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.

Improvement of the experience of colorectal cancer patients in Sweden with a regional cancer plan.

AIM: The Stockholm-Gotland Regional Cancer Plan was launched in 2012 to improve cancer care. A personal contact nurse (CN), an individual written care plan (IWCP) and a standardized care pathway (SCP) were introduced. The aim of the current study was to evaluate whether these efforts have resulted in an improved experience for patients treated for colorectal cancer. METHOD: Patients treated with bowel resection for colorectal cancer in the Stockholm-Gotland region between 1 January 2013 and 31 December 2017 were identified through the Swedish Colorectal Cancer Registry. Six to eight months postoperatively, the patients received a patient-reported experience questionnaire. Patients were classified as 'satisfied' or 'not satisfied'. RESULTS: The questionnaire was sent to 4465 patients, and 3154 (70.64%) responded. The proportion of patients assigned a CN increased over time (79.84%-88.44%) and so did the proportion of patients receiving an IWCP (39.36%-70.00%). The waiting times were significantly shortened during the study period. In multivariable analysis, access to a CN and an IWCP was independently associated with increased patient satisfaction (OR 3.03, 95% CI 2.28-4.02 and OR 1.64, 95% CI 1.38-1.94). Patients with a long waiting time were significantly less satisfied than patients with a short waiting time (OR 0.72, 95% CI 0.60-0.88). CONCLUSION: Implementation of a CN, IWCP and SCP has been successful, measured by a higher proportion of patients gaining access to these assets and shortened waiting times. This has led to an improved patient experience in patients treated for colorectal cancer in the Stockholm-Gotland region.

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.

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.

Low anterior resection syndrome after right- and left-sided resections for colonic cancer.

Background: This population-based cohort study aimed to evaluate occurrence of low anterior resection syndrome (LARS) and correlate this to health-related quality of life in patients who had undergone segmental colonic resection for colonic cancer in the Stockholm-Gotland region. The hypothesis was that there is a difference in occurrence of LARS depending on whether a right- or a left-sided resection was performed. Methods: Patients who underwent segmental colonic resection for colonic cancer stages I-III in the Stockholm-Gotland region in 2013-2015 received EORTC QLQ-C30, QLQ-CR29 and LARS score questionnaires 1 year after surgery. Clinical patient and tumour data were collected from the Swedish ColoRectal Cancer Registry. Patient-reported outcome measures were analysed in relation to type of colonic resection. Results: Questionnaires were sent to 866 patients and complete responses were provided by 517 (59·7 per cent). After right-sided resection 20·6 per cent reported major LARS. After left-sided resection the proportion with major LARS was 15·6 per cent. The odds ratio (OR) for major LARS after right-sided resection was 1·45 (95 per cent c.i. 1·02 to 2·06; P = 0·037) compared with left-sided resection. After adjustment for age and sex, an increase in the risk of major LARS after right- versus left-sided resection remained (OR 1·48, 1·03 to 2·13; P = 0·035). Major LARS correlated with impaired quality of life. Conclusion: Major LARS was more frequent after right-sided than following left-sided colonic resection. Major LARS reflected impaired quality of life.

Postoperative complications in relation to overall treatment time in patients with rectal cancer receiving neoadjuvant radiotherapy.

BACKGROUND: The optimal timing of surgery for rectal cancer after radiotherapy (RT) is disputed. The Stockholm III trial concluded that it was oncologically safe to delay surgery for 4-8 weeks after short-course RT (SRT), with fewer postoperative complications compared with SRT with surgery within a week. Other studies have indicated that an even shorter interval between RT and surgery (0-3 days) might be beneficial. The aim of this study was to identify the optimal interval to surgery after RT. METHODS: Patients were analysed as treated, in terms of overall treatment time (OTT), the interval from the start of RT until the day of surgery. Patients receiving SRT (5 × 5 Gy) were categorized according to OTT: 7 days (group A), 8-13 days (group B), 5-7 weeks (group C) and 8-13 weeks (group D). Patients receiving long-course RT (25 × 2 Gy) were grouped into those with an OTT of 9-11 weeks (group E) or 12-14 weeks (group F). Outcomes assessed were postoperative complications and early mortality. RESULTS: A total of 810 patients were analysed (group A, 100; group B, 247; group C, 192; group D, 160; group E, 52; group F, 59). Baseline patient characteristics were similar. There were significantly more overall complications in group B than in groups C and D. Adjusted odds ratios, with B as the reference group, were: 0·72 (95 per cent c.i. 0·40 to 1·32; P = 0·289), 0·50 (0·30 to 0·84; P = 0·009) and 0·39 (0·23 to 0·65; P < 0·001) for groups A, C and D respectively. Early mortality was similar in all groups. There were no significant differences between long-course RT groups. CONCLUSION: These results suggest that surgery should optimally be delayed for 4-12 weeks (OTT 5-13 weeks) after SRT.

