Annual hospital volume of surgery for gastrointestinal cancer in relation to prognosis

BackgroundStudies examining hospital volume for surgery for various gastrointestinal (GI) cancer types have shown conflicting results regarding the influence on long-term prognosis. The aim of this study was to examine annual hospital volume in relation to long-term survival after elective surgery for all GI cancers (esophagus, stomach, liver, pancreas, bile ducts, small bowel, colon, and rectum).MethodsPopulation-based cohort study including all 45,908 patients who underwent elective surgery for GI cancers in Sweden in 2005–2013. Follow-up was until 2016 for disease-specific 5-year mortality (main outcome) and 2018 for all-cause 5-year mortality (secondary outcome). Hospitals were divided into quartiles for each GI cancer according to a 4-year average annual volume of the year of surgery and three years earlier. Multivariable Cox regression provided hazard ratios (HRs) with 95% confidence intervals (CIs), adjusted for relevant confounders.ResultsHigher hospital volume was associated with a survival benefit in the large group of patients (n = 26,688) who underwent colon cancer resection, with HR 0.89 (95% CI 0.84–0.96) for disease-specific 5-year mortality comparing the highest with the lowest quartile. Higher hospital volume improved 5-year mortality in sub-groups of patients who underwent surgery for cancer of the esophagus, pancreas, and rectum. No such improvements were found for cancer of the stomach, liver, bile ducts, or small bowel.ConclusionLong-term survival was improved at higher volume hospitals for some GI cancers (colon, esophagus, pancreas, rectum), but not for others (stomach, liver, bile ducts, small bowel).     

Hospital volume and outcome in rectal cancer patients; results of a population-based study in the Netherlands

BackgroundClinically staged T1-3 rectal cancer (cT1-3) is generally treated by total mesorectal excision(TME) with or without neoadjuvant therapy and sometimes requires beyond TME-surgery, whereas cT4 rectal cancer often requires both. This study evaluates the outcome of cT1-3 and cT4 rectal cancer according to hospital volume.MethodsPatients undergoing rectal cancer surgery between 2005 and 2013 in the Netherlands were included from the National Cancer Registry. Hospitals were divided into low(1–20), medium(21–50) and high(>50 resections/year) volume for cT1-3 and low(1–4), medium(5–9) and high(≥10 resections/year) volume for cT4 rectal cancer. Cox-proportional hazards model was used for multivariable analysis of overall survival (OS).ResultsA total of 14.050 confirmed cT1-3 patients and 2.104 cT4 patients underwent surgery. In cT1-3 rectal cancer, there was no significant difference in 5-year OS related to high, medium and low hospital volume (70% vs. 69% vs. 69%). In cT4 rectal cancer, treatment in a high volume cT4 hospital was associated with a survival benefit compared to low volume cT4 hospitals (HR 0.81 95%CI 0.67–0.98) adjusted for non-treatment related confounders, but this was not significant after adjustment for neoadjuvant treatment. Patients with cT4-tumours treated in high volume hospitals had a significantly lower age, more synchronous metastases, more patients treated with neoadjuvant therapy and a higher pT-stage.ConclusionHospital volume was not associated with survival in cT1-3 rectal cancer. In cT4 rectal cancer, treatment in high volume cT4 hospitals was associated with improved survival compared to low volume cT4 hospitals, although this association lost statistical significance after correction for neoadjuvant treatment.     

Weekday of gastrectomy and long-term survival in gastric adenocarcinoma

BackgroundCancer surgery conducted late during the working week might decrease long-term survival for some tumours. Studies on how weekday of gastrectomy influences long-term survival following gastric cancer are few and show conflicting results, which prompted the present investigation.MethodsThis population-based cohort study included almost all patients who underwent gastrectomy for gastric adenocarcinoma in Sweden between 2006 and 2015, with follow-up throughout 2020. Associations between weekday of gastrectomy and 5-year all-cause mortality (main outcome) and 5-year disease-specific mortality (secondary outcome) were analysed using multivariable Cox regression. The hazard ratios (HR) with 95% confidence intervals (CI) were adjusted for age, sex, education, comorbidity, pathological tumour stage, tumour sub-location, neoadjuvant therapy, annual surgeon volume of gastrectomy, and calendar year.ResultsAmong 1678 patients, surgery on Thursday-Friday was not associated with any statistically significantly increased risk of 5-year all-cause mortality (HR 1.05, 95% CI 0.91–1.22) or 5-year disease-specific mortality (HR 1.04, 95% CI 0.89–1.23) compared to Monday-Wednesday. No associations were found when each weekday was analysed separately, with point estimates close to 1.00 (range 0.98–1.00) Monday-Thursday, but increased for Friday (HR 1.22, 95% CI 0.89–1.68) when fewer patients underwent surgery (4% of all). Stratified analyses by age, comorbidity, tumour stage, neoadjuvant therapy, surgeon volume, and tumour sub-location did not reveal any associations between weekday of surgery on Thursday-Friday compared with Monday-Wednesday and risk of 5-year all-cause mortality.ConclusionsWeekday of gastrectomy might not influence the 5-year survival in patients with gastric adenocarcinoma.     

