British Medical Bulletin 64:119-125 (2002)
© 2002 The British Council
Outcome following surgery for colorectal cancer
Colin S McArdle* and
David J Hole
* University Department of Surgery, Glasgow Royal Infirmary, Glasgow
Department of Public Health, University of Glasgow, Glasgow, UK
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Abstract
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There is evidence to suggest that survival following surgery
for colorectal cancer is improving. Audits undertaken in a single
institution between 1974–1979 and 1991–1994 provide
the opportunity to evaluate the extent to which earlier diagnosis
and better surgery contribute to the improvement in survival.
There was little evidence that patients were presenting at an
earlier stage during the latter period. In contrast, more patients
had a potentially curative resection. This analysis confirmed
that, over this period, there has been a substantial improvement
in survival following surgery for colorectal cancer; this improvement
was largely due to better surgery rather than earlier presentation.
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Introduction
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Colorectal cancer remains the second commonest cause of cancer
death in North America and Western Europe. Each year, there
are approximately 600,000 new cases diagnosed world-wide. There
are more than 130,000 new cases in the US and more than 28,000
in the UK.
In the UK, the incidence of colorectal cancer has been slowly increasing especially in men1,2, whereas in the US there is evidence that the incidence is now falling3. Survival has increased both in the UK (Table 1)1,2 and the US3.
Although registry-based data contain information on age, sex
and deprivation, such data do not have information on mode of
presentation, stage at diagnosis, the nature of surgery, whether
a ‘curative’ resection was achieved and whether
the patient received adjuvant therapy. It is, therefore, not
clear whether the observed improvement in survival is due to
earlier diagnosis or better treatment.
A recent audit of patients presenting with colorectal cancer to hospitals in central Scotland between 1991–1994 provides an opportunity to evaluate the extent to which individual factors contribute to the overall improvement in survival4. Of the 3200 patients included in the analysis, 35% were aged 75 years or over, 19% were socio-economically deprived, 31% presented as an emergency, and 15% had evidence of metastatic spread at the time of surgery. Of these 3200 patients, 2235 (70%) underwent apparently curative resection and 965 palliative resection. Postoperative mortality was 4.3% following curative resection and 9.8% after palliative resection. Of the total, 5% of patients received adjuvant therapy.
There were 2108 deaths. Overall, 52% of those undergoing apparently curative resection survived 5 years and 26% of those undergoing palliative resection survived 2 years. Cancer-specific survival after apparently curative resection was 66% at 5 years; cancer-specific survival following palliative resection was 29% at 2 years.
Age, sex and deprivation were to some extent interlinked. Older patients tended to present as an emergency, have colonic tumours, and have less advanced disease at the time of diagnosis (Table 2). There was no difference in the proportion of elderly patients undergoing potentially curative resection. Older patients were more likely to die following surgery, especially palliative surgery, more likely to die of their disease, and more likely to succumb to intercurrent illness (Table 3).
Females tended to be older, have right-sided tumours, present
as an emergency, have less advanced disease, and were more likely
to undergo potentially curative resection (
Table 4)
5. There
was no difference in postoperative mortality between the sexes.
Both overall and cancer-specific survival following potentially
curative resection was higher in females than males (
Table 5).
There was no difference in age, gender, mode of presentation,
extent of disease at diagnosis, type of resection or postoperative
mortality between the affluent and deprived (
Table 6)
6. More
of the deprived patients had rectal cancers. Following potentially
curative resection, overall and cancer-specific survival was
poorer in the deprived (
Table 7).
Patients who presented as an emergency tended to be older, female,
have colonic tumours, have more advanced disease, and were less
likely to undergo potentially curative resection (
Table 8).
Postoperative mortality was higher in the emergency group; overall
and cancer-specific survival was lower (
Table 9).
To address the question of whether the observed improvement
in survival was due to earlier diagnosis or better surgery,
we compared outcome between 1974–1979 and 1991–1994
in a single institution (Glasgow Royal Infirmary). The overall
resection rate was higher and, during the latter period, the
proportion of patients who underwent potentially curative resection
increased (
Table 10). Furthermore, between 1974–1979 and
1991–1994, postoperative mortality decreased, and overall
and cancer-specific survival following potentially curative
resection increased (
Table 11).
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Table 10 Comparison of baseline characteristics of patients (%) treated between 1974–1979 and 1991–1994 at Glasgow Royal Infirmary
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Table 11 Comparison of postoperative mortality and survival in patients treated between 1974–1979 and 1991–1994 at Glasgow Royal Infirmary
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There was little evidence that patients were presenting at an
earlier stage during the latter period, since the proportion
presenting as an emergency was unchanged and, although there
was a trend towards more patients with Dukes' stage A/B tumours,
this was not significant. Earlier presentation would, therefore,
not appear to be the underlying reason for the reduction in
mortality in the latter period.
