National differences in implementation of minimally invasive surgery for colorectal cancer and the influence on short-term outcomes.

BACKGROUND: The timing and degree of implementation of minimally invasive surgery (MIS) for colorectal cancer vary among countries. Insights in national differences regarding implementation of new surgical techniques and the effect on postoperative outcomes are important for quality assurance, can show potential areas for country-specific improvement, and might be illustrative and supportive for similar implementation programs in other countries. Therefore, this study aimed to evaluate differences in patient selection, applied techniques, and results of minimal invasive surgery for colorectal cancer between the Netherlands and Sweden. METHODS: Patients who underwent elective minimally invasive surgery for T1-3 colon or rectal cancer (2012-2018) registered in the Dutch ColoRectal Audit or Swedish ColoRectal Cancer Registry were included. Time trends in the application of MIS were determined. Outcomes were compared for time periods with a similar level of MIS implementation (Netherlands 2012-2013 versus Sweden 2017-2018). Multilevel analyses were performed to identify factors associated with adverse short-term outcomes. RESULTS: A total of 46,095 Dutch and 8,819 Swedish patients undergoing MIS for colorectal cancer were included. In Sweden, MIS implementation was approximately 5 years later than in the Netherlands, with more robotic surgery and lower volumes per hospital. Although conversion rates were higher in Sweden, oncological and surgical outcomes were comparable. MIS in the Netherlands for the years 2012-2013 resulted in a higher reoperation rate for colon cancer and a higher readmission rate but lower non-surgical complication rates for rectal cancer if compared with MIS in Sweden during 2017-2018. CONCLUSION: This study showed that the implementation of MIS for colorectal cancer occurred later in Sweden than the Netherlands, with comparable outcomes despite lower volumes. Our study demonstrates that new surgical techniques can be implemented at a national level in a controlled and safe way, with thorough quality assurance.

Family history of colorectal cancer and survival: a Swedish population-based study.

OBJECTIVES: A family history of colorectal cancer (CRC) is an established risk factor for developing CRC, whilst the impact of family history on prognosis is unclear. The present study assessed the association between family history and prognosis and, based on current evidence, explored whether this association was modified by age at diagnosis. METHODS: Using data from the Swedish Colorectal Cancer Registry (SCRCR) linked with the Multigeneration Register and the National Cancer Register, we identified 31 801 patients with a CRC diagnosed between 2007 and 2016. The SCRCR is a clinically rich database which includes information on the cancer stage, grade, location, treatment, complications and postoperative follow-up. RESULTS: We estimated excess mortality rate ratios (EMRR) for relative survival and hazard ratios (HR) for disease-free survival with 95% confidence intervals (CIs) using flexible parametric models. We found no association between family history and relative survival (EMRR = 0.96, 95% CIs: 0.89-1.03, P = 0.21) or disease-free survival (HR = 0.98, 95% CIs: 0.91-1.06, P = 0.64). However, age was found to modify the impact of family history on prognosis. Young patients (<50 at diagnosis) with a positive family history had less advanced (i.e. stages I and II) cancers than those with no family history (OR = 0.71, 95% CI: 0.56-0.89, P = 0.004) and lower excess mortality even after adjusting for cancer stage (EMMR = 0.63, 95% CIs: 0.47-0.84, P = 0.002). CONCLUSIONS: Our results suggest that young individuals with a family history of CRC may have greater health awareness, attend opportunistic screening and adopt lifestyle changes, leading to earlier diagnosis and better prognosis.

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.

