Socioeconomic and geographic differences in ablation of atrial fibrillation in Norway - a national cohort study.

BACKGROUND: The aim of this study was to analyse whether there are patient related or geographic differences in the use of catheter ablation among atrial fibrillation patients in Norway. METHODS: National population-based data on individual level of all Norwegians aged 25 to 75 diagnosed with atrial fibrillation from 2008 to 2017 were used to study the proportion treated with catheter ablation. Survival analysis, by Cox regression with attained age as time scale, separately by gender, was applied to examine the associations between ablation probability and educational level, income level, place of residence, and follow-up time. RESULTS: Substantial socioeconomic and geographic variation was documented. Atrial fibrillation patients with high level of education and high income were more frequently treated with ablation, and the education effect increased with increasing age. Patients living in the referral area of St. Olavs Hospital Trust had around three times as high ablation rates as patients living in the referral area of Finnmark Hospital Trust. CONCLUSIONS: Differences in health literacy, patient preference and demands are probably important causes of socioeconomic variation, and studies on how socioeconomic status influences the choice of treatment are warranted. Some of the geographic variation may reflect differences in ablation capacity. However, geographic variation related to differences in clinical practice and provider preferences implies a need for clearer guidelines, both at the specialist level and at the referring level.

Equitable access to cancer patient pathways in Norway - a national registry-based study.

BACKGROUND: In 2015, cancer patient pathways (CPP) were implemented in Norway to reduce unnecessary non-medical delay in the diagnostic process and start of treatment. The main aim of this study was to investigate the equality in access to CPPs for patients with either lung, colorectal, breast or prostate cancer in Norway. METHODS: National population-based data on individual level from 2015 to 2017 were used to study two proportions; i) patients in CPPs without the cancer diagnosis, and ii) cancer patients included in CPPs. Logistic regression was applied to examine the associations between these proportions and place of residence (hospital referral area), age, education, income, comorbidity and travel time to hospital. RESULTS: Age and place of residence were the two most important factors for describing the variation in proportions. For the CPP patients, inconsistent differences were found for income and education, while for the cancer patients the probability of being included in a CPP increased with income. CONCLUSIONS: The age effect can be related to both the increasing risk of cancer and increasing number of GP and hospital contacts with age. The non-systematic results for CPP patients according to income and education can be interpreted as equitable access, as opposed to the systematic differences found among cancer patients in different income groups. The inequalities between income groups among cancer patients and the inequalities based on the patients' place of residence, for both CPP and cancer patients, are unwarranted and need to be addressed.

Impact of parents' education on variation in hospital admissions for children: a population-based cohort study.

OBJECTIVES: To assess the impact of parental educational level on hospital admissions for children, and to evaluate whether differences in parents' educational level can explain geographic variation in admission rates. DESIGN: National cohort study. SETTING: The 18 hospital referral areas for children in Norway. PARTICIPANTS: All Norwegian children aged 1-16 years in the period 2008-2016 and their parents. MAIN OUTCOME MEASURES: Age- and gender-adjusted admission rates and probability of admission. RESULTS: Of 1 538 189 children, 156 087 (10.2%) had at least one admission in the study period. There was a nearly twofold (1.9) variation in admission rates between the hospital referral areas (3113 per 100 000 children, 95% CI: 3056 to 3169 vs 1627, 95% CI: 1599 to 1654). Area level variances in multilevel analysis did not change after adjusting for parental level of education. Children of parents with low level of education (maternal level of education, low vs high) had the highest admission rates (2016: 2587, 95% CI: 2512 to 2662 vs 1810, 95% CI: 1770 to 1849), the highest probability of being admitted (OR: 1.18, 95% CI: 1.16 to 1.20), the highest number of admissions (incidence rate ratio: 1.05, 95% CI: 1.01 to 1.10) and admissions with lower cost (-0.5%, 95% CI: -1.2% to 0.3%). CONCLUSIONS: Substantial geographic variation in hospital admission rates for children was found, but was not explained by parental educational level. Children of parents with low educational level had the highest admission probability, and the highest number of admissions, but the lowest cost of admissions. Our results suggest that the variation between the educational groups is not due to differences in medical needs, and may be characterised as unwarranted. However, the manner in which health professionals communicate and interact with parents with different educational levels might play an important role.

