Skip to main content

Advertisement

SpringerLink
Log in

The effect of comorbidities on outcomes in colorectal cancer survivors: a population-based cohort study

  • Published:
Journal of Cancer Survivorship Aims and scope Submit manuscript

Abstract

Purpose

To examine the prevalence of comorbidities and the association of these comorbidities with demographics, tumor characteristics, treatments received, overall survival, and causes of death in a population-based cohort of colorectal cancer (CRC) patients.

Methods

Adult patients with stage I–III CRC diagnosed between 2004 and 2015 were included. Comorbidities were captured using Charlson comorbidity index. Causes of death were categorized using International Classification of Diseases, tenth revision codes. Patients were categorized into five mutually exclusive comorbid groups (cardiovascular disease alone, diabetes alone, cardiovascular disease plus diabetes, other comorbidities, or no comorbidities). Data were analyzed using descriptive statistics, Kaplan-Meier survival analyses, and Cox proportional hazards models.

Results

There were 12,265 patients. Mean follow-up was 3.8 years. Approximately one third of patients had a least one comorbidity, with cardiovascular disease and diabetes being most common. There were statistically significant differences across comorbid groups on treatments received and overall survival. Those with comorbidity had lower odds of treatment and greater risk of death than those with no comorbidity. Those with cardiovascular disease plus diabetes fared the worst for prognosis (median overall survival 3.3 [2.8–3.7] years; adjusted HR for death, 2.27, 95% CI 2.0–2.6, p < .001). Cardiovascular disease was the most common cause of non-CRC death.

Conclusions

CRC patients with comorbidity received curative intent treatment less frequently and experienced worse outcomes than patients with no comorbidity. Cardiovascular disease was the most common cause of non-cancer death.

Implications for Cancer Survivors

Management of comorbidities, including healthy lifestyle coaching, at diagnosis and into survivorship is an important component of cancer care.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Canadian Cancer Society/Statistics Canada. Canadian Cancer Statistics 2016. 2016.www.cancer.ca. Accessed 21 Mar 2018.

  2. Sarfati D, Koczwara B, Jackson C. The impact of comorbidity on cancer and its treatment. CA Cancer J Clin. 2016;66(4):338–50. https://doi.org/10.3322/caac.21342.

    Article  Google Scholar 

  3. Sogaard M, Thomsen R, Bossen K, Sorensen HT, Horgaard M. The impact of comorbidity on cancer survival: a review. Clin Epidemiol. 2013;5:3–29.

    Article  Google Scholar 

  4. Canadian Institute for Health Information. Seniors and the health care system: what is the impact of multiple chronic conditions. 2011 www.cihi.ca. Accessed 4 Feb 2018.

  5. Ostenfeld EB, Norgaard M, Thomsen RW, Iversen LH, Jacobsen JB, Sogaard M. Comorbidity and survival of Danish patients with colon and rectal cancer from 2000–2011: a population-based cohort study. Clin Epidemiol. 2013;5(Suppl I):65–74. https://doi.org/10.2147/CLEP.S47154.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Statistics Canada. Table 102–0561. Leading causes of death, total population, by age group and sex, Canada. www5.statcan.gc.ca/cansim/a47. Accessed 29 Mar 2018.

  7. Sarfati D, Tan L, Blakely T, Pearce N. Comorbidity among patients with colon cancer in New Zealand. N Z Med J. 2011;142:76–88.

    Google Scholar 

  8. Zafar SY, Abernethy AP, Abbott DH, Grambow SC, Marcello JE, Herndon JE, et al. Comorbidity, age, race and stage at diagnosis in colorectal cancer: a retrospective parallel analysis of two health systems. BMC Cancer. 2008;8:345.

    Article  Google Scholar 

  9. Iversen LH, Norgaard M, Jacobsen J, Laruberg S, Sorensen HT. The impact of comorbidity on survival of Danish colorectal cancer patients from 1995-2006—a population-based cohort study. Dis Colon Rectum. 2009;52(1):71–8. https://doi.org/10.1007/DCR.0b013e3181974384.

