Validity of the Swedish Rectal Cancer Registry for patients treated with major abdominal surgery between 1995 and 1997

Oncological outcome following Hartmann's procedure compared with anterior resection and abdominoperineal resection for rectal cancer-The type of procedure does not influence local recurrence or distant metastasis: A population-based study

AIM

The type of surgical procedure used in rectal cancer treatment may affect cancer recurrence. The aim of this study was to determine whether the type of procedure influences oncological outcomes in rectal cancer surgery.

METHOD

We gathered data from the Swedish Colorectal Cancer Registry regarding patients with TNM Stage I-III rectal cancer who underwent R0/R1 surgery from 2013 to 2017. The outcomes after Hartmann's procedure (HP), anterior resection (AR) and abdominoperineal resection (APR) were compared, and a multivariable Cox regression analysis was performed. The primary outcome of the study was the local recurrence rate. The secondary outcomes were distant metastasis, disease-free survival and overall survival at 5 years as well as risk factors for local recurrence.

RESULTS

A total of 4741 patients were included in the study: 614 underwent HP, 3075 underwent AR and 1052 underwent APR. Multivariable Cox regression revealed no difference in local recurrence, distant metastasis or disease-free survival. Overall survival was higher following AR (OR 0.62, CI 0.54-0.72). Risk factors for local recurrence were intraoperative bowel perforation (OR 2.41, CI 1.33-4.40), a pT4 tumour (OR 1.93, CI 1.11-3.4) and a positive circumferential resection margin (OR 5.62, CI 3.28-9.61).

CONCLUSIONS

This nationwide study showed that the type of procedure did not affect the local recurrence rate or distant metastasis. In patients who are unfit for restorative surgery, HP is a viable alternative with oncological outcomes similar to those of APR.

A Validation of the Swedish Colorectal Cancer Register - With Focus on Histopathology, Complications and Recurrences

Background

There is an urgent need to evaluate the quality of healthcare systems to improve and deliver high-quality care. Clinical registries have become important platforms for performance measurements, improvements, and clinical research. Hence, the quality of data in registries is crucial. This study aimed to assess the validity of data in the Swedish Colorectal Cancer Register (SCRCR).

Methods

Seven hundred patients from 12 hospitals were randomly selected and proportionally distributed among three different hospital categories in Sweden using two-stage cluster sampling. Validity was assessed by re-abstracting data from the medical files of patients reported to the SCRCR in 2015. Data on histopathology, postoperative complications, and a 3-year follow-up were selected for validation. Re-abstracted data were defined as source data, and validity was defined as the proportion of cases in the SRCRC dataset that agreed with the source data. Validity was expressed as the percentage of exact agreement of non-missing data in both data sets, and Cohen´s kappa coefficient (κ) was used to measure the strength of the agreement.

Results

The median agreement of the categorical histopathology variables was 93.4% (κ = 0.83). The general postoperative complication variable showed substantial agreement (84.3%, κ = 0.61). Likewise, the variable for overall cancer recurrence showed an almost perfect agreement (95.7%, κ = 0.86), whereas specific variables for local recurrence and distant recurrence displayed only moderate and fair agreement (85.9% and 89.1%, κ = 0.58 and 0.34, respectively).

Conclusion

Validation of the SCRCR data showed high validity of pathology data and recurrence rates, whereas detailed data on recurrence were not as good. Data on postoperative complications were less reliable, although the incidence and Clavien-Dindo grading of severe complications (grade 3b or higher) were reliable.

Postoperative morbidity following Hartmann's procedure in comparison to anterior resection and abdominoperineal resection for rectal cancer-a population-based study

AIM

There is ongoing controversy regarding the extent to which Hartmann's procedure (HP) should be used in rectal cancer treatment. This study was designed to investigate 30-day postoperative morbidity and mortality following HP, anterior resection (AR) and abdominoperineal resection (APR) for rectal cancer using a national registry.

METHODS

All patients operated for rectal cancer, tumour height 5-15 cm, between the years 2010 and 2017, were identified through the Swedish colorectal cancer registry.

RESULTS

A total of 8476 patients were included: 1210 (14%) undergoing HP, 5406 (64%) AR and 1860 (22%) APR. HP was associated with an increased risk of intra-abdominal infection (OR 1.7, CI 1.26-2.28, P = 0.0004) compared to AR and APR, while APR was related to an increased risk of overall complications (OR 1.18, CI 1.01-1.40, P = 0.040). No significant difference was observed in the rate of reoperations and readmissions between HP, AR and APR, and type of surgical procedure was not a risk factor for 30-day mortality. Findings from a subgroup analysis of patients with a tumour 5-7 cm from the anal verge revealed that HP was not associated with increased risk for complications or 30-day mortality.

CONCLUSIONS

For patients where AR is not appropriate HP is a valid alternative with a favourable outcome. APR was associated with the highest overall 30-day complication rate.

Validation of primary and outcome data quality in a Swedish population-based breast cancer quality registry

BACKGROUND

Population-based cancer quality registries are of great importance for the improvement of cancer care. However, little is known about the quality of recurrence data in cancer quality registries. The aim of this study was to evaluate data quality in the regional Breast Cancer Quality Registry of Central Sweden, with emphasis on the validity of recorded information on recurrence.

METHODS

Validation by re-abstraction was performed on a random sample of 800 women with primary invasive breast cancer stage I-III diagnosed between 1993 and 2010, of which 400 had at least one registered recurrence and 400 had no registered recurrence. Registry data were compared with data from medical records. Exact agreement, correlation and kappa values, sensitivity and specificity were calculated.

RESULTS

Seven hundred forty-seven women (93%) were available for analysis. Exact agreement was high for diagnostics, tumor characteristics, surgery, and adjuvant oncological treatment (90% or more for most variables). The registry's sensitivity was low for regional recurrence (47%), but higher for local and distant recurrence (80% and 75%), whereas specificity was overall high (≥ 95%). Combining all recurrence categories irrespective of localization improved sensitivity to 90% with a specificity of 91%. In 87% of women, the date of first recurrence according to medical records fell within ± 90 days of the date recorded in the registry.

CONCLUSIONS

While the quality of data in the regional Breast Cancer Quality Registry was generally high, data accuracy on recurrences was lower. The overall precision of identifying any recurrence, irrespective of localization, was high. However, the accuracy of classification of recurrences (local, regional or distant) was lower, with evidence of underreporting for each of the recurrence categories. Given the importance of recurrence-related outcomes in the assessment of quality of care, efforts should be made to improve the reporting of recurrences.

Hartmann's procedure in rectal cancer surgery is often an intraoperative decision: a retrospective multicenter study

PURPOSE

This study aimed to investigate patient-related factors predicting the selection of rectal cancer patients to Hartmann's procedure as well as to investigate how often, and on what grounds, anterior resection is intraoperatively changed to Hartmann's procedure.

METHODS

Prospectively collected data from the Swedish Colorectal Cancer Registry regarding patients with rectal cancer operated upon from January 1 2007 to June 30 2017 in the county of Skåne were retrospectively reviewed. Data were expanded with further details from medical charts. A univariable analysis was performed to investigate variables associated with unplanned HP and significant variables included in a multivariable logistic regression analysis.

RESULTS

Altogether, 1141 patients who underwent Hartmann's procedure (275 patients, 24%), anterior resection (491 patients, 43%), or abdominoperineal resection (375 patients, 33%) were included. Patients undergoing Hartmann's procedure were significantly older and had more frequently comorbidity. The decision to perform Hartmann's procedure was made preoperatively in 209 (76%) patients, most commonly because of a comorbidity (27%) or oncological reasons (25%). Patient preference was noted in 8% of cases. In 64 cases (23%), the decision was made intraoperatively, most often due to anastomotic difficulties (60%) and oncological reasons (22%). Anastomotic difficulties were most often reported due to technical difficulties, a low tumor or neoadjuvant radiotherapy. Male gender was a significant risk factor for undergoing unplanned Hartmann's procedure.

CONCLUSIONS

The decision to perform Hartmann's procedure was frequently made intraoperatively. Hartmann's procedure should be considered and discussed preoperatively in old and frail patients, especially in the presence of mid-rectal cancer and/or male gender, since these factors increase the risk of intraoperative anastomotic difficulties.

Negative Prognostic Impact of Tumor Deposits in Rectal Cancer: A National Study Cohort

OBJECTIVE

To investigate whether tumor deposits (TDs) in rectal cancer are associated with increased recurrence risk and decreased survival.

