Variation in treatment and outcome of patients with rectal cancer by region, hospital type and volume in the Netherlands☆
Introduction
Worldwide, there is an increasing interest in variations in quality of cancer care. Many authors reported on differences in quality of care between hospitals analyzing the effects of differences in volume and specialization on patient outcome.1, 2, 3 Only a few studies revealed differences regarding other aspects of the care process, such as compliance to (national) guidelines.
In the Netherlands, colorectal cancer is the second most common type of cancer. In 2007, almost 12 000 patients were diagnosed with colorectal cancer of which approximately 3300 included patients with rectal cancer.4 In the same year, about 1000 patients died of rectal cancer.5
In the Netherlands, an improvement in survival of patients with rectal cancer has been demonstrated due to changes in treatment strategies,6, 7 including the wide clinical implementation of total mesorectal excision (TME) together with a shift from postoperative to preoperative radiotherapy. According to the current Dutch treatment guidelines, preoperative radiotherapy is recommended for patients with clinical T2–T3 tumours, while in case of locally advanced tumours preoperative chemoradiation is preferred.8 However, large interhospital variation in the use of radiotherapy was reported in a regional population-based study.9
Limited data exist on differences in treatment patterns of patients with rectal cancer and to what extent these differences could be explained by differences in hospital characteristics. Several studies revealed an association between high volume and better outcome after surgery for several cancers, such as cancer of the pancreas, esophagus and lung.1, 2, 10, 11, 12 However, the association between volume and outcome for rectal cancer surgery is not that clear: some reported lower postoperative mortality or better overall survival in patients who were operated in a high-volume hospital, while others did not find such relationship.13, 14, 15, 16 Studies examining the relation between type of hospital and outcome also published contrasting results for rectal cancer.14, 17, 18, 19
The aim of this study was to describe variation in treatment patterns and outcome according to region and characteristics of individual hospitals among patients with rectal cancer in the Netherlands.
Section snippets
Netherlands Cancer Registry
In the Netherlands, all newly diagnosed malignancies are registered in the nationwide population-based Netherlands Cancer Registry (NCR). The automated pathological archive (PALGA) and the Haematology Departments are the main sources of notification. The National Registry of Hospital Discharge Diagnosis is an additional source, which accounts for up to 8% of new cases.20 Data are collected from the medical records by specially trained registrars and are coded according to a national manual.
Treatment according to guidelines
Treatment was described as percentages per stage and age group (<75 years and ≥75 years). The influence of age at diagnosis, gender, year of diagnosis, depth of invasion, nodal involvement, type of hospital of diagnosis, hospital volume and CCC-region on the odds of receiving preoperative radiotherapy (including preoperative chemoradiation) in patients with T2/T3-M0 was examined using logistic regression analysis. For this analysis, patients diagnosed in the period 2003–2006 were used, because
Results
In the Netherlands 16 039 patients with rectal carcinoma were diagnosed in the period from 2001 to 2006. During this period, the number of annual diagnoses increased from 2325 in 2001 to 2918 in 2006. Of these patients 59% were male and 30% were aged 75 years or older. In total, 59% had T2/T3-M0 tumours, 10% had T4-M0 tumours and 17% had tumours with distant metastasis (M1). More than 50% of the patients were diagnosed in a teaching hospital for surgery and 6% were diagnosed in a university
Discussion
In this nationwide population-based study, examining cancer registry data of 16,039 patients with rectal carcinoma diagnosed in the period 2001–2006 in the Netherlands, we revealed marked variation in treatment patterns and outcome. Even after correction for differences in case-mix, there were substantial differences between individual hospitals in the proportion of patients receiving preoperative radiotherapy. In addition, we found variation between CCC-regions in the proportion of patients
Conflict of interest statement
None declared.
Funding
This article is published in a supplement sponsored by a grant from the Dutch Cancer Society. The Dutch Cancer Society did not influence the article in any way.
Acknowledgements
The authors thank the registration teams of the Comprehensive Cancer Centres for the collection of data for the Netherlands Cancer Registry and the investigators of the Netherlands Cancer Registry involved in the analyses of quality of cancer care.
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Study performed by the ‘Quality of cancer care’ taskforce of the Signalling Committee Cancer of the Dutch Cancer Society (the committees full report is available on www.kwfkankerbestrijding.nl).