Reproduction and marriage among male survivors of cancer in childhood, adolescence and young adulthood: a national cohort study.

BACKGROUND: Increased survival after cancer in young age has made long-term follow-up studies of high external validity important. In this national cohort study, we explored the impact of cancer in young age on reproduction and marital status in male survivors. METHODS: Hazard ratios (HRs) and relative risks (RRs) of reproductive and marital outcomes were studied for male survivors of cancer in young age (<25 years) and cancer-free male comparisons, born during 1965-1985, by linking compulsory national registries in Norway. RESULTS: Male cancer survivors (n=2687) had reduced paternity (HR: 0.72, 95% confidence interval (CI): 0.68-0.76). This was most apparent in survivors of testicular cancer, brain tumours, lymphoma, leukemia and bone tumours, and when diagnosed with cancer before 15 years of age. Male cancer survivors were more likely to avail of assisted reproduction (RR: 3.32, 95% CI: 2.68-4.11). There was no increased risk of perinatal death, congenital malformations, being small for gestational age, of low birth weight or preterm birth in their first offspring. Male cancer survivors were less likely to marry (HR: 0.93, 95% CI: 0.86-1.00), in particular brain tumour survivors. CONCLUSIONS: In this national cohort study, we demonstrated reduced paternity and increased use of assisted reproduction among male cancer survivors, but no adverse outcome for their first offspring at birth.

Increased uptake of social security benefits among long-term survivors of cancer in childhood, adolescence and young adulthood: a Norwegian population-based cohort study.

BACKGROUND: As the number of cancer survivors increases, their health and welfare have come into focus. Thus, long-term medical consequences of cancer at a young age (<25 years), obtained from social security benefit records, were studied. METHODS: Standardised incidence ratios (SIRs) of long-term medical consequences for 5-year cancer survivors, born during 1965-1985, were explored by linking population-based registries in Norway. RESULTS: Among the 5-year cancer survivors (4031 individuals), 29.7% received social security benefits. The survivors had an overall 4.4 times (95% confidence interval (95% CI): 4.1-4.6) higher risk of social security benefit uptake than the cancer-free population. Survivors of malignancies of bone and connective tissues (SIR: 10.8; 95% CI: 9.1-12.9), CNS tumours (SIR: 7.7; 95% CI: 6.9-8.6) and malignancies of the haematopoietic system (SIR: 6.1; 95% CI: 5.3-7.0) had the highest risks of social security benefits uptake. The most notified causes of social security benefit uptake were diseases of the nervous system, and injury and poisoning. CONCLUSION: The uptake of social security benefits among 5-year cancer survivors increased substantially and it may represent a solid outcome measure for the burden of the most severe late effects, especially in countries with comparable social welfare systems.

Effect of hospital caseload on long-term outcome after standardization of rectal cancer surgery at a national level.

BACKGROUND: The purpose of this prospective study was to examine the influence of hospital caseload on long-term outcome following standardization of rectal cancer surgery at a national level. METHODS: Data relating to all 3388 Norwegian patients with rectal cancer treated for cure between November 1993 and December 1999 were recorded in a national database. Treating hospitals were divided into four groups according to their annual caseload: hospitals in group 1 (n = 4) carried out 30 or more procedures, those in group 2 (n = 6) performed 20-29 procedures, group 3 (n = 16) 10-19 procedures and group 4 (n = 28) fewer than ten procedures. RESULTS: The 5-year local recurrence rates were 9.2, 14.7, 12.5 and 17.5 per cent (P = 0.003) and 5-year overall survival rates were 64.4, 64.0, 60.8 and 57.8 per cent (P = 0.105) respectively in the four hospital caseload groups. An annual hospital caseload of less than ten procedures increased the risk of local recurrence compared with that in hospitals where 30 or more procedures were performed each year (hazard ratio 1.9 (95 per cent confidence interval (c.i.) 1.3 to 2.7); P < 0.001). Overall survival was lower for patients treated at hospitals with an annual caseload of less than ten versus hospitals with 30 or more (hazard ratio 1.2 (95 per cent c.i. 1.0 to 1.5); P = 0.023). CONCLUSION: The rate of local recurrence was higher for hospitals with a low annual caseload of less than ten procedures than for hospitals with a high treatment volume of 30 or more. Patients treated in small hospitals also had a shorter long-term survival than those treated in large hospitals.

