Annika Sjövall

Loco-regional Recurrence from Colon Cancer: A Population-based Study

BackgroundThe survival after colon cancer surgery has not improved to the same extent as after rectal cancer treatment and studies on loco-regional recurrence after colon cancer surgery are scarce. The aim of this study was to assess the problem of loco-regional recurrence after potentially curative resections for colon cancer, regarding incidence, risk factors, management, and outcome.MethodsAll 1,856 patients submitted to potentially curative surgery for colon cancer in the Stockholm/Gotland region in Sweden between 1996 and 2000 were followed until January 2005 or until death. Follow-up data were prospectively collected. Risk factors for loco-regional recurrences were analyzed, treatment and outcome for patients with recurrence was studied.ResultsThe cumulative 5-year incidence of loco-regional recurrence was 11.5%. Tumor locations in the right flexure and in the sigmoid colon, bowel perforation and emergent surgery were identified as independent risk factors for loco-regional recurrence. The risk also increased with increasing T- and N-stage.The median survival for all 192 patients with loco-regional recurrence was 9 months. Surgery was performed in 110 (57%) patients. In 23 (12%) patients a complete tumor clearance was achieved and the estimated 5-year survival in this group was 43%.ConclusionLoco-regional recurrence from colon cancer is a significant clinical problem. A multidisciplinary treatment approach, including preoperative staging, a complete resection of the recurrence and more effective adjuvant treatments may improve the outcome.

Population-based data from the Swedish Colon Cancer Registry

Evaluating the external validity of clinical trials requires knowledge not only of the study population but also of a relevant reference population. The main aim of this study was to present data from a large, contemporary, population‐based cohort of patients with colonic cancer.

Epidemiology and prognosis of ovarian metastases in colorectal cancer

National guidelines for prophylactic oophorectomy in women with colorectal cancer are lacking. The aim of this population‐based cohort study was to report on the prevalence, incidence and prognosis of ovarian metastases from colorectal cancer, providing information relevant to the discussion of prophylactic oophorectomy.

Improved survival after an educational project on colon cancer management in the county of Stockholm--a population based cohort study.

INTRODUCTIONnOutcomes in rectal cancer have improved dramatically after the introduction of total mesorectal excision (TME). Recently, the TME concept has been transformed into that of complete mesocolic excision (CME) in an attempt to improve prognosis for patients with colon cancer.nnnPATIENTS AND METHODSnMultidisciplinary team (MDT) workshops including the CME concept were held annually between 2004 and 2008 at the Karolinska University Hospital. The workshops focused on preoperative staging, surgery and histopathology and included lectures and live surgery sessions. To compare survival before and after the Stockholm Colon Cancer Project all patients diagnosed with a right sided colon cancer between January 1, 2001 and December 31, 2003 (Group 1) and from January 1, 2006 until December 31, 2008 (Group 2) in Stockholm were identified from the Swedish ColoRectal Cancer Registry (SCRCR).nnnRESULTSnThe proportion of patients having a tumour resection and the proportion having emergency surgery was higher in Group 1. There were more early tumours and more R0 resections in Group 2. Overall survival in all diagnosed patients and disease free survival after tumour resection was improved in the second time period.nnnDISCUSSIONnSurgical teaching programmes may have an impact on the management and outcome in colon cancer. The exact impact from the Stockholm Colon Cancer Project cannot be established, however it is likely that it contributed to the improved survival.

Minimally invasive colorectal cancer surgery in Europe

AbstractMinimally invasive surgery (MIS) of colorectal cancer (CRC) was first introduced over 20 years ago and recently has gained increasing acceptance and usage beyond clinical trials. However, data on dissemination of the method across countries and on long-term outcomes are still sparse.In the context of a European collaborative study, a total of 112,023 CRC cases from 3 population-based (Nu200a=u200a109,695) and 4 institute-based clinical cancer registries (Nu200a=u200a2328) were studied and compared on the utilization of MIS versus open surgery. Cox regression models were applied to study associations between surgery type and survival of patients from the population-based registries. The study considered adjustment for potential confounders.The percentage of CRC patients undergoing MIS differed substantially between centers and generally increased over time. MIS was significantly less often used in stage II to IV colon cancer compared with stage I in most centers. MIS tended to be less often used in older (70+) than in younger colon cancer patients. MIS tended to be more often used in women than in men with rectal cancer. MIS was associated with significantly reduced mortality among colon cancer patients in the Netherlands (hazard ratio [HR] 0.66, 95% confidence interval [CI] (0.63–0.69), Sweden (HR 0.68, 95% CI 0.60–0.76), and Norway (HR 0.73, 95% CI 0.67–0.79). Likewise, MIS was associated with reduced mortality of rectal cancer patients in the Netherlands (HR 0.74, 95% CI 0.68–0.80) and Sweden (HR 0.77, 95% CI 0.66–0.90).Utilization of MIS in CRC resection is increasing, but large variation between European countries and clinical centers prevails. Our results support association of MIS with substantially enhanced survival among colon cancer patients. Further studies controlling for selection bias and residual confounding are needed to establish role of MIS in survival of patients.

