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Laparoscopy has become commonplace for the treatment of colon and rectal conditions. The advantages of laparoscopy over laparotomy have been clearly demonstrated for a number of general surgery procedures, and most general surgeons have adopted this technique. The benefits of laparoscopy include decreased pain, shorter hospitalization, earlier resumption of prc-opcrativc activity, and improved cosmetic results.1

The treatment of benign colon and rectal disorders exploits all the advantages of minimal access surgery and has been enhanced by the introduction of laparoscopy. The relatively large incisions necessary to achieve most colorectal procedures have been obvious reasons to pursue this technique. However, all these advantages may become secondary in the treatment of malignant disease of the colon and rectum. The use of laparoscopy for the treatment of cancer has been challenged with concerns regarding the ability to uphold the time-honored oncologic principles established with traditional surgical techniques.

To comply with the standards of curative surgery, the operator must perform complete mobilization of the colon from its attachments with as little manipulation of the tumor-bearing segment as possible. The surgeon must achieve adequate tumor-free margins and proximal ligation of the lymphvascular pedicle with systematic lymph node dissection.2

In this article I will discuss the validity of laparoscopy for colon rectal malignancy through analysis of studies in the literature. The focus will be on questions about the extent of organ removal, intra-operative tumor cell distribution with trocar site tumor implantation and the importance of surgical technique. This review will exclude surgery for rectal cancer because of its different rates and patterns of recurrence and because there are not randomized trials of evaluating lapatoscopic resection of rectal cancer. A mention will be made about the possible immunological advantage of laparoscopic cancer surgery, theorized by the Barcelona group. Finally, I will leave the ultimate verdict about the validity of laparoscopic colon-rectal surgery for cancer upon the conclusion of the ongoing multi-center randomized trials, which should yield information on the definitive outcome, the 5 year-survival and disease-free survival.

EXTENT OF ORGAN REMOVAL

The extent of bowel segment removal with its associated lymph-vascular drainage has been a concern of surgeons.3 Recent series, including retrospective and prospective studies, have demonstrated that these oncologic principles are not compromised by laparoscopic techniques when length of bowel resected, surgical margins, and yield of lymph nodes are compared.4,5 In a recent meta-analysis Korolija et al.6 examined reports on the results of laparoscopic or open colorectal procedures published between 1990 and 1999, and selected 35 papers with data on lymph node count and distal margin clearance, for a total of 3935 patients. There were 16 comparative studies, 6 open series, and 13 laparoscopic series of patients. The difference between open and laparoscopic surgery, including multiple-outcome random-effects models that account for correlation between multiple outcomes, was evaluated. The authors found that more lymph nodes were extracted laparoscopically (0.3-2.14 lymph nodes more) and that the average distal margin clearance was 4.6 cm with the laparoscopic approach and 5.3 with the open approach. This meta-analysis showed that the laparoscopic approach is as adequate as the conventional approach for extent of organ removal.

INTRO-OPERATIVE TUMOR CELL DISTRIBUTION AND PORT SITE METASTASIS

Laparascopic technique was feared to be associated with tumor cell distribution. The lack of the “soft touch” allowed by direct manual control and the tactile sensation of the specimen were felt to be a potential culprit and to increase the hematogenous and intraperitoneal tumor cell spread. This idea generated some of the most emotional debates, especially when associated with the issues of port site recurrence.

Some of the early series of laparoscopic resection for colorectal cancer included reports of cancer recurrence both in the incision for the extraction of the specimen and in the working trocar incisions.7 Cirocco et al.8 presented the fourth known case of abdominal wall recurrence after laparoscopy for colon cancer. The “alarming rate” of increase in the incidence of wound implantation was of great concern. The author felt this could represent ominous implications for the future of laparoscopic surgical procedures involving colorectal malignancy.

Wound recurrence of colorectal cancer after traditional colon-rectal surgery has been reported in 1928 by Sistrunk9 when colonie tumors were delivered through small incisions, especially after colostomy with polypectomy or with limited resections.

Reilly et al. reported a 1.5% incidence of wound metastases after laparotomy for colon and rectal cancer (26 cases in 1711 patients with cancer).10 Upon re-exploration he found that nine of these patients had diffuse carcmomatosis, in only 3 of the 1711 patients, 0.2% had isolated abdominal wall recurrences.

