THE NATIONAL COLORECTAL CANCER CARE SURVEY · The National Colorectal Cancer Care Survey Australian clinical practice in 2000 Prepared by Professor Allan D Spigelman and Dr Daniel

THE NATIONAL COLORECTAL

CANCER CARE SURVEY

Australian clinical practice in 2000

THE N

ATION

AL CO

LOREC

TAL C

AN

CER C

ARE SU

RVEY Australian clinical p

ractice in 2000

THE NATIONAL COLORECTAL CANCER

CARE SURVEY

Australian clinical practice in 2000

The National Colorectal Cancer Care Survey Australian clinical practice in 2000

Prepared by Professor Allan D Spigelman and Dr Daniel R McGrath, Clinical Governance Unit, Hunter Area Health Service and Discipline of Surgical Science, Faculty of Health, the University of Newcastle

Commissioned by the National Cancer Control Initiative on behalf of the Commonwealth Department of Health and Ageing

National Cancer Control Initiative1 Rathdowne StreetCarlton Vic 3053AustraliaTel: +61 (0)3 9635 5108Fax: +61 (0)3 9635 5320Email: [email protected]: www.ncci.org.au

Published October 2002

ISBN 1 876992 00 X

© Commonwealth of Australia 2002

Suggested citation: Clinical Governance Unit 2002: The National Colorectal Cancer Care Survey. Australian clinical practice in 2000. National Cancer Control Initiative, Melbourne, 1–124.

This document is available at www.ncci.org.au.

DEDICATION

The National Colorectal Cancer Care Survey is dedicated to the memory of the

late Emeritus Professor Richard Lovell AO MD MSc FRCP FRACP FACP (Hon),

formerly director of the National Cancer Control Initiative, whose knowledge

and initiative led to the establishment of the survey.

iv THE NATIONAL COLORECTAL CARE SURVEY

CO

NTE

NTS

■

vCONTENTS

■C

ON

TENTS

CONTENTSForeword .................................................................................................................................................................xiAcknowledgments ............................................................................................................................................. xiiiSummary ............................................................................................................................................................... xivRecommendations............................................................................................................................................. xviConcordance with the NHMRC Guidelines ............................................................................................ xviiAbbreviations and notes ............................................................................................................................... xxii

Cohorts .......................................................................................................................................................... xxiiNHMRC Guidelines........................................................................................................................................ xxiiA note on rounding...................................................................................................................................... xxii

Section 1: Introduction ..................................................................................................................................... 1Background ........................................................................................................................................................ 3Aims ...................................................................................................................................................................... 3Methods............................................................................................................................................................... 3

Administration of the survey.......................................................................................................................... 3Questionnaire development .......................................................................................................................... 4Data collection ................................................................................................................................................ 4Determination of location of patient and hospitals .................................................................................. 4Determination of cancer stage ..................................................................................................................... 4Data management........................................................................................................................................... 5Data analysis..................................................................................................................................................... 5Compilation of this report ............................................................................................................................. 5

Section 2: Results ................................................................................................................................................ 7Overall Response Rate ................................................................................................................................... 9

Response rate: all questionnaires.................................................................................................................. 9Surgical Questionnaire................................................................................................................................. 10

Response rate ................................................................................................................................................ 10Distribution of patients by age, sex and place of residence.................................................................. 10Location and type of hospitals ................................................................................................................... 12Travel for treatment ...................................................................................................................................... 14Number of colorectal cancers per patient ..................................................................................... 15 Site of colorectal cancer.............................................................................................................................. 15Mode of presentation................................................................................................................................... 16Pre-operative investigations: type, evidence of local invasion and confirmation of diagnosis ........ 17Surgery: not performed................................................................................................................................ 19Preparation for surgery: bowel preparation, thromboembolic prophylaxis, antibiotic prophylaxis,

pre-operative counselling and pre-operative visit by a stomal therapist ....................................... 20Characteristics of colorectal cancers: staging, patients’ age and mode of presentation .................. 22Number of patients per surgeon: by type of cancer, whether patients had an operation and

patients’ place of residence ................................................................................................................. 27Surgical management: mode of access, type of colorectal resection, operative evidence for local

invasion, post-operative residual cancer, oophorectomy and stoma formation .......................... 32Surgical management: assessing distance of rectal cancer from anal verge, extrafascial dissection,

isolation of small bowel from pelvis and other operative details (rectal cancer) ........................ 36Surgical management: abdomino-perineal resection, anterior resection, anastomosis, colonic

pouch formation, total mesorectal excision and permanent stoma formation .......................... 37Participation in clinical trials......................................................................................................................... 41Post-operative complications...................................................................................................................... 43Adjuvant therapy: chemotherapy and radiotherapy................................................................................. 44Follow-up: cancer recurrence and progression, palliative care, survival and causes of death........... 47

iv THE NATIONAL COLORECTAL CARE SURVEY

CO

NTE

NTS

■

vCONTENTS

■C

ON

TENTS

Medical Oncology Questionnaire ............................................................................................................. 49Response rate ............................................................................................................................................... 49Distribution of patients by age, sex and place of residence.................................................................. 50Location and type of hospitals ................................................................................................................... 51Travel for treatment ...................................................................................................................................... 51Characteristics of colorectal cancers: staging and patients’ age .......................................................... 52Number of patients per medical oncologist: average number treated and by patients’ place of

residence.................................................................................................................................................. 54Chemotherapy: timing, indications, duration of treatment, route of administration,

drugs used and scheduling of chemotherapy (5-FU) ....................................................................... 56Combined modality therapy........................................................................................................................ 59Participation in clinical trials......................................................................................................................... 59Complications of chemotherapy................................................................................................................ 61Follow-up: cancer recurrence and progression, palliative care, survival and causes of death........... 61

Radiation Oncology Questionnaire ......................................................................................................... 64Response rate ............................................................................................................................................... 64Distribution of patients by age, sex and place of residence.................................................................. 65Location and type of hospitals ................................................................................................................... 66Travel for treatment ...................................................................................................................................... 66Characteristics of colorectal cancers: staging and patients’ age ........................................................... 67Number of patients per radiation oncologist: average number treated and by patients’ place

of residence............................................................................................................................................. 69Pre-treatment histological confirmation of cancer .................................................................................. 71Radiotherapy: timing, indications, delivery, dose given, timing and total dose, fields used,

upper limit of field and boost fields .................................................................................................... 71Minimising small bowel irradiation ............................................................................................................. 74Combined modality therapy and chemotherapy drugs used................................................................. 75Participation in clinical trials......................................................................................................................... 75Complications of radiotherapy ................................................................................................................... 77Follow-up: cancer recurrence or progression, palliative care, survival and causes of death ............. 77

Variations Found............................................................................................................................................ 80Sex ................................................................................................................................................................... 80Rural/urban residence and clinician cohort ............................................................................................... 80Mode of presentation by surgeon cohort ................................................................................................. 80Site of colorectal cancer by surgeon cohort............................................................................................ 81Prophylactic antibiotic use........................................................................................................................... 81Antibiotic use and surgeon cohort ............................................................................................................. 81Bowel preparation and surgeon cohort ..................................................................................................... 82Anterior resection and surgeon cohort...................................................................................................... 82Post-operative complications...................................................................................................................... 83Clinical trials ................................................................................................................................................... 85Adjuvant therapy............................................................................................................................................ 86Notable variation by state or territory........................................................................................................ 89

Other Clinically Relevant Information.................................................................................................... 90Additional Tables and Figures Relating to NHMRC Guidelines .................................................... 97

Appendices......................................................................................................................................................... 101A Survey Administration ........................................................................................................................... 103B Clinicopathological Staging of Colorectal Cancers ..................................................................... 106C Participating Hospitals........................................................................................................................... 108D Study Denominators .............................................................................................................................. 114E Questionnaire Coversheet ..................................................................................................................... 115F Surgical Questionnaire ........................................................................................................................... 116G Medical Oncology Questionnaire ...................................................................................................... 120H Radiation Oncology Questionnaire................................................................................................... 122

vi THE NATIONAL COLORECTAL CARE SURVEY

CO

NTE

NTS

■

viiCONTENTS

■C

ON

TENTS

Figures 1 Mode of presentation of all 2015 patients................................................................. 17

2 Colorectal cancer stage by patients’ age and number of patients ....................... 23

3 Colorectal cancer stage by patients’ age and percentage within each age group ......................................................................................................................... 24

4 Colon cancer stage by patients’ age and number of patients................................ 24

5 Colon cancer stage by patients’ age and percentage within each age group ... 25

6 Rectal cancer stage by patients’ age and number of patients............................... 25

7 Rectal cancer stage by patients’ age and percentage within each age group .. 26

8 Percentage of patients within each Dukes’ stage according to mode of presentation ..................................................................................................................... 27

9 Number of patients per surgeon cohort ..................................................................... 28

10 Percentage of patients seen by each surgeon cohort by patients’ place of residence .......................................................................................................................... 32

11 Participation of surgical patients in clinical trials....................................................... 42

12 Colorectal cancer stage by patients’ age and number referred for medical oncology ............................................................................................................................. 53

13 Percentage of medical oncology referrals by Dukes’ stage of cancers for each age group .......................................................................................................................... 53

14 Average number of patients per medical oncologist cohort ................................. 54

15 Percentage of patients seen by each medical oncologist cohort by patients’ place of residence........................................................................................................... 55

16 Participation of all medical oncology patients in clinical trials............................... 60

17 Colorectal cancer stage by patients’ age and number referred for radiation oncology ............................................................................................................................. 68

18 Percentage of radiation oncology referrals by Dukes’ stage of cancers for each age group .......................................................................................................................... 68

19 Average number of patients per radiation oncologist cohort ............................... 69

20 Percentage of patients seen by each radiation oncologist cohort by patients’ place of residence ......................................................................................................... 70

21 Participation of all radiation oncology patients in clinical trials............................. 76

22 Combined modality therapy for high-risk rectal cancer........................................... 98

23 Radiotherapy for advanced rectal cancer .................................................................... 99

24 Laparoscopic surgery for colorectal cancer ............................................................... 100

vi THE NATIONAL COLORECTAL CARE SURVEY

CO

NTE

NTS

■

viiCONTENTS

■C

ON

TENTS

Tables 1 Response rates by speciality............................................................................................... 9

Surgical Questionnaire 2 Response rates by state or territory .............................................................................. 10

3 Age distribution of patients .............................................................................................. 10

4 Sex distribution by site of cancer.................................................................................... 11

5a–b Patients’ place of residence............................................................................................... 11

6–8 Location and type of hospitals......................................................................................... 12

9–11 Place of treatment, by hospital type and state or territory..................................... 14

12 Location of treating hospital in relation to patients’ place of residence ............. 15

13 Number of colorectal cancers per patient .................................................................. 15

14 Site of colorectal cancer .................................................................................................... 16

15 Mode of presentation by site of cancer ...................................................................... 16

16 Pre-operative colorectal investigations........................................................................... 18

17 Patients with rectal cancer who had an operation and who had an endorectal ultrasound.................................................................................................... 18

18–19 Patients and pre-operative histological confirmation of the diagnosis................. 19

20 Reasons why patients did not have an operation...................................................... 19

21 Use of bowel preparation by mode of presentation and site of cancer ............ 20

22 Use of deep venous thrombosis prophylaxis .............................................................. 20

23–24 Antibiotic prophylaxis and duration of use .................................................................. 21

25-27 Patients and their Dukes’ stage ....................................................................................... 22

28 Dukes’ stage and mode of presentation .............................................................. 26

29 Number of patients per surgeon cohort ...................................................................... 28

30–35 Number of patients treated, by state or territory...................................................... 29

36 Mode of surgical access .................................................................................................... 32

37 Nature of surgery ................................................................................................................ 33

38 Reasons for palliative surgery .......................................................................................... 33

39 Type of operation in elective and emergency patients ........................................... 34

40 Treatment of local invasion at operation (colorectal cancer) ................................. 35

41 Women who had an oophorectomy .............................................................................. 35

42 Temporary and permanent stomas by type .............................................................. 36

43 Method of recording distance of rectal cancer from the anal verge .................. 36

44 Rectal cancer site per surgeon cohort .......................................................................... 37

45 Abdomino-perineal resections by surgeon cohort and rectal cancer site ........ 38

46 Anterior resections by surgeon cohort and rectal cancer site .............................. 38

47 Ratio of anterior resections to abdomino-perineal resections ............................... 39

48 Type of anastomosis per surgeon cohort ..................................................................... 39

49 Colonic pouches formed per surgeon cohort .............................................................. 40

50 Total mesorectal excision by site of rectal cancer and surgeon cohort .............. 40

51–52 Number and percentage of and reason for permanent stomas by rectal cancer site ........................................................................................................... 41

53a–b Patients who were eligible for entry into a clinical trial per surgeon cohort .... 42

54 Post-operative complications ........................................................................................... 43

55–56 Adjuvant chemotherapy offered and given to patients with colon cancer by Dukes’ stage .................................................................................................................... 44

viii THE NATIONAL COLORECTAL CARE SURVEY

CO

NTE

NTS

■

ixCONTENTS

■C

ON

TENTS

57–58 Adjuvant chemotherapy offered and given to patients with rectal cancer by Dukes’ stage .................................................................................................................... 45

59–60 Adjuvant radiotherapy offered and given to patients with colon cancer by Dukes’ stage .................................................................................................................... 45

61–62 Adjuvant radiotherapy offered and given to patients with rectal cancer by Dukes’ stage .................................................................................................................... 46

63–64 Adjuvant radiotherapy given pre-operatively and post-operatively to patients with rectal cancer by Dukes’ stage ........................................................................... 47

65–66 Survival and cause of death ............................................................................................. 48

Medical Oncology Questionnaire 67 Response rate by patients’ location................................................................................ 49


69 Sex distribution of patients............................................................................................... 50

70 Patients’ place of residence............................................................................................... 50


74 Dukes’ stage of referred patients’ colon cancers, rectal cancers and all colorectal cancers ........................................................................................................... 52

75–76 Number of patients referred and treated per medical oncologist cohort.......... 54

77 Timing of chemotherapy in relation to surgery .......................................................... 56

78 Indications for chemotherapy .......................................................................................... 56

79 Planned duration of chemotherapy................................................................................ 57

80 Route of administration of chemotherapy ................................................................... 57

81 Chemotherapy drugs used .............................................................................................. 57

82–84 Scheduling of chemotherapy (5-FU) .............................................................................. 58

85 Radiotherapy utilisation ..................................................................................................... 59

86a-b Eligibility for and entry into a clinical trial per medical oncologist cohort ......... 60

87 Nature of complications .................................................................................................... 61

88 Site of recurrence for all 492 patients referred to medical oncologists ............. 62

89 Site of recurrence in the 445 patients who received chemotherapy ................. 62

90 Evidence of recurrence ..................................................................................................... 62

91 Referral to a palliative care service of patients with cancer recurrence or progression........................................................................................................................ 63


Radiation Oncology Questionnaire 94 Response rate by patients’ location................................................................................ 64


96 Sex distribution of patients............................................................................................... 65

97 Patients’ place of residence ............................................................................................. 65


101 Dukes’ stage of referred patients’ colon and rectal cancers and all colorectal cancers ............................................................................................................................. 67

102–103 Number of patients referred and treated per radiation oncologist ..................... 69

104 Histological verification prior to treatment.................................................................. 71

105 Timing of radiotherapy in relation to surgery ............................................................. 71

106 Indications for radiotherapy.............................................................................................. 72

107 Mode of radiotherapy delivery ........................................................................................ 72

108 Radiation dose given........................................................................................................... 72

viii THE NATIONAL COLORECTAL CARE SURVEY

CO

NTE

NTS

■

ixCONTENTS

■C

ON

TENTS

109 Timing and total dose of radiotherapy ......................................................................... 73

110–111 Fields used and upper limit of radiation field ............................................................. 73

112–113 Use and site of boost dose ............................................................................................... 74

114 Techniques employed to minimise small bowel irradiation in 133 patients .... 74

115 Timing of chemotherapy ................................................................................................... 75

116 Chemotherapy drugs used .............................................................................................. 75

117a–b Patients who were eligible for and entered into a clinical trial per radiation oncologist cohort ............................................................................................................. 76

118 Nature of complications ................................................................................................... 77

119 Site of recurrence for all 162 patients referred for radiotherapy ....................... 78

120 Evidence of recurrence ..................................................................................................... 78


Variations Found 123 Mode of presentation by surgeon cohort..................................................................... 80

124 Site of colorectal cancer by surgeon cohort ................................................................ 81

125–126 Type of prophylactic antibiotic used by mode of presentation and surgeon cohort ................................................................................................................................. 81

127 Use of bowel preparation by surgeon cohort.............................................................. 82

128 Wound infection by hospital insurance status ............................................................ 83

129–130 Wound infection by major anastomotic leak and any anastomotic leak ........... 83

131 Minor anastomotic leak by site of colorectal cancer ................................................ 84

132 Major anastomotic leak by surgeon cohort................................................................. 84

133 Use of deep venous thrombosis prophylaxis by surgeon cohort ........................... 84

134–135 Incidence of deep venous thrombosis and/or pulmonary embolism ................... 85

136 Patients entered into a clinical trial by state or territory......................................... 86

137 Node-positive colon cancer patients offered and given chemotherapy by age distribution................................................................................................................ 86

138–139 High-risk rectal cancer patients offered and given chemotherapy by age distribution and place of residence ........................................................................... 87

140–141 High-risk rectal cancer patients offered and given radiotherapy by age distribution and surgeon cohort ................................................................................. 88

142–144 Timing of radiotherapy given to patients with high-risk rectal cancer by place of residence, state or territory and surgeon cohort .................................. 88

145 Use of recommended deep venous thrombosis prophylaxis, recommended antibiotics and bowel preparation by state or territory ...................................... 89

146 Incidence of deep venous thrombosis and/or pulmonary embolism by state or territory.............................................................................................................. 90

147 Incidence of wound infection by state or territory .................................................... 90

148 Incidence of minor and major anastomotic leaks by state or territory .............. 91

149 Colorectal cancer stage by hospital insurance status ............................................... 91

150–153 Patients entered into a clinical trial variations............................................................ 91

154–157 Node-positive colon cancer patients offered and given chemotherapy variations ........................................................................................................................... 92

158–160 High-risk rectal cancer patients offered and given chemotherapy variations ........................................................................................................................... 94

161–163 High-risk rectal cancer patients offered and given radiotherapy variations ........................................................................................................................... 95

x THE NATIONAL COLORECTAL CARE SURVEY

CO

NTE

NTS

■

xiFOREWORD

■FO

REW

ORD

164 Timing of radiotherapy given to patients with high-risk rectal cancer by age ................................................................................................................. 96

165 Timing of radiotherapy given to patients with high-risk rectal cancer by hospital insurance status ........................................................................................ 96

166 Route of administration of chemotherapy for those patients with proven liver metastases ................................................................................................ 97

167 Operation performed for obstructing colorectal cancer .......................................... 97

168 Length of constructed colonic pouch ............................................................................. 99

x THE NATIONAL COLORECTAL CARE SURVEY

CO

NTE

NTS

■

xiFOREWORD

■FO

REW

ORD

FOREWORD

Colorectal cancer is the commonest cancer of Australians, if we exclude non-melanocytic skin cancer. It is the second commonest cause of cancer death in this country, and it has been estimated to cost the health system over A$200 million each year. As our population increases in number and as it ages, the incidence of colorectal cancer has been projected to increase by a further 15%−20% over the next five years.

How, then, should we be attempting to reduce the mortality from this important disease in the Australian community? There are opportunities for prevention, e.g. improving diet and screening families at risk, but perhaps the most important intervention is the widespread screening of an older, healthy population with faecal occult blood testing. There is good evidence from major trials overseas that this reduces the mortality from colorectal cancer in the screened population, presumably through detection of adenomatous polyps (pre-cancer) and cancers at an early stage of development. A colorectal cancer screening pilot implementation project is now underway to assess the most effective way of establishing a national program.

Treatment also influences mortality, and there are well-established guidelines approved by the National Health and Medical Research Council concerning best practice in the use of surgery and adjuvant therapy. The critical question, however, is whether best practice is being generally followed. The National Colorectal Cancer Care Survey provides a unique insight into this question. It is a survey which encompasses all patients newly diagnosed with colorectal cancer in Australia over a three-month period. The care they received has been assessed against the guidelines, and a wealth of instructive information has been forthcoming. I was encouraged to find that there was ‘good concordance across Australia between reported clinical care and the majority of the evidence-based NHMRC guidelines’, but there is still some way to go before complete concordance is achieved.

This survey has been a very important study, and it provides a sound basis for targeting remedial action to improve practice, and for longitudinal studies of the outcomes of care. Let us hope that the example that has been set is followed in other areas of health care where there is a high burden of disease and a substantial mortality.

Richard Smallwood AOCommonwealth Chief Medical Officer

xii THE NATIONAL COLORECTAL CARE SURVEY

FOR

EWO

RD ■

xiiiACKNOWLEDGMENTS

■A

CKN

OW

LEDG

MEN

TS

Colorectal cancer is the commonest cancer in non-smoking men and women. The last 25 years have seen significant attitudinal changes generally within the medical profession so that we now accept multidisciplinary teams, demand surgical and medical specialisation and highlight quality of life as a major treatment goal.

Patients with cancer arrive with an in-built prognosis. If their cancer has already spread too far, or if other treatments such as chemotherapy are but slightly effective for that particular cancer, then little can be done to prolong life. But in those with otherwise curable tumours, much can be gained by skilled care, and even more lost when standards slip.

Cancer surgeons realise:

1. That they must not kill the patient on the operating table.

2. That they must at almost all costs avoid local recurrence.

3. And in achieving the above two, they must leave the patient with a good quality of life.

In colorectal cancer surgery, prevention of death in hospital equates to the application of known preventatives, such as against pulmonary embolism and significant infection, and by avoiding anastomotic leak. Local recurrence may be reduced by meticulous surgery, perhaps in rectal cancer by the application of total mesorectal excision and/or radiotherapy. Quality of life can be inferred by the permanent stoma rate, bowel function (made better at least in the short term with a colon pouch) and continuing sexual and urinary normality.

To achieve higher standards and less variation in outcome, various Royal Colleges and Associations have issued guidelines of apparent best practice in a whole range of different diseases. These guidelines have themselves been beset by problems, not only in obtaining professional agreement about what should or should not be included, but also in keeping up to date with sometimes quite rapid change in practice or opinion. Furthermore, guidelines are but guidelines; they are not as yet rulebooks which mandate certain actions and preclude others − and quite rightly so. Lack of evidence of benefit does not mean no evidence of benefit and certainly does not necessarily equate to harm if applied contrary to the guidelines. This may explain why surgeons in this survey have voted with their feet and largely adopted total mesorectal excision (or extrafascial excision of the rectum), where the guideline has been lukewarm at best, and also why surgeons and oncologists seem quite frequently to apply chemotherapy to patients with stages less than Dukes’ C, relying on logical reasoning, on the one hand, allied to absence of actual evidence of harm on the other.

This outline of Australian clinical practice covering three months of the year 2000 supplies fascinating and important data. Treating clinicians do not always agree with their association’s guidelines − and at present they have the freedom to disagree, particularly given the scarce resources to keep the guidelines themselves at all times vibrant and relevant. Patients in rural areas or presenting as emergencies understandably have a reduced access to specialist care. But the future is writ large in capitals: big audit is here; change is inevitable; change is right − change heralded by important studies such as this.

Robin Phillips Dean, St Mark’s Academic Institute Honorary Professor of Colorectal Surgery, Imperial College Faculty of MedicineConsultant Surgeon, St Mark’s HospitalLondon

xii THE NATIONAL COLORECTAL CARE SURVEY

FOR

EWO

RD ■

xiiiACKNOWLEDGMENTS

■A

CKN

OW

LEDG

MEN

TS

ACKNOWLEDGMENTSWe thank the National Cancer Control Initiative and the Commonwealth Government (Department of Health and Ageing) for providing the major component of funds that enabled this survey to take place.

