the new south wales colorectal cancer care survey · management of locally advanced rectal cancer...

The New South Wales Colorectal Cancer Care Survey 2000 Part 1. Surgical management

Katie Armstrong Dianne O’Connell David Leong Allan Spigelman Bruce Armstrong The Cancer Council NSW The University Of Newcastle

April 2004

Acknowledgements The authors would like to thank the staff and volunteers who worked on the survey, the Advisory Group for providing important input on all scientific aspects of the survey, and all practitioners who contributed to the survey. We acknowledge the support and cooperation of the following professional colleges:

Royal Australasian College of Surgeons Royal Australasian College of Physicians Royal Australian and New Zealand College of Radiologists- Faculty of Radiation Oncology Medical Oncology Group of Australia Incorporated Gastroenterological Society of Australia

Cases were identified and made available through the NSW Central Cancer Registry. The Cancer Registry is managed and operated by The Cancer Council NSW under a contract with NSW Health. Treatment and management data were collected through grants from the National Health and Medical Research Council and MBF Australia. ISBN 1 86507 073 4 Key Words: colorectal cancer, surgical management, New South Wales, Australia Suggested citation: Armstrong K, O’Connell DL, Leong D, Spigelman AD, Armstrong BK. The New South Wales colorectal cancer care survey- Part 1 surgical management. The Cancer Council 2004. Published by The Cancer Council NSW, April 2004 Cancer Epidemiology Research Unit Cancer Research and Registers Division The Cancer Council NSW Locked Mail Bag 1 Kings Cross NSW 1340 Telephone: (02) 9334 1902 Fax: (02) 9334 1778 Email: [email protected] Internet: http://www.cancercouncil.com.au

Table of Contents

Summary.................................................................................................................... 1

Background ............................................................................................................... 6

Coverage.................................................................................................................... 7

Aims ........................................................................................................................... 7

Methods ..................................................................................................................... 8

Scope of this report .................................................................................................. 9

Data Quality ............................................................................................................... 9 Representativeness of the sample .......................................................................... 9 Timeliness of the cohort .......................................................................................... 9 Questionnaire response rate ................................................................................... 9 Validity of surgical questionnaire ........................................................................... 10 Accuracy of the data collected............................................................................... 10 Coverage of guideline recommendations .............................................................. 10

Results ..................................................................................................................... 12 Characteristics of patients studied......................................................................... 12 Characteristics of patients’ cancer......................................................................... 14

Number of primary cancers................................................................................ 14 Cancer site......................................................................................................... 14 Extent of cancer ................................................................................................. 16

Caseloads of surveyed surgeons .......................................................................... 17 Characteristics of treating institutions.................................................................... 19 Clinical presentation .............................................................................................. 21 Pre-treatment investigations for diagnosis and staging......................................... 23

Cancers of the colon and rectum....................................................................... 23 Cancer of the rectum only.................................................................................. 25 Pre-operative histological confirmation of diagnosis.......................................... 26

Preparation for surgery.......................................................................................... 27 Pre-operative referral to a stomal therapist........................................................ 27 Pre-operative bowel preparation........................................................................ 27 Thromboembolism prophylaxis .......................................................................... 28 Antibiotic prophylaxis ......................................................................................... 29

Initial surgical management................................................................................... 30 Intention of surgery ............................................................................................ 30

Surgery for primary colon cancer .......................................................................... 31 Management of cancers attached to contiguous structures .............................. 33 Surgical access.................................................................................................. 33 Oophorectomy ................................................................................................... 34

Surgery for rectal cancer ....................................................................................... 35

Local excision .................................................................................................... 39 Sphincter preservation ....................................................................................... 40 Colonic pouch .................................................................................................... 41

Emergency surgery ............................................................................................... 42 Surgical complications........................................................................................... 43 Use of chemotherapy and radiotherapy for colon cancer...................................... 44 Use of chemotherapy and radiotherapy for rectal cancer...................................... 48 Management of locally advanced rectal cancer .................................................... 53 Surgery for metastatic colorectal cancer ............................................................... 54 Participation in clinical trials................................................................................... 55 Follow-up intentions............................................................................................... 56

Further analyses proposed.................................................................................... 57

Appendix 1 Surgical Questionnaire ...................................................................... 59

Appendix 2 Membership of the Expert Advisory Group ..................................... 63

Appendix 3 Cancer stage assignment using questionnaire responses ............ 64

Appendix 4 Classification of hospitals ................................................................. 65

Appendix 5 References .......................................................................................... 66

NSW Colorectal Cancer Care Survey Summary

Summary The primary aim of the New South Wales (NSW) Colorectal Cancer Care Survey was to determine the proportion of colorectal cancer cases in NSW managed according to recommendations in the National Health and Medical Research Council guidelines (http://www.health.gov.au/nhmrc/publications/pdf/cp62.pdf). These guidelines were released and widely disseminated to practitioners involved in the management of patients with colorectal cancer including surgeons and radiation and medical oncologists in Australia just before the Survey began. Information was sought from primary treating practitioners regarding their management of patients newly diagnosed with colorectal cancer who were notified to the New South Wales (NSW) Central Cancer Registry between 1 February 2000 and 31 January 2001; 94% of eligible patients ascertained were diagnosed in 2000, 2% in 1999 and 4% in 2001. This report covers initial surgical treatment and referral for chemotherapy and radiotherapy. Data on surgical treatment were obtained on 3,095 (93%) of 3,314 eligible patients. Assessment of surgical management with reference to the guidelines was limited to 2,914 patients who had only one primary cancer diagnosed and generally also to the 2,810 patients who had some surgical treatment. Thirty-two of the NHMRC guidelines deal with primary surgical management. Concordance of management with guidelines is summarised below for 18 of the recommendations. NHMRC Guideline Management

Preoperative assessment Colonoscopy is the investigation of choice, but air contrast barium enema and sigmoidoscopy is an alternative to colonoscopy. If colonoscopy is incomplete, barium enema must be included. (Level III evidence)

79% of patients had colonoscopy, 3% had sigmoidoscopy and barium enema and 81% had either or both (Table 17).

Endorectal ultrasound is more accurate than either CT or MRI for assessing the depth of invasion and lymph node status. It is the preferred initial method of locally staging a rectal cancer preoperatively. While endorectal ultrasound is the most accurate method to preoperatively stage rectal cancer locally, it is not necessarily indicated for all rectal cancers. Its main role will be: • for advanced (T3–4) rectal cancers

where neoadjuvant therapy is being considered;

• for small cancers in the distal rectum

61% of patients who underwent surgery for rectal cancer had either CT scanning (59%) or endorectal ultrasound preoperatively (9%). This included: 66% of patients with T3 or T4 rectal cancers (8% had endorectal ultrasound); 89% of patients who had pre-operative radiotherapy (25% had endorectal ultrasound); and 48% of patients who had transanal local excision (18% had endorectal ultrasound) (Table 20).

The Cancer Council NSW 1

Summary NSW Colorectal Cancer Care Survey

where a local transanal excision may be an alternative to abdomino-perineal excision of the rectum with a permanent colostomy, so accurate assessment of the depth of local tumour invasion and state of the lymph nodes is essential; and

• if neoadjuvant chemoradiotherapy or a transanal local excision is planned. (No guideline given; quoted from page 64 of the NHMRC guidelines)

Preparation for surgery All patients [having elective surgery for rectal cancer] who have a reasonable chance of a postoperative stoma should be informed about this possibility. This includes a visit, where possible, by the stomal therapy nurse. (Expert opinion)

90% of patients who presented electively and had a stoma created, had been seen by a stomal therapist preoperatively (Table 22).

Randomised trials do not demonstrate a benefit from routine bowel preparation (Level II evidence). If bowel preparation is to be used, then both polyethylene glycol preparation and sodium phosphate preparations are effective, but polyethylene glycol is more acceptable and has lower postoperative complication rates. (Level II evidence)

90% of all patients and 96% of patients treated electively had bowel preparation. An oral preparation alone was used in 86% of all patients (Table 23).

All patients undergoing surgery for colorectal cancer should receive prophylaxis for thromboembolic disease. Unfractionated heparin, low molecular weight heparin, and intermittent calf compression are effective in reducing the incidence of thromboembolism. (Level I evidence)

98% of patients who had surgery for bowel cancer received heparin (fractionated or unfractionated), intermittent calf compression, or both (Table 24).

All patients undergoing colorectal cancer surgery require prophylactic antibiotics. (Level I evidence) A single preoperative dose of intravenous second or third generation cephalosporin and metronidazole is an effective regime. (Level II evidence)

94% of patients who had surgery for bowel cancer received antibiotics pre-operatively. A cephalosporin plus imidazole was given to only 28% of patients undergoing surgery (Table 25). 37% of patients who received antibiotic prophylaxis continued this treatment post-operatively (Table 26).

2 The Cancer Council NSW


Elective surgery for colon and rectal cancers

For fixed tumours, en bloc resection of primary colonic cancer, together with the attached organ or the abdominal wall, should be performed in an attempt to obtain a curative resection. No attempt should be made to assess if the attachment is benign or malignant at the time of surgery. (Expert opinion)

72% of patients who had a tumour that was adherent to adjacent structures, had this removed en bloc (Table 31).

Bilateral oophorectomy should be performed if there is obvious malignant disease of one or both ovaries. Prophylactic bilateral oophorectomy for colon cancer cannot be supported by the available evidence. (Expert opinion)

5% of women who had surgery for colon cancer had an oophorectomy performed as part of the primary surgical procedure. This procedure was performed with prophylactic intent for 2% (Table 33).

Elective surgery for rectal cancer only

Total excision of distal mesorectum beyond the transection of the rectal wall is not recommended as a routine procedure when resecting rectal cancer until more evidence is available to establish its efficacy. (Expert opinion)

23% of patients who underwent surgery for rectal cancer (excluding the rectosigmoid) did not have the mesorectum completely excised (Table 37).

Local excision of T1 rectal cancer is effective. (Level III evidence)

2.9% of rectal cancer patients underwent local excision, of whom 69% had a T1 tumour (Table 39). 10% of T1 rectal cancers were locally excised.

Sphincter-saving operations should be preferred to abdomino-perineal resection except in the presence of: • low-level infiltrating tumours with

unfavourable histological grade; • tumours such that adequate distal

clearance (>2 cm) cannot be achieved (often an operative decision);

• the sphincter mechanism is not adequate for continence;

• access to the pelvis makes restoration technically impossible (rare).

(Level III evidence)

Sphincter-conserving surgery was achieved for 70% of patients who had surgery for rectal cancer. This figure was 90% for patients with tumours of the upper and middle thirds of the rectum, and 45% for patients with tumours of the lower third (Table 40).

Where technically feasible, the colonic pouch may be the preferred form of reconstruction after low anterior resection of tumours of the lower half of the rectum

57% of patients who had sphincter preserving surgery for rectal cancer (excluding the rectosigmoid) had a colonic pouch constructed. For


Summary NSW Colorectal Cancer Care Survey

to improve short-term postoperative neorectal function. The ideal length of the pouch lies between 5 cm and 8 cm. (Level II evidence)

patients who had a pouch constructed, the length was between 5cm and 8cm for 83% (Table 41).

Referral for chemotherapy and radiotherapy People with resected node-positive colon cancer should be offered adjuvant therapy. (Level I evidence)

59% of patients who had resection for a node-positive bowel cancer received adjuvant chemotherapy; another 16% were considered for the treatment, but did not receive it (Table 46).

Postoperative 5-FU based chemotherapy and radiotherapy (combined modality therapy) is recommended for patients with high-risk rectal cancer. (Level II evidence)

13% of patients with tumours that had penetrated beyond the full thickness of the bowel wall, or involved regional nodes received post-operative combined modality therapy. However, another 12% of these patients received combined modality therapy based on pre-operative radiotherapy (Table 54).

Management of locally advanced rectal cancer Preoperative radiation therapy, possibly with chemotherapy, is recommended in rectal cancers fixed or tethered within the pelvis if it is felt down-staging will enable successful resection. (Level II evidence)

6% of patients having surgery for locally advanced (Stage T4) tumours underwent preoperative radiotherapy. Another 20% of patients in the same group had preoperative chemotherapy and radiotherapy (Table 56).

