Surgical Management of patients with primary

Colorectal Cancer over 12 years in the

South Western Sydney Local Health District public hospitals

Background

The South Western

Sydney Local Health District

(SWSLHD) is one of the most

populous areas in NSW

providing healthcare to over

819,000 residents [1].

The Public Hospitals in the

SWSLHD are:

Bankstown

Bowral

Camden

Campbelltown

Fairfield

Liverpool

Colorectal cancer

(CRC) is the second

most common cancer in

NSW.

It accounts for 13% of

all new cancer

diagnosed in NSW and

13% of cancer deaths [2].

A. Berthelsen1, M. Sharmin1, M. Morgan2

1SWSLHD Clinical Cancer Registry, Liverpool Hospital, NSW, AUSTRALIA. 2Division of Surgery, Bankstown Hospital, NSW, AUSTRALIA.

In 1997, The South Western Sydney Colorectal Tumour Group

established a database to collect information on patients with

colorectal cancer that were treated in the area.

In 2005, a Clinical Cancer Registry (ClinCR) was established in the

SWSLHD with funding from the Cancer Institute NSW.

When the ClinCR was formed the CRC database was incorporated

into the ClinCR and now has over 12 years of CRC data.

ClinCR collects a minimum data set for each new cancer that is

diagnosed and/or treated within the SWSLHD public facilities. A CRC

dataset extension for each new CRC case is also collected for

additional measures and indicators specific to the tumour stream.

Data collected between 1997 and 2001 had been analysed and

reported on by The South Western Sydney Colorectal Tumour group in

2005[3].

Figure 2. Incidence in Persons, NSW, CINSW 2008.

Figure 1. Geography of SWSLHD facilities.

MethodA retrospective review of the SWSLHD ClinCR was performed for the years

1997-2008.

3521 new cases of CRC were identified.

616 patients were excluded from this study as they did not have surgery.

2905 had surgery at one of the public hospitals in the SWSLHD and were

the focus of this study.

To identify changes, the first six years were compared to the

subsequent 6 years:

Cases diagnosed from 1997 to 2002 (n = 1349)

Cases diagnosed from 2003 to 2008 (n = 1556)

Variables examined are outlined in table 1.

Demographics

Gender

Age at diagnosis

Country of Birth

Tumour

Date of diagnosis

Primary site

Stage

Surgery

Operation type

Method of surgery

Elective or emergency

Stoma created

Regional lymph nodes examined

Re-operation within 30 days

Presentation

Symptoms or screening

Length of stay

Readmission within 30 days

The aim of this study was to identify any significant changes in the

surgical management of CRC patients in the SWSLHD

over a 12 year period, 1997 to 2008.

Table 1. Variables examined in this study.

Figure 3. Distribution of CRC cases in

SWSLHD (n = 2095).

Results

n=2905 %

SexMale 1622 (56)

Female 1283 (44)

Age at diagnosis20 - 29 10 (<1)

30 - 39 55 (2)

40 – 49 191 (7)

50 – 59 503 (17)

60 – 69 756 (26)

70 – 79 892 (31)

80 + 498 (17)

Country of BirthAustralia 1410 (48)

Overseas 1443 (50)

Unknown 52 (2)

HospitalBankstown 1216 (42)

Bowral 100 (3)

Camden & Campbelltown 575 (20)

Fairfield 321 (11)

Liverpool 693 (24)

Table 2. Patient characteristics.

Age ranged from 22 to 95 years, with the

median age at 69 years.

48% of patients were 70 years of age or

over at diagnosis.

50% were born overseas. Of these, 46%

came from European countries, followed by

23% from South East Asia.

42% of all operations were performed at

Bankstown Hospital.

The number of CRC cases diagnosed

each year ranged from 212 to 283.

429

460

466

500

625

667

713

780

858

910

1002

1065

1391

3260

3591

4418

4741

6905

Oesophagus

Liver

Myelodysplasia

Brain

Uterine

Stomach

Bladder

Thyroid

Pancreas

Leukaemia

Kidney

Cancer …

Non-Hodgkin's …

Lung

Melanoma

Breast

Bowel

Prostate

600 400 200 0 200 400 600

Colon (NOS)

Splenic flexure

Hepatic flexure

Descending colon

Transverse colon

Rectosigmoid

Ascending colon

Caecum

Sigmoid colon

Rectum

Female

Male

Of all the males 36% had a rectal cancer

compared to only 22% of the females.

Figure 4. Primary site of cancer by gender.

1. NSW Health Population Projection Series 1.2009. Department of Planning & State-wide Services Development Branch, NSW Health, March 2009.

2. Cancer Institute NSW. Cancer in NSW: Incidence and Mortality 2008. Cancer Institute NSW, August 2010.3. Wong SK. Kneebone A. Morgan M. Henderson CJ. Morgan A. Jalaludin B. Surgical management of colorectal cancer in south-western Sydney 1997-2001: a prospective series of 1293 unselected

cases from six public hospitals. ANZ J Surg 2005;75:776–782.4. Compton C. Greene F. The Staging of Colorectal Cancer: 2004 and Beyond. CA Cancer J Clin 2004; 54: 295 – 308.5. Ratto C. Sofo L. Ippoliti M. et al. Accurate lymph-node detection in colorectal specimen resected for cancer is of prognostic significance. Dis Colon Rectum 1999; 42: 143 – 158.

