NCPR-CC 2ND REPORT...4 Table 4.2: Table 4.4: Table 4.6: Table 3.1: Basis of diagnosis of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007

January 2019

© National Cancer Patient Registry - Colorectal Cancer (NCPR-CC)

Published by:

Clinical Research Centre, Sultanah Bahiyah Hospital, Alor Setar, Kedah

Contact:

National Cancer Patient Registry - Colorectal Cancer

NCPR-CC Coordinating Centre

c/o

Clinical Research Centre

Level 2, Sultanah Bahiyah Hospital

KM 6, Jalan Langgar

05460 Alor Setar, Kedah

Malaysia

General line : (604) 7406227 / 7390 / 7391

Fax : (604) 7407373

Disclaimer

Caution is advised when drawing conclusions from the report, as the findings

were generated using only the data from the NCPR-CC. Apart from that, the

interpretation of the findings was performed by the authors, and their views do

not necessarily reflect those of their affiliated institutions and the publisher. It is

also noteworthy that the notification of the latest conditions of patients is an

ongoing process, and the authors had ensured that the analysis was

conducted using the most up-to-date data.

This report is copyrighted. Reproduction and dissemination of this report in part

or in whole for research, educational or other non-commercial purposes are

authorized without any prior written permission from the copyright holders,

provided that the source is fully acknowledged.

Suggested citation

MRA Hassan, NRN Mustapha, SA Soelar, I Ismail, SMM Ali, MADM Mansor, HK

Chan. National Cancer Patient Registry - Colorectal Cancer: 2nd Report for

the Northern Malaysia (2007 – 2017). Alor Setar, Malaysia 2019.

2

TABLE OF CONTENTS TABLE OF CONTENTS .......................................................................................................................... 2 LIST OF TABLES.................................................................................................................................... 3 ACKNOWLEDGEMENT .......................................................................................................................... 7 FOREWORD ........................................................................................................................................... 8 NCPR-CC STEERING COMMITTEE ...................................................................................................... 9 MEDICAL WRITING COMMITTEE ....................................................................................................... 10 MEMBERS OF NCPR-CC COORDINATING CENTRE ........................................................................ 10 ABOUT THE NATIONAL CANCER PATIENT REGISTRY - COLORECTAL CANCER (NCPR – CC) 11

Introduction ........................................................................................................................................ 11 Rationale ........................................................................................................................................... 11 Objectives .......................................................................................................................................... 11

DESIGN OF THE REGISTRY REPORT ................................................................................................ 12 POPULATION & PATIENT RECRUITMENT ........................................................................................ 12

Selection of subjects .......................................................................................................................... 12 Inclusion criteria ................................................................................................................................. 12 Exclusion criteria................................................................................................................................ 12

DATA COLLECTION ............................................................................................................................ 13 DATABASE MONITORING AND DATA MANAGEMENT .................................................................... 13 SOURCE DATA PROVIDERS / SDP .................................................................................................... 14 SELECTION OF PATIENTS ................................................................................................................. 15 DATA ANALYSIS.................................................................................................................................. 16

Descriptive statistics and cross tabulation ......................................................................................... 16 Crude and age-standardised rates .................................................................................................... 16

CHAPTER 1: DEMOGRAPHICS ......................................................................................................... 19 RESULTS .......................................................................................................................................... 20

CHAPTER 2: RISK FACTORS AND CLINICAL PRESENTATIONS .................................................. 26 RESULTS .......................................................................................................................................... 27

CHAPTER 3: FINAL STAGING ........................................................................................................... 38 RESULTS .......................................................................................................................................... 39

CHAPTER 4: PATHOLOGY ................................................................................................................ 49 RESULTS .......................................................................................................................................... 50

CHAPTER 5: TREATMENT MODALITIES .......................................................................................... 57 RESULTS .......................................................................................................................................... 58

CHAPTER 6: INCIDENCE AND MORTALITY .................................................................................... 71 RESULTS .......................................................................................................................................... 72

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LIST OF TABLES

CHAPTER 1 : DEMOGRAPHICS

Table 2.1: Smoking status and diabetes mellitus of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ...................................................................................................... 27 Table 2.2: Smoking status by age group, gender, ethnicity and education level of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ..................................................... 28 Table 2.3: Diabetes mellitus by age group, gender, ethnicity and education level of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ..................................................... 29 Table 2.4: Personal cancer history of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 .................................................................................................................................. 30 Table 2.5: Family cancer history of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 .................................................................................................................................. 31 Table 2.6: Family cancer history by age group, gender, ethnicity and education level of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ......................................... 32 Table 2.7: Symptoms at diagnosis of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 .................................................................................................................................. 33 Table 2.8: Symptoms at diagnosis by age group of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ...................................................................................................... 34 Table 2.9: Symptoms at diagnosis by gender of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ................................................................................................................. 35 Table 2.10: Symptoms at diagnosis by ethnicity of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ...................................................................................................... 35

Figure 2.1: Distributions of smoking status and diabetes mellitus among colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ....................................... 36 Figure 2.2: Four most common clinical presentations at diagnosis among colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ....................................... 36

CHAPTER 2 : RISK FACTORS AND CLINICAL

PRESENTATIONS

Table 1.1: Total number of colorectal cancer cases by centres in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 .................................................................................................................................. 20 Table 1.2: Demographics of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ................................................................................................................................................ 21 Table 1.3: Age Distribution by gender and ethnicity of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ...................................................................................................... 22 Table 1.4: Gender distribution by ethnicity and education level of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ...................................................................................... 22

Figure 1.1: Distribution of age groups of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ....................................................................................... 23 Figure 1.2: Distribution of age groups by gender and ethnicity of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ........................................................ 23 Figure 1.3: Distribution of age groups by gender of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ....................................................................... 24

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Table 3.1: Basis of diagnosis of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 .................................................................................................................................. 39 Table 3.2: Basis of diagnosis by age group, gender, ethnicity and education level of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ..................................................... 40 Table 3.3: Primary cancer sites of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 .................................................................................................................................. 41 Table 3.4: Primary cancer sites by age group of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ................................................................................................................. 42 Table 3.5: Primary cancer sites by gender of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ................................................................................................................. 43 Table 3.6: Primary cancer sites by ethnicity of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ................................................................................................................. 43 Table 3.7: Clinical staging of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ................................................................................................................................................ 44 Table 3.8: Clinical staging by age group, gender, ethnicity and education level of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ..................................................... 45 Table 3.9: Clinical staging by family history of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ................................................................................................................. 46

Figure 3.1: Distribution of primary cancer sites among colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ....................................................................... 47 Figure 3.2: Distribution of clinical staging among colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ....................................................................... 47

CHAPTER 3 : FINAL STAGING

Table 4.1: Types of specimens used in histologic diagnosis of colorectal cancer in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ...................................................................................................... 50 Table 4.2: Primary cancer sites identified using resection specimens in colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ....................................................................... 50 Table 4.3: Pathologic (pTNM) staging of colorectal cancer based on resection specimens in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ...................................................................................... 51 Table 4.4: Post-neoadjuvant-chemotherapy pathologic evaluation (ypTNM) of colorectal cancer based on resection specimen in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 .............................. 52 Table 4.5: Number of examined and positive lymph nodes of colorectal cancer patients with resection specimens undergoing pathologic (pTNM) staging in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ................................................................................................................................................ 52 Table 4.6: Pathologic staging (pTNM) by number of lymph nodes examined of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ................................................................... 53 Table 4.7: Tumor differentiation and synchronous tumors of colorectal cancer patients with resection specimens undergoing pathologic (pTNM) staging in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ................................................................................................................................................ 54 Table 4.8: Pathologic staging (pTNM) by tumor differentiation of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ...................................................................................... 55

CHAPTER 4 : PATHOLOGY

5

Table 5.1: Treatment used in colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ................................................................................................................................................ 58 Table 5.2: Treatment used by age group of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ................................................................................................................. 59 Table 5.3: Treatment used by gender of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ................................................................................................................. 60 Table 5.4: Treatment used by ethnicity of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ................................................................................................................. 60 Table 5.5: Treatment used by clinical staging of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ................................................................................................................. 61 Table 5.6: Surgical interventions and procedures performed in colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ...................................................................................... 62 Table 5.7: Surgical interventions and procedures performed by age group of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ................................................................... 63 Table 5.8: Surgical interventions and procedures performed by gender of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ....................................................................... 64 Table 5.9: Surgical interventions and procedures performed by ethnicity of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ....................................................................... 65 Table 5.10: Surgical interventions and procedures performed by clinical staging of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ..................................................... 66 Table 5.11: Chemotherapy protocols or regimens of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ...................................................................................................... 67 Table 5.12: Chemotherapy protocols or regimens by clinical staging of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ....................................................................... 68

Figure 5.1: Distribution of treatment used of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ....................................................................................... 68

CHAPTER 5 : TREATMENT MODALITIES

6

Table 6.1: Status (alive/dead) by age group of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ................................................................................................................. 72 Table 6.2: Status (alive/dead) by gender and ethnicity of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ..................................................................................... 74 Table 6.3: Incidence rate (per 100,000) by age group of male and female colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ...................................................................... 75 Table 6.4: Mortality rate (per 100,000) by age group of male and female colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ...................................................................... 75 Table 6.5: Incidence rate (per 100,000) by age group of three ethnic groups of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ..................................................... 76 Table 6.6: Mortality rate (per 100,000) by age group of three ethnic groups of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 .................................................................. 76 Table 6.7: Incidence rate (per 100,000) by gender of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ..................................................................................................... 77 Table 6.8: Mortality rate (per 100,000) by gender of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ..................................................................................................... 77 Table 6.9: Incidence rate (per 100,000) by ethnicity of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ..................................................................................................... 78 Table 6.10: Mortality rate (per 100,000) by ethnicity of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ..................................................................................................... 79 Table 6.11: Status (alive/dead) by clinical staging of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 ..................................................................................................... 80

Figure 6.1: Distribution of age-standardized incidence rates (per 100,000) by gender of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 .......... 81 Figure 6.2: Distribution of age-standardized mortality rates (per 100,000) by gender of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 .......... 81 Figure 6.3: Distribution of age-standardized incidence rates (per 100,000) by ethnicity of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 .......... 82 Figure 6.4: Distribution of age-standardized mortality rates (per 100,000) by ethnicity of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017 .......... 82

CHAPTER 6 : PATIENT STATUS

7

ACKNOWLEDGEMENT

The National Cancer Patient Registry - Colorectal Cancer (NCPR-CC) team

would like to thank the following parties for their continuous support,

contribution, assistance and encouragement.

• Director-General of Health, Ministry of Health Malaysia, for his support and approval to publish the findings in this report.

• Ministry of Health Malaysia for funding the registry. • Members of the NCPR-CC steering committee for their expertise, time,

and effort dedicated to the registry.

• National Clinical Research Centre for the guidance and technical supports.

• All source data providers (SDPs), including both the public and private institutions.

• Heads and staff of the pathology, gastroenterology, oncology, and colorectal surgery services.

• All the histopathologists involved. • All hospital directors, clinicians and surgeons of the SDPs. • State epidemiologists of Perlis, Kedah and Penang. • Staff of medical record units of all the SDPs. • The registry coordinating centre team and technical support team. • Staff of the Clinical Research Centre, Sultanah Bahiyah Hospital, Alor

Setar, Kedah.

Thank you.

National Cancer Patient Registry - Colorectal Cancer (NCPR-CC)

Ministry of Health Malaysia

8

FOREWORD

Alhamdulillah, the National Cancer Patient Registry - Colorectal

Cancer (NCPR-CC) team is truly honoured to present our

second report on the epidemiology and burden of colorectal

cancer (CRC) in Northern Malaysia. Over the past few years,

we have been working collaboratively on collating data from all

the selected source data providers (SDPs) in Malaysia. In this

report, the data contributed by both the public and private

institutions across three states in Northern Malaysia, namely

Perlis, Kedah and Penang, are presented.