We acknowledge the invaluable assistance of The Cancer Council NSW. Their concurrently running NSW Colorectal Cancer Patterns of Care Survey formed the basis of this national study. Particular thanks are due to Dr David Leong and to Professor Bruce Armstrong who, together with Professor Allan Spigelman and other members of the NSW Working Party, greatly facilitated the development of the national survey.

We thank all individuals who participated in the survey.

We acknowledge the support and cooperation of the following professional colleges and organisations:

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

xiv THE NATIONAL COLORECTAL CARE SURVEY

SUM

MA

RY ■

xvSUMMARY

■SU

MM

ARY

SUMMARYThe National Colorectal Cancer Care Survey, which took place at the time of dissemination of the NHMRC’s Guidelines for the Prevention, Early Detection and Management of Colorectal Cancer (CRC) (NHMRC Guidelines), has shown that:

• Most clinicians provided data for this initiative when requested, despite multiple demands on their time.

• There was good concordance across Australia between reported clinical care and the majority of the evidence-based NHMRC Guidelines that were analysed in detail.

• The NHMRC Guidelines outline 86 specific guidelines. Of those guidelines concerned with investigation, treatment and follow-up, 46 are amenable to measurement. The questionnaires used in this study allowed for the detailed analysis of 23 of these 46 guidelines. There was less than 50% concordance for eight (35%) of the 23 guidelines. These guidelines, together with their associated levels of evidence, are listed as follows (see also ‘Concordance with NHMRC Guidelines’):

• colonic pouch formation (Level II evidence)

• antibiotic prophylaxis (Level II evidence)

• the use of bowel preparation (Level II evidence)

• the use of combined modality therapy for patients with rectal cancer (two recommendations: Level II evidence). The changing evidence within this rapidly evolving field may account for this finding.

• the use of hepatic arterial infusion for patients with liver metastases (Level II evidence), reflecting the limited availability of this technique

• the performance of total mesorectal excision for rectal cancer (Level − evidence)

• the conduct of laparoscopic surgery for curative treatment within randomised controlled trials; however, 75% of eligible consenting patients were enrolled in a trial (Level − evidence).

• The delivery of some aspects of care to patients with colorectal cancer, including the type of operation performed, was marked by significant variation according to the patients’ place of residence and clinician cohort. For example, surgeons seeing higher volumes of patients (those most likely to be specialist colorectal) had significantly lower rates of permanent stoma formation, higher rates of colonic pouches, higher rates of anterior resection (restoration of bowel continuity) and higher rates for the use of pre-operative radiotherapy for high-risk rectal cancer patients. The rates found for the higher volume surgeons accord with the recommendations in the NHMRC Guidelines; because the number of higher volume surgeons was small, most patients were, in fact, treated by lower volume surgeons. So most patients were not treated in accord with guidelines for the aspects of care outlined above. However, the reverse was true for the use of bowel preparation and prophylactic antibiotics: lower volume surgeons accorded with these guidelines. With regard to patients’ place of residence, the delivery of pre-operative radiotherapy was significantly less likely to have been given to rural residents than to others.

• Most patients received their treatment from a large number of specialists who treated patients with colorectal cancer infrequently (that is, fewer than four patients per three months).

• Participation in clinical trials was negligible, with significant variation across states and territories, This reflects the small number of trials that were available at the time of this survey.

xiv THE NATIONAL COLORECTAL CARE SURVEY

SUM

MA

RY ■

xvSUMMARY

■SU

MM

ARY

• Some of the early outcomes of patients with colorectal cancer, such as wound infection, were marked by significant variation according to the patients’ place of residence and the type of institution (public/private) in which treatment was delivered. For example, wound infections were significantly more common in public hospitals than private hospitals.

• The most significant factor determining referral for, and the administration of, adjuvant therapy was the patients’ age. That is, older patients were significantly less likely to be referred for, or given, adjuvant therapy.

• There was significant variation between the patients’ place of residence (rural/urban/capital city) and the number of patients seen by their clinician, so that patients treated in rural areas were more likely to be treated by surgeons who treated few patients with colorectal cancer.

• Surgeons with the highest volume of colorectal cancer patients saw a significantly greater proportion of patients with rectal cancer.

• Treatment complications accounted for 16% of deaths in surgical patients (that is, 30 of the 185 patients who died, out of a total of 2015 patients entered into the survey). Whether these are a result of preventable adverse events remains to be determined.

• Despite support from professional colleges and organisations, some clinicians refused to participate in the survey.

• An opportunity exists for the longitudinal observation of outcomes and correlation of outcomes with multiple variables as described in the survey.

xvi THE NATIONAL COLORECTAL CARE SURVEY

REC

OM

MEN

DAT

ION

S ■

xviiCONCORDANCE

■C

ON

CO

RDA

NC

E

RECOMMENDATIONSIt is recommended that:

• The delivery of care by a large number of surgeons who each treat relatively few patients with colorectal cancer be evaluated. This should take into account the need to maintain services outside capital cities and urban areas, together with the need to inform patients of evidence that shows that better outcomes correlate with increasing numbers of patients treated, specialisation of surgeons and associated multidisciplinary services.

• Further analysis of the deaths related to treatment complications occurs.

• The present cohorts of clinicians forms the basis of a Phase II Survey, whereby outcomes can be correlated with the variables outlined in this report.

• Consideration be given to the provision of incentives − such as linkage with continuing professional development programmes, registration, credentialling and appointment processes, and the use of remuneration incentives (for example, via differential health insurance rebates to practitioners) − to encourage concordance with evidence-based NHMRC Guidelines.

• Consideration be given to encouraging participation in such surveys by similar methods, perhaps by linkage with continuing professional development programmes, registration, credentialling and appointment processes, and by the use of remuneration incentives (for example, via differential health insurance rebates to practitioners).

• The NHMRC’s Guidelines for the Prevention, Early Detection and Management of Colorectal Cancer (CRC) be updated. This is currently being undertaken by a working party of the Australian Cancer Network. However, the guidelines should become a living document, capable of incorporating new evidence speedily. A ‘virtual’ Standing Working Party should be created and resourced appropriately. Members should communicate electronically as required by emerging evidence and should meet by teleconference every six months. Updates should be published on the Internet and should be linked to the websites of relevant professional colleges and other relevant organisations. It should be supported by a Coordinator, who might also support other, similar initiatives.

• A survey similar to this one be conducted at regular intervals, with a frequency of one survey every three years being the target.

• Relevant professional colleges and organisations address the findings of this survey.

xvi THE NATIONAL COLORECTAL CARE SURVEY

REC

OM

MEN

DAT

ION

S ■

xviiCONCORDANCE

■C

ON

CO

RDA

NC

E

CONCORDANCE WITH THE NHMRC GUIDELINESA list of 23 recommendations, as they appeared in the NHMRC Guidelines, follows. They are accompanied by the level of evidence that exists for each recommendation, together with the percentage (%) of concordance with each recommendation, the relevant numerator and denominator as determined by the results of this survey and the page numbers where these data can be found in this report.

Levels of evidence as defined by the NHMRC Guidelines are:

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 or case−control analytic studies, preferably from more than one centre or research group; or from multiple time-series with or without intervention.

Level − This was previously defined as Level IV evidence. It consists of the opinions of respected authorities based on clinical experience, descriptive studies or reports of expert committees; this level signifies the need for further research. However, the concept of expert opinion constituting Level IV evidence is no longer supported, and was presented in the NHMRC Guidelines as Level − evidence.

xviii THE NATIONAL COLORECTAL CARE SURVEY

CO

NC

ORD

AN

CE

■

xixCONCORDANCE

■C

ON

CO

RDA

NC

E

NHMRC Guidelines

Level of

evidence

% C

oncordance

with guid

elines

Num

erator /

Denom

inator

Page

PREPARATION FOR SURGERY

Thromboembolic prophylaxis

All patients undergoing surgery for colorectal cancer should receive prophylaxis for thromboembolic disease.

I 96% 1843/1911

20

Unfractionated heparin, low molecular weight heparin, and intermittent calf compression are effective in reducing the incidence of thromboembolism.

I 93% 1770/1911

20

Prophylactic antibiotics

All patients undergoing colorectal cancer surgery require prophylactic antibiotics.

I 94% 1787/1911

21

ADJUVANT THERAPY FOR COLON CANCER

Adjuvant therapy

People with resected node-positive colon cancer should be offered adjuvant therapy.

I 76% 432/572 44 & 86

MANAGEMENT OF LIVER METASTASES

Hepatic arterial infusion

Hepatic arterial infusion and intravenous chemotherapy should be regarded as acceptable alternatives.

I 85% 87/102 97

Total 92% 5919/6407

xviii THE NATIONAL COLORECTAL CARE SURVEY

CO

NC

ORD

AN

CE

■

xixCONCORDANCE

■C

ON

CO

RDA

NC

E

NHMRC Guidelines

Level of

evidence

% C

oncordance

with guid

elines

Num

erator /

Denom

inator

Page

ELECTIVE SURGERY FOR RECTAL CANCER

Colonic pouch

Where technically feasible, the colonic pouch may be the preferred form of reconstruction after low anterior resection of cancers of the lower half of the rectum to improve short-term post-operative neorectal function.

II 42% 98/233 40

PREPARATION FOR SURGERY

Prophylactic antibiotics

A single pre-operative dose of intravenous second- or third-generation cephalosporin and metronidazole is an effective regime.

II 35% 676/1911 21

Bowel preparation

Randomised trials do not demonstrate a benefit from routine bowel preparation.

II 12% 238/1911 20

ADJUVANT THERAPY FOR COLON CANCER

Adjuvant therapy

5-fluorouracil (5-FU) plus low-dose leucovorin for six months is the preferred option. Other adjuvant therapy regimens with similar reductions in the rate of relapse and mortality (30–40%) include:• 5-FU plus low-dose leucovorin plus levamisole for six months; and• 5-FU plus levamisole for one year.

II 56% 166/299 57

ADJUVANT THERAPY FOR RECTAL CANCER

Combined modality therapy

Post-operative 5-FU-based chemotherapy and radiotherapy (combined modality therapy) is recommended for patients with high-risk rectal cancer.

II 40% 52/129 98

When chemotherapy is given post-operatively in combination with radiotherapy, protracted venous infusion of 5-FU chemotherapy may offer further benefits in survival when compared to bolus 5-FU therapy. It is the recommended way of delivering combined modality therapy.

II 23% 12/52 98

RECURRENT AND ADVANCED RECTAL CANCER

Operable advanced rectal cancer

Pre-operative 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.

II 63% 40/64 99

MANAGEMENT OF LIVER METASTASES

Hepatic arterial infusion

Hepatic arterial infusion has shown survival benefit compared with best supportive care.

II 39% 9/23 97

Total 28% 1291/4622

xx THE NATIONAL COLORECTAL CARE SURVEY

CO

NC

ORD

AN

CE

■

xxiCONCORDANCE

■C

ON

CO

RDA

NC

E

NHMRC Guidelines

Level of

evidence

% C

oncordance

with guid

elines

Num

erator /

Denom

inator

Page

STAGING AND REPORTING

Staging data

ACPS staging, TNM staging and the data required to stage the patient should all be recorded to allow national and international comparisons.

III 96% 1827/1911

22

RECURRENT AND ADVANCED RECTAL CANCER

Inoperable advanced rectal cancer

Radiation therapy should be considered in patients with locally advanced rectal cancer not amenable to surgery.

III 76% 29/38 99


Colonic pouch

The ideal length of the pouch is between 5 cm and 8 cm. III 85% 83/98 99

Sphincter-saving operations

Sphincter-saving operations should be preferred to abdomino-perineal resection.Exceptions are 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).

III 72% 320/445 38

Total 91% 2259/2492

xx THE NATIONAL COLORECTAL CARE SURVEY

CO

NC

ORD

AN

CE

■

xxiCONCORDANCE

■C

ON

CO

RDA

NC

E

NHMRC Guidelines

Level of

evidence

% C

oncordance

with guid

elines

Num

erator /

Denom

inator

Page


Total mesorectal excision

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.

− 28% 124/445 40

Laparoscopic surgery

Laparoscopic surgery for the curative treatment of colorectal cancer should be performed only under the auspices of a randomised controlled trial.

− 14% 6/42 32 & 100

Stomal therapy

All patients who may require a temporary or permanent stoma should be seen by a stomal therapy nurse before the operation where this facility is available.

− 92% 707/768 21

ELECTIVE SURGERY FOR COLON CANCER

Oophorectomy

Prophylactic bilateral oophorectomy for colon cancer cannot be supported by the available evidence.

− 97% 843/865 35

FOLLOW-UP AFTER CURATIVE RESECTION FOR COLORECTAL CANCER

Follow-up

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.

− 89% 1326/1497

47

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

− 87% 1524/1760

47

Total 84% 4530/5377

xxii THE NATIONAL COLORECTAL CARE SURVEY

ABB

REV

IATI

ON

S ■ ABBREVIATIONS AND

NOTES

ACPS Australian Clinicopathological Staging

ACT Australian Capital Territory

Gy Gray; SI unit of absorbed radiation dose

NHMRC National Health and Medical Research Council

NSW New South Wales

NT Northern Territory

QLD Queensland

SA South Australia

TAS Tasmania

TNM Tumour, Node, Metastasis (staging system)

VIC Victoria

WA Western Australia

Cohorts

Information in this report is often grouped according to the number of colorectal cancer patients seen by the specialists surveyed in the three-month period of the survey. These groups of specialists are called ‘surgeon cohorts’, ‘medical oncologist cohorts’ and ‘radiation oncologist cohorts’.

NHMRC Guidelines

The NHMRC Guidelines referred to in this document are the Guidelines for the Prevention, Early Detection and Management of Colorectal Cancer (CRC), National Health and Medical Research Council, Commonwealth of Australia 1999.

A note on rounding

Due to rounding discrepancies, in some tables the actual totals of the percentage columns may be slightly more or less than the number given.

xxii THE NATIONAL COLORECTAL CARE SURVEY

ABB

REV

IATI

ON

S ■ SECTION 1:

INTRODUCTION

3INTRODUCTION

■IN

TROD

UC

TION

3INTRODUCTION

■IN

TROD

UC

TION

BackgroundThe National Colorectal Cancer Care Survey was undertaken to determine the management patterns for individuals newly diagnosed with colorectal cancer in a three-month period in 2000.

The survey took place at the time of dissemination of the NHMRC’s Guidelines for the Prevention, Early Detection and Management of Colorectal Cancer (CRC) (‘NHMRC Guidelines’). As outlined in that publication, colorectal cancer is ‘unequivocally a major health problem in Australia’. Each year over 10,000 people are diagnosed with colorectal cancer and over 4500 people die as a result of colorectal cancer.

AimsThe aims of the survey were:

(i) To provide a baseline measure of concordance of colorectal cancer management in Australia with the NHMRC Guidelines at the time of their dissemination.

(ii) To identify patient, tumour and practitioner variables associated with management.

(iii) To identify variations in practice and to outline strategies to address these as necessary.

(iv) To be in a position to collect information on outcomes for accrued cases in order to correlate them with practice and with the guidelines.

Methods

Administration of the survey

The survey was conducted under the auspices of the Clinical Governance Unit, Hunter Area Health Service, New South Wales and the Discipline of Surgical Science, Faculty of Health, the University of Newcastle, New South Wales.

The survey was funded by the Commonwealth Department of Health and Ageing via the National Cancer Control Initiative.

A Project Management Group and a Project Working Party were formed and they maintained an advisory role with regard to the establishment and conduct of the survey. The role of individual members of these bodies in the compilation of the report is described above.

A National Project Manager coordinated the survey. The Chair of the Project Working Committee (with the cooperation of the Project Working Party and the Project Management Group) supervised the National Project Manager.

A local project officer administered the survey for each state and territory Cancer Registry with the exception of the Australian Capital Territory, South Australia and Western Australia. The Australian Capital Territory Registry reports to the New South Wales Registry, hence the survey was administered

4 THE NATIONAL COLORECTAL CARE SURVEY

INTR

OD

UC

TIO

N ■

5INTRODUCTION

■IN

TROD

UC

TION

by the New South Wales Project Officer. Within South Australia, the Anti-Cancer Foundation of South Australia administered the conduct of the survey. The survey was administered in Western Australia by the Department of Public Health at the University of Western Australia.

Individuals within each state who participated in the administration of the survey are described in Appendix A, ‘Survey Administration’, together with the membership of the Project Management Group and Working Party.

Questionnaire development

A questionnaire coversheet accompanied all questionnaires sent to clinicians.

The NHMRC Guidelines outline 86 specific recommendations. Of those guidelines concerned with investigation, treatment and follow-up, 46 are amendable to measurement. The questionnaires used in this study allowed for the detailed analysis of 23 of these 46 guidelines. The selection criteria for these guidelines were constrained by the ability to record information concisely and the need to keep questionnaires as brief as possible to optimise response rates from busy clinicians. The questions included were based on the advice of the specialist advisory group from the related, but separate, NSW Colorectal Cancer Patterns of Care Survey.

See Appendices E to H for copies of these documents.

Data collection

All newly reported individuals diagnosed with colorectal cancer and notified to each Australian Cancer Registry (as is mandatory), over the three-month period between 1 February 2000 and 30 April 2000, were entered into the survey.

Data were supplied by the treating clinician in all states except Western Australia. Here, local practice determined that the Project Officer accessed and entered data directly into the relevant questionnaire. Data were also recorded by Project Officers for a number of cases in other states and territories.

Determination of location of patient and hospitals

The place of residence of patients was determined using the patient’s postcode and information provided by the Australian Bureau of Statistics. The hospital where patients were treated was similarly determined using the information on the questionnaire coversheet (see Appendix E).

Determination of cancer stage

The algorithm used to determine the stage of colorectal cancers is described in Appendix B.


INTR

OD

UC

TIO

N ■

5INTRODUCTION

■IN

TROD

UC

TION

Data management

A Microsoft Access database designed for the NSW Colorectal Cancer Patterns of Care Survey was adapted for the national survey.

De-identified data were transmitted from each local Cancer Registry or other administrative centre to the National Colorectal Cancer Care Office in Newcastle.

Data analysis

Professor Robert Gibberd, Centre for Clinical Epidemiology and Biostatistics, Faculty of Health, the University of Newcastle, provided statistical advice and analysis.

Raw data were extracted and evaluated. Data were entered into SAS (Statistical Analysis System) and are presented in terms of concordance with the NHMRC Guidelines as tables. Chi-square analysis was used to determine whether statistically significant differences were present. Logistic regression was used to determine whether differences between two or more variables were statistically significant.

These results are presented in the section titled ‘Variations Found’.

Compilation of this report

This report was written by Professor Allan Spigelman, Discipline of Surgical Science, Faculty of Health, the University of Newcastle and the Clinical Governance Unit, Hunter Area Health Service (Chair of the NCCCS Project Working Party); Dr Daniel McGrath, Lecturer, Discipline of Surgical Science, Faculty of Health, the University of Newcastle; and Ms Sandra Anderson, National Project Manager. Ms Judy Swan, Clinical Governance Unit, Hunter Area Health Service, provided additional support.

This report presents the data as they were reported on the questionnaires. Putative explanations of these data have been avoided as much as possible, in keeping with the aims of the survey, as outlined above. The results will, however, form part of the substance of manuscripts to be submitted for consideration for publication in peer-reviewed journals.

The Project Working Party reviewed the report. In addition, detailed reviews were carried out as follows:

• The section titled ‘Surgical Questionnaire’ was reviewed by Professor Allan Spigelman and Dr Daniel McGrath.

• The section titled ‘Medical Oncology Questionnaire’ was reviewed by Professor John Zalcberg, Dr David Leong and Associate Professor Robyn Ward, together with Professor Allan Spigelman and Dr Daniel McGrath.

• The section titled ‘Radiation Oncology Questionnaire’ was reviewed by Associate Professor Bryan Burmeister, together with Professor Allan Spigelman and Dr Daniel McGrath.

The report was further checked and edited by the National Cancer Control Initiative and the Publications Office, The Cancer Council Victoria.

SECTION 2: RESULTS

9RESULTS

■R

ESULTS

9RESULTS

■R

ESULTS

Overall Response RateThere were 2383 patients registered with an initial diagnosis of colorectal cancer. A total of 3339 questionnaires were sent to clinicians from the different specialities involved and 2669 questionnaires were returned, giving an overall response rate of 80%.

Response rate: all questionnaires

Table 1 outlines response rates according to speciality. These ranged from 68% for medical oncologists to 85% for surgeons.

Table 1 Response rates by speciality

Speciality Questionnaires Responserate (%)Sent Returned

Surgery 2383 2015 85

Medical oncology 722 492 68

Radiation oncology 234 162 69

Surgery, medical & radiation oncology 3339 2669 80


RES

ULT

S ■

11RESULTS

■R

ESULTS

Surgical Questionnaire

Response rate

Surgical questionnaires were sent for 2383 patients and were completed and returned for 2015 patients, of whom 1911 went on to have an operation. Table 2 outlines the response rates for the Surgical Questionnaire according to the location where the patients were registered. The response rate ranged from 71% in South Australia to 100% in the Northern Territory.

Table 2 Response rates by state or territory

Location Questionnaires Responserate (%)Sent Returned

NT 5 5 100

TAS 80 79 99

ACT 36 34 94

NSW 660 596 90

QLD 545 474 87

VIC 661 534 81

WA 166 130 78

SA 230 163 71

Total/overall % 2383 2015 85

Distribution of patients by age, sex and place of residence

Age distribution of patientsThe average age of patients was 68 years (median 70; range 16–100). Table 3 shows the age distribution of the patients. Most patients were older than 60 years.

Table 3 Age distribution of patients

Age (years) Patients

n %

0−49 135 7

50−59 301 15

60−69 567 28

70−79 673 33

80+ 339 17

Total 2015 100


RES

ULT

S ■

11RESULTS

■R

ESULTS

Sex distribution of patientsOverall there was a slightly greater proportion of males. There were almost equal numbers of males and females with colon cancer. There was, however, a marked preponderance of males with rectal cancer, with a male:female ratio of nearly 2:1 (P<0.0001; see Table 4).

Table 4 Sex distribution by site of cancer

Sex Colon cancer Rectal cancer Total

n % n % n %

Male 736 51 361 64 1097 54

Female 716 49 202 36 918 46

Total 1452 100 563 100 2015 100

Patients’ place of residenceMost patients lived in a capital city (Tables 5a and 5b).

Table 5a Place of residence of all patients

Place of residence All patients

n %

Capital city 1218 60

Urban 216 11

Rural 544 27

Unknown 37 2

Total 2015 100

Table 5b Place of residence of patients who had an operation

Place of residence Patients who had operation

n %


Urban 205 11

Rural 514 27

Unknown 37 2

Total 1911 100


RES

ULT

S ■

13RESULTS

■R

ESULTS

Location and type of hospitals

The identity of each participating hospital, together with its classification into capital city, urban or rural, can be found in Appendix C. Tables 6−11 outline the location and type of hospitals where patients in the survey received their treatment. As expected, most of the treating hospitals were within capital cities (Table 6).

Table 6 Location of hospitals

Hospital location Patients

n %


Urban 259 13

Rural 480 24

Unknown 118 6

Total 2015 100

Table 7 displays the number of hospitals and patients per location (state and territory) and the number and average number of patients treated per hospital. The location with the highest average number of patients per hospital was Queensland. The location with the most treating hospitals was New South Wales.