Surgery for metastatic colorectal cancer Patients with up to four lesions that can be safely removed with an adequate margin and have no evidence of extrahepatic disease should be considered for resection. (Level III evidence)

3% of patients presenting with liver metastases at the time of diagnosis of bowel cancer underwent liver resection concurrent with bowel resection (Table 57).

Participation in clinical trials Doctors should encourage patients with colorectal cancer to consider participating in appropriate clinical trials for which they are eligible. (Expert opinion)

Between 54% and 77% of patients who were eligible for a trial were offered the opportunity to participate. However only 4%-8% of all patients in this survey participated in a trial (Figure 1).

Follow-up intentions All patients who have undergone surgery for colorectal cancer should have specialist follow up in conjunction with the patient’s general practitioner. (Expert opinion)

For 73% to 94% of patients who had had curative surgery, their surgeon intended to be involved in their follow-up (Table 59).



There was high concordance between surgical practice for colorectal cancer in NSW in 2000 and major elements of the NHMRC guidelines – preoperative colonoscopic investigation, preoperative referral for stomal therapy when a stoma is likely, prophylaxis against thromboembolic disease, antibiotic prophylaxis, avoidance of prophylactic oophorectomy, and sphincter saving surgery for rectal cancer.

On the other hand, most patients had preoperative bowel preparation despite Level II evidence that it is not beneficial and a significant minority of patients (35%) continued on prophylactic antibiotics into the postoperative period despite Level II evidence that a single preoperative dose is sufficient.

There was evidence too of poorer concordance between practice and the guidelines in areas where recommended practice has changed in recent times. Few patients with T1 rectal cancer had local excision; although there is only Level III evidence in support of this practice. Only seventy five percent of patients with resected node positive colon cancer were offered adjuvant chemotherapy, which is supported by Level I evidence, and only 25% of patients with high risk rectal cancer had combined treatment with chemotherapy and radiotherapy, for which there is Level II evidence.

Taken as a whole, these findings suggest there is generally a high degree of conformity between the surgical treatment of colorectal cancer and well established, evidence-based practice; whereas conformity is less, sometimes much less, with recommended practices for which the evidence is more recent, particularly if the evidence is not deemed to be Level I.

More effective and rapid uptake of evidence into colorectal surgical practice might be achieved by regular review and updating of the NHMRC guidelines. This should be supported by more organised and active steps of professional organisations, health services and the new NSW Cancer Institute to ensure that guidelines are communicated to surgeons in ways that have been shown to influence practice.


Background NSW Colorectal Cancer Care Survey

Background

Australia has one of the highest incidence rates of colorectal cancer in the world. In 2000 there were 12,405 new cases and 4718 deaths from the disease.1 Important advances in the last decade such as the use of “adjuvant” post-operative chemotherapy 2,3 have allowed for significant improvement in its outcomes.

Comprehensive guidelines on the management of colorectal cancer were developed by the Clinical Oncological Society of Australia (COSA) in conjunction with the Australian Cancer Network (ACN). The guidelines were then endorsed by the National Health and Medical Research Council (NHMRC) and were released in late 1999. All surgeons and oncologists in Australia have been sent a copy of these guidelines4. The guidelines are available at http://www.health.gov.au/nhmrc/publications/pdf/cp62.pdf.

The availability of such a document defining “best practice” management is an important first step towards attaining optimum care, however there is evidence that dissemination of guidelines without rigorous active implementation has not always met with success in improving practice.5

Colorectal cancer audits to date indicate that there are substantial variations between practitioners in outcomes for rectal cancer. An audit of 645 patients in Glasgow revealed wide differences in outcomes such as anastomotic leakage (0-25%), post-operative mortality (0-20%) and 10-year survival (20-63%) between 13 surgeons.6 Two large studies, in Britain and Germany, found as much as a 10-fold difference in recurrence rates for rectal cancer between individual surgeons. These individual differences remained statistically significant after adjusting for other prognostic variables.7,8 Differences in practice possibly account for this variation.

In 1990 a United States National Cancer Institute consensus conference recommended adjuvant chemotherapy as the standard of care for patients with resected Stage III (Dukes C) colon cancer.9 A report published in 1999 on 477 patients admitted to a community-based Australian hospital between 1989-1994, found that only 5% of patients with Dukes C colon cancer commenced adjuvant chemotherapy, and only 3% completed a course10.

Given the evidence indicating significant variation in colorectal cancer treatments and outcomes, together with the availability of a defined standard of care and difficulties with the implementation of clinical management guidelines, it was considered timely to obtain a baseline record of existing management practices and outcomes for this disease in New South Wales.

Some of the data from the NSW survey contributed to the National Colorectal Cancer Care Survey which was conducted on all newly diagnosed colorectal cancer patients notified to each Australian Cancer Registry between 1 February and 30 April 200011. This survey showed among other things, that there was less than 50% concordance for eight of the 23 NHMRC Guidelines analysed. Variations in the types of operation performed, participation in clinical trials, and the use of adjuvant therapy (which varied by patient’s age) were also observed. In relation to the National Cancer Institute’s recommendation, 76% of patients with Stage C colon cancer were offered chemotherapy, with 64% of patients with Stage C colon cancer receiving it.


NSW Colorectal Cancer Care Survey Coverage and Aims

Coverage

This report describes the initial treatment of colorectal cancer (excluding carcinoma in-situ) in New South Wales (NSW), Australia, predominantly in the year 2000. All detailed analyses are based on patients who had only one primary colorectal cancer treated in the episode of care that was surveyed. Most analyses include only patients who had their cancer surgically excised.

Aims

The aims of the NSW Colorectal Cancer Care Survey were to obtain a comprehensive record of the management and outcomes of patients with newly diagnosed colorectal cancer in NSW in 2000. The survey sought to determine:

1. The proportion of colorectal cancer cases in NSW managed according to recommendations in the NHMRC guidelines.

2. The variables associated with the patient, their cancer and their doctor that are associated with management that is in accordance with guideline recommendations.

3. The two-year disease free survival and overall survival rates for the patients studied.

4. The level of concordance with the guidelines and how this relates to local recurrence, cancer specific and overall survival for this cohort.

This report addresses points 1 and 2 above only.


Methods NSW Colorectal Cancer Care Survey

Methods

Questionnaires were designed to record key aspects of the management of colorectal cancer described in the NHMRC guidelines. Separate questionnaires were used to collect information pertinent to surgery (Appendix 1), chemotherapy and radiotherapy. A multidisciplinary Expert Advisory Group of clinicians provided oversight for the development of these questionnaires (Appendix 2). Completion of the questionnaires by practitioners was validated against separate abstraction of information from records in a pilot study.

Patients newly diagnosed with colorectal cancer and notified to the NSW Central Cancer Registry between 1 February 2000 and 31 January 2001 were entered into this survey. Patients were excluded if they only had benign tumours, had a previous primary colorectal cancer, were treated outside NSW or were non-Australian residents.

Practitioners who treated these patients were identified from Cancer Registry notifications and were sent the relevant questionnaires seeking information on treatment received within their speciality. The contact details of other practitioners who treated these patients were also requested. The relevant questionnaires were then sent to these practitioners.

Unreturned questionnaires were followed up with reminder letters and phone calls. Field collection was done to abstract information from patients’ medical records if a practitioner requested it. Patients were not contacted for this survey.

Data collected were entered in an Access database then analysed using SAS (Statistical Analysis System, Version 8).

Approval for the conduct of this survey was obtained from the Ethics Committees of The Cancer Council NSW and the University of Newcastle. Where necessary, ethics clearance was also obtained from Area Health Services or institutions where field collection was performed.


NSW Colorectal Cancer Care Survey Data Quality

Scope of this report This report covers aspects related to the initial surgical management of the cohort. Separate reports will cover the following aspects of colorectal cancer management and outcomes:

• Histopathology reporting • Chemotherapy • Radiotherapy • Follow-up investigations and clinical outcomes

Data Quality Representativeness of the sample This was a population based survey, so it was essential that the cases included in the study were representative of all incident colorectal cancers in NSW during the study period. Since 1972, notification of malignant neoplasms to the Cancer Registry has been a statutory requirement in NSW for all public and private hospitals, pathology laboratories, radiation oncology departments, nursing homes and the Registry of Births, Deaths and Marriages. This has led to the keeping of accurate population statistics for most malignancies. In 2000, 94% of colon cancers and 96% of rectal cancer cases had histological verification of the disease. As a rough index of the completeness of notification, the proportion of cases in NSW where the only source of notification was from a death certificate was 0.4% for colon and 0.1% for rectal cancers.12 The accrual of consecutively notified cases of colorectal cancers for a 12-month period in NSW provides a sample representative of colorectal cases in NSW. Timeliness of the cohort Although this Survey intended to record the initial management of colorectal cancer newly diagnosed in NSW in 2000, cases were accrued according to the date of first cancer notification at the NSW Central Cancer Registry rather than the date of diagnosis. The breakdown of all notifications accrued in the survey by date of diagnosis is shown in Table 2; 94% of patients were diagnosed in 2000, 4% in 2001 and 2% in 1999. Questionnaire response rate Data were obtained for 3095 (93%) of 3314 surgical questionnaires sent to surgeons. This high return rate ensures that the surgical management recorded in the survey is representative of the management of patients with colorectal cancer in NSW.


Data Quality NSW Colorectal Cancer Care Survey

Cases for which data were available and those where data were not were compared on demographic characteristics (Table 2). There were no important differences in age and sex between those cases whose treatment details were available, and those whose details were not (Table 2). Validity of surgical questionnaire Questionnaires used in this survey were designed specifically to record aspects of management covered in the NHMRC guidelines. Performance indicators were developed to measure the conformity of practice to each of the major guideline recommendations. Data items required to construct each performance indicator were then identified. Questions were designed to collect information pertinent to the data items required. Accuracy of the data collected

A pilot study was performed before commencement of the main survey to test and validate the questionnaires for collecting information on the management of colorectal cancer from patients’ treating practitioners. Sixty questionnaires were sent to practitioners in metropolitan Sydney who were identified from an earlier batch of first colorectal notifications received at the NSW Central Cancer Registry. The survey’s project coordinator validated data provided from the practitioners by checking the completed forms against information held in patients’ hospital or clinic medical records.

The discrepancies found between the questionnaire and patient records were minor and did not indicate that any modifications to the questionnaire would be required.

For the main study, a trained field officer abstracted information from patient records when practitioners were unable to fill in the questionnaires but were willing to provide access to patient records. Coverage of guideline recommendations

Most recommendations relevant to colorectal cancer surgery have been covered in this survey. They span the following topics in the NHMRC Guidelines:

• Diagnostic tests and preoperative assessment • Preparation for surgery • Elective surgery for colon cancer • Elective surgery for rectal cancer • Emergency surgery • Adjuvant therapy for colon cancer (basic demographics only) • Adjuvant therapy for rectal cancer (basic demographics only) • Recurrent and advanced rectal cancer (surgical aspects only) • Management of liver metastases (surgical aspects only)

Several recommendations in the Guidelines were not covered, and they are listed below.


NSW Colorectal Cancer Care Survey Data Quality

1. If a transfusion is required, then autologous blood is preferable to allogeneic blood for reasons of infection control and resource use. (Level III evidence)*

2. Perioperative normothermia should be maintained. (Level III evidence)

3. As it is uncommon for spread to extend more than 1cm beyond the primary neoplasm, 2cm of distal clearance should be more than adequate in most instances. (Level III evidence)

4. The rectal stump can be irrigated with normal saline immediately before anastomosis for rectal and sigmoid tumours in an attempt to eradicate malignant cells from the perianastomosis zone. (Level III evidence)

5. There is no evidence that drains to coloanal and colorectal anastomoses are either beneficial or harmful. They should be used at the surgeon’s discretion. (Level II evidence)

Recommendations numbered 1, 2, 4 and 5 above were rated by the Expert Advisory Group as being of low priority during questionnaire development and thus were excluded. Information pertinent to recommendation 3 will be available from the audit of histopathology reports for this cohort and will be the subject of a later publication. Where sections of the report are relevant to the guidelines they have been stated. When no level of evidence is given it means that the guideline is based on consensus of expert opinion. * Level I Evidence obtained from systematic review of all relevant randomised

controlled trials. Level II Evidence obtained from at least one properly designed randomised controlled

trial. Level III Evidence obtained from a well designed controlled trial without

randomisation; or from well designed cohort of case-control analytic studies, preferably from more than one centre or research group; or from multiple time-series with or without the intervention.


