| 1. |
- Elliot, A. H., et al.
(författare)
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Impact of pre-treatment patient-related selection parameters on outcome in rectal cancer
- 2016
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Ingår i: European Journal of Surgical Oncology. - : Elsevier BV. - 0748-7983 .- 1532-2157. ; 42:11, s. 1667-1673
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Tidskriftsartikel (refereegranskat)abstract
- Background: Preoperative radiotherapy (RT) for rectal cancer reduces local recurrence rates and possibly also mortality. Patient-related parameters such as age and comorbidity have a major impact on selection to preoperative RT. The aim of this study was to investigate how this selection influences the outcome in rectal cancer regardless of dose or fractionation of RT.Methods: Data from the Swedish Colorectal Cancer Registry and the Swedish National Patient Register on all patients without distant metastasis who underwent elective trans-abdominal surgery for rectal cancer 2000-2010 in the Stockholm Gotland region was retrieved. Factors influencing survival and recurrence were identified by Cox regression analyses.Results: There were 2300 patients included. Among these 70.3% received preoperative RT. Three-year overall survival (OS), disease-free survival (DFS) and local recurrence rate were 80.2, 68.6 and 4.7%, respectively. All outcome measures were significantly improved over time. In a multivariable analysis in patients with comorbidity (Charlson comorbidity index score >= 1), OS were significantly better following preoperative RT than after surgery alone (HR 0.65, 95% CI 0.49-0.87). OS among patients with advanced age (>= 80 years), was not influenced by preoperative RT.Conclusion: OS among patients with comorbidity was better following preoperative RT than after surgery alone while no differences were seen among the elderly. This indicates that the selection process may be optimised for the patients with advanced age but comorbidity should be used cautiously for exclusion of patients from preoperative RT.
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| 2. |
- Elliot, A. H., et al.
(författare)
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Preoperative treatment selection in rectal cancer : A population-based cohort study
- 2014
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Ingår i: European Journal of Surgical Oncology. - : Elsevier BV. - 0748-7983 .- 1532-2157. ; 40:12, s. 1782-1788
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Tidskriftsartikel (refereegranskat)abstract
- Background: Preoperative radiotherapy and chemoradiotherapy for rectal cancer reduce local recurrence rates but is also associated with side effects. Thus, it is important to identify patients in whom the benefits exceed the risks. This study assessed the pretherapeutic parameters influencing the selection to preoperative treatment. Methods: Data on all patients in the Stockholm-Gotland area, Sweden, who underwent elective trans-abdominal surgery for rectal cancer in 2000-2010, was retrieved from the Regional Cancer Registry and the Swedish National Patient Register. Clinical variables were analysed in relation to selected preoperative therapy. Odds Ratios were derived from univariable and multivariable logistic regression models. Results: In total 2619 patients were included. Of these 1789 (68.3%) received preoperative radiotherapy or chemoradiotherapy. Over time, use of preoperative therapy increased (p < 0.001). In a multivariable model, age (>= 80 years) and comorbidity (Charlson Comorbidity Index score >= 2) were strongly correlated to omittance of preoperative treatment (OR: 0.05; 95% CI: 0.04-0.07 and 0.29; 95% CI: 0.21-0.39) but there was no difference between genders. Pre-treatment tumour stage was a strong predictor for selection to preoperative (chemo-) radiotherapy. However, 8.2% of patients with intermediate or advanced tumours were selected to no preoperative treatment while 55.0% of patients with early tumours were selected to preoperative therapy. Conclusions: The use of preoperative (chemo-) radiotherapy increased over time. Suboptimal adherence to guidelines appears to exist leading to a risk of overtreatment and to a small extent also undertreatment. More robust selection criteria, also including age and comorbidity should be developed.
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| 3. |
- Erlandsson, J., et al.
(författare)
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Postoperative complications in relation to overall treatment time in patients with rectal cancer receiving neoadjuvant radiotherapy
- 2019
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Ingår i: British Journal of Surgery. - : WILEY. - 0007-1323 .- 1365-2168. ; 106:9, s. 1248-1256
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Tidskriftsartikel (refereegranskat)abstract
- Background: The optimal timing of surgery for rectal cancer after radiotherapy (RT) is disputed. The Stockholm III trial concluded that it was oncologically safe to delay surgery for 4-8weeks after short-course RT (SRT), with fewer postoperative complications compared with SRT with surgery within a week. Other studies have indicated that an even shorter interval between RT and surgery (0-3 days) might be beneficial. The aim of this study was to identify the optimal interval to surgery after RT.Methods: Patients were analysed as treated, in terms of overall treatment time (OTT), the interval from the start of RT until the day of surgery. Patients receiving SRT (5x5Gy) were categorized according to OTT: 7 days (group A), 8-13 days (group B), 5-7weeks (group C) and 8-13weeks (group D). Patients receiving long-course RT (25x2Gy) were grouped into those with an OTT of 9-11weeks (group E) or 12-14weeks (group F). Outcomes assessed were postoperative complications and early mortality.Results: A total of 810 patients were analysed (group A, 100; group B, 247; group C, 192; group D, 160; group E, 52; group F, 59). Baseline patient characteristics were similar. There were significantly more overall complications in group B than in groups C and D. Adjusted odds ratios, with B as the reference group, were: 0.72 (95 per cent c. i. 0.40 to 1.32; P = 0.289), 0.50 (0.30 to 0.84; P = 0.009) and 0.39 (0.23 to 0.65; P < 0.001) for groups A, C and D respectively. Early mortality was similar in all groups. There were no significant differences between long-course RT groups.Conclusion: These results suggest that surgery should optimally be delayed for 4-12weeks (OTT 5-13weeks) after SRT.