Table 7 Distribution of treating hospitals in each state or territory

State/territory Treating hospitals (n) Patients (n) Average number of patients per hospital

QLD 60 474 7.9

NSW 82 596 7.3

TAS 11 79 7.2

VIC 77 534 6.9

ACT 5 34 6.8

WA 19 130 6.8

SA 30 163 5.4

NT 3 5 1.7

Total 287 2015 7.0


RES

ULT

S ■

13RESULTS

■R

ESULTS

Capital cities had an equal proportion of patients treated in public and private hospitals, while the proportion of patients treated in public hospitals was higher in urban and rural environments (Tables 8 and 9).

Table 8 Type of treating hospital

Hospital type Patients

n % of each group % of total

Capital city public 577 50 29

Capital city private 581 50 29

Urban public 150 58 7

Urban private 109 42 5

Rural public 311 65 15

Rural private 169 35 8

Unknown 118 100 6

Total 2015 − 100

Table 9 shows the type of hospital according to location (state or territory). For example, in the Australian Capital Territory, 35% of patients were treated in capital city private hospitals, whereas in Western Australia, 74% of patients treated in a capital city received their treatment in a private hospital. Fifty per cent of all capital city patients were treated in private hospitals.

Table 9 Patients treated by state or territory and type of hospital

Hospital type State/territory Total

ACT NSW NT QLD SA TAS VIC WA

Capital city private n%

12 156 3 120 72 30 130 58 581

35 43 75 63 50 64 44 74 50

Capital city public n%

22 209 1 72 71 17 165 20 577

65 57 25 38 50 36 56 26 50

Urban private n%

0 39 0 37 0 0 13 20 109

0 43 0 38 0 0 59 41 42

Urban public n%

0 52 0 60 0 0 9 29 150

0 57 0 62 0 0 41 59 58

Rural private n%

0 45 0 61 8 11 41 3 169

0 33 0 38 47 38 32 100 35

Rural public n%

0 93 1 101 9 18 89 0 311

0 67 100 62 53 62 68 0 65

Unknown n%

0 2 0 23 3 3 87 0 118

0 2 0 19 2.5 2.5 74 0 100


RES

ULT

S ■

15RESULTS

■R

ESULTS

Hospitals were designated tertiary referral status following review of Hospitals and Health Services: Buyers Guide 2000 (Edition 24, Kompass Australia). These hospitals are listed in Appendix C. Tables 10 and 11 show the number and percentage of all patients (2015) and of patients who had an operation (1911) according to the status of the hospitals.

Table 10 Place of treatment by hospital type and state or territory (all patients)

State/territory Tertiary referral hospitals Other hospitals

n % n %

ACT 8 24 26 76

NSW 158 27 438 73

NT 0 0 5 100

QLD 66 14 408 86

SA 50 31 113 69

TAS 17 22 62 78

VIC 74 14 460 86

WA 44 34 86 66

Total/overall % 417 21 1598 79

Table 11 Place of treatment by hospital type and state or territory (patients who had an operation)

State/territory Tertiary referral hospitals Other hospitals

n % n %

ACT 8 24 26 76

NSW 153 26 431 74

NT 0 0 5 100

QLD 63 14 375 86

SA 47 31 106 69

TAS 16 23 54 77

VIC 67 13 439 87

WA 37 31 84 69


Travel for treatment

A greater percentage of rural and urban patients travelled to hospitals outside their locality for surgery than did patients who lived in capital cities. Table 12 shows that, while 84% of patients who lived in a capital city received their operation there, only 64% of patients who lived in rural areas received their operation in a rural area (P<0.0001).


RES

ULT

S ■

15RESULTS

■R

ESULTS

Table 12 Location of treating hospital in relation to patients’ place of residence

Hospital location

Patients’ place of residence Total

Capital city Urban Rural Unknown

n % n % n % n %

Capital city 975 84 17 8 96 19 15 41 1103

Urban 54 5 137 67 53 10 5 14 249

Rural 67 6 46 22 330 64 14 38 457

Unknown 59 5 5 2 35 7 3 8 102

Total 1155 100 205 100 514 100 37 100 1911

Number of colorectal cancers per patient

Most patients had a single cancer, with 6% having more than one primary colorectal cancer (Table 13). Of the 112 patients with more than one colorectal cancer, 23 patients had a colon and rectal cancer and six had two or more rectal cancers, leaving 83 patients with synchronous colonic cancers. Exactly 100 patients had two primary colorectal cancers, nine patients had three primary colorectal cancers, one patient had four primary colorectal cancers and two patients had six primary colorectal cancers.

A total of 2145 colorectal cancers were reported.

Table 13 Number of colorectal cancers per patient

Colorectal cancers (n) Patients

n %

1 1902 94

2 100 5

>2 12 1

Unknown 1 <1

Total 2015 100

The average age of patients with only one colorectal cancer was 69 years (median 70; range 16–100). For the 100 patients with two colorectal cancers, the average age was 73 years (median 73; range 47–90). The average age for the nine patients with three colorectal cancers was 66 years (median 68; range 47–90). The patient with four colorectal cancers was 67 years old and the two patients with six colorectal cancers were 71 and 81 years old respectively.

Site of colorectal cancer

Of the 2015 patients, 1452 (72%) presented with a cancer in the colon and 563 (28%) presented with a cancer in the rectum.

Cancers occurred in the right hemicolon (caecum, ascending colon and hepatic flexure) on 28% of occasions; in the transverse colon on 8% of occasions; in the left hemicolon (splenic flexure, descending colon, sigmoid colon and rectosigmoid area) on 37% of occasions; and in the rectum on 27% of occasions (Table 14).


RES

ULT

S ■

17RESULTS

■R

ESULTS

Table 14 Site of colorectal cancer

Site of cancer n % Total

n %

Caecum 290 14 587 28

Ascending colon 203 10

Hepatic flexure 94 4

Transverse colon 163 8 163 8

Splenic flexure 65 3 785 37

Descending colon 75 4

Sigmoid colon 409 19

Rectosigmoid 236 11

Rectum – upper-third 114 5 569 27

Rectum – middle-third 199 10

Rectum – lower-third 256 12

Total 2104 * 100 2104 100

* If patients had two or more colorectal cancers in the same site (for example, in the ascending colon), only one cancer for that site is recorded in Table 14; hence the total number of cancers as described per site (2104) is less than the overall number of cancers (2145) that were reported

Mode of presentation

Patients were classified according to their mode of presentation into those who presented electively as a result of screening, those who presented electively as a result of symptoms and those who presented as emergencies (Table 15).

Table 15 Mode of presentation by site of cancer

Mode of presentation Colon Rectum * Patients

n % n %

Elective screening 96 5 22 1 118

Elective symptoms 1155 57 526 26 1681

Elective total 1251 62 548 27 1799

Emergency 201 10 15 1 216

Total/overall % 1452 ** 72 563 *** 28 2015

Percentages are of 2015 patients* Twenty-three patients presented with synchronous colon and rectal cancers; they are allocated to the rectal site** Of the 1452 patients with colon cancer, 1388 (1192 elective and 196 emergency) went on to have an operation*** Of the 563 patients with rectal cancer, 523 (508 elective and 15 emergency) went on to have an operation

Of the patients who presented through screening, 63 were screened because of a strong family history of colorectal cancer, 35 because of other risk factors and 12 as a result of population screening. A further eight patients had colorectal cancer detected as a result of screening, but the indications for screening were not reported.


RES

ULT

S ■

17RESULTS

■R

ESULTS

The majority of patients presented with symptoms regardless of whether the cancer was in the colon or in the rectum (Figure 1).

Figure 1 Mode of presentation of all 2015 patients

0%

20%

40%

60%

80%

100%

EmergencyElective symptomsElective screening

Perc

enta

ge

of 2

015

pat

ien

ts

Pre-operative investigations: type, evidence of local invasion and confirmation of diagnosis

Of the 1911 patients who had an operation, 1700 presented electively and 211 presented as an emergency.

Type of pre-operative colorectal investigationsTable 16 shows the pre-operative colorectal investigations performed on these 1911 patients. Most of these patients (1565; 82%) had a colonoscopy.


RES

ULT

S ■

19RESULTS

■R

ESULTS

Table 16 Pre-operative colorectal investigations

Investigation Elective Emergency All cases

n % n % n %

Colonoscopy only 1183 * 70 63 ** 30 1246 65

Colonoscopy plus another 307 18 12 6 319 17

Barium enema only 42 2 36 17 78 4

Sigmoidoscopy only 50 3 11 5 61 3

Barium enema plus 28 2 7 3 35 2

Others 85 5 69 33 154 8

None 5 <1 13 6 18 1

Total 1700 100 211 100 1911 100

* Nine of these patients had their colonoscopy intra-operatively** Two of these patients had their colonoscopy intra-operatively

A defined number of further investigations was also carried out, as outlined in question 6 of the Surgical Questionnaire (Appendix F). These included 946 patients who had a chest x-ray, 863 patients who had an abdomino-pelvic CT scan (559 for colon cancer; 304 for rectal cancer), 124 patients who had an abdomino-pelvic ultrasound scan and 10 patients who had an abdomino-pelvic MRI scan (three for colon cancer; seven for rectal cancer).

Within the investigation section of the questionnaire, there was also a box for ‘Others’. Analysis of these data showed that 82 patients had carcino-embryonic antigen (CEA) blood tests and 79 had liver function tests. These should be regarded as the minimum number of patients who had these investigations.

A minority of rectal cancer patients had a pre-operative endorectal ultrasound (Table 17).

Table 17 Patients with rectal cancer who had an operation and who had an endorectal ultrasound

Type of presentation Patients

n %

Elective presentation (508 patients) 79 16

Emergency presentation (15 patients) 3 20

Total/overall % 82 16

Of the 40 patients with rectal cancer who did not have an operation, three (all elective presentations) also had pre-operative endorectal ultrasound. Thus, 85 of all 563 patients (15%) with rectal cancer had this investigation. An additional 10 patients with colon cancer also had an endorectal ultrasound.

Pre-operative evidence of local invasionOf all 2015 patients, 210 (10%) had pre-operative evidence of local invasion by their cancer. Of these 210 patients, 140 were considered to have had resectable cancers and 137 of these had an operation. Of the three patients with resectable cancer who did not have an operation, two had radiotherapy only and the remaining patient had metastatic disease. All three of these patients had rectal cancer.

A further 56 patients with evidence of local invasion and whose cancers were thought not to be resectable underwent surgery (40 palliative procedures and 16 curative procedures).


RES

ULT

S ■

19RESULTS

■R

ESULTS

Pre-operative histological confirmation of diagnosisMost (73%) of the 2015 patients had the diagnosis of malignancy confirmed histologically pre-operatively. This occurred in over three-quarters of the elective patients, compared with just less than one-third of the emergency patients (Table 18).

Table 18 Patients who had a pre-operative histological confirmation of the diagnosis


n %




Of the 1911 patients who underwent surgery, 1405 (74%) had the diagnosis of malignancy confirmed histologically pre-operatively (Table 19).

Table 19 Patients who had an operation in whom there was pre-operative histological confirmation of the diagnosis


n %




Surgery: not performed

A total of 104 of the 2015 patients (5%) did not proceed to have an operation. These 104 patients consisted of 94 of the 1681 patients (6%) who presented electively with symptoms, five of the 118 patients (4%) who presented electively through screening and five of the 216 patients (2%) who presented as an emergency. Table 20 lists the reasons why these patients did not have an operation.

Table 20 Reasons why patients did not have an operationReason Colon cancer

patients (n)Rectal cancer patients (n)

Total

n %

Incurable disease 18 14 32 31

Unfit for surgery 16 8 24 23

Patient refused surgery 7 4 11 10

Other reason * 23 13 36 35

Unknown 0 1 1 1

Total 64 40 104 100

* The most common ‘Other reason’ given was the patient having undergone a colonoscopic polypectomy with adequate clearance


RES

ULT

S ■

21RESULTS

■R

ESULTS

Preparation for surgery: bowel preparation, thromboembolic prophylaxis, antibiotic prophylaxis, pre-operative counselling and pre-operative visit by a stomal therapist

Bowel preparationMost patients (1673 out of 1911; 88%) received some form of bowel preparation. Of the 1673 patients who received bowel preparation, most (1611; 96%) received this orally, while 99 (6%) were given an enema. In questionnaires for 17 patients (1%), the ‘Other’ response box was ticked.

Table 21 shows that bowel preparation was used in relatively fewer emergency patients than elective patients and in relatively fewer patients with colon cancer than with rectal cancer.

Table 21 Use of bowel preparation by mode of presentation and site of cancer

Bowel preparation Presentation Cancer site

Elective Emergency Colon Rectum

n % n % n % n %

None 125 7 113 54 217 16 21 4

Some 1575 93 98 46 1171 84 502 96

Total 1700 100 211 100 1388 100 523 100

Thromboembolic prophylaxisNearly all of the 1911 patients who had an operation received some form of thromboembolic prophylaxis, with only 68 (4%) of these patients not receiving any form of thromboembolic prophylaxis.

The methods used for prophylaxis are shown in Table 22.

Table 22 Use of deep venous thrombosis prophylaxis Method Patients

n %

Graduated stockings 1177 64

Unfractionated heparin 1070 58

Intermittent intra-operative calf compression or stimulation 1012 55

Low molecular weight heparin 619 34

Other * 37 2

Total 3915 −

Some patients received combined prophylactic measuresPercentages are of the 1843 patients who received some thromboembolic prophylaxis* For example, warfarin use, caval filter insertion

Of those who received thromboembolic prophylaxis, 1770 (96%) received prophylaxis as recommended by the NHMRC Guidelines. This figure equates to 93% of all 1911 patients who had an operation.


RES

ULT

S ■

21RESULTS

■R

ESULTS

Antibiotic prophylaxisMost patients (1787; 94%) received an antibiotic (Table 23), with two-thirds of those who were given antibiotics receiving a single dose (Table 24).

Table 23 Antibiotic prophylaxis Antibiotic Patients

n %

Cephalosporin 1182 66

Metronidazole 1141 64

Aminoglycoside 604 34

Other 274 15

Total 3201 −

Some patients received combined prophylactic antibioticsPercentages are of the 1787 patients who had an antibiotic

Table 24 Duration of antibiotic use

Dose Patients

n %

Single dose 1177 66

>1 dose 597 33

Unknown 13 1

Total 1787 100

Only 676 of the 1911 patients (35%) who had an operation were definitely given antibiotics as recommended in the NHMRC Guidelines.

Adequate antibiotic prophylaxis however, may have been given to an additional 917 patients in whom a broad-spectrum cephalosporin or metronidazole in combination with gentamicin was used. This statement is based on more recently published antibiotic guidelines (Therapeutic Guidelines: Antibiotic Eleventh edition, Therapeutic Guidelines Ltd 2000). A total of 1593 (676 plus 917; 83%) of the 1911 patients therefore may have received appropriate antibiotic prophylaxis.

Pre-operative counsellingOf the 1911 patients who had an operation, 1145 (60%) received pre-operative counselling by a health practitioner other than the surgeon.

Pre-operative visit by stomal therapistA total of 707 patients were visited by a stomal therapist pre-operatively. An additional 61 patients who presented as an emergency, and on whose questionnaires a visit by a stomal therapist was marked as being indicated, did not see a stomal therapist pre-operatively. In a further 38 patients, a visit was indicated but not performed because a service was not available. Thus, 99 patients did not see a stomal therapist despite the clinician indicating that such a visit was necessary. This represented 12% of the 806 patients (707 plus 99) who required such a visit.

With regard to stomal therapy, the NHMRC Guidelines recommend that ‘all patients who may require a temporary or permanent stoma should be seen by a stomal therapy nurse where this facility is available’.


RES

ULT

S ■

23RESULTS

■R

ESULTS

Hence, 707 out of 768 patients (92%) were seen by a stomal therapist where one was available. All the patients who were not seen by a stomal therapist presented as emergencies.

Of the 535 patients who actually received a stoma, 431 saw a stomal therapist. Of the 104 patients who did not see a stomal therapist, it was indicated on the questionnaire as not being necessary in 58 (11%), and was not available for the remaining 46 (9%).

Characteristics of colorectal cancers: staging, patients’ age and mode of presentation

There follows an outline of the pathological characteristics of the colorectal cancers themselves. These data are presented for the 1911 patients who had an operation, because staging requires examination of an operative specimen, except for those patients with metastases detected by pre-operative investigations (41 patients who would be classified as Dukes’ stage D). These 1911 patients consisted of 1388 patients with colon cancer and 523 patients with rectal cancer.

Dukes’ stage for all cancersStaging of colorectal cancer refers to the classification of the cancer according to its extent of spread, which correlates with outcome. Responses to Question 5 in the Surgical Questionnaire (see Appendix F) were used to map the Dukes’ stage for each patient as described in Appendix B. A modified Dukes’ staging system has been used to enable classification of patients with distant metastases (classified as Dukes’ D).

Tables 25, 26 and 27 show the Dukes’ stage for all resected colorectal cancers, colon cancers and rectal cancers respectively.

Table 25 All patients with resected colorectal cancers and their Dukes’ stage

Dukes’ stage Patients

n %

A 447 23

B 527 28

C 518 27

D 335 18

Unknown 84 4

Total 1911 100

Table 26 Colon cancer patients and their Dukes’ stage


n %

A 293 21

B 398 29

C 384 28

D 269 19

Unknown 44 3

Total 1388 100


RES

ULT

S ■

23RESULTS

■R

ESULTS

Table 27 Rectal cancer patients and their Dukes’ stage


n %

A 154 29

B 129 25

C 134 26

D 66 13

Unknown 40 8

Total 523 100

Table 27 includes 22 of the 23 patients (Table 15) who presented with synchronous colon and rectal cancers. These 22 patients proceeded to have an operation; the remaining patient with synchronous colon and rectal cancers did not.

Staging and patients’ ageThere was an inverse relationship between cancer stage and the age of patients. That is, younger patients tended to present with a greater proportion of more advanced (Dukes’ Stage C–D) cancers than did older patients. Figure 2 shows the distribution of all colorectal cancers by stage according to patient age group and the actual number of patients in that group, while Figure 3 shows the same data expressed in terms of percentages.

Figure 2 Colorectal cancer stage by patients’ age and number of patients

0

50

100

150

200Unknown

D

C

B

A

80+70 to 7960 to 6950 to 590 to 49

Nu

mb

er o

f pat

ien

ts p

er s

tag

e in

eac

h a

ge

gro

up

Age of patient


RES

ULT

S ■

25RESULTS

■R

ESULTS

Figure 3 Colorectal cancer stage by patients’ age and percentage within each age group

0

5

10

15

20

25

30

35Unknown

D

C

B

A

80+70 to 7960 to 6950 to 590 to 49

Perc

enta

ge

of p

atie

nts

per

sta

ge

in e

ach

ag

e g

rou

p

Age of patient

Figure 4 shows the distribution of colon cancers by stage according to patient age group and the actual number of patients in that group, while Figure 5 shows the same data expressed in terms of percentages.

Figure 4 Colon cancer stage by patients’ age and number of patients

0

30

60

90

120

150Unknown

D

C

B

A

80+70 to 7960 to 6950 to 590 to 49

Nu

mb

er o

f pat

ien

ts p

er s

tag

e in

eac

h a

ge

gro

up

Age of patient


RES

ULT

S ■

25RESULTS

■R

ESULTS

Figure 5 Colon cancer stage by patients’ age and percentage within each age group

0%

5%

10%

15%

20%

25%

30%

35%

40%Unknown

D

C

B

A

80+70 to 7960 to 6950 to 590 to 49

Perc

enta

ge

of p

atie

nts

per

sta

ge

in e

ach

ag

e g

rou

p

Age of patient

Figure 6 shows the distribution of rectal cancers by stage according to patient age group and the actual number of patients in that group, while Figure 7 shows the same data expressed in terms of percentages.

Figure 6 Rectal cancer stage by patients’ age and number of patients

0

10

20

30

40

50

60Unknown

D

C

B

A

80+70 to 7960 to 6950 to 590 to 49

Nu

mb

er o

f pat

ien

ts p

er s

tag

e in

eac

h a

ge

gro

up

Age of patient


RES

ULT

S ■

27RESULTS

■R

ESULTS

Figure 7 Rectal cancer stage by patients’ age and percentage within each age group

0%

5%

10%

15%

20%

25%

30%

35%

40%Unknown

D

C

B

A

80+70 to 7960 to 6950 to 590 to 49

Perc

enta

ge

of p

atie

nts

per

sta

ge

in e

ach

ag

e g

rou

p

Age of patient

Characteristics of cancers according to patients’ mode of presentation Those patients who presented as a result of screening were found to have a lesser proportion of advanced cancers following histopathological assessment of resected specimens. Table 28 displays the number of patients according to their Dukes’ staging and mode of presentation.

Table 28 Dukes’ stage and mode of presentation

Mode of presentation Dukes’ stage Total

A B C D Unknown

Elective (screening) 50 28 22 4 9 113

Elective (symptoms) 381 438 427 272 69 1587

Emergency 16 61 69 59 6 211

Total 447 527 518 335 84 1911

Figure 8 shows the percentage of patients according to their Dukes’ staging and mode of presentation. The percentage of patients with Dukes’ A cancers ranged from 44% (elective screening presentations) to 8% (emergency presentations).


RES

ULT

S ■

27RESULTS

■R

ESULTS

Figure 8 Percentage of patients within each Dukes’ stage according to mode of presentation

0%

10%

20%

30%

40%

50%Unknown

D

C

B

A

EmergencyElective symptomsElective screening

Perc

enta

ge

of p

atie

nts

fo

r eac

h s

tag

e

Number of patients per surgeon: by type of cancer, whether patients had an operation and patients’ place of residence

A total of 550 surgeons treated 2015 colorectal cancer patients (Table 29). The average number of patients treated per surgeon per month was 1.3.

Surgeons were grouped according to cohorts. Cohorts of surgeons were determined by the number of questionnaires returned on the patients that they had treated, as shown in Table 29. Most surgeons (75%) treated between one and four patients over three months. Within the group that saw between one and four patients per three months, the total number of patients seen was 757 and the average number of patients seen per month was 0.6. Only six surgeons returned questionnaires that indicated that they had seen more than 20 patients over three months.

Surgeons who saw such patients least often treated the majority of colorectal cancer patients.

It is unlikely that these data would alter had the survey achieved a 100% response rate, which would have provided data for an additional 368 patients seen and for a slightly lesser number of patients who would have had an operation.


RES

ULT

S ■

29RESULTS

■R

ESULTS

Table 29 Number of patients per surgeon cohortSurgeon cohort Surgeons Patients

n % n %

1–4 410 75 757 38

5–9 94 17 586 29

10–14 27 5 317 16

15–19 13 2 214 11

>20 6 1 141 7

Total 550 100 2015 100

In this and other tables, ‘surgeon cohort’ refers to surgeons grouped by the number of colorectal cancer patients seen over the three-month period of the survey

Figure 9 shows the average number of colorectal cancer patients seen over the three-month period of the study within each surgeon cohort.

Figure 9 Number of patients per surgeon cohort

0

5

10

15

20

25

20+15 to 1910 to 145 to 91 to 4

Ave

rag

e n

um

ber

of p

atie

nts

see

n p

er t

hre

e m

on

ths

Surgeon cohort

Tables 30 to 35 outline the overall number of patients per surgeon, by state or territory and according to cancer site.

Thus, Table 30 displays the number of patients with colorectal cancer according to the number of treating surgeons by location (that is, state or territory). The rows are divided by groups of patients (for example, 1−4 patients, 5−9 patients, etc.). Within each column are cells that list the total number of treating surgeons in that state or territory above the total number of patients seen by those surgeons. Thus, in New South Wales in the cohort of surgeons who saw 1–4 patients, 115 surgeons saw 217 patients.


