臺灣博碩士論文加值系統

目的﹕大腸直腸癌是世界上不分性別前三名好發的惡性腫瘤，而直腸癌又占其中30-35%。本研究的目的包括（1）進行直腸癌之從流行病學特徵描述；（2）探討直腸癌患者接受同歩化療電療後，腫瘤消退分級和病患的預後是否有關?以及評估直腸癌病患是否會因接受同歩化療電療後，而增加其他癌症發生的風險?
材料與方法﹕本研究首先使用美國國家型結直腸癌的資料庫（1995-2008）（SEER database），擷取大腸直腸組織型態為腺癌（adenocarcinoma）的病患列入分析，比較大腸癌和直腸癌之流行病學特徵，並比較各個直腸癌分期之預後。接著進行系統性文獻回顧與統合分析分析同歩接受化療電療後，腫瘤未完全消除與完全不反應的病患之預後狀況。本研究也執行另一文獻回顧與統合分析，綜合整理直腸癌病人接受同歩化療電療後攝護腺癌發生的風險；最後，並使用我國全民健康保險資料，選擇初診斷為直腸癌並接受直腸癌術式開刀之男性病人為研究對象，以世代追蹤研究設計比較一年內有接受電療和從未接受電療之病人其日後發生攝護腺癌之風險?
結果﹕大約35 ％的患者有癌症分期的資料。其中，在第IIB期，結腸癌患者比直腸癌增加4個月的存活。在第IIIC和IV期，直腸癌患者比結腸癌患者增加3個月的存活。 第IIB期大腸癌患者的預後比第IIIA期和第IIIB大腸癌較差。調整年齡，性別和種族後，第IIB期結腸癌患者具有比直腸癌更好的存活率，但第IIIC和IV期，直腸癌患者具有比結腸癌更好的存活率。在直腸癌患者經過術前化療電療後達到部分緩解後無病存活率的預後情形，搜尋後共有11個研究可供擷取資料， 其中6個研究有把完全反應的患者排除，部分緩解比上反應不佳的危害對比值為0.49 (95% CI, 0.28-0.85)。而所有11個研究進行了分析在一起，危害對比值是0.41 (95% CI, 0.25-0.67)。而直腸癌同歩化療電療後，共有5個相關的研究，在直腸癌的病人族群內，並未發現有增加攝護腺癌發生的機率（Pooled HR=1.12, 95% CI, 0.44-2.80）；但是若和一般族群比較，反而發現會下降攝護腺癌發生的機率（標準化發生比(SIR=0.40, 95% CI, 0.29-0.55)）。世代追蹤研究也發現，在長達最多13年（1998-2010）的觀察期間，相較於未接受電療者，男性直腸癌病人在手術後的一年內若接受電療，會增加攝護腺癌發生的風險，其危害對比值為1.73 (95% CI, 1.59-1.88)。
結論﹕直腸癌的預後並不比結腸癌差。局部晚期的結直腸癌預後比淺部腫瘤但合併區域淋巴結轉移較差。第ⅡB期可能需要更積極的化療，因為預後不好，其預後如同或比第三期更差。直腸癌患者經過術前化療後，達到部分緩解者的無病存活率比起反應不佳多了50％，應被視為有利的預後因素。雖然過去的統合分析顯示，在直腸癌病人除群中，同歩化療電療與前列腺癌發生的風險並無統計上的顯著相關性；但與一般族群比起來，直腸癌病接受同歩化療電療反而會降低前列腺癌發生的風險；惟本研究的世代追蹤研究反而是發現，同樣在直腸癌的患者中，同歩化療電療是會增加攝護腺癌發生的風險。