BACKGROUND

Tumor deposits (TDs) are considered a risk factor for recurrence after colon cancer resection, and the presence of TDs prompts adjuvant chemotherapy. The prognostic relevance of TDs in rectal cancer requires further exploration.

METHODS

All patients treated with abdominal resection surgery for rectal cancer in Sweden between 2011 and 2014 were eligible for inclusion in this retrospective cohort study based on prospectively collected data from the Swedish Colorectal Cancer Registry. The primary endpoint was local recurrence or distant metastasis. Secondary outcomes were overall and relative survival.

RESULTS

Five thousand four hundred fifty-five patients were identified of which 3769 patients were analyzed after exclusion. TDs were found in 404 (10.7%) patients, including 140 (3.7%) patients with N1c-status. In TD-positive patients, local recurrence and distant metastasis rates at 5 years were 6.3% [95% CI 3.8-8.8%] and 38.9% [95% CI, 33.6-43.5%] compared with 2.7% [95% CI, 2.1-3.3%] and 14.3% [95% CI, 13.1-15.5%] in TD-negative patients. In multivariable regression analysis, the risk of local recurrence and distant metastasis were increased; HR 1.86 [95% CI, 1.09-3.19; P =0.024] and 1.87 [95% CI, 1.52-2.31; P =<0.001], respectively. Overall survival at 5 years was 68.8% [95% CI, 64.4-73.4%] in TD-positive patients and 80.7% [95% CI, 79.4-82.1%] in TD-negative patients. pN1c-patients had similar outcomes regarding local recurrence, distant metastasis, and survival as pN1a-b stage patients. TD-positive pN1a-b patients had significantly worse outcomes whereas TDs did not affect outcomes in pN2a-b patients.

CONCLUSION

This study suggests that TDs have a negative impact on the prognosis in rectal cancer. Thus, efforts should be made to diagnose TD-positive rectal cancer patients preoperatively.

CRCBaSe: a Swedish register-based resource for colorectal adenocarcinoma research

OBJECTIVES

To facilitate high-quality register-based research on colorectal cancer (CRC) in Sweden by constructing a database consisting of CRC patients, matched comparators, and relatives.

MATERIAL AND METHODS

Patients with adenocarcinoma in the colon and/or rectum were identified in the Swedish Colorectal Cancer Register, a nationwide quality-of-care register. For each patient, six comparators from the general population were matched on birth year, sex, year of CRC diagnosis, and county. Comparators were free from CRC at the time of matching, but could later become cases. For both patients and comparators, first-degree relatives (parents, siblings, and children) were identified. Information from nationwide population-based registers was retrieved and linked to each individual in the database using the personal identification number unique to all Swedish residents.

RESULTS

A total of 76,831 CRC patients diagnosed between 1995 and 2016 were identified (51% colon, 49% rectal; before 2007 only rectal cancer patients were included). Among all patients, 37% were stage I-II, 22% stage III, and 22% stage IV. The median follow-up time was 11.9 years (inter-quartile range, IQR: 8.6-15.3). Together with comparators and relatives, the database contains 2,413,139 individuals with information on demographics, dates and causes of death, in- and outpatient healthcare records, cancer diagnoses, prescribed and dispensed drugs, childbirths (among women), and social security information (such as sick leave and early retirement).

CONCLUSION

The Colorectal Cancer Database Sweden (CRCBaSe) is a large and unique register-based data research platform, which opens up for clinically important, large epidemiological studies with innovative design in the field of colorectal adenocarcinoma.

Circumferential Resection Margin is Associated With Distant Metastasis After Rectal Cancer Surgery: A Nation-wide Population-based Study Cohort

OBJECTIVE

To evaluate circumferential resection margin (CRM) as a risk factor for distant metastasis (DM) in rectal cancer.

SUMMARY OF BACKGROUND DATA

The treatment of rectal cancer has evolved over the last decades. Surgical radicality is considered the most important factor in preventing recurrences including local and distant. CRM ≤1.0 mm is considered to increase recurrence risk. This study explores the risk of DM in relation to exact CRM.

METHODS

All patients treated with abdominal resection surgery for rectal cancer between 2005 and 2013 in Sweden were eligible for inclusion in this retrospective study. Primary endpoint was DM.

RESULTS

Twelve thousand one hundred forty-six cases were identified. Eight thousand five hundred ninety-three cases were analyzed after exclusion. Seven hundred seventeen (8.6%) patients had CRM ≤1.0mm and 7577 (91.4%) patients had CRM >1.0 mm. DM recurrence rate at 5 years was 42.1% (95% CI 32.5-50.3), 31.5% (95% CI 27.3-35.5), 25.8% (95% Confidence Interval (CI) 16.2-34.4), and 19.5% (95% CI 18.5-19.5) when CRM was 0.0 mm, 0.1 to 1.0 mm, 1.1 to 1.9 mm, and CRM ≥2mm, respectively. Multivariable analysis revealed higher DM risk in CRM 0.0-1.0 mm versus >1.0 mm (hazard ratio 1.30, 95% CI 1.05-1.60; P = 0.015). No significant difference in DM risk in CRM 1.1-1.9 mm versus ≥2.0 mm (hazard ratio 0.66, 95% CI 0.34-1.28; P = 0.224) could be detected.

CONCLUSIONS

The risk of DM decreases with increasing CRM. Moreover, CRM ≤1.0 mm is a significant risk factor for DM. Thus, CRM is a dominant factor when discussing risk of DM after rectal cancer surgery.

Low incidence of pelvic sepsis following Hartmann's procedure for rectal cancer: a retrospective multicentre study

BACKGROUND

Results of previous studies regarding pelvic sepsis after Hartmann's procedure (HP) for rectal cancer have been inconsistent and few studies report the risk factors. This study aimed to investigate the incidence of pelvic sepsis after HP, identify risk factors and describe when as well as how pelvic sepsis was diagnosed and treated.

METHODS

Data were collected from the Swedish Colorectal Cancer Registry on all patients undergoing HP for rectal cancer in the county of Skåne from 2007-2017. Patients diagnosed with pelvic sepsis were compared with patients without pelvic sepsis and risk factors for developing pelvic sepsis were analysed in a multivariable model.

RESULTS

A total of 252 patients were included in the study, with 149 (59%) males, and a median age of 75 years (range 20-92). Altogether, 27 patients (11%) were diagnosed with pelvic sepsis. Risk factors for developing pelvic sepsis were neoadjuvant radiotherapy (OR 7.96, 95% CI 2.54-35.36) and BMI over 25 kg/m² (OR 5.26, 95% CI 1.80-19.50). Median time from operation to diagnosis was 21 days (range 5-355) with 11 (40%) patients diagnosed beyond 30 days postoperatively. The majority of cases 19 (70%) were treated conservatively and none needed major surgery.

CONCLUSION

Pelvic sepsis occurred in 11% of patients. Neoadjuvant radiotherapy and higher BMI were significant risk factors for developing pelvic sepsis. Forty percent of patients were diagnosed later than 30 days postoperatively and most patients were successfully treated conservatively. Our findings suggest that HP is a valid treatment option for rectal cancer when anastomosis is inappropriate, even in patients receiving neoadjuvant radiotherapy.

Accuracy of magnetic resonance imaging staging of tumour and nodal stage in rectal cancer treated by primary surgery: a population-based study

AIM

The preoperative stage of rectal cancer is an important prognostic factor affecting treatment recommendations. Currently, magnetic resonance imaging (MRI) is used for clinical staging to identify patients who should be recommended for neoadjuvant oncological treatment. The aim of this work was to investigate the accuracy of the preoperative T- and N-stage and also involvement of the mesorectal fascia (MRF) as determined by MRI in a Swedish national cohort.

METHOD

Patients who had undergone resectional surgery for rectal cancer without neoadjuvant treatment in Sweden in the period 2013-2017 were identified through the Swedish Colorectal Cancer Registry (n = 2062). The T- and N-stage determined by preoperative MRI were compared with the histopathological results. The MRI-assessed MRF status was compared with the circumferential resection margin.

RESULTS

Sensitivity for differentiating T1-2 from T3-4 was 69% and specificity 77%. Sensitivity to detect N1-2 was 42% and specificity 81%. Sensitivity for MRF positivity was 50% and specificity 92%. Agreement analysed by weighted kappa analysis was 0.47 for T-stage [confidence interval (CI) 0.44-0.51], 0.24 for N-stage (CI 0.19-0.24) and 0.20 for MRF status (CI 0.12-0.29).

