-related morbidity at rectal resection. Given the potential benefit of fecal diversion, patient-oriented interventions to improve ostomy management, particularly during adjuvant chemotherapy, can be expected to yield marked benefits.

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BACKGROUND Although safety of combination chemotherapy without primary tumor resection (PTR) in patients with stage 4 colon cancer has been established, questions remain regarding potential survival benefit with PTR. The purpose of this study is to compare mortality rates in colon cancer patients with unresectable metastases who have and have not received PTR. METHODS An observational cohort study was conducted of patients with unresectable metastatic colon cancer identified from the National Cancer Data Base(2003-2005). Multivariate Cox regression analysis, with and without Propensity Score Weighting (PSW), was performed to compare survival outcomes. Instrumental Variable (IV) analysis, using the annual hospital-level PTR rate as the instrument, was utilized to account for treatment selection bias. To account for survivor treatment bias, where patients might die soon after diagnosis from different reasons, a landmark method was utilized. RESULTS PTR was performed in 57% of the total cohort (8641/15154) and 73.8 % of those at landmark (4,972/6,735). PTR was associated with a significant reduction in mortality using Cox regression (HR, 0.45; 95%CI, 0.44-0.47) or PSW (HR, 0.46; 95%CI, 0. 44-0.49). However, IV analysis showed a much smaller effect,(RMR, 0.91; 95%CI, 0.87-0.96). While a smaller benefit was seen on landmark method using Cox regression (HR, 0.6; 95%CI, 0.55-0.64) or PSW (HR, 0.59; 95%CI, 0.54-0.64), IV analysis showed no survival benefit (RMR, 0.97; 95%CI, 0.87-1.06). CONCLUSION Among patients with unresectable metastatic colon cancer, following adjustment for confounder effects, PTR was not associated with improved survival when compared to systemic chemotherapy; therefore routine non-curative PTR is not recommended.

Casitas B lymphoma (c-Cbl) is an E3 ubiquitin ligase and a negative regulator of colorectal cancer (CRC). Despite its high expression in immune cells, the effect of c-Cbl on the tumor microenvironment remains poorly understood. Here we demonstrate that c-Cbl alters the tumor microenvironment and suppresses Programmed cell death-1 (PD-1) protein, an immune checkpoint receptor. Using syngeneic CRC xenografts, we observed significantly higher growth of xenografts and infiltrating immune cells in c-Cbl+/− compared to c-Cbl+/+ mice. Tumor-associated CD8+ T-lymphocytes and macrophages of c-Cbl+/− mice showed 2–3-fold higher levels of PD-1. Functionally, macrophages from c-Cbl+/− mice showed a 4–5-fold reduction in tumor phagocytosis, which was restored with an anti-PD-1 neutralizing antibody suggesting regulation of PD-1 by c-Cbl. Further mechanistic probing revealed that C-terminus of c-Cbl interacted with the cytoplasmic tail of PD-1. c-Cbl destabilized PD-1 through ubiquitination- proteasomal degradation depending on c-Cbl’s RING finger function. This data demonstrates c-Cbl as an E3 ligase of PD-1 and a regulator of tumor microenvironment, both of which were unrecognized components of its tumor suppressive activity. Advancing immune checkpoint and c-Cbl biology, our study prompts for probing of PD-1 regulation by c-Cbl in conditions driven by immune checkpoint abnormalities such as cancers and autoimmune diseases.

Despite adjusting for stage and treatment differences, African American and Hispanic race predicted poor survival. The effect of age and treatment on breast cancer survival differs across races. Additional research is needed to accurately determine the reasons for worsened survival.

BACKGROUND: Women surgeons are underrepresented in academic surgery and may be subject to implicit gender bias. In colorectal surgery, women comprise 42% of new graduates, but only 19% of Diplomates in the United States. OBJECTIVE: We evaluated the representation of women at the 2017 American Society of Colon and Rectal Surgeons Scientific and Tripartite Meeting and assessed for implicit gender bias. DESIGN: This was a prospective observational study. SETTING: The study occurred at the 2017 Tripartite Meeting. MAIN OUTCOME MEASURES: The percentage of women in the formal program relative to conference attendees and forms of address. METHODS: Female program representation was quantified by role (moderator or speaker), session type, and topic. Introductions of speakers by moderators were classified as formal (using a professional title) or informal (using name only), and further stratified by gender. RESULTS: Of physicians and medical students, 32% (n=484) of the 1,532 attendees were women. Women comprised 28% of moderators (n=26) and 28% of speakers (n=80). The highest percentage of women moderators and speakers was in education (48%) and the lowest in techniques and technology (17%). In the 4¼7 sessions evaluated, female moderators were more likely than male moderators to use formal introductions (68.7% vs. 54.0%, p=0.02). There was no difference when female moderators formally introduced female versus male speakers (73.9% vs. 66.7%, p=0.52); however, male moderators were significantly less likely to formally introduce a female versus male speaker (36.4% vs. 59.2%, p=0.003). LIMITATIONS: Yearly program gender composition may fluctuate. Low numbers in certain areas limits interpretability. Other factors potentially influenced speaker introductions. CONCLUSIONS: Overall, program representation of women was similar to meeting demographics, although with low numbers in some topics. An imbalance in the formality of speaker introductions between genders was observed. Awareness of implicit gender bias may improve gender equity and inclusiveness in our specialty.

Education is a key component of patient care; however, evidence to support an improvement in clinical outcomes is lacking. Further study is needed by the use of rigorous designs to craft a feasible educational intervention that will lead to improved patient care and outcomes.