Time trends of short-term mortality for octogenarians undergoing a colorectal resection in North Europe.

BACKGROUND: Decreased cancer specific survival in older colorectal patients is mainly due to mortality in the first year, emphasizing the importance of the first postoperative year. This study aims to gain an overview and time trends of short-term mortality in octogenarians (≥80 years) with colorectal cancer across four North European countries. METHODS: Patients of 80 years or older, operated for colorectal cancer (stage I-III) between 2005 and 2014, were included. Population-based cohorts from Belgium, Denmark, the Netherlands, and Sweden were collected. Separately for colon- and rectal cancer, 30-day, 90-day, one-year, and excess one-year mortality were calculated. Also, short-term mortality over three time periods (2005-2008, 2009-2011, 2012-2014) was analyzed. RESULTS: In total, 35,158 colon cancer patients and 10,144 rectal cancer patients were included. For colon cancer, 90-day mortality rate was highest in Denmark (15%) and lowest in Sweden (8%). For rectal cancer, 90-day mortality rate was highest in Belgium (11%) and lowest in Sweden (7%). One-year excess mortality rate of colon cancer patients decreased from 2005 to 2008 to 2012-2014 for all countries (Belgium: 17%-11%, Denmark: 21%-15%, the Netherlands: 18%-10%, and Sweden: 10%-8%). For rectal cancer, from 2005 to 2008 to 2012-2014 one-year excess mortality rate decreased in the Netherlands from 16% to 7% and Sweden: 8%-2%). CONCLUSIONS: Short-term mortality rates were high in octogenarians operated for colorectal cancer. Short-term mortality rates differ across four North European countries, but decreased over time for both colon and rectal cancer patients in all countries.

Population-based study of surgical treatment with and without tumour resection in patients with locally recurrent rectal cancer.

BACKGROUND: Population-based studies of treatment of locally recurrent rectal cancer (LRRC) are lacking. The aim was to investigate the surgical treatment of patients with LRRC at a national population-based level. METHODS: All patients undergoing abdominal resection for primary rectal cancer between 1995 and 2002 in Sweden with LRRC as a first event were included. Detailed information about treatment, complications and outcomes was collected from the medical records. The patients were analysed in three groups: patients who had resection of the LRRC, those treated without tumour resection and patients who received best supportive care only. RESULTS: In all, 426 patients were included in the study. Of these, 149 (35·0 per cent) underwent tumour resection, 193 (45·3 per cent) had treatment without tumour resection and 84 (19·7 per cent) received best supportive care. Abdominoperineal resection was the most frequent surgical procedure, performed in 65 patients (43·6 per cent of those who had tumour resection). Thirteen patients had total pelvic exenteration. In total, 63·8 per cent of those whose tumour was resected had potentially curative surgery. After tumour resection, 62 patients (41·6 per cent) had a complication within 30 days. Patients who received surgical treatment without tumour resection had a lower complication rate but a significantly higher 30-day mortality rate than those who underwent tumour resection (10 versus 1·3 per cent respectively; P = 0·002). Of all patients included in the study, 22·3 per cent had potentially curative treatment and the 3-year survival rate for these patients was 56 per cent. CONCLUSION: LRRC is a serious condition with overall poor outcome. Patients undergoing curative surgery have an acceptable survival rate but substantial morbidity. There is room for improvement in the management of patients with LRRC.

Consensus and controversies regarding follow-up after treatment with curative intent of nonmetastatic colorectal cancer: a synopsis of guidelines used in countries represented in the European Society of Coloproctology.

AIM: It is common clinical practice to follow patients for a period of years after treatment with curative intent of nonmetastatic colorectal cancer, but follow-up strategies vary widely. The aim of this systematic review was to provide an overview of recommendations on this topic in guidelines from member countries of the European Society of Coloproctology, with supporting evidence. METHOD: A systematic search of Medline, Embase and the guideline databases Trip database, BMJ Best Practice and Guidelines International Network was performed. Quality assessment included use of the AGREE-II tool. All topics with recommendations from included guidelines were identified and categorized. For each subtopic, a conclusion was made followed by the degree of consensus and the highest level of evidence. RESULTS: Twenty-one guidelines were included. The majority recommended that structured follow-up should be offered, except for patients in whom treatment of recurrence would be inappropriate. It was generally agreed that clinical visits, measurement of carcinoembryoinc antigen and liver imaging should be part of follow-up, based on a high level of evidence, although the frequency is controversial. There was also consensus on imaging of the chest and pelvis in rectal cancer, as well as endoscopy, based on lower levels of evidence and with a level of intensity that was contradictory. CONCLUSION: In available guidelines, multimodal follow-up after treatment with curative intent of colorectal cancer is widely recommended, but the exact content and intensity are highly controversial. International agreement on the optimal follow-up schedule is unlikely to be achieved on current evidence, and further research should refocus on individualized 'patient-driven' follow-up and new biomarkers.