“Functional foods,” “nutraceuticals,” “designer foods” and “medicinal foods” are terms that describe foods, and key ingredients isolated from foods, that have non-nutritive or tertiary functional properties. Researchers, healthcare practitioners, laypersons, and the popular media use these words interchangeably. The purpose of this article is to present valid scientific information available on the physiologic actions of known constituents and combinations of constituents, as they naturally occur in “functional foods,” highlighting their medicinal and nutritive mechanisms of action in the body.

The scientific community continues to recognize and validate the considerable relationship between vegetable intake and cancer. Over 200 epidemiological studies show, with great consistency, that a low consumption of vegetables is directly associated with an increased risk of cancer (Table 1). Epidemiological studies also support the belief that dietary modification, through an increase in vegetable intake, could reduce the risk of cancer by 50% internationally. Specifically, researchers regard cruciferous vegetables, and particularly those that are members of the Brassica plant family, as critical elements in the risk reduction associated with vegetable intake and cancer. [4-8] Further, in people under 55 years of age, cruciferous vegetable intake is inversely correlated with colon cancer incidence and comparatively among smokers the chemoprotective benefits of Brassica consumption are even greater. [9,10] Van Poppel et al.  examined 6 cohort studies and 74 case control studies that supported an in verse correlation between Brassica consumption and cancer risk. The association was found to be most consistent for lung, stomach, colon, and rectal cancers, and least consistent for prostatic, endometrial, and ovarian cancers. In studies examining total vegetable consumption an inverse association with cancer risk is also found, with the Brassicas showing the strongest effects as a subgroup. Brassicas also are low in fat, low in calories, and are potent sources of vitamins, minerals, fiber, and phytochemicals, all of which have been linked to cancer prevention.

A discussion of the biochemical and physiologic implications of increasing one’s intake of cruciferous vegetables will follow. The term “chemoprevention,” for the purpose of this research article, refers to the strategic approach of decreasing one’s susceptibility to carcinogenic factors through the administration of dietary chemicals, as introduced to the body within the matrix from which they originated (i.e., ingesting the whole vegetable vs. an isolated fraction). The rationale behind emphasizing the use of whole vegetables as opposed to an isolated fraction (considered a chemoprotective agent) is that the degree to which the protective effect of vegetables can be attributed to the nutritional or tertiary components, and to what extent indirect effects such as an equivalent reduction in fat consumption and associated increase in vitamin, fiber and carotenoid intake may be responsible for the protective effect, is not well defined. Nonetheless, the dietary approach of increasing one’s intake of cruciferous vegetables to defend oneself from cancer-causing agents has become widely recognized in the medical research community as a realistic and rational practice in the war against cancer.

The rectum is the portion of the large bowel that lies in the pelvis, terminating at the anus. Cancer of the rectum is the disease characterized by the development of malignant cells in the lining or epithelium of the rectum. Malignant cells have changed such that they lose normal control mechanisms governing growth. These cells may invade surrounding local tissue or they may spread throughout the body and invade other organ systems.

The rectum is the continuation of the colon (part of the large bowel) after it leaves the abdomen and descends into the pelvis. Anatomically, it is divided into equal thirds; the upper, mid, and lower rectum.

The pelvis and other organs in the pelvis form boundaries to the rectum. Behind, or more accurately, posterior to the rectum is the sacrum (the lowest portion of the spine, closest to the pelvis). Laterally, on the sides, the rectum is bounded by soft tissue and bone. In front, the rectum is bounded by different organs in the male and female. In the male, the bladder and prostate are present. In the female, the vagina, uterus, and ovaries are present.

The upper rectum receives its blood supply from branches of the inferior mesenteric artery from the abdomen. The lower rectum has blood vessels entering from the sides of the pelvis. Lymph, a protein-rich fluid that bathes the cells of the body, is transported in small channels known as lymphatics. These channels run with the blood supply of the rectum. Lymph nodes are small filters through which the lymph flows on its way back to the blood stream. Cancer spreads elsewhere in the body by invading the lymph and vascular systems.

When a cell or cells lining the rectum become malignant, they first grow locally and may invade partially or totally through the wall of the rectum. The tumor here may invade surrounding tissue or the organs that bound it, a process known as local invasion. In this process, the tumor penetrates and may invade the lymphatics or the capillaries locally and gain access to the circulation in this way. As the malignant cells work their way to other areas of the body, they again become locally invasive in the new area to which they have spread. These tumor deposits, originating in the primary tumor in the rectum, are then known as metastasis. If metastases are found in the regional lymph nodes, they are known as regional metastases. If they are distant from the primary tumor, they are known as distant metastases. The patient with distant metastases may have widespread disease, also referred to as systemic disease. Thus the cancer originating in the rectum begins locally and, given time, may become systemic.