RES

ULT

S ■

29RESULTS

■R

ESULTS

Table 30 Number of patients treated per surgeon for each state or territory

Surgeon cohort

NSW VIC QLD SA WA TAS ACT NT Total

1–4 Surgeons 115 141 88 30 23 7 4 2 410

Patients 217 259 164 52 45 9 6 5 757

5–9 Surgeons 30 27 22 5 3 5 2 0 94

Patients 187 164 138 36 17 30 14 0 586

10–14 Surgeons 5 7 6 2 4 2 1 0 27

Patients 58 81 66 26 48 24 14 0 317

15–19 Surgeons 5 2 2 3 0 1 0 0 13

Patients 84 30 35 49 0 16 0 0 214

>20 Surgeons 2 0 3 0 1 0 0 0 6

Patients 50 0 71 0 20 0 0 0 141

Total Surgeons 157 177 121 40 31 15 7 2 550

Patients 596 534 474 163 130 79 34 5 2015

Colorectal cancer patients who had an operationTable 31 shows the number of colorectal cancer patients who had an operation per surgeon; 513 surgeons operated on 1911 patients over the three-month period of the survey. Thus, each surgeon operated on an average of 1.2 patients per month. Some 722 patients were operated on by 381 (74%) surgeons over three months. This cohort of surgeons operated on an average of one colorectal cancer patient per surgeon every 6.4 weeks.

Table 31 Number of operated patients with colorectal cancer per surgeon for each state or territory

Surgeon cohort


1–4 Surgeons 114 135 76 23 22 5 4 2 381

Patients 214 257 147 45 39 9 6 5 722

5–9 Surgeons 29 24 20 5 3 4 2 0 87

Patients 181 151 126 35 17 25 14 0 549

10–14 Surgeons 6 7 6 2 4 3 1 0 29

Patients 71 83 66 25 46 36 14 0 341

15–19 Surgeons 4 1 2 3 1 0 0 0 11

Patients 68 15 34 48 19 0 0 0 184

>20 Surgeons 2 0 3 0 0 0 0 0 5

Patients 50 0 65 0 0 0 0 0 115

Total Surgeon 155 167 107 33 30 12 7 2 513

Patient 584 506 438 153 121 70 34 5 1911


RES

ULT

S ■

31RESULTS

■R

ESULTS

All colon cancer patientsTable 32 shows the number of patients seen with colon cancer according to the number of surgeons by location.

Table 32 Number of colon cancer patients treated per surgeon for each state or territory

Surgeon cohort


1–4 Surgeons 113 136 85 27 22 9 5 2 399

Patients 212 241 161 46 40 15 9 3 727

5–9 Surgeons 22 18 14 5 4 4 1 0 68

Patients 134 109 90 32 26 27 7 0 425

10–14 Surgeons 3 3 6 4 2 2 1 0 21

Patients 34 35 69 47 22 21 10 0 238

15–19 Surgeons 2 0 2 0 0 0 0 0 4

Patients 32 0 30 0 0 0 0 0 62

Total Surgeons 140 157 107 36 28 15 7 2 492

Patients 412 385 350 125 88 63 26 3 1452

Colon cancer patients who had an operationTable 33 shows the number of colon cancer patients who had an operation per surgeon; 463 surgeons operated on 1388 patients over the three-month period of the survey. Thus, each surgeon operated on an average of one colon cancer patient per month. Some 694 patients were operated on by 374 (81%) surgeons and this cohort of surgeons operated on an average of one patient every 6.5 weeks. At the other end of the spectrum 5% of surgeons (24) operated on an average of one colon cancer patient every week.

Table 33 Number of operated patients with colon cancer per surgeon for each state or territory

Surgeon cohort


1– 4 Surgeons 113 130 74 23 21 6 5 2 374

Patients 211 237 145 42 36 11 9 3 694

5–9 Surgeons 21 16 13 5 4 5 1 0 65

Patients 129 98 85 31 26 36 7 0 412

10–14 Surgeons 3 3 8 4 2 1 1 0 22

Patients 34 34 95 46 21 10 10 0 250

15–19 Surgeons 2 0 0 0 0 0 0 0 2

Patients 32 0 0 0 0 0 0 0 32

Total Surgeons 139 149 95 32 27 12 7 2 463

Patients 406 369 325 119 83 57 26 3 1388


RES

ULT

S ■

31RESULTS

■R

ESULTS

All rectal cancer patientsThe same scenario (that is, most surgeons treating and operating on relatively few patients) is seen for those patients with rectal cancer (Tables 34 and 35).

Table 34 Number of rectal cancer patients treated per surgeon for each state or territory

Surgeon cohort


1–4 Surgeons 69 85 50 14 13 5 4 1 241

Patients 105 125 77 27 22 11 8 2 377

5–9 Surgeons 8 4 4 2 2 1 0 0 21

Patients 48 24 26 11 10 5 0 0 124

10–14 Surgeons 3 0 2 0 1 0 0 0 6

Patients 31 0 21 0 10 0 0 0 62

Total Surgeons 80 89 56 16 16 6 4 1 268

Patients 184 149 124 38 42 16 8 2 563

Rectal cancer patients who had an operationOverall, 252 surgeons operated on 523 patients with rectal cancer over the three-month period. On average, surgeons operated on 0.7 patients per month. The majority of surgeons (228; 90%) operated on fewer than four patients per three months, with surgeons in this group operating on an average of one patient with rectal cancer every 7.5 weeks.

As for colon cancer patients, there were a few surgeons who had a much higher throughput of patients with rectal cancer. Thus, 24 surgeons (nearly 10%) operated on an average of one rectal cancer patient every 1.8 weeks.

Table 35 Number of operated patients with rectal cancer per surgeon for each state or territory

Surgeon cohort


1–4 Surgeons 67 80 45 11 14 6 4 1 228

Patients 102 118 69 24 24 13 8 2 360

5–9 Surgeons 9 3 5 2 2 0 0 0 21

Patients 55 19 33 10 14 0 0 0 131

10 –14 Surgeons 2 0 1 0 0 0 0 0 3

Patients 21 0 11 0 0 0 0 0 32

Total Surgeons 78 83 51 13 16 6 4 1 252

Patient 178 137 113 34 38 13 8 2 523

All colorectal cancer patients by patients’ place of residencePatients in rural and urban areas were significantly (P< 0.001) more likely to have been treated by a surgeon who treated fewer patients than were patients in capital cities (Figure 10).


RES

ULT

S ■

33RESULTS

■R

ESULTS

Figure 10 Percentage of patients seen by each surgeon cohort by patients’ place of residence

0%

10%

20%

30%

40%

50%Rural

Urban

Capital city

20+15 to 1910 to 145 to 91 to 4

Perc

enta

ge

of p

atie

nts

wit

hin

eac

h g

rou

p

Surgeon cohort

Surgical management: mode of access, type of colorectal resection, operative evidence for local invasion, post-operative residual cancer, oophorectomy and stoma formation

Mode of accessAn open approach was used as the method of access for most patients (Table 36). Of the 56 patients who had a laparoscopic approach, 42 had a curative procedure. Of these 42 patients, six (14%) were enrolled in a clinical trial as recommended in the NHMRC Guidelines. However, only 11 of the laparoscopic patients were eligible for inclusion in a trial, and three of these were offered, but declined entry, into a trial. Thus, six of eight (75%) eligible consenting laparoscopic patients were enrolled in a study (see Figure 24).

Table 36 Mode of surgical access

Mode Patients

n %

Open 1855 97

Laparoscopic 56 3

Total 1911 100


RES

ULT

S ■

33RESULTS

■R

ESULTS

Type of colorectal resectionMost patients were said to have had a ‘curative’ resection (Table 37).

Table 37 Nature of surgery

Surgery aim Patients

n %

Curative 1563 82

Palliative 347 18

Unknown 1 <1

Total 1911 100

Table 38 lists the reasons why a palliative resection was performed.

Table 38 Reasons for palliative surgery

Reason for palliative surgery Patients

n %

Presence of distant metastases 254 73

Incomplete resection 58 17

Other reason 33 10

Unknown 2 <1

Total 347 100


RES

ULT

S ■

35RESULTS

■R

ESULTS

Table 39 shows the total number, percentage and type of operation performed.

Table 39 Type of operation in elective and emergency patients

Type of operation Elective patients (n)

Emergency patients (n)

Total

n %

Transanal endoscopic microsurgery 14 2 16 <1

Sigmoid colectomy 106 12 118 6

Segmental resection 32 6 38 2

Right hemicolectomy 469 55 524 25

Extended right hemicolectomy 79 24 103 5

Left hemicolectomy 85 18 103 5

Extended left hemicolectomy 15 4 19 <1

Subtotal colectomy 34 12 46 2

Total colectomy 28 6 34 2

Total proctocolectomy 8 1 9 <1

Hartmann’s procedure 32 30 62 3

High anterior resection 308 24 332 15

Low anterior resection 187 6 193 9

Ultra-low anterior resection 155 3 158 7

Abdomino-perineal resection 126 5 131 6

Liver resection 9 1 10 <1

Hepatic arterial catheter 3 0 3 <1

Pelvic exenteration 2 0 2 <1

Defunctioning stoma only 22 7 29 1

Laparotomy/laparoscopy only 7 0 7 <1

Other * 151 26 177 8

Total 1872 242 2114 100

Some patients had more than one operationPercentages are of the total number of operations (2114)* These were procedures performed in addition to the colorectal procedure, for example, liver biopsy, splenectomy, cholecystectomy, appendicectomy, hysterectomy, hernia repair


RES

ULT

S ■

35RESULTS

■R

ESULTS

Operative evidence for local invasionIn 297 patients with colorectal cancer, there was evidence at operation of local invasion. A frozen section for urgent histopathological examination was taken in 20 cases (17 colon cancer, three rectal cancer).

Table 40 shows how local invasion was dealt with.

Table 40 Treatment of local invasion at operation (colorectal cancer)

Surgical management Cancer site

Colon Rectum

n % n %

En bloc resection 142 60 32 52

Incomplete resection 49 21 10 16

Removed separately 6 3 5 8

No resection 37 16 15 24

Unknown 1 <1 − −

Total 235 17 62 12

Presence of residual colorectal cancer post-operativelyThere was evidence of residual colorectal cancer in 240 (178 colon cancer, 62 rectal cancer) or 12% of the 1911 patients who had an operation. The evidence was macroscopic in 184 patients and microscopic in 56 patients.

OophorectomyOnly a minority of the 865 women who underwent surgery had an oophorectomy. In 22 (3%) of women this was listed as being ‘prophylactic’ (Table 41), a procedure which is contrary to the NHMRC Guidelines. A ‘therapeutic’ oophorectomy (for the removal of ovaries involved with malignancy) was carried out in 31 women.

Table 41 Women who had an oophorectomy

Reason given for oophorectomy Patients

n %

Therapeutic 31 4

Prophylactic 22 3

Total 53 6

Percentages are of the 865 women who had an operation

Stoma formationOf the 1911 patients who had surgery, 535 (28%) had a stoma created. This was temporary in 325 (61%) and permanent in 210 (39%). The type of stoma formed is shown in Table 42. The most commonly formed stoma was a temporary ileostomy.


RES

ULT

S ■

37RESULTS

■R

ESULTS

Table 42 Temporary and permanent stomas by type

Type Temporary Permanent Total

n % n % n %

Colostomy 66 12 175 33 241 45

Ileostomy 253 47 35 7 288 54

Unknown 6 1 0 0 6 1

Total 325 61 210 39 535 100

Percentages are of the 535 patients with a stoma

Surgical management: assessing distance of rectal cancer from anal verge, extrafascial dissection, isolation of small bowel from pelvis and other operative details (rectal cancer)

Method used to assess distance of rectal cancer from the anal vergeThe rigid sigmoidoscope was the favoured instrument for assessing the distance of rectal cancers from the anal verge (Table 43).

Table 43 Method of recording distance of rectal cancer from the anal verge

Method Patients

n %

Rigid sigmoidoscopy 246 44

Flexible sigmoidoscopy 132 23

Digital rectal examination 105 19

Unknown 80 14

Total 563 100

Extrafascial dissectionMost patients with rectal cancer (390/523 or 75%) had an extrafascial dissection performed. The percentage of patients in each surgeon cohort who had an extrafascial dissection was:

• 70% (1−4 surgeon cohort)




• 71% (>20 surgeon cohort).

Isolation of the small bowel from the pelvisThe small bowel was isolated from the pelvis in 111 of the 523 patients with rectal cancer (21%). An omental sling was used on 28 occasions, mesh on four and another method on 43 occasions.


RES

ULT

S ■

37RESULTS

■R

ESULTS

The proportion of patients in whom the small bowel was isolated declined from 19% in the 1–4 surgeon cohort, to 15% in the 5–9 cohort, to 9% in the 10–14 cohort and to 2% in the >20 cohort. That is, surgeons who treated 1–4 patients over the three months said that they isolated the small bowel in 19% of their patients, compared with 2% of patients treated by surgeons who saw more than 20 patients over the three months.

Other operative details: rectal cancerMost rectal cancers were situated in the lower- or middle-third of the rectum (Table 44).

Table 44 shows the number of surgeons who operated on patients with rectal cancer according to the site of the rectal cancer. Surgeons who operated on more than 20 colorectal cancer patients per three months operated on the greatest proportion of patients with rectal cancers of the lower-third of the rectum. Fifty-two per cent of their patients with rectal cancer had cancers of the lower-third of the rectum, compared with 44% of patients in the surgeon cohort that operated on 1–4 patients. Conversely, patients with upper-third rectal cancers comprised 25% of the surgeon cohort that operated on 1–4 patients, compared with 5% of the surgeon cohort that operated on more than 20 patients (Table 44).

Table 44 Rectal cancer site per surgeon cohort

Surgeon cohort Rectal cancer site Total

Upper-third Middle-third Lower-third Multiple

n % n % n % n %

1–4 43 25 52 30 77 44 2 1 174

5–9 30 21 46 32 66 46 2 1 144

10–14 19 20 34 35 43 45 0 0 96

15–19 10 15 23 35 30 46 2 3 65

>20 2 5 19 43 23 52 0 0 44

Total/overall % 104 20 174 33 239 46 6 1 523

Surgical management: abdomino-perineal resection, anterior resection, anastomosis, colonic pouch formation, total mesorectal excision and permanent stoma formation

Abdomino-perineal resectionSurgeons who operated on 1–4 colorectal cancer patients in the three-month period of the survey performed a greater proportion of abdomino-perineal resections (52 of 174 patients; 30%) for the patients with rectal cancer than did those surgeons who operated on more than 20 patients (6 of 44 patients; 14%). See Table 45.


RES

ULT

S ■

39RESULTS

■R

ESULTS

Table 45 Abdomino-perineal resections by surgeon cohort and rectal cancer site

Surgeon cohort

Abdomino-perineal resection Total

Upper-third rectal cancer

Middle-third rectal cancer

Lower-third rectal cancer

Multiple rectal cancer

n % n % n % n % n %

1–4 1 2 5 10 46 60 0 0 52 30

5–9 1 3 3 7 32 48 0 0 36 25

10–14 0 0 3 9 16 37 0 − 19 20

15–19 0 0 0 0 12 40 0 0 12 18

>20 0 0 0 0 6 26 0 − 6 14

Total/overall %

2 2 11 6 112 47 0 0 125 * 24

Denominators used to calculate percentages are the numbers shown in Table 44* In addition, two patients had an abdomino-perineal resection for colon cancer. In another four of the abdomino-perineal resection patients, the necessary data were not available

Anterior resectionSurgeons who operated on 1–4 colorectal cancer patients during the three-month period of the survey performed a lesser proportion of anterior resections (101 of 174 patients; 58%) for patients with rectal cancer than did those surgeons who operated on more than 20 patients (28 of 44 patients; 64%) (P=0.04). See Table 46. This disparity was most marked for patients with lower-third rectal cancers, where 29% of patients operated on by the lowest volume surgeon cohort had an anterior resection, compared with 48% of those operated on by the highest volume surgeon cohort.

Table 46 Anterior resections by surgeon cohort and rectal cancer site

Surgeon cohort Anterior resection Total





n % n % n % n % n %

1–4 39 91 38 73 22 29 2 100 101 58

5–9 20 67 40 87 26 39 0 0 86 60

10–14 18 95 30 88 17 40 0 − 65 68

15–19 9 90 17 74 13 43 1 50 40 62

>20 1 50 16 84 11 48 0 − 28 64

Total/overall % 87 84 141 81 89 37 3 50 320 61

Denominators used to calculate percentages are the numbers shown in Table 44


RES

ULT

S ■

39RESULTS

■R

ESULTS

Ratio of anterior resections to abdomino-perineal resectionsSurgeons who operated on 1–4 colorectal cancer patients in the three-month period of the survey carried out relatively more abdomino-perineal resections than surgeons who operated on more than 20 patients in this period (Table 47).

Table 47 Ratio of anterior resections to abdomino-perineal resections

Surgeon cohort Upper-thirdratio

Middle-thirdratio

Lower-thirdratio

Multipleratio

Totalratio

1–4 39:1 8:1 1:2 2:0 2:1

5–9 20:1 13:1 1:1 0:0 3:1

10–14 18:0 10:1 1:1 0:0 3:1

15–19 9:0 17:0 1:1 1:0 3:1

>20 1:0 16:0 2:1 0:0 5:1

All surgeons 44:1 13:1 0.8:1 3:0 3:1

Anterior resection: method of anastomosisThere was a trend for surgeons to perform a greater proportion of ultra-low anastomoses when doing an anterior resection as they operated on more patients. For example, 71% of patients operated on by surgeons who operated on more than 20 patients in the three-month period of the survey had an ultra-low anastomosis, compared with 26% of those operated on by surgeons who operated on 1−4 patients in this period (Table 48).

Table 48 Type of anastomosis per surgeon cohort

Surgeon cohort Type of anastomosis Total

High Low Ultra-low

n % n % n %

1–4 19 19 56 55 26 26 101

5–9 5 6 34 39 47 55 86

10–14 7 11 20 31 38 58 65

15–19 4 10 15 38 21 52 40

>20 0 0 8 29 20 71 28

Total/overall % 35 11 133 42 152 47 320

Numbers and percentages in the above table are based on rectal cancer resections and exclude anterior resections carried out for those patients with sigmoid colon cancers. An additional 363 anterior resections were carried out on patients with colon cancer

Colonic pouch formationColonic pouches were formed more frequently by surgeons as the number of patients that they treated increased (Table 49). Thus, only 13% of the 101 patients with rectal cancer operated on by surgeons in the 1–4 surgeon cohort received a pouch, compared with 57% of the 28 anterior resection patients operated on by surgeons in the greater than 20 surgeon cohort. Once again, the disparity is even greater for patients with lower-third rectal cancers.

There were 98 colonic pouches constructed for the 233 patients (42%) with rectal cancer of the lower two-thirds of the rectum (Table 49). Although the relevant NHMRC Guideline refers to ‘lower half’ rectal cancers, it should be noted that patients with cancer of the lower two-thirds of the rectum have been included in our concordance tables (see beginning of this report).


RES

ULT

S ■

41RESULTS

■R

ESULTS

Table 49 Colonic pouches formed per surgeon cohort

Surgeon cohort

Colonic pouch Total





n % n % n % n % n %

1–4 1 3 8 21 4 18 0 0 13 13

5–9 2 10 14 35 15 58 0 0 31 36

10–14 4 22 8 27 11 65 0 0 23 35

15–19 0 0 12 71 9 69 1 1 22 55

>20 0 0 9 56 7 64 0 0 16 57

Total/overall % 7 8 51 36 46 52 1 33 105 33

Percentages are of the number of patients with rectal cancer who had an anterior resection per site per surgeon cohort. See Table 46

Total mesorectal excisionThe proportion of surgeons who declared that they had performed a total mesorectal excision for patients undergoing either anterior resection or abdomino-perineal resection for rectal cancer is shown in Table 50.

Table 50 Total mesorectal excision by site of rectal cancer and surgeon cohort

Surgeon cohort Total mesorectal excision Total





n % n % n % n % n %

1–4 15 38 31 72 55 81 2 100 103 67

5–9 6 29 24 79 53 91 0 0 93 76

10–14 9 50 27 82 30 91 0 0 66 79

15–19 1 11 11 65 23 92 0 0 35 67

>20 0 0 11 69 13 76 0 0 24 71

Total/overall % 31 35 104 68 174 87 3 67 321 72

Denominators used to calculate percentages are the sum of patients undergoing anterior resection or abdomino-perineal resection for rectal cancer as outlined in Tables 45 and 46

A further 17 patients had a total mesorectal excision. Eight patients underwent a Hartmann’s procedure, three a total proctocolectomy and six had various other procedures. An additional 29 patients with cancers arising in the colon had total mesorectal excision, 24 of whom had an anterior resection.

Permanent stoma formationOf the 523 rectal cancer patients who underwent an operation, 161 were given a permanent stoma. The site and surgeon cohort is outlined in Table 51. Permanent stomas were formed more frequently by those surgeons who operated on the lowest number of patients (36%) than by those who operated on the highest number (20%).


RES

ULT

S ■

41RESULTS

■R

ESULTS

Table 51 Number and percentage of permanent stomas by rectal cancer site

Surgeon cohort Permanent stoma Total





n % n % n % n % n %

1–4 6 14 9 17 47 61 0 0 62 36

5–9 5 17 6 13 35 53 1 50 47 33

10–14 0 0 4 12 22 51 0 − 26 27

15–19 1 10 2 9 14 47 0 0 17 26

>20 1 50 1 5 7 30 0 − 9 20

Total/overall % 13 13 22 13 125 52 1 17 161 31

Denominators used to calculate percentages are the numbers shown in Table 44

The reasons for the creation of a permanent stoma were supplied for 123 of the 161 patients who had a permanent stoma created for the treatment of their rectal cancer (Table 52). In 38 patients (24%), no reason for the creation of a permanent stoma was given.

Table 52 Reasons for creation of a permanent stoma (rectal cancer patients)

Reason for permanent stoma Patients

n %

Tumour too low for adequate distal margin (of >2 cm) 59 37

Resection margin involved sphincter 36 22

Excessive lateral spread of tumour 10 6

Sphincter function considered inadequate for good continence 10 6

Surgical access to pelvis was too difficult 8 5

Reason not given 38 24

Total 161 100

Participation in clinical trials

Only 4% (81 of 2015) of patients were entered into a clinical trial. Of these 81 patients, 67 were entered into randomised trials and 12 were entered into non-randomised trials. For two patients, the type of trial was not indicated (Figure 11).

The number of patients who were treated by surgeons and whose surgeons were involved in clinical trials was 610. Of these 610 patients, 465 were deemed ineligible for the trials with which the surgeon was involved. Thus, there were 145 patients (610 minus 465) eligible for inclusion in a trial. Of these 145 patients, 81 were actually entered into a trial, leaving 64 patients (145 minus 81) who were eligible for, but not entered into, a clinical trial. Of these 64 patients, 46 were not offered entry into a trial and 18 were offered, but declined, entry into a trial. Therefore, there were 127 (145 minus 18) eligible patients who would have consented to being entered into a trial. Thus, 36% (46 out of 127) of eligible consenting patients were not offered entry in a trial.


RES

ULT

S ■

43RESULTS

■R

ESULTS

Figure 11 Participation of surgical patients in clinical trials

Table 53a Patients who were eligible for entry into a clinical trial per surgeon cohort

Surgeon cohort Surgeons * Patients **

n % n %

1–4 36 9 42 6

5–9 20 21 37 7

10–14 11 41 42 12

15–19 7 54 21 11

>20 1 17 3 2


* Surgeons with patients eligible for entry into a clinical trial** Patients eligible for entry into a clinical trial

Table 53a shows the number and percentage of surgeons with patients eligible for entry into a clinical trial. The number and percentage of eligible patients who were actually entered into a clinical trial are shown in Table 53b.


