Astri Syse

Oncological outcomes after total mesorectal excision for cure for cancer of the lower rectum: Anterior vs. abdominoperineal resection

PURPOSE: This study was designed to examine the outcome of cancer of the lower rectum, particularly the rates of local recurrence and survival for tumors located in this area that have been treated by anterior or abdominoperineal resections. METHODS: A prospective, observational, national, cohort study which is part of the Norwegian Rectal Cancer Project. The present cohort includes all patients undergoing total mesorectal excision in 47 hospitals during the period November 1993 to December 1999. A total of 2,136 patients with rectal cancer within 12 cm of the anal verge were analyzed; there were 1,315 (62 percent) anterior resections and 821 (38 percent) abdominoperineal resections. The lower edge of the tumor was located 0 to 5 cm from the anal verge in 791 patients, 6 to 8 cm in 558 patients, and 9 to 12 cm in 787 patients. According to the TNM classification, there were 33 percent Stage I, 35 percent Stage II, and 32 percent Stage III. RESULTS: Univariate analyses: The five-year local recurrence rate was 15 percent in the lower level, 13 percent in the intermediate level, and 9 percent in the upper level (P = 0.014). It was 10 percent local recurrence after anterior resection and 15 percent after abdominoperineal resection (P = 0.008). The five-year survival rate was 59 percent in the lower level, 62 percent in the intermediate level, and 69 percent in the upper level (P < 0.001), respectively, and it was 68 percent in the anterior-resection group and 55 percent in the abdominoperineal-resection group (P < 0.001). Multivariate analyses: The level of the tumor influenced the risk of local recurrence (hazard ratio, 1.8; 95 percent confidence interval, 1.1–2.3), but the operative procedure, anterior resection vs. abdominoperineal resection, did not (hazard ratio, 1.2; 95 percent confidence interval, 0.7–1.8). On the contrary, operative procedure influenced survival (hazard ratio, 1.3; 95 percent confidence interval, 1–1.6), but tumor level did not (hazard ratio, 1.1; 95 percent confidence interval, 0.9–1.5). In addition to patient and tumor characteristics (T4 tumors), intraoperative bowel perforation and tumor involvement of the circumferential margin were identified as significant prognostic factors, which were more common in the lower rectum, explaining the inferior prognosis for tumors in this region. CONCLUSIONS: T4 tumors, R1 resections, and/or intraoperative perforation of the tumor or bowel wall are main features of low rectal cancers, causing inferior oncologic outcomes for tumors in this area. If surgery is optimized, preventing intraoperative perforation and involvement of the circumferential resection margin, the prognosis for cancers of the lower rectum seems not to be inherently different from that for tumors at higher levels. In that case, the level of the tumor or the type of resection will not be indicators for selecting patients for radiotherapy.

Inadvertent perforation during rectal cancer resection in Norway

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.

Effect of hospital caseload on long-term outcome after standardization of rectal cancer surgery at a national level

The purpose of this prospective study was to examine the influence of hospital caseload on long‐term outcome following standardization of rectal cancer surgery at a national level.

Total mesorectal excision for rectal cancer – what can be achieved by a national audit?

Objective  The results of rectal cancer surgery in Norway have been poor. In a national audit for the period 1986–88, 28% of the patients developed local recurrence (LR) following treatment with a curative intent. Five‐year overall survival was 55% for patients younger than 75 years. The aim of this study is to report how an initiative focusing on better surgery can improve the prognosis for rectal cancer patients on a national level.

Changes over time in the effect of marital status on cancer survival

BackgroundRates of all-cause and cause-specific mortality are higher among unmarried than married individuals. Cancer survival is also poorer in the unmarried population. Recently, some studies have found that the excess all-cause mortality of the unmarried has increased over time, and the same pattern has been shown for some specific causes of death. The objective of this study was to investigate whether there has been a similar change over time in marital status differences in cancer survival.MethodsDiscrete-time hazard regression models for cancer deaths among more than 440 000 women and men diagnosed with cancer 1970-2007 at age 30-89 were estimated, using register data encompassing the entire Norwegian population. More than 200 000 cancer deaths during over 2 million person-years of exposure were analyzed.ResultsThe excess mortality of the never-married compared to the married has increased steadily for men, in particular the elderly. Among elderly women, the excess mortality of the never-married compared to the married has increased, and there are indications of an increasing excess mortality of the widowed. The excess mortality of divorced men and women, however, has been stable.ConclusionsThere is no obvious explanation for the increasing disadvantage among the never-married. It could be due to a relatively poorer general health at time of diagnosis, either because of a more protective effect of partnership in a society that may have become less cohesive or because of more positive selection into marriage. Alternatively, it could be related to increasing differentials with respect to treatment. Todays complex cancer therapy regimens may be more difficult for never-married to follow, and health care interventions directed and adapted more specifically to the broad subgroup of never-married patients might be warranted.