By the time the primary tumor is originally detected, it is usually larger than one centimeter (about 3/8 inch) in size and has over a million cells. This amount of growth itself is estimated to take about three to seven years. Each time the cells double in number, the size of the tumor quadruples. Thus like most cancers, the part that is identified clinically is later in the progression than would be desired and screening becomes a very important endeavor to aid in earlier detection of this disease.

Passage of red blood with the stool, (noticeable bleeding with defecation), is much more common in rectal cancer than that originating in the colon because the tumor is much closer to the anus. Other symptoms (constipation and/ or diarrhea) are caused by obstruction and, less often, by local invasion of the tumor into pelvic organs or the sacrum. When the tumor has spread to distant sites, these metastases may cause dysfunction of the organ they have spread to. Distant metastasis usually occurs in the liver, less often to the lung(s), and rarely to the brain.

Demographics

There are about 36,500 cases of rectal cancer diagnosed per year in the United States. Together, colon and rectal cancers account for 10% of cancers in men and 11% of cancers in women. It is the second most common site-specific cancer affecting both men and women. (Lung cancer is the first affecting both men and women, breast is the leader in women and prostate the leader in men). About 8,500 people died from rectal cancer in the U.S. in 2000. In recent years the incidence of this disease is decreasing very slightly, as has the mortality rate. It is difficult to tell if the decrease in mortality reflects earlier diagnosis, less death related to the actual treatment of the disease, or a combination of both factors.

Cancer of the rectum is felt to arise sporadically in about 80% of those who develop the disease. 20% of cases are felt to have genetic predisposition that ranges from familial syndromes affecting 50% of the offspring of a mutation carrier, to a risk of 6% when there is just a family history of rectal cancer occurring in a first-degree relative. Development of rectal cancer at an early age suggests a genetically transmitted form of the disease as opposed to the sporadic form.

A prostate cancer prevention trial known as the Selenium and Vitamin E Cancer Prevention Trial (SELECT) is being coordinated by the Southwest Oncology Group to evaluate the effect of selenium and vitamin E in reducing the incidence of prostate cancer. SELECT will be conducted at more than 200 study centers across the United States, Canada and Puerto Rico.

Colorectal malignancy accounted for about 10 percent of cancer-related deaths last year in the United States. By the end of 1998, an estimated 131,600 new cases of colorectal cancer were diagnosed, and 56,500 persons died from the disease.[1]

When localized to the bowel, colorectal cancer is highly treatable and often curable. With early detection, the five-year survival rate for patients with this malignancy is 92 percent.[2] Although the incidence of colorectal cancer is increasing, the overall mortality rate is decreasing. Whether improved survival is a result of earlier detection, more accurate diagnosis, more effective treatment or the identification and removal of premalignant polyps is unclear.

A multidisciplinary panel of experts representing the American Cancer Society (ACS), the American College of Gastroenterology and the American Society of Gastrointestinal Endoscopists has made specific recommendations for the screening and surveillance of patients at average or increased risk for colorectal cancer (Table 1).[3] The American Academy of Family Physicians (AAFP) and the U.S. Preventive Services Task Force also recommend sigmoidoscopy, starting at 50 years of age. Interestingly, persons at increased risk account for only 25 percent of colorectal cancers.[3] Thus, most malignancies would be missed if screening were limited to the high-risk group.

TABLE 1
Guidelines for Colorectal Screening

Risk Category         Risk factors

Average risk     Age 50 years or older but
asymptomatic and without any
of the characteristics or situations
indicating increased risk

Increased risk   Close relative(s) have had colorectal
cancer or an adenomatous polyp
Family history of familial
adenomatous polyposis

Family history of hereditary
nonpolyposis colorectal cancer

History of adenomatous polyps

History of colorectal cancer

Inflammatory bowel disease

Risk Category        Recommendations

Average risk     Fecal occult blood screening yearly
Flexible sigmoidoscopy every 5 years or
colonoscopy every 10 years or double contrast
barium enema every 5 to 10 years

Increased risk   Same recommendations as above, but screening is
initiated when the patient is 40 years old

Genetic counseling/testing
In a gene carrier, flexible sigmoidoscopy every
12 months, beginning at puberty

Genetic counseling/testing
Examination of the entire colon every 1 to 2
years, starting when the patient is 20 to 30
years old

Examination of the entire colon yearly after the
patient is 40 years old

Colonoscopy 3 years after initial examination,
with subsequent examinations, depending on the
types of polyps detected

Complete examination 1 year after colon surgery;
if normal, reexamination of colon in 3 years; if
still normal, reexamination in 5 years

Surveillance colonoscopy every 1 to 2 years,
beginning after 8 years of disease in the
patient with pancolitis and after 15 years in
the patient with left colon involvement only

NOTE: These guidelines have not been endorsed by the American Academy of Family Physicians and the U.S. Preventive Services Task Force.