RES

ULT

S ■

43RESULTS

■R

ESULTS

Table 53b Eligible patients who were entered into a clinical trial per surgeon cohort

Surgeon cohort Patients

n %

1–4 22 52

5–9 16 43

10–14 28 67

15–19 12 57

>20 3 100

Total 81 56

Post-operative complications

Most patients did not sustain a post-operative complication (1335 of 1911; 70%).

The most common complication recorded fell into the ‘Other’ category, which included complications such as cardiac arrhythmia, respiratory dysfunction, electrolyte disturbance and urinary retention.

Table 54 lists the reported complications.

Table 54 Post-operative complications

Post-operative complication * Colon cancer Rectal cancer Total % **

Other complications 254 119 377 − ***

Wound infection 94 47 141 7

Anastomotic leak (major) 21 7 28 2 ****

Deep venous thrombosis 16 12 28 1

Pulmonary embolus 10 8 18 1

Anastomotic leak (minor) 3 10 13 1 ****

Total 398 203 605 − *

* Some patients had more than one complication** Expressed as a percentage of the 1911 patients who had an operation, except where stated*** A % is not given as * means that use of 1911 as the denominator is not valid**** Expressed as a percentage of 1634 patients who had an anastomosis

A major anastomotic leak is defined as an anastomotic leak requiring surgery, Question 22b3

of the Surgical Questionnaire (Appendix F).

A minor anastomotic leak is defined as an anastomotic leak not requiring surgery, Question 22b2

of the Surgical Questionnaire (Appendix F).


RES

ULT

S ■

45RESULTS

■R

ESULTS

Adjuvant therapy: chemotherapy and radiotherapy

Referral patterns for chemotherapy were evaluated and the results are shown in Tables 55–58.

Chemotherapy for colon cancerA total of 613 (44%) of the 1388 patients with colon cancer were offered chemotherapy (Table 55). Two hundred and ninety-three (76%) of the 384 patients with Dukes’ C cancer were in this group.

Table 55 Adjuvant chemotherapy offered to patients with colon cancer by Dukes’ stage

Dukes’ stage Patients per Dukes’ stage (n) Offered chemotherapy (n) %

A 293 17 6

B 398 114 29

C 384 293 76

D 269 181 67

Unknown 44 8 18


A total of 247 (64%) of the 384 patients with Dukes’ C colon cancer were given chemotherapy (Table 56)

Table 56 Adjuvant chemotherapy given to patients with colon cancer by Dukes’ stage

Dukes’ stage Patients per Dukes’ stage (n) Given chemotherapy (n) %

A 293 8 3

B 398 59 15

C 384 247 64

D 269 131 49

Unknown 44 3 7


The NHMRC Guidelines recommend the use of adjuvant therapy in people with node-positive colon cancer. These patients consist of all of those with Dukes’ C cancers and some of those with Dukes’ D cancers. Of the 572 patients with node-positive resected colon cancer in this study, 432 (76%) were offered chemotherapy. Of the 432 patients offered chemotherapy for node-positive resected colon cancer, 346 (80%) were given chemotherapy. Thus, 346 of 572 (60%) node-positive patients received chemotherapy. See Tables 137 and 154−157 for more details of these patients.

Fewer patients with colon cancer were node positive than the sum of the Dukes’ C and D patients, as some patients who were Dukes’ D did not necessarily have lymph node metastases or their node status may have been unknown.


RES

ULT

S ■

45RESULTS

■R

ESULTS

Chemotherapy for rectal cancerA total of 271 (52%) of the 523 patients with rectal cancer were offered chemotherapy (Table 57).

Table 57 Adjuvant chemotherapy offered to patients with rectal cancer by Dukes’ stage

Dukes’ stage Patients per Dukes’ stage (n) Offered chemotherapy (n) %

A 154 25 16

B 129 61 47

C 134 121 90

D 66 50 72

Unknown 40 14 35


A total of 217 (41%) of the 523 patients with rectal cancer were given chemotherapy (Table 58).

Table 58 Adjuvant chemotherapy given to patients with rectal cancer by Dukes’ stage

Dukes’ stage Patients per Dukes’ stage (n) Given chemotherapy (n) %

A 154 22 14

B 129 44 34

C 134 93 69

D 66 44 64

Unknown 40 14 35


Radiotherapy for colon cancerReferral patterns for adjuvant radiotherapy are described in Tables 59–64.

A total of 76 (5%) of the 1388 patients with colon cancer were offered radiotherapy (Table 59). Of these 76 patients, 31 (41%) had tumours of the rectosigmoid.

Table 59 Adjuvant radiotherapy offered to patients with colon cancer by Dukes’ stage

Dukes’ stage Patients per Dukes’ stage (n) Offered radiotherapy (n) %

A 293 4 1

B 398 16 5

C 384 28 7

D 269 26 10

Unknown 44 2 5


A total of 39 (3%) of the 1388 patients with colon cancer were given radiotherapy (Table 60). Of these 39 patients, 20 (51%) had tumours of the rectosigmoid.


RES

ULT

S ■

47RESULTS

■R

ESULTS

Table 60 Adjuvant radiotherapy given to patients with colon cancer by Dukes’ stage

Dukes’ stage Patients per Dukes’ stage (n) Given radiotherapy (n) %

A 293 3 1

B 398 5 1

C 384 16 4

D 269 15 6

Unknown 44 0 0


Radiotherapy for rectal cancerA total of 248 (47%) of the 523 patients with rectal cancer were offered radiotherapy (Table 61).

Table 61 Adjuvant radiotherapy offered to patients with rectal cancer by Dukes’ stage

Dukes’ stage Patients per Dukes’ stage (n) Offered adjuvant radiotherapy (n)

%

A 154 34 22

B 129 58 45

C 134 96 72

D 66 38 55

Unknown 40 22 55


A total of 200 (38%) of the 523 patients with rectal cancer were given radiotherapy (Table 62)

Table 62 Adjuvant radiotherapy given to patients with rectal cancer by Dukes’ stage

Dukes’ stage Patients per Dukes’ stage (n) Given adjuvant radiotherapy (n) %

A 154 27 18

B 129 47 36

C 134 74 55

D 66 32 46

Unknown 40 20 50



RES

ULT

S ■

47RESULTS

■R

ESULTS

A total of 138 (26%) of the 523 patients with rectal cancer were given pre-operative radiotherapy (Table 63).

Table 63 Adjuvant radiotherapy given pre-operatively to patients with rectal cancer by Dukes’ stage

Dukes’ stage Patients per Dukes’ stage (n) Given pre-operative radiotherapy (n)

%

A 154 25 16

B 129 39 30

C 134 42 31

D 66 17 25

Unknown 40 15 38


A total of 62 (12%) of the 523 patients with rectal cancer were given post-operative radiotherapy (Table 64).

Table 64 Adjuvant radiotherapy given post-operatively to patients with rectal cancer by Dukes’ stage

Dukes’ stage Patients per Dukes’ stage (n) Given post-operative radiotherapy (n)

%

A 154 2 1

B 129 8 6

C 134 32 24

D 66 15 22

Unknown 40 5 13


Follow-up: cancer recurrence and progression, palliative care, survival and causes of death

Cancer recurrence or progressionThere were 169 patients (8%) with colorectal cancer who had evidence of cancer recurrence or progression by the cessation of data collection. This consisted of 36 patients (21% of those with recurrence) with such evidence at the primary site, 98 (58%) with evidence in the liver, 22 (13%) in the lung and 65 patients (38%) with evidence of cancer progression at other sites. Some patients had evidence of recurrence at more than one site.

These observations were based on pathology results (35 patients), radiology results (82 patients), endoscopy (eight patients), clinical evidence (73 patients) and a rise in serum carcino-embryonic antigen levels (28 patients). Again, some patients had more than one pertinent result.


RES

ULT

S ■

49RESULTS

■R

ESULTS

Palliative care referralOf the 169 patients with evidence of recurrence or progression of their colorectal cancer, 91 were referred to a palliative care service and a further 10 were offered this service but declined. For 63 patients, the service was marked as ‘not indicated’, for one patient no service was available, and for two patients it is not known whether a referral was made.

SurvivalTable 65 shows that 9% of patients were deceased by the time data collection ended.

Table 65 Survival

Survival Patients

n %

Alive 1828 91

Deceased 185 9

Unknown 2 <1

Total 2015 100

Survival data correct at 22 March 2001

Of the 1828 surviving patients, 1568 (86%) will be followed up by their surgeons.

Of the 1828 surviving patients, 1760 had an operation. Of these 1760 patients, 1524 (87%) will be followed up by their surgeons. The NHMRC Guidelines recommend that follow-up should occur after curative resection. In this study, 1497 patients were deemed to have had a curative resection, of whom 1326 (89%) will be followed up by their surgeons.

Causes of deathThe causes of death are outlined in Table 66. Of the 185 deaths, 30 (16%) resulted from a complication of treatment within a minimum follow-up period of 10 months.

Table 66 Cause of death

Cause of death Patients Total

Colon cancer (n) Rectal cancer (n) n %

Colorectal cancer 64 26 90 49

Other cause 43 13 56 30

Treatment complication 25 5 30 16

Unknown 9 0 9 5

Total 141 44 185 100


RES

ULT

S ■

49RESULTS

■R

ESULTS

Medical Oncology Questionnaire

Response rate

During the period of the survey, 722 patients were recorded in the returned Surgical Questionnaire as having been referred to a medical oncologist, or were notified by a medical oncologist to the local cancer registry. Of the 722 questionnaires despatched to medical oncologists, 492 (68% response rate) were completed and returned by them (Table 67).

Table 67 outlines the response rate for the Medical Oncology Questionnaire according to where the patients were registered. The response rate ranged from 33% in the Northern Territory to 100% in Tasmania.

Table 67 Response rate by patients’ location

Location Questionnaires Responserate (%)Sent Returned

TAS 21 21 100

WA 59 50 85

NSW 189 149 79

VIC 223 169 76

ACT 10 7 70

SA 35 22 63

QLD 179 72 40

NT 6 2 33



RES

ULT

S ■

51RESULTS

■R

ESULTS


Age distribution of patientsThe average age of patients was 63 years (median 64; range 21–84).

Table 68 shows the age distribution of the patients. Most patients were older than 60 years.



n %

0−49 60 12

50−59 121 25

60−69 149 30

70−79 137 28

80+ 25 5

Total 492 100

Sex distribution of patientsThere was a slight preponderance of males (Table 69).

Table 69 Sex distribution of patients

Sex Patients

n %

Male 287 58

Female 205 42

Total 492 100

Patients’ place of residenceMost patients lived in a capital city (Table 70).

Table 70 Patients’ place of residence

Location Patients

n %

Capital city 308 63

Urban 43 9

Rural 135 27

Postcode missing 6 1

Total 492 100


RES

ULT

S ■

51RESULTS

■R

ESULTS


Most medical oncology patients were seen in a hospital within a capital city (Table 71).

See Appendix C for the identity and classification of hospitals.



n %

Capital city 285 58

Urban 40 8

Rural 87 18

Unknown 80 16

Total 492 100

Most medical oncology patients were seen in a public facility, particularly in rural areas (Table 72).



n %

Capital city private 113 40

Capital city public 172 60

Urban private 17 43

Urban public 23 57

Rural private 18 21

Rural public 69 79

Unknown 80 −

Total 492 −


Table 73 compares the location where medical oncology patients were treated with their place of residence. Over three-quarters of patients living in capital cities were referred to medical oncology units in capital cities. A lesser percentage of rural (50%) and urban (44%) patients were referred to medical oncology units within rural and urban areas respectively.


RES

ULT

S ■

53RESULTS

■R

ESULTS


Hospital location

Place of residence Total


n % n % n % n %

Capital city 239 78 6 14 35 26 5 83 285

Urban 7 2 19 44 14 10 0 0 40

Rural 10 3 10 23 67 50 0 0 87

Unknown 52 17 8 19 19 14 1 17 80

Total 308 100 43 100 135 100 6 100 492

Characteristics of colorectal cancers: staging and patients’ age

Dukes’ stage for all cancersTable 74 shows that more than twice as many referrals to medical oncologists were made for patients with colon cancer than were made for patients with rectal cancer.

Dukes’ Stage A and B cancers accounted for 25% of all referrals for rectal cancer, some of which may be explained by adjuvant treatment having been given pre-operatively, with subsequent down-staging of the cancer.

Table 74 Dukes’ stage of referred patients’ colon cancers, rectal cancers and all colorectal cancers

Dukes’ stage Colon cancer Rectal cancer Total

n % n % n %

A 5 1 14 3 19 4

B 52 11 26 5 78 16

C 175 36 61 12 236 48

D 98 20 33 7 131 27

Unknown 1 <1 24 5 25 5

Total 331 68 158 32 489* 100

Percentages are of all 492 patients referred for chemotherapy* In several patients, both the site of the cancer − that is, colon or rectum − and the stage of the cancer were unknown


RES

ULT

S ■

53RESULTS

■R

ESULTS

Staging and patients’ ageFigure 12 shows the distribution of cancers by stage according to patient age group and the actual number of cases in this group, while Figure 13 shows the same data expressed as percentages.

Figure 12 Colorectal cancer stage by patients’ age and number referred for medical oncology

0

10

20

30

40

50

60

70

80Unknown

D

C

B

A

80+70 to 7960 to 6950 to 590 to 49

Nu

mb

er o

f pat

ien

ts p

er s

tag

e in

eac

h a

ge

gro

up

Age of patient

Figure 13 Percentage of medical oncology referrals by Dukes’ stage of cancers for each age group

0%

10%

20%

30%

40%

50%

60%Unknown

D

C

B

A

80+70 to 7960 to 6950 to 590 to 49

Perc

enta

ge

of p

atie

nts

per

sta

ge

in e

ach

ag

e g

rou

p

Age of patient


RES

ULT

S ■

55RESULTS

■R

ESULTS

Number of patients per medical oncologist: average number treated and by patients’ place of residence

Most medical oncology referrals (76%) were to doctors who returned questionnaires on between one and nine patients over the three-month period of the survey (Table 75).

Table 75 Number of patients referred per medical oncologist cohort

Medical oncologist cohort Medical oncologists Patients

n % n %

1–4 99 72 183 37

5–9 29 21 190 39

10–14 5 4 52 11

15–19 4 3 67 14

Total 137 100 492 100

In this and other tables, ‘medical oncologist cohort’ refers to the number of colorectal cancer patients seen over the three-month period of the survey

Of the 492 patients referred to a medical oncologist, 445 (90%) received some form of chemotherapy. Tables 76 to 85, 87, 88 and 91 refer to this cohort of 445 patients.

Figure 14 shows the average number of colorectal cancer patients seen over the three-month period of the survey within each medical oncologist group.

Figure 14 Average number of patients per medical oncologist cohort

0

5

10

15

20

15 to 1910 to 145 to 91 to 4

Ave

rag

e n

um

ber

of p

atie

nts

see

n p

er t

hre

e m

on

ths

Medical oncologist cohort


RES

ULT

S ■

55RESULTS

■R

ESULTS

The 445 patients who received chemotherapy were treated by 131 medical oncologists. Thus, each medical oncologist returned questionnaires on an average of 3.4 patients per medical oncologist over three months, giving an average of just over one newly diagnosed patient with colorectal cancer per month per medical oncologist (Table 76).

Table 76 Number of patients treated per medical oncologist cohort

Medical oncologist cohort Medical oncologists Patients

n % n %

1–4 97 74 164 37

5–9 29 22 178 40

10–14 3 2 46 10

15–19 2 2 57 13

Total 131 100 445 100

Number of patients by patients’ place of residencePatients in rural and urban areas were significantly more likely (P=0.0026) to have been treated by a medical oncologist who treated a smaller number of patients than were patients in capital cities (Figure 15).

Figure 15 Percentage of patients seen by each medical oncologist cohort by patients’ place of residence

0%

10%

20%

30%

40%

50%

60%

70%

80%Rural

Urban

Capital City

15 to 1910 to 145 to 91 to 4

Perc

enta

ge

of p

atie

nts

wit

hin

eac

h g

rou

p

Medical oncologist cohort


RES

ULT

S ■

57RESULTS

■R

ESULTS

Chemotherapy: timing, indications, duration of treatment, route of administration, drugs used and scheduling of chemotherapy (5-FU)

TimingOf the 492 patients referred for medical oncology, 468 (95%) had an operation, while 425 (96%) of the 445 patients who received chemotherapy had an operation.

Almost all of the referred patients with colon cancer received chemotherapy after surgery, whereas most patients with rectal cancer were given some chemotherapy before surgery (Table 77).

Table 77 Timing of chemotherapy in relation to surgery

Timing Colon cancer Rectal cancer Total

n % n % n %

Before surgery 3 1 45 31 48 11

After surgery 289 97 61 42 350 79

Before and after surgery 1 <1 33 23 34 8

Patient did not have surgery

6 2 7 5 13 3

Total 299 100 146 100 445 100

IndicationsTable 78 shows more detail regarding the indications for chemotherapy.

Table 78 Indications for chemotherapy

Indication Colon cancer Rectal cancer Total

n % n % n %

Adjuvant post-operative treatment (no pre-operative chemotherapy)

224 75 47 32 271 61

Pre-operative treatment for locally advanced operable rectal cancer

− − 61 42 61 14

Pre-operative treatment for locally advanced inoperable rectal cancer

− − 17 12 17 4

Palliation of symptoms from metastases

46 15 13 9 59 13

Treatment of asymptomatic metastatic disease

29 10 8 5 37 8

Total 299 100 146 100 445 100


RES

ULT

S ■

57RESULTS

■R

ESULTS

Duration of treatmentEighty-eight per cent of chemotherapy treatment was planned to be for six months or less (Table 79).

Table 79 Planned duration of chemotherapy

Duration Patients

n %

<6 months 67 15

6 months 325 73

7−12 months 13 3

>12 months 33 7

Not recorded 7 2

Total 445 100

Route of administrationThe most common route of administration of chemotherapy was intravenous (Table 80).

Table 80 Route of administration of chemotherapy

Route of administration Patients

n %

Intravenous 421 95

Intrahepatic 12 3

Oral 12 3

Total 445 100

Drugs usedThe most commonly used drug was 5-fluorouracil (5-FU) (Table 81).

Table 81 Chemotherapy drugs used Drug used Colon cancer Rectal cancer Total

n % n % n %

5-FU 284 95 142 97 426 96

Low dose i.v. leucovorin 193 65 73 50 266 60

High dose i.v. leucovorin 59 20 12 8 71 16

Oral leucovorin 9 3 7 5 16 4

Oxaliplatin 6 2 1 1 7 2

Raltitrexed 4 1 1 1 5 1

Levamisole 3 1 0 0 3 1

Irinotecan 2 1 0 0 2 <1

Others 24 8 6 4 30 7

Total 584 − 242 − 826 −

More than one drug may have been given. ‘i.v.’ = intravenousPercentages are of all patients within this group. The denominators are colon cancer 299, rectal cancer 146, total 445


RES

ULT

S ■

59RESULTS

■R

ESULTS

Scheduling of chemotherapy (5-FU)Exactly three-quarters of the patients received their treatment by a bolus regime (Table 82).

Table 82 Scheduling of chemotherapy (5-FU)

Regimen Patients

n %

Mayo regimen/equivalent (bolus, five consecutive days, fourth weekly)

193 43

Roswell Park regimen/equivalent (single weekly bolus) 142 32

Infusion during radiotherapy 41 9

Infusion only 20 4

Other 34 8

Unknown 15 3

Total 445 100

Use of the above schedules (Table 82) by site of colorectal cancer is shown in Tables 83 and 84. These data relate to newly reported cases of colorectal cancer only.

Table 83 Scheduling of chemotherapy (5-FU) for colon cancer

Schedule Non-metastatic disease Metastatic disease Total (n)

n % n %

Mayo regimen/equivalent 109 51 30 35 139

Roswell Park regimen/equivalent

78 36 32 38 110

Infusion during radiotherapy 0 0 1 1 1

Infusion only 4 2 12 14 16

Other 13 6 7 8 20

Unknown 10 5 3 4 13

Total 214 100 85 100 299

Table 84 Scheduling of chemotherapy (5-FU) for rectal cancer

Schedule Non-metastatic disease Metastatic disease Total (n)

n % n %

Mayo regimen/equivalent 44 37 10 36 54

Roswell Park regimen/equivalent

22 19 10 36 32

Infusion during radiotherapy 36 31 4 14 40

Infusion only 2 2 2 7 4

Other 13 11 1 4 14

Unknown 1 1 1 4 2

Total 118 100 28 100 146


RES

ULT

S ■

59RESULTS

■R

ESULTS

Combined modality therapy

Radiotherapy was given in conjunction with chemotherapy in the majority of patients with rectal cancer only (Table 85).

Table 85 Radiotherapy utilisation

Was radiotherapy used? Colon Rectum Total

n % n % n %

Yes, with chemotherapy 12 4 107 73 119 27

Yes, not with chemotherapy (pre-operative radiotherapy)

0 0 6 4 6 1

Yes, not with chemotherapy (post-operative radiotherapy)

7 2 4 3 11 2

No 280 94 29 20 309 69

Total 299 100 146 100 445 100

Percentages are of all patients within each sub-group. The denominators are colon cancer 299, rectal cancer 146, total 445


Of the 492 patients who were referred for chemotherapy, 40 (8%) were entered into a clinical trial (Figure 16).

The number of patients who were referred to a medical oncologist and whose oncologist was involved in clinical trials was 292. Of these 292 patients, 220 were deemed ineligible for the trials with which the oncologist was involved. Thus, 72 patients (292 minus 220) were eligible for inclusion in a trial. Of these 72 patients, 40 were actually entered into a trial, leaving 32 patients (72 minus 40) who were eligible for, but not entered into, a clinical trial. Of these 32 patients, 14 were not offered entry into a trial and 18 were offered, but declined, entry into a trial. There were therefore 54 (72 minus 18) eligible patients who consented to being entered into a trial. Thus, 26% (14 out of 54) of eligible consenting patients were not offered entry in a trial.


RES

ULT

S ■

61RESULTS

■R

ESULTS

Figure 16 Participation of all medical oncology patients in clinical trials

Table 86a Eligibility for entry into a clinical trial per medical oncologist cohort

Medical oncologist cohort Medical oncologists * Patients **

n % n %

1–4 21 21 27 15

5–9 13 45 30 16

10–14 3 60 9 17

15–19 2 50 6 9


* Medical oncologists with patients eligible for entry into a clinical trial** Patients eligible for entry into a clinical trial

Table 86a shows the number and percentage of medical oncologists with patients eligible for entry into a clinical trial. The number and percentage of eligible patients who were actually entered into a clinical trial are shown in Table 86b.


RES

ULT

S ■

61RESULTS

■R

ESULTS

Table 86b Eligible patients who were entered into a clinical trial per medical oncologist cohort

Medical oncologist cohort Patients

n %

1–4 12 16

5–9 22 73

10–14 2 22

15–19 4 67


Complications of chemotherapy

Of the 445 patients who received treatment, 63 (14%) developed a complication requiring hospitalisation, of which enteritis/diarrhoea was reported most commonly (Table 87).

Table 87 Nature of complications

Complication n % * % **

Enteritis/diarrhoea 34 54 8

Stomatitis 15 24 3

Febrile neutropenia 13 21 3

Other 20 32 4

Total 82 − −

Some patients may have had more than one complication* Expressed as a percentage of the 63 patients experiencing a complication** Expressed as a percentage of all 445 patients who received chemotherapy

Follow-up: cancer recurrence and progression, palliative care referral, survival and causes of death

Cancer recurrence or progressionOf the 492 patients referred for chemotherapy, recurrence or progression was noted to have occurred in 85 (17%) by the cessation of data collection. The sites of recurrence are shown in Table 88. The liver was the most common site for patients experiencing a recurrence (81%). Overall, 14% of all patients referred for chemotherapy developed liver recurrences.