The information highlighted in this report includes the incidence

and mortality of CRC, and its socio-demographic, clinical and

histopathological profiles. Such information is valuable in

helping identify the risk factors of CRC, as well as devise

strategies to improve the overall CRC prevention and

management in Malaysia.

I would also like to take this opportunity to congratulate and

convey my utmost gratitude to all the team members, who had

been contributing immensely to the success of this report,

directly or indirectly. Indeed, it was not an easy task. It has

become a reality as a result of dedication and teamwork from

the NCPR-CC steering committee and all the parties involved.

I would also like to extend our sincere appreciation to the

Director General of Health, Ministry of Health Malaysia, and

the National Clinical Research Centre for their continuous

financial and technical support. Without them, this project

would not be possible.

Thank you.

Datuk Dr Muhammad Radzi bin Abu Hassan

Principal Investigator

National Cancer Patient Registry-Colorectal Cancer (NCPR-CC)

Such information is valuable in helping identify risk factors of CRC, as well as devising strategies

to improve the overall CRC

prevention and management in

Malaysia. ”

“

9

NCPR-CC STEERING COMMITTEE

NAME INSTITUTION Datuk Dr Muhammad Radzi Abu Hassan Department of Internal Medicine,

Sultanah Bahiyah Hospital, Alor Setar, Kedah

Datin Dr Nik Raihan Nik Mustapha Department of Pathology,


Dato’ Dr Fitjerald Henry Department of Surgery, Selayang Hospital, Selangor

Dr Hajjah Rosaida Hj Mohd Said Department of Internal Medicine,

Ampang Hospital, Kuala Lumpur

Dr Arjunan Saravanan Department of Internal Medicine,

Kuala Lumpur Hospital

Mr Nik Azim Nik Abdullah Department of Surgery,

Sarawak General Hospital

Dr Noor Laili Mokhtar Department of Pathology,

Serdang Hospital, Selangor

Dr Mukarramah bt Che Ayub Department of Pathology,

Raja Perempuan Zainab II Hospital, Kelantan

Mr Andee Dzulkarnaen Zakaria Department of Surgery,

Science University of Malaysia Hospital

Prof Datuk Dr Ismail Sagap Department of Surgery,

National University of Malaysia Hospital

Dr Gerard Lim Chin Chye Department of Radiotherapy & Oncology,

National Cancer Institute

Dr Azizah Ab Manan National Cancer Registry,

National Cancer Institute

Dr Shahrul Bariyah Ahmad Non-Communicable Disease Unit,

Kedah State Health Department

Dr Sharifah Saffinas Syed Soffian Non-Communicable Disease Unit,

Kedah State Health Department

Dr Farzaana Adam Non-Communicable Disease Unit,

Penang State Health Department

Dr Nordin Bin Mohamed Non-Communicable Disease Unit,

Perlis State Health Department

Dr Goh Pik Pin Director,

Institute of Clinical Research

Dr Jamaiyah Haniff Malaysia Healthcare Performance Unit,

Ministry of Health Malaysia

Mr Patrick Lum See Kai Precision Soft Sdn Bhd

10

MEDICAL WRITING COMMITTEE

NAME INSTITUTION Datuk Dr Muhammad Radzi Abu Hassan Senior Consultant,

Department of Medicine,


Datin Dr Nik Raihan Nik Mustapha Senior Consultant, Department of Pathology,


Mr Chan Huan Keat Pharmacist, Clinical Research Centre,


Dr Siti Maisarah Md. Ali Medical Officer, Clinical Research Centre,


Dr Mohd Ammar Dzakirin bin Mansor Medical Officer, Clinical Research Centre,


Mr Shahrul Aiman Soelar Statistician, Clinical Research Centre,


Ms Ibtisam Ismail Research Officer, Clinical Research Centre,


MEMBERS OF NCPR-CC COORDINATING CENTRE

ROLE NAME Principle Investigator Datuk Dr Muhammad Radzi Abu Hassan

Manager Ms Ibtisam Ismail Ms Faizah Ahmad

Statistician/

Graphic Designer Mr Shahrul Aiman Soelar

Medical Officer Dr Siti Maisarah Md. Ali Dr Mohd Ammar Dzakirin bin Mansor

Pharmacist Mr Chan Huan Keat

Nurses Ms Siti Aishah Aris Mr Mohamad Faiz bin Mustafa

Registry Coordinators Ms Wan Muhana Abdullah Ms Nor Hafiza Johari

Ms Zainab Shafie

Ms Siti Ertina Asli

Ms Neoh Poh Tiew

Ms Jambi Md Hussain

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ABOUT THE NATIONAL CANCER PATIENT REGISTRY -

COLORECTAL CANCER (NCPR – CC)

Introduction The National Cancer Patient Registry - Colorectal Cancer (NCPR – CC) was started in October 2007, involving nine hospitals in Malaysia at the initial stage.

It was designed as a multi-centre and multidisciplinary project, engaging

gastroenterologists, colorectal surgeons, pathologists and oncologists. Up until

2017, this registry had been expanded to involve a total of 25 hospitals across

the country.

The registry is fully funded by the Ministry of Health with the realization that its

establishment is crucial in understanding the epidemiology and burden of

colorectal cancer in Malaysia. The grant has been disbursed through the

Clinical Research Centre, while the coordinating centre of the registry is based

at the Clinical Research Centre, Sultanah Bahiyah Hospital, Alor Setar, Kedah.

Rationale The NCPR - CC has been systematically collecting data on all aspects of

colorectal cancer as to its prevention, management, and treatment in

Malaysia. One of the aims of the registry is to guide the Ministry of Health

Malaysia in formulating policies for the prevention and management of

colorectal cancer (CRC). In addition, the information may also be beneficial

for non-governmental organizations, private healthcare providers and

healthcare industries.

Objectives The objectives of this report are:

1. To estimate the incidence and mortality rates of CRC in Northern

Malaysia.

2. To explore the socio-demographic profiles of CRC patients in Northern

Malaysia.

3. To determine the risk factors of CRC in Northern Malaysia.

4. To study the cancer stages and clinical presentations at diagnosis, as

well as the histopathological profiles of tumors among CRC patients in

Northern Malaysia.

5. To evaluate the treatment modalities commonly used in CRC patients

in Northern Malaysia.

12

DESIGN OF THE REGISTRY REPORT A multi-centre, cross-sectional study design was applied to explore the

epidemiology and burden of CRC in Northern Malaysia. All confirmed CRC

cases from the participating source data providers (SDPs) which met the

inclusion criteria were included in the analysis. These cases were identified by

gastroenterologists, colorectal surgeons, pathologists, oncologists, and health

care staff who directly and indirectly took part in the CRC management.

POPULATION & PATIENT RECRUITMENT

Selection of subjects For a report of a patient registry, the inclusion criteria were kept deliberately

broad. To ensure that the findings presented were representative of the

targeted population, all the patients who were followed up for the CRC

treatment at any of the hospitals in Northern Malaysia (the states of Perlis,

Kedah, and Penang) were included in the analysis.

Inclusion criteria • All histologically verified or clinically diagnosed primary CRC cases

during January 2007 and December 2017 irrespective of stages and

duration of disease.

Exclusion criteria • Non-adenocarcinoma cases (e.g. neuroendocrine tumors &

lymphomas), anal cancer, and metastatic lesions to colon and rectum.

• Non-Malaysians.

13

DATA COLLECTION The data on demographics, clinical history, family history, tumor

histopathology, and treatment (including surgical, oncology, and palliative

treatment) was obtained from patient medical records by designated officers,

supervised by site coordinators and investigators.

There were no prescribed study visits. Patients attended the clinical sites as and

when required, as per standard of care at these sites. The required data of any

new or existing cases were collected as they became available, and were

subsequently notified to the registry by the SDPs.

The data were collected using standardized, web-based electronic case

report forms (eCRFs) which were readily available to all the SDPs. The data

collection via eCRFs, along with the maintenance of the database, were

implemented using a third-party software application (Datamed Clinical

Computing Services Sdn. Bhd.), which was fully validated and conformed to

the regulatory requirements for electronic data capture. Alternatively, a hard

copy of CRF was used for data collection whenever the eCRF was not

available due to any technical reasons.

The pathologic staging was performed based on the 5th edition TNM staging

system. The current status of the registered cases (dead or alive) was

ascertained by cross-checking with the records of the National Registration

Department, Ministry of Home Affairs Malaysia.

DATABASE MONITORING AND DATA MANAGEMENT Database monitoring and management, with the technical support from the

Datamed Clinical Computing Services Sdn. Bhd., were performed by research

assistants under the supervision of the principal investigator and the Clinical

Research Centre, Sultanah Bahiyah Hospital, in compliance with the patient

data protection regulations.

14

SOURCE DATA PROVIDERS / SDP All the cases notified to the registry were identified through a combination of

different sources, including notification by medical professionals and patient

medical records. Besides, histopathology reports were also used as an

important source for the identification of new cases. All cases obtained from

the sources other than notification by physicians were crossed-checked with

the registry to avoid duplication, and the treating physicians were

subsequently requested to notify any cases which were yet to be captured by

the registry.

In this report, the findings were generated based on the data contributed by

all the participating SDPs in Northern Malaysia, which are as listed below:

PERLIS

• State Health Department, Perlis

• Tuanku Fauziah Hospital, Kangar

KEDAH

• State Health Department, Kedah

• Sultanah Bahiyah Hospital, Alor Setar

• Sultan Abdul Halim Hospital, Sungai Petani

• Kulim Hospital, Kulim

• Putra Medical Centre, Alor Setar

• Kedah Medical Centre, Alor Setar

• Pantai Hospital, Sungai Petani

• Metro Specialist Hospital, Sungai Petani

PULAU PINANG

• State Health Department, Pulau Pinang

• Pulau Pinang Hospital, Pulau Pinang

• Seberang Jaya Hospital, Pulau Pinang

• Kepala Batas Hospital, Pulau Pinang

• Lam Wah Ee Hospital, Pulau Pinang

• Penang Adventist Hospital, Pulau Pinang

• Island Hospital, Pulau Pinang

• Pantai Hospital, Pulau Pinang

• Loh Guan Lye Specialists Center,

Pulau Pinang

• Advanced Medical and Dental Institute,

Pulau Pinang

• KPJ Penang Specialist Hospital,

Pulau Pinang

15

SELECTION OF PATIENTS In total, 16,238 CRC cases were notified to the registry by all the SDPs in

Northern Malaysia between February 2007 and December 2017. After

excluding the duplicate cases, and the cases diagnosed before and after the

study period, a total of 6,172 cases were included for further analysis. The

summary of the patient selection process is illustrated below:

ANALYSIS

DATA

Note: JKN – State Health Department. JPN – National Registration Department.

16

DATA ANALYSIS

Descriptive statistics and cross tabulation Data cleaning, management and analyses were performed using the R

Software for Windows Version 3.5.11. The results of the analysis for categorical

data were presented as frequencies and percentages, while those for

numerical data were expressed as means and standard deviations (SDs), or

medians and interquartile ranges, as appropriate.

Crude and age-standardised rates The crude and age-standardised rates (ASRs) for both the incidence and

mortality of CRC were computed. ASR is defined as the incidence or mortality

rate of a disease per 100,000 in a population with a standard age structure. It

is an internationally accepted parameter to reflect the incidence or mortality

rate of a disease by taking both the population size and age into

consideration.

In this study, ASR was calculated by using the following equation:

ASR = ∑𝑟𝑖 (𝑛𝑖𝑠𝑁𝑖𝑠)

where 𝑟𝑖 is the weight factor for the world standard population of the ith age class recommended by the World Health Organization,2 𝑛𝑖𝑠 is the CRC incidence or mortality in the population of the ith age class generated from

the data of the NCPR-CC, and 𝑁𝑖𝑠 is the population size of the ith age class obtained from the Department of Statistics, Malaysia3.