Postoperative complications after colorectal cancer surgery and the association with long-term survival

BackgroundComplications after colorectal cancer surgery can worsen long-term survival. The aim of this nationwide study was to determine the impact of different types of complications on overall survival (OS) and conditional survival if still alive one year postoperatively (CS-1) after colorectal cancer surgery.Materials and methodsAll patients registered in the Dutch ColoRectal Audit after resection of primary colorectal cancer between 2011 and 2017 and with known survival status were included. Multivariable Cox regression models were used to assess the association of complications with OS and CS-1, thereby calculating the Hazard Ratio (HR) with 95% Confidence Interval.Results43,908 colon and 16,955 rectal cancer patients were included. Median follow-up time was 66.1 and 66.5 months, respectively. Five-year OS after colon cancer resection was 73.2% without complications, and 65.4% with surgical, 52.9% with non-surgical and 51.8% with combined type of complications (p < 0.001). Corresponding 5-year OS for rectal cancer patients was 76.9%, 72.7%, 64.9%, and 63.2% (p < 0.001). In colon cancer, multivariable analyses revealed HR 1.198 (1.136–1.264) for surgical, HR 1.489 (1.423–1.558) for non-surgical and HR 1.590 (1.505–1.681) for combined type of complications. For rectal cancer, these HRs were 1.193 (1.097–1.2297), 1.456 (1.346–1.329), and 1.489 (1.357–1.633). Surgical complications were associated with worse CS-1 in rectal cancer (HR 1.140 (1.050–1.260), but not in colon cancer (HR 1.007 (0.943–1.075)).ConclusionNon-surgical complications have higher impact on survival than surgical complications. The impact of surgical complications on survival was still measurable after surviving the first year in rectal cancer but not in colon cancer patients.     

Postoperative mortality in elderly patients with colorectal cancer: The impact of age,time-trends and competing risks of dying

BackgroundWorse prognosis in elderly colorectal cancer (CRC) patients may be cancer or treatment related, or death from other causes. This population-based study aimed to compare survival among non-metastatic CRC patients between age groups and notice time trends in mortality rates.MethodsPrimary stage I-III CRC patients who underwent resection between 2008 and 2013 were selected from the Netherlands Cancer Registry. Patients were divided into three equally distributed age groups and a separated group including the oldest old (<65, 65–74, 75–84 and ≥ 85 years). Survival rates were calculated by age groups and tumour localization. Relative excess risks of death, 30-day, 1-year mortality and 1-year excess mortality were calculated.Results52296 patients were included. Age-related differences in 5-year overall survival were observed (colon cancer: 82%, 73%, 56% and 35%; rectal cancer: 82%, 74%, 56% and 38%; p < 0.0001). Age-related differences were less prominent in relative survival and disappeared in conditional relative survival (condition of surviving 1 year). Thirty-day mortality rates decreased over time (colon cancer: 4.9%–3.4%; rectal cancer: 3.0%–1.7%); 1-year mortality rates decreased from 11.9% to 9.6% in colon cancer and from 8.0% to 6.4% in rectal cancer. One-year excess mortality increased with age (17.3% and 12.9% in patients with colon or rectal cancer aged ≥85 years).ConclusionOne-year mortality rates remain high in elderly patients. Age-related differences in survival disappeared after adjustment for expected death from other causes and first-year mortality. Beneficial time trends in 1-year mortality rates underline that survival in elderly after CRC surgery is modifiable.     

