Teaching Efforts to Spread TME Surgery in Sweden
Lars Påhlman, Urban Karlbom
L. Påhlman (u)
Colorectal Unit, Department of Surgery, University Hospital, 751 85 Uppsala, Sweden
e-mail: lars.pahlman@surgsci.uu.se
Introduction
Rectal cancer surgery in Sweden has changed dramatically during the last three decades. In the early to late 1970s very bad results were noted, with high local recurrence rates, and most Swedish centres reported a local failure rate above 30% [1]. It was thought that this was a matter of the complexity of the tumour growth and tumour biology. Therefore, radiotherapy was considered to be the solution to reduce the local recurrence rate. Subsequently, three large trials were conducted in Sweden during the 1980s. The Stockholm/Malmö trial compared preoperative short-course radiotherapy, 25 gray (Gy) in 1 week versus surgery alone [2]. The Uppsala trial compared preoperative short-course radiotherapy versus postoperative radiotherapy to 60 Gy in patients with a tumour at stage B or C [3], and the Swedish Rectal Cancer Trial compared the use of short-course 25 Gy in 1 week versus surgery alone [4]. The data from those three trials can be summarised as follows: preoperative radiotherapy is superior to postopera- tive radiotherapy, the local failure rates are reduced from around 30% to 15%, and this reduction will have an overall survival benefit. However, an interest- ing finding from these trials was the fact that in many hospitals, half of the pa- tients were operated upon by a surgeon doing less than one rectal cancer per year.
During the same time period, data from single centres all around the world showed very low local recurrence rates, and surgeons started to claim that the high local recurrence rate was a matter of bad surgery and had really nothing to do with tumour biology [5–7]. The new type of surgery is the total mesorectal excision technique (TME), and it has been adopted in many centres in Sweden. Also in Sweden, several centres could prove very low local recurrence rates after having embarked on the new surgical technique [8–10].
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Teaching Efforts to Spread TME Surgery in Sweden 83
Concentration of Surgery to Fewer Units and Auditing the Results
Due to the findings that some hospitals did worse than others and the fact that too many surgeons performed the operations, it was postulated that surgery should be concentrated to fewer hospitals. In Sweden in the early 1990s, many small hospitals were closed due to economic reasons and infrastructural changes in health care.
In addition, workshops teaching TME surgery were given all around Sweden, and rectal cancer was no longer considered a procedure for general surgeons.
The results from these workshops have been proven to be beneficial [11]. The auditing of the results was also highlighted and became necessary, since due to this new infrastructure and the concentration of rectal cancer surgery to fewer centres, many surgeons wanted to have some confirmation that this was the correct way to do the surgery. Therefore, by the initiative from the Swedish Board of Health and Welfare, the Swedish Rectal Cancer Register (SRCR) was started in 1995.
The Swedish Rectal Cancer Register
The SRCR has data on preoperative investigations, surgical technique, and postop- erative complications [12]. It is mandatory for all units dealing with rectal cancer to fill in a specific questionnaire after patient discharge. Moreover, all patients must be reported on once a year postoperatively, where oncological end-points such as distant metastases and local recurrences are reported as well as long-term side effects and complications.
The Swedish health care system is organised into six health care regions, and in each region there is an oncological centre responsible for that specific area of the country. According to Swedish law, all cases of cancer must be reported by both the clinician and the pathology department, to this specific oncological centre. Therefore, the Swedish Cancer Register has almost 100% coverage of all cancers diagnosed and treated in our country. In the SRCR, 99.5% of all rectal cancers are registered, indicating a true population-based register. Each region has its own registration formula with slight regional differences dependent upon local interest of research. However, there is a similar mini-database, where all on- cological centres report to one centre responsible for collecting all the data and performing a yearly national report. By definition a rectal cancer is 15 cm from the anal verge. Approximately 1,500 new cases per year are diagnosed, giving al- most 13,000 patients recorded in our register today. Due to the large numbers it is now possible to evaluate trends in the treatment, as well as 5 years’ onco- logical data. To summarise, 50% of all patients with a rectal cancer will have a sphincter-preserved procedure, i.e. an anterior resection, and 25% will have an abdominal perineal excision. The rest of the patients will have other procedures such as a low Hartmann, and a local excision, and approximately 5% of all patients will not be operated upon at all due to distant spread or being too old and/or fragile.
84 Lars Påhlman and Urban Karlbom
How to Use Those Data
All yearly reports are displayed on the web-site of the Swedish National Board of Health and Welfare [12]. So far the annual reports are splitting the figures into different regions of Sweden. There are data from each hospital, but those have not yet been presented due to too small numbers when divided not only into hospitals but also different treatment options. However, all hospitals will have their own specific report together with the national report, which makes it possible for each department of surgery to check whether or not their own data are within the accepted frames. Many specific end-points have been noted, such as the type of procedures presented above, the overall postoperative complications, re-operation rates, postoperative mortality, local recurrence rates, and survival figures for all Dukes’ stages, among others. Having identified the median values for each relevant endpoint, it has been decided that these figures should be the guidelines for the gold standards in the treatment of rectal cancer. All units have been urged to try to fulfil the criteria for being a good unit. If a single unit has figures below the accepted range of good quality, the unit must within a short period of time (2 years) prove that they can reach those figures. Similarly, those with good results must prove that they are still producing good results [13].
Summary and Conclusion
The whole infrastructure of rectal cancer treatment in Sweden has changed dra- matically due to the awareness of the local recurrence rate, good surgical technique, and selective use of radiotherapy. Surgeons have been trained in a proper way, and it has been proven that the outcome has improved enormously in our country [14].
Due to repeated reports from the SRCR to each unit, it is possible for every surgeon to follow the process. It has been shown that the outcome for not only colon cancer but also rectal cancer has improved dramatically during the last 40 years, and there is a marked improvement in survival from approximately 40% in the early 1960s to almost 60% in the late 1990s [15]. An interesting phenomenon is that the relative 5-year survival rate has, during the 5-year cohort, been better for patients with colon cancer compared to those with rectal cancer. For the last two 5-year cohorts in Sweden, 1990–1995 and 1996–2000, the results for rectal cancer patients have improved, and in the most recent cohort, rectal cancer patients are actually doing better than colon cancer patients in terms of relative survival [16]. This increase has been interpreted to be a result of much better surgery, a more selective use of radiotherapy, but most of all an awareness of the results and focus on good auditing.
This quality assurance and quality control of rectal cancer surgery is important and will be mandatory in the future for all units to not only know the results but also be able to present them in a way that patients can understand. We are facing a new generation of young patients who are familiar with the Internet and find all types of information before having surgery. It is obvious that only the best units will survive in such a competition, and the only way to be able to compete is to show
Teaching Efforts to Spread TME Surgery in Sweden 85
good results within a good and validated population-based quality registration, as is the situation for many different diseases in Sweden today. A tremendous change has been seen in our country over the last two decades, and it is in part a result of registration and quality auditing, where the results are displayed to the surgeons.
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