Information from Winawer SJ, Fletcher RH, Miller L, Godlee F, Stolar MH, Mulrow CD, et al. Colorectal cancer screening: clinical guidelines and rationale. Gastroenterology 1997;112:594-642 [Published erratum in Gastroenterology 1997;112:1422].

To date, no randomized, controlled trials have shown that flexible sigmoidoscopy reduces the mortality rate associated with colorectal cancer. However, in one case-control study[4] it was found that in patients screened with rigid sigmoidoscopy the risk of fatal distal colon cancer was only 30 percent of the risk in unscreened patients.

Flexible sigmoidoscopy is a valuable procedural skill for family physicians. Many physicians acquire this skill in residency training and thus are more likely to use it later in practice.[5] On January 1, 1998, Medicare began covering colorectal cancer screening. Physicians should now be able to convince more patients to undergo sigmoidoscopy.

Colorectal cancer is one of the most common malignant tumours in western countries. It is the second leading cause of cancer death in the United States [1]. In Britain, colorectal cancer causes 20000 deaths annually [2]. In Finland, colorectal cancer was in fifth place in men and in third place in women among all cancers in the 1980s [3]. The number of colorectal cancers will increase in the future. It is predicted that in Finland the number of new colorectal cancers will almost double by the first decade after 2000 [3].

Cancer of the colon and rectum is especially a disease of older people, as incidence doubles with every decade of age over 40 years [2]. Necropsy studies show that the prevalence of colorectal cancer in asymptomatic patients is 1.6% in 50-60 year olds and 3% in those over 75 [4]. An improvement has been found in the 5-year relative survival rates in all age groups for both colonic and rectal cancers [5].

Delay in the diagnosis of colorectal cancer is still a problem although improvement has been taking place during recent decades. A reduction in the delay before treatment has been reported from 7 months in 1950 to 2 months in 1970 [6]. The time from the first symptom to the first medical consultation has been reported to be 113.4 days (16.2 weeks) for rectal cancer and 88.9 days (12.7 weeks) for colonic cancer [7]. The time from first examination to treatment was 154.0 days (22.0 weeks) for rectal cancer and 135.1 days (19.3 weeks) for colonic cancer [7]. The delay may be a particular problem for those patients in whom emergency surgery becomes necessary (obstruction or perforation). Emergency surgery is associated with higher hospital fatality than elective surgery. Early diagnosis may place more patients in the elective group. As a whole, the present delay in diagnosing colorectal cancer is a considerable one and needs attention.

This retrospective study was planned to find out how the diagnosis and related factors differ in elderly patients compared with younger ones.

Patients

The medical histories of 178 consecutive colorectal cancer patients were examined retrospectively from hospital records. The patients were admitted to and treated in Turku University Hospital and Turku City Hospital during the years 1989 and 1990. The group consisted of 79 men and 99 women. The average age at the time of diagnosis was 71.0 (SD [+ or -] 12.6, range 27-97) years in the whole group, 69.1 (SD [+ or -] 12.3, range 32-97) years in men and 72.6 (SD [+ or -] 12.7, range 27-93) years in women.

Methods

The patients’ medical histories were studied by the same physician (M.K.) and the information collected in a planned form. The main symptom at the time of diagnosis was recorded (blood in stools, diarrhoea, constipation, obstruction, stomach pain, loss of weight, general weakness, other symptom). The time between onset of symptoms and the first medical consultation, and the time between the first medical consultation and diagnosis were recorded. The haemoglobin value was obtained from all records. Rectal examination was recorded as follows: (1) normal, (2) palpable tumour, and (3) information lacking. Special interest was focused on the methods of diagnosis (barium enema, rectoscopy, sigmoidoscopy, colonoscopy, operation, autopsy) and also on the possibility that some diagnostic method missed a tumour. These variables were compared between three age groups (under 65 years old, 65-80 years old and over 80 years old) and between sexes.

