Improving survival rates for patients with colorectal cancer.

Between 1 January 1984 and 31 December 1990, 575 patients were operated on for colorectal cancer. The surgical procedure was performed consistently and no patients were lost to follow-up. Almost half of the patients (284 of 575) had tumours of stage I or II, with 5-year survival rates over 90 per cent. After extending the resection margins in 28 cases of colonic carcinoma there has been no case of tumour recurrence. The overall 5-year survival rate for patients with colonic carcinoma was 81 per cent. Complete resection of the mesorectum was mandatory for rectal resection. One-third of the carcinomas in the lower third of the rectum could be resected with maintenance of bowel continuity and an abdominoperineal resection avoided. Not only was the tumour recurrence rate in the former patients lower (10.5 per cent) compared with that in those undergoing abdominoperineal resection (14.3 per cent) but the 5-year survival rate at 90 versus 52 per cent was significantly higher. The overall 5-year survival rate for patients with rectal carcinoma was 71 per cent.     

Postoperative body-weight loss and survival after curative resection for gastric cancer

BACKGROUND: Body-weight loss has been reported as a poor prognostic factor for some malignancies. The purpose of this study was to evaluate the prognostic value of postoperative body-weight loss in patients with gastric cancer. METHODS: In 564 patients who underwent curative resection for gastric cancer, usual body-weight, body-weight at the time of resection and that 6 and 12 months after resection were recorded prospectively. RESULTS: The 5-year survival rate of patients who lost more than 5 per cent of their 6-month postoperative weight by 12 months after resection was 63 per cent while that of patients who maintained 95 per cent or more of their 6-month postoperative weight was 84 per cent (P < 0.001). Multivariate analysis revealed that serosal invasion, nodal metastasis, body-weight loss during the second 6-month interval after resection and extent of gastric resection were independent prognostic indicators. CONCLUSION: When a patient loses body-weight during the second 6-month interval after curative resection for gastric cancer, recurrent disease should be suspected.     

Hospital volume does not influence long-term survival of patients undergoing surgery for oesophageal or gastric cancer

BACKGROUND: Guidelines suggest that surgery for oesophageal and gastric cancer should be conducted in large cancer centres. This national study examined the relationship between hospital volume and outcome in Scotland. METHODS: This was a prospective, population-based study of 3293 consecutive patients with oesophageal or gastric cancer diagnosed between 1997 and 1999. Some 1302 patients underwent surgery and were followed for 5 years after operation. RESULTS: The 5-year adjusted overall survival rate for the 3293 patients was 18.7 (95 per cent confidence interval (c.i.) 17.2 to 20.2) per cent and that after surgical resection was 39.6 (95 per cent c.i. 36.3 to 43.0) per cent. Death within 1 year after surgical resection was associated with a postoperative complication (odds ratio (OR) 2.5 (95 per cent c.i. 1.6 to 3.8); P < 0.001) or resection margin involvement by tumour (OR 7.2 (95 per cent c.i. 1.1 to 47.5); P = 0.042) after adjustment for age, sex and tumour location. There was no relationship between hospital volume and postoperative morbidity or mortality, nor between survival and volume of patients either for hospital of diagnosis or hospital of surgery. CONCLUSION: This population-based study of oesophageal and gastric cancer suggests that the link between hospital volume and long-term survival for patients undergoing surgery requires re-evaluation.     

Improving survival in gastric cancer: review of operative mortality in English language publications from 1970

In this review of English language publications from 1970, operative mortality following surgery for gastric cancer has been analysed. Operative mortality has declined in series reporting operations in successive decades to 1970, 1980 and 1990. Series reporting patients having surgery for gastric cancer in the decade to 1990 show a mean operative mortality rate of 7.8 per cent (median 4.6 per cent). This improvement may have contributed to the declining mortality rates for gastric cancer in the face of unchanging surgical workload. Results of operations for gastric cancer should be reported in a standard manner.     