1 Team RC. R: A language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing; 2014. 2014. 2 Ahmad OB, Boschi-Pinto C, Lopez AD, Murray CJ, Lozano R, Inoue M, et al. Age standardization of rates: a new WHO standard. World Health Organization Geneva; 2001. 3 Malaysia JP. Taburan penduduk dan ciri-ciri asas demografi. Laporan Banci Penduduk Dan Perumahan Malaysia Kuala Lumpur: Jabatan Perangkaan Malaysia 2010.

17

54.1% MALE FEMALE

45.9%

1.1% 1.5%

60years

3.4% 3.6%

9.0% 10.5%

22.8% 22.5%

63.8% 61.8% 62.9%

22.6%

9.7%

3.5%

1.3%

QUICK FACTS!

18

QUICK FACTS!

19

CHAPTER 1: DEMOGRAPHICS

• From 2007 to 2017, a total of 6,172 colorectal cancer (CRC) cases in Northern Malaysia were notified to the registry. Generally, no

considerable changes in the number of CRC cases were observed

across the years. The highest number of CRC cases was recorded in 2016

(n=634), and the lowest in 2007 (n=426) (Table 1.1).

• The age of CRC patients ranged from 14 to 98 years, with a mean of 63.1 (SD=13.00) years. Of all the patients, 6.2% did not receive formal

education. Most of them had secondary education (14.7%), and only

3.8% had tertiary education (Table 1.2).

• Most of the patients were male (54.1%) (Table 1.2). The number of CRC cases was also found to increase with age until 65-70 years and decline

afterwards, and similar trends were observed in men and women (Table

1.3).

• Among all the ethnic groups, Chinese recorded the highest number of CRC cases (n=1923; 57.5%), followed by Malay (n=1180 cases; 35.3%)

and Indian (n=197 cases; 5.9%). Men recorded a higher number of cases

as compared with women in all the ethnic groups (Table 1.4).

20

RESULTS

Table 1.1: Total number of colorectal cancer cases by centres in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017

Participating Hospitals All patients

Year

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)

1 1,384 (22.4) 77 (18.1) 133 (23.1) 140 (23.7) 126 (21.0) 134 (25.0) 81 (15.1) 134 (24.5) 121 (21.9) 168 (27.2) 147 (23.2) 123 (22.2) 2 1,043 (16.9) 14 (3.3) 75 (13.0) 89 (15.1) 96 (16.0) 93 (17.3) 88 (16.4) 111 (20.3) 109 (19.7) 112 (18.1) 148 (23.3) 108 (19.5) 3 824 (13.4) 8 (1.9) 110 (19.1) 87 (14.7) 86 (14.3) 78 (14.5) 91 (17.0) 78 (14.2) 62 (11.2) 85 (13.8) 63 (9.9) 76 (13.7) 4 430 (7.0) 3 (0.7) 37 (6.4) 39 (6.6) 46 (7.7) 41 (7.6) 34 (6.3) 38 (6.9) 53 (9.6) 44 (7.1) 41 (6.5) 54 (9.7) 5 428 (6.9) 128 (30.0) 32 (5.6) 33 (5.6) 24 (4.0) 16 (3.0) 21 (3.9) 21 (3.8) 17 (3.1) 32 (5.2) 51 (8.0) 53 (9.6) 6 342 (5.5) 27 (6.3) 35 (6.1) 20 (3.4) 29 (4.8) 24 (4.5) 24 (4.5) 31 (5.7) 41 (7.4) 28 (4.5) 49 (7.7) 34 (6.1) 7 270 (4.4) 15 (3.5) 29 (5.0) 15 (2.5) 18 (3.0) 15 (2.8) 41 (7.6) 30 (5.5) 37 (6.7) 38 (6.1) 17 (2.7) 15 (2.7) 8 252 (4.1) 6 (1.4) 36 (6.3) 39 (6.6) 38 (6.3) 26 (4.8) 32 (6.0) 26 (4.7) 39 (7.1) 10 (1.6) 0 (0.0) 0 (0.0) 9 248 (4.0) 139 (32.6) 8 (1.4) 7 (1.2) 11 (1.8) 7 (1.3) 3 (0.6) 6 (1.1) 7 (1.3) 19 (3.1) 26 (4.1) 15 (2.7) 10 243 (3.9) 5 (1.2) 21 (3.7) 18 (3.1) 28 (4.7) 20 (3.7) 23 (4.3) 23 (4.2) 21 (3.8) 31 (5.0) 33 (5.2) 20 (3.6) 11 207 (3.4) 1 (0.2) 17 (3.0) 37 (6.3) 23 (3.8) 21 (3.9) 23 (4.3) 6 (1.1) 16 (2.9) 17 (2.8) 23 (3.6) 23 (4.2) 12 185 (3.0) 2 (0.5) 19 (3.3) 31 (5.3) 34 (5.7) 35 (6.5) 41 (7.6) 18 (3.3) 4 (0.7) 1 (0.2) 0 (0.0) 0 (0.0) 13 68 (1.1) 0 (0.0) 3 (0.5) 9 (1.5) 10 (1.7) 6 (1.1) 11 (2.1) 2 (0.4) 4 (0.7) 8 (1.3) 8 (1.3) 7 (1.3) 14 67 (1.1) 0 (0.0) 4 (0.7) 14 (2.4) 14 (2.3) 6 (1.1) 5 (0.9) 4 (0.7) 7 (1.3) 4 (0.6) 3 (0.5) 6 (1.1) 15 58 (0.9) 1 (0.2) 5 (0.9) 7 (1.2) 5 (0.8) 11 (2.0) 7 (1.3) 6 (1.1) 3 (0.5) 6 (1.0) 6 (0.9) 1 (0.2) 16 55 (0.9) 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.2) 0 (0.0) 2 (0.4) 3 (0.5) 7 (1.3) 11 (1.8) 14 (2.2) 17 (3.1) 17 29 (0.5) 0 (0.0) 7 (1.2) 5 (0.8) 4 (0.7) 3 (0.6) 1 (0.2) 3 (0.5) 0 (0.0) 1 (0.2) 3 (0.5) 2 (0.4) 18 20 (0.3) 0 (0.0) 4 (0.7) 0 (0.0) 6 (1.0) 0 (0.0) 2 (0.4) 6 (1.1) 2 (0.4) 0 (0.0) 0 (0.0) 0 (0.0) 19 11 (0.2) 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.2) 0 (0.0) 4 (0.7) 1 (0.2) 1 (0.2) 2 (0.3) 2 (0.3) 0 (0.0) 20 8 (0.1) 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.2) 1 (0.2) 2 (0.4) 1 (0.2) 2 (0.4) 1 (0.2) 0 (0.0) 0 (0.0) Overall 6,172 (100.0) 426 (100.0) 575 (100.0) 590 (100.0) 601 (100.0) 537 (100.0) 536 (100.0) 548 (100.0) 553 (100.0) 618 (100.0) 634 (100.0) 554 (100.0)

21

Table 1.2: Demographics of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017

Characteristics

All patients, n=6,172

Year

2007, n=426 2008, n=575 2009, n=590 2010, n=601 2011, n=537 2012, n=536 2013, n=548 2014, n=553 2015, n=618 2016, n=634 2017, n=554

n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)

Age (years) n 6,172 426 575 590 601 537 536 548 553 618 634 554

Mean 63.1 62.9 63.0 64.2 62.7 63.5 63.4 63.2 62.4 62.5 62.9 63.2 Standard Deviation 13.00 13.04 13.36 13.16 13.23 13.06 13.27 12.83 13.33 12.68 12.43 12.67

Age groups (years) 80 565 (9.2) 32 (7.5) 58 (10.1) 58 (9.8) 55 (9.2) 54 (10.1) 54 (10.1) 54 (9.9) 49 (8.9) 53 (8.6) 51 (8.0) 47 (8.5)

Gender Male 3,342 (54.1) 224 (52.6) 303 (52.7) 324 (54.9) 327 (54.4) 299 (55.7) 303 (56.5) 295 (53.8) 316 (57.1) 320 (51.8) 317 (50.0) 314 (56.7) Female 2,830 (45.9) 202 (47.4) 272 (47.3) 266 (45.1) 274 (45.6) 238 (44.3) 233 (43.5) 253 (46.2) 237 (42.9) 298 (48.2) 317 (50.0) 240 (43.3)

Ethnicity Malay 2,216 (35.9) 122 (28.6) 172 (29.9) 212 (35.9) 215 (35.8) 178 (33.1) 179 (33.4) 185 (33.8) 224 (40.5) 217 (35.1) 275 (43.4) 237 (42.8) Chinese 3,503 (56.8) 272 (63.8) 347 (60.3) 333 (56.4) 343 (57.1) 314 (58.5) 318 (59.3) 321 (58.6) 298 (53.9) 359 (58.1) 315 (49.7) 283 (51.1) Indian 382 (6.2) 29 (6.8) 47 (8.2) 34 (5.8) 38 (6.3) 36 (6.7) 30 (5.6) 37 (6.8) 26 (4.7) 37 (6.0) 39 (6.2) 29 (5.2) Others 71 (1.2) 3 (0.7) 9 (1.6) 11 (1.9) 5 (0.8) 9 (1.7) 9 (1.7) 5 (0.9) 5 (0.9) 5 (0.8) 5 (0.8) 5 (0.9)

Education level No formal education 385 (6.2) 1 (0.2) 50 (8.7) 38 (6.4) 37 (6.2) 25 (4.7) 48 (9.0) 53 (9.7) 70 (12.7) 36 (5.8) 20 (3.2) 7 (1.3) Primary 594 (9.6) 7 (1.6) 48 (8.3) 58 (9.8) 59 (9.8) 54 (10.1) 64 (11.9) 65 (11.9) 81 (14.6) 66 (10.7) 50 (7.9) 42 (7.6) Secondary 906 (14.7) 14 (3.3) 48 (8.3) 66 (11.2) 72 (12.0) 49 (9.1) 71 (13.2) 89 (16.2) 141 (25.5) 142 (23.0) 109 (17.2) 105 (19.0) Tertiary 234 (3.8) 2 (0.5) 18 (3.1) 15 (2.5) 26 (4.3) 13 (2.4) 20 (3.7) 30 (5.5) 34 (6.1) 22 (3.6) 26 (4.1) 28 (5.1) Unknown 4,053 (65.7) 402 (94.4) 411 (71.5) 413 (70.0) 407 (67.7) 396 (73.7) 333 (62.1) 311 (56.8) 227 (41.0) 352 (57.0) 429 (67.7) 372 (67.1)

22

Table 1.3: Age Distribution by gender and ethnicity of colorectal cancer

patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017

Characteristics

Gender Ethnicity

Male Female Malay Chinese Indian Others

n (%) n (%) n (%) n (%) n (%) n (%)

Age groups (years)

80 270 (8.1) 295 (10.4) 103 (4.6) 441 (12.6) 13 (3.4) 8 (11.3) Overall 3,342 (100.0) 2,830 (100.0) 2,216 (100.0) 3,503 (100.0) 382 (100.0) 71 (100.0)

Table 1.4: Gender distribution by ethnicity and education level of colorectal

cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017

Characteristics Male, n=3,342 Female, n=2,830

n (%) n (%)

Ethnicity Malay 1,180 (35.3) 1,036 (36.6) Chinese 1,923 (57.5) 1,580 (55.8) Indian 197 (5.9) 185 (6.5) Others 42 (1.3) 29 (1.0)

Education level No formal education 160 (4.8) 225 (8.0) Primary 315 (9.4) 279 (9.9) Secondary 523 (15.6) 383 (13.5) Tertiary 160 (4.8) 74 (2.6) Unknown 2,184 (65.4) 1,869 (66.0)

23

Figure 1.1: Distribution of age groups of colorectal cancer patients in Northern

Malaysia; NCPR-Colorectal Cancer, 2007-2017

Figure 1.2: Distribution of age groups by gender and ethnicity of colorectal

cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017

24

Figure 1.3: Distribution of age groups by gender of colorectal cancer patients

in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017

25

3.0%

CRC HISTORY

FAMILY

16.9% DIABETES

31.4% Altered

bowel habit

25.3% Blood in the stool /

Per rectal bleeding

25.6% Abdominal/

Anal pain

18.2% Weight loss

QUICK FACTS!