The differences between means were compared by Student’s t test. The Mann-Whitney U test was used for data with nonparametric distribution. Comparisons between groups were made using Pearson’s [[chi].sup.2] test.

Results

The main symptom: Seven different main symptoms were identified in this group of colorectal cancer patients. Table I shows the main symptoms which did not differ between the three age groups.

[TABULAR DATA OMITTED]

The time from the first symptom to the first medical consultation: This could be identified in 101 patients and was 82.8 days in the whole group, 77.8 days in men and 86.6 days in women. Table II shows the mean time in three age groups in men and women; men under 65 years old and women over 80 years had a longer interval between first symptom and first medical examination than the other groups.

Table II. Time from the first symptom to the first medical consultation in three age groups in men and women

Days
Age group
(years)       Mean          [+ or -] SD     n
Men
<65           112.7(a)       95.0           18
65-80          38.1(b)       54.7           16
>80            78.8          62.6            9
All            77.8          81.2           43
Women
<65            77.9          94.5           11
65-80          75.2          53.9           28
>80           108.3         114.0           19
All            86.6          85.3           58
(a) p = 0.0081 as compared with men aged 65 80 years.
(b) p = 0.034 as compared with women aged 65-80
years.

Objective To examine whether anti-inflammatory drug treatment protects against the commoner cancers in the United Kingdom.

Design Case-control study using the general practice research database.

Setting Practices throughout United Kingdom providing data to the database.

Subjects Patients who had a first diagnosis of five gastrointestinal (oesophagus, stomach, colon, rectum, and pancreas) cancers and four non-gastrointestinal (bladder, breast, lung, and prostate) cancers in 1993-5 for whom prescription data were available for the at least the previous 36 months. Each case was matched for age, sex, and general practice with three controls.

Main outcome measure Risk of cancer.

Results In 12 174 cancer cases and 34 934 controls overall risk of the nine cancers was not significantly reduced among those who had received at least seven prescriptions in the 13-36 months before cancer diagnosis (odds ratio 0.98, 95% confidence interval 0.89 to 1.07). Findings were nevertheless compatible with protective effects from anti-inflammatory drugs against cancers of the oesophagus (0.64, 0.41 to 0.98), stomach (0.51, 0.33 to 0.79), colon (0.76, 0.58 to 1.00), and rectum (0.75, 0.49 to 1.14) with dose related trends. The risk of pancreatic cancer (1.49, 1.02 to 2.18) and prostatic cancer (1.33, 1.07 to 1.64) was increased among patients who had received at least seven prescriptions, but the trend was dose related for only pancreatic cancer.

Conclusions Anti-inflammatory drugs may protect against oesophageal and gastric cancer as well as colon and rectal cancer. The increased risks of pancreatic and prostatic cancer could be due to chance or to undetected biases and warrant further investigation.

Introduction

Epidemiological evidence has consistently shown that people who have taken aspirin or other non-steroidal anti-inflammatory drugs are at reduced risk of developing or dying from colon cancer.[1 2] The extent to which treatment protects against other cancers is unclear, although in epidemiological studies fewer fatal cases of gastric and oesophageal cancer than expected have been found[2] and the occurrence of experimentally induced bladder, breast, and colon cancer in animals has been reduced by giving non-steroidal anti-inflammatory drugs concurrently with carcinogens.[3-5]

The extent to which treatment might protect against different varieties of cancer in humans could be investigated by separate case-control or case-cohort studies, but this time consuming and labour intensive method can be avoided by examining information held on automated databases that record drug prescriptions and clinical outcomes. We used the general practice research database to examine information about previous prescription of aspirin and other nonsteroidal anti-inflammatory drugs and occurrence of the common cancers in the United Kingdom.

Methods

The general practice research database is a national dataset managed for the Department of Health containing anonymised patient records on about four million UK residents. Contributing general practices, which are distributed throughout the United Kingdom, record standard data on demography, morbidity, and prescriptions and selected other information. The quality of data is regularly assessed.[6] With ethics committee approval we identified practices with at least four years of information meeting the required standard and abstracted data on all patients with a first diagnosis of five gastrointestinal cancers (oesophagus, stomach, pancreas, colon, and rectum) and four non-gastrointestinal cancers (bladder, breast, lung, and prostate) during 1993-5. Each case was then individually matched for age (within five years), sex, and general practice with three controls. Controls were patients without a diagnosis of the case’s type of cancer at the time the case was diagnosed. We also obtained information on recorded current smoking habits.

