background and scope materials and …...colorectal cancer is the second most commonly diagnosed...
TRANSCRIPT
M. Sharmin1, A. Berthelsen1, M. Morgan2, A. Fowler3, S. Avery1
1SWSLHD Clinical Cancer Registry, Liverpool Hospital, 2Division of Surgery, Bankstown Hospital, 3Cancer Therapy Centre, SWSLHD
BACKGROUND AND SCOPE
Colorectal cancer is the second most commonly diagnosed cancer in females and the third in males, with over 1.2 million new cancer
cases diagnosed per year worldwide. The highest incidence rates are found in Australia/ New Zealand, Europe, and North America [1].
The latest national figures available reveals colorectal cancer was the second most common cancer in New South Wales (NSW),
comprising 13% of all cancers diagnosed in NSW and 12.8% in the South Western Sydney Local Health District (SWSLHD) [2].
South Western Sydney is a large metropolitan area in NSW, Australia, covering an area of 6237km2. SWSLHD is one of the most
populous area health districts in NSW providing healthcare to over 819,000 residents [3].
Rectal cancer represents approximately 35% of all colorectal cancers diagnosed and/treated in SWSLHD and approximately 4.5% of
all malignant cancers in the district [4].
Guidelines have been introduced for management of rectal cancer internationally and in Australia. In 2005, the National Health &
Medical Research Council (NHMRC) published the update of the 1999 document 'Clinical practice guidelines for the prevention, early
detection and management of colorectal cancer' which was developed by the Australian Cancer Network. These guidelines are
evidence-based. They have been produced by a multidisciplinary team and are proposed as basis for sound decision making [5].
NHMRC’s guidelines have recommended adjuvant radiotherapy (RT) for patients with stage II and III rectal cancer. Previous clinical
studies indicate that utilisation of RT in rectal cancer remains low and there seems to be a correlation between patients’ age and
utilisation of RT [6].
Figure 1: Age-Standardized Colorectal Cancer Incidence Rates by Gender
and World Area, 2008 [1].
60 40 20 0 20 40
South-Eastern Asia
Micronesia/ Polynesia
Southern Africa
Eastern Asia
Central and Eastern Europe
Northern America
Northern Europe
Southern Europe
Western Europe
Australia/ New Zealand
Males Females
0.3%
0.8%
1.3%
1.6%
2.8%
2.9%
3.6%
4.2%
7.5%
7.7%
8.7%
11.1%
12.1%
12.8%
22.7%
Eye
Bone and connective…
Myelodysplasia
Neurological
Ill Defined and…
Head and Neck
Thyroid/Endocrine
Gynaecological
Skin
Lymphohaematopoietic
Upper GI
Respiratory
Breast
Colorectal
Urogenital
The objective of this investigation is to examine the incidence, demographics, stage and preoperative or postoperative status
of radiotherapy in newly diagnosed and treated rectal cancer patients within the SWSLHD over a 12 year period.
MATERIALS AND METHOD
The data on newly diagnosed rectal cancer cases used in this analysis were collected from the
SWSLHD Clinical Cancer Registry (ClinCR).
ClinCR collects a minimum data set for each new cancer and the colorectal dataset extension
for each new colorectal case that is diagnosed and/or treated within the SWSLHD public
facilities [see figure 3].
• The core dataset describes cancer type, staging, treatment and quality of care.
• The dataset extension captures additional measures and indicators specific to the
tumour stream.
Figure 3: South Western Sydney Local Health District. Eligibility:
Patients identified for inclusion in this investigation were drawn from the SWSLHD ClinCR database according to the following criteria:
• A diagnosis of primary rectal cancer between January 1997 and December 2008.
• Patients with previously diagnosed rectal cancers or secondary malignancies were excluded.
• Recto-sigmoid cancers were excluded.
• Diagnosed and/ or treated within SWSLHD public facilities. RT is provided by Liverpool and Macarthur Cancer Therapy Centres.
• Treatments analysed were only the first course treatment provided in SWSLHD public facilities.
Staging:
The American Joint Committee on Cancer (AJCC) TNM staging system was used in this study. For the purpose of this study, the staging of
some patients has been modified to incorporate the pre-operative staging for patients receiving preoperative chemoradiation. In instances
where patients did not have preoperative treatment, the pathological stage became the final stage regardless of initial clinical stage.