Symptoms of Colorectal Cancer

13.4%

1.4%

CRC HISTORY

PAST

SMOKING HISTORY

26

CHAPTER 2: RISK FACTORS AND CLINICAL

PRESENTATIONS

• Of the 6,172 colorectal cancer (CRC) patients, 16.9% were found to have diabetes mellitus. Active and former smokers composed 8.1% and

5.3% of the cases, respectively (Table 2.1).

• More men were found to be either active or former smokers than women (Table 2.2). Meanwhile, most of the patients who had diabetes mellitus

were Chinese and aged between 60 and 69 years (Table 2.3).

• Despite being the known risk factors for CRC, a positive personal or family CRC history was only reported in 1.4 and 3.0% of the patients

(Table 2.4 and 2.5). However, 3.4% of the patients reported a positive

family history of other types of cancer; the most common type was

breast cancer (27.5%) (Table 2.5). Furthermore, a higher proportion of

patients aged between 60 and 69 years were found to have a positive

family history of cancer as compared with those from the other age

groups (Table 2.6).

• The most common clinical presentations at diagnosis of CRC were altered bowel habits (21.4%), abdominal or anal pain (25.6%), blood in

stool or per rectal bleeding (25.3%), weight loss (18.2%), anemia (7.0%),

loss of appetite (6.9%) and intestinal obstruction (5.8%) (Table 2.7). These

clinical presentations did not considerably vary by age group, gender

and ethnicity (Table 2.8, 2.9 and 2.10).

27

RESULTS

Table 2.1: Smoking status and diabetes mellitus of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal

Cancer, 2007-2017

Characteristics


Year

2007, n=426 2008, n=575 2009, n=590 2010, n=601 2011, n=537 2012, n=536 2013, n=548 2014, n=553 2015, n=618 2016, n=634 2017, n=554

n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)

Smoking status Never 1,811 (29.3) 21 (4.9) 136 (23.7) 159 (26.9) 190 (31.6) 159 (29.6) 210 (39.2) 203 (37.0) 240 (43.4) 225 (36.4) 164 (25.9) 104 (18.8) Former (quit > 30 days) 330 (5.3) 5 (1.2) 30 (5.2) 43 (7.3) 42 (7.0) 33 (6.1) 28 (5.2) 28 (5.1) 36 (6.5) 29 (4.7) 27 (4.3) 29 (5.2) Current 500 (8.1) 9 (2.1) 44 (7.7) 44 (7.5) 58 (9.7) 49 (9.1) 65 (12.1) 56 (10.2) 77 (13.9) 41 (6.6) 26 (4.1) 31 (5.6) Unknown 3,531 (57.2) 391 (91.8) 365 (63.5) 344 (58.3) 311 (51.7) 296 (55.1) 233 (43.5) 261 (47.6) 200 (36.2) 323 (52.3) 417 (65.8) 390 (70.4)

Diabetes mellitus No 2,883 (46.7) 34 (8.0) 206 (35.8) 255 (43.2) 281 (46.8) 244 (45.4) 311 (58.0) 299 (54.6) 336 (60.8) 345 (55.8) 312 (49.2) 260 (46.9) Yes 1,042 (16.9) 17 (4.0) 81 (14.1) 94 (15.9) 86 (14.3) 109 (20.3) 110 (20.5) 100 (18.2) 114 (20.6) 109 (17.6) 123 (19.4) 99 (17.9) Unknown 2,247 (36.4) 375 (88.0) 288 (50.1) 241 (40.8) 234 (38.9) 184 (34.3) 115 (21.5) 149 (27.2) 103 (18.6) 164 (26.5) 199 (31.4) 195 (35.2)

28

Table 2.2: Smoking status by age group, gender, ethnicity and education

level of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal

Cancer, 2007-2017

Characteristics

Smoking Status

Never, n=1,811 Former (quit > 30 days), n=330 Current, n=500

n (%) n (%) n (%)

Age group (years) 80 141 (7.8) 14 (4.2) 60 (12.0)

Gender Male 656 (36.2) 313 (94.8) 470 (94.0) Female 1,155 (63.8) 17 (5.2) 30 (6.0)

Ethnicity Malay 664 (36.7) 194 (58.8) 197 (39.4) Chinese 1,019 (56.3) 114 (34.5) 273 (54.6) Indian 113 (6.2) 18 (5.5) 23 (4.6) Others 15 (0.8) 4 (1.2) 7 (1.4)

Education level No formal education 245 (13.5) 24 (7.3) 71 (14.2) Primary 345 (19.1) 54 (16.4) 126 (25.2) Secondary 527 (29.1) 113 (34.2) 142 (28.4) Tertiary 146 (8.1) 27 (8.2) 37 (7.4) Unknown 548 (30.3) 112 (33.9) 124 (24.8)

29

Table 2.3: Diabetes mellitus by age group, gender, ethnicity and education


Cancer, 2007-2017

Characteristics

Diabetes Mellitus

No, n=2,883 Yes, n=1,042

n (%) n (%)

Age group (years) 80 246 (8.5) 94 (9.0)

Gender Male 1,580 (54.8) 542 (52.0) Female 1,305 (45.3) 458 (44.0)

Ethnicity Malay 1,100 (38.2) 390 (37.4) Chinese 1,626 (56.4) 515 (49.4) Indian 130 (4.5) 85 (8.2) Others 29 (1.0) 10 (1.0)

Education level No formal education 260 (9.0) 116 (11.1) Primary 426 (14.8) 154 (14.8) Secondary 654 (22.7) 222 (21.3) Tertiary 186 (6.5) 45 (4.3) Unknown 1,357 (47.1) 505 (48.5)

30

Table 2.4: Personal cancer history of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-

2017

Characteristics


Year

2007, n=426 2008, n=575 2009, n=590 2010, n=601 2011, n=537 2012, n=536 2013, n=548 2014, n=553 2015, n=618 2016, n=634 2017, n=554

n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)

Past medical history of cancers Colorectal 85 (1.4) 3 (0.7) 6 (1.0) 6 (1.0) 11 (1.8) 9 (1.7) 11 (2.1) 8 (1.5) 4 (0.7) 12 (1.9) 12 (1.9) 3 (0.5)

Ovarian 18 (0.3) 0 (0.0) 0 (0.0) 2 (0.3) 0 (0.0) 2 (0.4) 0 (0.0) 3 (0.5) 2 (0.4) 6 (1.0) 2 (0.3) 1 (0.2) Gastric 9 (0.1) 0 (0.0) 2 (0.3) 1 (0.2) 1 (0.2) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.2) 2 (0.3) 2 (0.4) Urinary tract 7 (0.1) 0 (0.0) 0 (0.0) 0 (0.0) 2 (0.3) 2 (0.4) 1 (0.2) 0 (0.0) 0 (0.0) 1 (0.2) 1 (0.2) 0 (0.0) Endometrial 5 (0.1) 0 (0.0) 0 (0.0) 1 (0.2) 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.2) 0 (0.0) 0 (0.0) 2 (0.3) 1 (0.2) Hepatobiliary 3 (0.0) 0 (0.0) 1 (0.2) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.2) 0 (0.0) 0 (0.0) 1 (0.2) Small bowel 1 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.2) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)

31

Table 2.5: Family cancer history of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017

Characteristics


Year

2007, n=426 2008, n=575 2009, n=590 2010, n=601 2011, n=537 2012, n=536 2013, n=548 2014, n=553 2015, n=618 2016, n=634 2017, n=554

n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)

Family history of colorectal cancer * 186 (3.0) 2 (0.5) 18 (3.1) 20 (3.4) 14 (2.3) 16 (3.0) 23 (4.3) 15 (2.7) 17 (3.1) 26 (4.2) 18 (2.8) 17 (3.1) Number of family members 1 133 (71.5) 2 (100.0) 15 (83.3) 18 (90.0) 12 (85.7) 12 (75.0) 16 (69.6) 12 (80.0) 6 (35.3) 17 (65.4) 11 (61.1) 12 (70.6) ≥2 29 (15.6) 0 (0.0) 3 (16.7) 1 (5.0) 2 (14.3) 4 (25.0) 5 (21.7) 3 (20.0) 1 (5.9) 5 (19.2) 2 (11.1) 3 (17.6) Unknown 24 (12.9) 0 (0.0) 0 (0.0) 1 (5.0) 0 (0.0) 0 (0.0) 2 (8.7) 0 (0.0) 10 (58.8) 4 (15.4) 5 (27.8) 2 (11.8)

Family history of other cancer * 211 (3.4) 3 (0.7) 19 (3.3) 17 (2.9) 20 (3.3) 16 (3.0) 29 (5.4) 23 (4.2) 29 (5.2) 30 (4.9) 13 (2.1) 12 (2.2) Number of family members 1 137 (64.9) 2 (66.7) 15 (78.9) 12 (70.6) 12 (60.0) 11 (68.8) 19 (65.5) 10 (43.5) 14 (48.3) 22 (73.3) 11 (84.6) 9 (75.0) ≥2 33 (15.6) 0 (0.0) 2 (10.5) 5 (29.4) 3 (15.0) 4 (25.0) 5 (17.2) 3 (13.0) 4 (13.8) 3 (10.0) 1 (7.7) 3 (25.0) Unknown 41 (19.4) 1 (33.3) 2 (10.5) 0 (0.0) 5 (25.0) 1 (6.3) 5 (17.2) 10 (43.5) 11 (37.9) 5 (16.7) 1 (7.7) 0 (0.0) Type of cancer Breast 58 (27.5) 0 (0.0) 2 (10.5) 7 (41.2) 4 (20.0) 4 (25.0) 7 (24.1) 7 (30.4) 6 (20.7) 9 (30.0) 6 (46.2) 6 (50.0) Lung 26 (12.3) 0 (0.0) 4 (21.1) 2 (11.8) 5 (25.0) 2 (12.5) 4 (13.8) 0 (0.0) 2 (6.9) 4 (13.3) 2 (15.4) 1 (8.3) Ovary 10 (4.7) 0 (0.0) 0 (0.0) 0 (0.0) 2 (10.0) 0 (0.0) 2 (6.9) 3 (13.0) 0 (0.0) 1 (3.3) 1 (7.7) 1 (8.3) Prostate 10 (4.7) 0 (0.0) 2 (10.5) 1 (5.9) 0 (0.0) 1 (6.3) 1 (3.4) 1 (4.3) 1 (3.4) 0 (0.0) 0 (0.0) 3 (25.0) Endometrium 4 (1.9) 0 (0.0) 2 (10.5) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (4.3) 1 (3.4) 0 (0.0) 0 (0.0) 0 (0.0)

Note : *First-degree family members.