    Article  PubMed  Google Scholar 

  10. Hahn EE, Gould MK, Munoz-Plaza CE, Lee JS, Parry C, Shen E. Understanding comorbidity profiles and their effect on treatment and survival in patients with colorectal cancer. J Natl Compr Cancer Netw. 2018;16(1):23–34. https://doi.org/10.6004/jnccn.2017.7026.

    Article  Google Scholar 

  11. Erichsen R, Horvath-Puho E, Iversen LH, et al. Does comorbidity interact with colorectal cancer to increase mortality? A nationwide population-based cohort study. Br J Cancer. 2013;109:2005–13. https://doi.org/10.1038/bjc.2013.541.

    Article  CAS  Google Scholar 

  12. Dasgupta P, Youlden DR, Baade PD. An analysis of competing mortality risks among colorectal cancer survivors in Queensland, 1996-2009. Cancer Causes Control. 2013;24:897–909. https://doi.org/10.1007/s10552-013-0166-4.

    Article  PubMed  Google Scholar 

  13. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, et al. The strengthening of the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61:344–0. https://doi.org/10.1016/j.jclinepi.2001.22.008.

    Article  Google Scholar 

  14. Statistics Canada. Ethnocultural portrait of Canada highlight tables, 2016 census. http://www12.statcan.ca/english/census16/data/highlights/ethnic/index.cfm?Lang. Accessed 31 Mar 2011.

  15. Statistics Canada. Table 206–0021. Income statistics by economic family type and income source, Canada, provinces and selected census metropolitan areas (CMAs). www5.statcan.gc.ca/cansim/a47. Accessed 17 Feb 2018.

  16. Collaborative Stage Data Collection System. About collaborative stage. Retrieved from www.cancerstaging.org/cstage/about/Pages. Accessed 4 Feb 2018.

  17. Preen DB, Holman CDJ, Spilsbury K, Semmens JB, Brameld KJ. Length of comorbidity lookback period affect regression model performance of administrative health data. J Clin Epidemiol. 2006;59:940–6. https://doi.org/10.1016/j.jclinepi.2005.12.013.

    Article  PubMed  Google Scholar 

  18. Deyo R, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992;45(6):613–9.

    Article  CAS  Google Scholar 

  19. Alberta Health Services. Early stage colon cancer treatment. 2017. www.albertahealthservices.ca/cancerguidelines. Accessed 17 Mar 2018.

  20. BC Cancer Agency. BC Cancer Agency drug manual: fluorouracil. 2015. www.bccanceragency.bc.ca/drug-database-site. Accessed 4 Feb 2018.

  21. BC Cancer Agency. BC Cancer Agency drug manual: oxaliplatin. 2015. Retrieved from www.bccanceragency.bc.ca/drug-database-site. Accessed 4 Feb 2018.

  22. WHO. Classification of Disease: ICD-10 online version. 2016. Accessed 10 Oct 2017.

  23. Kleinbaum DG, Klein M. Survival analysis: a self learning text. Statistics for biology and health. 3rd ed. New York: Springer; 2013.

    Google Scholar 

  24. Public Health Agency of Canada. How healthy are Canadian? A trend analysis of the health of Canadians from a healthy living and chronic disease perspective. 2016. https://www.canada.ca/en/public-health/services/publications/healthy-living/how-healthy-canadians.html. Accessed 10 Mar 2018.

  25. Cho H, Mariotto AB, Mann BS, Klabunde CN, Feuer EJ. Assessing non-cancer related health status of US cancer patients: other-cause survival and comorbidity prevalence. Am J Epidemiol. 2013;178(3):339–49. https://doi.org/10.1093/aje/kws580.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Sarfati D, Gurney J, Lim BT, et al. Identifying important comorbidity among cancer populations using administrative data: prevalence and impact on survival. Asia Pac J Clin Oncol. 2013;12(1) https://doi.org/10.1111/ajco.12130. published online ahead of print December 19, 2013.

