2 Minute Medicine Rewind September 18, 2023

Non-erosive gastro-oesophageal reflux disease and incidence of oesophageal adenocarcinoma in three Nordic countries: population based cohort study

1. Patients with non-erosive gastro-esophageal reflux disease (GERD) do not have an increased incidence of developing esophageal adenocarcinoma compared to the general population.

Evidence Rating Level: 2 (Good)

For patients with gastro-esophageal reflux disease (GERD), endoscopic findings of mucosal erosion or metaplasia are associated with increased risk of esophageal adenocarcinoma. However, there has been no study to determine whether patients with non-erosive GERD, meaning normal endoscopic mucosal findings, are at increased risk for this type of malignancy. Therefore, this population based study based in Denmark, Finland, and Sweden aimed to compare the incidence of esophageal adenocarcinoma between patients with non-erosive GERD and the general population. The non-erosive GERD patients consisted of individuals with at least 1 endoscopy done between 1987 to 2019, with no baseline diagnosis of esophageal cancer, gastric cancer, or Barrett esophagus. Patients were excluded if they had an endoscopy prior to the study period, before the age of 18, or after the age of 90. A cohort of erosive GERD patients were also analyzed for validation purposes. Additionally, standardized incidence ratios were calculated using the general population incidence. In total, there were 285,811 non-erosive GERD patients, with a follow-up of 2,081,051 person-years (median 6.3 years). There were 200,745 erosive GERD patients analyzed. The results showed that 0.08% of non-erosive GERD patients developed esophageal adenocarcinoma, with an incidence of 11.0 per 100,000 person-years, and a standardized incidence ratio of 1.04 (95% CI 0.91-1.18). In comparison, the erosive GERD cohort had a prevalence of 0.27% developing cancer, with an incidence of 31.0 per 100,000 person-years, and a standardized incidence ratio of 2.36 (95% CI 2.17-2.57). Overall, this study demonstrated that the incidence of esophageal adenocarcinoma in non-erosive GERD patients is similar to that of the general population.

Combined Digital Interventions for Pain Reduction in Patients Undergoing Knee Replacement: A Randomized Clinical Trial

1. Following total knee replacement (TKR) for osteoarthritis, patients randomized to a combined digital intervention experienced less pain, less disability, and increased physical activity at 12 months follow-up, compared to care usual.

Evidence Rating Level: 1 (Excellent)

Patients who undergo total knee replacement (TKR) for osteoarthritis (OA) may continue to have ongoing pain and limited function, with some reports showing that 10% of patients are dissatisfied at 2 years of follow-up. Digital interventions are one strategy shown to improve pain and increase activity after TKR. However, it is unclear whether combining multiple digital interventions confers a functional benefit. Therefore, this multicentre clinical trial based in Australia aimed to compare patients’ post-TKR pain, randomized to undergo either a combined digital technology intervention or care as usual. The study population consisted of 102 patients post-TKR for OA, admitted for rehabilitation to a hospital, and randomized 1:1 to the control and intervention. The digital intervention was a 6-month package consisting of an iPad app program with exercises developed by physiotherapists and surgeons, a Fitbit tracker, and 3 months of health coaching every second week. The outcomes were measured at 3, 6, and 12 months, with the primary outcome being pain measured by the Numeric Pain Rating Scale (from 0-10). Secondary outcomes included the Pain Disability Index score (from 0-70), physical activity participation, sedentary behaviour in hours per week, and quality of life. The results demonstrated a clinically significant reduction in pain in the intervention group: The mean NRS difference between groups was 0.94 (95% CI -1.70 to -0.20, p = 0.01). The reduction was largest at 12 months (MD -4.91, 95% CI -5.63 to -4.19). Additionally, the intervention group was associated with a lower mean Pain Disability Index score (MD -5.42, 95% CI -10.00 to -0.83), mean 1572 more steps per day (95% CI 345-2798 steps), and a mean 19.85 more minutes of stepping time per day (95% CI 6.31-33.38 minutes). Overall, this study showed that for patients over 12 months post-TKR, a combined digital intervention was associated with improved pain, less disability, and more physical activity than care as usual.

Patient-Reported Outcomes of Omission of Breast Surgery Following Neoadjuvant Systemic Therapy: A Nonrandomized Clinical Trial

1. For early-stage invasive breast cancer patients who had excellent responses to neoadjuvant systemic therapy (NST), omission of breast surgery was associated with decision comfort, negligible differences between breasts, and excellent quality of life, all measures which improved over 36 months follow-up.