32

Table 2.6: Family cancer history by age group, gender, ethnicity and

education level of colorectal cancer patients in Northern Malaysia; NCPR-

Colorectal Cancer, 2007-2017

Characteristics

Family history of colorectal cancer * Family history of other cancer *

No, n=5,986 Yes, n=186 No, n=5,961 Yes, n=211

n (%) n (%) n (%) n (%)

Age group (years) 80 261 (4.4) 8 (4.3) 241 (4.0) 11 (5.2)

Gender Male 1,717 (28.7) 96 (51.6) 1600 (26.8) 116 (55.0) Female 1358 (22.7) 90 (48.4) 1275 (21.4) 95 (45.0)

Ethnicity Malay 1276 (21.3) 78 (41.9) 1222 (20.5) 82 (38.9) Chinese 1592 (26.6) 89 (47.8) 1464 (24.6) 108 (51.2) Indian 176 (2.9) 15 (8.1) 159 (2.7) 19 (9.0) Others 31 (0.5) 4 (2.2) 30 (0.5) 2 (0.9)

Education level No formal education 341 (5.7) 17 (9.1) 331 (5.6) 16 (7.6) Primary 541 (9.0) 27 (14.5) 518 (8.7) 33 (15.6) Secondary 802 (13.4) 62 (33.3) 789 (13.2) 62 (29.4) Tertiary 200 (3.3) 17 (9.1) 191 (3.2) 25 (11.8) Unknown 4,102 (68.5) 63 (33.9) 4,132 (69.3) 75 (35.5)


33

Table 2.7: Symptoms at diagnosis of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-

2017

Characteristics


Year

2007, n=426

2008, n=575

2009, n=590

2010, n=601

2011, n=537

2012, n=536

2013, n=548

2014, n=553

2015, n=618

2016, n=634

2017, n=554

n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)

Symptom Altered bowel habits 1,937 (31.4) 22 (5.2) 143 (24.9) 181 (30.7) 191 (31.8) 189 (35.2) 201 (37.5) 200 (36.5) 186 (33.6) 233 (37.7) 210 (33.1) 181 (32.7)

Abdominal/anal pain 1,583 (25.6) 16 (3.8) 147 (25.6) 150 (25.4) 164 (27.3) 141 (26.3) 173 (32.3) 160 (29.2) 161 (29.1) 170 (27.5) 152 (24.0) 149 (26.9) Blood in the stool/per rectal bleeding 1,564 (25.3) 15 (3.5) 93 (16.2) 147 (24.9) 154 (25.6) 160 (29.8) 180 (33.6) 142 (25.9) 135 (24.4) 171 (27.7) 188 (29.7) 179 (32.3) Weight loss 1,124 (18.2) 13 (3.1) 84 (14.6) 96 (16.3) 123 (20.5) 114 (21.2) 107 (20.0) 118 (21.5) 94 (17.0) 144 (23.3) 129 (20.3) 102 (18.4) Anemia 430 (7.0) 5 (1.2) 30 (5.2) 43 (7.3) 51 (8.5) 39 (7.3) 57 (10.6) 36 (6.6) 27 (4.9) 52 (8.4) 57 (9.0) 33 (6.0) Appetite loss 427 (6.9) 5 (1.2) 44 (7.7) 54 (9.2) 49 (8.2) 39 (7.3) 39 (7.3) 30 (5.5) 27 (4.9) 61 (9.9) 35 (5.5) 44 (7.9) Intestinal obstruction 356 (5.8) 1 (0.2) 7 (1.2) 31 (5.3) 39 (6.5) 33 (6.1) 52 (9.7) 28 (5.1) 35 (6.3) 42 (6.8) 44 (6.9) 44 (7.9) Vomiting 132 (2.1) 0 (0.0) 16 (2.8) 15 (2.5) 11 (1.8) 10 (1.9) 13 (2.4) 8 (1.5) 8 (1.4) 13 (2.1) 15 (2.4) 23 (4.2) Tenesmus 107 (1.7) 6 (1.4) 12 (2.1) 16 (2.7) 13 (2.2) 7 (1.3) 8 (1.5) 7 (1.3) 9 (1.6) 18 (2.9) 8 (1.3) 3 (0.5) Lethargy 79 (1.3) 1 (0.2) 8 (1.4) 10 (1.7) 13 (2.2) 5 (0.9) 6 (1.1) 2 (0.4) 3 (0.5) 12 (1.9) 5 (0.8) 14 (2.5) Nausea 30 (0.5) 0 (0.0) 3 (0.5) 8 (1.4) 3 (0.5) 2 (0.4) 2 (0.4) 1 (0.2) 1 (0.2) 5 (0.8) 2 (0.3) 3 (0.5) Fever 22 (0.4) 1 (0.2) 4 (0.7) 2 (0.3) 2 (0.3) 1 (0.2) 2 (0.4) 1 (0.2) 4 (0.7) 3 (0.5) 2 (0.3) 0 (0.0) Dyspepsia 8 (0.1) 0 (0.0) 2 (0.3) 0 (0.0) 1 (0.2) 1 (0.2) 1 (0.2) 1 (0.2) 2 (0.4) 0 (0.0) 0 (0.0) 0 (0.0) Giddiness 7 (0.1) 1 (0.2) 1 (0.2) 1 (0.2) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.2) 0 (0.0) 3 (0.5) Dizziness 4 (0.1) 0 (0.0) 0 (0.0) 1 (0.2) 0 (0.0) 2 (0.4) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.2) 0 (0.0)

34

Table 2.8: Symptoms at diagnosis by age group of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal

Cancer, 2007-2017

Characteristics


Age group (years)

80, n=565

n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)

Symptom Altered bowel habits 1,937 (31.4) 4 (14.3) 15 (29.4) 24 (32.4) 40 (28.6) 68 (29.7) 127 (34.2) 199 (32.8) 252 (31.8) 313 (34.9) 299 (32.8) 264 (31.3) 182 (27.5) 150 (26.5)

Abdominal/anal pain 1,583 (25.6) 5 (17.9) 16 (31.4) 23 (31.1) 35 (25.0) 84 (36.7) 103 (27.8) 157 (25.9) 194 (24.5) 249 (27.8) 221 (24.2) 214 (25.4) 144 (21.7) 138 (24.4) Blood in the stool/per rectal bleeding 1,564 (25.3) 2 (7.1) 16 (31.4) 21 (28.4) 30 (21.4) 55 (24.0) 92 (24.8) 157 (25.9) 207 (26.1) 252 (28.1) 269 (29.5) 209 (24.8) 130 (19.6) 124 (21.9) Weight loss 1,124 (18.2) 0 (0.0) 10 (19.6) 16 (21.6) 19 (13.6) 44 (19.2) 74 (19.9) 113 (18.6) 148 (18.7) 178 (19.9) 202 (22.1) 156 (18.5) 100 (15.1) 64 (11.3) Anemia 430 (7.0) 3 (10.7) 6 (11.8) 5 (6.8) 6 (4.3) 12 (5.2) 25 (6.7) 49 (8.1) 41 (5.2) 62 (6.9) 54 (5.9) 58 (6.9) 41 (6.2) 68 (12.0) Appetite loss 427 (6.9) 0 (0.0) 3 (5.9) 4 (5.4) 8 (5.7) 12 (5.2) 26 (7.0) 42 (6.9) 49 (6.2) 70 (7.8) 75 (8.2) 66 (7.8) 44 (6.6) 28 (5.0) Intestinal obstruction 356 (5.8) 2 (7.1) 3 (5.9) 9 (12.2) 8 (5.7) 17 (7.4) 27 (7.3) 23 (3.8) 40 (5.1) 63 (7.0) 54 (5.9) 48 (5.7) 34 (5.1) 28 (5.0) Vomiting 132 (2.1) 0 (0.0) 1 (2.0) 2 (2.7) 2 (1.4) 7 (3.1) 8 (2.2) 15 (2.5) 17 (2.1) 20 (2.2) 18 (2.0) 15 (1.8) 15 (2.3) 12 (2.1) Tenesmus 107 (1.7) 0 (0.0) 1 (2.0) 3 (4.1) 1 (0.7) 5 (2.2) 5 (1.3) 10 (1.6) 17 (2.1) 22 (2.5) 16 (1.8) 16 (1.9) 6 (0.9) 5 (0.9) Lethargy 79 (1.3) 0 (0.0) 0 (0.0) 0 (0.0) 2 (1.4) 2 (0.9) 5 (1.3) 6 (1.0) 9 (1.1) 12 (1.3) 12 (1.3) 10 (1.2) 8 (1.2) 13 (2.3) Nausea 30 (0.5) 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.7) 1 (0.4) 5 (1.3) 2 (0.3) 2 (0.3) 7 (0.8) 2 (0.2) 5 (0.6) 4 (0.6) 1 (0.2) Fever 22 (0.4) 0 (0.0) 0 (0.0) 1 (1.4) 0 (0.0) 0 (0.0) 1 (0.3) 2 (0.3) 3 (0.4) 0 (0.0) 7 (0.8) 5 (0.6) 0 (0.0) 3 (0.5) Dyspepsia 8 (0.1) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 2 (0.3) 2 (0.3) 1 (0.1) 2 (0.2) 0 (0.0) 0 (0.0) 1 (0.2) Giddiness 7 (0.1) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.3) 0 (0.0) 0 (0.0) 2 (0.2) 1 (0.1) 2 (0.2) 0 (0.0) 1 (0.2) Dizziness 4 (0.1) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.2) 0 (0.0) 1 (0.1) 0 (0.0) 0 (0.0) 2 (0.3) 0 (0.0)

35

Table 2.9: Symptoms at diagnosis by gender of colorectal cancer patients in

Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017

Characteristics


Gender

Male, n=3,342

Female, n=2,830

n (%) n (%) n (%)

Symptom Altered bowel habits 1,937 (31.4) 1,082 (32.4) 855 (30.2) Abdominal/anal pain 1,583 (25.6) 819 (24.5) 764 (27.0) Blood in the stool/per rectal bleeding 1,564 (25.3) 857 (25.6) 707 (25.0) Weight loss 1,124 (18.2) 631 (18.9) 493 (17.4) Anemia 430 (7.0) 218 (6.5) 212 (7.5) Appetite loss 427 (6.9) 236 (7.1) 191 (6.7) Intestinal obstruction 356 (5.8) 212 (6.3) 144 (5.1) Vomiting 132 (2.1) 70 (2.1) 62 (2.2) Tenesmus 107 (1.7) 64 (1.9) 43 (1.5) Lethargy 79 (1.3) 30 (0.9) 49 (1.7) Nausea 30 (0.5) 12 (0.4) 18 (0.6) Fever 22 (0.4) 11 (0.3) 11 (0.4) Dyspepsia 8 (0.1) 6 (0.2) 2 (0.1) Giddiness 7 (0.1) 3 (0.1) 4 (0.1) Dizziness 4 (0.1) 3 (0.1) 1 (0.0)

Table 2.10: Symptoms at diagnosis by ethnicity of colorectal cancer patients

in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017

Characteristics


Ethnicity

Malay, n=2,216

Chinese, n=3,503

Indian, n=382

Others, n=71

n (%) n (%) n (%) n (%) n (%)

Symptom Altered bowel habits 1,937 (31.4) 818 (36.9) 984 (28.1) 113 (29.6) 22 (31.0) Abdominal/anal pain 1,583 (25.6) 603 (27.2) 878 (25.1) 86 (22.5) 16 (22.5) Blood in the stool/per rectal bleeding 1,564 (25.3) 605 (27.3) 850 (24.3) 92 (24.1) 17 (23.9) Weight loss 1,124 (18.2) 584 (26.4) 454 (13.0) 74 (19.4) 12 (16.9) Anemia 430 (7.0) 142 (6.4) 256 (7.3) 28 (7.3) 4 (5.6) Appetite loss 427 (6.9) 239 (10.8) 149 (4.3) 34 (8.9) 5 (7.0) Intestinal obstruction 356 (5.8) 181 (8.2) 156 (4.5) 17 (4.5) 2 (2.8) Vomiting 132 (2.1) 73 (3.3) 47 (1.3) 10 (2.6) 2 (2.8) Tenesmus 107 (1.7) 73 (3.3) 28 (0.8) 5 (1.3) 1 (1.4) Lethargy 79 (1.3) 49 (2.2) 26 (0.7) 4 (1.0) 0 (0.0) Nausea 30 (0.5) 19 (0.9) 9 (0.3) 2 (0.5) 0 (0.0) Fever 22 (0.4) 13 (0.6) 8 (0.2) 0 (0.0) 1 (1.4) Dyspepsia 8 (0.1) 4 (0.2) 4 (0.1) 0 (0.0) 0 (0.0) Giddiness 7 (0.1) 5 (0.2) 2 (0.1) 0 (0.0) 0 (0.0) Dizziness 4 (0.1) 1 (0.0) 2 (0.1) 1 (0.3) 0 (0.0)

36

Figure 2.1: Distributions of smoking status and diabetes mellitus among

colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer,

2007-2017

Figure 2.2: Four most common clinical presentations at diagnosis among

colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer,

2007-2017

37

QUICK FACTS!