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| 4. |
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| 5. |
- Kodeda, Karl, et al.
(författare)
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Time trends, improvements and national auditing of rectal cancer management over an 18-year period
- 2015
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Ingår i: Colorectal Disease. - : Wiley. - 1462-8910 .- 1463-1318. ; 17:9, s. O168-O179
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Tidskriftsartikel (refereegranskat)abstract
- Aim: The main aims were to explore time trends in the management and outcome of patients with rectal cancer in a national cohort and to evaluate the possible impact of national auditing on overall outcomes. A secondary aim was to provide population-based data for appraisal of external validity in selected patient series.Method: Data from the Swedish ColoRectal Cancer Registry with virtually complete national coverage were utilized in this cohort study on 29925 patients with rectal cancer diagnosed between 1995 and 2012. Of eligible patients, nine were excluded.Results: During the study period, overall, relative and disease-free survival increased. Postoperative mortality after 30 and 90days decreased to 1.7% and 2.9%. The 5-year local recurrence rate dropped to 5.0%. Resection margins improved, as did peri-operative blood loss despite more multivisceral resections being performed. Fewer patients underwent palliative resection and the proportion of non-operated patients increased. The proportions of temporary and permanent stoma formation increased. Preoperative radiotherapy and chemoradiotherapy became more common as did multidisciplinary team conferences. Variability in rectal cancer management between healthcare regions diminished over time when new aspects of patient care were audited.Conclusion: There have been substantial changes over time in the management of patients with rectal cancer, reflected in improved outcome. Much indirect evidence indicates that auditing matters, but without a control group it is not possible to draw firm conclusions regarding the possible impact of a quality control registry on faster shifts in time trends, decreased variability and improvements. Registry data were made available for reference.
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| 6. |
- Martling, A., et al.
(författare)
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Risk of second primary cancer in patients treated with radiotherapy for rectal cancer
- 2017
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Ingår i: British Journal of Surgery. - : Oxford University Press (OUP). - 0007-1323 .- 1365-2168. ; 104:3, s. 278-287
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Tidskriftsartikel (refereegranskat)abstract
- Background: Many patients with rectal cancer receive radiotherapy (RT) to reduce the risk of local recurrence. Radiation may give rise to adverse effects, including second primary cancers. In view of the divergent results of previous studies, the present study evaluated the risk of second primary cancer following RT in all randomized RT rectal cancer trials conducted in Sweden and in the Swedish ColoRectal Cancer Registry (SCRCR).Methods: Patients included in five randomized trials and the SCRCR were linked to the Swedish Cancer Registry. Cox regression models estimated the hazard ratio (HR) of second primary cancer among patients who received RT compared with those who did not.Results: A total of 13 457 patients were included in this study; 7024 (52.2 per cent) received RT and 6433 (47.8 per cent) had surgery alone. Overall, no increased risk of second primary cancer was observed with RT (HR 1.03; 95 per cent c. i. 0.92 to 1.15), independently of follow-up time and location within or outside of the irradiated volume. In the randomized trials, with longer follow-up (maximum 31 years), a slight increase was observed outside of (HR 1.33, 1.01 to 1.74) but not within (HR 1.11, 0.73 to 1.67) the irradiated volume. Irradiated men had a lower risk of prostate cancer than those treated with surgery alone (HR 068, 0.51 to 091).Conclusion: Overall, there was no increased risk of second primary cancer following RT for rectal cancer within or outside of the irradiated volume up to 20 years of follow-up. Men with rectal cancer who received RT had a reduced risk of prostate cancer.
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| 7. |
- Pettersson, D., et al.