Treatment guidelines:
• National Guideline on rectal cancer:
NHMRC guidelines (2005) for rectal cancer patients recommend RT for high risk patients with stage II (T3/T4) and stage III (node
positive) disease [6].
• International Guideline on rectal cancer:
Commission on Cancer (CoC) Quality of care measures states, RT should be considered or administered within 6 months (180 days) of
diagnosis for patients under the age of 80 with clinical or pathologic AJCC T4N0M0 or Stage III receiving surgical resection for rectal
cancer [9].
Figure 2: Top 14 Groups, Incidence, Persons, South Western Sydney, 2008 [4].
RESULTS
n = 1031 (%)
Gender
Female 341 (33)
Male 690 (67)
Age Range
20 - 29 4 (<1)
30 - 39 17 (2)
40 – 49 80 (8)
50 – 59 239 (23)
60 – 69 278 (27)
70 – 79 267 (26)
80 + 146 (14)
Country of Birth
Australia 471 (46)
Overseas 560 (54)
Socioeconomic status
1st quintile 134 (13)
2nd quintile 2 (<1)
3rd quintile 320 (31)
4th quintile 282 (27)
5th quintile 225 (22)
Overseas or Outside
SWSLHD 68 (7)
Residence on diagnosis (LGA)
Bankstown 250 (24)
Camden 56 (5)
Campbelltown 145 (14)
Fairfield 224 (22)
Liverpool 170 (16)
Wingecarribee 28 (3)
Wollondilly 38 (4)
Other 120 (12)
AJCC/TNM Stage
Stage I 223 (22)
Stage II 314 (30)
Stage III 318 (31)
Stage IV 159 (15)
Indeterminate 17 (2)
Given radiotherapy
Yes 469 (45)
No 562 (55)
• 1031 rectal cancer cases were
identified according to the
inclusion criteria.
• The median age of patients at
diagnosis was 66 years; the
range was from 22 to 101
years.
• Majority of the patients were
less than 80 years of age with
a clear male predominance
(67%).
• At least 54% of patients were
born overseas. Amongst those
born overseas, 25% were from
Europe, 10% were from South-
East Asia, 6% were from UK
and 5% were from Middle East.
• 13% of patients were classified
within the highest socioeconomic
status quintile for SWSLHD,
while majority of patients (58%)
were within the 3rd and 4th
quintile.
• A large number of patients
diagnosed with rectal cancer
resided either in Bankstown
(24%) or Fairfield (22%) at the
time of diagnosis. 12% of all
patients resided outside the
local government area
boundaries for the local health
district.
• 45% of patients received RT
alone or with other treatment
modalities and, the remaining
55% did not receive RT.
• Of those patients that received RT, 96%
received RT with other treatment
modalities. Amongst those patients, 79%
had a combined treatment of surgery,
chemotherapy and RT.
• 56% of patients received RT
preoperatively and 35% postoperatively.
This is consistent with other studies and
clinical treatment practice favouring
preoperative RT [6, 7, 8].
14%
79%
4% 3%
S + R
S + R + C
R
R + C
• Studies have indicated that patients with
lower third rectal tumours were more likely
to receive RT than those in upper third [6].
As shown in figure 6, 40% of lower third
rectal tumours vs 15% of upper third
rectal tumours received RT.
• 433 stage II and III cancers of the mid and
lower third of the rectum were identified.
Of these, 79% received RT with other
treatment modalities.
21%
26% 39%
14%
40%
42%
15%
3%
Lower third Middle third Upper third Not measured
RT not given
RT given
Figure 5: Rectal tumour site and RT distribution.
Figure 4: RT given with other treatment modalities in SWSLHD.
Table 1: Patient characteristics.
0%
25%
50%
75%
100%
RT Not Given RT Given
Figure 6: AJCC/TNM stage by RT in SWSLHD.
• 61% of stage II and 72% of stage III
patients received RT within Liverpool and
Macarthur Cancer Therapy Centres.
• According to the Australian National
Colorectal Cancer Survey, SWSLHD is
proportionately treating more patients.
• Survey indicates that only 36% of stage II
and 55% of stage III rectal cancers
received RT [7].
0
10
20
30
40
50
60
70
80
Stage I
Stage II
Stage III
Stage IV
• RT for rectal cancer patients
declined with increasing age at
diagnosis, particularly in
patients aged 80 years and
over [see figure 7].
• Only 8% of patients 80 years
and over received RT.
Figure 7: RT by Stage and Age group within SWSLHD.