Results NSW Colorectal Cancer Care Survey

Results Characteristics of patients studied Details of the surgical treatment were available for 92% of the 3377 eligible patients accrued. The reasons for loss of patients from the survey are detailed in Table 1. A comparison using basic demographic information available to the NSW Central Cancer Registry indicates that there are no important differences in age and sex between those cases whose treatment details were available, and those whose details were not. Most cases had their cancer diagnosed in 2000 (Table 2). Table 1. Accrual into the survey n

New cases of colorectal cancer notified 1/2/2000 – 31/1/2001 3443

Cases excluded: 66

Practitioner indicated that the patient did not have a diagnosis of colorectal cancer 36

Treatment was administered outside of NSW 9

Patient had a previous colorectal cancer 21 Eligible cases 3377 (100%)

No questionnaire sent (unknown doctor) 63 (1.9%)

No response from practitioner 219 (6.5%)

Surgical questionnaires returned 3095 (91.6%)


NSW Colorectal Cancer Care Survey Results

Table 2. Characteristics of patients according to whether or not a

surgical questionnaire was completed Completed Questionnaire Yes No Total n % n % n % Age (years) 0-59 681 22 59 21 740 22 60-69 813 26 72 26 885 26 70-79 1034 34 98 35 1132 34 80+ 567 18 53 19 620 18 Sex Male 1776 57 165 58 1941 57 Female 1319 43 117 42 1436 43 Accessibility to health services Highly Accessible 2580 83 232 82 2812 83 Accessible 445 14 39 14 484 14 Moderately Accessible 48 2 5 2 53 2 Remote/Very Remote 22 1 6 2 28 1 Year of diagnosis 2001 122 4 16 6 138 4 2000 2900 94 259 92 3159 94 1999 73 2 7 2 80 2 Total patients 3095 92 282 8 3377 100



Characteristics of patients’ cancer

Number of primary cancers

Table 3. Number of primary cancers Number of primary cancers Patients n % 1 2914 94 2 163 5 >2 18 1 Total patients 3095 100

For simplicity and clarity of presentation in this report, all subsequent analyses are based on patients who had only one cancer. That is, patients with multiple synchronous primary cancers were excluded from the analyses.

Cancer site Approximately 60% of cancers occurred in the colon, of which the right and left colon accounted for nearly equal proportions (Table 4).

Table 4. Distribution of bowel cancers

Cancer Site Total

n % Right colon 732 25 Caecum 362 12 Ascending colon 262 9 Hepatic flexure 108 4 Transverse colon 222 8 Left colon 772 27 Splenic flexure 96 3 Descending colon 115 4 Sigmoid colon 561 19 Rectosigmoid 304 10 Rectum 884 30 Upper third 195 7 Middle third 299 10 Lower third 390 13

Total patients 2914 100

Unless stated otherwise, the convention in this report is for the rectosigmoid to be classified as part of the rectum.



The relatively even site distribution of colon cancers in men and women and a predominance of rectal cancer in men that were observed are in keeping with the current epidemiological literature on this disease (Table 5). Table 5. Distribution of cancer site by patients’ sex and age Cancer Site

Right colon

Transverse colon

Left colon

Recto-sigmoid

Rectum Total

n=732 n=222 n=772 n=304 n=884 % % % % % n % Sex Male 48 43 57 60 68 1670 57 Female 52 57 43 40 32 1244 43 Age (years) 0-59 15 18 25 21 27 649 22 60-69 23 32 27 30 26 776 27 70-79 35 30 33 32 33 962 33 80+ 27 20 15 17 14 527 18 Total (%) 25 8 27 10 30 2914 100



Extent of cancer For simplicity, we have presented cancer “stage” in terms of the extent of the cancer at diagnosis rather than in categories of any one of the staging schemes (see Appendix 3). The question used to elicit disease extent requested the respondent to “use the most accurate clinical or pathological staging information available”. For ease of reference we refer to “extent of cancer” as “stage” hereafter. Rectal cancer was generally diagnosed at an earlier stage than colon cancer (Table 6). Stage was little different between men and women and appeared unrelated to remoteness of residence (Table 7). Table 6. Distribution of cancer site by cancer stage Cancer Stage

Subm

ucos

a/ m

uscu

laris

Beyo

nd

bowe

l wall

Regi

onal

node

s

Dist

ant

met

asta

ses

Miss

ing/

un

know

n

Total n=808 n=774 n=773 n=482 n=77 % % % % % n % Cancer site Right colon 23* 33 27 16 1 732 25 Transverse colon 16 37 27 19 1 222 8 Left colon 25 24 28 20 3 772 27 Rectosigmoid 27 22 27 21 2 304 10 Rectum 37 22 25 12 4 884 30 Total (%) 28 27 27 17 3 2914 100 * Percentages in this table are row percentages

Table 7. Distribution of cancer stage by sex, age and remoteness of

residence Cancer Stage

Subm

ucos

a/ m

uscu

laris

Beyo

nd

bowe

l wall

Regi

onal

node

s

Dist

ant

met

asta

ses

Miss

ing/

un

know

n

Total n=808 n=774 n=773 n=482 n=77 % % % % % n % Sex Male 29* 26 26 16 3 1670 57 Female 26 28 27 17 2 1244 43 Age (years) 0-59 24 23 31 19 3 649 22 60-69 29 25 27 17 2 776 27 70-79 30 27 25 15 2 962 33 80+ 26 31 24 15 5 527 18 ARIA category Highly accessible 28 27 26 17 3 2423 83 Accessible 28 25 30 14 3 424 15 Moderately accessible 36 20 24 18 2 45 2 Remote/Very remote 27 27 23 23 0 22 1 Total (%) 28 27 27 17 3 2914 100 * Percentages in this table are row percentages



Caseloads of surveyed surgeons Sixty percent of patients in this survey were managed by a small proportion (17%) of surgeons who had a higher colorectal cancer caseload, ie greater than 20 cases per annum. Eighteen percent were managed by surgeons who treated fewer than 10 cases during the 12-month survey period (Table 8). Nearly two thirds of surgeons treated less than one patient per month. Patients were more likely to be treated by a higher caseload surgeon if they lived in an area with high accessibility to services and were treated in a principal referral or private hospital (Table 9). Surgeons with higher caseloads treated larger proportions of patients with rectal cancer. Surgeons’ caseloads did not seem to be related to tumour stage. Table 8. Distribution of patients and surgeons by surgeons’

caseload Surgeons Caseload* Patients Surgeons n % n % <10 537 18 174 65 10-20 627 22 47 18 21-30 535 18 22 8 31-60 645 22 17 6 >60 570 20 8 3 Total 2914 100 268 100 * Number of patients’ surgeon had in the survey Table 9. Factors associated with surgeons’ caseload Surgeons caseload <10 10-20 21-30 31-60 >60 Total n=537 n=627 n=535 n=645 n=570 % % % % % n % ARIA category of patients’ residence Highly accessible 77 70 78 92 97 2423 83 Accessible 18 29 17 7 2 424 15 Moderately accessible 3 1 2 1 1 45 2 Remote/Very remote 2 0 3 0 0 22 1 Hospital type Principal referral 27 15 32 49 41 962 33 Other public 38 48 34 16 2 797 27 Private 32 35 32 34 56 1101 38 Unknown 3 2 2 2 1 54 2 Cancer site Colon 70 62 57 55 53 1726 59 Rectum 30 38 43 45 47 1188 41 Cancer stage Submucosa/muscularis 25 28 27 26 32 808 28 Beyond bowel wall 23 29 28 25 28 774 27 Regional nodes 28 24 26 30 24 773 27 Distant metastases 19 15 17 17 14 482 17 Missing or unknown 4 3 2 2 2 77 3 Total (%) 18 22 18 22 20 2914 100



Patients who resided within the boundaries of a metropolitan Area Health Service were more likely to receive their surgical care from a practitioner with a higher caseload, compared to patients residing elsewhere (Table 10). Table 10. Distribution of surgeons’ caseload by Area Health Service of

patients’ residence Area Health Service Surgeons caseload <10 10-20 21-30 31-60 >60 Total n=537 n=627 n=535 n=645 n=570 % % % % % n % Metropolitan 50 42 54 56 87 1692 59 South Eastern Sydney 11 14 8 11 38 481 17 Central Sydney 10 4 9 18 11 307 11 South Western Sydney 9 9 12 12 0 250 9 Western Sydney 9 3 1 9 6 170 6 Wentworth 4 0 8 0 0 65 2 Northern Sydney 7 12 16 6 32 419 14 Other urban 19 16 21 34 11 599 20 Central Coast 4 2 19 4 <1 160 5 Hunter 10 13 <1 17 0 251 9 Illawarra 5 1 2 13 11 188 6 Rural 32 40 26 10 1 623 22 Far West 1 0 0 0 0 4 <1 Greater Murray 8 7 4 0 0 109 4 Macquarie 3 0 4 0 0 36 1 Mid North Coast 3 11 5 4 0 141 5 Mid Western 3 6 4 0 0 74 3 New England 4 3 5 0 0 64 2 Northern Rivers 4 10 0 4 0 110 4 Southern 3 1 2 0 <1 31 1 Unknown 3 2 2 2 1 54 2 Total (%) 18 22 18 22 20 2914 100



Characteristics of treating institutions For estimation of hospital caseload, the hospital that notified the NSW Central Cancer Registry of the admission entailing surgical treatment was regarded as the treating institution (see Appendix 4). Higher caseload hospitals were more likely to be situated in metropolitan Area Health Services. They were also more likely to be either a teaching hospital or a private hospital (Table 11). Table 11. Types of treating institutions and hospital colorectal cancer

surgical caseload Hospital caseload <25 25-50 51-95 >95 Unknown Total n=683 n=711 n=692 n=774 n=54 % % % % % n % Hospital location Metropolitan 37 50 73 75 0 1691 58 Other urban 22 5 27 25 0 567 19 Rural 41 45 0 0 0 602 21 Unknown 0 0 0 0 100 54 2 Hospital type Principal referral 2 13 60 58 0 962 33 Other public 50 51 0 12 0 797 27 Private 48 36 40 30 0 1101 38 Unknown 0 0 0 0 100 54 2 Cancer site Colon 65 60 54 59 46 1726 59 Rectum 35 40 46 41 54 1188 41 Cancer stage Submucosa/muscularis 30 27 28 25 39 808 28 Beyond bowel wall 25 28 25 28 20 774 27 Regional nodes 29 26 27 25 20 773 26 Distant metastases 13 17 17 19 19 482 16 Missing or unknown 3 2 2 3 2 77 3 Total (%) 23 24 24 27 2 2914 100



Patients residing in highly accessible areas were more likely to be treated in a metropolitan or other urban hospital. They were also more likely to be treated in a principal referral hospital (Table 12). Table 12. Treating hospital in relation to patients’ place of residence ARIA category of patient’s residence Highly

accessible Accessible Moderately

accessible Remote/

Very Remote Total

n=2423 n=424 n=45 n=22 % % % % n % Hospital location Metropolitan 68 9 22 9 1691 58 Other urban 23 4 2 0 567 19 Rural 8 85 76 86 602 21 Unknown 2 2 0 6 54 2 Hospital type Principal referral 38 7 16 9 962 33 Other public 22 54 73 64 797 27 Private 39 37 11 23 1101 38 Unknown 2 2 0 5 54 2 Total (%) 83 15 2 1 2914 100