Cancer of the gastric stump following distal gastrectomy for cancer

BACKGROUND: Cancer of the gastric stump (CGS) after distal gastrectomy for cancer has not been characterized in a large study. The aim of this study was to investigate the clinicopathological features and outcome of CGS following distal gastrectomy for cancer. METHODS: Patients with CGS following distal gastrectomy for gastric cancer diagnosed between 1970 and 2002 were reviewed retrospectively. RESULTS: A total of 108 patients was identified. The median interval between the initial gastrectomy and resection for CGS was 7.5 (range 1-41) years. The depth of tumour invasion was T1 in 67 patients, T2 in 16, T3 in eight and T4 in 17 patients. Endoscopic mucosal resection was performed in 25 patients with T1 tumours. R0 resection was achieved in 103 patients. The overall 5-year survival rate was 53.1 per cent. The 5-year survival rates for patients with T1, T2, T3 and T4 disease were 76, 40, 13 and 9 per cent respectively. CONCLUSION: The outcome for patients with non-early CGS was poor. Early detection of CGS is important following distal gastrectomy for gastric cancer and strict surveillance is recommended for at least 10 years after the initial gastrectomy.     

Gastric cancer: a 25-year review

Between 1957 and 1981, 31,716 cases of gastric cancer were registered in the West Midlands, UK. The age-standardized incidence has shown a decrease from 17.42 per 100,000 population during the first quinquennium to 15.30 per 100,000 in the last. There was an apparent increase in the proportion of proximal lesions with a decrease in the proportion of distal, antral cancers. The stage of disease at diagnosis remained constant with 79 per cent of patients having stage IV disease. Less than 1 per cent presented with stage I disease. As a result, the curative resection rate was 21 per cent. The operative mortality rates for curative partial gastrectomy and total gastrectomy were 13 and 29 per cent respectively. Surgeons undertaking more than nine total gastrectomies annually had an overall mean operative mortality rate of 22 per cent. Overall age-adjusted survival at 5 years was 5 per cent. Survival at 5 years for stage I, II and III disease was 72, 32 and 10 per cent respectively. There was a significant increase in survival time for those treated by curative resection between 1972 and 1981 compared with the previous decade. The implications for the management of gastric cancer are discussed.     

Improving results in the treatment of gastric cancer: an 11-year audit

Of 280 patients presenting to one hospital with gastric cancer between 1975 and 1985, 97 (35 per cent) did not undergo surgery and 29 per cent (54 out of 183) of those who did had no resection performed. The 30-day operative mortality rate in the study period was 15 per cent (28 out of 183) but in the subsequent 4-year period this fell to 7 per cent (5 out of 69). The survival rate correlated significantly with depth of invasion but not with tumour site or degree of differentiation. The incidence of early gastric cancer in this series was 5 per cent but the 5-year survival rate in this group was 52 per cent suggesting that the true incidence might be even lower. The overall 5-year survival rate in our area 20 years ago was only 5.2 per cent but in this series it was 11 per cent overall and 24 per cent after resection, and with actuarial correction 15 per cent overall and 28 per cent after resection. The continuing improvement in operative mortality rates and in 5-year survival rates gives grounds for optimism, but the disease must be diagnosed earlier if this improvement in outlook is to continue.     

Improvement in survival following surgery for colorectal cancer

BACKGROUND: Recent reports based on registry data have shown that survival after surgery for colorectal cancer is improving in the UK. It is not clear whether these improvements are due to earlier presentation or more effective treatment. METHODS: Outcome for 645 patients with colorectal cancer admitted to Glasgow Royal Infirmary between 1974 and 1979 was compared with that for 354 patients admitted between 1991 and 1994. RESULTS: More patients in the later period had Dukes' A or B tumours and fewer had evidence of metastatic spread (P < 0.001); more underwent potentially curative resection (57.6 versus 49.9 per cent; P < 0.001) and fewer underwent palliative diversion. The overall postoperative mortality rate fell from 14.1 to 8.5 per cent (P = 0.017). Overall and cancer-specific 5-year survival after potentially curative resection increased from 40.1 to 60.5 per cent and from 47.3 to 71.7 per cent respectively (both P < 0.001). Compared with the earlier period, the adjusted hazard ratio for cancer-specific survival following potentially curative resection was 0.452 (95 per cent confidence interval 0.329 to 0.622; P < 0.001). CONCLUSION: The observed improvement in survival was mainly due to improvements in the quality of surgery and in perioperative care rather than earlier presentation.     

