Improved survival of patients with rectal cancer since 1980: a population-based study
Introduction
The treatment of patients with mobile cancer of the rectum and rectosigmoid has changed over the last few decades. In South-east Netherlands, close co-operation between oncological specialists developed in the 1980s and early 1990s. Retrospective analyses of population-based data were performed to evaluate the outcome of rectal cancer treatment 1, 2, 3, 4. In a study of 178 patients without residual disease or distant metastases, receiving adjuvant postoperative radiotherapy during the period of 1974–1989, the 5-year overall survival and disease-free survival rates were 42 and 37%, respectively [3]. The respective rates for Dukes' stage B2 (pT3, N0, M0) were 59 and 53%, and 25% for both for stage C2 (pT1-4, N+, M0). Five-year local relapse rates were 27% for Dukes' stage B2 and 40% for stage C2. In another study, including 232 patients from five community hospitals and treated surgically with curative intent between 1981 and 1986, adjuvant postoperative radiotherapy was given to 27% of all Dukes' stage B2 patients and to 50% of all stage C patients [4]. The surgical technique was not standardised and referral for adjuvant postoperative radiotherapy was at the surgeon's discretion. The 5-year survival rate was 58% and the local recurrence rate of 18% did not seem to be affected by application of postoperative radiotherapy. Furthermore, no significant difference was found between the participating hospitals, each of them with a surgical staff of 3–6 surgeons, of whom some had only just started to specialise in colorectal cancer surgery.
On the basis of our regional experiences and the results from the literature regarding the possibilities of pre-operative radiotherapy 5, 6, 7 and total mesorectal excision (TME) 8, 9, steps were taken to improve loco-regional control in patients with mobile rectal cancer. A new regional treatment protocol was developed, including preoperative radiotherapy for mobile rectal cancer and steps were taken to stimulate the use of total mesorectal excision (TME). Furthermore, intra-operative electron beam radiation therapy was developed for locally advanced and locally recurrent rectal cancer [10]. In view of these changes in the treatment of rectal cancer, we decided to determine their effect on the prognosis for patients with rectal cancer by performing a detailed analysis of 3635 patients with invasive rectal cancer diagnosed and treated in South-east Netherlands since 1980.
Section snippets
Patients
Data were provided by the population-based Eindhoven Cancer Registry, which covers a well-defined area with approximately 900 000 inhabitants in South-east Netherlands. It has been recognised since 1978 by the International Association of Cancer Registries [11]. Registration is based on notification of newly-diagnosed cases by the three departments of pathology and the radiotherapy department and data were obtained from medical records in the eight community hospitals in the region and from
Stage distribution and patterns of care
No major shifts in the distribution of tumour stage occurred between 1980 and 2000, also when analysed for each age group separately (data not shown). The proportion of patients with positive lymph nodes remained stable: 73% in the period 1980–1989 and 71% in the following two periods. However, among the patients with positive lymph nodes, the proportion with more than three positive lymph nodes increased from 5.5% (21/383) in the period 1980–1989 to 30% (95/320) in the period 1995–2000.
The use
Discussion
The data of a population-based cancer registry, covering eight general hospitals in South-east Netherlands, show that the management of and the prognosis for patients with rectal cancer have improved substantially since 1980, with the most striking changes taking place after 1994. The development of new regional guidelines and the participation in the TME trial of the Dutch Colorectal Cancer Study Group have brought quality of care to a higher level. These activities took place within the
Conclusion
The obvious sub-specialisation of surgeons in colorectal surgery, the shift from postoperative towards preoperative radiotherapy (5×5 Gy) for patients with mobile rectal cancer and the widespread use of TME surgery, within or outside the setting of randomised clinical trials, have been the most striking changes in the management of rectal cancer in South-east Netherlands during the last 20 years. No improvements in the distribution of tumour stage were observed, making it very likely that the
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