CONCLUSION

In this study, accuracy of the preoperative MRI was lower than expected for rectal cancers. Overstaging might lead to potentially harmful neoadjuvant treatment and understaging can lead to a higher risk of tumour recurrence. The results of this study show that efforts should be made to increase the accuracy of the preoperative evaluation in order to optimize treatment recommendations.

Postoperative nonsteroidal anti-inflammatory drugs in relation to recurrence, survival and anastomotic leakage after surgery for colorectal cancer

AIM

The aim of this work was to investigate whether nonsteroidal anti-inflammatory drugs (NSAIDs) could be beneficial or harmful when used perioperatively for colorectal cancer patients, as inflammation may affect occult disease and anastomotic healing.

METHOD

This is a protocol-based retrospective cohort study on colorectal cancer patients operated on between 2007 and 2012 at 21 hospitals in Sweden. NSAID exposure was retrieved from postoperative analgesia protocols, while outcomes and patient data were retrieved from the Swedish Colorectal Cancer Registry. Older or severely comorbid patients, as well as those with disseminated or nonradically operated tumours were excluded. Multivariable regression with adjustment for confounders was performed, estimating hazard ratios (HRs) for long-term outcomes and odds ratios (ORs) for short-term outcomes, including 95% confidence intervals (CIs).

RESULTS

Some 6945 patients remained after exclusion, of whom 3996 were treated at hospitals where a NSAID protocol was in place. No association was seen between NSAIDs and recurrence-free survival (HR 0.97, 95% CI 0.87-1.09). However, a reduction in cancer recurrence was detected (HR 0.83, 95% CI 0.72-0.95), which remained significant when stratifying into locoregional (HR 0.68, 95% CI 0.48-0.97) and distant recurrences (HR 0.85, 95% CI 0.74-0.98). Anastomotic leakage was less frequent (HR 0.69%, 95% CI 0.51-0.94) in the NSAID-exposed, mainly due to a risk reduction in colo-rectal and ileo-rectal anastomoses (HR 0.47, 95% CI 0.33-0.68).

CONCLUSION

There was no association between NSAID exposure and recurrence-free survival, but an association with reduced cancer recurrence and the rate of anastomotic leakage was detected, which may depend on tumour site and anastomotic location.

Permanent stoma rates after anterior resection for rectal cancer: risk prediction scoring using preoperative variables

BACKGROUND

A permanent stoma after anterior resection for rectal cancer is common. Preoperative counselling could be improved by providing individualized accurate prediction modelling.

METHODS

Patients who underwent anterior resection between 2007 and 2015 were identified from the Swedish Colorectal Cancer Registry. National Patient Registry data were added to determine presence of a stoma 2 years after surgery. A training set based on the years 2007-2013 was employed in an ensemble of prediction models. Judged by the area under the receiving operating characteristic curve (AUROC), data from the years 2014-2015 were used to evaluate the predictive ability of all models. The best performing model was subsequently implemented in typical clinical scenarios and in an online calculator to predict the permanent stoma risk.

RESULTS

Patients in the training set (n = 3512) and the test set (n = 1136) had similar permanent stoma rates (13.6 and 15.2 per cent). The logistic regression model with a forward/backward procedure was the most parsimonious among several similarly performing models (AUROC 0.67, 95 per cent c.i. 0.63 to 0.72). Key predictors included co-morbidity, local tumour category, presence of metastasis, neoadjuvant therapy, defunctioning stoma use, tumour height, and hospital volume; the interaction between age and metastasis was also predictive.

CONCLUSION

Using routinely available preoperative data, the stoma outcome at 2 years after anterior resection for rectal cancer can be predicted fairly accurately.

Postoperative non-steroidal anti-inflammatory drug use and oncological outcomes of rectal cancer

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are known to suppress the inflammatory response after surgery and are often used for pain control. This study aimed to investigate NSAID use after radical surgical resection for rectal cancer and long-term oncological outcomes.

METHODS

A cohort of patients who underwent anterior resection for rectal cancer between 2007 and 2013 in 15 hospitals in Sweden was investigated retrospectively. Data were obtained from the Swedish Colorectal Cancer Registry and medical records; follow-up was undertaken until July 2019. Patients who received NSAID treatment for at least 2 days after surgery were compared with controls who did not, and the primary outcome was recurrence-free survival. Cox regression modelling with confounder adjustment, propensity score matching, and an instrumental variables approach were used; missing data were handled by multiple imputation.

RESULTS

The cohort included 1341 patients, 362 (27.0 per cent) of whom received NSAIDs after operation. In analyses using conventional regression and propensity score matching, there was no significant association between postoperative NSAID use and recurrence-free survival (adjusted hazard ratio (HR) 1.02, 0.79 to 1.33). The instrumental variables approach, including individual hospital as the instrumental variable and clinicopathological variables as co-variables, suggested a potential improvement in the NSAID group (HR 0.61, 0.38 to 0.99).

CONCLUSION

conventional modelling did not demonstrate an association between postoperative NSAID use and recurrence-free survival in patients with rectal cancer, although an instrumental variables approach suggested a potential benefit.

International evaluation of circumferential resection margins after rectal cancer resection: insights from the Swedish and Dutch audits

AIM

This study aimed to determine predictive factors for the circumferential resection margin (CRM) within two northern European countries with supposed similarity in providing rectal cancer care.

METHOD

Data for all patients undergoing rectal resection for clinical tumour node metastasis (TNM) stage I-III rectal cancer were extracted from the Swedish ColoRectal Cancer Registry and the Dutch ColoRectal Audit (2011-2015). Separate analyses were performed for cT1-3 and cT4 stage. Predictive factors for the CRM were determined using univariable and multivariable logistic regression analyses.

RESULTS

A total of 6444 Swedish and 12 089 Dutch patients were analysed. Over time the number of hospitals treating rectal cancer decreased from 52 to 42 in Sweden, and 82 to 79 in the Netherlands. In the Swedish population, proportions of cT4 stage (17% vs 8%), multivisceral resection (14% vs 7%) and abdominoperineal excision (APR) (37% vs 31%) were higher. The overall proportion of patients with a positive CRM (CRM+) was 7.8% in Sweden and 5.4% in the Netherlands. In both populations with cT1-3 stage disease, common independent risk factors for CRM+ were cT3, APR and multivisceral resection. No common risk factors for CRM+ in cT4 stage disease were found. An independent impact of hospital volume on CRM+ could be demonstrated for the cT1-3 Dutch population.

CONCLUSION

Within two northern European countries with implemented clinical auditing, rectal cancer care might potentially be improved by further optimizing the treatment of distal and locally advanced rectal cancer.

Risk of local recurrence of rectal cancer and circumferential resection margin: population-based cohort study

Background

A circumferential resection margin (CRM) of 1·0 mm or less after rectal cancer surgery is thought to increase the risk of local recurrence (LR). This retrospective population-based study examined how CRM distance affects the LR risk.

Methods

Data from the Swedish Colorectal Cancer Registry were used in a retrospective analysis of rectal cancers resected between 2005 and 2013. The primary endpoint was LR.

Results

A total of 12 146 patients were identified, of whom 8392 were included in the analysis; 739 patients had a CRM of 1·0 mm or less and 7653 had a CRM larger than 1·0 mm. The mean follow-up time was 51 months. There were 66 LRs (8·9 per cent) in the group with a CRM of 1·0 mm or less, and 256 (3·3 per cent) among patients with a CRM larger than 1·0 mm. The LR rate was 17·0 per cent (27 of 159), 6·7 per cent (39 of 580), 1·9 per cent (2 of 103) and 3·4 per cent (254 of 7550) when the CRM was 0, 0·1–1·0, 1·1–1·9 and at least 2·0 mm respectively. The risk of LR among patients with a CRM of 0 mm was higher than that in all other subgroups with a larger CRM (P &lt; 0·050). There was no difference in LR between the subgroups with CRM 1·1–1·9 mm and at least 2·0 mm. LR was diagnosed earlier when the CRM was 1·0 mm or less.

Conclusion

LR risk is related to exact CRM, with the highest risk in patients with a CRM of 0 mm. Close monitoring of patients with no measurable clear margin may allow early detection of LR.

Population-based analysis of outcomes with early-age colorectal cancer

BACKGROUND

The aim was to evaluate differences in stage, treatment and prognosis in patients aged less than 50 years with colorectal cancer compared with older age groups.