References

Conclusion

n %

SiteColon 1866 (64)

Rectum 1039 (36)

Dukes StagingA 536 (19)

B 920 (32)

C 912 (31)

D 514 (18)

Unknown 23 (1)

First Course TreatmentSurgery 1613 (56)

Surgery + Chemotherapy 884 (30)

Surgery + Radiotherapy +

Chemotherapy

354 (12)

Surgery + Radiotherapy 54 (2)

Table 3. Tumour and treatment data.

64% of primary cancers were in the colon

and 36% were in the rectum (170 rectosigmoid

cancers were included in the rectal cases).

0

10

20

30

40

50

A B C D

Less than 50 years 50 years and greater

Figure 5.

Dukes

staging by

Age.

Patients aged less than 50 years at diagnosis

were more likely to present with Dukes C or D

than those aged over 50 years.

Correspondence to:

Angela Berthelsen BHealth(Hon)Cancer Information Manager

SWSLHD Area Clinical Cancer Registry

Tel: 02 9612 0622

Angela.Berthelsen@sswahs.nsw.gov.au

http://intranet.sswahs.nsw.gov.au/SSWAHS

/Cancer

PATIENT CHARACTERISTICS

0

25

50

75

100

Open Laparoscopic Unknown

%

1997-2002

2003-2008

Figure 9. Method of surgery.

Laparoscopic colorectal

surgery began in SWSLHD in

late 2001 therefore in the

first six year period less than

2% of operations were

performed

laparoscopically.

2003 – 2008 period, one

quarter of all operations

were performed using a

laparoscopic technique.

0

5

10

15

20

25

30

35

Colon Rectum

11%

6%

32%

21%

%1997 - 2002

2003 - 2008

Figure 10. Length of stay ≤ 7 days.

Overall, for all CRC, 1997 –

2002 period only 9% had a

length of stay (LOS) ≤7 days

compared to 28% in 2003-

2008.

2003 – 2008 period, of

those who had an open

operation 19% had a LOS ≤7

days, however for those who

were operated on using a

laparoscopic technique

their LOS ≤7 days was 54%.

Using a modified Dukes’ stage, 51% were

staged as Dukes A or B, 31% as Dukes C and 18%

as Dukes D.

Of those that had surgery, 56% received surgery

alone, while 30% had surgery and

chemotherapy. A further 12% had

surgery, radiotherapy and chemotherapy.

53%

38%

6%

2% 1%

Colectomy Anterior resection

Abdominoperineal resection Colostomy formation only

Other Figure 6. Type

of surgery.

Majority of surgery performed were colectomy

(53%).

82% of all operations were elective and 17%

were emergency surgery.

High volume surgeons refers to those who performed ≥ 20

CRC resections per year and Low volume is < 20 CRC

resections per year.

1997 – 2002 period, 53% of all operations were performed

by high volume surgeons. This increased to 67% in the

second six year period.

High volume surgeons performed 16% more of the rectal

cancer surgery in the second six years and 13% more of the

colon cancer surgeries.Figure 8. Tumour type by surgeon cohort.

In the second 6 year period, significantly more operations were performed by specialist colorectal surgeons, this is due to the formation of a CRC surgery unit.

There has been a significant increase in the number of operations performed using a laparoscopic technique, which has lead to a decrease in LOS.

Results have shown an increase in the number of regional lymph nodes examined as recommended in other studies [4, 5].

Further research will involve looking at the long-term cancer outcomes in these groups of patients.

1%

35%

61%

3%

1997-2002

0

1 - 11

12+

Unknown

2%

19%

77%

2%

2003-2008

0

1 - 11

12+

Unknown

In the first six

years, 61%

had 12 or

more lymph

nodes

examined

compared to

77% in the

second six

year period.Figure 11. Regional lymph node examined.

(SWSLHD pathology dept. uses a synoptic reporting system for all CRC cases).

CHANGES OVER 12 YEARS

Rectum 1997-

2002

Rectum 2003-

2008

Colon 1997-2002 Colon 2003-2008

38%

22%

52%39%

62%

78%

48%61%

Low volume High volume

SITE, STAGE AND TREATMENT

1997 - 2002 2003 - 2008

53%

47%

67%

33%

High volume Low volume

Surgeon cohort

Figure 7. Surgeon cohort distribution.

Method of surgery Length of stay

Regional lymph nodes examined Other results

Results remained similar across both time periods for the following

variables – sex, age at diagnosis, site, stage, operation type, elective or

emergency surgery, readmitted within 30 days and reoperation within 30

days.

Of the rectal cancer patients, 24% had a permanent colostomy formation

in 1997-2002 compared to 19% in 2003-2008. There was an increase in

temporary ileostomy formation – from 22% in 1997-2002 to 34% in 2003-2008.

From 2000 – 2006, 4% of patients presented through screening compared

with 7.5% during 2007 and 2008 (this data was collected from 2000

onwards).

64%

30%

6%

Colon Rectum Rectosigmoid