Impact of anastomotic leakage on long-term survival of patients undergoing curative resection for colorectal cancer

BACKGROUND: The impact of anastomotic leakage on immediate postoperative mortality in patients undergoing potentially curative resection for colorectal cancer is well recognized. Its impact on long-term survival is less clear. The aim of the present study was to evaluate the relationship between anastomotic leakage and long-term survival in patients undergoing potentially curative resection for colorectal cancer. METHODS: A total of 2235 patients who underwent potentially curative resection for colorectal cancer between 1991 and 1994 in Scotland were included in the study. Five-year survival rates and adjusted hazard ratios were calculated. RESULTS: Fourteen (16 per cent) of the 86 patients with an anastomotic leak died within 30 days of surgery compared with 83 (3.9 per cent) of 2149 without a leak. The 5-year cancer-specific survival rate, including postoperative deaths, was 42 per cent in patients with an anastomotic leak compared with 66.9 per cent in those with no leak (P < 0.001). Excluding postoperative deaths, respective values were 50 and 68.0 per cent (P < 0.001). The adjusted relative hazard ratios, for patients with an anastomotic leak compared with those without a leak, and excluding 30-day mortality, were 1.61 (95 per cent confidence interval (c.i.) 1.19 to 2.16; P = 0.002) for overall survival and 1.99 (95 per cent c.i. 1.42 to 2.79; P < 0.001) for cancer-specific survival. CONCLUSION: Development of an anastomotic leak is associated with worse long-term survival after potentially curative resection for colorectal cancer.     

Impact of radiotherapy on local recurrence of rectal cancer in Norway

BACKGROUND: The purpose of this study was to analyse the impact of radiotherapy on local recurrence of rectal cancer in Norway after the national implementation of total mesorectal excision (TME). METHODS: This was a prospective national cohort study of 4113 patients undergoing major resection of rectal carcinoma between November 1993 and December 2001. RESULTS: The proportion of patients who had radiotherapy before or after operation increased from 4.6 per cent in 1994 to 23.0 per cent in 2001. The cumulative 5-year local recurrence rate decreased from 16.2 to 10.7 per cent. Multivariable analysis showed that preoperative radiotherapy significantly reduced local recurrence (hazard ratio 0.59 (95 per cent confidence interval 0.39 to 0.87)). The use of preoperative radiotherapy in patients from a local hospital offering radiotherapy was 50 per cent higher than that for patients from a hospital without such services (P = 0.003); cumulative 5-year local recurrence rates for these patients were 10.6 and 15.8 per cent respectively (P < 0.001). CONCLUSION: Following national implementation of TME for rectal cancer, increased use of preoperative radiotherapy appeared to reduce recurrence rates further.     

Influence of volume and specialization on survival following surgery for colorectal cancer

BACKGROUND: Previous studies have shown that significant surgeon-related differences in survival exist following surgery for colorectal cancer. It is not clear whether these differences were due to differences in caseload or degree of specialization. METHODS: Outcome in 3200 patients who underwent resection for colorectal cancer between 1991 and 1994 was analysed on the basis of caseload and degree of specialization of individual surgeons. Five-year survival rates, and the corresponding hazard ratios adjusted for case mix, were calculated. RESULTS: Cancer-specific survival rate at 5 years following curative resection varied among surgeons from 53.4 to 84.6 per cent; the adjusted hazard ratios varied from 0.48 to 1.55. Cancer-specific survival rate at 5 years following curative resection was 70.2, 62.0 and 65.9 per cent for surgeons with a high, medium and low case volume respectively. There were no consistent differences in the adjusted hazard ratios by volume. Cancer-specific survival rate at 5 years following curative resection was 72.7 per cent for those treated by specialists and 63.8 per cent for those treated by non-specialists; the adjusted hazard ratio for non-specialists was 1.35 (95 per cent confidence interval 1.13 to 1.62; P = 0.001). CONCLUSION: The differences in outcome following apparently curative resection for colorectal cancer among surgeons appear to reflect the degree of specialization rather than case volume. It is likely that increased specialization will lead to further improvements in survival.     