METHODS

This population-based study included all patients diagnosed with colorectal cancer in Sweden, 2010-2015. Disease stage, treatment, 5-year disease-free survival (DFS) and relative survival were analysed in relation to age groups: less than 50, 50-74 and at least 75 years.

RESULTS

Of 34 434 patients included, 24·1, 19·7 and 14·0 per cent of patients aged less than 50, 50-74 and at least 75 years respectively were diagnosed with stage IV disease (P < 0·001). Adverse histopathological features were more common in young patients. Among patients aged less than 50 years, adjuvant chemotherapy was given to 18·9, 42·0 and 93·9 per cent of those with stage I, III and III disease respectively, compared with 0·7, 4·4 and 29·6 per cent of those aged 75 years or older (P < 0·001). Stage-adjusted DFS at 5 years for patients under 50 years old was 0·96, 0·90 and 0·77 in stage I, II and III respectively. Corresponding proportions were 0·88, 0·82 and 0·68 among patients aged 50-74 years, and 0·69, 0·62 and 0·49 for those aged 75 years or older. Relative survival was better for young patients only among those with stage III disease.

CONCLUSION

Patients younger than 50 years with colorectal cancer had a poorer stage at diagnosis and received more intensive oncological treatment. DFS was better than that among older patients in early-stage disease.

Tumor and nodal staging of colon cancer: accuracy of preoperative computed tomography at a Swedish high-volume center

Background

When deciding treatment options for patients with colon cancer, accurate staging is required. In Sweden, the main preoperative evaluation modality to determine tumor and nodal stage is computed tomography (CT).

Purpose

The aim of this study was to investigate how well the preoperative (CT-determined) clinical tumor and nodal stage (cTN) correlated with the postoperative histopathological stage (pTN). Another aim was to validate the tumor and nodal stage data in the Swedish Colorectal Cancer Registry (SCRCR).

Material and Methods

The SCRCR was used to identify patients with colon cancer, treated at a Swedish high-volume center during 2013-2016 (n = 974). Data were gathered from medical records regarding cTN and pTN stage, and predefined patient and tumor variables. The agreement between cTN and pTN was analyzed using kappa statistics.

Results

After excluding patients with either pre- or postoperative TN stage missing, 383 patients remained for further analyses. The analyses showed an agreement between cT and pT of κ: 0.27 and between cN and pN of κ: 0.21 (fair agreement). When comparing tumors with low (T1-3; N0) versus high risk (T4; N1-2), the kappa value was 0.19 (slight agreement). When comparing the SCRCR to medical records, 78% of completely staged tumors had been correctly reported.

Conclusion

The agreement between cTN and pTN was low in this study population, indicating a need for enhanced precision of the preoperative staging process. A high frequency of erroneous preoperative staging data in the SCRCR shows the need for further efforts of ensuring correct data transfers into the registry.

Parastomal hernias causing symptoms or requiring surgical repair after colorectal cancer surgery-a national population-based cohort study

PURPOSE

Parastomal hernia is a complication with high morbidity that affects the patient's quality of life. The aim of this study was to assess the cumulative incidence of parastomal hernia in patients who have undergone colorectal cancer surgery and to identify potential risk factors that could predispose to the development of this type of hernia in a large population-based cohort over a long follow-up period.

METHODS

The Swedish Colorectal Cancer Registry and the National Patient Register were used to collect study cohort data between January 2007 and September 2013. All patients undergoing colorectal cancer surgery including a permanent stoma were included in the study group.

RESULTS

A total of 39,984 patients were registered during the study period. Of these, 7649 received a permanent stoma. Multivariate proportional hazard analysis, based on 6329 patients for whom all covariates could be retrieved, showed that the only independent risk factor for developing a parastomal hernia was BMI ≥ 30 (HR 1.49; 95% CI 1.02-2.17; p < 0.037). A slightly elevated hazard ratio was found for preoperative radiotherapy (HR 1.36; 95% CI 0.96-1.91; p < 0.070). The cumulative incidence of patients diagnosed or surgically treated for parastomal hernia over a follow-up period of 5 years was 7.7% (95% CI 6.1-9.2%).

CONCLUSIONS

The cumulative incidence of parastomal hernia causing symptoms or requiring surgery after 5 years was at least 7.7%. Obesity increases the risk of developing parastomal hernia.

Population-based study of surgical treatment with and without tumour resection in patients with locally recurrent rectal cancer

BACKGROUND

Population-based studies of treatment of locally recurrent rectal cancer (LRRC) are lacking. The aim was to investigate the surgical treatment of patients with LRRC at a national population-based level.

METHODS

All patients undergoing abdominal resection for primary rectal cancer between 1995 and 2002 in Sweden with LRRC as a first event were included. Detailed information about treatment, complications and outcomes was collected from the medical records. The patients were analysed in three groups: patients who had resection of the LRRC, those treated without tumour resection and patients who received best supportive care only.

RESULTS

In all, 426 patients were included in the study. Of these, 149 (35·0 per cent) underwent tumour resection, 193 (45·3 per cent) had treatment without tumour resection and 84 (19·7 per cent) received best supportive care. Abdominoperineal resection was the most frequent surgical procedure, performed in 65 patients (43·6 per cent of those who had tumour resection). Thirteen patients had total pelvic exenteration. In total, 63·8 per cent of those whose tumour was resected had potentially curative surgery. After tumour resection, 62 patients (41·6 per cent) had a complication within 30 days. Patients who received surgical treatment without tumour resection had a lower complication rate but a significantly higher 30-day mortality rate than those who underwent tumour resection (10 versus 1·3 per cent respectively; P = 0·002). Of all patients included in the study, 22·3 per cent had potentially curative treatment and the 3-year survival rate for these patients was 56 per cent.

CONCLUSION

LRRC is a serious condition with overall poor outcome. Patients undergoing curative surgery have an acceptable survival rate but substantial morbidity. There is room for improvement in the management of patients with LRRC.

Evaluation of the Swedish Colorectal Cancer Registry: an overview of completeness, timeliness, comparability and validity

BACKGROUND

The Swedish Colorectal Cancer Registry (SCRCR) is a national registry established in 1995 for rectal cancer, and also including colon cancer since 2007. Knowledge of the quality of the registry is vital in order to draw correct conclusions from studies based on the registry. The aim of this study was to assess the completeness, timeliness, comparability and validity of the SCRCR.

MATERIAL AND METHODS

Completeness, timeliness and comparability of the registry were estimated. From the SCRCR year 2008, 500 cases were randomly selected to examine the validity of the registry and 486 cases were retrieved. Using hospital patient records as source documents, 130 variables in the SCRCR were reabstracted using the SCRCR registration forms and then compared with the original files.

RESULT

During the period 2008-2015, the average completeness of the SCRCR was 98.5% for colon cancer and 98.8% for rectal cancer. Timeliness improved between the years 2008 and 2015, with 98% of the patients registered within 12 months for the year 2015. For most of the variables, comparability was estimated to be reproducible and comparable with other registries. Regarding the validity of the registry, when comparing reabstracted data with the original SCRCR data, average agreement was 90%.

CONCLUSION

The SCRCR can be considered a reliable registry useful for quality assurance and research. Standardization and improvements in journal documentation are needed to improve future evaluation of the source documents.

Disparities in colorectal cancer between Northern and SouthernSweden - a report from the new RISK North database

BACKGROUND

Geographic cancer health disparities have been reported in Sweden. The disparities are not fully understood, but may be attributed to differences in exposure to risk factors as well as differences in health care, socioeconomics and demography. The aim of this study was to describe the new nationwide population based RISK North database and its potential by analysing health disparities in colorectal cancer between Northern and Southern Sweden.

METHODS

Cancer-specific data from the National Cancer Quality Registers for colorectal, gastric and oesophageal cancer and brain tumours were linked to several nationwide registers hereby creating a new database - RISK North. To exemplify the potential of RISK North, we analyzed differences in colorectal cancer incidence, mortality and survival in relation to gender, age, cohabitation and education between Northern and Southern Sweden 2007-2013.

RESULTS

In colon cancer, the age-adjusted incidence per 100.000 was lower in Northern than Southern Sweden, 35.9 in the North vs. 41.1 in the South (p < .01); mortality rates were 11.0 vs. 12.2 (p < .01). For rectal cancer, incidence rates were 17.6 vs. 19.7 (p < .01) and mortality rates 5.33 vs. 5.89 (p = .07), respectively. The largest difference in incidence was demonstrated for colon cancer among individuals >79 years old (190. vs. 237, i.e., ∼20%). Survival in colon cancer was higher in Southern Sweden, HR 0.92 (0.87-0.98) adjusted for age, gender, co-habiting, education and m-stage at diagnosis. No difference in survival was seen for rectal cancer.