4.8% Ascending colon

21.0% Sigmoid colon

4.6% Caecum

34.6% Rectum

2.9% Descending colon

0.7% Anorectum

3.1% Transverse Colon

13.8% Rectosigmoid

6.7% STAGE I

17.5% STAGE II

21.2% STAGE III

18.2% STAGE IV

36.3% UNKNOWN

38

CHAPTER 3: FINAL STAGING

• Most (94.1%) of the colorectal cancer (CRC) patients were diagnosed based on the histology of the primary tumor (Table 3.1). No differences

were observed between age groups, genders, ethnic groups and

education levels in the basis of diagnosis (Table 3.2).

• Rectum (34.6%) was identified as the most common primary cancer site, while left-sided tumor (65.6%) was found to be more common than right-

sided tumor (9.0%) (Table 3.3). The trend remained consistent across age

groups, genders and ethnic groups (Table 3.4, 3.5 and 3.6).

• Most of the patients (39.4%) had advanced stages (III and IV) of CRC, while 24.2% of the patients had stage I or II CRC (Table 3.7).

• The patients with advanced stages (III and IV) of CRC were mainly in the age group of 60-69 years, men, and Chinese (Table 3.8).

• Less than 10% of the patients were reported to have a positive cancer history (Table 3.9).

39

RESULTS

Table 3.1: Basis of diagnosis of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017

Characteristics


Year

2007, n=426 2008, n=575 2009, n=590 2010, n=601 2011, n=537 2012, n=536 2013, n=548 2014, n=553 2015, n=618 2016, n=634 2017, n=554

n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)

Basis of diagnosis

Histology of primary tumour 5,808 (94.1) 409 (96.0) 559 (97.2) 532 (90.2) 560 (93.2) 511 (95.2) 524 (97.8) 530 (96.7) 551 (99.6) 546 (88.3) 585 (92.3) 501 (90.4) Clinical investigations 865 (14.0) 9 (2.1) 37 (6.4) 33 (5.6) 83 (13.8) 86 (16.0) 130 (24.3) 73 (13.3) 90 (16.3) 112 (18.1) 110 (17.4) 102 (18.4) Cytology 181 (2.9) 6 (1.4) 14 (2.4) 10 (1.7) 22 (3.7) 17 (3.2) 17 (3.2) 21 (3.8) 17 (3.1) 16 (2.6) 10 (1.6) 31 (5.6) Specific tumor markers 73 (1.2) 0 (0.0) 3 (0.5) 1 (0.2) 1 (0.2) 2 (0.4) 17 (3.2) 6 (1.1) 6 (1.1) 15 (2.4) 9 (1.4) 13 (2.3) Histology of metastasis 71 (1.2) 4 (0.9) 0 (0.0) 5 (0.8) 3 (0.5) 3 (0.6) 5 (0.9) 7 (1.3) 7 (1.3) 7 (1.1) 15 (2.4) 15 (2.7) Death certificate only 14 (0.2) 1 (0.2) 0 (0.0) 10 (1.7) 0 (0.0) 3 (0.6) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)

40

Table 3.2: Basis of diagnosis by age group, gender, ethnicity and education level of colorectal cancer patients in


Characteristics

Basis of diagnosis

Histology of primary tumour, n=5,808

Clinical investigations, n=865

Cytology, n=181

Specific tumor markers, n=73

Histology of metastasis, n=71

Death certificate only, n=14

n (%) n (%) n (%) n (%) n (%) n (%)

Age group (years) 80 507 (8.7) 90 (10.4) 8 (4.4) 3 (4.1) 3 (4.2) 1 (7.1)

Gender Male 3,162 (54.4) 438 (50.6) 101 (55.8) 41 (56.2) 40 (56.3) 11 (78.6) Female 2646 (45.6) 427 (49.4) 80 (44.2) 32 (43.8) 31 (43.7) 3 (21.4)

Ethnicity Malay 2092 (36.0) 284 (32.8) 95 (52.5) 32 (43.8) 40 (56.3) 3 (21.4) Chinese 3311 (57.0) 528 (61.0) 72 (39.8) 37 (50.7) 28 (39.4) 10 (71.4) Indian 353 (6.1) 45 (5.2) 12 (6.6) 4 (5.5) 3 (4.2) 1 (7.1) Others 52 (0.9) 8 (0.9) 2 (1.1) 0 (0.0) 0 (0.0) 0 (0.0)

Education level No formal education 376 (6.5) 71 (8.2) 23 (12.7) 9 (12.3) 11 (15.5) 0 (0.0) Primary 583 (10.0) 87 (10.1) 34 (18.8) 5 (6.8) 12 (16.9) 1 (7.1) Secondary 888 (15.3) 152 (17.6) 51 (28.2) 19 (26.0) 18 (25.4) 0 (0.0) Tertiary 228 (3.9) 27 (3.1) 6 (3.3) 2 (2.7) 5 (7.0) 0 (0.0) Unknown 3,733 (64.3) 528 (61.0) 67 (37.0) 38 (52.1) 25 (35.2) 13 (92.9)

41

Table 3.3: Primary cancer sites of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017

Characteristics


Year

2007, n=426 2008, n=575 2009, n=590 2010, n=601 2011, n=537 2012, n=536 2013, n=548 2014, n=553 2015, n=618 2016, n=634 2017, n=554

n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)

Primary cancer site

Rectum 2,136 (34.6) 146 (34.3) 208 (36.2) 224 (38.0) 208 (34.6) 202 (37.6) 171 (31.9) 158 (28.8) 188 (34.0) 215 (34.8) 215 (33.9) 201 (36.3) Colon, unspecified 1,467 (23.8) 123 (28.9) 142 (24.7) 125 (21.2) 132 (22.0) 115 (21.4) 129 (24.1) 159 (29.0) 145 (26.2) 147 (23.8) 131 (20.7) 119 (21.5) Sigmoid colon 1,298 (21.0) 89 (20.9) 99 (17.2) 148 (25.1) 144 (24.0) 132 (24.6) 111 (20.7) 115 (21.0) 107 (19.3) 114 (18.4) 135 (21.3) 104 (18.8) Rectosigmoid 851 (13.8) 29 (6.8) 62 (10.8) 87 (14.7) 79 (13.1) 75 (14.0) 82 (15.3) 71 (13.0) 71 (12.8) 98 (15.9) 106 (16.7) 91 (16.4) Ascending colon 296 (4.8) 12 (2.8) 31 (5.4) 28 (4.7) 25 (4.2) 19 (3.5) 21 (3.9) 27 (4.9) 26 (4.7) 39 (6.3) 36 (5.7) 32 (5.8) Caecum 285 (4.6) 17 (4.0) 26 (4.5) 28 (4.7) 33 (5.5) 23 (4.3) 26 (4.9) 17 (3.1) 19 (3.4) 36 (5.8) 33 (5.2) 27 (4.9) Transverse colon 190 (3.1) 12 (2.8) 18 (3.1) 14 (2.4) 22 (3.7) 12 (2.2) 22 (4.1) 25 (4.6) 12 (2.2) 17 (2.8) 23 (3.6) 13 (2.3) Descending colon 178 (2.9) 6 (1.4) 14 (2.4) 14 (2.4) 17 (2.8) 15 (2.8) 13 (2.4) 14 (2.6) 18 (3.3) 22 (3.6) 30 (4.7) 15 (2.7) Hepatic flexure 113 (1.8) 1 (0.2) 12 (2.1) 12 (2.0) 13 (2.2) 7 (1.3) 10 (1.9) 6 (1.1) 11 (2.0) 12 (1.9) 15 (2.4) 14 (2.5) Splenic flexure 90 (1.5) 4 (0.9) 10 (1.7) 9 (1.5) 12 (2.0) 5 (0.9) 5 (0.9) 3 (0.5) 9 (1.6) 14 (2.3) 12 (1.9) 7 (1.3) Anorectum 46 (0.7) 0 (0.0) 2 (0.3) 10 (1.7) 5 (0.8) 4 (0.7) 6 (1.1) 5 (0.9) 4 (0.7) 4 (0.6) 2 (0.3) 4 (0.7)

Primary cancer site

Colon, unspecified 1,467 (23.8) 123 (28.9) 142 (24.7) 125 (21.2) 132 (22.0) 115 (21.4) 129 (24.1) 159 (29.0) 145 (26.2) 147 (23.8) 131 (20.7) 119 (21.5) Left sided 4,047 (65.6) 273 (64.1) 365 (63.5) 399 (67.6) 400 (66.6) 374 (69.6) 350 (65.3) 341 (62.2) 355 (64.2) 391 (63.3) 431 (68.0) 368 (66.4) Right sided 554 (9.0) 28 (6.6) 55 (9.6) 51 (8.6) 58 (9.7) 41 (7.6) 50 (9.3) 45 (8.2) 51 (9.2) 63 (10.2) 57 (9.0) 55 (9.9) Both sided 104 (1.7) 2 (0.5) 13 (2.3) 15 (2.5) 11 (1.8) 7 (1.3) 7 (1.3) 3 (0.5) 2 (0.4) 17 (2.8) 15 (2.4) 12 (2.2)

42

Table 3.4: Primary cancer sites by age group of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal

Cancer, 2007-2017

Characteristics


Age group (years)

80, n=565

n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)