Surgical treatment of carcinoma of the gastric stump

To evaluate retrospectively the surgical treatment of patients with gastric stump cancer following gastrectomy for benign disease, we reviewed 52 patients operated on at the National Cancer Centre, Tokyo, between 1962 and 1988. Resection was carried out in 47 patients (90 per cent) and with curative intent in 36 (69 per cent). Stage distribution was: stage 1, 15 patients; stage 2, 5; stage 3, 9; stage 4, 23. In 36 cases curatively resected, 32 had completion total gastrectomy and four had subtotal resection. An R1 resection was performed in 11 patients and an R2 in 25. We had two hospital deaths and a 5-year survival rate excluding hospital deaths of 39 per cent. The 5-year survival rates of resected cases, curative cases and those having metastatic nodes were 43 per cent, 57 per cent and 29 per cent respectively. Radical resection is a reasonable treatment for gastric stump cancer as it is for primary cancer of the stomach.     

Esophageal carcinoma. Improved quality of survival with resection

Twenty years ago the experience with carcinoma of the esophagus at Vanderbilt University and affiliated hospitals was reported in 263 patients. Overall 5-year survival was 2 per cent. Esophagectomy was possible in 89 patients (34%) and was associated with a 32 per cent mortality. This study updates the authors' experience with squamous cell carcinoma of the esophagus in 311 patients seen from 1966 to 1985. Overall 5-year survival has increased to 6 per cent. Esophageal resection was accomplished in 104 patients (33%), with a 10 per cent operative mortality and 41 per cent complication rate. Multi-variant analysis disclosed that smoking, alcohol use, sex, race, and site of tumor did not influence survival. Actuarial survival rates following esophageal resection were 51 per cent at 1 year, 21 per cent at 2 years, and 13 per cent at 5 years. These survival rates were not influenced by adjuvant radiotherapy. Radiation therapy was used for attempted cure in 83 patients. Actuarial survival rates following curative doses of radiation were 29 per cent at 1 year, 15 per cent at 2 years, and 4 per cent at 5 years. These survival rates were significantly (P less than 0.001) lower than survival rates following esophagectomy. The quality of life following treatment was good or fair in 83 per cent of patients undergoing esophagectomy and good or fair in 64 per cent of patients receiving "curative" doses of radiation. The results of this review demonstrate that esophageal resection using the Lewis operation or transhiatal esophagectomy can be done with an acceptable operative mortality, results in prolonged survival, and improves the quality of life.     

Local recurrence after curative resection for rectal cancer is associated with anterior position of the tumour

BACKGROUND: Mobilization of rectal cancer can be difficult if the tumour is located anteriorly and may result in a higher incidence of local recurrence. The aim of this study was to determine whether local recurrence and survival following curative resection of rectal cancer were associated with the position of the tumour. METHODS: Data were drawn from a comprehensive, prospective hospital registry of all resections for rectal cancer from January 1990 to December 1998, with follow-up to December 2003. RESULTS: The 5-year local recurrence rate was 15.9 (95 per cent confidence interval (c.i.) 11.0 to 22.8) per cent in 176 patients with tumours that had an anterior component compared with 5.8 (95 per cent c.i. 2.8 to 11.9) per cent in 132 patients with tumours without an anterior component (P = 0.009). This association persisted after adjustment for other factors linked to local recurrence (hazard ratio (HR) 2.4 (95 per cent c.i. 1.1 to 5.4)). Similarly, anterior position had a significant negative independent association with survival (HR 1.4 (95 per cent c.i. 1.0 to 2.00)). CONCLUSION: Anterior position is an independent negative prognostic factor for both local recurrence and survival after curative resection of rectal cancer.     