Treatment rates for lumbar spine surgery in Norway and Northern Norway Regional Health Authority 2014-18. / Behandlingsrater for ryggkirurgi i Norge og Helse Nord 2014­18.

BACKGROUND: The objective of this study was to investigate whether the service provision for lumbar spine surgery within the Northern Norway Regional Health Authority area complies with the distribution of functions that has been decided for the hospitals in the region, and whether there are any geographical variations in service provision. We therefore studied the treatment rates in Norway as a whole and in the Northern Norway Regional Health Authority area, and assessed the activity in the region. MATERIAL AND METHOD: We included lumbar spine procedures in the Norwegian Patient Registry from the years 2014-2018 in a retrospective analysis and estimated treatment rates standardised by sex and age for Norway as a whole, the health regions and the health enterprises in Northern Norway Regional Health Authority. We estimated the local coverage as the proportion of patients who had undergone surgery in a hospital within their own area of residence. RESULTS: The treatment rate for lumbar spine surgery in Norway amounted to approximately 120 procedures per 100 000 inhabitants per year for the entire period. The number of spine procedures nationwide increased from 5 995 in 2014 to 6 494 in 2018 because of a general population growth. The treatment rates for fractures and simple spine procedures were approximately identical throughout Norway, but the rate for complex spine procedures among residents within the area of Northern Norway Regional Health Authority amounted to 57 % of the national average. Local coverage within the Northern Norway Regional Health Authority area increased from 60 % to 84 % during the period. The local hospital functions for simple spine procedures at Nordland and Helgeland hospitals (approximately 30 %) and the regional function for complex spine surgery at the University Hospital of North Norway (55 %) had a low degree of local coverage. INTERPRETATION: The treatment rate for complex spine procedures and the local coverage for all surgical procedures for degenerative lumbar spine disease were lower within the Northern Norway Regional Health Authority area than in the country as a whole. For this to be compensated in this region, we have estimated that the activity needs to be increased by approximately 170 procedures per year.

Wrist malpractice claims in Northern Norway 2005-2014. Lessons to be learned.

Rough weather conditions in the subarctic areas of Norway may influence on the risk of wrist fracture. We implemented data from the Norwegian System of Patient Injury Compensation (NPE). All claims due to wrist surgery, performed at the public hospitals in Northern Norway, during 2005-2014 were analyzed. We employed the ICD-10 classification codes S52.5 (fracture of distal end of radius) and S52.6 (fracture of distal end of radius and ulna). Treatment was defined by NCSP codes. 84 patients (0.3%) complained. Females complained four times more often than males did (P = 0.005) and received five times more frequently a compensation (P < 0.001). NPE accepted 34 claims (40%) for injury compensation (0.1% of patients). The percentage of claims accepted for compensation decreased from 48% to 30% during study period, probably due to delay in filling claims. The main causes of complains were pain, reduced range of motion, malfunction and weakness (35/84). The main causes of compensation were "operative treatment should have been performed" (14/34) and "wrong operative method applied" (13/34). The mean amount per compensation was €14,927 (€0-€52,995). Stonger focus on quality of care, updated guidelines and shared decission-making may reduce the number og complains and compensations.

Treatment of wrist fractures 2009-14. / Behandling av håndleddsbrudd 2009 ­ 14.

