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Recent trends in colorectal cancer in Norway:

incidence, management and outcomes

Arne Wibe, MD, PhD

Professor of Surgery

St. Olavs Hospital

Trondheim, Norway

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Contents

• Collection of data• Incidence• Outcomes• Conclusions

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Population trends

• 4.8 million, 12% increase in 25 yrs.• 11% immigrants from > 200 countries

• Estimated population 2030; • 5.8 million • 20% > 65 yrs.

Cancer in Norway 2008

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Cancer Registry of Norway

Cancer in Norway 2008

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Collection of data

• National cancer registry since 1952

• Compulsory reporting of all cancers and some precancrous lesions - all hospitals / health institutions- all physicians

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Age adjusted incidence of colorectal cancer in the Nordic countries

Nordcan

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Colon cancer Rectal and anal cancer

Cancer in Norway 2008

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Colon cancer Rectal and anal cancer

Cancer in Norway 2008

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Interpretation

• Incidence of colon and rectal cancer have been increasing for decades, but the overall picture is one of stabilisation for colon cancer and possibly recent decline for rectal cancer

• Of particular note is the increasing survival and declining mortality for rectal cancer

• Among the likely determinants are the introduction of total mesorectal excision, increasing specialisation, and some use of preoperative chemoradiotherapy (20% 2004)

Cancer in Norway 2008

Hansen M, Thesis 2010

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Why has the relative survival for rectal cancer increased more

in men than in women?

1993 2008

Men 46% 62%

Women 57% 67%

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Is that because…

the more difficult the dissection,the more benefit of an optimisedsurgical technique?

for APR, more use of preop. radiotherapy?- 17% in men vs. 13% in women*, (mean age 71 vs. 73)

for women, the relative survival was higher in the beginning, thus their potential for an increase will be less?

* Hansen M, Thesis 2010

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The Norwegian Colorectal Cancer Registry

Database: 26 000 records

16 000 rectal cancer cases since 1993

10 000 colon cancer cases since 2007

Wibe, ECC 2010

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Rectal cancer – pts. treated for cure: reduced local recurrence, increased survival,

reduced complications

• 5-year local recurrence 1986-1988 28% 1994 18%1999 9%2000-2004 7%

• 5-year survival 1986-1988 55% 1993-1999 71%

• Anastomotic leaks1994 17%1999 8%

Ris

k o

f dea

th (l

og

scal

e)

Time of operation

0.8

1.0

1.2

1994 1995 1996 1997 1998 1999 2000

Wibe et al. Colorectal Disease 2006; 8: 224-229

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Variation in rate oflocal recurrence between hospitals

Hospital caseload

250200150100500

Rate

of

loca

l recu

rre

nce (

5 y

ears

)60

55

50

45

40

35

30

25

20

15

10

5

0

Wibe et al. Colorectal Disease 2006; 8: 224-229

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Due to variation of results treatment has been centralized

• 1994: 55 hospitalsRecommended by the association of surgeons:”rectal cancer surgery should only be performed

by specialists in gastrointestinal surgery”

• 2000: 40 hospitalsDedicated colorectal surgeons treating rectal cancer

• 2004: 25 hospitalsHealthcare bureaucracy introduced formal regulations:

”Only multidisciplinary teams of dedicated experts may treat rectal cancer”

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What happened to hospitals having inferior results for rectal cancer,though continuing treatment?

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Haugesund Central Hospital

5-yr local recurrence 5-yr overall survival

1993-98 31% 48%

1999-01 11% 70%

2002-04 6%

2005-2009 No local recurrence at Haugesund Central Hospital

Best paper Norwegian Association of Surgeons 2008, Moen A C et al. abstract no 116

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What did they do in Haugesund?

How did they manage to improve that quickly?

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2000 2001 2002 2003 2004 2005 2006 2007 2008

Cylindric amputation

Laparoscopic resection

CT + Rectal ultrasound

Oncologist

Neoadjuvant tr.tacc. to guidelines

Up-date radiologist

GI oncologist

Always GI surgeons

MRI

Multidiscpl. meetings

Pathologist

CT in follow-upNew retractors

Stent as bridge to surgery

Best paper Norwegian Association of Surgeons 2008, Moen A C et al. abstract no 116

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They managed to improve within a few years,…

because they focused on ”all the details”,

i.e. important factors for quality assurance;

- guidelines

- training

- competence

- technology

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Levanger hospital –394 patients 1980-2004

Patients treated with curative intent:

Local recurrence 5-yr survival

1980-89 4% 65%

1990-99 19% 58%

2000-04 2% 71%

p = 0.006

Jullumstrø, Wibe, Lydersen, Edna. Thesis NTNU 2010

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How could this happen?

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That happened because…

- they did not focus on quality assurance during the 90-ties

- they did not stick to their optimised guidelines, they violated their own treatment protocol

- neither they attended the national workshops, as everybody knew this staff could handle rectal cancer

- in 2000 they started to attend the workshops

Jullumstrø, Wibe, Lydersen, Edna. Thesis NTNU 2010

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Recent initiatives by the Ministry of Health

• 2010: National guidelines on work-up, treatment and follow-up of colorectal cancer

- developed by the Norwegian Gastrointestinal Cancer Group

- revised once a year

• 2011: National guidelines on organisation of work-up and treatment of cancer, from receiving information on cancer: - 10 days for starting work-up

- 20 days for starting treatment

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Conclusion

• The incidence of colon cancer is still increasing, while rectal cancer has culminated

• Although the use of adjuvant chemotherapy for stage III colon cancer, the outcome of rectal cancer has exceeded that of colon cancer

• Most of the reduction of local recurrence and the increased survival for rectal cancer happened when preoperative radiochemotherapy was uncommon in Norway

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Conclusion II

Standards of care are best explained by healthcare structures and processes of care

For complex medical treatment, the skills of the team of clinicians and the hospital organizational skill are equally important

Quality assurance at different health care levels can only be evaluated within audits, during which underperforming departments are likely to improve

Wibe et al. Br J Surg 2005;92:217-224

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Questions to be answered – from the organizer

1. Can we hope for similar results for colon as for rectal cancer?

2. Are there signs of such improvement?

3. What is the best approach on the road ahead?

1. But not that much, and not that fast, because the potential for improvement is less, but may be prof. Hohenberger has another view?

2. Yes, there is a steady and continuous tendency of increasing survival

3. The best approach is as always, focus on all the details, and MDT`s seem encouraging

Yes, we can!

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arne.wibe@ntnu.no