Primary cancer site Rectum 2,136 (34.6) 4 (14.3) 17 (33.3) 27 (36.5) 52 (37.1) 72 (31.4) 128 (34.5) 221 (36.4) 297 (37.5) 323 (36.0) 338 (37.1) 285 (33.8) 199 (30.0) 173 (30.6) Colon, unspecified 1,467 (23.8) 16 (57.1) 16 (31.4) 22 (29.7) 38 (27.1) 65 (28.4) 93 (25.1) 131 (21.6) 176 (22.2) 203 (22.7) 197 (21.6) 194 (23.0) 170 (25.6) 146 (25.8) Sigmoid colon 1,298 (21.0) 5 (17.9) 14 (27.5) 11 (14.9) 25 (17.9) 40 (17.5) 72 (19.4) 125 (20.6) 182 (23.0) 198 (22.1) 188 (20.6) 176 (20.9) 146 (22.0) 116 (20.5) Rectosigmoid 851 (13.8) 4 (14.3) 8 (15.7) 7 (9.5) 15 (10.7) 22 (9.6) 57 (15.4) 95 (15.7) 110 (13.9) 147 (16.4) 118 (12.9) 124 (14.7) 83 (12.5) 61 (10.8) Ascending colon 296 (4.8) 2 (7.1) 1 (2.0) 3 (4.1) 5 (3.6) 7 (3.1) 14 (3.8) 22 (3.6) 32 (4.0) 36 (4.0) 50 (5.5) 47 (5.6) 46 (6.9) 31 (5.5) Caecum 285 (4.6) 0 (0.0) 1 (2.0) 1 (1.4) 5 (3.6) 13 (5.7) 16 (4.3) 28 (4.6) 33 (4.2) 33 (3.7) 46 (5.0) 37 (4.4) 38 (5.7) 34 (6.0) Transverse colon 190 (3.1) 0 (0.0) 1 (2.0) 6 (8.1) 6 (4.3) 12 (5.2) 8 (2.2) 13 (2.1) 21 (2.7) 28 (3.1) 25 (2.7) 30 (3.6) 22 (3.3) 18 (3.2) Descending colon 178 (2.9) 0 (0.0) 1 (2.0) 2 (2.7) 2 (1.4) 10 (4.4) 7 (1.9) 24 (4.0) 25 (3.2) 21 (2.3) 29 (3.2) 29 (3.4) 14 (2.1) 14 (2.5) Hepatic flexure 113 (1.8) 1 (3.6) 1 (2.0) 2 (2.7) 2 (1.4) 4 (1.7) 5 (1.3) 9 (1.5) 13 (1.6) 11 (1.2) 24 (2.6) 16 (1.9) 13 (2.0) 12 (2.1) Splenic flexure 90 (1.5) 0 (0.0) 0 (0.0) 1 (1.4) 4 (2.9) 4 (1.7) 4 (1.1) 10 (1.6) 7 (0.9) 12 (1.3) 14 (1.5) 15 (1.8) 8 (1.2) 11 (1.9) Anorectum 46 (0.7) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 5 (2.2) 4 (1.1) 6 (1.0) 8 (1.0) 6 (0.7) 7 (0.8) 4 (0.5) 3 (0.5) 3 (0.5)

Primary cancer site Colon, unspecified 1,467 (23.8) 16 (57.1) 16 (31.4) 22 (29.7) 38 (27.1) 65 (28.4) 93 (25.1) 131 (21.6) 176 (22.2) 203 (22.7) 197 (21.6) 194 (23.0) 170 (25.6) 146 (25.8) Left sided 4,047 (65.6) 9 (32.1) 32 (62.7) 46 (62.2) 90 (64.3) 141 (61.6) 244 (65.8) 419 (69.0) 543 (68.6) 617 (68.9) 603 (66.1) 556 (65.9) 402 (60.6) 345 (61.1) Right sided 554 (9.0) 3 (10.7) 2 (3.9) 5 (6.8) 10 (7.1) 19 (8.3) 33 (8.9) 50 (8.2) 65 (8.2) 60 (6.7) 91 (10.0) 74 (8.8) 77 (11.6) 65 (11.5) Both sided 104 (1.7) 0 (0.0) 1 (2.0) 1 (1.4) 2 (1.4) 4 (1.7) 1 (0.3) 7 (1.2) 8 (1.0) 16 (1.8) 21 (2.3) 20 (2.4) 14 (2.1) 9 (1.6)

43

Table 3.5: Primary cancer sites by gender of colorectal cancer patients in


Characteristics


Gender

Male, n=3,342

Female, n=2,830

n (%) n (%) n (%)

Primary cancer site Rectum 2,136 (34.6) 1,286 (38.5) 850 (30.0) Colon, unspecified 1,467 (23.8) 732 (21.9) 735 (26.0) Sigmoid colon 1,298 (21.0) 696 (20.8) 602 (21.3) Rectosigmoid 851 (13.8) 454 (13.6) 397 (14.0) Ascending colon 296 (4.8) 151 (4.5) 145 (5.1) Caecum 285 (4.6) 144 (4.3) 141 (5.0) Transverse colon 190 (3.1) 87 (2.6) 103 (3.6) Descending colon 178 (2.9) 99 (3.0) 79 (2.8) Hepatic flexure 113 (1.8) 50 (1.5) 63 (2.2) Splenic flexure 90 (1.5) 59 (1.8) 31 (1.1) Anorectum 46 (0.7) 25 (0.7) 21 (0.7)

Primary cancer site Colon, unspecified 1,467 (23.8) 732 (21.9) 735 (26.0) Left sided 4,047 (65.6) 2,284 (68.3) 1,763 (62.3) Right sided 554 (9.0) 263 (7.9) 291 (10.3) Both sided 104 (1.7) 63 (1.9) 41 (1.4)

Table 3.6: Primary cancer sites by ethnicity of colorectal cancer patients in


Characteristics


Ethnicity

Malay, n=2,216

Chinese, n=3,503

Indian, n=382

Others, n=71

n (%) n (%) n (%) n (%) n (%)

Primary cancer site Rectum 2,136 (34.6) 861 (38.9) 1,110 (31.7) 143 (37.4) 22 (31.0) Colon, unspecified 1,467 (23.8) 508 (22.9) 840 (24.0) 96 (25.1) 23 (32.4) Sigmoid colon 1,298 (21.0) 456 (20.6) 760 (21.7) 67 (17.5) 15 (21.1) Rectosigmoid 851 (13.8) 328 (14.8) 451 (12.9) 67 (17.5) 5 (7.0) Ascending colon 296 (4.8) 75 (3.4) 199 (5.7) 21 (5.5) 1 (1.4) Caecum 285 (4.6) 71 (3.2) 190 (5.4) 20 (5.2) 4 (5.6) Transverse colon 190 (3.1) 55 (2.5) 127 (3.6) 7 (1.8) 1 (1.4) Descending colon 178 (2.9) 58 (2.6) 111 (3.2) 8 (2.1) 1 (1.4) Hepatic flexure 113 (1.8) 40 (1.8) 59 (1.7) 12 (3.1) 2 (2.8) Splenic flexure 90 (1.5) 26 (1.2) 60 (1.7) 3 (0.8) 1 (1.4) Anorectum 46 (0.7) 19 (0.9) 23 (0.7) 4 (1.0) 0 (0.0)

Primary cancer site Colon, unspecified 1,467 (23.8) 508 (22.9) 840 (24.0) 96 (25.1) 23 (32.4) Left sided 4,047 (65.6) 1,527 (68.9) 2,243 (64.0) 236 (61.8) 41 (57.7) Right sided 554 (9.0) 153 (6.9) 354 (10.1) 40 (10.5) 7 (9.9) Both sided 104 (1.7) 28 (1.3) 66 (1.9) 10 (2.6) 0 (0.0)

44

Table 3.7: Clinical staging of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017

Characteristics


Year

2007, n=426 2008, n=575 2009, n=590 2010, n=601 2011, n=537 2012, n=536 2013, n=548 2014, n=553 2015, n=618 2016, n=634 2017, n=554

n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)

Clinical Staging

I 416 (6.7) 13 (3.1) 53 (9.2) 48 (8.1) 46 (7.7) 33 (6.1) 42 (7.8) 45 (8.2) 37 (6.7) 27 (4.4) 44 (6.9) 28 (5.1) II 1,081 (17.5) 43 (10.1) 98 (17.0) 105 (17.8) 121 (20.1) 112 (20.9) 117 (21.8) 86 (15.7) 103 (18.6) 107 (17.3) 97 (15.3) 92 (16.6) III 1,311 (21.2) 52 (12.2) 83 (14.4) 125 (21.2) 150 (25.0) 125 (23.3) 110 (20.5) 103 (18.8) 119 (21.5) 149 (24.1) 161 (25.4) 134 (24.2) IV 1,121 (18.2) 51 (12.0) 104 (18.1) 96 (16.3) 97 (16.1) 102 (19.0) 127 (23.7) 122 (22.3) 122 (22.1) 116 (18.8) 102 (16.1) 82 (14.8) Unknown 2,243 (36.3) 267 (62.7) 237 (41.2) 216 (36.6) 187 (31.1) 165 (30.7) 140 (26.1) 192 (35.0) 172 (31.1) 219 (35.4) 230 (36.3) 218 (39.4)

45

Table 3.8: Clinical staging by age group, gender, ethnicity and education


Cancer, 2007-2017

Characteristics

Clinical Staging

Stage I, n=416

Stage II, n=1,081

Stage III, n=1,311

Stage IV, n=1,121

Unknown, n=2,243

n (%) n (%) n (%) n (%) n (%)

Age group (years) 80 32 (7.7) 100 (9.3) 84 (6.4) 70 (6.2) 279 (12.4)

Gender Male 241 (57.9) 600 (55.5) 692 (52.8) 600 (53.5) 1,209 (53.9) Female 175 (42.1) 481 (44.5) 619 (47.2) 521 (46.5) 1,034 (46.1)

Ethnicity Malay 134 (32.2) 364 (33.7) 561 (42.8) 538 (48.0) 619 (27.6) Chinese 249 (59.9) 645 (59.7) 661 (50.4) 515 (45.9) 1,433 (63.9) Indian 29 (7.0) 65 (6.0) 83 (6.3) 53 (4.7) 152 (6.8) Others 4 (1.0) 7 (0.6) 6 (0.5) 15 (1.3) 39 (1.7)

Education level No formal education 44 (10.6) 85 (7.9) 94 (7.2) 93 (8.3) 69 (3.1) Primary 43 (10.3) 123 (11.4) 158 (12.1) 189 (16.9) 81 (3.6) Secondary 62 (14.9) 206 (19.1) 298 (22.7) 234 (20.9) 106 (4.7) Tertiary 21 (5.0) 43 (4.0) 79 (6.0) 65 (5.8) 26 (1.2) Unknown 246 (59.1) 624 (57.7) 682 (52.0) 540 (48.2) 1,961 (87.4)

46

Table 3.9: Clinical staging by family history of colorectal cancer patients in


Characteristics

Clinical Staging

Stage I, n=416

Stage II, n=1,081

Stage III, n=1,311

Stage IV, n=1,121

Unknown, n=2,243

n (%) n (%) n (%) n (%) n (%)

Family history of colorectal cancer * 12 (2.9) 48 (4.4) 66 (5.0) 41 (3.7) 19 (0.8) Number of family members

1 7 (58.3) 27 (56.3) 55 (83.3) 30 (73.2) 14 (73.7) ≥2 3 (25.0) 14 (29.2) 3 (4.5) 6 (14.6) 3 (15.8) Unknown 2 (16.7) 7 (14.6) 8 (12.1) 5 (12.2) 2 (10.5)

Family history of other cancer * 18 (4.3) 49 (4.5) 59 (4.5) 63 (5.6) 22 (1.0) Number of family members

1 11 (61.1) 31 (63.3) 41 (69.5) 43 (68.3) 11 (50.0) ≥2 2 (11.1) 10 (20.4) 10 (16.9) 8 (12.7) 3 (13.6) Unknown 5 (27.8) 8 (16.3) 8 (13.6) 12 (19.0) 8 (36.4) Type of cancer

Lung 0 (0.0) 7 (0.6) 7 (0.5) 9 (0.8) 3 (0.1) Breast 7 (1.7) 10 (0.9) 16 (1.2) 20 (1.8) 5 (0.2) Ovary 1 (0.2) 1 (0.1) 4 (0.3) 3 (0.3) 1 (0.0) Prostate 1 (0.2) 4 (0.4) 1 (0.1) 4 (0.4) 0 (0.0) Endometrium 1 (0.2) 1 (0.1) 0 (0.0) 2 (0.2) 0 (0.0)


47

Figure 3.1: Distribution of primary cancer sites among colorectal cancer

patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017

Figure 3.2: Distribution of clinical staging among colorectal cancer patients in


48

QUICK FACTS!

2.7 %

9.4 %

44.5 %

18.1 %

16.8 %

22.5 %

34.8 %

25.9% UNKNOWN

25.3% UNKNOWN

NUMBER OF

LYMPH NODES EXAMINED

49

CHAPTER 4: PATHOLOGY

• Only 66.7% (n=4,118) of the specimens (n=6,172) with a confirmed histologic diagnosis of colorectal cancer were resection specimens,

while the rest were biopsy specimens (Table 4.1).