(författare)
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Impaired postoperative leucocyte counts after preoperative radiotherapy for rectal cancer in the Stockholm III Trial
- 2013
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Ingår i: British Journal of Surgery. - : Oxford University Press (OUP). - 0007-1323 .- 1365-2168. ; 100:7, s. 969-U145
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Tidskriftsartikel (refereegranskat)abstract
- Background: Radiotherapy (RT) in rectal cancer increases postoperative morbidity. A suggested reason is RT-induced bone marrow depression resulting in impaired leucocyte counts. The ongoing Stockholm III Trial randomizes patients with operable rectal cancers to short-course RT with immediate surgery (SRT), short-course RT with surgery delayed for 4-8 weeks (SRT-delay) and long-course RT with surgery delayed for 4-8 weeks (LRT-delay). This study examined differences between the randomization arms regarding leucocyte response and postoperative complications. Methods: Patients randomized in the Stockholm III Trial between October 1998 and November 2010 were included. Data were collected in a prospective register. Additional data were obtained by retrospective review of clinical records. Results: Of 657 randomized patients, 585 had data on leucocytes. The SRT arm had the highest proportion of postoperative complications (SRT, 52.5 per cent; SRT-delay, 39.4 per cent; LRT-delay, 41 per cent; P = 0.010). There was no association between low preoperative leucocyte count and postoperative complications (P = 0.238). Irrespective of randomization arm, patients with an impaired postoperative to preoperative leucocyte ratio had the highest rate of complications (low ratio, 56.6 per cent; intermediate ratio, 46.9 per cent; high ratio, 36.3 per cent; P = 0.010). The SRT arm had the highest proportion of low ratios (SRT, 48.9 per cent; SRT-delay, 22.8 per cent; LRT-delay, 22 per cent; P < 0.001). Conclusion: An impaired postoperative leucocyte response is associated with postoperative complications. The highest risk is with immediate surgery following short-course radiotherapy. Registration number: NCT 00904813 (http://www.clinicaltrials.gov).
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| 8. |
- Pettersson, D., et al.
(författare)
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Preoperative short-course radiotherapy with delayed surgery in primary rectal cancer
- 2012
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Ingår i: British Journal of Surgery. - : Oxford University Press (OUP). - 0007-1323 .- 1365-2168. ; 99:4, s. 577-583
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Tidskriftsartikel (refereegranskat)abstract
- Background: Short-course radiotherapy (SRT) with immediate surgery and long-course chemoradiotherapy (CRT) are currently the standard preoperative treatment options for rectal cancer. SRT with surgery delayed for 4-8 weeks (SRT-delay) is an option described for patients with locally advanced tumours who are not fit for CRT. This study examined early toxicity, response to radiotherapy (RT) and short-term outcomes of SRT-delay. Methods: Patients in the Stockholm region diagnosed with rectal cancer between January 2002 and December 2008, who received SRT (25 Gy over 5-7 days) and had surgery with resection of the primary tumour more than 4 weeks after the start of RT, were identified from a prospective register. Additional data were obtained by retrospective review of clinical records. Results: A total of 112 patients had SRT and delayed surgery. The reasons given for SRT included primary unresectable disease and co-morbidities. Severe RT-induced toxicity was noted in six patients (5.4 per cent). Signs of tumour regression were seen on magnetic resonance imaging in 74 per cent of patients reassessed after RT. Pathological stage (44.9 versus 60.7 per cent stage 0-II; P < 0.001), tumour category (11.9 versus 29.4 per cent T0-T2; P < 0.001) and node category (45.8 versus 63.6 per cent N0; P = 0.014) were significantly lower than those at initial assessment. Nine patients (8.0 per cent) had a complete pathological response. Conclusion: The SRT-delay schedule was a feasible alternative with low toxicity. The study indicated a downstaging effect of SRT if surgery was delayed.
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| 9. |
- Pettersson, D., et al.
(författare)
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Tumour regression in the randomized Stockholm III Trial ofradiotherapy regimens for rectal cancer
- 2015
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Ingår i: British Journal of Surgery. - : Oxford University Press (OUP). - 0007-1323 .- 1365-2168. ; 102:8, s. 972-978
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Tidskriftsartikel (refereegranskat)abstract
- BackgroundThe Stockholm III Trial randomized patients with primary operable rectal cancers to either short-course radiotherapy (RT) with immediate surgery (SRT), short-course RT with surgery delayed 4-8 weeks (SRT-delay) or long-course RT with surgery delayed 4-8 weeks. This preplanned interim analysis examined the pathological outcome of delaying surgery. MethodsPatients randomized to the SRT and SRT-delay arms in the Stockholm III Trial between October 1998 and November 2010 were included, and data were collected in a prospective register. Additional data regarding tumour regression grade, according to Dworak, and circumferential margin were obtained by reassessment of histopathological slides. ResultsA total of 462 of 545 randomized patients had specimens available for reassessment. Patients randomized to SRT-delay had earlier ypT categories, and a higher rate of pathological complete responses (118 versus 17 per cent; P=0001) and Dworak grade 4 tumour regression (101 versus 17 per cent; P<0001) than patients randomized to SRT without delay. Positive circumferential resection margins were uncommon (63 per cent) and rates did not differ between the two treatment arms. ConclusionShort-course RT induces tumour downstaging if surgery is performed after an interval of 4-8 weeks.
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