Elsevier

European Journal of Cancer

Volume 39, Issue 14, September 2003, Pages 2073-2079
European Journal of Cancer

Improved survival of patients with rectal cancer since 1980: a population-based study

https://doi.org/10.1016/S0959-8049(03)00493-3Get rights and content

Abstract

The treatment of rectal cancer has changed over the last two decades as far as surgical techniques and radiotherapy are concerned. We studied the changes in patterns of care for patients with rectal cancer and the effect on prognosis. All patients with cancer of the rectum or rectosigmoid in South-east Netherlands, diagnosed in the period of 1980–2000, were included in our analyses (n=3635). The use of surgery as the only treatment decreased from 62% in the period of 1980–1989 to 42% in the period of 1995–2000, whereas the combination of surgery and radiotherapy increased from 26 to 40%. The use of postoperative radiotherapy decreased from 25 to 4%, while preoperative radiotherapy increased from 1 to 35%. Patients aged 75 years or older were less likely to receive radiotherapy. After adjustment for age, gender, tumour stage and tumour site, significant improvements in the relative risk of death were observed between the periods of 1995–2000 and 1980–1989 for patients under 60 years of age (Relative Risk (RR)=0.45; 95% Confidence Interval (CI)=0.35–0.58) and those 60–74 years old (RR=0.62; 95% CI 0.53–0.72). No improvement in the risk of death was found for patients aged 75 years and over. No improvements in the distribution of tumour stage were observed, making it very likely that the continuing increase in population-based survival among patients aged <75 years results from the shift from postoperative to preoperative radiotherapy, the development of the total mesorectal excision technique and the related tendency to subspecialisation of surgeons in colorectal cancer surgery.

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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