In contrast, more patients had their tumour resected and more had a potentially curative resection. This increase in the resection rates was achieved in parallel with a reduction in postoperative mortality. This suggests that better peri-operative care and improved surgical technique have been the main factors underlying the substantial reduction in mortality.
There are two possible explanations for the differences in outcome, namely the number of patients treated by each surgeon and whether these surgeons were specialists or not.
One large study reported that high-volume surgeons had lower postoperative mortality rates compared to low-volume surgeons, but the absolute magnitude of the difference was small7. However, the majority of studies which have addressed this question have failed to demonstrate significant relationship between case volume and postoperative mortality8,9, local recurrence9,10 or survival9,11,12.
The question of specialisation is more complex. The best evidence to date comes from the Swedish and Canadian studies. Analysis of 1399 rectal cancer patients, randomised within the Swedish pre-operative radiotherapy studies, showed that local recurrence rates were lower and survival rates significantly higher in those patients treated by surgeons with more than 10 years' experience as a specialist9. In the smaller Canadian study, rectal cancer patients treated by colorectal-trained surgeons had significantly lower local recurrence rates and higher cancer specific survival rates, independent of caseload13.
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Conclusions
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This analysis confirms that, over the last two decades at a
time when adjuvant chemotherapy was hardly used, there has been
a substantial improvement in survival following surgery for
colorectal cancer. This improvement is largely due to better
surgery and the development of specialisation rather than earlier
presentation. As the proportion of patients with colorectal
cancer treated by specialist colorectal surgeons increases,
one might anticipate that further substantial improvements in
survival will occur.
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Footnotes
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Correspondence to: Prof. Colin S McArdle, University Department
of Surgery, Glasgow Royal Infirmary, Glasgow G31 2ER, UK
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References
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- Scottish Cancer Intelligence Unit. Trends in Cancer Survival in Scotland 1971–1995. Edinburgh: Information and Statistics Division, 2000; 54–71
- Coleman MP, Babb P, Damiecki P et al. Cancer Survival Trends in England and Wales, 1971–1995: Deprivation and NHS Region. London: The Stationary Office, 1999
- Ries LA, Wingo PA, Miller DS et al. The annual report to the nation on the status of cancer, 1973–1997, with a special section on colorectal cancer. Cancer 2000; 88: 2398–424[CrossRef][Web of Science][Medline]
- McArdle CS, Hole DJ. Outcome following surgery for colorectal cancer: analysis by hospital after adjustment for case-mix and deprivation. Br J Cancer 2002; 86: 331–5[CrossRef][Web of Science][Medline]
- McArdle CS, McMillan DC, Hole DJ. Male gender adversely affects survival following surgery for colorectal cancer. 2002; Submitted
- Hole DJ, McArdle CS. Impact of socioeconomic deprivation on outcome after surgery for colorectal cancer. Br J Surg 2002; 89: 586–90[Medline]
- Harmon JW, Tang DG, Gordon TA et al. Hospital volume can serve as a surrogate for surgeon volume for achieving excellent outcomes in colorectal resection. Ann Surg 1999; 230: 404–11[CrossRef][Web of Science][Medline]
- Mella J, Biffin A, Radcliffe AG, Stamatakis JD, Steele RJC. Population-based audit of colorectal cancer management in two UK health regions. Br J Surg 1997; 84: 1731–6[CrossRef][Web of Science][Medline]
- Holm T, Johansson H, Cedermark B, Ekelund G, Rutqvist LE. Influence of hospital- and surgeon-related factors on outcome after treatment of rectal cancer with or without preoperative radiotherapy. Br J Surg 1997; 84: 657–63[CrossRef][Web of Science][Medline]
- Hermanek P, Wiebelt H, Staimmer D, Riedl S. Prognostic factors of rectum carcinoma – experience of the German multicentre study SGCRC. Tumori 1995; 81 (Suppl): 60–4[Web of Science][Medline]
- Parry JM, Collins S, Mathers J, Scott NA, Woodman CB. Influence of volume of work on the outcome of treatment for patients with colorectal cancer. Br J Surg 1999; 86: 475–81[CrossRef][Web of Science][Medline]
- Kee F, Wilson RH, Harper C et al. Influence of hospital and clinician workload on survival from colorectal cancer: cohort study. BMJ 1999; 318: 1381–6[Abstract/Free Full Text]
- Porter GA, Soskolne CL, Yakimets WW, Newman SC. Surgeon-related factors and outcome in rectal cancer. Ann Surg 1998; 227: 157–67[CrossRef][Web of Science][Medline]
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Abstract
Introduction