Oncologic treatment strategies and relative survival of patients with stage I-III rectal cancer - A EURECCA international comparison between the Netherlands, Belgium, Denmark, Sweden, England, Ireland, Spain, and Lithuania.

INTRODUCTION: The aim of this EURECCA international comparison is to compare oncologic treatment strategies and relative survival of patients with stage I-III rectal cancer between European countries. MATERIAL AND METHODS: Population-based national cohort data from the Netherlands (NL), Belgium (BE), Denmark (DK), Sweden (SE), England (ENG), Ireland (IE), Spain (ES), and single-centre data from Lithuania (LT) were obtained. All operated patients with (y)pTNM stage I-III rectal cancer diagnosed between 2004 and 2009 were included. Oncologic treatment strategies and relative survival were calculated and compared between neighbouring countries. RESULTS: We included 57,120 patients. Treatment strategies differed between NL and BE (p < 0.001), DK and SE (p < 0.001), and ENG and IE (p < 0.001). More preoperative radiotherapy as single treatment before surgery was administered in NL compared with BE (59.7% vs. 13.1%), in SE compared with DK (55.1% vs. 10.4%), and in ENG compared with IE (15.2% vs. 9.6%). Less postoperative chemotherapy was given in NL (9.6% vs. 39.1%), in SE (7.9% vs. 14.1%), and in IE (12.6% vs. 18.5%) compared with their neighbouring country. In ES, 55.1% of patients received preoperative chemoradiation and 62.3% postoperative chemotherapy. There were no significant differences in relative survival between neighbouring countries. CONCLUSION: Large differences in oncologic treatment strategies for patients with (y)pTNM I-III rectal cancer were observed across European countries. No clear relation between oncologic treatment strategies and relative survival was observed. Further research into selection criteria for specific treatments could eventually lead to individualised and optimal treatment for patients with non-metastasised rectal cancer.

Session 1: The surgeon as a prognostic factor in colon and rectal cancer?

The impact of quality of surgery, colorectal surgical specialization, training and expertise has been far greater on survival outcomes than adjuvant and neoadjuvant therapies. The review of the evidence by Professor Martling and expert discussion addresses the evidence base and the crucial importance of the surgeon as a prognostic factor, and how this has been relatively neglected in comparison to other resources invested in improving the treatment of colorectal cancer.

Prediction of outcome after curative surgery for colorectal cancer: preoperative haemoglobin, C-reactive protein and albumin.

AIM: The aim was to evaluate a scoring system using the values of preoperative haemoglobin, C-reactive protein (CRP) and albumin to predict colorectal cancer recurrence and survival. METHOD: Data on all curative resections for Stages I-III colorectal cancer performed at a tertiary referral hospital in 2007-2010 were recorded in the Swedish Colorectal Cancer Registry and were matched to local databases for laboratory results and blood transfusion. Patients who died within 30 days or during primary hospital admission were excluded. Preoperative haemoglobin, CRP and albumin levels were recorded for 417 patients. A score (0-3) was derived on the presence of anaemia (Hb < 120 g/l for women and < 130 g/l for men), raised CRP (> 10 mg/ml) and low albumin (< 35 g/dl). The risks for recurrence and impaired overall survival were assessed using Cox regression analyses. RESULTS: Impaired overall survival was found when one, two or three of the criteria anaemia, elevated CRP and low albumin were present prior to surgery [hazard ratio (HR) 3.61, 95% CI 1.66-7.85; HR 3.91, 95% CI 1.75-8.74; HR 4.85, 95% CI 2.15-10.93, respectively]. The risk for recurrence, however, was not related to the presence of these criteria. CONCLUSION: Overall survival after curative surgery for Stages I-III colorectal cancer is impaired when anaemia, elevated CRP or low albumin exist prior to surgery.

Complete mesocolic excision in right-sided colon cancer does not increase severe short-term postoperative adverse events.