RES

ULT

S ■

63RESULTS

■R

ESULTS

Table 88 Site of recurrence for all 492 patients referred to medical oncologists

Site of recurrence Patients (n) Percentage who experienced a

recurrence (n=85)

Percentage referred for chemotherapy

(n=492)

Liver 69 81 14

Lung 17 20 3

Primary site of tumour 12 14 2

Other 10 11 2

Total 108 − −

There may have been more than one site of cancer recurrence

Of the 445 patients who actually received chemotherapy, 77 (17%) developed evidence of cancer recurrence or progression after the commencement of treatment (Table 89).

Table 89 Site of recurrence in the 445 patients who received chemotherapy

Site of recurrence Patients (n) Percentage who experienced a

recurrence (n=77)

Percentage who received chemotherapy

(n=445)

Liver 61 79 14

Lung 14 18 3

Primary site of tumour 9 12 2

Other 10 13 2

Total 94 − −

There may have been more than one site of cancer recurrence

Evidence for cancer recurrence or progressionThe diagnosis in most of the 85 patients with cancer recurrence or progression was based on radiological evidence (Table 90).

Table 90 Evidence of recurrence

How recurrence was diagnosed Patients

n %

Radiology 71 84

Elevated carcino-embryonic antigen 35 41

Clinical 29 34

Pathology 19 22

Endoscopy 2 2

Total 156 −

More than one method may have been used for the diagnosis of recurrence


RES

ULT

S ■

63RESULTS

■R

ESULTS

Palliative care referralOf the 85 patients from the group of 492 patients referred for chemotherapy and who were thought to have a recurrence or progression of their cancer, 48 (56%) were offered a referral to a palliative care service. Of the 77 patients who received chemotherapy and who had a recurrence, 44 (57%) were offered a referral to a palliative care service. A palliative care service was noted to be unavailable in one case (Table 91).

Table 91 Referral to a palliative care service of patients with cancer recurrence or progression

Referral to palliative care service Patients referred for chemotherapy (n=492)

Patients received chemotherapy (n=445)

Referred 43 39

Referral not indicated 36 32

Patient declined referral 5 5

Service not available 1 1



Table 92 Survival

Survival Patients

n %

Alive 449 91

Dead 41 8

Unknown 2 <1

Total 492 100


Of the 449 surviving patients, 295 (66%) will be followed up by their medical oncologist.

Causes of death The causes of death are outlined in Table 93. The most common recorded cause of death was recurrence of colorectal cancer.


Cause of death Patients

n %

Colorectal cancer 34 83

Treatment complication 2 5

Other cause 3 7

Unknown 2 5

Total 41 100


RES

ULT

S ■

65RESULTS

■R

ESULTS

Radiation Oncology Questionnaire

Response rate

During the period of the survey, 234 patients were recorded in the returned Surgical Questionnaire as having been referred to a radiation oncologist, or were notified by a radiation oncologist to the local cancer registry. Of the 234 questionnaires despatched to radiation oncologists, 162 (69% response rate) were completed and returned by them (Table 94).

Table 94 outlines the response rates for the Radiation Oncology Questionnaire according to where the patients were registered. The response rate ranged from 17% in the Northern Territory to 100% in Western Australia, Tasmania and the Australian Capital Territory.

Table 94 Response rate by patients’ location

Location Questionnaires Response rate (%)

Sent Returned

ACT 2 2 100

TAS 5 5 100

WA 13 13 100

NSW 73 64 88

QLD 64 46 72

SA 12 8 67

VIC 59 23 39

NT 6 1 17



RES

ULT

S ■

65RESULTS

■R

ESULTS


Age distribution of patientsThe average age of patients was 63 years (median 65; range 26–85).

Table 95 shows the age distribution of the patients. Most patients were older than 60 years.



n %

0−49 20 12

50−59 32 20

60−69 56 34

70−79 43 27

80+ 11 7

Total 162 100

Sex distribution of patientsThere was a marked difference in sex, with a male:female ratio of almost 3:1 (P<0.0001). See Table 96.

Table 96 Sex distribution of patients

Sex Patients

n %

Male 116 72

Female 46 28

Total 162 100

Patients’ place of residenceMost patients lived in a capital city (Table 97).

Table 97 Patients’ place of residence

Location Patients

n %

Capital city 93 57

Urban 24 15

Rural 41 25

Unknown 4 2

Total 162 100


RES

ULT

S ■

67RESULTS

■R

ESULTS


Most radiation oncology patients were seen in a capital city (Table 98). Despite 25% of patients residing in a rural area (Table 97), only 4% of all patients were seen by a radiation oncologist in a rural hospital (Table 98).

See Appendix C for the identity and classification of hospitals.



n %

Capital city 112 69

Urban 24 15

Rural 6 4

Unknown 20 12

Total 162 100

Most radiation oncology patients were seen in a public facility, particularly in rural areas (Table 99).



n %

Capital city private 29 26

Capital city public 83 74

Urban private 11 46

Urban public 13 54

Rural private 1 17

Rural public 5 83

Unknown 20 −

Total 162 −


Table 100 compares the location where radiation oncology patients were treated with their place of residence. Nearly 90% of patients living in capital cities were referred to radiation oncology units in capital cities. A lesser percentage of urban (58%) and rural patients (10%) were referred to radiation oncology units within urban and rural areas respectively.


RES

ULT

S ■

67RESULTS

■R

ESULTS


Hospital location Place of residence Total


n % n % n % n %

Capital city 81 87 7 29 21 51 3 75 112

Urban 2 2 14 58 8 20 0 0 24

Rural 1 1 1 4 4 10 0 0 6

Unknown 9 10 2 8 8 20 1 25 20

Total 93 100 24 100 41 100 4 100 162

Characteristics of colorectal cancers: staging and patients’ age

Table 101 shows that most of the referrals to radiation oncologists were made for patients with rectal cancer. That 27% of patients with rectal cancer had an unknown Dukes’ stage is accounted for by the fact that most patients were seen by the radiation oncologist pre-operatively (see Table 105), and thus the Dukes’ stage, which is dependant on the operative findings, was not available.

Table 101 Dukes’ stage of referred patients’ colon and rectal cancers and all colorectal cancers

Dukes’ stage Colon cancer Rectal cancer Total

n % n % n %

A 0 0 14 9 14 9

B 5 3 24 15 29 18

C 5 3 42 26 47 29

D 8 5 19 12 27 17

Unknown 1 1 44 27 45 28

Total 19 12 143 88 162 100

Percentages are of all 162 patients referred for radiotherapy

Staging and patients’ ageFigure 17 shows the distribution of cancers by stage according to age group and the actual number of cases in this group, while Figure 18 shows the same data expressed as percentages.


RES

ULT

S ■

69RESULTS

■R

ESULTS

Figure 17 Colorectal cancer stage by patients’ age and number referred for radiation oncology

0

2

4

6

8

10

12

14

16

18

20Unknown

D

C

B

A

80+70 to 7960 to 6950 to 590 to 49

Nu

mb

er o

f pat

ien

ts p

er s

tag

e in

eac

h a

ge

gro

up

Age of patient

Figure 18 Percentage of radiation oncology referrals by Dukes’ stage of cancers for each age group

0%

5%

10%

15%

20%

25%

30%

35%

40%Unknown

D

C

B

A

80+70 to 7960 to 6950 to 590 to 49

Perc

enta

ge

of p

atie

nts

per

sta

ge

in e

ach

ag

e g

rou

p

Age of patient


RES

ULT

S ■

69RESULTS

■R

ESULTS

Number of patients per radiation oncologist: average number treated and by patients’ place of residence

Most radiation oncology referrals (69%) were to doctors who returned questionnaires on between one and four patients over the three-month period of the survey (Table 102).

Table 102 Number of patients referred per radiation oncologist

Radiation oncologist cohort Radiation oncologists Patients

n % n %

1–4 56 89 111 69

5–9 6 10 37 23

10–14 1 2 14 9

Total 63 100 162 100

In this and other tables, ‘radiation oncologist cohort’ refers to the number of colorectal cancer patients seen over the three-month period of the survey

Of the 162 patients referred to a radiation oncologist, 154 (95%) received some form of radiotherapy. Tables 103–108, 110–114 and 118 refer to this cohort of 154 patients.

Figure 19 shows the average number of colorectal cancer patients seen over the three-month period of the survey within each radiation oncologist group.

Figure 19 Average number of patients per radiation oncologist cohort

0

3

6

9

12

15

10 to 145 to 91 to 4

Ave

rag

e n

um

ber

of p

atie

nts

see

n p

er t

hre

e m

on

ths

Radiation oncologist cohort


RES

ULT

S ■

71RESULTS

■R

ESULTS

Patients’ place of residencePatients in rural and urban areas were significantly (P=0.02) more likely to have been treated by a radiation oncologist who treated a smaller number of patients than were patients in capital cities (Figure 20).

Figure 20 Percentage of patients seen by each radiation oncologist cohort by patients’ place of residence

0%

20%

40%

60%

80%

100%Rural

Urban

Capital City

10 to 145 to 91 to 4

Perc

enta

ge

of p

atie

nts

wit

hin

eac

h g

rou

p

Radiation oncologist cohort

Questionnaires were returned for a total of 154 patients who received radiotherapy and who were treated by 61 radiation oncologists. Thus, each radiation oncologist returned questionnaires on an average of 2.5 patients over three months, giving an average of less than one newly diagnosed patient with colorectal cancer per radiation oncologist per month (Table 103).

Table 103 Number of patients treated per radiation oncologistRadiation oncologist cohort Radiation oncologists Patients

n % n %

1–4 55 90 109 71

5–9 5 8 31 20

10–14 1 2 14 9

Total 61 100 154 100


RES

ULT

S ■

71RESULTS

■R

ESULTS

Pre-treatment histological confirmation of cancer

Nearly all patients (96%) had histological confirmation of colorectal cancer prior to commencing treatment (Table 104).

Table 104 Histological verification prior to treatment

Verification Patients

n %

Yes 148 96

No 3 2

Uncertain 3 2

Total 154 100

Radiotherapy: timing, indications, delivery, dose given, timing and total dose, fields used, upper limit of field and boost fields

Of the 162 patients referred for radiotherapy, 154 (95%) had an operation, while 146 of the 154 (95%) patients of those who received radiotherapy had an operation.

TimingNearly two-thirds of those who received radiation oncology did so pre-operatively (Table 105).

Table 105 Timing of radiotherapy in relation to surgery

Radiotherapy received Patients

n %

Before surgery 97 63

After surgery 33 21

Unknown 24 16

Total 154 100

IndicationsTable 106 displays the indication for radiotherapy. Most of the patients who received radiotherapy had it as pre-operative treatment for what was presumed to be resectable rectal cancer.


RES

ULT

S ■

73RESULTS

■R

ESULTS

Table 106 Indications for radiotherapy

Indication Patients

n %

Pre-operative treatment for initially resectable rectal cancer 65 42

Adjuvant post-operative treatment for rectal cancer 33 21

Pre-operative treatment for initially unresectable rectal cancer 32 21

Palliation of locally advanced or metastatic disease 20 13

Definitive treatment 2 1

Unknown 2 1

Total 154 100

DeliveryMore than 90% of patients received radiotherapy by external beam (Table 107).

Table 107 Mode of radiotherapy delivery

Mode Patients

n %

External beam 143 93

Interstitial 8 5

Unknown 3 2

Total 154 100

Dose givenMore than three-quarters of the patients received a medium to high dose of radiotherapy (Table 108).

Table 108 Radiation dose given

Dose Patients

n %

Medium/high dose 118 77

Low dose 28 18

Unknown 8 5

Total 154 100

Medium/high dose is equivalent to ≥35 Gy and low dose is equivalent to <35 Gy


RES

ULT

S ■

73RESULTS

■R

ESULTS

Timing and total dose of radiotherapyTable 109 shows that of the 97 patients who received pre-operative radiotherapy, 80% received a medium or high total dose. Of the 33 patients who received post-operative radiotherapy, 88% received a medium or high total dose.

Table 109 Timing and total dose of radiotherapy

Dose Timing: pre-operative Timing: post-operative

n % n %

Medium/high dose 78 80 29 88

Low dose 19 20 2 6

Unknown 0 0 2 6

Total 97 100 33 100

Medium/high dose is equivalent to ≥35 Gy and low dose is equivalent to <35 Gy

Fields usedMore than 90% of patients received their radiotherapy utilising the 3- or 4-field methods (Table 110).

Table 110 Fields used

Fields used Patients

n %

3 field 74 48

4 field 67 44

Anterior to posterior/Posterior to anterior 6 4

Unknown 7 5

Total 154 100

Upper limit of fieldFor most patients, the upper limit of the radiation field was at the level of the L

5/S

1 vertebrae

(Table 111).

Table 111 Upper limit of radiation field

Upper limit Patients

n %

Pelvic brim 31 20

L5/S

1106 69

Above L5/S

19 6

Unknown 8 5

Total 154 100


RES

ULT

S ■

75RESULTS

■R

ESULTS

Boost fieldsLess than half (41%) of patients received a boost dose (Table 112).

Table 112 Use of boost dose

Boost dose used Patients

n %

Yes 63 41

No 83 54

Unknown 8 5

Total 154 100

The average boost dose given was 7.1 Gy (range 5.4–50.7 Gy), with one unknown dose. Of the 63 patients who received a boost dose, most received this to the tumour bed (Table 113).

Table 113 Site of boost

Boost site Patients

n %

Tumour bed alone 41 65

Sacral hollow and tumour bed 14 22

Sacral hollow alone 7 11

Unknown 1 2

Total 63 100

Minimising small bowel irradiation

Table 114 shows the methods used to reduce the amount of irradiation to the small bowel. These methods were used in most patients (133; 86%).

Table 114 Techniques employed to minimise small bowel irradiation in 133 patients

Mode Patients

n % * % **

Shielding 93 70 60

Small bowel contrast simulation 61 46 40

Bladder distension 45 34 29

Bellyboard 42 32 27

Immobilisation moulds 3 2 2

Intestinal mesh/sling 1 1 1

Other 18 14 12

Total 263 − −

More than one technique was used in some patients; hence the total is greater than 133* Expressed as a percentage of the 133 patients who had a minimisation technique employed** Expressed as a percentage of the 154 patients who received radiotherapy


RES

ULT

S ■

75RESULTS

■R

ESULTS

Combined modality therapy and chemotherapy drugs used

Of those patients who received radiotherapy, 120 also received chemotherapy. Table 115 shows the number and percentage of patients who received this combined modality therapy, together with the timing of each therapy.

Table 115 Timing of chemotherapy

Timing of chemotherapy Patients

n %

Only with radiotherapy 43 36

Completely separate from radiotherapy 14 12

Combination of the above * 63 53

Total 120 100

* That is, chemotherapy was given both together with and separate from radiotherapy

Chemotherapy − drugs usedNearly all patients (98%) who received chemotherapy in conjunction with radiotherapy received 5-fluorouracil (5-FU) (Table 116). This was given as an infusion during radiotherapy in 71 patients (59%) and as a bolus in 32 patients (27%). The schedule was unknown in 17 patients.

Table 116 Chemotherapy drugs used

Drug used Patients

n % *

5-FU 118 98

Leucovorin 55 46

Other 3 3

Unknown 1 1

Total 177 −

Patients may have received more than one drug* Expressed as a percentage of the 120 patients who received chemotherapy


Less than 3% (five of 162) of all the patients referred were entered into a clinical trial (Figure 21).

Ninety-two patients were referred to a radiation oncologist where the oncologist was involved in clinical trials. Of these 92 patients, 80 were deemed ineligible for the trials with which the oncologist was involved. Thus, there were 12 patients (92 minus 80) eligible for inclusion in a trial. Of these 12 patients, five were actually entered into a trial, leaving seven patients (12 minus five) who were eligible for, but not entered into, a clinical trial. Of these seven patients, four were not offered entry into a trial and three were offered, but declined, entry into a trial. There were therefore nine (12 minus three) eligible patients who consented to being entered into a trial. Thus, 44% (four out of nine) of eligible consenting patients were not offered entry in a trial.


RES

ULT

S ■

77RESULTS

■R

ESULTS

Figure 21 Participation of all radiation oncology patients in clinical trials

Table 117a Patients who were eligible for entry into a clinical trial per radiation oncologist cohort

Radiation oncologist cohort Radiation oncologists * Patients **

n % n %

1–4 7 13 11 10

5–9 0 0 0 0

10–14 1 100 1 7


* Radiation oncologists with patients eligible for entry into a clinical trial** Patients eligible for entry into a clinical trial

Table 117a shows the number of radiation oncologists with patients eligible for entry into a clinical trial. The number and percentage of eligible patients who were actually entered into a clinical trial are shown in Table 117b.


RES

ULT

S ■

77RESULTS

■R

ESULTS

Table 117b Eligible patients who were entered into a clinical trial per radiation oncologist cohort

Radiation oncologist cohort Patients

n %

1–4 4 36

5–9 0 0

10–14 1 100

Total 5 42

Complications of radiotherapy

Of the 154 patients who received treatment, 17 (11%) developed a complication requiring hospitalisation, with bowel obstruction/perforation reported most commonly (Table 118).

Table 118 Nature of complications

Complication Patients

n % * % **

Bowel obstruction/perforation 4 24 3

Enteritis 3 18 2

Febrile neutropenia 2 12 1

Other 8 47 5

Total 17 100 −

Patients may have had more than one complication* Expressed as a percentage of the 17 patients experiencing a complication** Expressed as a percentage of all 154 patients who received radiotherapy

Follow-up: cancer recurrence or progression, palliative care, survival and causes of death

Cancer recurrence or progressionOf the 162 patients referred for radiotherapy, recurrence or progression was noted to have occurred in 21 (13%) by the cessation of data collection. The same number of patients with recurrences was seen in those who were actually given radiotherapy. The site of recurrence is shown in Table 119. The liver was the most common site for patients experiencing a recurrence (57%). Overall, 7% of all patients referred for radiotherapy developed liver recurrences.


RES

ULT

S ■

79RESULTS

■R

ESULTS

Table 119 Site of recurrence for all 162 patients referred for radiotherapy

Site of recurrence Patients

n % * % **

Liver 12 57 7

Primary site 7 33 4

Lung 3 14 2

Other 6 29 4

Total 28 − −

There may have been more than one site of cancer recurrence* Expressed as a percentage of the 28 patients experiencing a recurrence (for example, 57% of patients with a recurrence or progression exhibited such in their liver)** Expressed as a percentage of all 162 patients who were referred for radiotherapy

Evidence for cancer recurrence or progressionThe diagnosis in most of the 21 patients with cancer recurrence or progression was based on clinical evidence (Table 120).

Table 120 Evidence of recurrence

Diagnosis Patients

n % *

Clinical 11 52

Pathology 8 38

Radiology 8 38

Elevated carcino-embryonic antigen 3 14

Unknown 1 5

Total 31 −

Patients may have had more than one method used for the diagnosis of recurrence* Expressed as a percentage of the 21 patients experiencing a recurrence

Palliative care referralOf the 21 patients from the group of 162 patients who were thought to have a recurrence or progression of their cancer, 10 (48%) were offered a referral to a palliative care service. A referral to a palliative care service was recorded as ‘not indicated’ in 10 (48%) and it was not known whether a referral was made in one.


RES

ULT

S ■

79RESULTS

■R

ESULTS


Table 121 Survival

Survival Patients

n %

Alive 151 93

Dead 11 7

Total 162 100


Of the 151 surviving patients, 69 (46%) will be followed up by their radiation oncologist.

Causes of deathThe causes of death are outlined in Table 122. The most common recorded cause of death was recurrence of colorectal cancer.


Cause of death Patients

n %

Colorectal cancer 8 73

Treatment complication 1 9

Other cause 2 18

Total 11 100


RES

ULT

S ■

81RESULTS

■R

ESULTS

Variations FoundStatistical analyses were performed as described in the methods section. Statistically significant differences were determined using chi-square and logistic regression analyses and are defined as having a P value as less than (<) 0.05. These are listed below, together with trends of interest that did not reach statistical significance.

Sex

Of the 563 patients with rectal cancer, most were male (361, 64%); there were 202 females (36%) (P =0.05). See Table 4.

Rural/urban residence and clinician cohort

Patients in rural and urban areas were significantly more likely to have been treated by a clinician who treated a lesser volume of patients than were patients in capital cities (see Figures 10, 15 and 20). The level of statistical significance was P<0.0001 for surgeons, P=0.0026 for medical oncologists and P=0.02 for radiation oncologists.

Mode of presentation by surgeon cohort

Surgeons who operated on higher numbers of patients with colorectal cancer were more likely to have operated on patients who presented electively rather than as emergencies (P<0.0001). See Table 123.

Table 123 Mode of presentation by surgeon cohort

Surgeon cohort Elective Emergency Total

n % n %

1–4 601 83 121 17 722

5–9 501 91 48 9 549

10–14 319 94 22 6 341

15–19 170 92 14 8 184

>20 109 95 6 5 115

Total/overall % 1700 89 211 11 1911


RES

ULT

S ■

81RESULTS

■R

ESULTS

Site of colorectal cancer by surgeon cohort

Surgeons who operated on higher numbers of patients with colorectal cancer were more likely to have patients with rectal cancer comprise a greater proportion of their caseload (P=0.002). See Table 124.

Table 124 Site of colorectal cancer by surgeon cohort

Surgeon cohort Colon cancer Rectal cancer Total

n % n %

1–4 548 76 174 24 722

5–9 405 74 144 26 549

10–14 245 72 96 28 341

15–19 119 65 65 35 184

>20 71 62 44 38 115

Total/overall % 1388 73 523 27 1911

Prophylactic antibiotic use

Emergency patients (93/211) were more likely to have received antibiotics as recommended than were elective patients (583/1700; P=0.02). See Table 125.

Table 125 Type of prophylactic antibiotic used by mode of presentation

Prophylactic antibiotic use Elective Emergency Total

n % n %

Recommended 1 583 34 93 44 676

Adequate 2 832 49 85 40 917

Other 171 10 23 11 194

None 114 7 10 5 124

Total 1700 100 211 100 1911

1 NHMRC Guidelines2 Therapeutic Guidelines: Antibiotic

Antibiotic use and surgeon cohort

Surgeons who operated on higher volumes of patients with colorectal cancer were less likely to have used antibiotics as recommended in the NHMRC Guidelines than were surgeons who operated on fewer patients with colorectal cancer (P<0.0001). See Table 126. A trend for use of recommended antibiotics to be associated with fewer wound infections did not reach statistical significance, perhaps because of the small number of reported infections for each of the four sub-groups. These sub-groups were:


RES

ULT

S ■

83RESULTS

■R

ESULTS

1 Recommended antibiotics definitely used (Recommended)

2 Recommended antibiotics may have been used (based on more recently published antibiotic guidelines − see Therapeutic Guidelines: Antibiotic Eleventh edition, Therapeutic Guidelines Ltd 2000) (Adequate)

3 Recommended antibiotics definitely not used (Other)

4 No antibiotics used (None)

Table 126 Type of prophylactic antibiotic used by surgeon cohort

Surgeon cohort Recommended 1 Adequate 2 Other None Total

n % n % n % n %

1–4 313 43 276 38 75 10 58 8 722

5–9 194 35 277 50 53 10 25 5 549

10–14 139 41 154 45 42 12 6 2 341

15–19 29 16 117 64 9 5 29 16 184

>20 1 1 93 81 15 13 6 5 115

Total/overall % 676 35 917 48 194 10 124 6 1911

1 NHMRC Guidelines2 Therapeutic Guidelines: Antibiotic

Bowel preparation and surgeon cohort

Surgeons who operated on higher volumes of patients with colorectal cancer were more likely to have used bowel preparation on their patients than were surgeons who operated on fewer patients with colorectal cancer (P<0.0001). See Table 127.