8%
2%
<1%
23%
67%
RT not recommended
Patient declined RT
Patient wishes to betreated outside SWSLHD
Patient was not referred toSWSLHD Cancer TherapyCentres
RT given
Figure 8: Stage II and Stage III disease by RT treatment within SWSLHD.
• Overall, 67% of patients with
stage II and stage III disease
received RT in SWSLHD.
• 33% of patients with stage II and
stage III did not receive RT. Of
those, 10% had a reason for no
RT (RT was not recommended due
to poor performance status or
patient declined RT or patient
wishes to be treated elsewhere)
and 23% of patients were not
referred to SWSLHD cancer
therapy centres [see figure 8].
DISCUSSION AND CONCLUSION • Patterns remained broadly similar to other studies. Over the 12 years it was noted that RT utilisation declined with increasing age at
diagnosis, particularly in patients aged 70 – 80+ years.
• 23% of patients under 80 years of age who did not receive RT with Stage II or III disease, majority had a stage IIA disease. Also, these
patients were not referred to SWSLHD Cancer Therapy Centres, it is believed some were possibly treated outside SWSLHD. The SWSLHD
ClinCR program’s scope is limited to collecting minimum dataset for new cancer cases that are diagnosed and/or treated within the
SWSLHD public facilities. However, the Cancer Institute NSW - Centre for Health Record linkage projects offers a means to close this
information gap.
• This data offers opportunities for quality projects that further investigate the individual circumstances around those patients who did not
receive RT with Stage II or III disease.
• Introduction of the NHMRC guidelines made a difference to RT utilisation in Stage II rectal cancer patients in SWSLHD, with an increase of
9% of patients receiving RT.
• Results identified will inform local clinicians about RT utilisation in rectal cancer patients in SWSLHD.
• Further research into treatment patterns, referral rates and patient outcomes will enhance clinical practice and service provision.
REFERENCES
1. Jemal, A et al. Global Cancer Statistics. A Cancer Journal for Clinicians 2011; 61 (2): 69-90.
2. Cancer Institute NSW. Cancer in NSW: Incidence Mortality Report 2008. Cancer Institute NSW, Sydney, 2010.
3. NSW Health Population Projection Series 1. 2009. Department of Planning & State-wide Services Development
Branch, NSW Health March 2009.
4. Cancer Institute NSW. Online statistics module. Cancer Institute NSW, Sydney, 2011. Available at:
http://www.cancerinstitute.org.au/data-and-statistics/cancer-statistics/online-statistics-module (accessed August
2011).
5. Australian Cancer Network Revision Committee. Clinical Practice Guidelines for the Prevention, Early Detection, and
Management of Colorectal Cancer. National Health and Medical Research Council, Canberra 2005.
6. Hegi-Johnson, F et al. Utilisation of radiotherapy for rectal cancer in Greater Western Sydney 1994 - 2001. Asia
Pacific Journal of Clinical Oncology 2007; 3: 134-142.
7. National Cancer Control Initiative. The National Colorectal Care Survey. Cancer Australia, Canberra 2003.
8. Wong SK et al. Surgical Management of Colorectal Cancer in South-Western Sydney 1997-2001: A prospective
series of 1293 unselected cases from six public hospitals 2005; ANZ. Surg. 75: 776-782.
9. Commission on Caner. Coc Quality of care Measure. American College of Surgeons, Cancer Program, Chicago,
2011. Available at: http://www.facs.org/cancer/ncdb/rectalmeasure.pdf (accessed August 2011).
All correspondence to:
Mahbuba Sharmin BMedSci, BSci(HIM), MBA
Cancer information Manager
SWSLHD Clinical Cancer Registry
Locked Bag 7103, Liverpool BC 1871
(02) 9612 0619
http://intranet.sswahs.nsw.gov.au/sswahs/cancer/
Treatment
• Of those, 23% of patients who did not have RT, 67 cases (61%) had stage IIA disease.
• Introduction of the NHMRC guidelines in 2005 made a difference to RT utilisation in stage II
rectal cancer patients in SWSLHD, with an increase of 9% of patients receiving RT.
• Patterns remained broadly similar with other studies for stage III patients with no significant
difference in RT utilisation. This is consistent with experience in both North America and
Europe [6].
• According to the CoC guideline, SWSLHD results indicate that 97% of patients received RT
within 6 months of diagnosis.
Population
Eligibility
Staging
Treatment Guidelines