ANTECEDENTES: El objetivo del estudio fue evaluar las diferencias en estadio, tratamiento y pronóstico en pacientes con cáncer colorrectal (colorectal cancer, CRC) de edad inferior a 50 años en comparación con los grupos de mayor edad. MÉTODOS: Estudio de base poblacional de todos los pacientes con CRC en Suecia 2010-2015. Se analizaron el estadio, tratamiento, supervivencia libre de enfermedad (disease-free survival, DFS) a los 5 años y supervivencia relativa (relative survival, RS) en los grupos de edad de < 50, 50-74, ≥ 75 años. RESULTADOS: De 34.434 pacientes incluidos, tenían un estadio IV en el momento del diagnóstico en el 24,1%, 19,7% y 14,0% de los pacientes de < 50, 50-74 y ≥ 75 años de edad, respectivamente (P < 0,001). Las características histopatológicas desfavorables fueron más frecuentes en pacientes jóvenes. Se administró quimioterapia adyuvante al 18,9%, 42,0% y 93,9% de los pacientes con edad inferior a 50 años con estadios I, II y III de la enfermedad respectivamente, en comparación con el 0,7%, 4,4% y 29,6% de los pacientes ≥ 75 años con estadios I, II y III, respectivamente (P < 0,001). La DFS ajustada por estadio de la enfermedad en los pacientes de < 50 años fue 0,96, 0,94 y 0,77 para los estadios I, II y III, respectivamente. Las proporciones correspondientes de DFS en los pacientes de edad entre 50-74 años fueron 0,88, 0,82 y 0,68, respectivamente, y, para los pacientes de ≥ 75 de edad fueron 0,69, 0,62 y 0,49, respectivamente. La RS fue solo mejor en los pacientes jóvenes con estadio III de la enfermedad. CONCLUSIÓN: Los pacientes menores de 50 años con CRC tenían un estadio peor de la enfermedad en el momento del diagnóstico y recibieron un tratamiento oncológico más intenso. La DFS fue mejor en comparación con pacientes mayores con estadio más temprano de la enfermedad.

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.

Increasing incidence of colorectal cancer among the younger population in Sweden.

BACKGROUND: The incidence of colorectal cancer in patients aged less than 50 years is increasing in Western countries. This population-based study investigated the age- and sex-specific incidence of colorectal cancer over time in Sweden, and characterized trends in tumour localization and stage at diagnosis. METHODS: Patients diagnosed with colorectal cancer between 1970 and 2016 were identified from the Swedish Cancer Registry, and categorized by sex, age and tumour location. The incidence and average annual percentage change (AAPC) were estimated and compared between age groups. RESULTS: There was an overall increase in the incidence of colorectal cancer between 1970 and 2006, but a decrease in 2006-2016 (AAPC -0·55 (95 per cent c.i. -1·02 to -0·07) per cent). The largest increase in colonic cancer was in 1995-2005 in women aged less than 50 years (AAPC 2·30 (0·09 to 4·56) per cent versus 0·04 (-1·35 to 1·44) and - 0·67 (-1·62 to 0·28) per cent in women aged 50-74 and 75 years or more respectively). Since 1990, rectal cancer increased in patients of both sexes aged below 50 years, with higher AAPC values in women (2006-2016: 2·01 (-1·46 to 5·61) per cent versus 0·20 (-2·25 to 2·71) per cent in men). Younger patients were more likely than those aged 50-74 and 75 years or more to present with stage III-IV colonic (66·2, 57·6 and 49·6 per cent respectively) and rectal (61·2, 54·3 and 51·3 per cent) cancer. From the mid 1990s, rates of proximal and distal colorectal cancer, and rectal cancer were increased in patients aged less than 50 years. CONCLUSION: The overall incidence of colorectal cancer in Sweden decreased in the past decade. However, in patients under 50 years of age the incidence of colorectal cancer - proximal, distal and rectal - continued to increase over time.

ANTECEDENTES: La incidencia del cáncer colorrectal (CCR) en pacientes < 50 años está aumentando en los países occidentales. El objetivo de este estudio de base poblacional fue investigar las tendencias y la incidencia específica por edad y sexo del CCR a lo largo del tiempo en Suecia, así como caracterizar las tendencias en la localización tumoral y en el estadio del CCR en el momento del diagnóstico. MÉTODOS: Los pacientes diagnosticados con CCR entre 1970 y 2016 fueron identificados a partir del Registro de Cáncer de Suecia. Se clasificaron por sexo, edad y localización del tumor. Se calcularon la incidencia media y el promedio del cambio porcentual anual (average annual percentage change, AAPC), comparándose entre los grupos de edad. RESULTADOS: Globalmente, la incidencia de CCR aumentó entre 1970-2006, pero se observó una disminución de 0,6% (i.c. del 95% -1,02 a 0,07) entre 2006-2016. El AAPC del cáncer de colon aumentó con el tiempo tanto en mujeres como en varones. En particular, el mayor aumento se observó entre 1995-2005 en mujeres de < 50 años, que presentaron un AAPC de cáncer de colon de 2,3% (i.c. del 95% 0,09 a 4,56), mayor en comparación con los grupos de edad más avanzada (50-74 años: 0,04%; i.c. del 95% -1,35 a 1,44; grupo de edad 75+: -0,67%; i.c. del 95% -1,62 a 0,28), aunque el análisis de datos proporcionó valores limitados de i.c del 95%. En los varones de < 50 años, el AAPC del cáncer de colon aumentó en un 1,2% (i.c. del 95% -0,80 a 3,21) entre 2006-2016, pero la diferencia no fue significativa en comparación con otros grupos de edad. Desde 1990, los cánceres rectales aumentaron en pacientes de < 50 años, en ambos sexos y en particular en mujeres más que en varones (2006-2016: mujeres 2,0%, i.c. del 95% −1,46 a 5,61 versus varones 0,2%, i.c. del 95% -2,25 a 2,71). En comparación con los grupos de mayor edad, los pacientes de < 50 años tenían más probabilidades de presentar cáncer de colon en estadio III/IV (66%, 58% y 50% en los grupos de edad de < 50, 50-74 y mayores de 75 años, respectivamente) y cáncer de recto (61%, 54% y 51% en los grupos de edad de < 50, 50-74 y mayores de 75 años, respectivamente). Desde mediados de los 90 se observaron tasas cada vez mayores de CCR proximal, distal y de cáncer de recto en pacientes de < 50 años. CONCLUSIÓN: La incidencia global de CCR en Suecia disminuyó en la última década. Sin embargo, en pacientes menores de 50 años, la incidencia del cáncer colorrectal, proximal, distal y rectal ha continuado aumentando a lo largo del tiempo.