CONCLUSIONS

The new RISK North database enabled analysis of cancer disparities between Northern and Southern Sweden. The incidence of colorectal cancer were lower in the North of Sweden whereas colon cancer survival was higher in the South. These differences can be further analysed utilising the RISK North database.

Risk factors for appendiceal and colorectal peritoneal metastases

BACKGROUND

Early diagnosis to target minimal volume disease has received increased attention in the management of appendiceal and colorectal peritoneal metastases (PM). This study aimed to identify risk factors for appendiceal, colon and rectal PM.

METHODS

Data were retrieved from the Swedish Colorectal Cancer Registry for all patients undergoing bowel resection of appendiceal and colorectal tumours, in Sweden, 2007-2015. Risk factors for synchronous and metachronous PM were analysed with multivariate logistic and Cox proportional hazard regression models.

RESULTS

Synchronous PM was most common in appendiceal cancer (23.5%), followed by colon (3.1%) and rectal (0.6%) cancer. The 5-year cumulative incidence was 9.0% for appendiceal, 2.5% for right colon, 1.8% for left colon and 1.2% for rectal cancer. In appendiceal cancer (n = 327), T4, N2, mucinous tumour, and non-radical surgery were associated with PM. In colon cancer (n = 24,399), synchronous PM were primarily associated with T4 (OR 18.37, 95% CI 8.12-41.53), T3 and N2 but also with N1, right-sided tumour, mucinous tumour, vascular and perineural invasion, female gender, age <60 and emergency surgery. These factors were also associated with metachronous PM. In rectal cancer (n = 10,394), T4 (OR 19.12, 95% CI 5.52-66.24), proximal tumour and mucinous tumour were associated with synchronous PM and T4 and mucinous tumour with metachronous PM.

CONCLUSIONS

This study shows that appendiceal cancer, right-sided colon cancer, advanced tumour and node stages and mucinous histopathology are the main high-risk features for PM and should increase the awareness of current or future PM.

Data quality in the Swedish Quality Register of Gynecologic Cancer - a Swedish Gynecologic Cancer Group (SweGCG) study

AIM

The aim of this study is to evaluate the quality of data on endometrial (EC) and ovarian, fallopian tube, peritoneal, abdominal or pelvic cancers (OC) registered in the Swedish Quality Register of Gynecologic Cancer (SQRGC).

METHOD

A random sample of 500 patients was identified in the SQRGC and their medical charts were reviewed for re-abstraction of 31 selected core variables by an independent validator. The data in the SQRGC and the re-abstracted data were compared. The data were collected from 25 hospitals evenly distributed throughout Sweden. The main outcomes were comparability, timeliness, completeness and validity. Coverage was compared with the National Cancer Register (NCR). Timeliness was defined as the speed of registration i.e. when patients were registered in the SQRGC relative to date of diagnosis. Internationally accepted coding systems for stage, grading and histologic type were used ensuring a high degree of comparability. Correlations were estimated using Pearson's correlation coefficient and Cohen´s kappa coefficient.

RESULTS

The completeness was 95%. The timeliness was 88-91% within 12 months of diagnosis. The median degree of agreement between re-abstracted data and data in the SQRGC was 82.1%, with a median kappa value of 0.73 for ordinate variables and a median Pearson's correlation coefficient of 0.96. The agreements for the type of surgery were 76% (95% CI 70-81%; kappa 0.49) and type of primary treatment 90% (95% CI 87-94%; kappa 0.85) in OC and in EC 88% (95% CI 84-93%; kappa 0.84). The agreements for the FIGO stage were in OC and EC 74% (95% CI 68-80%; kappa 0.69) and 87% (95% CI 82-91%; kappa 0.79), respectively.

CONCLUSIONS

The data in the Swedish Quality Register for Gynecologic Cancer are of adequate quality in order to be used as a basis for research and to evaluate possible differences in treatment, lead times and treatment results.

Late leakage after anterior resection: a defunctioning stoma alters the clinical course of anastomotic leakage

AIM

Anastomotic leakage (AL) is common after anterior resection (AR). Long term clinical outcomes of AL including late presenting leakage (LL) are not well studied. This study was undertaken to assess clinical features of LL with respect to incidence, association with predisposing factors and need for re-intervention.

METHODS

The Swedish Colorectal Cancer Registry (SCRCR) was explored for AL cases after AR for rectal cancer in patients operated in the south of Sweden from 1 January 2001 to 31 December 2011. Demographic data, surgical technical details, number of postoperative days (POD) until diagnosis of AL, presenting symptoms, methods of diagnosis and treatment were retrieved from medical records. LL was defined according to different cut-offs as leakages occurring after hospital discharge (LLAHD), after 30 POD (LL ≥ POD 30) and after 90 POD (LL ≥ POD 90).

RESULTS

In total, 1442 patients were operated on with AR of whom 144 cases of AL (10%) were identified. Median time from operation to follow-up was 87 months (range 21-162). LLAHD, LL ≥ POD 30 and LL ≥ POD 90 were present in 51%, 24% and 9% respectively. All categories of LL were associated with a defunctioning stoma. Relaparotomy was significantly less often employed in LLAHD, but not in other categories of LL.

CONCLUSION

LL constitutes a substantial portion of all AL after AR for rectal cancer. The large proportion of LLAHD calls for awareness in the outpatient setting.

Low risk of intra-abdominal infections in rectal cancer patients treated with Hartmann's procedure: a report from a national registry

PURPOSE

To describe the postoperative surgical complications in patients with rectal cancer undergoing Hartmann's procedure (HP).

METHODS

Data were retrieved from the Swedish Colorectal Cancer Registry for all patients with rectal cancer undergoing HP in 2007-2014. A retrospective analysis was performed using prospectively recorded data. Characteristics of patients and risk factors for intra-abdominal infection and re-laparotomy were analysed.

RESULTS

Of 10,940 patients resected for rectal cancer, 1452 (13%) underwent HP (median age, 77 years). The American Society of Anesthesiologists (ASA) score was 3-4 in 43% of patients; 15% had distant metastases and 62% underwent a low HP. The intra-abdominal infection rate was 8% and re-laparotomy rate was 10%. Multivariable logistic regression analysis identified preoperative radiotherapy (OR, 1.78; 95% CI, 1.14-2.77), intra-operative bowel perforation (OR, 1.99; 95% CI, 1.08-3.67), T4 tumours (OR, 1.68; 95% CI 1.04-2.69) and female gender (OR, 1.73; 95% CI, 1.15-2.61) as risk factors for intra-abdominal infection. ASA score 3-4 (OR, 1.62; 95% CI, 1.12-2.34), elevated BMI (OR, 1.05; 95% CI, 1.02-1.09) and female gender (OR, 2.06; CI, 1.41-3.00) were risk factors for re-laparotomy after HP. The rate of intra-abdominal infection was not increased after a low HP.

CONCLUSIONS

Despite older age and co-morbidities including more advanced cancer, patients undergoing Hartmann's procedure had low rates of serious postoperative complications and re-laparotomy. A low HP was not associated with a higher rate of intra-abdominal infection. HP seems to be appropriate for old and frail patients with rectal cancer.

Substantial underreporting of anastomotic leakage after anterior resection for rectal cancer in the Swedish Colorectal Cancer Registry

BACKGROUND

The causes and effects of anastomotic leakage after anterior resection are difficult to study in small samples and have thus been evaluated using large population-based national registries. To assess the accuracy of such research, registries should be validated continuously.

MATERIAL AND METHODS

Patients who underwent anterior resection for rectal cancer during 2007-2013 in 15 different hospitals in three healthcare regions in Sweden were included in the study. Registry data and information from patient records were retrieved. Registered anastomotic leakage within 30 postoperative days was evaluated, using all available registry data and using only the main variable anastomotic insufficiency. With the consensus definition of anastomotic leakage developed by the International Study Group on Rectal Cancer as reference, validity measures were calculated.

RESULTS

Some 1507 patients were included in the study. The negative and positive predictive values for registered anastomotic leakage were 96 and 88%, respectively, while the κ-value amounted to 0.76. The false-negative rate was 29%, whereas the false-positive rate reached 1.3% (the vast majority consisting of actual leaks, but occurring after postoperative day 30). Using the main variable anastomotic insufficiency only, the false-negative rate rose to 41%.

