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Recent trends in colorectal cancer in Norway:
incidence, management and outcomes
Arne Wibe, MD, PhD
Professor of Surgery
St. Olavs Hospital
Trondheim, Norway
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Contents
•
•
•
•
Collection of data
Incidence
Outcomes
Conclusions
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Population trends
• 4.8 million, 12% increase in 25 yrs.
• 11% immigrants from > 200 countries
• Estimated population 2030;
• 5.8 million
• 20% > 65 yrs.
Cancer in Norway 2008
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Cancer Registry of Norway
Cancer in Norway 2008
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Collection of data
• National cancer registry since 1952
• Compulsory reporting of all cancers
and some precancrous lesions
- all hospitals / health institutions
- all physicians
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Age adjusted incidence of
colorectal cancer in the Nordic countries
Nordcan
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Colon cancer
Rectal and anal cancer
Cancer in Norway 2008
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Colon cancer
Rectal and anal cancer
Cancer in Norway 2008
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Interpretation
• Incidence of colon and rectal cancer have been
increasing for decades, but the overall picture is one
of stabilisation for colon cancer and possibly recent
decline for rectal cancer
• Of particular note is the increasing survival and
declining mortality for rectal cancer
• Among the likely determinants are the introduction of
total mesorectal excision, increasing specialisation,
and some use of preoperative chemoradiotherapy
(20% 2004)
Hansen M, Thesis 2010
Cancer in Norway 2008
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Why has the relative survival
for rectal cancer increased more
in men than in women?
1993
2008
Men
46%
62%
Women
57%
67%
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Is that because…
for women, the relative survival was higher
in the beginning, thus their potential for
an increase will be less?
for APR, more use of preop. radiotherapy?
- 17% in men vs. 13% in women*, (mean age 71 vs. 73)
the more difficult the dissection,
the more benefit of an optimised
surgical technique?
* Hansen M, Thesis 2010
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The Norwegian Colorectal Cancer Registry
Database: 26 000 records
16 000 rectal cancer cases since 1993
10 000 colon cancer cases since 2007
Wibe, ECC 2010
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Rectal cancer – pts. treated for cure:
reduced local recurrence, increased survival,
reduced complications
• 5-year local recurrence
1986-1988
28%
1994
18%
1999
9%
2000-2004
7%
55%
71%
1.2
Risk of death (log scale)
• 5-year survival
1986-1988
1993-1999
• Anastomotic leaks
1994
17%
1999
8%
1.0
0.8
1994
Wibe et al. Colorectal Disease 2006; 8: 224-229
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1995
1996
1997
1998
Time of operation
1999
2000
Variation in rate of
local recurrence between hospitals
60
Rate of local recurrence (5 years)
55
50
45
40
35
30
25
20
15
10
5
0
0
50
100
150
200
250
Hospital caseload
Wibe et al. Colorectal Disease 2006; 8: 224-229
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Due to variation of results
treatment has been centralized
• 1994: 55 hospitals
Recommended by the association of surgeons:
”rectal cancer surgery should only be performed
by specialists in gastrointestinal surgery”
• 2000: 40 hospitals
Dedicated colorectal surgeons treating rectal cancer
• 2004: 25 hospitals
Healthcare bureaucracy introduced formal regulations:
”Only multidisciplinary teams of dedicated experts may treat
rectal cancer”
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What happened to hospitals having
inferior results for rectal cancer,
though continuing treatment?
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Haugesund Central Hospital
5-yr local recurrence
5-yr overall survival
1993-98
31%
48%
1999-01
11%
70%
2002-04
6%
2005-2009
No local recurrence at Haugesund Central Hospital
Best paper Norwegian Association of Surgeons 2008, Moen A C et al. abstract no 116
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What did they do in Haugesund?
How did they manage to
improve that quickly?
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Neoadjuvant tr.t
Always
acc. to guidelines GI surgeons
Cylindric
amputation
GI oncologist
Oncologist
2000
2001
New
retractors
2002
2003
Pathologist
Multidiscpl.
meetings
2004
2005
Up-date
radiologist
CT + Rectal
ultrasound
Laparoscopic
resection
2006
2007
2008
CT in follow-up
Stent as bridge
to surgery
MRI
Best paper Norwegian Association of Surgeons 2008, Moen A C et al. abstract no 116
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They managed to improve
within a few years,…
because they focused on ”all the details”,
i.e. important factors for quality assurance;
- guidelines
- training
- competence
- technology
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Levanger hospital –
394 patients 1980-2004
Patients treated with curative intent:
1980-89
Local recurrence 5-yr survival
4%
65%
1990-99
19%
58%
2000-04
2%
p = 0.006
71%
Jullumstrø, Wibe, Lydersen, Edna. Thesis NTNU 2010
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How could this happen?
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That happened because…
- they did not focus on quality assurance during
the 90-ties
- they did not stick to their optimised guidelines,
they violated their own treatment protocol
- neither they attended the national workshops,
as everybody knew this staff could handle rectal cancer
- in 2000 they started to attend the workshops
Jullumstrø, Wibe, Lydersen, Edna. Thesis NTNU 2010
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Recent initiatives by
the Ministry of Health
• 2010: National guidelines on work-up, treatment and
follow-up of colorectal cancer
- developed by the Norwegian Gastrointestinal
Cancer Group
- revised once a year
• 2011: National guidelines on organisation of work-up
and treatment of cancer,
from receiving information on cancer:
- 10 days for starting work-up
- 20 days for starting treatment
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Conclusion
• The incidence of colon cancer is still increasing,
while rectal cancer has culminated
• Although the use of adjuvant chemotherapy for stage
III colon cancer, the outcome of rectal cancer has
exceeded that of colon cancer
• Most of the reduction of local recurrence and the
increased survival for rectal cancer happened when
preoperative radiochemotherapy was uncommon in
Norway
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Conclusion II
Standards of care are best explained by healthcare
structures and processes of care
For complex medical treatment, the skills of the team
of clinicians and the hospital organizational skill are
equally important
Quality assurance at different health care levels can
only be evaluated within audits, during which
underperforming departments are likely to improve
Wibe et al. Br J Surg 2005;92:217-224
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Questions to be answered – from the organizer
1. Can we hope for similar results for colon as for rectal cancer?
2. Are there signs of such improvement?
3. What is the best approach on the road ahead?
Yes, we can!
1. But not that much, and not that fast, because the potential
for improvement is less, but may be prof. Hohenberger
has another view?
2.
Yes, there is a steady and continuous tendency of
increasing survival
3.
The best approach is as always, focus on all the details,
and MDT`s seem encouraging
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[email protected]
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