Norway: valid (as opposed to informed) consent.

The traditional concept of "informed" consent may be too restrictive; "valid" consent may be a more manageable criterion. Norway's 1999 Patients' Rights Act comes into force on Jan 1, 2001. This essay asks if this new legislation is compatible with this concept of valid consent--and concludes that it is.

The right to accept and the right to refuse.

The main purpose of this paper is to show that the civil commitment acts of the Nordic countries are in conflict with the ideal of symmetry, i.e. the idea that if a person has the competence (and therefore the right) to accept hospitalisation he or she should also be considered competent (and therefore have the right) to refuse hospitalisation. First, we distinguish between one narrow and one wide concept of coercion in relation to hospital admission; second, we demonstrate that the narrow concept of coercion is used or presupposed with reference to hospitalisation in the Nordic countries; and third, we discuss, from a normative point of view, the rather disturbing asymmetrical conception of patient's competence and rights implied by this narrow concept of coercion. Though the ideal of symmetry supports the use of the wide concept of coercion in civil commitment acts, it does not decide the issue. To justify a change from a narrow to a wide concept would also require empirical data about the practical implications.

Inadvertent perforation during rectal cancer resection in Norway.

BACKGROUND: Inadvertent perforation of the bowel or tumour is a relatively common complication during resection of rectal cancer. The purpose of this study was to examine intraoperative perforation following the introduction of mesorectal excision as a standard surgical technique in Norway. METHODS: This was a prospective national cohort study of 2873 patients undergoing major resection of rectal carcinoma at 54 Norwegian hospitals from November 1993 to December 1999. RESULTS: The overall perforation rate was 8.1 per cent (234 of 2873 patients). In a multivariate analysis, the risk of perforation was significantly greater in patients undergoing abdominoperineal resection (odds ratio (OR) 5.6 (95 per cent confidence interval (c.i.) 3.5 to 8.8)) and in those aged 80 years or more (OR 2.0 (95 per cent c.i. 1.2 to 3.5)). The 5-year local recurrence rate was 28.8 per cent following perforation, compared with 9.9 per cent in patients with no perforation (P<0.001); survival rates were 41.5 and 67.1 per cent respectively (P<0.001). CONCLUSION: The risk of intraoperative perforation was significantly greater in patients with rectal cancer undergoing abdominoperineal resection and in those aged 80 years or more. The high local recurrence rates and reduced survival following perforation call for increased attention to avoid this complication.

Total mesorectal excision for rectal cancer--what can be achieved by a national audit?

OBJECTIVE: The results of rectal cancer surgery in Norway have been poor. In a national audit for the period 1986-88, 28% of the patients developed local recurrence (LR) following treatment with a curative intent. Five-year overall survival was 55% for patients younger than 75 years. The aim of this study is to report how an initiative focusing on better surgery can improve the prognosis for rectal cancer patients on a national level. METHODS: In 1994, the Norwegian Rectal Cancer Group was founded. The aim of this initiative was to improve the surgical standard by implementing total mesorectal excision (TME) on a national level and to evaluate the results. A number of courses were arranged to teach the surgeons the TME technique, and pathologists were trained to increase the standard of both macroscopic and microscopic assessment of specimens. A rectal cancer registry was established, and all surgical departments treating rectal cancer were invited to transfer their clinical data to this registry. Each department regularly receives its own results together with the national average for comparison and quality control. RESULTS: The Rectal Cancer Registry includes all patients with rectal cancer diagnosed since November 1993. From then until December 1999, 5382 patients had a tumour located within 16 cm from the anal verge, and 3432 patients underwent rectal resection with a curative intent. Of these, 9% had adjuvant radiotherapy, and 2% were given chemotherapy. There was a rapid implementation of the new technique, as 78% underwent TME in 1994, increasing to 96% in 1998. After 39 months mean follow-up the rate of local recurrence was 8%, and 5-year overall survival was 71% for patients younger than 75 years. CONCLUSIONS: An optimized surgical technique (TME) for rectal cancer can reduce the rate of local recurrence and increase overall survival. This improved surgical treatment can be implemented on a national level within a few years. Specialization of surgeons, feedback of results and a separate rectal cancer registry are thought to be major contributors to the improved treatment.