AIM: The aim was to assess whether complete mesocolic excision (CME) in patients with right-sided colon cancer is related to short-term mortality or postoperative adverse events requiring reoperation. The complete mobilization of an integral mesocolon and central ligation of blood vessels are essential steps in CME surgery. The resultant specimen, with an intact mesocolic fascia and a high number of harvested lymph nodes, is believed to be oncologically favourable. However, it has been suggested that CME surgery may increase the risk of intra-operative severe adverse events, due to exposure of vital retroperitoneal organs and large blood vessels. METHOD: In a population-based, nested case-control study, all residents in the Stockholm County operated for right-sided colon cancer from 2004 until 2012 were identified from the Swedish Colorectal Cancer Registry. Patients who died within 90 days after surgery or were reoperated within 30 days after surgery, or during the index hospital stay, were defined as cases. Two controls per case were randomly sampled and individually matched for age, sex, TNM stage and emergency vs elective surgery. Exposure status (CME surgery) was assessed from original surgical reports. RESULTS: The estimated proportion of CME surgery was 14.8% (35 of 236) for cases and 19.5% (92 of 473) for controls. The unadjusted OR for short-term mortality or reoperation after CME surgery was 0.72 (95% CI: 0.47-1.10; P = 0.15). The ORs were lower in the late part of the study (0.51; 95% CI: 0.26-1.01) and in high volume hospitals (0.61, 95% CI: 0.35-1.06). CONCLUSIONS: The present study does not indicate that CME surgery is associated with an increased risk of severe adverse events such as 90-day mortality or reoperation.

Pelvic local recurrence from colorectal cancer: surgical challenge with changing preconditions.

AIM: Although the rate of local recurrence (LR) after colorectal cancer surgery has decreased, it still poses major surgical and oncological challenges. The aims of this study, based on an audit from a tertiary referral centre, was to evaluate determinants associated with outcomes after surgery for pelvic LR and how these have changed over time. METHOD: Retrospective analysis of all resections for pelvic LR of colorectal cancer performed at the Karolinska University Hospital from January 2003 until August 2009 (period 1) and from September 2009 until November 2013 (period 2) . RESULTS: Ninety-five patients with pelvic LR were operated on with a curative intent. An R0 resection was achieved in 77% and an R1 resection in 23%. Lateral compartments were invaded in 48% and this proportion increased in resections performed in period 2 (37% vs 60%, P = 0.05). R1 resections were associated with a higher risk of local re-recurrence than R0 resections (64% vs 16%; OR = 8.90, 95% CI: 2.71-29.78). Lateral recurrences were associated with a lower R0-resection rate than nonlateral recurrences (63% vs 90%; OR = 0.20, 95% CI: 0.05-0.64) and a higher risk of treatment failure in terms of local re-recurrence or distant metastases, or death, as first event (hazard ratio [HR] = 1.75, 95% CI: 1.06-2.75). However, in a multivariate analysis only R1 resections remained a significant prognostic factor for treatment failure (HR = 2.37, 95% CI: 1.32-4.27). CONCLUSION: The proportion of lateral pelvic recurrences has increased over time. In comparison with non-lateral LRs, lateral LRs are more difficult to resect radically and are associated with worse overall and disease-free survival. However, with radical surgery many patients with pelvic locally recurrent colorectal cancer may be offered curative treatment.

Muscles of the trunk and pelvis are responsive to testosterone administration: data from testosterone dose-response study in young healthy men.

Testosterone dose-dependently increases appendicular muscle mass. However, the effects of testosterone administration on the core muscles of the trunk and the pelvis have not been evaluated. The present study evaluated the effects of testosterone administration on truncal and pelvic muscles in a dose-response trial. Participants were young healthy men aged 18-50 years participating in the 5α-Reductase (5aR) Trial. All participants received monthly injections of 7.5 mg leuprolide acetate to suppress endogenous testosterone production and weekly injections of 50, 125, 300, or 600 mg of testosterone enanthate and were randomized to receive either 2.5 mg dutasteride (5aR inhibitor) or placebo daily for 20 weeks. Muscles of the trunk and the pelvis were measured at baseline and the end of treatment using 1.5-Tesla magnetic resonance imaging. The dose effect of testosterone on changes in the psoas major muscle area was the primary outcome; secondary outcomes included changes in paraspinal, abdominal, pelvic floor, ischiocavernosus, and obturator internus muscles. The association between changes in testosterone levels and muscle area was also assessed. Testosterone dose-dependently increased areas of all truncal and pelvic muscles. The estimated change (95% confidence interval) of muscle area increase per 100 mg of testosterone enanthate dosage increase was 0.622 cm2 (0.394, 0.850) for psoas; 1.789 cm2 (1.317, 2.261) for paraspinal muscles, 2.530 cm2 (1.627, 3.434) for total abdominal muscles, 0.455 cm2 (0.233, 0.678) for obturator internus, and 0.082 cm2 (0.003, 0.045) for ischiocavernosus; the increase in these volumes was significantly associated with the changes in on-treatment total and free serum testosterone concentrations. In conclusion, core muscles of the trunk and pelvis are responsive to testosterone administration. Future trials should evaluate the potential role of testosterone administration in frail men who are predisposed to falls and men with pelvic floor dysfunction.