    Article  Google Scholar 

  27. Hahn EE, Gould MK, Munoz-Plaza CE, Lee JS, Parry C, Shen E. Understanding comorbidity profiles and their effect on treatment and survival in patients with colorectal cancer. J Natl Compr Cancer Netw. 2018;16(1):23–34. https://doi.org/10.6004/jccn.2017.7026.

    Article  Google Scholar 

  28. Janssen-Heijnen MLG, Houterman S, Lemmens VEPP, Louwman MWJ, Maas HAAM, Coebergh JWW. Prognostic impact of increasing age and comorbidity in cancer patients: a population-based approach. Crit Rev Oncol Hematol. 2005;55:231–40. https://doi.org/10.1016/j.critrevonc.2005.04.008.

    Article  PubMed  Google Scholar 

  29. Rodrigues G, Sanatani M. Age and comorbidity considerations related to radiotherapy and chemotherapy administration. Semin Radiat Oncol. 2012;22:227–83. https://doi.org/10.1016/jsemradonc.2012.05.004.

    Article  Google Scholar 

  30. Cronin DP, Harlan LC, Potosky AL, Clegg LX, Stevens JL, Mooney MM. Patterns of care for adjuvant therapy in a random population-based sample of patients diagnosed with colorectal cancer. Am J Gastroenterol. 2006;101:2308–18. https://doi.org/10.1111/j.1572-0241.2006.00775.x.

    Article  CAS  PubMed  Google Scholar 

  31. Sarfati D, Hill S, Blakely T, Robson B, Purdie G, Dennett E, et al. The effect of comorbidity on the use of adjuvant chemotherapy and survival from colon cancer: a retrospective cohort study. BMC Cancer. 2009;9:110. https://doi.org/10.1186/1471-2407-9-116.

    Article  Google Scholar 

  32. Gross CP, McAvay GJ, Guo Z, Tinetti ME. The impact of chronic illnesses on the use and effectiveness of adjuvant chemotherapy for colon cancer. Cancer. 2007;109(12):2410–9. https://doi.org/10.1002/cncr.22726.

    Article  PubMed  Google Scholar 

  33. Keating NL, Landrum MB, Klabunde CN, Fletcher RH, Rogers SO, Doucette WR, et al. Adjuvant chemotherapy for stage III colon cancer: do physicians agree about the importance of patient age and comorbidity. J Clin Oncol. 2008;26(15):2532–7. https://doi.org/10.1200/JCO.2007.15.9434.

    Article  PubMed  Google Scholar 

  34. Shayeb ME, Scarfe W, Yasui Y, Winget M. Reasons physicians do not recommend and patients refuse adjuvant chemotherapy for stage III colon cancer: a populations-based chart review. BMC Res Notes. 2012;5:269. https://doi.org/10.1186/1756-0500-5-2569.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Kutner JS, Vu KO, Prindiville SA, Byers TE. Patient age and cancer treatment decisions: patient and physician views. Cancer Pract. 2000;8(3):114–9.

    Article  CAS  Google Scholar 

  36. Etzioni DA, El-Khoueiry AB, Beart RW. Rates and predictors of chemotherapy use of stage III colon cancer: a systematic review. Cancer. 2008;113(12):3289. https://doi.org/10.1002/cncr.23958.

    Article  Google Scholar 

  37. Lemmens VEPP, Janssen-Heijnen MLG, Verheij CDGW, Houterman S, van Driel OJR, Coebergh JWW. Comorbidity leads to altered treatment and worse survival of elderly patients with colorectal cancer. Br J Surg. 2005;92:615–23. https://doi.org/10.1002/bjs.4913.

    Article  CAS  PubMed  Google Scholar 

  38. Sjodahl R, Rosell J, Starkhammar H. Causes of death after surgery for colon cancer—impact of other diseases, urgent admittance, and gender. Scand J Gastroenterol. 2013;48(10):1160–5. https://doi.org/10.3109/00365521.2013.828771.

    Article  PubMed  Google Scholar 

  39. van Erning RN, van Steenbergen LN, Lemmens VEPP, et al. Conditional survival for long-term colorectal cancer survivors in the Netherlands: who do best? Eur J Cancer. 2014;50:1731–9. https://doi.org/10.1016/j.ejca.2014.04.009.