Colorectal cancer in the Department of C?te-d'Or

The present study is based on the data of the digestive tract cancer registry set up for the French department of Cote d'Or (population 455,727). During 1976-1980, 581 colon cancers and 489 rectal cancers were diagnosed. They represent 47 per cent of all recorded gastro intestinal cancers. The annual adjusted incidence rates for colon cancers, adjusted to the world population were 17.5 for males, 13.3 for females. The corresponding rates for rectal cancers were 18.2 for males, 9.7 for females. These rates rank among the high rates found in North America and Western Europe. They are particularly high for rectal cancers. There was an urban predominance for colon cancer in males. Among colorectal cancers, 75 per cent were located in the rectum or sigmoid. Sixty-one per cent of the cases of large bowel cancer underwent curative surgery. The overall 5-year survival rate was 30.0 per cent for colon cancer, 27.4 per cent for rectal cancer. After curative surgery the 5 year survival rates were respectively 53.7 per cent and 47.8 per cent. The most important determinant of survival was the pathological stage of the tumour. These results underline the fact that by its frequency and its severity, colorectal cancer represents a major cancer problem.     

No difference between lowest and highest volume hospitals in outcome after colorectal cancer surgery in the southern Netherlands

Aim

To investigate the quality of surgical colorectal cancer (CRC) care in the southern Netherlands by evaluating differences between the five hospitals with the lowest volume and the five hospitals with the highest volume.

Methods

Patients who underwent resection for primary CRC diagnosed between 2008 and 2011 in southern Netherlands were included (n = 5655). The five hospitals performing <130 resections/year were classified ‘low volume’; the five hospitals performing ≥130 resections/year ‘high volume’. Differences in surgical approach, circumferential resection margins (CRM), anastomotic leakage and 30-day mortality between hospital volumes were analysed using Chi² tests. Expected proportions anastomotic leakage and 30-day mortality were calculated using multivariable logistic regression. Crude 3-year survival was calculated using Kaplan–Meier curves. Cox regression was used to discriminate independent risk factors for death.

Results

23% of patients with locally advanced rectal cancer (LARC) diagnosed in a low volume centre was referred to a high volume centre. Patients with colon cancer underwent less laparoscopic surgery and less urgent surgery in low compared to high volume hospitals (10% versus 32%, p < 0.0001, and 8% versus 11%, p = 0.003, respectively). For rectal cancer, rates of abdominoperineal resections versus low anterior resections, and CRM were not associated with hospital volume. Anastomotic leakage, 30-day mortality, and survival did not differ between hospital volumes.

Conclusion

In southern Netherlands, low volume hospitals deliver similar high quality surgical CRC care as high volume hospitals in terms of CRM, anastomotic leakage and survival, also after adjustment for casemix. However, this excludes LARC since a substantial proportion was referred to high volume hospitals.     

Predictors of undergoing multivisceral resection,margin status and survival in Dutch patients with locally advanced colorectal cancer

BackgroundThe aim of this nationwide observational study was to evaluate factors associated with multivisceral resection (MVR), margin status and overall survival in locally advanced colorectal cancer (CRC).Material and methodsPatients with (y)pT4, cM0 CRC between 2006 and 2017 were selected from the Netherlands Cancer Registry. Cox-proportional hazards modelling was used for survival analysis, stratified for T4a and T4b. Annual hospital volume cut-off was 75 for colon and 40 for rectal resections.ResultsA total of 11.930 patients were included and 2410 patients (20.2%) underwent MVR. Factors associated with MVR for colon and rectal cancer besides cT4 category were more recent diagnosis (OR 3.61, CI 95% 3.06–4.25 (colon) and OR 2.72, CI 95% 1.82–4.08 (rectum)) and high hospital volume (OR 1.20, CI 95% 1.05–1.38 (colon) and OR 2.17, CI 95% 1.55–3.04 (rectum)). Patients ≥70 year were less likely to undergo MVR for colon cancer (OR 0.80, 95% CI 0.70–0.90). Risk factors for incomplete resection were cT4 (OR 3.08, CI 95% 2.35–4.04 (colon) and OR 1.82, CI 95% 1.13–2.94 (rectum)) and poor/undifferentiated tumors (OR 1.41, CI 95% 1.14–1.72 (colon) and OR 1.69, CI 95% 1.05–2.74 (rectum)). More recent diagnosis was independently associated with less incomplete resections in colon cancer (OR 0.58, CI 95% 0.40–0.76). Independent predictors of survival were age, resection margin, nodal status and adjuvant chemotherapy, but not MVR.ConclusionTreatment of locally advanced CRC with MVR at population level was influenced by year of diagnosis and hospital volume. Margin status in colon cancer improved substantially over time.     