Evidence Rating Level: 2 (Good)

Including validated patient-reported outcome measures (PROMs) in clinical trials is particularly important for research involving shared patient decision-making, such as in studies involving de-escalation of cancer treatment. This current multicentre prospective trial aimed to evaluate PROs following omission of breast surgery in cancers that responded exceedingly well to neoadjuvant systemic therapy (NST). The study population consisted of women with invasive cT1-2 N0-1 M0, triple negative or ERBB2-positive breast cancer, who completed NST. Once no pathologic evidence of remaining disease was found in the breast or axilla, these patients proceeded to radiotherapy or therapies specific to their tumour’s molecular subtype. There were 3 PROMs used: the Decision Regret Scale (DRS) from 0-100, the Breast Cancer Treatment Outcomes Scale (BCTOS) assessing differences in pain and function between breasts from 0-88, and the Functional Assessment of Cancer Therapy – Lymphedema (FACT-B+4) assessing quality of life from 0-148. These were assessed at baseline, 6, 12, and 36 months after radiotherapy completion. In total, there were 31 included patients, with a median (IQR) follow-up of 32.4 (20.3-40.0) months. The results showed that the decision comfort at baseline was high, with a median (IQR) DRS of 10 (0-25), but also improved over time, with a score of 0 (0-5) at 6 months. Furthermore, there were negligible differences noted between breasts at baseline, as evidenced by the low median (IQR) BCTOS score (1.05, 95% CI 1.00-1.23), though this score increased significantly at 36 months (1.36, 95% CI 1.18-1.64, p < 0.001). Finally, the median (IQR) baseline FACT-B score was 121 (111-134) indicating high quality of life, increasing significantly to 133 (122-136) at 12 months (p = 0.04). Overall, this study showed that for early-stage breast cancer patients with excellent response to NST, omission of breast surgery was associated with decision comfort, minimal between-breast differences, and high quality of life that both improved over time.

Mortality risk after the first occurrence of osteoporotic vertebral compression fractures in the general population: A nationwide cohort study

1. Patients with a new diagnosis of osteoporotic vertebral compression fracture (OVCF) are at higher risk of mortality compared to their sex- and age-matched controls.

2. Factors that increase the risk of mortality amongst OVCF patients include: Male sex, older age, low-income, high Charlson Comorbidity Index, and medical comorbidities such as CHF, cancer, and stroke.

Evidence Rating Level: 2 (Good)

Osteoporotic vertebral compression fractures (OVCF) are one of the most common osteoporotic fractures. OVCFs can cause tremendous pain and instability, further increasing risk of falls. They may also increase the risk of mortality from complications of kyphosis, such as pulmonary disease. This current retrospective cohort study based in South Korea examined the mortality risk after first OVCF event. Data was analyzed from 2010 to 2012, where patients with a new diagnosis of OVCF were matched 1:3 to members of the general population, with the same sex and age. The mortality rate was compared between the two groups, and the demographics and comorbidities were also compared. In total, there were 291,203 OVCF patients and 873,609 control patients, with a median follow-up of 5.87 years. The mortality rate was 24.3% in the OVCF group and 19.6% in the control group, with a higher risk in OVCF patients (adjusted hazard ratio 1.22, 95% CI 1.20-1.33). The analysis of demographics and comorbidities found that OVCF patients who were male, more elderly, low-income, and with high Charlson Comorbidity Index were associated with greater mortality. Chronic comorbidities also increased the mortality risk, with congestive heart failure being the highest risk (HR 2.26, 95% CI 2.21-2.30), with cancer and stroke being the next highest-risk comorbidities. Overall, this study showed that patients with a new diagnosis of OVCF are at a higher risk of mortality than the sex and age matched general population.

Rectal cancer presentation during the COVID-19 pandemic: Are decreasing screening rates leading to an increase in acute presentations?

1. Despite the decrease in colonoscopies performed at the start of the COVID-19 pandemic, there was no difference in the percentage of colorectal cancer (CRC) presentations at a later stage or with higher acuity, when comparing patients diagnosed with rectal adenocarcinoma pre-pandemic and during the pandemic.

Evidence Rating Level: 2 (Good)

Colonoscopies as part of colorectal cancer (CRC) screening are instrumental in the early diagnosis of CRC, and have been associated with a 75% reduction in mortality for those diagnosed with left-sided colon cancer, likely due to earlier detection. However, during the initial months of the COVID-19 pandemic, there were cancellations of non-urgent procedures, resulting in a 90% relative reduction in scopes performed in the US and England in April 2020. Therefore, this retrospective study aimed to determine if the cancellations from the COVID-19 led to more acute presentations of rectal adenocarcinoma, or presentations at a later stage, in comparison to pre-pandemic times. The study population included all patients diagnosed with rectal adenocarcinoma between 2016 and 2021 at a single centre. Pre-COVID patients were defined as a diagnosis made before March 1, 2020. With regards to outcomes, an acute presentation was defined as a visit to the emergency department or admission to hospital with symptoms related to rectal cancer. In total, there were 208 patients included, 163 of which comprised the pre-COVID cohort. The results showed that the stage at presentation was similar, with the majority presenting with stage III (40.0% pre-COVID vs 33.3% COVID, p = 0.26). The rate of patients bleeding as the presenting complaint or presenting after CRC screening were similar as well (50.3% pre-COVID vs 42.2% COVID for bleeding, and 24.5% pre-COVID vs 24.4% for COVID respectively). Following adjustment for covariates, there was still no difference in acute presentation between the pre-COVID and COVID cohorts (odds ratio 1.24, 95% CI 0.57-2.72, p = 0.59). Overall, this study demonstrated that despite a decrease in CRC screening at the start of the COVID-19 pandemic, there was no increased proportion of acute CRC presentations or later stage, compared to pre-pandemic times.

Image: PD

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