    Article  PubMed  Google Scholar 

  40. Zaorsky NG, Churilla TM, Egleston BL, Fisher SG, Ridge JA, Horwitz EM, et al. Causes of death among cancer patients. Ann Oncol. 2017;28:400–7. https://doi.org/10.1093/annonc/mdw604.

    Article  CAS  PubMed  Google Scholar 

  41. Koene RJ, Prizment AE, Blaes A, Konety SH. Shared risk factors in cardiovascular disease and cancer. Circulation. 2016;133(11):1104–14. https://doi.org/10.1161/CIRCULATIONAHA.115.020406.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Weaver KE, Foraker RE, Alfano CM, Rowland JH, Arora NK, Bellizzi KM, et al. Cardiovascular risk factors among long-term survivors of breast, prostate, colorectal, and gynecological cancers: a gap in survivor care? J Cancer Surviv. 2013;7:253–61. https://doi.org/10.1007/s11764-013-0267-9.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Quan H, Li B, Couris CM, Fushimi K, Graham P, Hider P, et al. Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries. Am J Epidemiol. 2013;173(6):676–82. https://doi.org/10.1093/aje/kwq433.

    Article  Google Scholar 

  44. Extermann M. Measuring comorbidity in older cancer patients. Eur J Cancer. 2000;36:453–71.

    Article  CAS  Google Scholar 

  45. Institute of Medicine and National Research Council. From cancer patient to cancer survivor: lost in transition. 2006. http://nap.edu/11468. Accessed 21 May 2018.

Download references

Funding

Dr. Cuthbert has postdoctoral salary support through the University of Calgary, Cumming School of Medicine Arnie Charbonneau Cancer Institute and O’Brien Institute for Public Health and the Canadian Institutes of Health Research. No additional funding was obtained for this study.

Author information

Authors and Affiliations

  1. Cumming School of Medicine, University of Calgary, 3330 Hospital Drive N.W., Calgary, AB, T2N 4N1, Canada

    Colleen A. Cuthbert

  2. Departments of Community Health Sciences and Medicine, University of Calgary, 3330 Hospital Drive N.W., Calgary, AB, T2N 4N1, Canada

    Brenda R. Hemmelgarn

  3. Departments of Surgery, Community Health Sciences, and Oncology, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive N.W., Calgary, AB, T2N 4Z6, Canada

    Yuan Xu

  4. Departments of Oncology and Medicine, University of Calgary, 3330 Hospital Drive N.W., Calgary, AB, T2N 4N1, Canada

    Winson Y. Cheung

Authors
  1. Colleen A. Cuthbert
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Brenda R. Hemmelgarn
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Yuan Xu
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Winson Y. Cheung
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Colleen Cuthbert: conceptualization, formal analysis, and writing, reviewing, and editing. Brenda Hemmelgarn: conceptualization, formal analysis, and writing, reviewing, and editing. Yuan Xu: data abstraction, reviewing, and editing. Winson Cheung: conceptualization, formal analysis, and writing, reviewing, and editing.

Corresponding author

Correspondence to Colleen A. Cuthbert.

Ethics declarations

This study received approval from the Health Research Ethics Board of Alberta (HREBA.CC-17-0034-REN1). Study findings are reported according to Strengthening of the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

Conflict of interest

The authors declare that they have no conflict of interest.

Research involving human subjects

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required.

Electronic supplementary material

ESM 1

(DOCX 142 kb)

ESM 2

(DOCX 17 kb)

ESM 3

(DOCX 21 kb)

ESM 4

(DOCX 18 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Cuthbert, C.A., Hemmelgarn, B.R., Xu, Y. et al. The effect of comorbidities on outcomes in colorectal cancer survivors: a population-based cohort study. J Cancer Surviv 12, 733–743 (2018). https://doi.org/10.1007/s11764-018-0710-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11764-018-0710-z

Keywords

Search

Navigation