Preoperative hemoglobin count and prognosis of esophageal cancer,a population-based nationwide study in Finland

BackgroundThe prognostic value of preoperative hemoglobin in patients undergoing esophagectomy is unknown. The aim of this study was to examine whether preoperative hemoglobin is associated with prognosis in patients undergoing esophagectomy for cancer.Materials and methodsThis was a population-based nationwide retrospective cohort study in Finland, using Finnish National Esophago-Gastric Cancer Cohort (FINEGO). Esophagectomy patients with available preoperative hemoglobin measurement were included. Multivariable cox regression provided hazard ratios (HR) with 95% confidence intervals (CI), adjusted for calendar period of surgery, age at surgery, sex, comorbidity (Charlson Comorbidity Index), tumor histology, tumor stage, neoadjuvant therapy, type of surgery (minimally invasive or open) and annual hospital volume.ResultsOf the 1313 patients, 932 (71.0%) were men and 799 (60.9%) had esophageal adenocarcinoma. Overall all-cause mortality was significantly higher in the lowest hemoglobin count tertile (HR 1.26 (1.07–1.47)) compared to the highest tertile, but this association was attenuated after adjustment for confounding. No differences were found between the preoperative hemoglobin groups in the adjusted analyses of 90-day all-cause, 5-year all-cause, and 5-year cancer-specific mortality.ConclusionIn this population-based nationwide study, preoperative hemoglobin count had no independent prognostic significance in esophageal cancer.     

Volume and outcome in colorectal cancer surgery

AimsThere is a growing consensus to concentrate high-risk surgical procedures to high volume surgeons in high volume hospitals. However, there is fierce debate about centralizing more common malignancies such as colorectal cancer. The objective of this review is to conduct a meta-analysis using the best evidence available on the volume-outcome relationship for colorectal cancer treatment.MethodsA systematic search was performed to identify all relevant articles studying the relation between hospital and/or surgeon volume and clinical outcomes for colorectal cancer. Using strict inclusion criteria, 23 articles were selected concerning colon cancer, rectal cancer or both diseases together as ‘colorectal cancer’. Pooled estimated effect sizes were calculated using the casemix adjusted outcomes of the highest volume group opposed to the lowest volume group.ResultsHigh volume hospitals have a significantly lower postoperative mortality in half of the pooled results. Non significant results show a trend in favour of high volume hospitals. All results showed a significantly better long term survival in high volume hospitals. High volume surgeons have a lower postoperative mortality, although evidence is sparse. All analyses showed a significantly better long term survival in favour of high volume surgeons.ConclusionsThe results show a clear and consistent relation between high volume providers and improved long term survival. This applies to both high volume hospitals and high volume surgeons. Most results show a relation between high volume providers and a reduced postoperative mortality, but evidence is less convincing.In the ideal world, extensive population based audit registrations with casemix adjusted feedback should make rigid minimal volume standards obsolete. Until then, using volume criteria for hospitals and surgeons treating colorectal cancer can improve mortality and especially long term survival.     

Anastomotic leakage as a risk factor for the long-term outcome after curative resection of colon cancer

Aims

Long-term outcome for curative colon cancer surgery may be impaired by anastomotic leakage, but most studies regard colon and rectal cancer patients as one group. The aim of this study was to determine whether anastomotic leakage following potentially curative resection for colon cancer is a risk factor for postoperative mortality and for long-term survival.

Patients and methods

Medical records of a cohort of 440 consecutive patients undergoing 445 curative resections for explicit colon cancer with primary anastomosis above the peritoneal reflection were reviewed. Therefore patients with rectal cancer were not included. Diagnosis of leakage was made by clinical features or abdominal CT-scans.

Results

The study population consisted of 266 men and the mean age was 68.6 years. Median follow-up time was 66.5 months. Anastomotic leakage occurred in 12 patients. Four of these died within 30 days after surgery compared to 15 of the remaining 428 patients without leakage (p < 0.001). The 5-year overall survival rate was 25% in patients with anastomotic leakage compared to 61.2% in those without leakage (p < 0.001). Excluding 30-day mortality, respective values were 33.3 and 63.7% (p = 0.02).