CONCLUSIONS

There is considerable underreporting of anastomotic leakage after anterior resection for rectal cancer in the Swedish Colorectal Cancer Registry. It is probable that this causes an underestimation of the true effects of leakage on patient outcomes, and further quality control is needed.

Management and prognosis of locally recurrent rectal cancer - A national population-based study

BACKGROUND

The rate of local recurrence of rectal cancer (LRRC) has decreased but the condition remains a therapeutic challenge. This study aimed to examine treatment and prognosis in patients with LRRC in Sweden. Special focus was directed towards potential differences between geographical regions and time periods.

METHOD

All patients with LRRC as first event, following primary surgery for rectal cancer performed during the period 1995-2002, were included in this national population-based cohort-study. Data were collected from the Swedish Colorectal Cancer Registry and from medical records. The cohort was divided into three time periods, based on the date of diagnosis of the LRRC.

RESULTS

In total, 426 patients fulfilled the inclusion criteria. Treatment with curative intent was performed in 149 patients (35%), including 121 patients who had a surgical resection of the LRRC. R0-resection was achieved in 64 patients (53%). Patients with a non-centrally located tumour were more likely to have positive resection margins (R1/R2) (OR 5.02, 95% CI:2.25-11.21). Five-year survival for patients resected with curative intent was 43% after R0-resection and 14% after R1-resection. There were no significant differences in treatment intention or R0-resection rate between time periods or regions. The risk of any failure was significantly higher in R1-resected patients compared with R0-resected patients (HR 2.04, 95% CI:1.22-3.40).

CONCLUSION

A complete resection of the LRRC is essential for potentially curative treatment. Time period and region had no influence on either margin status or prognosis.

Population-based study of factors predicting treatment intention in patients with locally recurrent rectal cancer

Background

Local recurrence of rectal cancer (LRRC) is associated with poor survival unless curative treatment is performed. The aim of this study was to investigate predictive factors for treatment with curative intent in patients with LRRC.

Methods

Population-based data for patients treated for primary rectal cancer between 1995 and 2002, and with LRRC reported as first event were collected from the Swedish Colorectal Cancer Registry and medical records. The associations between patient-, primary tumour- and LRRC-related factors and intention of the treatment for LRRC were determined. The impact of the identified predictive factors on prognosis after treatment with curative intent was also assessed.

Results

A total of 426 patients were included in the study, of whom 149 (35·0 per cent) received treatment with curative intent. Factors significantly associated with treatment of the LRRC with palliative intent were primary surgery with abdominoperineal resection (odds ratio (OR) 5·16, 95 per cent c.i. 2·97 to 8·97), age at diagnosis of LRRC at least 80 years (OR 4·82, 2·37 to 9·80), symptoms at diagnosis (OR 2·79, 1·56 to 5·01) and non-central location of the LRRC (OR 1·79, 1·15 to 2·79). The overall 5-year survival rate was 8·9 per cent for all patients and 23·1 per cent among those treated with curative intent. In patients treated with curative intent, factors associated with increased risk of death were age 80 years or more (hazard ratio (HR) 2·44, 95 per cent c.i. 1·55 to 3·86), presence of symptoms (HR 1·92, 1·20 to 3·05), non-central tumour location (HR 1·51, 1·01 to 2·26) and presence of hydronephrosis (HR 2·02, 1·18 to 3·44).

Conclusion

Non-central location of the LRRC, presence of symptoms and age at least 80 years at diagnosis of the LRRC were associated with treatment with palliative intent.

The importance of rectal washout for the oncological outcome after Hartmann's procedure for rectal cancer: analysis of population-based data from the Swedish Colorectal Cancer Registry

BACKGROUND

During rectal cancer surgery the bowel may contain viable, exfoliated cancer cells, a potential source for local recurrence (LR). The amount and viability of these cells can be reduced using intraoperative rectal washout, a procedure that reduces the LR risk after anterior resection. The aim of this study was to analyse the impact of washout on oncological outcome when performed in Hartmann's procedure (HP) for rectal cancer.

METHODS

A national cohort study on data for patients registered from 1995 to 2007 in the Swedish Colorectal Cancer Registry was carried out. The final analysis included patients belonging to TNM stages I-III who had undergone R0 HP with a registered 5-year follow-up. Multivariate analysis was performed.

RESULTS

A total of 1188 patients were analysed (686 washout and 502 no washout). No differences were detected between the washout group and the no washout group concerning rates of LR [7% (49/686) vs. 10% (49/502); p = 0.13], distant metastasis (DM) [17% (119/686) vs. 18% (93/502); p = 0.65], and overall recurrence (OAR) [21% (145/686) vs. 24% (120/502); p = 0.29]. For both groups, the 5-year cancer-specific survival was below 50%. In multivariate analysis, washout neither decreased the risk of LR, DM, or OAR nor increased overall or the cancer-specific 5-year survival.

CONCLUSIONS

The oncological outcome did not improve when washout was performed in HP for rectal cancer.

Lymphovascular and perineural invasion in stage II rectal cancer: a report from the Swedish colorectal cancer registry

BACKGROUND

Adjuvant chemotherapy for stage II and III rectal cancer patients is a matter of discussion. The aim of the present study was to evaluate the prognostic value of lymphovascular (LVI) and perineural (PNI) invasion in stage II rectal cancer on a national level.

MATERIALS AND METHODS

Clinico-pathological factors associated with disease-free survival (DFS) and time to recurrence in stage II rectal cancer patients were analyzed from patient data registered in the Swedish Colorectal Cancer Registry between 2006 and 2012.

RESULTS

Of 2649 patients with TNM stage II disease, 1395 (53%) received preoperative radiotherapy and 456 (17%) preoperative chemoradiotherapy. LVI and PNI were detected in 387 (15%) and 269 (10%) patients, respectively. Adjuvant chemotherapy was planned in 14%, but more often if LVI or PNI was detected (25% and 31%, respectively, p < .001 for both). The three-year DFS and time to recurrence were 78% and 17%, respectively. Both LVI and PNI indicated worse outcome. In patients not receiving postoperative chemotherapy, the risks of recurrence after three years were 20% if LVI was seen and 22% if PNI was detected (p < .001 for both). In the absence of LVI and PNI, it was 13% and 12%, respectively. In a multivariate Cox regression analysis, patients with LVI (hazard ratio 1.44, 95% CI 1.09-1.90; p = .011) and PNI (hazard ratio 1.80, 95% CI 1.34-2.43, p < .001) had significantly increased risks of recurrence.

CONCLUSIONS

Stage II rectal cancer patients with LVI and PNI have an increased risk of recurrence which emphasizes the need to properly evaluate the role of adjuvant chemotherapy particularly in these subgroups.

Validation of data quality in the Swedish National Register for Oesophageal and Gastric Cancer

Background

The Swedish National Register for Oesophageal and Gastric Cancer (NREV) was launched in 2006. Data are reported at diagnosis (diagnostic survey), at the time of surgery (surgical survey) and at first outpatient follow-up (follow-up survey). The aim of this study was to evaluate data originating from NREV in terms of comparability, completeness, accuracy and timeliness.

Methods

Coding routines were compared with international standards and completeness was evaluated by means of a 5-year (2009–2013) comparison with mandatory national registers. Validity was tested by comparison with reabstracted data from source medical records in 400 patients chosen randomly with stratification for hospital size and catchment area population. Timeliness of registration was described.

Results

Coding routines followed national and international guidelines. Compared with the Swedish Cancer Registry from 2009 to 2013, 6069 (95·5 per cent) of 6354 patients were registered in NREV at the time of data extraction. Of 60 variables investigated, 10 966 of 12 035 original entries were correct in the reabstraction, resulting in an exact agreement of 91·1 per cent in the register. There were 782 (6·5 per cent) incorrect and 287 (2·4 per cent) missing entries. Median time to registration was 3·9, 3·4 and 4·1 months for diagnostic, surgical and follow-up surveys respectively.

Conclusion

NREV has reached a position with good coverage of those with the relevant diagnoses, and contains comparable and valid data. Quality data on each variable are available. Timeliness is an area with potential for improvement.

Work Loss Duration and Predictors Following Rectal Cancer Treatment among Patients with and without Prediagnostic Work Loss

BACKGROUND

The number of working-age rectal cancer survivors is increasing due to early detection and improved treatment. However, work loss duration and predictors among them have not been studied thoroughly.