Purposes: Colorectal cancer is the third most commonly diagnosed cancer in male and female worldwide. Rectal cancer accounts for 30 to 35% of colorectal cancer cases. Chemoradiation therapy has been the standard treatment nowadays for rectal cancer at stage T3/N(+). This study aimed to (1) describe rectal cancer epidemiology; (2) investigate whether prognosis was associated with tumor regression grading in rectal cancer patients with pre-operative chemoradiation therapy? and (3) assesse risk of secondary cancer onset from post radiation therapy.
Materials and Methods: Data analyzed included colorectal cancer (1995–2008) from the Surveillance, Epidemiology, and End Results Program (SEER) database. Only adenocarcinoma was included for the analysis. Systematic review and meta-analysis were conducted to investigate the prognosis associated with partial and poor tumor regression in rectum cancer patients with chemoradiation therapy. We also performed another systematic review and meta-analysis to summarize the evidence concerning the risk of prostate cancer following chemoradiation therapy. Finally, we used the National Health Insurance Research Database (NHIRD) to identify male rectal cancer patients who underwent surgery. With a cohort study design, this study compared the subsequent risks of prostate cancer between the patients receiving radiation therapy within one year after diagnosis of rectal cancer and those receiving no radiation therapy.
Results: Around 35% of patients had cancer stage information. Among them, colon cancer patients had better survival than those with rectal cancer, by a margin of 4 months in stage IIB. In stage IIIC and stage IV, rectal cancer patients had better survival than colon cancer patients, by about 3 months. Stage IIB colorectal cancer patients had a poorer prognosis than those with stage IIIA and IIIB colorectal cancer. After adjustment of age, sex and race, colon cancer patients had better survival than rectal cancer of stage IIB, but in stage IIIC and IV, rectal cancer patients had better survival than colon cancer. As for chemoradiation effects of rectal cancer, pooled hazard ratio (HR) was 0.49 (95% Confidence Interval (CI), 0.28–0.85) for the 6 studies that excluded all patients with complete response and compared partial response with poor response. It was 0.41 (95% CI, 0.25–0.67) when all 11 of the studies were analyzed together. Regarding late effects of chemoradiation therapy of rectal cancer, the summary data of 5 studies reported no significant increase in risk of prostate cancer pooled HR=1.12 (95% CI, 0.44-2.80) in rectum cancer patients receiving chemoradiation therapy, as opposed to those who do not have such therapy. On the other hand, chemoradiation therapy was associated with a significantly reduced standardized incidence ratio (SIR) (0.40, 95% CI, 0.29-0.55) of prostate cancer in rectum cancer patients, as compared to the general population. Male rectal cancer patients from NHIRD showed increased prostate cancer incidence after receiving radiation therapy within 1 year diagnosis of rectal cancer compared with those without receiving any radiation therapy (HR 1.73; 95% CI 1.59-1.88).
Conclusion: Prognosis of rectal cancer was not worse than that of colon cancer. Local advanced colorectal cancer had a poorer prognosis than local regional lymph node metastasis. Stage IIB might require more aggressive chemotherapy, and no less than that for stage III. Partial tumor response of chemoradiation therapy of rectal cancer is associated with a 50% improvement in disease-free survival and should be considered as a favorable prognostic factor. According to the current evidence, rectum cancer patients who received radiation therapy showed no significant effect on prostate cancer incidence, as compared to rectal cancer patients who received no such therapy, but showed a significantly reduced risk of prostate cancer as compared to the general population. The present cohort analysis demonstrated that radiation therapy for rectal cancer is associated with a increased prostate cancer risk of prostate cancer.

Acknowledgement...................... 3
Abstract..........................5
Abstract in Chinese.................... 7
Table of Contents..................... 9
List of Tables...................... 11
List of Figures......................12
Abbreviations...................... 13
Chapter 1 Preface...................... 14
Background ＆ objectives................ 14
Chapter 2 Literature Review................ 15
2.1 Epidemiology of Rectal Cancer versus Colon Cancer...15
2.2 Partial Response of Chemoradiaion therapy of Rectal
Cancer......................... 15
2.3 Secondary Prostate Cancer after Radiation Therapy for
Primary Rectal Cancer................. 16
2.4 Secondary Prostate Cancer after Radiation Therapy for
Primary Rectal Cancer, a Population Based Study.... 17
Chapter 3 Materials and Methods..............18
3.1 Epidemiology of Rectal Cancer versus Colon Cancer...18
3.2 Partial Response of Chemoradiaion therapy of Rectal
Cancer........................ 19
3.3 Secondary Prostate Cancer after Radiation Therapy for
Primary Rectal Cancer.................20
3.4 Secondary Prostate Cancer after Radiation Therapy for
Primary Rectal Cancer, a Population Based Study....21
Chapter 4 Results.................... 24
4.1 Epidemiology of Rectal Cancer versus Colon Cancer. 24
4.2 Partial Response of Chemoradiaion therapy of Rectal
Cancer........................ 24
4.3 Secondary Prostate Cancer after Radiation Therapy for
Primary Rectal Cancer.................26
4.4 Secondary Prostate Cancer after Radiation Therapy for
Primary Rectal Cancer, a Population Based Study....27
Chapter 5 Discussion................... 28
Main finding....................... 28
5.1 Epidemiology of Rectal Cancer versus Colon Cancer...29
5.2 Partial Response of Chemoradiaion therapy of Rectal
Cancer........................ 30
5.3 Secondary Prostate Cancer after Radiation Therapy for Primary Rectal Cancer...................32
5.4 Secondary Prostate Cancer after Radiation Therapy for
Primary Rectal Cancer, a Population Based Study....35
Chapter 6 Conclusions...................36
References........................ 37
Tables.......................... 44
Figures..........................57
Related Publications................... 70

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