Does cancer affect marriage rates

IntroductionFinding a life partner is of great importance for persons’ life satisfaction, but cancer’s potential impact on family life is not well described. Cancer’s impact on marriage formation rates was therefore explored.MethodData on the entire unmarried Norwegian population aged 17–44 in 1974–2001 (N = 2.2 million) come from the Cancer Registry and the Central Population Register. Marriage rates for 12,100 persons diagnosed with cancer were compared to marriage rates for otherwise similar persons using discrete-time hazard regression models.ResultsMen with cancer had a marriage probability that was five percent higher (OR 1.05, CI 1.01–1.11) than cancer-free men. No cancer forms reduced men’s marriage rates, and significantly elevated rates were seen after skin and testicular cancer (OR 1.16 and 1.11). Cancer did not impact significantly on women’s overall marriage rate (OR 0.95, CI 0.90–1.00), but pronounced deficiencies were seen after brain and breast cancer (OR 0.62 and 0.74). Skin cancer elevated women’s marriage rate (OR 1.27). Male cancer survivors with children were more likely to marry than their female counterparts. Significant increases in cancer survivors’ marriage rates were observed over time.ConclusionMarrying after cancer is more common today than previously, and only slight overall differences were observed in cancer survivors’ marriage rates relative to those of the cancer-free population. However, while brain and breast cancer in women is associated with reduced marriage rates, testicular cancer is associated with increased rates. The differences observed between common cancer forms in young adults deserve further exploration.Implications for cancer survivorsIn general, marriage rates in survivors of most types of cancer are very similar to those in the population as a whole. Women with brain and breast cancer have lower marriage rates than their cancer-free counterparts. While it is necessary to identify exactly why this was observed, the information can alert those with these cancers to the potential impact on marriage and thus work to reduce the possible effect, if desired.

Children and young adults with parents with cancer: a population-based study

Video abstract Video

Is mortality after childhood cancer dependent on social or economic resources of parents? A population-based study

Diagnostic and treatment protocols for childhood cancer are generally standardized, and therefore, survival ought to be fairly equal across social strata in societies with free public health care readily available. Nevertheless, our study explores whether there are disparities in mortality after childhood cancer in Norway depending on socioeconomic status of parents. Limited knowledge on differentials exists from earlier analyses. Discrete‐time hazard regression models for all‐cause mortality for the first 10 years after diagnosis were estimated for all Norwegian children (younger than 20 years), who were diagnosed with cancer during 1974–2007 (N = 6,280), using data from five national registers. Mortality was reduced by about 15% for children with highly educated mothers and children without siblings. These effects were most pronounced for cancers predicted to encompass intense, long‐lasting treatments resulting in chronic health problems. Neither earnings nor the marital status of parents affected childrens survival. This large, registry‐based study suggests that time constraints and various noneconomic rewards of parents from their education appears to have an impact on childhood cancer survival. It may be that children with resourceful parents are healthier at the outset and/or are more likely to avoid later health problems. It may also be that children of well‐informed and strongly involved parents are offered better treatment or are able to make better use of what is offered, for instance, by adhering more closely to recommendations for follow‐up treatment. The possibility of such differentials in offered and actual treatment should be addressed in future research.

New malignancies after squamous cell carcinoma and melanomas: a population-based study from Norway

BackgroundSkin cancer survivors experience an increased risk for subsequent malignancies but the associated risk factors are poorly understood. This study examined the risk of a new primary cancer following an initial skin cancer and assessed risk factors associated with second primary cancers.MethodsAll invasive cutaneous malignant melanomas (CMM, N = 28 069) and squamous cell carcinomas (SCC, N = 24 620) diagnosed in Norway during 1955–2008 were included. Rates of new primary cancers in skin cancer survivors were compared to rates of primary malignancies in the general population using standardized incidence ratios (SIR). Discrete-time logistic regression models were applied to individual-level data to estimate cancer risk among those with and without a prior skin cancer, accounting for residential region, education, income, parenthood, marital status and parental cancer status, using a 20% random sample of the entire Norwegian population as reference. Further analyses of the skin cancer cohort were undertaken to determine risk factors related to subsequent cancers.ResultsDuring follow-up, 9608 new primary cancers occurred after an initial skin cancer. SIR analyses showed 50% and 90% increased risks for any cancer after CMM and SCC, respectively (p < 0.01). The logistic regression model suggested even stronger increase after SCC (130%). The highest risk was seen for subsequent skin cancers, but several non-skin cancers were also diagnosed in excess: oral, lung, colon, breast, prostate, thyroid, leukemia, lymphoma and central nervous system. Factors that were associated with increased risk of subsequent cancers include male sex, older age, lower residential latitude, being married and low education and income. Parental cancer did not increase the risk of a subsequent cancer after SCC, but was a significant predictor among younger CMM survivors.ConclusionsOur results provide information on shared environmental and genetic risk factors for first and later cancers and may help to identify individuals at high risk for subsequent cancers, which will be important as skin cancer incidence continues to rise.

Reproduction and marriage among male survivors of cancer in childhood, adolescence and young adulthood: a national cohort study

Background:Increased survival after cancer in young age has made long-term follow-up studies of high external validity important. In this national cohort study, we explored the impact of cancer in young age on reproduction and marital status in male survivors.Methods:Hazard ratios (HRs) and relative risks (RRs) of reproductive and marital outcomes were studied for male survivors of cancer in young age (<25 years) and cancer-free male comparisons, born during 1965–1985, by linking compulsory national registries in Norway.Results:Male cancer survivors (n=2687) had reduced paternity (HR: 0.72, 95% confidence interval (CI): 0.68–0.76). This was most apparent in survivors of testicular cancer, brain tumours, lymphoma, leukemia and bone tumours, and when diagnosed with cancer before 15 years of age. Male cancer survivors were more likely to avail of assisted reproduction (RR: 3.32, 95% CI: 2.68–4.11). There was no increased risk of perinatal death, congenital malformations, being small for gestational age, of low birth weight or preterm birth in their first offspring. Male cancer survivors were less likely to marry (HR: 0.93, 95% CI: 0.86–1.00), in particular brain tumour survivors.Conclusions:In this national cohort study, we demonstrated reduced paternity and increased use of assisted reproduction among male cancer survivors, but no adverse outcome for their first offspring at birth.