Clinical presentation The most commonly reported presenting symptoms of bowel cancer were rectal bleeding, change in bowel habit, abdominal discomfort and anaemia. Only 5% of cancers in this survey were detected by screening. Abdominal discomfort, bowel obstruction and anaemia were more common presentations for colon cancers, whereas change in bowel habit, rectal bleeding, and rectal symptoms were more common for rectal cancers (Table 13). Table 13. Clinical presentation by cancer site Presentation Cancer Site

Colon Rectum Total n=1726 n=1188 * % % n % Screen detected 6 3 137 5 Population screening 2 1 42 1 Family history of bowel cancer 4 2 97 3 Other risk factors 3 2 83 3 Elective presentation 78 92 2444 84 Change in bowel habit 24 41 905 31 Anaemia 29 7 589 20 Stable bleeding per rectum 22 65 1152 40 Other rectal symptoms 1 14 185 6 Abdominal pain/discomfort 30 12 649 22 Symptoms from metastases 3 1 59 2 Other symptoms# 16 12 412 14 Emergency presentation 16 5 333 11 Bowel perforation 2 1 44 2 Acute bowel obstruction 14 3 280 10 Major bleeding per rectum 1 1 21 1 Total (%) 59 41 2914 100 # Some surgeons entered more than 1 response under “Other symptoms”, giving a total of 548 responses. They were re-assigned to an existing symptom category in the table above, whenever appropriate. This applied to 110 of 438 such responses. *As patients may have more than one symptom the column subtotals may be greater than the category total



Patients 80 years of age or older were less likely to have screen-detected cancers, or to be treated electively (Table 14). Table 14. Clinical presentation by age Presentation Age (years) 0-59 60-69 70-79 80+ Total n=649 n=776 n=962 n=527 % % % % n % Screen detected 5 6 5 2 137 5 Elective 84 84 85 82 2444 84 Emergency 10 10 11 16 333 11 Total (%) 22 27 33 18 2914 100 Patients in less accessible areas were less likely to have screen-detected cancers, than those in highly accessible areas (Table 15). Table 15. Clinical presentation by remoteness of residence Presentation Geographic Remoteness Highly

accessible Accessible Moderately accessible

Remote/Very Remote Total

n=2423 n=424 n=45 n=22 % % % % n % Screen detected 5 5 2 0 137 5 Elective 85 79 76 91 2444 84 Emergency 10 16 22 9 333 11 Total (%) 83 15 2 1 2914 100 Patients whose cancers were diagnosed by screening were more likely to have earlier stage cancers (Table 16). Symptoms associated with later stage cancers included abdominal pain or discomfort, bowel perforation and bowel obstruction. Rectal bleeding was associated with earlier stage cancers (data not shown). Table 16. Clinical presentation by cancer stage Presentation Cancer Stage

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Total n=808 n=774 n=773 n=482 n=77 % % % % % n % Screen detected 59* 17 18 5 1 137 5 Elective 29 27 26 15 3 2444 84 Emergency 7 29 32 29 2 333 11 Total (%) 28 27 27 17 3 2914 100 * Percentages in this table are row percentages



Pre-treatment investigations for diagnosis and staging

Cancers of the colon and rectum Guideline “Colonoscopy is the investigation of choice, but air contrast barium enema and sigmoidoscopy is an alternative to colonoscopy. Barium enema must be included with colonoscopy if colonoscopy is incomplete. (Level III evidence)” Altogether, 81% of patients had bowel imaging. Patients with an emergency presentation (eg bowel perforation or obstruction, or major lower gastrointestinal haemorrhage) were much less likely to have bowel imaging pre-operatively. Patients who had elective surgery were more likely to have imaging investigations for distant metastases than were patients who had emergency surgery or patients who had no surgery (Table 17).

Increasing age was associated with decreasing use of bowel imaging pre-operatively (Table 18).

Patients living in more remote areas were slightly less likely to have pre-operative investigations of any kind (Table 19). Table 17. Pre-treatment investigations by mode of presentation - all

patients studied Investigation Mode of presentation

Elective surgery

Emergency surgery

No surgery Total

n=2478 n=332 n=104 % % % n % No investigations performed 1 8 1 44 2 Bowel Imaging (a) Colonoscopy 85 30 82 2296 79 (b) Sigmoidoscopy with barium enema 3 3 0 81 3 Either (a) or (b) 87 32 82 2351 81 Imaging for distant metastases CT scan 53 43 36 1501 52 MRI scan 0 0 0 2 0 Abdominal/pelvic ultrasound 6 3 2 155 5 Chest X-ray 54 46 22 1511 52 Other investigations* 25 23 19 723 25 Total (%) 85 11 4 2914 100 * Other investigations were serum carcino-embryonic antigen in 300 (10%) patients and examination under anaesthesia, laparoscopy or diagnostic laparotomy in 14 patients (<1%). The 104 patients listed in Table 17 as having had no surgical procedure have been excluded from all subsequent tables unless otherwise specified. These 104 patients comprised 48 in whom an endoscopic polypectomy was considered adequate, 21 judged to be incurable, 20 judged to be medically unfit for surgery, 12 who refused surgery and 3 who left NSW before being treated.



Table 18. Pre-operative investigations by patients’ age Investigation Age (years)

0-59 60-69 70-79 80+ Total n=635 n=757 n=924 n=494 % % % % n % No investigations performed 1 1 2 2 43 2 Bowel Imaging (a) Colonoscopy 81 81 79 72 2211 79 (b) Sigmoidoscopy + barium enema 3 3 3 2 81 3 Either (a) or (b) 83 82 81 73 2266 81 Imaging for distant metastases CT scan 58 56 47 48 1464 52 MRI scan 0 <1 0 <1 2 0 Abdominal/pelvic ultrasound 7 5 6 4 153 5 Chest X-ray 52 54 54 52 1488 53 Total surgically treated (%) 23 27 33 18 2810 100 Table 19. Pre-operative investigations by remoteness of residence Investigation Geographic remoteness

Highly accessible Accessible Moderately

accessible Remote/

Very Remote

Total

n=2338 n=406 n=44 n=22 % % % % n % No investigations performed 1 2 0 5 43 2 Bowel Imaging (a) Colonoscopy 79 77 70 73 2211 79 (b) Sigmoidoscopy + barium enema 3 2 5 0 81 3 Either (a) or (b) 81 79 75 73 2266 81 Imaging for distant metastases CT scan 54 42 43 36 1464 52 MRI scan <1 0 6 0 2 <1 Abdominal/pelvic ultrasound 6 2 9 9 153 5 Chest X-ray 53 52 48 45 1581 53 Total surgically treated (%) 84 14 2 1 2810 100



Cancer of the rectum only Guideline “Endorectal ultrasound is more accurate than either CT or MRI for assessing the depth of invasion and lymph node status. It is the preferred initial method of locally staging a rectal cancer preoperatively. While endorectal ultrasound is the most accurate method to preoperatively stage rectal cancer locally, it is not necessarily indicated for all rectal cancers. Its main role will be:

• for advanced (T3–4) rectal cancers where neoadjuvant therapy is being considered;

• for small cancers in the distal rectum where a local transanal excision may be an alternative to abdomino-perineal excision of the rectum with a permanent colostomy, so accurate assessment of the depth of local tumour invasion and state of the lymph nodes is essential; and

• if neoadjuvant chemoradiotherapy or a transanal local excision is

planned.” (No guideline given; quoted from page 64 of the NHMRC guidelines).

CT scanning was used much more commonly than endorectal ultrasound in all guideline categories. High proportions of patients who had locally advanced rectal cancer, pre-operative radiotherapy or both, had a CT scan or endorectal ultrasound. The latter was rarely used without a CT scan. In contrast, just under half the patients who had transanal excision had a CT scan or endorectal ultrasound and the two were rarely used in combination. Table 20. Investigations for locoregional staging of rectal cancers Investigation

Patient categories CT Scan Endorectal Ultrasound

Either CT scan or Endorectal

Ultrasound Total % % % n Guideline categories Locally advanced cancers (T3-4) 65 8 66 634 Treated with pre-operative radiotherapy 86 25 89 167 Both locally advanced and treated with pre-operative radiotherapy

91 24 93 114

Excised transanally 33 18 48 33 All other categories 50 6 52 419 Total surgically treated for rectal cancer (%) 59 9 61 1137



Pre-operative histological confirmation of diagnosis Guideline Although this is not mentioned in the NHMRC guidelines, guidelines in the UK have recommended, “histology should be considered mandatory in a rectal cancer which might result either in permanent stoma formation or an ultra low anterior resection, or when pre-operative radiotherapy is being considered”. A pre-operative histological diagnosis of rectal cancer was obtained in 90% or more of the three guideline categories. Table 21. Patients’ who had a pre-operative histological diagnosis of

cancer Patient categories Pre-operative histological confirmation Yes No Missing Total % % % n Guideline categories Rectal cancer- lower third 93 6 1 369 Rectal cancer- permanent stoma 90 9 1 267 Rectal cancer- pre-operative radiotherapy 98 1 1 167 All other rectal cancers 82 17 1 662 All colon cancers 65 34 1 1673 Total surgically treated (%) 73 26 1 2810 * Percentages in this table are row percentages



Preparation for surgery

Pre-operative referral to a stomal therapist Guideline “All patients who have a reasonable chance of a postoperative stoma should be informed about this possibility. This includes a visit, where possible, by the stomal therapy nurse. (Level III evidence)” Ninety percent of patients who had a stoma created during elective surgery were referred to a stomal therapist pre-operatively. Table 22. Pre-operative referral to a stomal therapist Pre-operative referral to stomal therapist amongst patients who had: Total n % Guideline categories Rectal cancer surgery 1137 67 Stoma created 745 82 Stoma created during elective surgery 627 90 Stoma created during emergency surgery 118 40 All other patients 1532 12 Total surgically treated (%) 2810 36

Pre-operative bowel preparation Guideline “Randomised trials do not demonstrate a benefit from routine bowel preparation. (Level II evidence) If bowel preparation is to be used, then both polyethylene glycol preparation and sodium phosphate preparations are effective, but polyethylene glycol is more acceptable and has lower postoperative complication rates. (Level II evidence)”

Nearly all patients (96%) who had elective surgery received bowel preparation pre-operatively. Few patients who had bowel preparation were prepared with an enema. Compared to patients who had elective surgery, larger proportions of patients who had emergency surgery had an enema or no bowel preparation pre-operatively (Table 23). Table 23. Incidence of pre-operative bowel preparation Bowel Preparation Presentation Elective Emergency Total n=2478 n=332 % % n % No 4 58 288 10 Yes 96 41 2514 90 Oral only 94 32 2424 86 Enema only 1 7 40 1 Oral and enema 2 2 50 2 Missing or unknown 0 1 8 0 Total surgically treated (%) 88 12 2810 100



Thromboembolism prophylaxis Guideline “All patients undergoing surgery for colorectal cancer should receive prophylaxis for thromboembolic disease. Unfractionated heparin, low molecular weight heparin, and intermittent calf compression are effective in reducing the incidence of thromboembolism. (Level I evidence)”

Ninety eight percent of patients who had surgery received prophylaxis against thromboembolism. Heparin and calf compression with or without graduated stockings was the commonest prophylactic regimen. Less than 2% of patients received neither heparin nor calf compression. Table 24. Incidence of thromboembolic prophylaxis Use of thromboembolic prophylaxis Total n % No 26 1 Yes 2767 98 Heparin only 232 8 Calf compression only 50 2 Graduated (TED) stockings only 14 1 Heparin and calf compression +/- stockings 2169 77 Heparin plus stockings only 229 8 Graduated (TED) stockings and calf compression only 72 3 Other only 1 0 Missing or unknown 17 1 Total surgically treated 2810 100