Administration of adjuvant chemotherapy for stage II-III colon cancer patients: An European population-based study

The advantage of adjuvant chemotherapy (ACT) for treating Stage III colon cancer patients is well established and widely accepted. However, many patients with Stage III colon cancer do not receive ACT. Moreover, there are controversies around the effectiveness of ACT for Stage II patients. We investigated the administration of ACT and its association with overall survival in resected Stage II (overall and stratified by low‐/high‐risk) and Stage III colon cancer patients in three European countries including The Netherlands (2009–2014), Belgium (2009–2013) and Sweden (2009–2014). Hazard ratios (HR) for death were obtained by Cox regression models adjusted for potential confounders. A total of 60244 resected colon cancer patients with pathological Stages II and III were analyzed. A small proportion (range 9–24%) of Stage II and over half (range 55–68%) of Stage III patients received ACT. Administration of ACT in Stages II and III tumors decreased with higher age of patients. Administration of ACT was significantly associated with higher overall survival in high‐risk Stage II patients (in The Netherlands (HR; 95%CIu2009=u20090.82 (0.67–0.99), Belgium (0.73; 0.59–0.90) and Sweden (0.58; 0.44–0.75)), and in Stage III patients (in The Netherlands (0.47; 0.43–0.50), Belgium (0.46; 0.41–0.50) and Sweden (0.48; 0.43–0.54)). In Stage III, results were consistent across subgroups including elderly patients. Our results show an association of ACT with higher survival among Stage III and high‐risk Stage II colon cancer patients. Further investigations are needed on the selection criteria of Stages II and III colon cancer patients for ACT.

Complete Mesocolic Excision (CME) in right sided colon cancer does not increase severe short term postoperative adverse events

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.

Neoadjuvant Therapy in Rectal Cancer Patients With Clinical Stage II to III Across European Countries: Variations and Outcomes

Background: Neoadjuvant therapy improves survival of patients with clinical stage II and III rectal cancer in clinical trials. In this study, we investigated the administration of neoadjuvant radiotherapy (neo‐RT) and neoadjuvant chemoradiotherapy (neo‐CRT) and its association with survival in resected patients in 2 European countries (The Netherlands and Sweden) and at 3 specialist centers. Materials and Methods: Administration of neoadjuvant treatment (all registries) and overall survival after surgery in The Netherlands and Sweden were assessed. Hazard ratios (HRs) were obtained using Cox regression adjusted for potential confounders. Results: A total of 16,095 rectal cancer patients with clinical stage II and III were eligible for analyses. Large variations in administration of neo‐RT and neo‐CRT were observed. Elderly patients less often received neo‐RT and neo‐CRT. Patients with stage III disease received neo‐CRT more frequently than neo‐RT. Administration of neo‐RT versus surgery without neoadjuvant treatment was significantly associated with improved survival in The Netherlands (HR, 0.62; 95% confidence interval [CI], 0.53–0.73) as well as in Sweden (HR, 0.79; 95% CI, 0.69–0.90). Administration of neo‐CRT was associated with enhanced survival in The Netherlands (HR, 0.62; 95% CI, 0.50–0.78) but not in Sweden (HR, 0.97; 95% CI, 0.80–1.18). The mortality of patients treated with neo‐CRT compared with neo‐RT showed inconsistent results in population‐based centers. Conclusions: Our results support an association of neo‐RT with enhanced survival among stage II and III rectal cancer patients. Comparing neo‐CRT with neo‐RT, larger variations and inconsistent results with respect to survival were observed across centers. Micro‐Abstract: This study is the largest observational study on neoadjuvant therapy in patients with stage II & III rectal cancer by including high‐quality data from large population‐based and clinical cancer registries. We observed large variations in administration of neoadjuvant chemo(radio)therapy across European countries. Our results support major survival advantages of patients treated with neoadjuvant radiotherapy.

Waiting times for cancer patients in Sweden: A nationwide population-based study

Aims: The reported long waiting times for cancer patients have mostly been related to prognostic outcome and less to patient-related experience to outcome. We assessed waiting times for patients with cancer of the breast, prostate, colon or rectum in Sweden. Methods: The median time from referral to start of treatment was assessed using data from clinical cancer registers for patients who received curative treatment during 2011, 2012 and 2013. Results: The median overall waiting time in different counties ranged from 7 to 28 days for breast cancer, from 117 to 280 days for prostate cancer, from 27 to 64 days for colon cancer and from 48 to 80 days for rectal cancer. For the entire nation, the median time from referral to start of treatment remained unchanged from 2011 to 2013 for each cancer diagnosis. Conclusions: Large variations were found in waiting times between different counties in Sweden and between different types of cancer. The long waiting times identified in this study emphasize the need to improve national programmes for more rapid diagnosis and treatment.