Influence of postoperative morbidity on long-term survival following liver resection for colorectal metastases

BACKGROUND: Survival after resection of colorectal liver metastases may be influenced by the patient, the primary tumour and the liver metastases. Postoperative morbidity is associated with poor survival in several cancers. The aim of this retrospective study was to evaluate prognostic factors of survival after resection of colorectal liver metastases, including postoperative morbidity. METHODS: From 1985 to 2000, 311 consecutive patients with liver metastases from colorectal cancer underwent resection with curative intent. Univariate and multivariate analyses were performed to assess the influence of age, sex, site and stage of the colorectal tumour, disease-free interval, number, size and distribution of metastases, type of hepatectomy, pedicular clamping, resection margin, blood transfusion, postoperative morbidity and adjuvant chemotherapy on overall and disease-free survival. RESULTS: The postoperative mortality and morbidity rates were 3 and 30 per cent respectively. The 3- and 5-year overall survival rates were 53 and 36 per cent respectively. Both overall and disease-free survival rates were independently associated with nodal status of the colorectal tumour, number of metastases and postoperative morbidity. Patients with postoperative morbidity had an overall and disease-free 5-year survival rate half that of patients with no morbidity: 21 versus 42 per cent for overall survival (P < 0.001) and 12 versus 28 per cent for disease-free survival (P = 0.001) respectively. CONCLUSION: Long-term survival can be altered by postoperative morbidity after resection of colorectal liver metastases by increasing the risk of tumour recurrence. This justifies optimizing the surgical treatment of colorectal liver metastases to decrease postoperative morbidity and the use of efficient adjuvant treatments in patients with postoperative morbidity.     

Cause-specific actuarial survival analysis: a useful method for reporting survival data in men with clinically localized carcinoma of the prostate

The primary objective of this retrospective 15-year survival analysis of 57 men with clinical stage B1 carcinoma of the prostate undergoing radical prostatectomy between 1951 and 1963 is to compute the cause-specific curve for these men and argue why it is a useful method to report survival data in men with clinically localized prostatic cancer. Historically, survival following radical prostatectomy and radiotherapy has been reported using all cause survival analysis. Cause-specific survival focuses on the impact of a disease process on survival, since men dying of causes unrelated to carcinoma of the prostate are considered lost to followup as of date of death of such unrelated causes. Cause-specific survival analysis reduces the impact of age, medical condition and other risk factors on survival rates. The cause-specific 15-year actuarial survival rate in our patients was 86 per cent. The 95 per cent confidence interval for this 15-year survival rate was 76.9 to 90.1 per cent. Based upon this series of patients with clinical stage B1 carcinoma of the prostate who undergo radical prostatectomy one may state that the chance of death of carcinoma of the prostate within 15 years of surgery averages 14 +/- 5 per cent. The cause-specific survival curve reached a plateau at 10 years, indicating that most men who survive 10 years are cured of the disease. With the Cox model regression analysis, mortality in this series was related positively to age at operation when the outcome variable was death of all causes (p equals 0.003) but it was unrelated to age when the outcome variable was prostate cancer mortality (p equals 0.85). Cause-specific survival rates are a more precise indicator of the impact of a therapeutic modality on survival and, therefore, they are useful to report survival data in men with localized carcinoma of the prostate and other disease when death from competing causes is an important consideration.     

Emergency presentation of colorectal cancer is associated with poor 5-year survival

BACKGROUND: Previous studies have reported that emergency presentation of colorectal cancer is associated with poor outcome. Many of these studies were small and most were not adjusted for case mix. The aim of this study was to establish, after adjusting for case mix, the magnitude of the differences in postoperative mortality and survival between patients undergoing elective surgery and those presenting as an emergency. METHODS: Three thousand two hundred patients who underwent surgery for colorectal cancer between 1991 and 1994 in Scotland were studied. Five-year survival rates and adjusted hazard ratios were calculated. RESULTS: Some 1603 (72.4 per cent) of 2214 elective patients had a potentially curative resection compared with 632 (64.1 per cent) of 986 patients who presented as an emergency (P < 0.001). Following curative resection, the postoperative mortality rate was 2.8 per cent after elective and 8.2 per cent after emergency operation (P < 0.001). Overall survival at 5 years was 57.5 per cent after elective and 39.1 per cent after emergency curative surgery (P < 0.001); cancer-specific survival at 5 years was 70.9 and 52.9 per cent respectively (P < 0.001). The adjusted hazard ratio for overall survival after emergency relative to elective surgery was 1.68 (95 per cent confidence interval (c.i.) 1.49 to 1.90; P < 0.001) and that for cancer-specific survival was 1.90 (95 per cent c.i. 1.62 to 2.22; P < 0.001). CONCLUSION: Following apparently curative resection for colorectal cancer, there was an excess of both cancer-related and intercurrent deaths in patients who presented as an emergency.     