METHODS

We identified 3,438 patients with stage I-III rectal cancer, 18 to 61 years of age in the Swedish Colorectal Cancer Register 1996-2009. Information on work loss due to sick leave or disability pension was collected from 2 years before diagnosis to 5 years after (until December 31st, 2013). Incidence rate ratios (IRR) of work loss were estimated in a negative binominal model by clinical characteristics for the 1st and 2nd-5th years after diagnosis. Patients were stratified by prediagnostic work loss.

RESULTS

Patients without prediagnostic work loss (74%) experienced median 147 days (25th and 75th percentile: 55 and 281) of work loss during the 1st year after diagnosis. Work loss rates (2nd-5th years) were significantly increased among relapse-free patients diagnosed in stage III [IRR = 1.92; 95% confidence interval (CI), 1.52-2.43], operated with abdominoperineal resection (IRR = 1.26; 95% CI, 1.03-1.56), and treated with neoadjuvant (chemo)radiotherapy (IRR = 1.46; 95% CI, 1.06-2.02). Patients with prediagnostic work loss (26%) experienced median 336 days (25th and 75th percentile: 183 and 365) of work loss during the 1st year, and rates did not vary clinically till 5 years.

CONCLUSION

Without prediagnostic work loss, disease- and treatment-related factors could help identify rectal cancer patients in need of early interventions to facilitate return to work.

IMPACT

Clinical awareness around prediagnostic and postdiagnostic work loss and individualized cancer rehabilitation programs should be emphasized among cancer survivors. Cancer Epidemiol Biomarkers Prev; 25(6); 987-94. ©2016 AACR.

Self-reported wellbeing and body image after abdominoperineal excision for rectal cancer

PURPOSE

Patients with low rectal cancer are often operated with an abdominoperineal excision (APE) rendering them a permanent stoma. The surgical procedure itself, the cancer diagnosis, and the permanent stoma might all affect quality of life. The aim of this study was to explore wellbeing and body image 3 years after APE in a population-based cohort of patients.

METHODS

All patients with rectal cancer operated with an APE between 2007 and 2009 were identified using the Swedish ColoRectal Cancer Registry. A total of 545 patients answered a questionnaire 3 years after surgery. Two open-ended questions were analyzed with a mixed method design using both qualitative and quantitative content analysis. Main themes and sub-themes on wellbeing and body image were identified.

RESULTS

Three main themes were identified: bodily limitations, mental suffering, and acceptance. Bodily limitations included other symptoms than stoma-related problems. A majority of patients expressed acceptance to their situation regardless of bodily limitations and mental suffering. However, 18 % did not describe any acceptance of their current situation.

CONCLUSIONS

Most patients expressed acceptance reflecting wellbeing 3 years after APE for rectal cancer. There is, however, a subset of patients (18 %) who describe bodily limitations and mental suffering without acceptance and who require further support. Many aspects of the portrayed bodily limitations and mental suffering could be prevented or treated.

TRIAL REGISTRATION

NCT01296984.

Nationwide improvement of rectal cancer treatment outcomes in Norway, 1993-2010

BACKGROUND

The Norwegian Rectal Cancer Project was initated in 1993 with the aims of improving surgery, decreasing local recurrence rates, improving survival, and establishing a national rectal cancer registry. Here we present results from the Norwegian Colorectal Cancer Registry (NCCR) from 1993 to 2010.

MATERIAL AND METHODS

A total of 15 193 patients were diagnosed with rectal cancer in Norway 1993-2010, and were registered with clinical data regarding diagnosis, treatment, locoregional recurrences and distant metastases. Of these, 10 796 with non-metastatic disease underwent tumour resection. The results were stratified into five time periods, and the treatment outcomes were compared. Recurrence rates are presented for the 9785 patients who underwent curative major resection (R0/R1).

RESULTS

Among all 15 193 patients, relative five-year survival increased from 54.1% in 1993-1997 to 63.4% in 2007-2010 (p < 0.001). Among the 10 796 patients with stage I-III disease who underwent tumour resection, from 1993-1997 to 2007-2010, relative five-year survival improved from 71.2% to 80.6% (p < 0.001). An increasing proportion of these patients underwent surgery at large-volume hospitals; and 30- and 100-day mortality rates, respectively, decreased from 3.0% to 1.4% (p < 0.001) and from 5.1% to 3.0% (p < 0.011). Use of preoperative chemoradiotherapy increased from 6.5% in 1993 to 39.0% in 2010 (p < 0.001). Estimated local recurrence rate after major resection (R0/R1) decreased from 14.5% in 1993-1997 to 5.0% in 2007-2009 (p < 0.001), and distant recurrence rate decreased from 26.0% to 20.2% (p < 0.001).

CONCLUSION

Long-term outcomes from a national population-based rectal cancer registry are presented. Improvements in rectal cancer treatment have led to decreased recurrence rates of 5% and increased survival on a national level.

Validity of Norwegian Rectal Cancer Registry data at a major university hospital 1997-2005

BACKGROUND

The Norwegian Rectal Cancer Registry (NRCR) has been used extensively to monitor patient treatment and outcomes since its establishment in 1993. Control of data validity is crucial to ensure reliable information, but an audit of the NRCR data validity has not been performed so far. This study aims to validate NRCR data on patients diagnosed in the period 1997-2005, Department of Surgery, Haukeland University Hospital.

MATERIAL AND METHODS

The material comprises NRCR data on all 482 patients diagnosed with rectal cancer in the period 1997-2005 at a major Norwegian university hospital. We checked 50 variables for discrepancies by comparing NRCR data with the medical records. All erroneous registrations were recorded.

RESULTS

One hundred patients (21%) had one or more data discrepancies in the registry, and 131 errors (0.5%) were noted in total. Sixteen variables (32%) had no erroneous registrations. Pre-operative CT and type of surgical procedure had the highest proportion of erroneous registrations (2.1%). Recorded errors were grouped into five variable categories: Pre-operative evaluation and adjuvant treatment (40 errors), surgical treatment (44 errors), pathological evaluation (20 errors), complications (7 errors) and oncological outcomes (20 errors). The majority of erroneous registrations (45%) were considered minor in severity, 27% were moderate and 28% were major.

CONCLUSION

Assessment of the NRCR data from a nine-year period showed a good data validity in this hospital cohort.

Time trends, improvements and national auditing of rectal cancer management over an 18-year period

AIM

The main aims were to explore time trends in the management and outcome of patients with rectal cancer in a national cohort and to evaluate the possible impact of national auditing on overall outcomes. A secondary aim was to provide population-based data for appraisal of external validity in selected patient series.

METHOD

Data from the Swedish ColoRectal Cancer Registry with virtually complete national coverage were utilized in this cohort study on 29 925 patients with rectal cancer diagnosed between 1995 and 2012. Of eligible patients, nine were excluded.

RESULTS

During the study period, overall, relative and disease-free survival increased. Postoperative mortality after 30 and 90 days decreased to 1.7% and 2.9%. The 5-year local recurrence rate dropped to 5.0%. Resection margins improved, as did peri-operative blood loss despite more multivisceral resections being performed. Fewer patients underwent palliative resection and the proportion of non-operated patients increased. The proportions of temporary and permanent stoma formation increased. Preoperative radiotherapy and chemoradiotherapy became more common as did multidisciplinary team conferences. Variability in rectal cancer management between healthcare regions diminished over time when new aspects of patient care were audited.

CONCLUSION

There have been substantial changes over time in the management of patients with rectal cancer, reflected in improved outcome. Much indirect evidence indicates that auditing matters, but without a control group it is not possible to draw firm conclusions regarding the possible impact of a quality control registry on faster shifts in time trends, decreased variability and improvements. Registry data were made available for reference.

Tumour regression in the randomized Stockholm III Trial of radiotherapy regimens for rectal cancer

Background

The Stockholm III Trial randomized patients with primary operable rectal cancers to either short‐course radiotherapy (RT) with immediate surgery (SRT), short‐course RT with surgery delayed 4–8 weeks (SRT‐delay) or long‐course RT with surgery delayed 4–8 weeks. This preplanned interim analysis examined the pathological outcome of delaying surgery.

Methods

Patients randomized to the SRT and SRT‐delay arms in the Stockholm III Trial between October 1998 and November 2010 were included, and data were collected in a prospective register. Additional data regarding tumour regression grade, according to Dworak, and circumferential margin were obtained by reassessment of histopathological slides.

