The importance of surgery in colorectal cancer treatment
Authors: Eva Angenete
Journal: The Lancet Oncology (2018)

In The Lancet Oncology, Sara Benitez Majano and colleagues1Majano SB Girolamo CD Rachet B et al.Surgical treatment and survival from colorectal cancer in Denmark, England, Norway, and Sweden: a population-based study.Lancet Oncol. 2018; (published Dec 10.)http://dx.doi.org/10.1016/S1470-2045(18)30646-6Google Scholar have engaged with a very important topic. Previous data have indicated poorer treatment results for colorectal cancer in both Denmark and England compared with those in similar western countries.2Maringe C Walters S Rachet B et al.Stage at diagnosis and colorectal cancer survival in six high-income countries: a population-based study of patients diagnosed during 2000–2007.Acta Oncol. 2013; 52: 919-932Crossref PubMed Scopus (157) Google Scholar The continuous audit and assessment of outcomes is important to better understand the reality of cancer care each country and thus, this study is of interest to the public. Majano and colleagues identified that an important difference between the countries studied regarding surgery for colorectal cancer was probably not the technique, but rather the frequency of surgical resection. The proportion of patients treated with resectional surgery ranged from 68·4% in England to 81·3% in Sweden for colon cancer, and from 59·9% in England to 70·8% in Sweden for rectal cancer; this range was wider for patients older than 75 years (colon cancer 59·7% to 80·9%; rectal cancer 45·7% to 61·9%). What are the implications from these results? Majano and colleagues' paper highlights the importance of surgery in the treatment of colorectal cancer. It is possible that attitudes towards surgery in the older patient population should be altered in England, but the data in this study do not include comorbidity, and the risk for increased perioperative mortality should not be underestimated. It is important to continue to assess results of resectional surgery to avoid doing more harm than good. Preoperative optimisation of patients must be a focus of research, to increase the percentage of patients that are able to undergo resectional surgery in the future. What other factors could be influencing these results? During the study period, the standardised referral pathway had already been introduced in Denmark in 2010. It has since been introduced in Sweden, Norway, and the UK, but none of these three countries had this process running nationally in 2010. There is scarce scientific evidence that a standardised referral pathway improves survival. Another preoperative difference between the countries studied was colorectal cancer screening. Screening for colorectal cancer was introduced in the UK in 2006, but none of the other countries had nationwide screening during the study period 2010–12. To some extent, socioeconomic differences might explain between-country variations2Maringe C Walters S Rachet B et al.Stage at diagnosis and colorectal cancer survival in six high-income countries: a population-based study of patients diagnosed during 2000–2007.Acta Oncol. 2013; 52: 919-932Crossref PubMed Scopus (157) Google Scholar because there is often a lower participation in screening programmes in more deprived areas. Perhaps the effect of screening was seen in rectal cancer, where diagnoses of stage I to III disease were more common in England than in the other countries, but, unfortunately, this effect was not reflected in improved survival. Benitez Majano and colleagues' study shows that the previously reported2Maringe C Walters S Rachet B et al.Stage at diagnosis and colorectal cancer survival in six high-income countries: a population-based study of patients diagnosed during 2000–2007.Acta Oncol. 2013; 52: 919-932Crossref PubMed Scopus (157) Google Scholar poorer treatment results for Denmark than those for Norway and Sweden have improved, particularly for rectal cancer. This improvement is very promising, but the reasons are less easy to identify. Perhaps this change is due to the increased use of surgical resections for rectal cancer, but the authors also suggest that improved results could be partly attributed to laparoscopic surgery, which has been shown to be safe in the long term and confers short-term advantages in the management of colorectal cancer.3Buunen M Veldkamp R Hop WC et al.Survival after laparoscopic surgery versus open surgery for colon cancer: long-term outcome of a randomised clinical trial.Lancet Oncol. 2009; 10: 44-52Summary Full Text Full Text PDF PubMed Scopus (1073) Google Scholar, 4Green BL Marshall HC Collinson F et al.Long-term follow-up of the Medical Research Council CLASICC trial of conventional versus laparoscopically assisted resection in colorectal cancer.Br J Surg. 2013; 100: 75-82Crossref PubMed Scopus (474) Google Scholar, 5Bonjer HJ Deijen CL Abis GA et al.A randomized trial of laparoscopic versus open surgery for rectal cancer.N Engl J Med. 2015; 372: 1324-1332Crossref PubMed Scopus (842) Google Scholar During the study period, laparoscopic surgery for rectal cancer was very differently implemented in the four countries, with Denmark having 75% of patients operated with laparoscopic technique compared with about 20% of patients in Sweden, according to national quality registry data. England also had a high percentage of patients operated laparoscopically, but had the lowest patient survival of the four countries. Two trials6Stevenson AR Solomon MJ Lumley JW et al.Effect of laparoscopic-assisted resection vs open resection on pathological outcomes in rectal cancer: the ALaCaRT randomized clinical trial.JAMA. 2015; 314: 1356-1363Crossref PubMed Scopus (685) Google Scholar, 7Fleshman J Branda M Sargent DJ et al.Effect of laparoscopic-assisted resection vs open resection of stage ii or iii rectal cancer on pathologic outcomes: the acosog z6051 randomized clinical trial.JAMA. 2015; 314: 1346-1355Crossref PubMed Scopus (739) Google Scholar published in 2015, studying oncological surrogate variables in rectal cancer, have even suggested that open surgery might be superior to laparoscopy. Taken all together, it is unlikely that laparoscopic surgery is the main reason for the improved survival in patients with rectal cancer in Denmark shown in this study. Another surgical difference that was less emphasised in guidelines in England than in recommendations from the other countries in this study was complete mesocolic excision. However, the superiority of this technique compared with others remains to be shown, and complete mesocolic excision has not been swiftly introduced in all countries. In Stockholm, where the technique has been introduced in a structured manner, only about 20% of patients undergoing surgery for colon cancer between 2004 and 2012 had complete mesocolic excision.8Bernhoff R Sjovall A Buchli C Granath F Hol T Martling A Complete mesocolic excision (CME) in right sided colon cancer does not increase severe short term postoperative adverse events.Colorectal Dis. 2018; 20: 383-389Crossref PubMed Scopus (19) Google Scholar Similar data have been published from Denmark.9Bertelsen CA Neuenschwander AU Jansen JE et al.Disease-free survival after complete mesocolic excision compared with conventional colon cancer surgery: a retrospective, population-based study.Lancet Oncol. 2015; 16: 161-168Summary Full Text Full Text PDF PubMed Scopus (317) Google Scholar Nonetheless, it is interesting that recommendations for England are less specific than other countries' guidelines; does this in fact result in poorer survival because of unspecified surgical treatment? Future research must focus on including data on patient frailty and comorbidity, which should be added to registry data, as Majano and colleagues have suggested. The facilitation of easier interpretation and comparison of data from several national registries must also be a concern for policy makers, because benchmarking of results and making comparisons between countries might help to identify important new areas to improve survival in patients with colorectal cancer. I declare no competing interests. Surgical treatment and survival from colorectal cancer in Denmark, England, Norway, and Sweden: a population-based studySurvival from colon cancer and rectal cancer in England and colon cancer in Denmark was lower than in Norway and Sweden. Survival paralleled the relative provision of resectional surgery in these countries. Differences in patient selection for surgery, especially in patients older than 75 years or individuals with advanced disease, might partly explain these differences in international colorectal cancer survival. Full-Text PDF Open Access