BACKGROUND: The purpose of the study was to conduct a systematic analysis based on data from the Norwegian Patient Registry and describe the incidence and treatment of wrist fractures among adults, at national level and in the catchment areas of the various regional health authorities. MATERIAL AND METHOD: A search was conducted in the Norwegian Patient Registry for all patients aged ≥ 18 years with diagnosis codes for wrist fractures in the period 2009­2014. Age, sex and type of treatment were recorded. The results are presented as rates adjusted for age and sex for the catchment areas of Norway's 21 regional health authorities. RESULTS: In the period 2009­2014, a total of 75 132 patients aged ≥ 18 years were registered as having a wrist fracture. Almost 1/3 of these patients received operative treatment. During this period, the age- and sex-adjusted rate of wrist fractures in Norway averaged 244 per 100 000 inhabitants per year. Operation rates varied across catchment areas by a factor of three, and the use of plates by a factor of nine. INTERPRETATION: We found great variation in clinical practice, which is reflected in differences in operation rates and choice of surgical method across the catchment areas to which the patients belong.

Calculating the 30-day Survival Rate in Acute Myocardial Infarction: Should we Use the Treatment Chain or the Hospital Catchment Model?

INTRODUCTION: Acute myocardial infarction (AMI) is a potentially deadly disease and significant efforts have been concentrated on improving hospital performance. A 30-day survival rate has become a key quality of care indicator. In Northern Norway, some patients undergoing AMI are directly transferred to the Regional Cardiac Intervention Center at the University Hospital of North Norway in Tromsø. Here, coronary angiography and percutaneous coronary intervention is performed. Consequently, local hospitals may be bypassed in the treatment chain, generating differences in case mix, and making the treatment chain model difficult to interpret. We aimed to compare the treatment chain model with an alternative based on patients' place of living. METHODS: Between 2013 and 2015, a total of 3,155 patients were registered in the Norwegian Patient Registry database. All patients were categorized according to their local hospital's catchment area. The method of Guo-Romano, with an indifference interval of 0.02, was used to test whether a hospital was an outlier or not. We adjusted for age, sex, comorbidity, and number of prior hospitalizations. CONCLUSIONS: We revealed the 30-day AMI survival figure ranging between 88.0% and 93.5% (absolute difference 5.5%) using the hospital catchment method. The treatment chain rate ranged between 86.0% and 94.0% (absolute difference 8.0%). The latter figure is the one published as the National Quality of Care Measure in Norway. Local hospitals may get negative attention even though their catchment area is well served. We recommend the hospital catchment method as the first choice when measuring equality of care.

The use of surgery for cervical degenerative disease in Norway in the period 2008-2014 : A population-based study of 6511 procedures.

BACKGROUND: The incidence rate of surgical treatment of cervical degenerative diseases (CDD) has increased in the USA and a large geographic variation has been shown. Little is known about such rates in Scandinavia and Europe. The aim of this population-based study was to (1) investigate annual incidence rates of operations performed in Norway, (2) to compare trends and variations in rates for surgical indications with and without myelopathy, and (3) to compare variations in the use of surgery between residential areas. METHODS: Patients operated for CDD and recorded in the Norwegian Patient Registry from 2008 to 2014 were evaluated according to residential areas (resident county and Regional Health Authority (RHA) area), age, gender, treating hospital, and whether myelopathy was present or not. Surgical rates were adjusted for age and gender. Data from private health care were also included. RESULTS: The annual surgical rates increased by 74.1 % from 2008 to 2014 (12.5/100,000 inhabitants). The largest increase was for surgical treatment of radiculopathy, 86.5 %. Surgical rates for CDD varied in 2014 with a ratio of 1.5 between the highest and lowest RHA and with a ratio of 2.5 between the different residential counties within one RHA. The treatment rates for myelopathy were relatively stable over time, but showed an increase of 2.1/100,000 (44.6 %) from 2013 to 2014. CONCLUSIONS: Our study shows that the rate of surgical treatment for radiculopathy due to CDD has increased substantially from 2008 to 2014 for all RHAs in Norway. The incidence rate for surgical treatment of myelopathy was more stable. An unexplained and moderate geographic variation was found.