Results

A total of 462 of 545 randomized patients had specimens available for reassessment. Patients randomized to SRT‐delay had earlier ypT categories, and a higher rate of pathological complete responses (11·8 versus 1·7 per cent; P = 0·001) and Dworak grade 4 tumour regression (10·1 versus 1·7 per cent; P < 0·001) than patients randomized to SRT without delay. Positive circumferential resection margins were uncommon (6·3 per cent) and rates did not differ between the two treatment arms.

Conclusion

Short‐course RT induces tumour downstaging if surgery is performed after an interval of 4–8 weeks.

Short‐course therapy with delay causes downstaging

Tumour staging of oesophageal cancer in the Swedish Cancer Registry: A nationwide validation study

BACKGROUND

Tumour stage was introduced to the Swedish Cancer Registry in 2004, but this key variable for prognostic research has not yet been validated. We validated the tumour stage data in surgically treated oesophageal cancer patients.

MATERIAL AND METHODS

Completeness and accuracy of tumour stage according to the TNM system ("Tumour Node Metastasis") in the Cancer Registry were compared with a cohort study including comprehensive tumour stage data based on the pathological TNM of almost all patients operated for oesophageal cancer in 2006-2010 in Sweden.

RESULTS

Of the 397 patients with pathological TNM data in the comparison cohort, the Cancer Registry reported an overall TNM stage in 390 patients (98.2%), which was based on the pathological TNM of 104 patients (26.2%), the clinical TNM of 183 patients (46.1%), and the pathological or clinical TNM (undefined) of 110 patients (27.7%). The completeness for the separate T, N, and M components was 89.4%, 90.9%, and 85.1%, respectively. The concordance with tumour stage was 98.2%, while it was 51.1%, 70.5%, and 80.4% for the separate T, N, and M components, respectively. While the concordance with tumour stage was high for all TNM assessment groups (98.1-98.4%), the concordance of the T and N components was highest when using pathological TNM (82.7% and 95.2%, respectively), and the concordance of the M component was highest when using clinical TNM (88.5%).

CONCLUSION

Although the overall completeness of tumour stage is high, the recording of pathological TNM stage and individual components could be improved within the Swedish Cancer Registry.

Time to local recurrence as a prognostic factor in patients with rectal cancer

AIMS

Survival after the local recurrence of rectal cancer is influenced by several factors. The aim of this study was to ascertain whether the time interval from primary surgery for rectal cancer to local recurrence diagnosis has any impact on survival.

METHODS

Population-based data was collected from the Swedish Colorectal Cancer Registry. 7410 patients were operated with radical abdominal surgery for rectal cancer during the period 1995-2002. Of these, 386 (5%) developed a local recurrence as a first event. The patients were divided into two groups: early local recurrence (ELR), diagnosed <12 months after primary surgery, and late local recurrence (LLR), diagnosed ≥12 months after primary surgery. Kaplan-Meier curves and hazard ratios were calculated for survival analyses. Survival was calculated from the date of the local recurrence diagnosis to death or end of follow-up.

RESULTS

Ninety-five patients had ELR and 291 patients LLR. Median time to local recurrence was 1.7 (0.1-7.9) years. Patients with a stage III primary tumour and non-irradiated patients were more common in the ELR compared with the LLR group. Factors that influenced survival were age at diagnosis of local recurrence (p < 0.001), stage of primary tumour (p = 0.027), and surgical resection of local recurrence (p < 0.001). Time to diagnosis of local recurrence had no influence on survival.

CONCLUSIONS

No difference in survival from date of diagnosis of local recurrence was seen between patients with ELR and patients with LLR. All patients with local recurrence should therefore be assessed for potential curative surgery, disregarding time to local recurrence.

Persistent perineal morbidity is common following abdominoperineal excision for rectal cancer

PURPOSE

Short-term complications related to the perineal wound after abdominoperineal excision (APE) are a well-known problem. Perineal morbidity in the longer term is an almost unexplored area. The aim of this cross-sectional study was to investigate the prevalence of perineal symptoms 3 years after APE for rectal cancer, to identify potential risk factors and to explore the relationship between perineal morbidity and global quality of life.

METHOD

All patients who underwent APE in Sweden between 2007 and 2009 (n = 1373) were identified through the Swedish Colorectal Cancer Registry. Surviving patients were contacted 3 years after surgery and asked about participation. A total of 545 patients completed a detailed questionnaire. Clinical data was collected from the registry and surgical charts.

RESULTS

Perineal symptoms occurred in 50 % of all patients 3 years after APE and more frequently in women (58 vs. 44 %; p = 0.001). Delayed healing of the perineal wound (>4 weeks) occurred in 25 % of all patients and more frequently after extralevator APE (ELAPE) than after conventional APE (32 vs. 11 %, p < 0.001). Delayed healing was associated with an increased risk of more severe perineal symptoms (relative risk (RR) 1.50, 95 % confidence interval (95 % CI) 1.09-2.05). Patients with more severe perineal symptoms (n = 129) had a significantly lower global quality of life as measured by EQ-5D visual analogue scale (VAS; median 75 vs. 83 points on the 100-point scale; p < 0.001).

CONCLUSION

Persistent perineal symptoms are common after APE and may have an impact on patients' quality of life. Delayed wound healing may be a risk factor for persistent symptoms. Further studies are needed to identify avoidable clinical factors for the development of persistent perineal morbidity. CLINICALTRIALS.

GOV IDENTIFIER

NCT01296984.

A population-based cohort study on adherence to practice guidelines for adjuvant chemotherapy in colorectal cancer

BACKGROUND

The value of adjuvant chemotherapy in colorectal cancer is well studied, and guidelines have been established. Little is known about how treatment guidelines are implemented in the everyday clinical setting.

METHODS

This national population-based study on nearly 34,000 patients with colorectal cancer evaluates the adherence to present clinical guidelines for adjuvant chemotherapy. Virtually all patients with colorectal cancer in Sweden during the years 2007-2012 and data from the Swedish Colorectal Cancer Registry were included.

RESULTS

In colon cancer stage III, adherence to national guidelines was associated with lower age, presence of multidisciplinary team (MDT) conference, low co-morbidity, and worse N stage. The MDT forum also affected whether or not high-risk stage II colon cancer patients were considered for adjuvant chemotherapy. Rectal cancer patients both in stage II and III were considered for adjuvant chemotherapy less often than colon cancer patients, but the same factors influenced the decision. Adjuvant chemotherapy was started later than eight weeks after surgery in 30% of colon cancer patients and in 38% of rectal cancer patients.

CONCLUSIONS

In Sweden, the adherence to national guidelines for adjuvant chemotherapy in colon cancer stage III is acceptable in younger and healthier patients. MDT conferences are of major importance and affect whether patients are recommended for adjuvant chemotherapy. Special consideration needs to be given to certain subgroups of patients, particularly older patients and patients with poorly differentiated tumors. There is a need to shorten the waiting time until start of chemotherapy.

Arterial ligation in anterior resection for rectal cancer: A validation study of the Swedish Colorectal Cancer Registry

BACKGROUND

The level of arterial ligation has been a variable of the Swedish Colorectal Cancer Registry since 2007. The aim of this study is to evaluate the accuracy of this registry variable in relation to anterior resection for rectal cancer.

METHODS

The operative charts of all cardiovascularly compromised patients who underwent anterior resection during the period 2007-2010 in Sweden were retrieved and compared to the registry. We selected the study population to reflect the common assumption that these patients would be more sensitive to a compromised visceral blood flow. Levels of vascular ligation were defined, both oncologically and functionally, and their sensitivity, specificity, positive and negative predictive values, level of agreement and Cohen's kappa were calculated.

RESULTS

Some 744 (94.5%) patients were eligible for analysis. Functional high tie level showed a sensitivity of 80.2% and a specificity of 90.1%. Positive and negative predictive values were 87.7 and 83.8%, respectively. Level of agreement was 85.5% and Cohen's kappa 0.70. The corresponding calculations for oncologic tie level yielded similar results.

CONCLUSION

The suboptimal validity of the Swedish Colorectal Cancer Registry regarding the level of vascular ligation might be problematic. For analyses with rare positive outcomes, such bowel ischaemia, or with minor expected differences in outcomes, it would be beneficial to collect data directly from the operative charts of the medical records in order to increase the chance of identifying clinically relevant differences.