Data on prescriptions for aspirin and other non-steroidal anti-inflammatory drugs (all drugs listed in British National Formulary subsection 10.1.1) were extracted for each case and control for the 13-36 months before cancer diagnosis (and equivalent data were extracted for controls). Information on smoking habits was used to classify patients as ever smokers or never smokers. Conditional logistic regression was used to analyse associations between numbers of prescriptions and risk of cancer for all sites together and each separately. Odds ratios (adjusted for smoking habits and age) were calculated with 95% confidence intervals, and dose-response relations were tested for trend. In the primary analyses we examined overall cancer incidence in relation to drug use and compared risks of gastrointestinal and non-gastrointestinal cancers.

Results

We identified 12 174 patients with a first diagnosis of the study cancers in 1993-5 who had prescription data available for the previous 36 months. Eighteen patients with multiple cancers were excluded from analyses of individual sites, with their controls. Table 1 shows, for each cancer site, the numbers of cases and matched controls by sex and the numbers who had ever received prescriptions for aspirin or other nonsteroidal anti-inflammatory drugs.

Beans Against Cancer?

“… and let them give us pulse to eat and water to drink.” -Daniel 1.12

Beans are among our most ancient foods. The major problem in discussing Phaseolus vulgaris is, well, its vulgarity. No other kind of food elicits as much low humor as “the musical fruit.” Benjamin Franklin, a vegetarian who knew his beans, once wrote a whole essay on this most unlikely of topics. He proposed a scientific prize for the inventor who could come up with “some drug, wholesome and not disagreeable, to be mixed with our common food, or sauces, that shall render the natural discharges of Wind from our bodies not only inoffensive, but agreeable as perfumes.” Like many utopian dreams of the Enlightenment, this one came to naught. That mighty Wind is, alas, still with us.

However, we should not allow a little intestinal rumbling to come between us and a truly beneficial food. Happily, beans received a major boost from the Bean Research Unit of the Department of Agriculture (USDA). The US Midwest produces much of the world’s bean supply, so it is perhaps understandable that these Michigan scientists are unabashedly partisan toward beans. However, the facts speak for themselves: the common dry bean turns out to be an outstanding source of antioxidants. When these USDA scientists analyzed the colored seed coats of twelve different types of beans they found that these legumes contained many of the same antioxidants (such as anthocyanins) that are also found in pricier berries and fruits, and also in wine. “Although these polyphenols can cause problems in digestibility,” they admitted, “they may be important dietary supplements with beneficial health effects.”

Most of the antioxidant benefit of fruits and vegetables comes from the component that gives them their color. Just as with the beta-carotene that makes the carrot orange and the lycopene that turns the tomato and the watermelon their gorgeous shades of red, so it is with beans: the darker the hue, the more abundant the supply of valuable micronutrients. According to another recent study, the amount of antioxidants varies greatly in kidney beans, but in general the greatest amount is found in red and black varieties (Choung 2003). In shopping, therefore, shun the pale cannellini and Great Northern and go for the more colorful varieties.

Taking the Pulse of the Pulses

At various times, scientists have tried to agree upon the ideal anti-cancer diet. These consensus statements by large groups of experts have generally spoken in positive tones about peas, beans and lentils (the group collectively known as pulses or legumes) and cowpeas (a related category that includes black-eyed peas). For example, the World Cancer Relief Fund/American Institute for Cancer Research (WCRF/AICR) committee included general recommendations concerning legume consumption. The opinion of the committee was that, in order to minimize the risk of developing cancer, 45-60% of dietary calories should come from starchy or protein-rich foods of plant origin. Pulses are included in this category. The World Health Organization (WHO) has also recommended a daily consumption of 30 grams (about an ounce) of pulses, including nuts and seeds, to reduce the risk of heart disease and some types of cancer.

A breakthrough in nutritional thinking came three years ago when scientists showed that people who ate legumes four times per week had a 22% lower risk of heart disease compared with people who consumed legumes less than once per week (Bazzano 2001). This finally gave empirical justification to the childhood jingle that beans are “good for the heart.” And although beans are high in carbohydrates they have a low-glycemic index (i.e., they are slowly digested), and therefore “provide a sustained source of energy that curbs caloric intake and helps to maintain weight” (Smith 2003). Because of this, beans can help people with diabetes to maintain healthy blood sugar levels.