Conclusion

Although anastomotic failure after colon cancer surgery is rare, it is a very severe complication that not only impairs the perioperative morbidity and mortality but also significantly influences the long-term outcome negatively.     

Curative rectal cancer surgery in a low-volume hospital: A quality assessment

Aims

Hospital volume or caseload is often used as a surrogate measure for quality of care in rectal cancer treatment. The aim of this study was to assess outcome in a low-volume hospital and secondly to examine the impact of surgeon volume on the results.

Methods

A retrospective review of 131 patients' charts identified 102 patients receiving apparently curative resections for rectal cancer in the period 1993–2002. Our study population did not differ significantly from the national average except for shift towards more advanced Dukes stage (p = 0.00) and a higher rate of node positive patients at time of diagnosis (p = 0.00).

Results

There were no significant differences from the national outcome results, neither in perioperative mortality or complications, nor 5-year survival or local recurrences. Thirteen different on-staff surgeons performed rectal cancer surgery in our hospital in the decade, and median annual caseload was four. We detect a difference in 5-year survival when grouping the surgeons by annual caseload, but the significance is inconclusive. It is, however, interesting that in 85% of the resections, two or more certified gastrointestinal surgeons with specific training were involved. A relatively high number (9%) of discrepancies between the Norwegian Rectal Cancer Registry (NRCR) database and the local hospital database were identified.

Conclusion

Adequate results for surgical outcome can be achieved in a low-volume hospital. Surgeon volume showed inconclusive impact for our results of outcome. A local quality initiative is justified in addition to national registries.     

Survival benefit of combined curative resection of the stomach (D2 resection) and liver in gastric cancer patients with liver metastases

BackgroundThe benefit of surgical resection of liver metastases from gastric cancer has not been well established. The aim of this study was to evaluate the rationale for hepatic resection in patients with hepatic metastases from gastric cancer.MethodsAmong 10 259 patients diagnosed with gastric adenocarcinoma in the Yonsei University Health System from 1995 to 2005, we reviewed the records of 58 patients with liver-only metastases from gastric cancer who underwent gastric resection regardless of hepatic surgery.ResultsThe overall 1-year, 3-year, and 5-year survival rates of 41 patients who underwent hepatic resection with curative intent were 75.3%, 31.7%, and 20.8%, respectively, and three patients survived >7 years. Of the 41 patients, 22 had complete resection and 19 had palliative resection. Between the curative and palliative resections, survival rates after curative intent were not different. The number of liver metastasis (solitary or multiple) was a marginally significant prognostic factor for survival.ConclusionsSurgery for liver metastases arising from gastric adenocarcinoma is reasonable if complete resection seems feasible after careful preoperative staging, even if complete resection is not actually achieved. Hepatic resection should be considered as an option for gastric cancer patients with hepatic metastases.     

Mortality and complication management after surgery for colorectal cancer depending on the DKG minimum amounts for hospital volume

BackgroundThe German Cancer Society (“Deutsche Krebsgesellschaft”; DKG) certifies on a volunteer base colorectal cancer centers based on, among other things, minimum operative amounts (at least 30 oncological colon cancer resections and 20 oncological rectal cancer resections per year). In this work, nationwide hospital mortality and death after documented complications (‘Failure to Rescue’ = FtR) were evaluated depending on the fulfillment of the minimum amounts.MethodsThis is a retrospective analysis of the nationwide hospital billing data (DRG data, 2012–2017). Categorization is based on the DKG minimum quantities (fully, partially or not fulfilled).ResultsOf 287,227 patients analyzed, 56.5% were operated in centers that met the DKG minimum amounts. The overall hospital mortality rate was 5.0%. In centers which met the minimum quantities, it was significantly lower (4.3%) than in hospitals which partially (5.7%) or not (6.2%) met the minimum quantities. The risk-adjusted hospital mortality rate for patients in hospitals who meet the minimum amount was 20% lower (OR 0.80; 95% CI [0.74–0.87], p < 0.001). For complications, both surgical and non-surgical, there was an unadjusted and adjusted lower FtR in hospitals that met the minimum amounts (e.g. anastomotic leak: 11.2% vs. 15.6%, p < 0.001; pulmonary artery embolism 21.3% vs. 28.2%, p = 0.001).ConclusionThere is a 1/3 lower mortality and FtR rate after surgery for a colon or rectal cancer in centers fulfilling the DKG minimum amounts. The presented data implicate that there is an urgent need for a nationwide centralization program.     

