Elsevier

Radiotherapy and Oncology

Volume 121, Issue 3, December 2016, Pages 357-363
Radiotherapy and Oncology

Rectal cancer treatment strategy
Two countries – Two treatment strategies for rectal cancer

https://doi.org/10.1016/j.radonc.2016.11.010Get rights and content

Abstract

Background and purpose

Trials in rectal cancer have shown that radiotherapy (RT) decreases local recurrence rates, whereas the effects on survival are uncertain. Swedish and Norwegian oncologists have had different treatment recommendations. The aim was to evaluate local recurrence rates and survival in the two countries.

Patients and methods

Between 1995 and 2012 rectal cancer patients registered in Sweden and Norway were analyzed, presenting population-based “real world” data.

Results

Totally 29,029 Swedish and 15,456 Norwegian patients were analyzed. Resection for cure was performed in two-thirds of the patients. RT was given to 49% of Swedish patients, mainly short-course RT and to 26% of Norwegian patients, predominantly chemoradiotherapy (CRT). In Sweden, the proportion irradiated was stable whereas in Norway, an increase from 10% to 40% was seen. Local 5-year recurrence rates were initially higher in Norway (12%) than in Sweden (8%), whereas they were equally low (4%) during the latter time. No survival differences were seen, however, survival improved with time in both countries.

Conclusions

Two entirely different approaches to preoperative therapy resulted in similar survival with initially higher local recurrence rates in Norway, but similarly low rates in later years. This raises questions about optimal RT rates and regimens.

Section snippets

Patients

The Norwegian Rectal Cancer Registry was established in 1993, and the Swedish Rectal Cancer Registry in 1995. Between 1995 and 2012 totally 29,029 patients in Sweden and 15,456 patients in Norway were registered (Table 1). These numbers correspond to an annual incidence of 18.8 per 100,000 inhabitants in Sweden and 19.5 in Norway. The corresponding age-standardized rates (World 1960) are 8.8 and 10.6, respectively.

Surgery, staging and adjuvant chemotherapy

The majority of surgeons had adopted the TME-technique in both countries prior to

Characteristics of patients with rectal cancer in Sweden and Norway

There were no differences in gender or age distribution between the countries (Table 1). Approximately 20% of the patients had synchronous metastases with a slightly higher proportion in Norway than Sweden, probably due to different registration routines. This proportion did not change with time (data not shown). A major resection (AR, HA, APE or rarely procto-colectomy) was performed in 66–69% of the patients and a local excision in 3–5% with no differences between countries. Patients who did

Discussion

The countries used two different approaches to rectal cancer treatment, preoperative radiotherapy plus TME to many patients in Sweden, and TME alone to most patients initially followed by an increased use of preoperative CRT during recent years in Norway. With these two different approaches, no survival differences could be detected. However, the local recurrence rates were initially lower in Sweden, until the use of CRT increased in Norway. In recent years, although RT regimens and rates

Conclusion

Over a time period of 19 years, population-based rectal cancer registry data from Sweden and Norway have shown that different treatment strategies have had an impact on local recurrence rates, but not on survival. At present, there are still differences in the use and choice of regimens of preoperative therapy, but both countries have similar good outcomes in terms of local recurrence and survival.

Conflict of interest

None of the authors have any conflict of interest to report.

Acknowledgements

Late Professor Lars Påhlman for his dedicated work to improve treatment and prognosis for rectal cancer patients worldwide and for his contribution to this work initially. Financial support was received from the Swedish Cancer Society, Sweden.

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