Research over the past 20 years has in general, supported the health-promoting properties of beans. One older survey found that people who ate lots of beans enjoyed a measure of protection against breast, prostate and colon cancer (Correa 1981). Another study found an inverse trend between legume consumption and the incidence of prostate cancer (Kolonel 2000). Two experimental studies showed that feeding rodents navy, black and pinto beans inhibited the incidence of colon cancer by 52 to 57% (Hangen 2002 and Hughes 1997).

However, in most Western countries, beans get little respect and therefore little research interest. In cancer circles, it’s genes, not beans, that attract the big bucks. Questions on surveys about food consumption typically lump together all pulses, a category that generally includes nuts, seeds, lentils, peas, soy beans as well as all types of dry beans. There has been a tendency to look on beans as a source of cheap calories, but nothing more.

Beaneaters

Culturally, one cannot think of beans without thinking of Boston. At one time the local baseball team was even called the “Beaneaters.” Boston has since become a home of haute cuisine, but here in rural New England we still adhere to the old ways. The Bean Supper is a prominent feature of the social calendar, whether at the local clapboard church, Town House or Odd Fellows’ Hall. But, as a general rule, bean consumption declines as one’s socioeconomic standing improves. (The exceptions being the health-food conscious and the Tex-Mex crazed.) Consumption in Western countries tends to be quite low–a few pounds per head per year.

JENKINTOWN, Pa. — The National Comprehensive Cancer Network announces an important new publication and authoritative source of information to guide the selection of appropriate treatment for patients. The first three chapters of the NCCN Drugs & Biologics Compendium(TM) have been recently released and focus on the appropriate use of drugs and biologics in colon, rectal, and anal cancers.

“A variety of constituencies in the health care community look to NCCN for evaluative information to aid their decision-making. NCCN again is responding to these needs by providing evaluative recommendations in an easy-to-use format,” said William T. McGivney, PhD, CEO of the NCCN. “One target audience for the NCCN Drugs & Biologics Compendium(TM) comprises decision-makers at insurance/managed care companies, PBMs, etc. who seek authoritative and definitive information to establish coverage policies. In cancer care, the issue of the appropriateness of use beyond FDA-approved labeling is critical and is addressed extensively by the Compendium.”

The NCCN Drugs & Biologics Compendium(TM) delineates the appropriate uses of drugs and biologics in the care of cancer patients. The Compendium’s identified uses are derived directly from the NCCN Clinical Practice Guidelines in Oncology(TM), recognized and applied nationally as the standard for clinical policy in oncology. As with the guidelines, the Compendium will span the continuum of cancer care from early stage to advanced stage disease, from supportive care to palliative care. The Compendium is made available free of charge in user-friendly electronic and paper formats.

The Compendium lists disease indications and specific recommendations for use as described in the NCCN Guidelines. The end-user is also provided the recommendation category that defines the level of evidence and degree of consensus that support the recommendation. Published “chapter-by-chapter”, future chapters of the Compendium will concentrate on acute myeloid leukemia, chronic myelogenous leukemia, lung cancer, kidney cancer, testicular cancer, non-Hodgkin’s lymphoma, and breast cancer. NCCN anticipates that it will require 18-24 months to develop a full compendium from the guidelines that address appropriate treatment for 97% of all cancer patients and all major supportive care areas.

For more information on the NCCN Drugs & Biologics Compendium(TM) and other NCCN programs, please contact NCCN at 215-690-0255 or at www.nccn.org.

The National Comprehensive Cancer Network (NCCN), an alliance of 19 of the world’s leading cancer centers, is an authoritative source of information to help patients and health professionals make informed decisions about cancer care. Through the collective expertise of its member institutions, the NCCN develops, updates, and disseminates a complete library of clinical practice guidelines. These guidelines are the standard for clinical policy in oncology. NCCN’s complete spectrum of programs emphasizes improving the quality, effectiveness, and efficiency of oncology practice. Programs include: Clinical Practice Guidelines in Oncology, Drugs & Biologics Compendium, Treatment Guidelines for Patients, the Journal of the National Comprehensive Cancer Network, Leukemia Resource Line, educational conferences and symposia for clinicians, Oncology Outcomes Project, Clinical Trials Network, Cancer Case Manager, and collaborations with managed care organizations. The NCCN member institutions are: City of Hope Cancer Center, Los Angeles, CA; Dana-Farber/Partners CancerCare, Boston, MA; Duke Comprehensive Cancer Center, Durham, NC; Fox Chase Cancer Center, Philadelphia, PA; Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT; Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance, Seattle, WA; Arthur G. James Cancer Hospital and Richard J. Solove Research Institute at The Ohio State University, Columbus, OH; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD; Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL; Memorial Sloan-Kettering Cancer Center, New York, NY; H. Lee Moffitt Cancer Center & Research Institute at the University of South Florida, Tampa, FL; Roswell Park Cancer Institute, Buffalo, NY; St. Jude Children’s Research Hospital/University of Tennessee Cancer Institute, Memphis, TN; Stanford Hospital and Clinics, Stanford, CA; UCSF Comprehensive Cancer Center, San Francisco, CA; University of Alabama at Birmingham Comprehensive Cancer Center, Birmingham, AL; University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; UNMC Eppley Cancer Center at The Nebraska Medical Center, Omaha, NE; and University of Texas M. D. Anderson Cancer Center, Houston, TX.

