The effect of individual-level factors in survival prognosis for colorectal cancer in Malaysia

Anis K. Ghazali, Thomas J. Keegan, Mohd R. Abu Hassan, Benjamin M. Taylor


Background: In Malaysia, colorectal cancer is the second most common type of cancer for both sexes, represents 10.2% of total cancer cases in Malaysia. This study aims to identify the effect of individual-level factors on survival prognosis for patients with colorectal cancer in Malaysia.

Methods: The study involved 4412 of colorectal cancer patients in Malaysia with histologically verified primary colorectal cancer, diagnosed between 2008 and 2013 (ICD-10, C18-C20), recorded in the database of National Cancer Patient Registry- Colorectal Cancer (NCPR-CC) Malaysia. We investigated the effect of individual characteristics such as age, gender, education as well as clinical characteristics such as cancer staging, cancer site and treatment modalities on survival prognosis after a diagnosis of colorectal cancer using a Cox regression survival model.

Results: Patients diagnosed at stage IV had an almost 6-fold greater risk of dying from colorectal cancer than those with stage I. Age, third-degree education, poor tumour differentiation, the presence of distant metastases and receiving ‘other’ treatments were the other factors that increased the risk of death for colorectal cancer patients in Malaysian population.

Conclusions: Our analysis revealed that the severity of the disease lead to poor prognosis in colorectal cancer in the population after adjusting for other individual characteristics. Health education programs targeting high risk group and emphasizing the importance of early detection of cancer as well as knowledge on the importance of cancer treatment should be implemented. Formulation of a better screening program needs to be extended so that it is a genuinely national program.


Survival, Colorectal cancer, Prognosis

Full Text:



Douaiher J, Ravipati A, Grams B, Chowdhury S, Alatise O, Are C, et al. Colorectal cancer- global burden, trends, and geographical variations. J Surg Oncol. 2017;115:619-30.

Ferlay J, Soerjomataram I I, Dikshit R, Eser S, Mathers C, Rebelo, M, et al. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer. 2014;136(5):359-86.

Omar ZA, Ibrahim Tamin NS. National Cancer Registry Report Malaysia Cancer Statistics Data and Figure 2007. Malaysia Natl Cancer Regist. 2011: 85-87.

Ghazali AK, Musa KI, Naing NN, Mahmood Z. Prognostic factors in patients with colorectal cancer at Hospital Universiti Sains Malaysia. Asian J Surg. 2010;33:127-33.

Cox DR. Regression models and life tables. J R Stat Soc Ser B. 1972;34(2):187-220.

Therneau TM. A Package for Survival Analysis in S. 2015. Available at: package=survival. Accessed on 3 January 2019.

Perme MP, Stare J, Estève J. On estimation in relative survival. Biometrics. 2012;68:113-20.

Roche L, Danieli C, Belot A, Grosclaude P, Bouvier A.M, Velten M, et al. Cancer net survival on registry data: use of the new unbiased Pohar-Perme estimator and magnitude of the bias with the classical methods. Int J cancer. 2013;132:2359-69.

Coleman MP, Quaresma M, Berrino F, Lutz J-M, De Angelis R, Capocaccia R, et al. Cancer survival in five continents: a worldwide population-based study (CONCORD). Lancet Oncol. 2008;9:730-56.

Sant M, Allemani C, Santaquilani M, Knijn A, Marchesi F, Capocaccia R, et al. EUROCARE-4. Survival of cancer patients diagnosed in 1995--1999. Results and commentary. Eur J Cancer. 2009;45:931-91.

Kotake K, Asano M, Ozawa H, Kobayashi H, Sugihara K. Gender differences in colorectal cancer survival in Japan. Int J Clin Oncol. 2016;21:194-203.

Maringe C, Walters S, Rachet B, Butler J, Fields T, Finan P, et al. Stage at diagnosis and colorectal cancer survival in six high-income countries: a population-based study of patients diagnosed during 2000--2007. Acta Oncol (Madr). 2013;52:919-32.

McKay A, Donaleshen J, Helewa RM, Park J, Wirtzfeld D, Hochman D, et al. Does young age influence the prognosis of colorectal cancer: a population-based analysis. World J Surg Oncol. 2014;12:370.

Stornes T, Wibe A, Romundstad PR, Endreseth BH. Outcomes of rectal cancer treatment - influence of age? Int J Colorectal Dis. 2014;29:825-34.

Widdison AL, Barnett SW, Betambeau N. The impact of age on outcome after surgery for colorectal adenocarcinoma. Ann R Coll Surg Engl. 2011;93:445-50.

