A decade ago, the five-year post-operative survival rate was just slightly higher than half, 55 per cent. For some hospitals, the figures were far worse while others were far better. Tremendous strides forward were made from 1993 to 1999. In 1999, the five-year post-operative survival rate was 71 per cent, a 30 per cent improvement, statistically speaking. It is unusual for a single project to produce such impressive results in the field of cancer treatment.
Strikes 1000 Norwegians a year
Rectal cancer is not a rare form of cancer; it strikes more than 1000 Norwegians a year. The improved treatment results mean that 160 people per year live longer lives, without appreciable distress from cancer.
Hospitals not previously up to standards are no longer operating on rectal cancer. The project keeps hospitals "on the straight and narrow". All hospitals can compare their results with the national average, and no one likes to be last. Moreover, if the local recurrence rate rises, the hospital is notified, and measures are initiated. In brief, training, monitoring and skills maintenance are the policy instruments applied.
"There is still room for improvement", remarks Project Manager Arne Wibe, senior medical officer at St. Olav's Hospital in Trondheim.
Should operate at least 10 patients per year
"We see there are still differences between hospitals. About 20 to 30 per cent of the hospitals report that only five per cent of the patients get new tumours in the pelvic area during the first five years after surgery. On the other hand, some hospitals report a figure of more than 15 per cent. Our goal is to raise quality at the hospitals whose results are still not good enough. Improvements may include improving the quality of the surgery and examining the patients thoroughly prior to operating. At that point, it is possible to identify high-risk patients who need additional treatment such as radiotherapy", explains Wibe.
The results of the project indicate that hospital volume should be at least 10 such operations per year. A lower volume more readily leads to lower quality and a higher rate of recurrence.
Technically difficult
The rectum is the 20-cm segment of the intestine between the colon and the anus. Tumour removal in this area poses technical difficulties. Prior to 1993, the operation was nonetheless performed at many small hospitals and by surgeons without special training.
The National Training Programme for Surgeons was introduced in 1993. Surgeons were trained in the TME method under the auspices of the programme. TME stands for total mesorectal excision, and refers to the removal of a cluster of lymph nodes around the bowel, sparing nerves and others organs.
"These improved surgical techniques give patients more than just a better chance of survival. Far fewer suffer post-surgical complications. There are also far fewer colostomies performed", adds Wibe.
Today, this procedure is generally performed only by specially trained surgeons.
Debate about radiotherapy
International practice is to treat rectal cancer with a combination of radiotherapy, chemotherapy and surgery. In Norway, the introduction of the new surgical technique means that patients with small tumours may be able to avoid radiotherapy and chemotherapy altogether. The additional treatments are reserved for tumours that have perforated the intestinal wall and invaded another organ.
The congress will include a debate on the importance of radiotherapy as a supplementary treatment.
"We are of the opinion that surgery alone is the best treatment for tumours up to a certain size. Administering radiotherapy in advance can damage tissue which may, in turn, lead to more complications in connection with surgery. Radiotherapy also increases the risk of damaging the small intestine and thus causing side effects such as diminished intestinal function. For tumours that have perforated the intestinal wall and invaded another organ, on the other hand, it would be feasible to give radiotherapy. This covers about 15 per cent of the patients", continues Wibe.