Laparoscopic versus open resection for rectal cancer: An individual patient data meta analysis of randomized controlled trials

Background and aimsThe role of laparoscopic rectal cancer resection remains controversial. Thus, we aimed to conduct a one-stage meta-analysis with reconstructed patient-level data using randomized trial data to compare long-term oncologic efficacy of laparoscopic and open surgical resection for rectal cancer.MethodsMedline, EMBASE and Scopus were searched for articles comparing laparoscopic with open surgery for rectal cancer. Primary outcome was disease free survival (DFS) while secondary outcome was overall survival (OS). One-stage meta-analysis was conducted using patient-level survival data reconstructed from Kaplan-Meier curves with Web Plot Digitizer. Shared-frailty and stratified Cox models were fitted to compare survival endpoints.ResultsSeven randomized trials involving 1767 laparoscopic and 1293 open resections for rectal cancer were included. There were no significant differences between both groups for DFS and OS with respective hazard ratio estimates of 0.91 (95% CI: 0.78–1.06, p = 0.241) and 0.86 (95% CI:0.73–1.02, p = 0.090). Sensitivity analysis for non-metastatic patients and patients with mid and lower rectal cancer showed no significant differences in OS and DFS between both surgical approaches. In the laparoscopic arm, improved DFS was noted for stage II (HR: 0.73, 95% CI:0.54–0.98, p = 0.036) and stage III rectal cancers (HR: 0.74, 95% CI:0.55–0.99, p = 0.041).ConclusionsThis meta-analysis concludes that laparoscopic rectal cancer resection does not compromise long-term oncologic outcomes compared with open surgery with potential survival benefits for a minimal access approach in patients with stage II and III rectal cancer.     

Long-term results of radical surgery for rectal cancer: multivariate analysis of prognostic factors influencing survival and local recurrence.

AIMS: To evaluate consistent radical surgery performed over a 13-year period for rectal cancer in terms of local tumour control and long-term survival. METHODS: Radical surgical procedure principally using total mesorectal excision (TME) for middle and lower rectal tumours, high ligation of the inferior mesenteric artery and sphincter-saving resections (SSR) whenever possible, has been performed prospectively since January 1984. RESULTS: Tumour resection was possible in 98.8% (636/644), potentially curative resections (UICC/AJCC R0 resection) in 85.7% (552/644) and sphincter preservation in 71.7% (462/644). Five- and 10-year observed survival rates, surgical mortality not excluded, for all patients were 49.2% and 37.4%. Tumour-adjusted 5- and 10-year survival rates were 60.5% and 55.3%. For curatively operated patients (UICC/AJCC R0) 5- and 10-year observed survival rates were 56.3% and 42.6% and tumour-adjusted survival rates were 68.6% and 62.7%. The 5- and 10-year local recurrence rates for R0 resected patients were 12.0% and 12.6%. Post-operative hospital mortality was 3.1%. CONCLUSIONS: Multivariate analysis using Cox's model identified increasing pT category and pN category, old age and low tumour location as detrimental factors having independent influence on survival. For local tumour failure only pT and pN category as well as adjuvant radiation therapy were identified in the Cox model as having an independent detrimental influence.     

Conditional survival for long-term colorectal cancer survivors in the Netherlands: who do best?

AimWith the increase in the number of long-term colorectal cancer (CRC) survivors, there is a growing need for subgroup-specific analysis of conditional survival.MethodsAll 137,030 stage I–III CRC patients diagnosed in the Netherlands between 1989 and 2008 aged 15–89 years were selected from the Netherlands Cancer Registry. We determined conditional 5-year relative survival rates, according to age, subsite and tumour stage for each additional year survived up to 15 years after diagnosis as well as trends in absolute risks for and distribution of causes of death during follow-up.ResultsMinimal excess mortality (conditional 5-year relative survival >95%) was observed 1 year after diagnosis for stage I colon cancer patients, while for rectal cancer patients this was seen after 6 years. For stage II and III CRC, minimal excess mortality was seen 7 years after diagnosis for colon cancer, while for rectal cancer this was 12 years. The differences in conditional 5-year relative survival between colon and rectal cancer diminished over time for all patients, except for stage III patients aged 60–89 years. The absolute risk to die from CRC diminished sharply over time and was below 5% after 5 years. The proportion of patients dying from CRC decreased over time after diagnosis while the proportions of patients dying from other cancers, cardiovascular disease and other causes increased.ConclusionPrognosis for CRC survivors improved with each additional year survived, with the largest improvements in the first years after diagnosis. Quantitative insight into conditional relative survival estimates is useful for caregivers to inform and counsel patients with stage I–III colon and rectal cancer during follow-up.     