Fu J, Yang J, Tan Y, Jiang M, Wen F, Huang Y, et al. Young patients (35 years old) with colorectal cancer have worse outcomes due to more advanced disease: a 30-year retrospective review. Medicine (Baltimore). 2014;93:1-7.

Hassan MRA, Ismail I, Suan MAM, Ahmad F, Khazim WKW, Othman Z, et al. Incidence and mortality rates of colorectal cancer in Malaysia. Epidemiol Health. 2016;38:1-5.

Cavalli-Björkman N, Lambe M, Eaker S, Sandin F, Glimelius B. Differences according to educational level in the management and survival of colorectal cancer in Sweden. Eur J Cancer. 2011;47:1398-1406.

Rasouli MA, Moradi G, Roshani D, Nikkhoo B, Ghaderi E, Ghaytasi B. Prognostic factors and survival of colorectal cancer in Kurdistan province, Iran: A population-based study (2009--2014). Medicine (Baltimore). 2017;96:1-7.

Walter V, Jansen L, Hoffmeister M, Brenner H. Smoking and survival of colorectal cancer patients: systematic review and meta-analysis. Ann Oncol. 2014;25:1517-25.

Phipps AI, Shi Q, Newcomb PA, Nelson GD, Dargent DJ, Alberts SR, et al. Associations between cigarette smoking status and colon cancer prognosis among participants in North Central Cancer Treatment Group Phase III Trial N0147. J Clin Oncol. 2013;31:2016-23.

Boyle T, Fritschi L, Platell C, Heyworth J. Lifestyle factors associated with survival after colorectal cancer diagnosis. Br J Cancer. 2013;109:814.

Sharp L, McDevitt J, Brown C, Comber H. Smoking at diagnosis significantly decreases 5-year cancer-specific survival in a population-based cohort of 18 166 colon cancer patients. Aliment Pharmacol Ther. 2017;45:788-800.

Phipps AI, Baron J, Newcomb PA. Prediagnostic smoking history, alcohol consumption, and colorectal cancer survival: the Seattle Colon Cancer Family Registry. Cancer. 2011;117:4948-57.

Chao A, Thun MJ, Jacobs EJ, Henley SJ, Rodriguez C, Calle EE. Cigarette smoking and colorectal cancer mortality in the cancer prevention study II. J Natl Cancer Inst. 2000;92:1888-96.

Price TJ, Beeke C, Ullah S, Padbury R, Maddern G, Roder D, et al. Does the primary site of colorectal cancer impact outcomes for patients with metastatic disease? Cancer. 2015;121:830-5.

Yeole BB, Sunny L, Swaminathan R, Sankaranarayanan R, Parkin DM. Population-based survival from colorectal cancer in Mumbai,(Bombay) India. Eur J Cancer. 2001;37:1402-8.

Lydrup M-L, Höglund P. Gender aspects of survival after surgical treatment for rectal cancer. Color Dis. 2015;17:390-6.

Cheung WY, Shi Q, O’connell M, Cassidy J, Blanke CD, Kerr DJ, et al. The predictive and prognostic value of sex in early-stage colon cancer: a pooled analysis of 33,345 patients from the ACCENT database. Clin Colorectal Cancer. 2013;12:179-87.

Majek O, Gondos A, Jansen L, Emrich K, Holleczek B, Katalinic A, et al. Sex differences in colorectal cancer survival: population-based analysis of 164,996 colorectal cancer patients in Germany. PLoS One. 2013;8:e68077.

Mandelson MT, Miglioretti D, Newcomb PA, Harrison R, Potter JD. Hormone replacement therapy in relation to survival in women diagnosed with colon cancer. Cancer Causes Control. 2003;14:979-84.

Aguero F, Murta-Nascimento C, Gallén M, Andreu-Garcia M, Pera M, Hernandez C, et al. Colorectal cancer survival: results from a hospital-based cancer registry. Rev Esp Enferm Dig. 2012;104:572-7.

Mills KT, Bellows CF, Hoffman AE, Kelly TN, Gagliardi G. Diabetes and colorectal cancer prognosis: a meta-analysis. Dis Colon Rectum. 2013;56:1304.

American Cancer Society. Survival Rates for Colorectal Cancer, by Stage. 2018.Avaialable at detection-diagnosis-staging/survival-rates.html# references. Accessed on 10 March 2017.

Shi R, Kodali MD, Wang SC, Lavu K.C, Liu L, Shows JR, et al. Mortality risk factors and survival of colon cancer patient. J Clin Oncol. 2013;31:e14653-e14653.

Cancer Research UK. Campaign evaluation. 2014. Available at health-professional/early-diagnosis-activities/be-clear-on-cancer/bowel-cancer-campaign/evaluation# BCOC bowel evaluation1. Accessed on 11 May 2017.