• The most common primary cancer site identified based on the location of the resection specimens was rectum 1,475 (35.8%), while left-sided

tumors (69.1%) were found to be more common than right-sided tumors

(9.1%) (Table 4.2).

• The data of the registry was obtained from different sources which varied in depth and methods. Consequently, the information on the size and

extent of tumor (T) and the number of positive lymph nodes (N) was only

available for 74.7% and 74.1% of the patients with resection specimens

undergoing pathologic (pTNM) staging (n=4,007), respectively. Of these

patients, the majority were staged as T3 (44.5%) and N0 (34.8%) (Table

4.3).

• Likewise, of the 111 patients with resection specimens undergoing post-neoadjuvant- chemotherapy pathologic (ypTNM) staging, the majority

were also staged as T3 (45.9%) and N0 (39.6%) (Table 4.4).

• The information on the number of nodes examined and positive nodes was available for 39.6% (n=1,586) of the patients with resection

specimens undergoing pTNM staging. Approximately 60% of them had

more than 12 lymph nodes examined. The vast majority of them had at

least one positive node detected despite the number of lymph nodes

examined (Table 4.5). However, the patients who had more than 12

lymph nodes examined were shown to have more advanced T and N

stages in general (Table 4.6).

• Most of the tumors (44.8%) were found to be moderately differentiated (Table 4.7). The poorly differentiated tumors generally had more

advanced T and N stages than did those which were well and

moderately differentiated (Table 4.8).

50

RESULTS

Table 4.1: Types of specimens used in histologic diagnosis of colorectal cancer in Northern Malaysia; NCPR-Colorectal

Cancer, 2007-2017

Characteristics


Year

2007, n=426 2008, n=575 2009, n=590 2010, n=601 2011, n=537 2012, n=536 2013, n=548 2014, n=553 2015, n=618 2016, n=634 2017, n=554

n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)

Specimen type

Biopsy specimen 2,054 (33.3) 266 (62.4) 231 (40.2) 205 (34.7) 173 (28.8) 158 (29.4) 129 (24.1) 170 (31.0) 153 (27.7) 190 (30.7) 192 (30.3) 187 (33.8) Bowel resection 4,118 (66.7) 160 (37.6) 344 (59.8) 385 (65.3) 428 (71.2) 379 (70.6) 407 (75.9) 378 (69.0) 400 (72.3) 428 (69.3) 442 (69.7) 367 (66.2)

Table 4.2: Primary cancer sites identified using resection specimens in colorectal cancer patients in Northern Malaysia;

NCPR-Colorectal Cancer, 2007-2017

Characteristics


Year

2007, n=160 2008, n=344 2009, n=385 2010, n=428 2011, n=379 2012, n=407 2013, n=378 2014, n=400 2015, n=428 2016, n=442 2017, n=367

n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)

Primary cancer site

Rectum 1,475 (35.8) 57 (35.6) 133 (38.7) 151 (39.2) 159 (37.1) 150 (39.6) 134 (32.9) 106 (28.0) 137 (34.3) 146 (34.1) 165 (37.3) 137 (37.3) Sigmoid colon 959 (23.3) 40 (25.0) 71 (20.6) 111 (28.8) 116 (27.1) 98 (25.9) 100 (24.6) 87 (23.0) 85 (21.3) 83 (19.4) 97 (21.9) 71 (19.3) Colon, unspecified 809 (19.6) 41 (25.6) 71 (20.6) 56 (14.5) 71 (16.6) 71 (18.7) 76 (18.7) 104 (27.5) 91 (22.8) 90 (21.0) 73 (16.5) 65 (17.7) Rectosigmoid 679 (16.5) 16 (10.0) 39 (11.3) 66 (17.1) 67 (15.7) 65 (17.2) 71 (17.4) 58 (15.3) 59 (14.8) 84 (19.6) 93 (21.0) 61 (16.6) Ascending colon 204 (5.0) 2 (1.3) 18 (5.2) 24 (6.2) 17 (4.0) 11 (2.9) 20 (4.9) 21 (5.6) 20 (5.0) 28 (6.5) 23 (5.2) 20 (5.4) Caecum 187 (4.5) 5 (3.1) 18 (5.2) 19 (4.9) 27 (6.3) 17 (4.5) 16 (3.9) 12 (3.2) 13 (3.3) 24 (5.6) 19 (4.3) 17 (4.6) Transverse colon 143 (3.5) 4 (2.5) 12 (3.5) 12 (3.1) 14 (3.3) 10 (2.6) 22 (5.4) 18 (4.8) 8 (2.0) 15 (3.5) 16 (3.6) 12 (3.3) Descending colon 133 (3.2) 2 (1.3) 10 (2.9) 13 (3.4) 15 (3.5) 12 (3.2) 10 (2.5) 9 (2.4) 15 (3.8) 14 (3.3) 23 (5.2) 10 (2.7) Hepatic flexure 98 (2.4) 1 (0.6) 10 (2.9) 12 (3.1) 12 (2.8) 7 (1.8) 8 (2.0) 5 (1.3) 11 (2.8) 9 (2.1) 12 (2.7) 11 (3.0) Splenic flexure 71 (1.7) 3 (1.9) 8 (2.3) 6 (1.6) 10 (2.3) 3 (0.8) 4 (1.0) 3 (0.8) 7 (1.8) 12 (2.8) 9 (2.0) 6 (1.6) Anorectum 38 (0.9) 0 (0.0) 2 (0.6) 7 (1.8) 3 (0.7) 4 (1.1) 6 (1.5) 2 (0.5) 4 (1.0) 4 (0.9) 2 (0.5) 4 (1.1)

Primary cancer site

Colon, unspecified 809 (19.6) 41 (25.6) 71 (20.6) 56 (14.5) 71 (16.6) 71 (18.7) 76 (18.7) 104 (27.5) 91 (22.8) 90 (21.0) 73 (16.5) 65 (17.7) Left sided 2,846 (69.1) 111 (69.4) 228 (66.3) 276 (71.7) 303 (70.8) 274 (72.3) 287 (70.5) 238 (63.0) 268 (67.0) 281 (65.7) 323 (73.1) 257 (70.0) Right sided 373 (9.1) 6 (3.8) 32 (9.3) 39 (10.1) 43 (10.0) 27 (7.1) 37 (9.1) 33 (8.7) 39 (9.8) 45 (10.5) 35 (7.9) 37 (10.1) Both sided 90 (2.2) 2 (1.3) 13 (3.8) 14 (3.6) 11 (2.6) 7 (1.8) 7 (1.7) 3 (0.8) 2 (0.5) 12 (2.8) 11 (2.5) 8 (2.2)

51

Table 4.3: Pathologic (pTNM) staging of colorectal cancer based on resection specimens in Northern Malaysia; NCPR-

Colorectal Cancer, 2007-2017

Characteristics


Year

2007, n=158 2008, n=343 2009, n=382 2010, n=416 2011, n=373 2012, n=402 2013, n=360 2014, n=384 2015, n=406 2016, n=430 2017, n=353

n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)

T T1 110 (2.7) 0 (0.0) 7 (2.0) 12 (3.1) 8 (1.9) 8 (2.1) 13 (3.2) 16 (4.4) 12 (3.1) 14 (3.4) 7 (1.6) 13 (3.7) T2 376 (9.4) 2 (1.3) 43 (12.5) 39 (10.2) 28 (6.7) 25 (6.7) 39 (9.7) 43 (11.9) 40 (10.4) 34 (8.4) 47 (10.9) 36 (10.2) T3 1,783 (44.5) 14 (8.9) 101 (29.4) 144 (37.7) 168 (40.4) 190 (50.9) 200 (49.8) 187 (51.9) 214 (55.7) 217 (53.4) 182 (42.3) 166 (47.0) T4 726 (18.1) 15 (9.5) 77 (22.4) 88 (23.0) 64 (15.4) 48 (12.9) 68 (16.9) 57 (15.8) 75 (19.5) 87 (21.4) 84 (19.5) 63 (17.8) Unknown 1,012 (25.3) 127 (80.4) 115 (33.5) 99 (25.9) 148 (35.6) 102 (27.3) 82 (20.4) 57 (15.8) 43 (11.2) 54 (13.3) 110 (25.6) 75 (21.2)

N N0 1,396 (34.8) 13 (8.2) 113 (32.9) 147 (38.5) 115 (27.6) 136 (36.5) 154 (38.3) 144 (40.0) 162 (42.2) 152 (37.4) 139 (32.3) 121 (34.3) N1 900 (22.5) 8 (5.1) 60 (17.5) 73 (19.1) 94 (22.6) 71 (19.0) 91 (22.6) 85 (23.6) 105 (27.3) 110 (27.1) 102 (23.7) 101 (28.6) N2 672 (16.8) 9 (5.7) 55 (16.0) 60 (15.7) 59 (14.2) 65 (17.4) 72 (17.9) 70 (19.4) 70 (18.2) 83 (20.4) 77 (17.9) 52 (14.7) Unknown 1,039 (25.9) 128 (81.0) 115 (33.5) 102 (26.7) 148 (35.6) 101 (27.1) 85 (21.1) 61 (16.9) 47 (12.2) 61 (15.0) 112 (26.0) 79 (22.4)

M M0 1,755 (43.8) 9 (5.7) 104 (30.3) 119 (31.2) 133 (32.0) 139 (37.3) 175 (43.5) 181 (50.3) 224 (58.3) 238 (58.6) 227 (52.8) 206 (58.4) M1 604 (15.1) 9 (5.7) 48 (14.0) 34 (8.9) 39 (9.4) 46 (12.3) 63 (15.7) 80 (22.2) 88 (22.9) 85 (20.9) 62 (14.4) 50 (14.2) Unknown 1,648 (41.1) 140 (88.6) 191 (55.7) 229 (59.9) 244 (58.7) 188 (50.4) 164 (40.8) 99 (27.5) 72 (18.8) 83 (20.4) 141 (32.8) 97 (27.5)

52

Table 4.4: Post-neoadjuvant-chemotherapy pathologic evaluation (ypTNM) of colorectal cancer based on resection

specimen in Northern Malaysia; NCPR-Colorectal Cancer, 2007-2017

Characteristics

All patients, n=111

Year

2007, n=2 2008, n=1 2009, n=3 2010, n=12 2011, n=6 2012, n=5 2013, n=18 2014, n=16 2015, n=22 2016, n=12 2017, n=14

n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)

T T1 1 (0.9) 0 (0.0) 0 (0.0) 0 (0.0) 1 (8.3) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) T2 16 (14.4) 0 (0.0) 0 (0.0) 1 (33.3) 2 (16.7) 0 (0.0) 0 (0.0) 0 (0.0) 3 (18.8) 1 (4.5) 6 (50.0) 3 (21.4) T3 51 (45.9) 0 (0.0) 0 (0.0) 1 (33.3) 4 (33.3) 2 (33.3) 1 (20.0) 9 (50.0) 10 (62.5) 13 (59.1) 3 (25.0) 8 (57.1) T4 34 (30.6) 1 (50.0) 1 (100.0) 1 (33.3) 5 (41.7) 3 (50.0) 1 (20.0) 8 (44.4) 3 (18.8) 5 (22.7) 3 (25.0) 3 (21.4) Unknown 9 (8.1) 1 (50.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (16.7) 3 (60.0) 1 (5.6) 0 (0.0) 3 (13.6) 0 (0.0) 0 (0.0)

N N0 44 (39.6) 2 (100.0) 1 (100.0) 2 (

Documents

NCPR-CC 2ND REPORT...4 Table 4.2: Table 4.4: Table 4.6: Table 3.1: Basis of diagnosis of colorectal cancer patients in Northern Malaysia; NCPR-Colorectal Cancer, 2007