Hepatic metastases from colorectal cancer

Over the last 30 years, the benefits of surgical resection and systemic chemotherapy in the management of hepatic metastases from colorectal cancer have been established. Actually, surgical resections are feasible with a very low mortality and a 5-year survival that approaches 50 %, but only 10 % to 20 % of patients are candidate to surgery. The others gain benefit from chemotherapy with more and more active drugs. To improve this overall picture, efforts have been made to increase the number of patients that could be candidates for surgery and to decrease the risk of recurrence after surgical resection. Shrinkage of tumours after administration of preoperative chemotherapy and availability of ablative techniques (radiofrequency and cryotherapy) now permit to treat with curative intent metastases initially considered as non resectable. Chemotherapeutic regimens to decrease the risk of postoperative recurrence are actually tested in clinical trials.     

结直肠癌5-FU和亚叶酸辅助化疗的评价

目的：评估5－FU和亚叶酸辅助化疗能否提高结直肠癌根治术的疗效。方法：自1988年以来共有225例结直肠癌根治术后应用5－FU利亚叶酸辅助化疗，术后每月一次，连续5天给予亚叶酸150mg和5－FU1．0g／日，6～9个疗程。其中随访满5年可作评估者66例，包括结肠癌38例和直肠癌28例。结果：66例的5年生存率为66．67％，结肠癌为73．68％．直肠癌为57．14％。Dukes—中国改良分期A期的5年生存率结肠癌为100％，直肠癌为80％；B期结肠癌为90．91％．直肠癌为50％；C期结肠癌为60．87％，直肠癌为42．85％，但统计学上结肠癌与直肠癌的差异不显著（P＞0．05）。术后复发率B期结肠癌为18．18％．直肠癌为50％（P＞0．05）；C期结肠癌34．78％．直肠癌71．43％（P＝0．032）。复发病例B期和C期各有1例生存5年以上。结论。提示5－FU和亚叶酸辅助化疗对降低Dukes’C期结肠癌术后复发有肯定疗效。至于对Dukes’B期术后复发车以及对5年生存率的作用，由于病例数偏少，尚不能得出有统计学意义的结论，有待进一步积累病例。     

Variation in treatment and outcome of patients with rectal cancer by region,hospital type and volume in the Netherlands

BackgroundAim of this study was to describe treatment patterns and outcome according to region and hospital type and volume among patients with rectal cancer in the Netherlands.MethodsAll patients with rectal carcinoma diagnosed in the period 2001–2006 were selected from the Netherlands Cancer Registry. Logistic regression analyses were performed to examine the influence of relevant factors on the odds of receiving preoperative radiotherapy and on the odds of postoperative mortality. Relative survival analysis was used to estimate relative excess risk of dying according to hospital type and volume.ResultsIn total, 16 039 patients were selected. Patients diagnosed in a teaching or university hospital had a lower odds (OR 0.85; 95% CI 0.73–0.99 and OR 0.70; 95% CI 0.52–0.92) and patients diagnosed in a hospital performing >50 resections per year had a higher odds (OR 1.95; 95% CI 1.09–1.76) of receiving preoperative radiotherapy. A large variation between individual hospitals in rates of preoperative radiotherapy and between Comprehensive Cancer Centre-regions in the administration of preoperative chemoradiation was revealed. Postoperative mortality was not correlated to hospital type or volume. Patients with T1-M0 tumours diagnosed in a hospital with >50 resections per year had a better survival compared to patients diagnosed in a hospital with <25 resections per year (RER 0.11; 95% CI 0.02–0.78).ConclusionThis study demonstrated variation in treatment and outcome of patients with rectal cancer in the Netherlands, with differences related to hospital volume and hospitals teaching or academic status. However, variation in treatment patterns between individual hospitals proved to be much larger than could be explained by the investigated characteristics. Future studies should focus on the reasons behind these differences, which could lead to a higher proportion of patients receiving optimal treatment for their stage of the disease.