Treatment for colon cancer depends on how invasive it is and whether it’s metastatic, meaning that it’s spread.

Although treatments vary some, colon cancer must be cut out, with an adequate margin of healthy cells to be sure that it’s all been removed. Dr. Brent Christensen said that surgeons go for a 5- centimeter margin all around it, at a safe minimum.

Christensen, vice chairman of the Department of Surgery at LDS Hospital, and Dr. Leslye Ingersoll, a radiation oncologist at Utah Valley Regional Medical Center, will be featured in today’s Deseret Morning News/Intermountain Health Care Hotline. From 10 a.m. to noon, they’ll take calls about colon cancer and screening, as well as offer some prevention tips.

When a tumor in the colon is removed, along with the lymph nodes, the remaining sections are rejoined. Then the surgeon “explores the abdomen and looks at the liver to make sure it’s not a metastatic tumor.”

If the tumor has spread, some surgeons will remove tumors from the liver, as well. Others will refer the patient to a liver specialist, depending on how much experience he or she has with livers, he said.

A pathologist examines what has been removed to see how far into the colon wall the cancer extends. If it is on the surface and lymph nodes are not involved, it’s a stage 1 tumor, which has about a 95 percent chance of a cure without further care.

Follow-up colonoscopies, blood tests and examinations then take place at three months, six months and yearly after that if there’s no recurrence.

When the tumor extends deeper into the muscle but hasn’t reached the lymph nodes, it’s stage 2 with a 70 percent chance of survival with surgery alone. (There’s a different classification system, called Duke’s A, B, C or D that is comparable to the stages 1 to 4).

At stage 3 — in the lymph nodes and deeper into the wall — surgery alone yields only a 30 percent cure rate. Chemotherapy is added and improves the cure rate to 70 percent.

“Chemotherapy for colon cancer was not considered a good option until about the 1990s,” Christensen said. “Then a combination was developed that worked very well.”

Radiation is also used with colon cancer.

At stage 4, metastatic, in the lungs, liver, etc., the prognosis is “very poor,” he said.

That’s why screening is so important. A colonoscopy can detect precancerous changes in the colon, like polyps, that can be removed before they become a problem.

“I think people are a lot better over the years. We see more people coming in, they’re not afraid of it (the colonoscopy),” Christensen said. But there are holdouts. “Some people do a little ostrich, head in the sand.”

Colonoscopy, where a specialist examines the colon with a scope, is considered the gold standard screening, he said, because early changes can be removed, suspicious sections biopsied.

But Christensen believes that there is a place for “virtual colonoscopy” as well. It’s a CT scan of the colon. But the hard part of a colonoscopy is the preparation to clean out the bowel. You need that for a scan as well.

The virtual colonoscopy will see lesions down to 1 centimeter in size but not smaller ones. He believes the virtual colonoscopy will come into its own when so many people have gotten the message on screening that those who do colonoscopies can’t keep up.

The virtual test may become the initial screening, but for that to happen, prices would have to drop and insurance companies start paying for it. If the technology ever improves to pick up smaller lesions, that would make it more valuable as well, he said.

As for recovery, it depends on what is found. In most cases, someone with surgery for colon cancer will be in the hospital as much as a week, waiting for bowel function to return so he can eat and to make sure that bleeding, leaking or infection aren’t a problem.

Those who have laparoscopic surgery seem to recover a little faster, but it isn’t always possible to do the surgery that way.

If the cancer is too low in the rectum to resect and leave sphincter muscles intact, an individual must have a colostomy, where the bowel is channeled out through the wall of the abdomen into a bag.