Screening vs. non-screening detected colorectal cancer: Differences in pre-therapeutic work up and treatment.

Objectives To compare preoperative staging, multidisciplinary team-assessment, and treatment in patients with screening detected and non-screening detected colorectal cancer. Methods Data on patient and tumour characteristics, staging, multidisciplinary team-assessment and treatment in patients with screening and non-screening detected colorectal cancer from 2008 to 2012 were collected from the Stockholm-Gotland screening register and the Swedish Colorectal Cancer Registry. Results The screening group had a higher proportion of stage I disease (41 vs. 15%; p < 0.001), a more complete staging of primary tumour and metastases and were more frequently multidisciplinary team-assessed than the non-screening group ( p < 0.001). In both groups, patients with endoscopically resected cancers were less completely staged and multidisciplinary team-assessed than patients with surgically resected cancers ( p < 0.001). No statistically significant differences were observed between the screening and non-screening groups in the use of neoadjuvant treatment in rectal cancer (68 vs.76%), surgical treatment with local excision techniques in stage I rectal cancer (6 vs. 9%) or adjuvant chemotherapy in stages II and III disease (46 vs. 52%). Emergency interventions for colorectal cancer occurred in 4% of screening participants vs. 11% of non-compliers. Conclusions Screening detected cancer patients were staged and multidisciplinary team assessed more extensively than patients with non-screening detected cancers. Staging and multidisciplinary team assessment prior to endoscopic resection was less complete compared with surgical resection. Extensive surgical and (neo)adjuvant treatment was given in stage I disease. Participation in screening reduced the risk of emergency surgery for colorectal cancer.

Local excision in early rectal cancer-outcome worse than expected: a population based study.

BACKGROUND: Considering the morbidity and mortality after abdominal surgery for rectal cancer, our aim was to determine whether local excision in Stage I rectal cancer provides long-term survival equivalent to TME surgery, particularly in elderly patients. METHODS: Data on 3694 consecutive patients with Stage I rectal cancer operated 1995-2006, were collected from the Swedish Rectal Cancer Register, a population-based, prospectively sampled data-base. Risk factors for death within 5 years after surgery, local recurrence rates, cumulative relative and overall survival rates were calculated for patients ≥ and <80 years-of-age. ASA grading related to surgical technique was analysed in a separate sample. RESULTS: Local excision (LE) was associated with an increased mortality risk both ≥80 (HR 1.55) and <80 years-of-age (HR 1.45). After LE the 5-year local recurrence rate was 11.2% and the total and relative cumulative 5-year survival was 0.62 and 0.81 respectively. Hartmann's procedure (HA) showed an increased mortality risk only in younger patients (HR 2.15). The overall local recurrence rate was 7.2% with HA. Male gender (HR 1.70) and age (HR 1.06) were associated with a significantly increased mortality risk in all age groups. The ASA-grade was higher among patients operated with LE compared to Anterior Resection/Abdominoperineal resection. CONCLUSION: Local excision has a poor outcome in the elderly. A negative selection bias towards old age and high co-morbidity could explain this. Hartmann's procedure has a high risk for mortality and local recurrence in younger patients.