Antibiotic prophylaxis Guideline “All patients undergoing colorectal cancer surgery require prophylactic antibiotics. (Level I evidence) A single preoperative dose of intravenous second or third generation cephalosporin and metronidazole is an effective regime. (Level II evidence)” Ninety four percent of patients received pre-operative antibiotic prophylaxis (Table 25). Only a minority (28%) received a combination of a cephalosporin and an imidazole. Treatment was continued post-operatively in over a third of cases, contrary to the guidelines (Table 26). Table 25. Incidence of antibiotic prophylaxis Use of antibiotic prophylaxis Total n % No 153 5 Yes 2638 94 Cephalosporin only 817 29 Cephalosporin and imidazole 800 28 Cephalosporin plus other 122 4 Imidazole only 28 1 Aminoglycoside only 82 3 Aminoglycoside plus imidazole 766 27 Other only 23 1 Missing or unknown 19 1 Total surgically treated 2810 100 Table 26. Duration of antibiotic use Dose Total n % Single dose 1657 63 >1 dose 974 37 Missing or unknown 7 0 Total patients receiving antibiotic prophylaxis 2638 100



Initial surgical management

Intention of surgery Eighty three percent of patients were treated with curative intent. In the remaining 477 patients treatment was palliative because of known distant metastases (82%), incomplete resection of the cancer (9%) and for other reasons (10%). Patients were less likely to have curative surgery if they presented as an emergency and least likely if they had metastatic cancer. Patients had surgery with curative intent irrespective of their age (Table 27). Table 27. Factors determining surgical intentions Intention of surgery Palliative Curative Total n=477 n=2333 % % n % Cancer stage Submucosa/muscularis 0* 100 767 27 Beyond bowel wall 3 97 773 28 Regional nodes 6 94 773 28 Distant metastases 88 12 456 16 Unknown or missing 12 88 41 1 Age (years) 0-59 19 81 635 23 60-69 17 83 757 27 70-79 16 84 924 33 80+ 16 84 494 18 Presentation Elective 15 85 2478 88 Emergency 33 67 332 12 Total surgically treated (%) 17 83 2810 100 * Percentages in this table are row percentages



Surgery for primary colon cancer Guideline “Resection of colon cancer should be based on appropriate excision of the lymphovascular drainage of the segment of the colon in which the cancer is situated. Resection, where feasible, should be to the origin of the major segmental blood vessels. The amount of colon resected should correspond to the extent of vascular and lymphatic clearance. (Expert opinion)” A total of 1673 patients who were surgically treated for colon cancer had a procedure aimed at curative or palliative treatment of the primary cancer. Surgical procedures are detailed in Tables 28-30. Table 28. Surgical treatment of primary colon cancer Procedure Cancer Site

Right Colon Transverse

Colon Left Colon Total n=725 n=218 n=730 % % % n % Defunctioning stoma only <1 0 1 7 <1 Laparotomy/laparoscopy only 0 0 1 4 <1 Sigmoid colectomy 0 0 21 152 9 Segmental resection <1 17 2 53 3 Right hemicolectomy 92 21 1 724 43 Extended right hemicolectomy 4 50 4 167 10 Left hemicolectomy <1 6 21 168 10 Extended left hemicolectomy 0 1 2 17 1 Subtotal colectomy 1 3 3 39 2 Total colectomy 1 3 1 20 1 Total proctocolectomy <1 <1 <1 4 <1 Hartmann’s procedure 0 0 8 59 4 High anterior resection 0 0 32 231 14 Low anterior resection 0 0 2 17 1 Ultra low anterior resection 0 0 <1 2 <1 Abdomino-perineal resection <1 0 <1 2 <1 Other only <1 0 1 7 <1 *Total surgically treated for colon cancer (%) 43 13 44 1673 100 * Includes 131 patients who underwent an additional procedure, they include: 1 segmental resection, 4 sigmoid colectomy, 14 anterior resection, 7 insertion of hepatic arterial catheter, 9 liver resection of which 2 patients also had catheter insertion, 96 patients had a surgical procedure that was classified as ‘other’



Table 29. Surgical treatment of primary colon cancer by stage Procedure Cancer Stage

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Total n=372 n=514 n=468 n=302 n=17 % % % % % n % Defunctioning stoma only 0 <1 <1 2 0 7 <1 Laparotomy/laparoscopy only 0 0 0 1 0 4 <1 Sigmoid colectomy 12 7 8 11 18 152 9 Segmental resection 2 3 3 5 0 53 3 Right hemicolectomy 45 48 40 38 35 724 43 Extended right hemicolectomy 6 13 9 10 6 167 10 Left hemicolectomy 9 11 11 9 12 168 10 Extended left hemicolectomy 1 1 1 1 0 17 1 Subtotal colectomy 3 2 2 3 12 39 2 Total colectomy 2 1 1 1 0 20 1 Total proctocolectomy <1 <1 <1 0 0 4 <1 Hartmann’s procedure 1 3 5 7 0 59 4 High anterior resection 17 11 17 11 18 231 14 Low anterior resection 1 1 2 1 0 17 1 Ultra low anterior resection <1 <1 0 0 0 2 <1 Abdomino-perineal resection <1 0 <1 0 0 2 <1 Other only 1 <1 <1 1 0 7 <1 Total surgically treated for colon cancer (%) 22 31 28 18 1 1673 100 Table 30. Surgical treatment of primary colon cancer by presentation Procedure Surgery type

Elective Emergency Total n=1400 n=273 % % n % Defunctioning stoma only <1 1 7 <1 Laparotomy/laparoscopy only <1 0 4 <1 Sigmoid colectomy 10 5 152 9 Segmental resection 3 4 53 3 Right hemicolectomy 46 30 724 43 Extended right hemicolectomy 8 21 167 10 Left hemicolectomy 10 9 168 10 Extended left hemicolectomy 1 1 17 1 Subtotal colectomy 2 7 39 2 Total colectomy 1 1 20 1 Total proctocolectomy <1 <1 4 <1 Hartmann’s procedure 1 16 59 4 High anterior resection 16 5 231 14 Low anterior resection 1 <1 17 1 Ultra low anterior resection <1 0 2 <1 Abdomino-perineal resection <1 0 2 <1 Pelvic exenteration 0 0 0 0 Other only <1 1 7 <1 Total surgically treated for colon cancer (%) 84 16 1673 100



Management of cancers attached to contiguous structures Guideline “For fixed tumours, en bloc resection of primary colonic cancer, together with the attached organ or the abdominal wall, should be performed in an attempt to obtain a curative resection. No attempt should be made to assess if the attachment is benign or malignant at the time of surgery. (Expert opinion)” Two hundred and sixty nine or 16% of cases who had surgery for colon cancer were found to have cancers adhering to adjacent structures. En bloc removal was done in most of them. Table 31. Management of cancers attached to contiguous structures Surgical management Total n % En bloc removal 193 72 Removed piecemeal 17 6 Incomplete resection 40 15 No resection 19 7 Total patients with colon cancers adhering to adjacent structures 269 100

Surgical access The NHMRC Guidelines note that “There are no prospective randomised studies that are suitable to support the case for or against laparoscopic-assisted procedures for colon cancer.” One percent of patients who had surgical treatment for colon cancer had laparoscopic surgery (Table 32).

Table 32. Mode of surgical access Mode Total n % Laparotomy 1649 99 Laparoscopy 22 1 Unknown 2 0 Total surgically treated for colon cancer 1673 100



Oophorectomy Guideline “Bilateral oophorectomy should be performed if there is obvious malignant disease of one or both ovaries. Prophylactic bilateral oophorectomy for colon cancer cannot be supported by the available evidence. (Expert opinion)” Five percent of women who had surgery for colon cancer had an oophorectomy performed as part of the primary surgical procedure (Table 33). In 2% of these cases (13 women) the oophorectomy was said to be prophylactic, contrary to the guideline. Table 33. Incidence and intention of oophorectomy Oophorectomy Total n % No 728 89 Yes 39 5 Prophylaxis 13 2 Ovary(ies) clinically involved 26 3 Missing or unknown 50 6 Total women with colon cancer 817 100



Surgery for rectal cancer Guideline “Total excision of distal mesorectum beyond the transection of the rectal wall is not recommended as a routine procedure when resecting rectal cancer until more evidence is available to establish its efficacy. (Expert opinion)” A total of 1137 patients who were surgically treated for rectal cancer had a procedure aimed at curative or palliative treatment of the primary cancer. Surgical procedures are detailed in Tables 34-36. Table 34. Surgical treatment of primary rectal cancer Procedure Cancer Site

Rectosigmoid

Rectum Upper Third

Rectum Middle

Third

Rectum Lower Third Total

n=296 n=184 n=288 n=369 % % % % n % Defunctioning stoma only 1 2 1 2 15 1 Laparotomy/laparoscopy only <1 0 0 <1 2 <1 Local excision 0 0 1 8 32 3 Sigmoid colectomy 2 0 0 0 6 1 Right hemicolectomy <1 0 <1 0 2 <1 Left hemicolectomy 2 0 0 0 5 <1 Extended left hemicolectomy <1 0 0 0 1 <1 Subtotal colectomy 0 1 0 0 1 <1 Total colectomy 1 0 <1 0 3 <1 Total proctocolectomy <1 2 1 1 9 1 Hartmann’s procedure 9 9 7 1 70 6 High anterior resection 63 23 1 0 232 20 Low anterior resection 20 57 42 5 302 27 Ultra low anterior resection 1 5 42 30 247 22 Abdomino-perineal resection 0 1 3 52 201 18 Pelvic exenteration 0 1 0 1 3 <1 Liver resection 0 0 <1 0 1 <1 Other only 1 1 1 0 5 <1 *Total surgically treated for rectal cancer (%) 26 16 25 26 1137 100 * Includes 61 patients that underwent another procedure. They include: 1 local excision,1 sigmoid colectomy, 6 hemicolectomy, 6 insertion of hepatic arterial catheter, 8 liver resection (includes 1 patient that had catheter insertion), 2 pelvic exenteration. 39 patients had a procedure classified as ‘other’.



Table 35. Surgical treatment of primary rectal cancer by stage Procedure Cancer Stage

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n=395 n=259 n=305 n=154 n=24 % % % % % n % Defunctioning stoma only 0 1 <1 6 13 15 1 Laparotomy/laparoscopy only 0 <1 0 1 0 2 <1 Local excision 8 0 0 1 0 32 3 Sigmoid colectomy <1 0 <1 2 0 6 1 Right hemicolectomy <1 0 0 1 0 2 <1 Left hemicolectomy 1 0 <1 0 4 5 <1

1 <1 Extended left hemicolectomy 0 0 <1 0 0 Subtotal colectomy <1 0 0 0 0 1 <1 Total colectomy 1 0 <1 0 0 3 <1 Total proctocolectomy 1 1 1 1 0 9 1 Hartmann’s procedure 2 7 8 14 0 70 6 High anterior resection 19 20 20 26 8 232 20 Low anterior resection 22 30 31 25 17 302 27 Ultra low anterior resection 26 23 20 12 21 247 22 Abdomino-perineal resection 20 17 17 11 33 201 18 Pelvic exenteration 0 1 0 1 0 3 <1 Liver resection 0 0 <1 0 0 1 <1 Other only 1 0 0 1 4 5 <1 Total surgically treated for rectal cancer (%) 35 23 27 14 2 1137 100

Table 36. Surgical treatment of primary rectal cancer by presentation Procedure Surgery type

Elective Emergency Total n=1078 n=59 % % n % Defunctioning stoma only 1 3 15 1 Laparotomy/laparoscopy only <1 0 2 <1 Local excision 3 2 32 3 Sigmoid colectomy 1 0 6 1 Right hemicolectomy <1 0 3 <1 Left hemicolectomy <1 2 5 <1 Extended left hemicolectomy <1 0 1 <1 Subtotal colectomy <1 0 1 <1 Total colectomy <1 0 3 <1 Total proctocolectomy 1 2 9 1 Hartmann’s procedure 4 42 70 6 High anterior resection 20 25 232 20 Low anterior resection 28 8 302 27 Ultra low anterior resection 23 3 247 22 Abdomino-perineal resection 18 8 201 18 Pelvic exenteration <1 2 3 <1 Liver resection <1 0 1 <1 Other only <1 2 5 <1 Total surgically treated for rectal cancer (%) 95 5 1137 100



Extrafascial dissection was carried out in a very high proportion of rectal cancers with little variation by level of the cancer. Sphincter preservation was achieved in 72% of cases and in over 90% when the cancer was in the upper or middle third of the rectum. Patients with more distal tumours were more likely to have total mesorectal excision, contrary to the Guidelines but reflective of more recent evidence. Less than a third of cases with a tumour of the lower two thirds of the rectum had a colonic pouch created. Small bowel isolation was undertaken in about 8% of cases undergoing surgery for cancer of the rectum (Table 37). Table 37. Specific aspects of surgical treatment of rectal cancer,

excluding rectosigmoid cancer * Procedure Rectal cancer site

Upper third

Middle third

Lower third

Total

n=184 n=288 n=369 % % % n % Extrafascial dissection Yes 86 90 84 727 86 No 8 6 11 72 9 Uncertain 5 4 4 38 5 Missing data 1 1 1 4 0 Complete excision of mesorectum Yes 46 76 79 593 71 No 48 17 15 194 23 Uncertain 5 6 6 49 6 Missing data 1 0 1 5 1 Colonic pouch Yes 6 34 21 185 22 No 86 64 64 578 69 Not applicable 7 2 14 70 8 Missing data 1 0 2 8 1 Small bowel isolation No 91 91 87 751 89 Omental sling 5 5 5 41 5 Mesh 0 0 1 4 0 Other 3 3 4 27 3 Missing data 1 1 3 18 2 Sphincter Preservation Yes 94 93 44 602 72 No 3 6 52 214 25 Missing data/invalid response 3 2 4 25 3 Total surgically treated for rectal cancer (%) 22 34 44 841 100 * This information was not collected for 296 cases where the cancer was located in the rectosigmoid.