Norwegian patients with colon cancer start their adjuvant therapy too late.

BACKGROUND: For patients with colon cancer who are to receive adjuvant chemotherapy according to national guidelines, such therapy must be initiated no more than 4-6 weeks after the surgical intervention. We wished to investigate whether these guidelines are being complied with. We also wished to see whether the type of surgery (open or laparoscopic) had any effect on the time elapsing before initiation of adjuvant therapy. MATERIAL AND METHOD: The material includes 1,132 patients who had undergone surgery for colon cancer in the period 2008-2013 and who received adjuvant chemotherapy. Surgical treatment and adjuvant chemotherapy are defined through diagnosis and procedural codes in the Norwegian Patient Register for the period 2008-2013. RESULTS: On average, 44.7 days passed after the surgical intervention before the patients commenced their adjuvant chemotherapy. For 49% of the patients, the adjuvant therapy was not initiated within the six-week deadline. Patients who had undergone laparoscopic surgery were hospitalised for shorter periods (6.5 days versus 10.7 days) and had fewer complications (7.6% versus 16.4%) when compared to patients who had undergone open surgery, yet still failed to start their adjuvant therapy correspondingly earlier. INTERPRETATION: Measures should be taken to improve quality, thus ensuring that the guidelines are complied with and that patients start their required adjuvant therapy earlier. For those who have undergone laparoscopic surgery, it ought to be simple to reap the gains from shorter hospitalisation periods and fewer complications in the form of a more rapid initiation of adjuvant therapy.

Anal carcinoma - Survival and recurrence in a large cohort of patients treated according to Nordic guidelines.

OBJECTIVE: To evaluate treatment outcome in a large population-based cohort of patients with anal cancer treated according to Nordic guidelines. MATERIAL: Clinical data were collected on 1266 patients with anal squamous cell carcinoma diagnosed from 2000 to 2007 in Sweden, Norway and Denmark. 886 of the patients received radiotherapy 54-64Gy with or without chemotherapy (5-fluorouracil plus cisplatin or mitomycin) according to different protocols, stratified by tumor stage. RESULTS: High age, male gender, large primary tumor, lymph node metastases, distant metastases, poor performance status, and non-inclusion into a protocol were all independent factors associated with worse outcome. Among patients treated according to any of the protocols, the 3-year recurrence-free survival ranged from 63% to 76%, with locoregional recurrences in 17% and distant metastases in 11% of patients. The highest rate of inguinal recurrence (11%) was seen in patients with small primary tumors, treated without inguinal irradiation. CONCLUSIONS: Good treatment efficacy was obtained with Nordic, widely implemented, guidelines for treatment of anal cancer. Inguinal prophylactic irradiation should be recommended also for small primary tumors.

Faecal incontinence after chemoradiotherapy in anal cancer survivors: long-term results of a national cohort.

PURPOSE: To examine the prevalence and severity of faecal incontinence amongst anal cancer survivors after chemoradiotherapy. MATERIAL AND METHODS: Anal cancer survivors from a complete, unselected, national cohort, minimum 2-years follow-up, were invited to a cross-sectional study. The St. Mark's incontinence score was used to evaluate occurrence and degree of faecal incontinence the last four weeks. The results were compared to age- and sex-matched volunteers from the general population. RESULTS: Of 199 invited survivors and 1211 volunteers, 66% and 21%, respectively, signed informed consent. The survivors had significantly higher St. Mark's score than the volunteers (mean 9.7 vs. 1.1, p<0.001). Incontinence of stool of any degree was reported by 43% vs. 5% (OR 4.0, CI 2.73-6.01), and urgency was reported by 64% vs. 6% (OR 6.6, CI 4.38-9.90) of the survivors and volunteers, respectively. Only 29% of those with leakage of liquid stool used constipating drugs. Survivors of locally advanced tumours had a higher incontinence score (p<0.01). CONCLUSIONS: Moderate to severe faecal incontinence is common amongst anal cancer survivors. Post-treatment follow-up should include the evaluation of continence, and incontinent survivors should be offered better symptom management and multidisciplinary approach if simple measures are insufficient.