Table 127 Use of bowel preparation by surgeon cohort

Surgeon cohort Bowel prep used Bowel prep not used Total

n % n %

1–4 595 82 127 18 722

5–9 507 92 42 8 549

10–14 302 89 39 11 341

15–19 158 86 26 14 184

20 + 111 97 4 3 115

Total/overall % 1673 88 238 12 1911

Anterior resection and surgeon cohort

Surgeons who operated on higher volumes of patients with colorectal cancer were more likely to perform an anterior resection for rectal cancer (P=0.04). See Table 46.


RES

ULT

S ■

83RESULTS

■R

ESULTS

Post-operative complications

Wound infection and hospital insurance statusPatients treated in a private hospital were less likely to sustain a wound infection (40/819) than were patients treated in a public hospital (89/990; P=0.0009). See Table 128.

Table 128 Wound infection by hospital insurance status

Hospital type Wound infection No wound infection Total

n % n %

Public hospital 89 9 901 91 990

Private hospital 40 5 779 95 819

Unknown 12 12 90 88 102

Total/overall % 141 7 1770 93 1911

Anastomotic leakPatients who had a major anastomotic leak were more likely to have had a wound infection (7/28) than were patients who did not have a major anastomotic leak (113/1606; P=0.003). See Table 129.

Table 129 Wound infection by major anastomotic leak

Anastomotic leak Wound infection No wound infection Patients who had an anastomosis (n)n % n %

Major anastomotic leak 7 25 21 75 28

No anastomotic leak 113 7 1493 93 1606

Total/overall % 120 7 1514 93 1634

Patients who had a major anastomotic leak, combined with those who had a minor anastomotic leak (10/41), were more likely to have had a wound infection than patients who did not have an anastomotic leak (110/1593; P=0.004). See Table 130.

Table 130 Wound infection by any anastomotic leak

Anastomotic leak Wound infection No wound infection Patients who had an anastomosis (n)n % n %

Any anastomotic leak 10 24 31 76 41

No anastomotic leak 110 7 1483 93 1593

Total/overall % 120 7 1514 93 1634

Patients with rectal cancer were more likely to have sustained a minor anastomotic leak (10/326) than were patients with colon cancer (3/1308; P=0.0003). There was a trend for surgeons who operated on higher numbers of patients to have fewer major anastomotic leaks in their patients. This trend did not reach statistical significance, perhaps because of small numbers. See Tables 131 and 132.


RES

ULT

S ■

85RESULTS

■R

ESULTS

Table 131 Minor anastomotic leak by site of colorectal cancer

Cancer site Minor leak No leak Patients who had an anastomosis (n)n % n %

Colon 3 <1 1305 >99 1308

Rectum 10 3 316 97 326

Total/overall % 13 1 1621 99 1634

Table 132 Major anastomotic leak by surgeon cohort

Surgeon cohort Major leak No leak Patients who had an anastomosis (n)n % n %

1–4 13 2 598 98 611

5–9 8 2 464 98 472

10–14 3 1 299 99 302

15–19 4 3 148 97 152

>20 0 0 97 100 97

Total/overall % 28 2 1606 98 1634

Deep venous thrombosis and pulmonary embolismThere was greater use of recommended prophylaxis against deep venous thrombosis by surgeons who operated on higher volumes of patients than by surgeons who operated on fewer patients (P=0.001). A trend for more patients to sustain a deep venous thrombosis and/or pulmonary embolus, when recommended prophylaxis was omitted, did not reach statistical significance, perhaps because of small numbers. See Tables 133 and 134.

Table 133 Use of deep venous thrombosis prophylaxis by surgeon cohort

Surgeon cohort Recommended Other None Total

n % n % n %

1–4 659 91 28 4 35 5 722

5–9 498 91 25 5 26 5 549

10–14 322 94 16 5 3 1 341

15–19 176 96 4 2 4 2 184

20+ 115 100 0 0 0 0 115

Total/overall % 1770 93 73 4 68 4 1911


RES

ULT

S ■

85RESULTS

■R

ESULTS

Table 134 Incidence of deep venous thrombosis (DVT) and/or pulmonary embolism by type of deep venous thrombosis prophylaxis used

Type of prophylaxis DVT Pulmonary embolism

DVT ± pulmonary embolism

Total

n % n % n % n

Recommended prophylaxis 25 1 16 1 37 2 78

Other prophylaxis 1 1 1 1 2 3 4

No prophylaxis 2 1 1 1 2 3 5

Total/overall % 28 1 18 1 41 * 2 87

Percentages are of the number of patients who had DVT prophylaxis – see Table 133 (so 2% of all 1770 patients who had recommended DVT prophylaxis had either a DVT or a pulmonary embolism)* Five patients had both a DVT and a pulmonary embolism

Patients with rectal cancer were more likely to develop a deep venous thrombosis and/or pulmonary embolus (20/523) than were patients with colon cancer (21/1388; P=0.02) See Table 135.

Patients with rectal cancer were twice as likely to sustain a pulmonary embolus (10/523 or 1.53%) than were patients with colon cancer (8/1388 or 0.72%). This difference did not reach statistical significance, perhaps because of the small numbers of patients who sustained a pulmonary embolus. See Table 135.

Table 135 Incidence of deep venous thrombosis and/or pulmonary embolism by site of colorectal cancer

Cancer site DVT Pulmonary embolism

DVT ± pulmonary embolism

Total

n % n % n %

Colon 16 1 8 1 21 2 45

Rectum 12 2 10 2 20 4 52

Total/overall % 28 1 18 1 41 * 2 −

Percentages are of the 1388 patients who had colon cancer and the 523 patients who had a rectal cancer respectively* Five patients had both a DVT and a pulmonary embolism

Clinical trials

The number of patients entered into clinical trials was analysed according to location of residence (capital city, urban, rural), by state/territory, age of patient, hospital insurance status and surgeon cohort. Only state/territory (P=0.01) was found to be a significant indicator, with patients in South Australia being more likely to be entered into a clinical trial, with 14% of 103 patients being entered into a clinical trial. See also tables in ‘Other clinically relevant information’.


RES

ULT

S ■

87RESULTS

■R

ESULTS

Table 136 Patients entered into a clinical trial by state or territory

State/territory Patients

n %

ACT 0 0

NSW 31 5

NT 0 0

QLD 11 2

SA 14 9

TAS 0 0

VIC 24 4

WA 1 1


Adjuvant therapy

Node-positive colon cancer patients offered and given chemotherapyWhether patients with node-positive (that is involved with cancer) colon cancer were offered chemotherapy was analysed by location of residence (capital city, urban, rural), state/territory, age of patient, hospital insurance status and surgeon cohort. Only age (P<0.0001) was found to be a significant predictor, with older patients being less likely to be offered chemotherapy. Whether patients with node-positive colon cancer were given chemotherapy was analysed by location of residence (capital city, urban, rural), by state/territory, age of patient, hospital insurance status, and surgeon cohort (determined by volume of patients). Only age (P<0.0001) was found to be a significant predictor, with older patients being less likely to be given chemotherapy. See Table 137. See also tables in ‘Other clinically relevant information’.

Table 137 Node-positive colon cancer patients offered and given chemotherapy by age distribution

Patients’ age Offered chemotherapy Given chemotherapy All node-positive colon cancer patients (n)

n % n %

0−49 40 93 35 88 43

50−59 90 89 83 92 101

60−69 140 88 121 86 159

70−79 128 73 92 72 175

80+ 34 36 15 44 94

Total/overall % 432 76 346 80 572

The percentages in the ‘Offered chemotherapy’ column are of patients with node-positive colon cancer. The percentages in the ‘Given chemotherapy’ column are of patients offered chemotherapy


RES

ULT

S ■

87RESULTS

■R

ESULTS

High-risk rectal cancer patients offered and given chemotherapyWhether patients with high-risk rectal cancer (see Appendix B) were offered chemotherapy was analysed by location of residence (capital city, urban, rural), state/territory, age of patient, hospital insurance status and surgeon cohort. Only age (P<0.001) and location of residence (P=0.04) were found to be significant predictors. Older patients were less likely to be offered chemotherapy. Patients were more likely to be offered chemotherapy if they lived outside a capital city. Whether patients with high-risk rectal cancer (Appendix B) were given chemotherapy was analysed by location of residence (capital city, urban, rural), state/territory, age of patient, hospital insurance status and surgeon cohort. Only age (P=0.002) was found to be a significant predictor. Patients were less likely to be given chemotherapy as they aged. See Table 138. See also tables in ‘Other clinically relevant information’.

Table 138 High-risk rectal cancer patients offered and given chemotherapy by age distribution Patients’ age Offered chemotherapy Given chemotherapy All high-risk rectal

cancer patients (n)n % n %

0−49 24 82 20 83 29

50−59 50 88 44 88 57

60−69 74 74 65 88 100

70−79 74 69 48 65 107

80+ 10 26 4 40 39

Total/overall % 232 70 181 70 332

The percentages in the ‘Offered chemotherapy’ column are of patients with high-risk rectal cancer. The percentages in the ‘Given chemotherapy’ column are of patients offered chemotherapy

Table 139 High-risk rectal cancer patients offered and given chemotherapy by place of residence

Patients’ place of residence

Offered chemotherapy Given chemotherapy All high-risk rectal cancer patients (n)n % n %

Capital city 129 65 102 79 200

Urban 31 72 21 68 43

Rural 66 80 53 80 83

Unknown 6 100 5 83 6

Total/overall % 232 70 181 70 332

High-risk rectal cancer patients offered and given radiotherapyWhether patients with high-risk rectal cancer were offered radiotherapy was analysed by location of residence (capital city, urban, rural), state/territory, age of patient, hospital insurance status and surgeon cohort. Only age (P=0.006) and surgeon cohort (P=0.01) were found to be significant predictors. Older patients were less likely to be offered radiotherapy. Patients were more likely to be offered radiotherapy if their surgeon operated on a higher volume of patients. See Tables 140 and 141. See also tables in ‘Other clinically relevant information’.


RES

ULT

S ■

89RESULTS

■R

ESULTS

Table 140 High-risk rectal cancer patients offered and given radiotherapy by age distribution

Patients’ age Offered radiotherapy Given radiotherapy All high-risk rectal cancer patients (n)n % n %

0−49 23 80 21 91 29

50−59 37 65 33 89 57

60−69 58 58 50 86 100

70−79 64 60 46 72 107

80+ 14 36 7 50 39

Total/overall % 196 59 157 80 332

In Tables 140 and 141, the percentages in the ‘Offered radiotherapy’ column are of patients with high-risk rectal cancer. The percentages in the ‘Given radiotherapy’ column are of patients offered radiotherapy

Table 141 High-risk rectal cancer patients offered and given radiotherapy by surgeon cohort

Surgeon cohort Offered radiotherapy Given radiotherapy All high-risk rectal cancer patients (n)n % n %

1–4 64 60 49 77 107

5–9 58 62 47 81 94

10–14 27 47 21 78 58

15–19 22 51 17 77 43

20+ 25 83 23 92 30

Total/overall % 196 59 157 80 332

Timing of radiotherapy for patients with high-risk rectal cancerWhether patients with high-risk rectal cancer (Appendix B) were given pre-operative radiotherapy was analysed by patients’ place of residence (capital city, urban, rural), state/territory, age of patient, hospital insurance status and surgeon cohort. Patients’ place of residence (P=0.004), state/territory (P=0.005) and surgeon cohort (P=0.02) were found to be significant predictors of utilisation of pre-operative radiotherapy. Thus, those patients residing in rural areas were less likely to have pre-operative radiotherapy for high-risk rectal cancer. Patients with high-risk rectal cancer were more likely to receive pre-operative radiotherapy if their surgeon operated on a higher volume of patients. There was significant variation between states and territories. See Tables 142, 143 and 144. See also tables in ‘Other clinically relevant information’.

Table 142 Timing of radiotherapy given to patients with high-risk rectal cancer by place of residence

Patients’ place of residence Pre-operative radiotherapy Post-operative radiotherapy

Total

n % n %

Capital city 65 68 30 32 95

Urban 15 83 3 17 21

Rural 18 44 23 56 41

Unknown 3 100 0 0 3

Total/overall % 101 64 56 36 157

In Tables 141 to 143, percentages are of those with high-risk rectal cancer given radiotherapy


RES

ULT

S ■

89RESULTS

■R

ESULTS

Table 143 Timing of radiotherapy given to patients with high-risk rectal cancer by state or territory

State/territory Pre-operative radiotherapy Post-operative radiotherapy Total

n % n %

ACT 0 0 2 100 2

NSW 41 69 18 31 59

NT 0 0 2 100 2

QLD 25 76 8 24 33

SA 4 40 6 60 10

TAS 0 0 1 100 1

VIC 23 55 19 45 42

WA 8 100 0 0 8

Total/overall % 101 64 56 36 157

Table 144 Timing of radiotherapy given to patients with high-risk rectal cancer by surgeon cohort

Surgeon cohort Pre-operative radiotherapy Post-operative radiotherapy Total

n % n %

1–4 30 61 19 39 49

5–9 31 66 16 34 47

10–14 12 57 9 43 21

15–19 7 41 10 59 17

20+ 21 91 2 9 23

Total/overall % 101 64 56 36 157

Notable variation by state or territory

Analysis of the data by state or territory revealed the following additional significant variations.

Table 145 Use of recommended deep venous thrombosis prophylaxis, recommended antibiotics and bowel preparation by state or territory

State/territory Recommendeddeep venous thrombosis

prophylaxis (%)

Recommendedantibiotic use (%)

Bowelpreparation not used

* (%)

ACT 100 94 26

NSW 98 30 10

NT 60 5 20

QLD 90 21 5

SA 94 35 13

TAS 99 16 11

VIC 91 46 18

WA 80 65 22

P<0.0001 P<0.0001 P<0.0001

* The use of bowel preparation is not recommended in the guidelines


RES

ULT

S ■

91RESULTS

■R

ESULTS

Other Clinically Relevant InformationThe following tables show data regarding variations which were not statistically significant.

Surgical complications and interstate variation

Table 146 Incidence of deep venous thrombosis and/or pulmonary embolism by state or territory

State/territory DVT Pulmonary embolism DVT ± PE

n % n % n %

ACT 0 0 0 0 0 0

NSW 7 1 5 1 10 2

NT 0 0 0 0 0 0

QLD 9 2 4 1 12 3

SA 3 2 3 2 5 3

TAS 0 0 0 0 0 0

VIC 6 1 4 1 10 2

WA 3 2 2 2 4 3

Total/overall % 28 1 18 1 41 * 2

P=0.77 P=0.84 P=0.41

* Five patients had both a DVT and a pulmonary embolism

Table 147 Incidence of wound infection by state or territory

State/territory Wound infection

n %

ACT 3 9

NSW 41 7

NT 0 0

QLD 34 8

SA 9 6

TAS 4 6

VIC 30 6

WA 20 17


P=0.126


RES

ULT

S ■

91RESULTS

■R

ESULTS

Table 148 Incidence of minor and major anastomotic leaks by state or territory

State/territory Minor leak Major leak Total

n % n % n %

ACT 0 0 1 4 1 4

NSW 4 1 8 2 12 2

NT 0 0 0 0 0 0

QLD 5 1 7 2 12 3

SA 0 0 2 2 2 2

TAS 0 0 1 2 1 2

VIC 3 1 6 1 9 2

WA 1 1 3 3 4 4

Total/overall % 13 1 28 2 41 2

P=0.96

Table 149 Colorectal cancer stage by hospital insurance status

Dukes’ stage Public Private Unknown

n % n % n %

A 228 23 194 24 25 25

B 261 26 239 29 27 26

C 284 29 210 26 24 24

D 174 18 138 17 23 23

Unknown 43 4 38 5 3 3

Total 990 100 819 100 102 100

Clinical trials variations

Table 150 Patients entered into a clinical trial by place of residence

Patients’ place of residence Patients

n %

Capital city 66 5

Urban 3 1

Rural 12 2

Unknown 0 0



RES

ULT

S ■

93RESULTS

■R

ESULTS

Table 151 Patients entered into a clinical trial by age of patient

Patients’ age Patients

n %

0−49 6 4

50−59 21 7

60−69 22 4

70−79 23 3

80+ 9 3


Table 152 Patients entered into a clinical trial by hospital insurance status

Hospital insurance status Patients

n %

Public 58 6

Private 22 3

Unknown 1 1


Table 153 Patients entered into a clinical trial by surgeon cohort

Surgeon cohort Patients

n %

1–4 22 3

5–9 16 3

10–14 28 8

15–19 12 6

>20 3 2


Adjuvant therapy variations

Table 154 Node-positive colon cancer patients offered and given chemotherapy by place of residence

Patients’ place of residence

Offered chemotherapy Given chemotherapy All node-positive colon cancer patients (n)n % n %

Capital city 263 76 211 80 346

Urban 36 68 27 75 54

Rural 130 79 106 82 165

Unknown 3 43 2 67 7

Total/overall % 432 76 346 80 572

In Tables 154 to 157, the percentages in the ‘Offered chemotherapy’ column are of patients with node-positive colon cancer. The percentages in the ‘Given chemotherapy’ column are of patients offered chemotherapy


RES

ULT

S ■

93RESULTS

■R

ESULTS

Table 155 Node-positive colon cancer patients offered and given chemotherapy by state or territory

State/territory Offered chemotherapy Given chemotherapy All node-positive colon cancer patients (n)n % n %

ACT 8 73 7 88 11

NSW 117 74 82 70 158

NT 2 100 2 100 2

QLD 101 74 86 85 136

SA 36 77 28 78 47

TAS 13 68 10 77 19

VIC 126 79 107 58 159

WA 29 73 24 53 40

Total/overall % 432 76 346 80 572

Table 156 Node-positive colon cancer patients offered and given chemotherapy by hospital insurance status

Hospital insurance status

Offered chemotherapy Given chemotherapy All node-positive colon cancer patients (n)

n % n %

Public 227 75 176 78 303

Private 187 78 153 81 241

Unknown 18 64 17 94 28

Total/overall % 432 76 346 80 572

Table 157 Node-positive colon cancer patients offered and given chemotherapy by surgeon cohort

Surgeon cohort Offered chemotherapy Given chemotherapy All node-positive colon cancer patients (n)n % n %

1–4 178 75 139 78 238

5–9 122 80 96 79 152

10–14 72 72 61 85 100

15–19 37 74 32 86 50

>20 23 72 18 78 32

Total/overall % 432 76 346 80 572


RES

ULT

S ■

95RESULTS

■R

ESULTS

Table 158 High-risk rectal cancer patients offered and given chemotherapy by state or territory

State/territory Offered chemotherapy Given chemotherapy All high-risk rectal cancer patients (n)n % n %

ACT 4 100 3 75 4

NSW 81 73 59 73 111

NT 2 100 2 100 2

QLD 50 66 43 86 76

SA 14 58 10 71 24

TAS 3 50 2 67 6

VIC 64 72 51 80 89

WA 14 70 11 79 20

Total/overall % 232 70 181 70 332

In Tables 158–160, the percentages in the ‘Offered chemotherapy’ column are of patients with high-risk rectal cancer. The percentages in the ‘Given chemotherapy’ column are of patients offered chemotherapy

Table 159 High-risk rectal cancer patients offered and given chemotherapy by hospital insurance status


Offered chemotherapy Given chemotherapy All high-risk rectal cancer patients (n)n % n %

Public 128 74 98 77 173

Private 88 65 67 76 135

Unknown 16 67 16 100 24

Total/overall % 232 70 181 70 332

Table 160 High-risk rectal cancer patients offered and given chemotherapy by surgeon cohort

Surgeon cohort Offered chemotherapy Given chemotherapy All high-risk rectal cancer patients (n)n % n %

1–4 77 72 60 78 107

5–9 65 69 52 80 94

10–14 37 64 25 68 58

15–19 30 70 21 70 43

20+ 23 77 23 100 30

Total/overall % 232 70 181 70 332


RES

ULT

S ■

95RESULTS

■R

ESULTS

Table 161 High-risk rectal cancer patients offered and given radiotherapy by place of residence

Place of residence Offered radiotherapy Given radiotherapy All high-risk rectal cancer patients (n)n % n %

Capital city 113 57 95 84 200

Urban 27 63 18 67 43

Rural 53 64 41 77 83

Unknown 3 50 3 100 6

Total/overall % 196 59 157 80 332

In Tables 161–163, the percentages in the ‘Offered radiotherapy’ column are of patients with high-risk rectal cancer. The percentages in the ‘Given radiotherapy’ column are of patients offered radiotherapy

Table 162 High-risk rectal cancer patients offered and given radiotherapy by state or territory

State/territory Offered radiotherapy Given radiotherapy All high-risk rectal cancer patients (n)n % n %

ACT 2 50 2 100 4

NSW 75 68 59 89 111

NT 2 100 2 100 2

QLD 41 54 33 80 76

SA 13 54 10 77 24

TAS 1 17 1 100 6

VIC 53 60 42 79 89

WA 9 45 8 89 20

Total/overall % 196 59 157 80 332

Table 163 High-risk rectal cancer patients offered and given radiotherapy by hospital insurance status


Offered radiotherapy Given radiotherapy All high-risk rectal cancer patients (n)n % n %

Public 115 66 94 82 173

Private 66 49 49 74 135

Unknown 15 63 14 93 24

Total/overall % 196 59 157 80 332


RES

ULT

S ■

97RESULTS

■R

ESULTS

Table 164 Timing of radiotherapy given to patients with high-risk rectal cancer by age

Patients’ age Pre-operative radiotherapy Post-operative radiotherapy Total

n % n %

0−49 14 67 7 33 21

50−59 21 64 12 36 33

60−69 29 58 21 42 50

70−79 33 72 13 28 46

80+ 4 57 3 43 7

Total/overall % 101 64 56 36 157

In Tables 164 and 165, percentages are of those with high-risk rectal cancer given radiotherapy

Table 165 Timing of radiotherapy given to patients with high-risk rectal cancer by hospital insurance status


Pre-operative radiotherapy Post-operative radiotherapy Total

n % n %

Public 61 65 33 35 94

Private 34 69 15 31 49

Unknown 6 43 8 57 14

Total/overall % 101 64 56 36 157


RES

ULT

S ■

97RESULTS

■R

ESULTS

Additional Tables and Figures Relating to NHMRC Guidelines

Table 166 Route of administration of chemotherapy for those patients with proven liver metastases

Route of administration Patients

n %

Intravenous 78 76

Intrahepatic 9 9

Oral 1 1

None 14 * 14

Total 102 100

* Chemotherapy not given; this figure was defined as ‘best supportive care’ in order to calculate denominator for the NHMRC Guideline on hepatic arterial infusion. See ‘Concordance with the NHMRC Guidelines’, page xvii

Table 167 Operation performed for obstructing colorectal cancer

Operation Patients

n %

Segmental resection 65 60

Subtotal colectomy & anastomosis 15 14

Hartmann’s procedure 25 23

Defunctioning stoma only 3 3

Total 108 100


RES

ULT

S ■

99RESULTS

■R

ESULTS

Figure 22 Combined modality therapy for high-risk rectal cancer


RES

ULT

S ■

99RESULTS

■R

ESULTS

Figure 23 Radiotherapy for advanced rectal cancer

Table 168 Length of constructed colonic pouch

Length of pouch n %

<50 mm 7 7

50–80 mm 83 85

>80 mm 2 2

Unknown 6 6

Total 98 100


RES

ULT

S ■

Figure 24 Laparoscopic surgery for colorectal cancer


RES

ULT

S ■ APPENDICES

103APPENDICES

■A

PPEND

ICES

103APPENDICES

■A

PPEND

ICES

Appendix A Survey Administration

Project Management Group and Working Party

Professor Allan Spigelman (Chair, Working Party), Head, Discipline of Surgical Science, Faculty of Health, the University of Newcastle and Director, Clinical Governance Unit, Hunter Area Health Service