Extrafascial dissection was more often done by higher caseload surgeons. Patients who had palliative surgery were less likely to have extrafascial dissection (Table 38). Table 38. Frequency of extrafascial dissection by surgeons’ caseload,

hospital characteristics and surgical intention * Extrafascial dissection

Yes No Uncertain Missing Total n=727 n=72 n=38 n=4 % % % % n % Surgeons’ colorectal cancer caseload

<10 72† 19 9 0 89 11 10-20 87 8 4 1 159 19 21-30 83 9 7 1 161 19 31-60 90 7 3 0 222 26 >60 91 6 3 0 210 25 Hospital location Metropolitan 88 8 4 1 505 60 Other urban 86 11 3 0 156 19 Rural 83 9 7 1 161 19 Unknown 89 11 0 0 19 2 Hospital type Principal referral 91 6 3 0 294 35 Other public 86 6 8 1 200 24 Private 83 13 4 1 328 40 Unknown 90 11 0 0 19 2 Surgical intention Cure 90 6 4 0 740 88 Palliation 61 27 10 2 101 12 Total surgically treated for rectal cancer (%) 86 9 5 0 841 100 * This information was not collected for 296 cases where the cancer was located in the rectosigmoid. † Percentages in this table are row percentages



Local excision Guideline “Local excision of T1 rectal cancer is effective. (Level III evidence) Local excision of rectal cancers can only be a curative procedure if there are no lymph node metastases. Predicting nodal involvement remains difficult, therefore radical transabdominal resection remains the treatment of choice in patients with rectal cancer. (Level III evidence)

In less fit patients, or where the alternative is abdomino-perineal resection and permanent colostomy, local excision has a role in managing rectal cancer. However in such patients, only a small percentage (5 –10%) of rectal cancers meet recommended guidelines for local therapy. These guidelines are:

• mobile tumour <3 cm • T1 on endoanal ultrasound • well-differentiated on histology (biopsy). (Level III evidence)”

In only 2.9% (33/1137) of rectal cancer patients was the cancer excised locally. Two thirds of these patients had T1 cancers, the remainder had T2 cancers (except for one patient with distant metastases) (Table 39). Less than half the patients had pelvic imaging before the procedure. Table 39. Local excision of rectal cancer by patients’ characteristics Characteristics Total n % Age (years) 0-59 3 9 60-69 5 15 70-79 16 49 80+ 9 27 Cancer site in rectum Rectosigmoid 1 3 Upper third 0 0 Middle third 3 9 Lower third 29 88 Pre-operative locoregional staging investigations Endorectal ultrasound 6 18 Abdomino-pelvic CT scan 11 33 Abdomino-pelvic MRI scan 0 0 None of the above 17 52 Surgical intention Cure 30 91 Palliation 3 9 Presence of distant metastases at diagnosis 1 3 Local tumour (T) stage for cases without distant metastases T1 22 69 T2 10 31 T3 0 0 Locoregional nodal (N) stage for cases without distant metastases Negative 5 16 Positive 0 0 Not known to surgeon 26 81 Information missing from questionnaire 1 3 Total rectal cases that underwent local excision 33 100



Sphincter preservation Guideline “Sphincter-saving operations should be preferred to abdomino-perineal resection except in the presence of:

• low-level infiltrating tumours with unfavourable histological grade • tumours such that adequate distal clearance (>2 cm) cannot be

achieved (often an operative decision) • the sphincter mechanism is not adequate for continence • access to the pelvis makes restoration technically impossible (rare) (Level III evidence)”

Sphincter preservation was achieved in 72% of patients treated surgically for rectal cancer (Table 37), and in 93% when the cancer was in the upper or middle third (44% lower third). A temporary stoma was required for 34% of patients with rectal cancer who had surgery, 30% required a permanent stoma (Table 40). The most common reason given for a stoma was the proximity of the cancer to the anal verge (data not shown). Older patients appeared less likely to have any stoma, particularly a temporary stoma. Patients with distant metastases were more likely to have a permanent stoma than patients with less extensive disease. Table 40. Determinants of stoma type amongst rectal cancer cases * Stoma type

None Temporary Permanent Missing Total % % % % n % Age (years) 0-59 29† 42 29 1 235 28 60-69 33 39 27 0 227 27 70-79 38 30 31 0 277 33 80+ 46 18 36 0 102 12 Cancer stage Submucosa/muscularis 41 31 27 1 317 38 Beyond bowel wall 31 39 29 1 191 23 Regional nodes 34 38 28 0 223 27 Distant metastases 33 25 41 1 91 11 Missing or unknown 5 47 47 0 19 2 Complete excision of mesorectum Yes 25 40 34 1 593 71 No 67 20 13 0 194 23 Uncertain 29 27 45 0 49 6 Missing data 25 50 25 0 5 1 Cancer site

23 1 10 0 288 34

44

Upper third 66 10 184 22 Middle third 42 48 Lower third 14 30 55 1 369 Total surgically treated for rectal cancer (%) 34 35 30 0 841 100 * This information was not collected for 296 cases where the cancer is located in the rectosigmoid † Percentages in this table are row percentages



Colonic pouch

Total

Guideline “Where technically feasible, the colonic pouch may be the preferred form of reconstruction after low anterior resection of tumours of the lower half of the rectum to improve short-term postoperative neorectal function. (Level II evidence) The ideal length of the pouch lies between 5 cm and 8 cm. (Level III evidence)” Fifty seven percent of patients who had a sphincter preserving operation for cancer of the lower third of the rectum also had a colonic pouch constructed. This figure was 38% when the cancer was in the middle third of the rectum. In 83% the pouch length was 5 to 8cms (Table 41). Table 41. Length of colonic pouch in patients who had a pouch

constructed Colonic pouch length (cm) n %

3

<5 3 2 5-8 153 83 >8 2 Missing length 26 14 Total surgically treated for rectal cancer who had colonic pouch 185 100



Emergency surgery Guideline “A clinical diagnosis of large bowel obstruction is to be confirmed by a plain radiograph of abdomen and a limited gastrografin enema and sigmoidoscopy (preferably flexible) to exclude pseudo-obstruction. (Level III evidence)

For left-sided obstructing cancer, the lesion is resected, either as a Hartmann’s procedure with an end colostomy or as a subtotal colectomy and ileocolic or ileorectal anastomosis. Segmental resection and anastomosis may be performed, if preceded by intraoperative on-table colonic lavage. (Level II evidence)” Emergency presentation is defined as a presentation with acute bowel obstruction, perforation or massive lower gastrointestinal haemorrhage. The pre-operative management of patients presenting as an emergency is covered in Tables 17, 22 and 23, surgical treatment in Tables 30 and 36, and post-operative complications in Table 44. Thirty five percent of emergency patients had a Hartmann’s procedure and a further 9% had a Subtotal colectomy (Table 42). Table 42. Surgical treatment of primary cancers in patients with a left-

sided obstructing cancer Procedure Total %* n

9 Segmental resection

14

18

†Other surgical procedure

Total cases with obstructing left-sided cancer

Hartmann’s procedure 53 35 Subtotal colectomy 14

3 2 Sigmoid colectomy 16 10 Right hemicolectomy 4 3 Extended right hemicolectomy 14 9 Left hemicolectomy 21 Extended left hemicolectomy 2 1 Total colectomy or proctocolectomy 1 1 High anterior resection 28 Low anterior resection 5 3

10 7 Defunctioning stoma only 4 3

153 100

*Column total exceeds 100% as some patients have undergone more than one procedure † 10 ‘other’ procedures include: 4 excisions of adjacent organs, 1 appendectomy, 2 other minor procedures, 2 biopsies, and 1 gynaecological procedure other than oophorectomy.



Surgical complications The reported rate of complications was low. Generally the anastomotic leakage rate was low. There was a slightly higher incidence of anastomotic leakage for rectal cancer patients who underwent surgery than colon cancer patients (Table 43). Patients having emergency surgery had higher complication (especially wound infection) and fatality rates than those having elective surgery (Table 44). Table 43. Complications of surgery by site of primary cancer Complication Cancer site

Colon Rectum Total n=1673 n=1137 % %

77

†Minor anastomotic leak 29 1 †Major anastomotic leak 1 Deep venous thrombosis

1

#Multiple complications

60

n % No complication 79 74 2156 Wound infection 5 5 133 5

1 2 1 2 34 0 1 11 0

Pulmonary embolus 1 1 33 *Other complications 12 15 361 13 Death 2 1 43 2

0 1 15 1 Total surgically treated (%) 40 2810 100 † Re-operation or death distinguishes a major anastomotic leak from a minor one * The most common ‘other’ complication is cardiac complications. Others include ileus or bowel obstruction, respiratory complications, infection, renal or urological complications and wound complication. # Includes 10 patients with wound infection, 6 of those with an anastomotic leak and 9 of those with thromboembolism.

Table 44. Complications of surgery by surgical intervention Complication Surgical intervention Elective Emergency Total n=2478 n=332 % % n % No complication 78 66 2156 77

Minor anastomotic leak 34 1 11 0

Pulmonary embolus 1 33 1 12

88

Wound infection 4 8 133 5 1 2 29 1

Major anastomotic leak 1 1 Deep venous thrombosis 0 1

1 Other complications 16 361 13 Death 1 5 43 2 Multiple complications 0 1 15 1 Total surgically treated (%) 12 2810 100



Use of chemotherapy and radiotherapy for colon cancer

Forty one percent of patients with colon cancer who had regional lymph node involvement did not receive adjuvant chemotherapy (Table 45).