Impaired health-related quality of life after chemoradiotherapy for anal cancer: late effects in a national cohort of 128 survivors.

BACKGROUND: Chemoradiotherapy is an effective treatment for anal cancer, yet from follow-up many survivors seem to suffer from late effects. Data of long-term health-related quality of life (HRQOL) in anal cancer survivors are limited, and there is a growing interest in cancer survivorship. MATERIAL AND METHODS: A national cohort of all anal cancer survivors treated with curative chemoradiotherapy in 2000-2007 was invited to a cross-sectional study. Of 199 eligible survivors, 128 (64%) returned the questionnaires, the median time since diagnosis was 66 months. The median age was 61 years and 79% were women. HRQOL was evaluated with EORTC questionnaires QLQ-C30 and QLQ-CR29, and neurotoxicity with the Scale of Chemotherapy-Induced Neurotoxicity. An age- and sex-matched reference group of volunteers (n = 269) not treated for pelvic cancer answered the same questionnaires. Results from QLQ-C30 of the reference group were compared to Norwegian and Dutch normative data. RESULTS: The mean scores of anal cancer survivors were poorer compared to volunteers and normative data. Anal cancer survivors reported significant impairment of function, especially social and role function, compared to the volunteers (difference ≥ 20 points, p < 0.001). Survivors had markedly increased scores for fatigue, dyspnoea, insomnia and diarrhoea (difference ≥ 15 points, p < 0.001). The global quality of life was significantly reduced (difference 15 points, p < 0.001). Anal cancer survivors had increased stool frequency, more buttock pain, flatulence, faecal incontinence, impotence (males), dyspareunia and reduced sexual interest (females) (difference ≥ 15 points, p < 0.001). There was increased frequency of tinnitus in survivors treated with cisplatin-based chemotherapy (p = 0.004). CONCLUSIONS: Survivors after chemoradiotherapy for anal cancer have significant long-term impairment of HRQOL. Reduced social, role and sexual function, and increased diarrhoea, incontinence for gas and stools, and buttock pain were commonly reported. Increased awareness of this may lead to better management of late effects and better care for cancer survivors.

Chemoradiotherapy of anal carcinoma: survival and recurrence in an unselected national cohort.

PURPOSE: To evaluate treatment results, elucidate whether national guidelines were followed, and identify areas demanding further treatment optimization. METHODS AND MATERIAL: Between July 2000 and June 2007, 328 patients were treated with curatively intended chemoradiotherapy (CRT) for nonmetastatic squamous cell carcinoma of the anal region, according to national treatment guidelines based on tumor stage. RESULTS: Complete response after CRT was obtained in 87% of patients, rising to 93% after salvage surgery. Chemotherapy, elective irradiation of the groin and salvage surgery were performed to a lesser extent in elderly patients, mainly because of frailty and comorbidity. Recurrence occurred in 24% of the patients, resulting in a 3- and 5-year recurrence-free survival (RFS) of 79% and 74%, respectively. Locoregional recurrences dominated, most commonly in the primary tumor site. Recurrence was treated with curative intent in 45% of the cases. The 3- and 5-year overall survival were 79% and 66%, and cancer-specific survival (CSS) were 84% and 75%, respectively. The risk of adverse outcome increased significantly with more locally advanced tumors and for male gender in multivariable analyses for RFS and CSS. CONCLUSIONS: The treatment results are in accordance with similar cohorts. The primary treatment control rate was high, but there was a significant risk of locoregional recurrence in advanced tumors. The loyalty to national guidelines was broad, although individual adjustments occurred. However, caution to avoid toxicity must not lead to inadequate treatment. Male gender seems to have inferior outcome.