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.     

Recurrence and survival after mesorectal excision for rectal cancer

BACKGROUND: Mesorectal excision for rectal cancer has resulted in local recurrence rates of 3-11 per cent compared with up to 38 per cent after conventional methods. The results of a prospective Danish study with a historical control group are presented. METHODS: Three hundred and eleven patients with a mobile rectal cancer had mesorectal excision with curative intent performed by certified surgeons and were followed for 3 years. Demographic, perioperative and follow-up data were recorded prospectively. A series of patients who had conventional operations for rectal cancer served as a control group. RESULTS: The cumulative 3-year local recurrence rate was 11 per cent after mesorectal excision compared with 30 per cent after conventional surgery (hazard ratio (HR) 0.33 (95 per cent confidence interval (c.i.) 0.21 to 0.52); P < 0.001). Multivariate regression analysis showed that only advanced age (HR 0.97 (95 per cent c.i. 0.94 to 1.00); P = 0.048) and tumour in the lower third of the rectum (HR 0.21 (95 per cent c.i. 0.04 to 1.97); P = 0.075) were marginal independent predictors of local recurrence after mesorectal excision. The cumulative crude 3-year survival rate was 77 per cent after mesorectal excision and 62 per cent after conventional surgery (HR 0.58 (95 per cent c.i. 0.43 to 0.77); P < 0.001). Age was the only independent predictor of death after mesorectal excision (HR 1.04 (95 per cent c.i. 1.02 to 1.07); P = 0.001). CONCLUSION: Mesorectal excision is associated with a considerably lower risk of local recurrence and a better survival rate than conventional surgery, and is the optimum method for rectal cancer resection.     

Changing pattern of histological type, location, stage and outcome of surgical treatment of gastric carcinoma

BACKGROUND: There are indications that some features of gastric carcinoma are changing, with a possible impact on prognosis. The aim of this study was to examine any changes in type, location, stage, resection rate, postoperative mortality rate or prognosis for patients with gastric carcinoma in a well defined population. METHODS: During 1974-1991, 1161 new cases of gastric adenocarcinoma were diagnosed in Osterg?tland County, Sweden. Tumour location, Laurén histological type, tumour node metastasis (TNM) stage, radicality of tumour resection and postoperative complications were recorded after histological re-evaluation of tissue specimens and examination of all patient records. Dates of death were obtained from the Swedish Central Bureau of Statistics. Time trends were studied by comparing the intervals 1974-1982 (period 1) and 1983-1991 (period 2). RESULTS: The proportion of diffuse type of adenocarcinoma increased (from 27 to 35 per cent), while that of mixed type decreased (from 16 to 9 per cent) and that of intestinal type was unchanged. The proportion of tumours located in the proximal two-thirds of the stomach increased (from 32 to 42 per cent) and the proportion of patients with tumours in TNM stage IV decreased (from 32 to 25 per cent). Overall tumour resection rates were unchanged, although the proportion of radical total gastrectomies increased (from 36 to 50 per cent). Excluding tumours of the cardia or gastric remnant after previous ulcer surgery, the 5-year relative survival rate after radical resection increased from 25 to 36 per cent and the postoperative mortality rate decreased for both radical (from 11 to 4 per cent) and palliative (from 18 to 6 per cent) resection. CONCLUSION: The patterns of tumour histology, location and stage of gastric carcinoma have changed in the authors' region. These changes were paralleled by a significant improvement in survival and postoperative mortality rates.