Guideline “People with resected node-positive colon cancer should be offered adjuvant therapy. (Level I evidence) The value of adjuvant therapy in Dukes B (stage II) colon cancer has not been demonstrated uniformly. Adjuvant therapy in this group is not recommended except for patients with ‘poor prognosis’ stage II disease who, after discussion, wish to have treatment of entry into an appropriate clinical trial, which is recommended. (Level II evidence)”

Younger patients were more likely to have adjuvant chemotherapy than older patients (Table 46). Table 45. Chemotherapy referral for colon cancer by cancer stage Cancer stage Chemotherapy referral

No* Yes Total Patient

declined Not

treated Treated

n=951 n=64 n=135 n=523 % % % % n % Submucosa/muscularis 95 1 2

73 Regional nodes

30 Missing or unknown 17 1

3 372 22 Beyond bowel wall 3 8 16 514 31

26 9 7 59 468 28 Distant metastases 2 16 52 302 18

76 6 0 18

Total surgically treated (%) 57 4 8 31 1673 100 * Includes 85 (5 %) patients in which chemotherapy referral was either missing or unknown



Table 46. Chemotherapy referral for patients with node positive colon

cancer by patient characteristics Cancer stage Chemotherapy referral


declined Not

treated Treated

n=120 n=40 n=34 n=274 % %

2

% % n % Age (years) 0-59 8 6 84 109 23 60-69 19 3 4 74 126 27 70-79 29 14 8 49 147 31 80+ 51 16 13 20 86 18 ARIA category Highly Accessible 25 10 8 58 385 82 Accessible 29 4 4 63 75 16 Moderately Accessible 40 0 20 40 5 1 Remote/Very Remote 50 0 0 50 3 1 Total surgically treated (%) 26 9 7 59 468 100 * Includes 25 (5 %) patients in which chemotherapy referral was either missing or unknown Table 47. Radiotherapy referral for colon cancer by cancer stage Cancer stage Radiotherapy referral


declined Not

treated Treated

n=1624 n=9 n=22 n=18

Submucosa/muscularis 0 1 0 372 22

468 302

100 0 0 0

% % % % n %

99 Beyond bowel wall 98 0 1 1 514 31 Regional nodes 95 1 2 2 28 Distant metastases 96 1 2 1 18 Missing or unknown 17 1 Total surgically treated (%) 97 1 1 1 1673 100 * Includes 117 (7%) patients in which radiotherapy referral was either missing or unknown



Table 48. Chemotherapy and radiotherapy given to colon cancer

patients by cancer stage Cancer Stage

Subm

ucos

a/ m

uscu

laris

Beyo

nd

bowe

l wall

Regi

onal

node

s

Dist

ant

met

asta

ses

Miss

ing/

un

know

n

Total

n=372 n=514 n=468 n=302 n=17 % % % % % n % No adjuvant therapy* 98 83 41 48 82 1146 69 Radiotherapy only 0 <1 <1 <1 0 4 0

<1 Post-operatively 0 <1 <1 0 4 0 Chemotherapy only 2 16 57 51

30 Pre & post-operatively 0 0

18 509 30 Post-operatively 2 16 57 50 18 506

0 0 0 1 3 Combined modality therapy 0 1 2 1 0 14 1 Post-operatively 0 1 1 1 0 12 <1 Pre-op XRT & post-op chemo 0 0 <1 0 0 1 0 Post-op XRT & pre-op & post-op chemo 0 0 0 <1 0 1 0 Total surgically treated (%) 22 31 28 18 1 1673 100 * Includes 18 (2 %) and 26 (2 %) patients in which chemotherapy and radiotherapy referral respectively was missing or unknown



Table 49. Chemotherapy and radiotherapy given to colon cancer

patients by Area Health Service Area Health Service Chemotherapy and radiotherapy given None Radiotherapy

only Chemotherapy

only Combined

Modality Total n=1146 n=4 n=509 n=14 % % %

South Eastern Sydney 70† 1 28 1

41 9 Western Sydney 0 95 6 Wentworth 61

0 0

24 159 10 6

21

Far West 70

0

0 3

1 4

<1

% n %

Metropolitan 67 <1 31 1 966 58 2 272 16

Central Sydney 72 28 0 163 10 South Western Sydney 58 1 1 149

67 32 1 3 36 0 36 2

Northern Sydney 68 0 31 <1 251 15 Other urban 71 29 0 346 21 Central Coast 63 37 0 81 5 Hunter 76 0 0 Illawarra 69 0 31 0 106 Rural 69 0 29 2 339

0 0 100 0 2 <1 Greater Murray 0 26 4 57 3 Macquarie 61 39 0 28 2 Mid North Coast 67 0 33 0 78 5 Mid Western 78 20 40 2 New England 70 0 27 2 44 3 Northern Rivers 69 0 30 74 Southern 75 0 19 6 16 1 Unknown 77 0 23 0 22 1 Total (%) 69 30 1 1673 100

† Percentages in this table are row percentages



Use of chemotherapy and radiotherapy for rectal cancer Guideline “Postoperative 5-FU based chemotherapy and radiotherapy (combined modality therapy) is recommended for patients with high-risk rectal cancer. (Level II evidence)” High-risk rectal cancer is defined as cancer that involves the full thickness of the bowel wall or involves regional lymph nodes. Forty eight percent of patients with high-risk rectal cancer (including rectosigmoid cancer) received chemotherapy (Table 51).

Thirty three percent of patients with high-risk rectal cancer received radiotherapy. Patients who did not undergo extrafascial dissection were more likely to receive adjuvant radiotherapy (Table 53).

Twenty six percent of high-risk rectal cancer patients received combined modality therapy. In just over half of these patients radiotherapy was given post-operatively (Table 54). Table 50. Chemotherapy referral for rectal cancer by cancer stage Cancer stage Chemotherapy referral


declined Not

treated Treated

n=155 n=14 n=26 n=101

Submucosa/muscularis 96† 1 High-Risk 8

9 68 23

51 5 2

Submucosa/muscularis 35

5 19

% % % % n % Rectosigmoid cancers

0 3 78 26 41 7 44 150 51

Beyond bowel wall 66 9 16 Regional nodes 21 7 5 67 82 28 Distant metastases 22 2 25 63 21 Missing or unknown 80 0 0 20 Other rectal cancers n=460 n=34 n=50 n=297

91 1 2 6 317 38 High-Risk 6 9 50 414 50 Beyond bowel wall 60 5 5 30 191 23 Regional nodes 13 7 12 67 223 27 Distant metastases 23 4 9 64 91 11 Missing or unknown 32 0 63 2 Total surgically treated (%) 54 4 7 35 1137 100 * Includes 18 (2 %) patients in which chemotherapy referral was missing or unknown † Percentages in this table are row percentages



Table 51. Chemotherapy referral of patients with high-risk rectal cancer

by patients’ characteristics Cancer stage Chemotherapy referral No* Yes Total Patient

declined Not

treated Treated

n=207 n=38 n=46 n=273 % % % % n % Age (years) 0-59 21 1 7 71 159 28 60-69 33 2 5 60 144 26 70-79 40 10 13 38 182 32 80+ 68 19 6 6 79 14 Accessibility to health services Highly Accessible 39 7 8 47 458 81 Accessible 26 8 9 57 89 16 Moderately Accessible 33 0 17 50 12 2 Remote/Very Remote 40 0 0 60 5 1 Total surgically treated (%) 37 7 8 48 564 100 * Includes 8 (1%) patients in which chemotherapy referral was missing or unknown

Table 52. Radiotherapy referral for rectal cancer by cancer stage Cancer stage Radiotherapy referral


declined Not

treated Treated n=265 n=9 n=8 n=14

Submucosa/muscularis 99† 0

21

% % % % n % Rectosigmoid cancers

1 0 78 26 High-Risk 87 4 3 7 150 51 Beyond bowel wall 88 6 0 6 68 23 Regional nodes 85 2 5 7 82 28 Distant metastases 86 3 6 5 63 Missing or unknown 80 0 0 20 5 2 Other rectal cancers n=499 n=31 n=44 n=267 Submucosa/muscularis 82 2 4 13

68 19

317 38 High-Risk 46 5 7 42 414 50 Beyond bowel wall 57 4 3 37 191 23 Regional nodes 37 7 9 47 223 27 Distant metastases 48 3 5 43 91 11 Missing or unknown 26 0 5 2 Total surgically treated (%) 67 4 5 25 1137 100 * Includes 26 (2 %) patients in which radiotherapy referral was missing or unknown † Percentages in this table are row percentages



Table 53. Radiotherapy referral of patients with high-risk rectal cancer

by patients’ characteristics Cancer stage Radiotherapy referral No* Yes Total Patient

declined Not

treated Treated

n=321 n=28 n=31 n=184 % % % % n % Age (years) 0-59 52 2 5 41 159 28 60-69 55 2 5 38 144 26 70-79 54 7 7 32 182 32 80+ 77 11 5 6 79 14 ARIA category Highly Accessible 58 5 5 32 458 81 Accessible 6 6 34

25 55 89 16

Moderately Accessible 33 0 42 12 2 Remote/Very Remote 40 0 60 0 5 0 Extrafascial dissection# n=191 n=22 n=27 n=174 414 100 Yes 47 6 6 41 381 92 No 31 0 6 63 16 4 Uncertain 31 0 13 56 16 4 Missing data 100 0 0 0 1 0 Total surgically treated (%) 57 5 6 33 564 100 * Includes 15 (3 %) patients in which radiotherapy referral was missing or unknown # Excludes 150 patients with rectosigmoid cancer



Table 54. Chemotherapy and radiotherapy given to rectal cancer

patients by cancer stage Cancer Stage

Subm

ucos

a/ m

uscu

laris

High

-Risk

Beyo

nd

bowe

l wall

Regi

onal

node

s

Dist

ant

met

asta

ses

Miss

ing/

un

know

n

Total n=395 n=564 n=259 n=305 n=154 n=24 % % % % n % % No adjuvant therapy* 89 45 63 29 38 42 674 59 Radiotherapy only 5 7 10 4 Pre-operatively 4 4

2

3 4 65 6 5 7 3 2 46 4

Post-operatively 1 2 3 1 1 0 19 Chemotherapy only 1 23 8 35 34

0 <1 0

0 0

0 182 16 Pre-operatively 0 <1 1 0 2 Post-operatively 1 22 8 34 34 0 180 16 Pre & post-operatively 0 0 0 0 0 0 Combined modality therapy 5 26 18 32 24 54 216 19 Pre-operatively 3 6 9 4 5 38

10 4 3 4 20 2

Pre-op XRT & pre-op & post-op chemo 1 0

0 0

63 6 Post-operatively 1 13 4 21 4 93 8 Pre-op XRT & post-op chemo 0 2 1

1 4 4 4 6 8 38 3 Post-op XRT & pre-op chemo 0 0 0 0 1 0 Post-op XRT & pre-op & post-op chemo <1 0 <1 0 1 0 Total surgically treated (%) 35 50 23 27 14 2 1137 100 * Includes 18 (2 %) and 26 (2 %) patients in which chemotherapy and radiotherapy referral respectively was missing or unknown.



Table 55. Chemotherapy and radiotherapy given to rectal cancer

patients by Area Health Service Area Health Service Chemotherapy and radiotherapy given None Radiotherapy

only Chemotherapy

only Combined

Modality Total n=674 n=65 n=182 n=216 % % % % n %

7 17 59 South Eastern Sydney 57† 17

226

54 Hunter 67 13

21 9

50 0 0 50 2 <1 Greater Murray 59

7 1

15 29

Unknown 61 4 2

Total (%)

Metropolitan 58 19 673 12 17 14 196

Central Sydney 65 4 14 17 133 12 South Western Sydney 43 5 21 31 91 8 Western Sydney 59 5 11 25 64 6 Wentworth 70 0 19 11 27 2 Northern Sydney 58 6 19 17 162 14

Other urban 64 5 15 17 20 Central Coast 9 9 28 65 6

5 15 85 7 Illawarra 68 1 76 7 Rural 60 4 15 22 210 19 Far West

4 12 25 51 4 Macquarie 100 0 0 0 Mid North Coast 64 2 15 20 55 5 Mid Western 38 7 21 34 29 3 New England 68 0 11 21 19 2 Northern Rivers 61 3 21 33 3 Southern 57 14 0 14 1

14 21 28

59 6 16 19 1137 100

† Percentages in this table are row percentages



Management of locally advanced rectal cancer Guideline “Preoperative radiation therapy, possibly with chemotherapy, is recommended in rectal cancers fixed or tethered within the pelvis if it is felt down-staging will enable successful resection. (Level II evidence) Radiation therapy should be considered in patients with locally advanced rectal cancer not amenable to surgery. (Level III evidence)” For the purposes of this section Stage T4 rectal cancers were considered to be “fixed or tethered within the pelvis” and are described as locally advanced.

Only three patients with T4 rectal cancers were not treated surgically; two of them were given radiotherapy.

Treatment modality Distant metastases

Fifty one percent of patients treated surgically for locally advanced rectal cancer also received radiotherapy (Table 56). An additional 28% were given chemotherapy but not radiotherapy. The addition of chemotherapy was more likely when patients also had distant metastases.