Methodological challenges in hip fracture registration: the Harstad Injury Registry.

The aim of the study was to evaluate a hospital-based injury recording system on hip fracture registration in elderly persons aged + 65 years from 1994 through 2008, and to examine the agreement between the number of validated fractures and the number of fractures reported to the Norwegian Patient Registry using three different sources: (1) Medical records, (2) Patient administrative system and (3) The hospital's hip fracture record to the Norwegian Patient Registry from 2002 through 2008. The injury recording system included 582 hip fracture events and 535 (92%) were confirmed through the medical records. Reasons for non-verification were different coding failures. Searching the patient administrative system using ICD codes identified 16 hip fractures not included in the fracture registry between 2002 through 2008. The total number was the same as the number of hip fractures reported to the Norwegian Patient Registry using ICD codes alone for identification. The conclusion is that on well-defined diagnosis like hip fractures, local fracture registries may obtain a high degree of reliability if different sources are available for quality control. Well-functioning patient administrative systems may be used to study numbers of hip fractures.

Sexual function in females after radiotherapy for rectal cancer.

BACKGROUND: Knowledge about female sexual problems after pre- or postoperative (chemo-)radiotherapy and radical resection of rectal cancer is limited. The aim of this study was to compare self-rated sexual functioning in women treated with or without radiotherapy (RT+ vs. RT-), at least two years after surgery for rectal cancer. METHODS AND MATERIALS: Female patients diagnosed from 1993 to 2003 were identified from a national database, the Norwegian Rectal Cancer Registry. Eligible patients were without recurrence or metastases at the time of the study. The Sexual function and Vaginal Changes Questionnaire (SVQ) was used to measure sexual functioning. RESULTS: Questionnaires were returned from 172 of 332 invited and eligible women (52%). The mean age was 65 years (range 42-79) and the time since surgery for rectal cancer was 4.5 years (range 2.6-12.4). Sexual interest was not significantly impaired in RT+ (n=62) compared to RT- (n=110) women. RT+ women reported more vaginal problems in terms of vaginal dryness (50% vs. 24%), dyspareunia (35% vs. 11%) and reduced vaginal dimension (35% vs. 6%) compared with RT- patients; however, they did not have significantly more worries about their sex life. CONCLUSION: An increased risk of dyspareunia and vaginal dryness was observed in women following surgery combined with (chemo-)radiotherapy compared with women treated with surgery alone. Further research is required to determine the effect of adjuvant therapy on female sexual function.

Sexual function in males after radiotherapy for rectal cancer.

PURPOSE: Knowledge of sexual problems after pre- or postoperative radiotherapy (RT) with 50 Gy for rectal cancer is limited. In this study, we aimed to compare self-rated sexual functioning in irradiated (RT+) and nonirradiated (RT-) male patients at least 2 years after surgery for rectal cancer. METHODS AND MATERIALS: Patients diagnosed with rectal cancer from 1993 to 2003 were identified from the Norwegian Rectal Cancer Registry. Male patients without recurrence at the time of the study. The International Index of Erectile Function, a self-rated instrument, was used to assess sexual functioning, and serum levels of serum testosterone were measured. RESULTS: Questionnaires were returned from 241 patients a median of 4.5 years after surgery. The median age was 67 years at survey. RT+ patients (n = 108) had significantly poorer scores for erectile function, orgasmic function, intercourse satisfaction, and overall satisfaction with sex life compared with RT- patients (n = 133). In multiple age-adjusted analysis, the odds ratio for moderate-severe erectile dysfunction in RT+ patients was 7.3 compared with RT- patients (p <0.001). Furthermore, erectile dysfunction of this degree was associated with low serum testosterone (p = 0.01). CONCLUSION: RT for rectal cancer is associated with significant long-term effects on sexual function in males.