Ms Sandra Anderson (National Project Manager), Hunter Area Health Service

Professor Bruce Armstrong, NSW Cancer Council

Mr Andrew Benson, Commonwealth Department of Health and Ageing (May 1999–November 2000)

Associate Professor Bryan Burmeister, Royal Australian and New Zealand College of Radiologists, Faculty of Radiation Oncology

Professor Robert Burton, Director, The Cancer Council Victoria

Professor Alan Coates, Chief Executive Officer, Australian Cancer Society

Professor Mark Elwood, Director, National Cancer Control Initiative

Dr Lin Fritschi, The University of Western Australia (from February 2001)

Professor Robert Gibberd, Centre for Clinical Epidemiology and Biostatistics, The University of Newcastle

Dr David Hill, Director, Centre for Behavioural Research in Cancer, Cancer Control Research Institute, The Cancer Council Victoria

Dr Paul Ireland, Deputy Director, National Cancer Control Initiative

Professor Konrad Jamrozik, The University of Western Australia (July–November 2000)

Dr Rosemary Knight, Director, Asthma and Cancer Control Section, Commonwealth Department of Health and Ageing (from November 2000)

Dr Barbara Leggett, Gastroenterological Society of Australia

Dr David Leong, Oncologist, Canberra

Emeritus Professor Richard Lovell, National Cancer Control Initiative (May 1999 until his retirement from the National Cancer Control Initiative in June 1999)

Mr Adam Martin, Health Sciences Research Group, The University of Newcastle

Dr Daniel McGrath, Discipline of Surgical Science, The University of Newcastle

Emeritus Professor Tom Reeve, Executive Officer, Australian Cancer Network

Dr Russell Stitz, Royal Australasian College of Surgeons

Professor Robert Thomas, Peter MacCallum Cancer Institute, Melbourne

Professor John Zalcberg, Medical Oncology Group of Australia Incorporated


APP

END

ICES

■

105APPENDICES

■A

PPEND

ICES

State and territory advisers

Australian Capital Territory

ACT Department of Health, Housing and Community Care

Dr Bruce Shadbolt (Director, Clinical Epidemiology and Health Outcomes Centre and the ACT Cancer Registry)

Mrs Barbara Stuart-Harris (Manager, ACT Cancer Registry)

New South Wales

Cancer Research and Registers Division, NSW Cancer Council

Professor Bruce Armstrong (Director)

Mrs Elizabeth Tracey (Manager, NSW Central Cancer Registry)

Ms Katie Farac (NSW Project Manager, Cancer Epidemiology Research Unit)

Dr Dianne O’Connell (Senior Epidemiologist, Cancer Epidemiology Research Unit)

Mr Graham Edgar (Database Developer, Information Technology Department)

Mrs Anthea Kowe (Field Officer, Cancer Epidemiology Research Unit)

Northern Territory

Northern Territory Cancer Registry Epidemiology Branch, Territory Health Services

Mr Edouard d’Espaignet (Registrar, Northern Territory Cancer Registry)

Mr Yuejen Zhao (Epidemiologist, Northern Territory Cancer Registry)

Ms Maxene Woods (Manager, Northern Territory Cancer Registry)

Queensland

Health Information Centre

Queensland Cancer Registry, Queensland Cancer Fund

Dr Ian Ring (Manager, Health Information Centre, Queensland Cancer Registry Queensland Cancer Fund)

Ms Judy Symmons (Health Information Manager, Queensland Cancer Registry, Queensland Cancer Fund)

Mrs Margaret Chadwick (Project Officer)

South Australia

Anti-Cancer Foundation of South Australia

Associate Professor Kerry Kirke (Executive Director, Anti-Cancer Foundation of South Australia, Chair, South Australian Colorectal Cancer Advisory Group)

Epidemiology Branch and Cancer Registry, South Australia

Epidemiology Branch and Cancer Registry

Dr Wayne Clapton, Anti-Cancer Foundation of South Australia, South Australian Cancer Registry, Epidemiology Branch


APP

END

ICES

■

105APPENDICES

■A

PPEND

ICES

Ms Joanne Bell (Project Officer)

Ms Heather Hall (Project Officer)

Tasmania

Tasmania Cancer Registry

Menzies Centre for Population Health Research

Professor Terry Dwyer (Director, Menzies Centre for Population Health and Research)

Dr Alison Venn (Director, Tasmania Cancer Registry)

Mrs Shevaun Pavlides (Registrar)

Mrs Vanessa Webb (Project Officer)

Victoria

Victorian Cancer Registry

Cancer Epidemiology Centre

Professor Robert Burton (Director, The Cancer Council Victoria)

Professor Graham Giles (Director, Epidemiology Centre and Victorian Cancer Registry)

Ms Helen Farrugia (Programs Manager)

Ms Kathryn Whitfield (Registrar)

Ms Jennifer Petersen (Project Officer)

Ms Charmaine Payne (Project Officer)

Ms Voula Sarakinis (Project Officer)

The Cancer Council Victoria

Western Australia

Western Australia Cancer Registry

Dr Tim Threlfall (Western Australian Cancer Register)

Department of Public Health, The University of Western Australia

Dr Lin Fritschi (Occupational and Environmental Epidemiology Group, Department of Public Health, University of Western Australia) (from February 2001)

Professor Konrad Jamrozik, Department of Public Health, University of Western Australia (July–November 2000)

Ms Marlene Kolybaba (Research Associate)


APP

END

ICES

■

107APPENDICES

■A

PPEND

ICES

Appendix B Clinicopathological Staging of Colorectal Cancers

Dukes’ Staging System Australian Clinicopathological Staging (ACPS) System

Tumour, Node, Metastasis (TNM) Staging System

Unknown a1 b2 c1 Unknown a1 b2 c1

an b1 c1 an b1 c1

Ao/In-Situ − Ao/In-Situ a2 b2 c1 Tis N0 M0

A a3 b2 c1 A a3 b2 c1 T1 N0 M0

a4 b2 c1 a4 b2 c1

B a5 b2 c1 B a5 b2 c1 T3–T4 N0 M0

a6 b2 c1 a6 b2 c1

a7 b2 c1 a7 b2 c1

C an b3–5 c1 C an b3–5 c1 T1–T4, N1–N3 M0

D an bn c2–5 D an bn c2–5 Tn Nn M1

For key to a1-7; b1-5; c1-5, see Questions 5a, 5b, 5c of the Surgical Questionnaire (reproduced below).

5 (a) Local tumour stage (use the most accurate clinical or pathological staging information available; for >1 primary, select most advanced):

a1 ¨ unknown

a2 ¨ carcinoma in situ (severe dysplasia)

a3 ¨ submucosal involvement

a4 ¨ involvement of muscularis propria

a5 ¨ subserosa (or perirectal tissues)

a6 ¨ serosal involvement

a7 ¨ adjacent organ invasion


APP

END

ICES

■

107APPENDICES

■A

PPEND

ICES

(b) Spread to lymph nodes (any combination):

b1 ¨ unknown

b2 ¨ not involved

b3 ¨ epi-, para-, retro-colic or mesenteric

b4 ¨ apical

b5 ¨ distant: (name chain)

(c) Sites of distant spread: (any combination)

c1 ¨ none known

c2 ¨ non-adjacent peritoneum

c3 ¨ liver

c4 ¨ lung

c5 ¨ other(s):

‘n’ refers to any variable. For example, bn means b1−5, so for Dukes’ Stage D, if there is distant organ spread, irrespective of the tumour detail and the involvement of lymph nodes, the tumour is staged as Dukes’ D.

‘Tis’ refers to carcinoma in situ or severe dysplasia.

Mapping of Dukes’ stage to Australian Clinicopathological Staging (ACPS) System and Tumour, Node, Metastasis (TNM) System is based on the NHMRC Guidelines for the Prevention, Early Detection and Management of Colorectal Cancer, pages 108–119 and 123.

High-risk rectal cancer – A high-risk rectal cancer was defined as a T3–T4 tumour which corresponds to a5,6,7 of primary spread of the tumour from the questionnaire, and any tumour irrespective of primary spread that has been shown to be node positive.


APP

END

ICES

■

109APPENDICES

■A

PPEND

ICES

Appendix C Participating HospitalsAll hospital information was correct at time of final draft (November 2001)

.

State Hospital Hospital type Tertiary referral hospital

ACT Calvary Public Hospital Capital city public

Calvary Private Hospital Capital city private

The Canberra Hospital Capital city public YES

John James Memorial Hospital Capital city private

The National Capital Private Hospital Capital city private

NSW Albury Base Hospital Rural public

Albury Wodonga Private Hospital Rural private

Armidale New England District Hospital Rural public

Bankstown-Lidcombe Hospital Capital city public

Baringa Private Hospital Rural private

Bathurst Base Hospital Rural public

Berkeley Vale Private Hospital Urban private

Bigge Street Private Hospital Capital city private

Blacktown Hospital Capital city public

Blue Mountains District Anzac Memorial Hospital Rural public

Bowral & District Hospital Rural public

Calvary Hospital, Wagga Wagga Rural private

Campbelltown Hospital Capital city public

Cape Hawke Community Private Hospital Rural private

Charles Wentworth Private Hospital Capital city private

Christo Road Private Hospital Urban private

Coffs Harbour Base Hospital Rural public

Concord Repatriation General Hospital Capital city public YES

Delmar Private Hospital Capital city private

Diagnostic Endoscopy Centre Capital city private

Dubbo Base Hospital Rural public

Dubbo Private Hospital Rural private

Dudley Private Hospital Rural private

Eastern Suburbs Endoscopy Clinic Capital city private

Fairfield Hospital Capital city public

Gosford Hospital Urban public

Hawkesbury District Health Service Ltd Rural private

The Hills Private Hospital Capital city private

Holroyd Private Hospital Capital city private

The Hornsby Ku-ring-gai Hospital Capital city public

Illawarra Private Hospital Urban private

Jamison Private Hospital Capital city private

John Hunter Hospital Urban public YES

Kareena Private Hospital Capital city private

Lake Macquarie Private Hospital Urban private

Lismore Base Hospital Rural public


APP

END

ICES

■

109APPENDICES

■A

PPEND

ICES

Lithgow District Hospital Rural public

Liverpool Hospital Capital city public

Macarthur Private Hospital Capital city private

Manly Hospital Capital city public

Manning Base Hospital Rural public

Mater Misericordiae Hospital Capital city private

Mayo Private Hospital Rural private

Mona Vale Hospital Capital city public

Mount Druitt Hospital Capital city public

Nepean Hospital Penrith Capital city public

Newcastle Mater Misericordiae Hospital Urban public

North Gosford Private Hospital Urban private

North Shore Private Hospital Capital city private

Nowra Community Hospital Rural private

NSW Private Hospital (Ashfield) Capital city private

Orange Base Hospital Rural public

Peninsula Private Hospital Capital city private

Port Macquarie Base Hospital Rural public

President Private Hospital Capital city private

The Prince of Wales Hospital Capital city public YES

Prince of Wales Private Hospital Capital city private

Royal North Shore Hospital Capital city public YES

Royal Prince Alfred Hospital Capital city public YES

Ryde Hospital Capital city public

Shellharbour Hospital Rural private

Southern Highlands Private Hospital Rural private

St George Hospital Capital city public YES

St George Private Hospital Capital city private

St Vincent’s Public Hospital Capital city public YES

St Vincent’s Private Hospital, Bathurst Rural private

St Vincent’s Private Hospital, Lismore Rural private

St Vincent’s Private Hospital, Sydney Capital city private

Strathfield Private Hospital Capital city private

The Sutherland Hospital, Caringbah Capital city public

Sydney Adventist Hospital Capital city private

Sydney Hospital Capital city public

Tamara Private Hospital Rural private

Tamworth Base Hospital Rural public

Toronto Private Hospital Urban private

Tweed Heads District Hospital Rural public

Wagga Wagga Base Hospital Rural public

Wagga Wagga Day Surgery Rural public

Warner’s Bay Private Hospital Urban private

Westmead Hospital Capital city public YES

Wollongong Hospital Urban public

Wolper Jewish Hospital Capital city private

NT Alice Springs Hospital Rural public

Darwin Private Hospital Capital city private

Royal Darwin Hospital Capital city public


APP

END

ICES

■

111APPENDICES

■A

PPEND

ICES

QLD Allamanda Private Hospital Urban private

Andrea Ahern Private Hospital Rural private

Atherton District Hospital Rural public

Buderim Private Hospital Rural private

Bundaberg Base Hospital Rural public

Caboolture Hospital Rural public

Cairns Base Hospital Urban public

Calvary Private Hospital Capital city private

Eastern Endoscopy Centre Capital city private

Friendly Society Private Hospital Rural private

Gladstone Hospital Rural public

Gold Coast Hospital Urban public

Greenslopes Private Hospital Capital city private

Gympie Hospital Rural public

Hervey Bay Hospital Rural public

Hillcrest Private Hospital Rural private

Holy Sprit Hospital Capital city private

Ingham Hospital Rural public

Ipswich Hospital Rural public

John Flynn Hospital Urban private

Kingaroy Hospital Rural public

Logan Day Surgery Urban private

Logan Hospital Urban public

Mackay Base Hospital Rural public

Mater Adult Hospital Capital city private

Mater Misericordiae Hospital, Rockhampton Rural private

Mater Misericordiae Private Hospital Capital city private

Mater Misericordiae Hospital, Bundaberg Rural private

Mater Misericordiae Hospital, Mackay Rural private

Mater Misericordiae Hospital Townsville Urban private

Nambour General Hospital Rural public

Noosa Hospital Rural private

North West Private Hospital Capital city private

Pindara Private Hospital Urban private

Pioneer Valley Private Hospital Rural private

The Prince Charles Hospital Capital city public YES

Princess Alexandra Hospital Capital city public YES

Queen Elizabeth II Jubilee Hospital Capital city public

Redcliffe Hospital Rural public

Riverview Private Hospital Rural private

Rockhampton Hospital Rural public

Royal Brisbane Hospital Capital city public YES

Selangor Private Hospital Rural private

St Andrew’s War Memorial Hospital Capital city private

St Andrew’s Private Hospital Ipswich Rural private

St Andrew’s Toowoomba Hospital Rural private

St Aubyn’s Private Hospital Rural private

St Stephens Private Hospital Rural private

St Vincent’s Hospital Toowoomba Rural private


APP

END

ICES

■

111APPENDICES

■A

PPEND

ICES

Stanthrope Public Hospital Rural public

Sunnybank Private Hospital Capital city private

Toowoomba Base Hospital Rural public

Townsville General Hospital Urban public

Warwick Hospital Rural public

Wesley Clinic for Haematology & Oncology Capital city private

The Wesley Park Haven Hospital Capital city private

The Wesley Hospital Capital city private

SA Ashford Community Hospital Incorporated Capital city private

Burnside War Memorial Hospital Inc Capital city private

Calvary Hospital Adelaide Inc Capital city private

Flinders Medical Centre Capital city public YES

Flinders Private Hospital Capital city private

Glenelg Community Hospital Incorporated Capital city private

Lyell McEwin Hospital Capital city public

The Memorial Hospital Inc Capital city private

Modbury Public Hospital Capital city public

Mount Barker District Soldiers Memorial Hospital Inc Rural public

Mount Gambier Private Hospital Inc Rural private

Mount Gambier Public Hospital Inc Rural public

Naracoorte Hospital Inc Rural public

Noarlunga Private Hospital Inc Capital city private

Noarlunga Public Hospital Inc Capital city public

North Eastern Community Hospital Incorporated Capital city private

Port Lincoln Hospital Inc Rural public

Port Pirie Hospital Inc Rural public

The Queen Elizabeth Hospital Capital city public YES

Renmark Paringa District Hospital Inc Rural public

Repatriation General Hospital – Daw Park Capital city public

Riverland Private Hospital Inc Rural private

Riverland Regional Hospital Inc Rural public

Royal Adelaide Hospital Capital city public YES

St Andrew’s Hospital Inc Capital city private

St Margaret’s Hospital Incorporated Capital city public

Stirling & Districts Hospital Inc Rural private

Wakefield Hospital Capital city private

Western Community Hospital Inc Capital city private

TAS Calvary Hospital Hobart Inc Capital city private

Launceston General Hospital Rural public

Mersey Community Hospital Rural public

North West Private Hospital, Burnie Rural private

North-West Regional Hospital, Burnie Rural public

Royal Hobart Hospital Capital city public YES

St Helen’s Private Hospital Hobart Capital city private

St John’s Hospital Capital city private

St Luke’s Private Hospital Ltd Rural private

St Vincent’s Hospital (Launceston) Ltd Rural private

The Hobart Private Hospital Capital city private

VIC The Alfred Hospital Capital city public YES


APP

END

ICES

■

113APPENDICES

■A

PPEND

ICES

Angliss Hospital Capital city public

Austin & Repatriation Medical Centre Capital city public YES

The Avenue Hospital Capital city private

Bairnsdale Regional Health Service Rural public

Ballarat Base Hospital Rural public

The Bays Hospital – Mornington Capital city private

Beleura Private Hospital Capital city private

Bendigo Health Care Group Rural public

Box Hill Gardens Day Surgery Capital city private

Box Hill Hospital Capital city public

Brighton Private Hospital Capital city private

Cabrini Hospital Capital city private

Central Wellington Health Service Rural public

Como Private Hospital Rural private

Cotham Private Hospital Rural private

Dandenong Hospital Capital city public

East Grampians Hospital Rural public

Echuca Regional Health Rural public

Epworth Hospital Capital city private

Freemasons Hospital Capital city private

The Geelong Private Hospital Urban private

Gippsland Southern Health Service Rural public

Goulburn Valley Health Rural public

Hamilton Base Hospital Rural public

Hartwell Private Hospital Capital city private

Hawthorn Private Hospital Capital city private

John Fawkner Private Hospital Capital city private

Knox Private Hospital Urban private

Latrobe Regional Hospital Rural public

Lilydale Private Hospital Capital city private

Linacre Private Hospital Capital city private

Malvern Private Hospital Capital city private

Maroondah Hospital Capital city public

Maryborough Hospital Rural public

Maryvale Private Hospital Rural private

Masada Private Hospital Capital city private

Melbourne Private Hospital Capital city private

Mercy Private Hospital Capital city private

Mildura Private Hospital Rural private

Mitcham Private Hospital Capital city private

Monash Medical Centre Capital city public YES

Mountain District Private Hospital Rural private

Mount Alvernia Mercy Hospital Rural private

The Northern Hospital Capital city public

Peninsula Private Hospital Capital city private

Peter MacCallum Cancer Institute Capital city public YES

Portland & District Hospital Rural public

Ringwood Private Hospital Capital city private

The Royal Melbourne Hospital Capital city public YES


APP

END

ICES

■

113APPENDICES

■A

PPEND

ICES

Sandringham & District Memorial Hospital Capital city public

South Eastern Endoscopy Capital city private

Shepparton Private Hospital Rural private

South Eastern Private Hospital Capital city private

St John of God Health Care, Ballarat Rural private

St John of God Health Care, Warrnambool Rural private

St John of God Health Care, Geelong Urban private

St Vincent’s Hospital Melbourne Limited Capital city public YES

St Vincent’s & Mercy Private Hospital Capital city private

Sunshine Hospital Capital city public

Swan Hill District Hospital Rural public

Timboon & District Hospital Rural public

The Valley Private Hospital Rural private

Wangaratta District Base Hospital Rural public

Wangaratta Private Hospital Rural private

Warringal Private Hospital Capital city private

Waverley Private Hospital Capital city private

Western Hospital Capital city public

Western Private Hospital Capital city private

West Gippsland Hospital Rural public

The Williamstown Hospital Capital city public

Wimmera Health Care Group, Dimboola Rural public

Wodonga District Hospital Rural public

Wonthaggi & District Hospital Rural public

WA Armadale Health Service Capital city public

Bethesda Hospital Inc Capital city private

Fremantle Hospital Urban public YES

Fremantle Kaleeya Hospital Urban private

Glengarry Hospital Capital city private

Hollywood Private Hospital Capital city private

Joondalup Private Hospital Capital city private

Mercy Hospital Mount Lawley Capital city private

Mount Hospital Capital city private

Osborne Park Hospital Capital city public

Rockingham Family Hospital Rural private

Royal Perth Hospital Capital city public YES

Sir Charles Gairdner Hospital Capital city public YES

St John of God Health Care, Bunbury Rural private

St John of God Health Care, Murdoch Capital city private

St John of God Health Care, Subiaco Capital city private

Swan District Hospital Capital city public


APP

END

ICES

■

115APPENDICES

■A

PPEND

ICES

Appendix D Study Denominators Number of

2015 All study patients

1911 All patients who had an operation

1452 All patients with colon cancer

1388 All colon cancer patients who had an operation

563 All patients with rectal cancer

523 All rectal cancer patients who had an operation

1799 All elective patients

1700 All elective patients who had an operation

216 All emergency patients

211 All emergency patients who had an operation

918 Females in study

865 Females who had an operation

1634 Patients who had an anastomosis

445 Sum of anterior resections and abdomino-perineal resections

906 Patients offered chemotherapy from the Surgical Questionnaire

680 Patients given chemotherapy from the Surgical Questionnaire

336 Patients offered radiotherapy from the Surgical Questionnaire

246 Patients given radiotherapy from the Surgical Questionnaire

535 Patients with a stoma

431 Patients where a stomal therapist was available for those with a stoma

332 Patients with high-risk rectal cancer

572 Patients with node-positive colon cancer

492 Returned Medical Oncology Questionnaires

445 Number of patients who received chemotherapy, derived from the returned Medical Oncology Questionnaires

162 Returned Radiation Oncology Questionnaires

154 Number of patients who received radiotherapy, derived from the returned Radiation Oncology Questionnaires


APP

END

ICES

■

115APPENDICES

■A

PPEND

ICES

Appendix E Questionnaire Coversheet

��

��

��

��

��

��

��

��

��

��

��

��

� ��

� ��

� ��

� ��

� ��

� ��

��

��

��

��


APP

END

ICES

■

117APPENDICES

■A

PPEND

ICES

Appendix F Surgical Questionnaire

�

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��


APP

END

ICES

■

117APPENDICES

■A

PPEND

ICES

�

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��


APP

END

ICES

■

119APPENDICES

■A

PPEND

ICES

�

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��‡��

��

��


APP

END

ICES

■

119APPENDICES

■A

PPEND

ICES

�

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��


APP

END

ICES

■

121APPENDICES

■A

PPEND

ICES

Appendix G Medical Oncology Questionnaire

�

��

��

��

��

��

��

��

��

��

��

� ��

��

� ��

��

��

��

��

��

��

��

��

��

��

��

��

�� ‡��

��

��

��


APP

END

ICES

■

121APPENDICES

■A

PPEND

ICES

�

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��


APP

END

ICES

■

123APPENDICES

■A

PPEND

ICES

Appendix H: Radiation Oncology Questionnaire

�

��

��

� ��

��

��

��

��

��

��

� ��

��

� ��

��

��

�

��

��

��

��

��

��

��

��

��

��

��

��

��


APP

END

ICES

■

123APPENDICES

■A

PPEND

ICES

�

��

��

��

� ��

��

��

��

� ��

��

��

��

��

��

� ��

��

��

��

��

��

��

Documents

THE NATIONAL COLORECTAL CANCER CARE SURVEY · The National Colorectal Cancer Care Survey Australian clinical practice in 2000 Prepared by Professor Allan D Spigelman and Dr Daniel