Table 56. Management of patients with locally advanced (stage T4) rectal

cancers who had surgery

No Yes Total n=34 n=37 n % % % Surgery alone

24 22

48

26 16 15 21

Surgery plus pre-operative radiotherapy only 3 8 4 6 Surgery plus post-operative radiotherapy only 6 0 2 3 Surgery plus chemotherapy only 32 20 28 Surgery plus chemotherapy and pre-operative radiotherapy 18 14 20 Surgery plus chemotherapy and post-operative radiotherapy 23 22 16 22

Total surgically treated (%) 52 71 100



Surgery for metastatic colorectal cancer Guideline “Patients with up to four lesions that can be safely removed with an adequate margin and have no evidence of extrahepatic disease should be considered for resection. (Level III evidence)

HAI (Hepatic arterial infusion) and intravenous chemotherapy should be regarded as acceptable alternatives. (Level I evidence)”

Of 482 patients with Stage D (see Appendix 3) cancer at diagnosis, 26 had no surgical treatment. Ninety five percent had surgery (Table 57). Table 57. Surgical management of patients with stage D cancers Surgical procedure Total

n % Laparatomy/laparoscopy only 5 1 Defunctioning stoma only 14 3 Tumour bypass only 3

Resection of primary tumour plus liver resection 3

1 Resection of primary tumour only 407 89 Resection of primary tumour plus catheter insertion 13 3

12 Resection of primary tumour plus liver resection & catheter insertion 2 0 Total surgically treated 456 100

Fifty six percent of the 456 patients with Stage D cancer who had some surgical treatment had isolated liver metastases; of these 14 (5%) had liver resection and 12 (5%) had a Hepatic Arterial Infusion catheter inserted. Two percent had intravenous chemotherapy (data not shown). Table 58. Referral for chemotherapy or radiotherapy for patients with

stage D cancers Referral for adjuvant therapy Total n % Chemotherapy only 263 58 Radiotherapy only 4 1 Chemotherapy and radiotherapy 56 12 Neither* 133

29

Total surgically treated 456 100 * Includes 32 (7%) and 18 (4%) patients where the information was missing or unknown for radiotherapy and chemotherapy referral respectively



Participation in clinical trials Guideline “Doctors should encourage patients with colorectal cancer to consider participating in appropriate clinical trials for which they are eligible. (Expert opinion)” Surgeons attending nearly two thirds of patients indicated that they did not participate in any clinical trials. For about a third of the remaining patients, their surgeons considered them to be eligible for a clinical trial. Of this group, 44% were recorded as having been entered into a clinical trial. Just over three quarters (79%) of those entered were recorded as having been randomised. Thus the actual proportion of patients participating in a clinical trial was 4% and could have been as high as 8% depending on whether patients with missing data are included in the denominator. Figure 1. Participation of surgical patients in clinical trials

Surgeon not involved in trials1853 (65.9%)

No suitable trial for patient613 (21.8%)

Not offered participation68 (23.1%)

Offered trial; declined28 (9.5%)

Randomised102 (78.5%)

Not-randomised12 (9.2%)

Missing data16 (12.3%)

Entered into trial130 (44.0%)


Patient eligible for a trial294 (10.5%)


Total number of surgical cases2810



Follow-up intentions Guideline “Follow up of patients after curative resection for colorectal cancer is recommended as it allows practitioners to monitor patient outcomes arising from their treatment, and it is consistent with patients’ desires. (Expert opinion) All patients who have undergone surgery for colorectal cancer should have specialist follow up in conjunction with the patient’s general practitioner. (Expert opinion)”

Surgeons intended to follow up almost 75% of those patients who had curative surgery. Surgeons intended to follow up a lower proportion of older patients compared with younger patients (Table 59).

Table 59. Surgeon’s follow-up intentions for patients treated with

curative intent by characteristics of patients and cancer * Patient characteristics Follow-Up Intentions Intended Not

Intended Unknown or

Missing Total

n=1614 n=130 n=461 % % % n % Age (years) 0-59 75† 4 21 60-69 75 21 603 27 70-79 74

316 14

68 6 26 34 2

702 32

56 3 179 8

1484 67

505 23 4 5 21 726 33

80+ 66 14 20 371 17 ARIA category Highly Accessible 73 5 22 1842 83 Accessible 73 8 19 Moderately Accessible Remote/Very Remote 54 15 31 13 1 Cancer stage Submucosa/muscularis 74 6 20 731 33 Beyond bowel wall 72 7 21 Regional nodes 74 5 21 683 31 Distant metastases 68 8 24 53 2 Missing or unknown 81 6 13 36 2 Chemotherapy or radiotherapy given Chemotherapy only 76 4 20 486 22 Radiotherapy only 73 4 23 Combined modality therapy 74 2 23 Neither 72 7 21 Total curative resection (%) 73 6 21 2205 100 * Excludes 128 cases that are deceased or their vital status is unknown † Percentages in this table are row percentages


NSW Colorectal Cancer Care Survey Further Analyses

Further analyses proposed The data collected for this survey are intended for further analysis and publications. These include the following:

Edward Ford Building A27

Reports from other data collected in this survey A similar report will be released on chemotherapy and radiotherapy treatment for colorectal cancer, once data collection has been finalised. Follow-up data on patient outcomes was collected in 2003 and will be covered in a separate report. Further analysis and dissemination of data collected on surgical management Further analysis will be undertaken to identify demographic variables pertinent to patients, practitioners and hospitals that are associated with compliance of colorectal cancer management with the NHMRC guideline recommendations. These data will be submitted for consideration of publication in major peer-reviewed medical journals. Economic analysis will be undertaken to estimate the direct health costs incurred in NSW for the surgical management of colorectal cancer. In addition, third parties may request the data collected in suitably de-identified form for further analysis. Proposals should be made in writing and are subject to the approval of the survey’s Expert Advisory Group and any necessary ethical clearances. Such proposals can be discussed beforehand by contacting: Professor Bruce Armstrong

Head, School of Public Health

The University of Sydney NSW 2006, Australia E-mail: [email protected] Phone: +61 (0) 2 9036 9018 Fax: +61 (0) 2 9036 9019


Appendices NSW Colorectal Cancer Care Survey

Appendices


NSW Colorectal Cancer Care Survey Appendices

Appendix 1 Surgical Questionnaire



Appendix 2 Membership of the Expert Advisory Group

• Dr Stephen Ackland, Department of Medical Oncology, Newcastle Mater Hospital.

• Professor Bruce Armstrong*, Head, School of Public Health and Medical

Foundation Fellow, University of Sydney. • Associate Professor Pierre Chapuis, Department of Surgery, Concord Hospital.

• Dr Andrew Kneebone, Department of Radiation Oncology, Liverpool

Hospital.

• Professor Allan Spigelman*, Professor of Surgical Science, Faculty of Health, University of Newcastle; Director, Clinical Governance Unit and Area Cancer Services, Hunter Area Health Service.

• Dr David Leong*, Medical Oncologist, PhD student, Centre for Clinical

Epidemiology and Biostatistics, University of Newcastle.

• Associate Professor Dianne O’Connell, Senior Epidemiologist, Cancer Epidemiology Research Unit, Cancer Council NSW.

• Associate Professor Michael Solomon, Department of Surgery,

Royal Prince Alfred Hospital.

* chief investigators



Appendix 3 Cancer stage assignment using questionnaire responses For reference, the surgical questionnaire is in Appendix 1.

Questionnaire response Cancer stage Local spread:

Spread to nodes:

Distant spread:

ACP Stage

Dukes’ Stage

TNM Stage

Carcinoma in- situ

Not involved No distant spread

A0 ¢- 0 (T1sN0M0)

Submucosa Not involved No distant spread

A ¥A I (T1N0M0)

Muscularis propria


A A I (T2N0M0)

Subserosa Serosal

No distant spread

B £B Not involved II (T3N0M0)

Adjacent organ(s)


B B II (T4N0M0)

Any except line of resection

Epi-, para-, retro-colic or mesenteric

No distant spread

C C III (Any T, N1M0)

Any except line of resection

Apical node(s) No distant spread

C C III (Any T, N2M0)

Line of resection Yes or No No distant spread

D Not* defined

IV (Any T, Any N, M0)

Any Yes or No Non-adjacent peritoneum Liver Lung Other

D Not* defined

IV (Any T, Any N, M1)

¢ This would be classified as “A” under the Astler & Coller modification of Dukes’ staging ¥ This would be classified as “B1” under the Astler & Coller modification of Dukes’ staging £ This would be classified as “B2” under the Astler & Coller modification of Dukes’ staging * Not defined in classical Duke’s classification



Appendix 4 Classification of hospitals

Area Health Services The table below lists NSW’s Area Health Services (AHSs), which are further classified into Metropolitan, Other Urban or Rural according to the hospital’s AHS attachment.

Classification of hospitals by NSW AHS attachment

Area Health Service Classification Central Sydney Metropolitan South Eastern Sydney Metropolitan South Western Sydney Metropolitan Western Sydney Metropolitan Wentworth Metropolitan Northern Sydney Metropolitan Central Coast Other urban Hunter Other urban* Illawarra Other urban* Far West Rural Greater Murray Rural Macquarie Rural Mid North Coast Rural Mid Western Rural New England Rural Northern Rivers Rural Southern Rural * The exceptions are for Cessnock, Maitland, Muswellbrook and Shoalhaven District Hospitals, which are classified as rural. Principal referral hospitals

NSW Health’s Peer Group system was used to classify hospitals as Principal Referral centres. Further details are available on the NSW Health Website on http://www.health.nsw.gov.au/iasd/iad/yb9899/hospgroups.html. Such hospitals include:

• Concord Hospital • Gosford District Hospital

• John Hunter Hospital • Liverpool Hospital

• Prince of Wales Hospital • Prince Henry Hospital • Royal North Shore Hospital • Royal Prince Alfred Hospital

• Illawarra Regional Hospital

• Nepean Hospital

• St George Hospital • St Vincent's Hospital (Darlinghurst) • Westmead Hospital



Appendix 5 References

1. Australian Institute of Health and Welfare (AIHW) & Australasian Association of Cancer Registries (AACR) 2003. Cancer in Australia 2000. AIHW cat. no. CAN 18. Canberra: AIHW (Cancer Series no. 23).

2. Gastrointestinal Tumor Study Group: Prolongation of the disease-free interval in surgically treated rectal carcinoma. N Engl J Med 1985; 312:1465-72.

3. Moertel CG, Fleming TR, MacDonald JS et al. Levamisole and Fluorouracil for adjuvant therapy of resected colon carcinoma. N Engl J Med 1990; 332:352-8.

4. National Health and Medical Research Council. Guidelines for the Prevention, Early Detection and Management of Colorectal Cancer. Canberra: AGPS, 1999.

5. Lomas J, Anderson K, Dominck-Pierre et al. Do practice guidelines guide practice? N Eng J Med 1989; 321:1306-11.

6. McArdle CS, Hole D. Impact of variability among surgeons on postoperative morbidity and mortality and ultimate survival. BMJ 1991; 302:1501-1505.

7. Phillips RKS, Hittinger R, Blesovsky L et al. Local recurrence following 'curative' surgery for large bowel cancer: I. The overall picture. Br J Surg 1984; 71:12-16.

8. Hermanek P, Wiebelt H, Staimmer D, Riedl S and the German Study Group Colo-Rectal Carcinoma (SGCRC) Prognostic factors of rectum carcinoma - experience of the German Multicentre Study SGCRC. Tumori 1995; 81(Supplement):60-64.

9. NIH Consensus Conference: Adjuvant therapy for patients with colon and rectal cancer. JAMA 1990; 264:1444-1450

10. Burton RC. Surgery and cancer: opinion, evidence and proof. J Surg Oncol 1999; 71:1-3.

11. Spigelman AD, McGrath DR. Clinical Governance Unit 2002: The National Colorectal Cancer Care Survey. Australian clinical practice in 2000. National Cancer Control Initiative, Melbourne, 1-124.

12. Coates M, McCredie M, Armstrong B. Cancer in New South Wales. Incidence and Mortality 1993. NSW Cancer Council.


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