Colorectal cancer metastatic to the brain: time trends in presentation and outcome.

OBJECTIVE: It was the aim of this study to compare differences in disease pattern, patient characteristics and survival in patient cohorts treated during different decades. METHODS: We conducted a retrospective analysis of all patients with brain metastases from colorectal cancer treated between 1983 and June 2008 in Northern Norway. The patients were assigned to 3 different groups, based on the decade of treatment. RESULTS: The time interval between first cancer diagnosis and brain metastases has significantly increased over time. The use of chemotherapy before development of brain metastases has also increased. Only few patients did not harbour extracranial metastases. Chemotherapy after diagnosis of brain metastases has been used exclusively in the present decade, but in only 3 patients. Combined surgical resection or radiosurgery plus whole-brain radiotherapy has increasingly been utilized, but whole-brain radiotherapy alone remained the cornerstone. Neither survival from first cancer diagnosis nor from brain metastasis treatment has improved significantly; however, with up to 17 patients, the groups were small. Three factors were significantly associated with better survival: good performance status, limited number of brain metastases (1 vs. 2-3 vs. 4 or more) and absence of extracranial metastases. The prognostic impact of the recursive partitioning analysis classes was confirmed, while the new graded prognostic assessment index performed less well. CONCLUSIONS: Median survival was maximum 6 months in all decades, despite the increasing use of more aggressive treatment. As most patients harbour extracranial metastases that threaten their lives, systemic treatment might theoretically play a role in the management of these patients, but more data need to be collected to confirm the clinical impact of this approach.

[Palliative chemotherapy and radiotherapy for metastatic colorectal cancer]. / Palliativ kjemoterapi og strålebehandling ved metastatisk kolorektal cancer.

BACKGROUND: There are 3 450 new cases of colorectal cancer in Norway annually. In half of the patients, metastatic disease will evolve with time. Palliative chemo- or radiotherapy can prolong disease- and symptom control when cure is not feasible. MATERIAL AND METHODS: This paper is based on publications retrieved from a PubMed search, the authors' knowledge of the field and on recent conference abstracts. RESULTS AND INTERPRETATION: Patients with metastatic colorectal cancer should initially be considered for surgery, and judged if secondary surgery is a possibility. Palliative chemotherapy is used to increase survival and maintain quality of life. 5-FU/calsiumfolinat combined with oxaliplatin or irinotecan is usually given as first line treatment for patients below 75 years--and most of them respond. Median survival is close to two years. Bevacizumab combined with an irinotecan regimen is an alternative first line treatment. Elderly patients are judged on an individual basis. Half of the patients will receive second line therapy with the alternative chemotherapy schedule. Cetuximab combined with irinotecan is a possible third line treatment. Palliative radiotherapy is most often used for inoperable rectal cancer, local recurrences, and bone or brain metastases.

[Recurrence of rectal cancer--treatment in Norwegian hospitals]. / Residiv av endetarmskreft--synspunkter på behandling.

BACKGROUND: The aim of this study was to examine if Norwegian surgeons had a passive attitude to treatment of patients with local recurrence of rectal cancer after primary treatment and if attitudes to treatment differed between hospitals. MATERIAL AND METHODS: All 46 departments for gastrointestinal surgery in Norway answered a questionnaire detailing their policy for workup, referral and treatment of patients with pelvic recurrence after surgery for rectal cancer. RESULTS: All hospitals used MRI for evaluation of the pelvis. Most clinics initially considered the patients potentially curable. Many wished to refer the patients to hospitals with more competence. Most patients in Norway are treated in eight different departments. Most of the surgeons give preoperative chemoradiotherapy before surgical resection of the local recurrence. INTERPRETATION: There seems to be a reasonable consensus among Norwegian surgeons about treatment of recurrent rectal cancer. The doctors themselves have to a certain degree centralized the treatment. Patients with recurrent rectal cancer should be discussed in multidisciplinary teams.