1. 1 Recent trends in colorectal cancer in Norway: incidence, management and outcomes Arne Wibe, MD, PhD Professor of Surgery St. Olavs Hospital Trondheim, Norway

2. 2 Contents Collection of data Incidence Outcomes Conclusions

3. 3 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

4. 4 Cancer Registry of Norway Cancer in Norway 2008

5. 5 Collection of data National cancer registry since 1952 Compulsory reporting of all cancers and some precancrous lesions - all hospitals / health institutions - all physicians

6. 6 Age adjusted incidence of colorectal cancer in the Nordic countries Nordcan

7. 7 Colon cancer Rectal and anal cancer Cancer in Norway 2008

8. 8 Colon cancer Rectal and anal cancer Cancer in Norway 2008

9. 9 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

10. 10 Why has the relative survival for rectal cancer increased more in men than in women? 19932008 Men 46% 62% Women57%67%

11. 11 Is that because… the more difficult the dissection, the more benefit of an optimised surgical 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

12. 12 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

13. 13 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 leaks 1994 17% 1999 8% Wibe et al. Colorectal Disease 2006; 8: 224-229

14. 14 Variation in rate of local recurrence between hospitals Wibe et al. Colorectal Disease 2006; 8: 224-229

15. 15 Due to variation of results treatment has been centralized 1994: 55 hospitals Recommended by the association of surgeons: ”rectal cancer surgery should only be performed by specialists in gastrointestinal surgery” 2000: 40 hospitals Dedicated colorectal surgeons treating rectal cancer 2004: 25 hospitals Healthcare bureaucracy introduced formal regulations: ”Only multidisciplinary teams of dedicated experts may treat rectal cancer”

16. 16 What happened to hospitals having inferior results for rectal cancer, though continuing treatment?

17. 17 Haugesund Central Hospital 5-yr local recurrence 5-yr overall survival 1993-9831% 48% 1999-0111% 70% 2002-04 6% 2005-2009No local recurrence at Haugesund Central Hospital Best paper Norwegian Association of Surgeons 2008, Moen A C et al. abstract no 116

18. 18 What did they do in Haugesund? How did they manage to improve that quickly?

19. 19 2000 2001 2002 2003 2004 2005 2006 2007 2008 Cylindric amputation Laparoscopic resection CT + Rectal ultrasound Oncologist Neoadjuvant tr.t acc. 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

20. 20 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

21. 21 Levanger hospital – 394 patients 1980-2004 Patients treated with curative intent: Local recurrence5-yr survival 1980-89 4% 65% 1990-9919% 58% 2000-04 2% 71% p = 0.006 Jullumstrø, Wibe, Lydersen, Edna. Thesis NTNU 2010

22. 22 How could this happen?

23. 23 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

24. 24 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

25. 25 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

26. 26 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

27. 27 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!

28. 28 arne.wibe@ntnu.no