Gut 1999;44:377–381 377 Evidence of improving survival of patients with rectal cancer in France: a population based study Gut: first published as 10.1136/gut.44.3.377 on 1 March 1999. Downloaded from C Finn-Faivre, J Maurel, A M Benhamiche, C Herbert, E Mitry, G Launoy, J Faivre Abstract ment in perioperative care. These improve- Background—Over the past 20 years there ments have been initiated in specialised centres have been many changes in the manage- and their impact on the overall population is ment of rectal cancer. Their impact on the not well known. Most available data about the overall population is not well known. prognosis of rectal cancer have been published Aims—To determine trends in manage- by these specialised centres; however, there is ment and prognosis of rectal cancer in two an unavoidable bias in their figures. Population French regions. based studies recording all cases diagnosed in a Subjects—1978 patients with a rectal car- well defined population represent the only way cinoma diagnosed between 1978 and 1993. to assess real improvements in the manage- Methods—Time trends in treatment, ment of this cancer. Such studies are rare stage at diagnosis, operative mortality, because they require accurate and detailed data and survival were studied on a four year collection which is only done thoroughly by basis. A non-conditional logistic cancer registries. The objective of our study regression was performed to obtain an was to determine changes in time trends in odds ratio for each period adjusted for the therapeutic approaches, stage at diagnosis, and other variables. To estimate the independ- prognosis in two French regions over the ent eVect of the period a multivariate period 1978–1993. relative survival analysis was performed. Results—Over the 16 year period resec- Population and methods tion rates increased from 66.0% to 80.1%; POPULATION the increase was particularly noticeable Two French population based registries of for sphincter saving procedures (+30.6% digestive tract cancers were included in the per four years, p=0.03). The percentage of study (fig 1): Calvados (Normandy) and Côte- patients receiving adjuvant radiotherapy d’Or (Burgundy). Cancer registration began in increased from 24.0% to 40.0% (p=0.02). Côte-d’Or in 1976 (493 931 inhabitants ac- The proportion of patients with Dukes’ cording to the 1990 census) and in Calvados in http://gut.bmj.com/ type A cancer increased from 17.7% to 1978 (620 000 inhabitants according to the 30.6% with a corresponding decrease in 1990 census). Information is regularly ob- those with more advanced disease. Opera- tained from pathologists, hospital and private tive mortality decreased by 31.1% per four physicians (gastroenterologists, surgeons, on- years (p=0.03). All these improvements cologists, general practitioners, radiothera- have resulted in a dramatic increase in pists), as well as from public administration relative survival (from 35.4% for the 1978– (death certificates). No cases were registered on October 1, 2021 by guest. Protected copyright. Registre Bourguignon 1981 period to 57.0% for the 1985–1989 des Cancers Digestifs through death certificates alone but these were (INSERM CRI 95 05), period). used to identify missing cases. Because of the Faculté de Medecine, Conclusions—Substantial advances in the involvement of the entire medical profession Dijon, France management of rectal cancer have been we assumed that nearly all newly diagnosed C Finn-Faivre achieved, but there is evidence that fur- cases were recorded. The quality and exhaus- A M Benhamiche ther improvements can be made in order tivity of these two registries is certified every E Mitry J Faivre to increase survival. four years by an audit of the National Institute (Gut 1999;44:377–381) for Health and Medical Research (INSERM). Registre des Tumeurs These two cancer registries include accurate Digestives du Calvados Keywords: rectal cancer; treatment; stage at diagnosis; data related to the clinical features, diagnostic survival; time trends; cancer registries (INSERM CJF 96 06), strategies, treatment, stage at diagnosis, and CHU Côte de follow up of the patients. The study period Nacre—Faculté de Médecine, Caen, Rectal cancer represents a major health prob- extended from 1978 to 1993. A total of 2984 France lem with an estimated 10 000 new cases each incident cases of rectal cancers has been J Maurel year in France.1 Its prognosis remains poor in recorded (ICD-9 154). Cancers of the recto- C Herbert sigmoid junction (ICD-9 154.0; n=1006) as G Launoy Europe with a five year survival rate of 33.0% for the 1978–1985 period.2 Over the past 20 well as cancer of the anal canal (ICD-9 154.3; n=196) were not included because of their Correspondence to: years there have been many changes in the Dr C Finn-Faivre, Registre management of rectal cancer. These include diVerent management. However, a total of Bourguignon des Cancers improved diagnostic procedures, new thera- 1978 patients with a cancer of the rectal Digestifs (INSERM CRI 95 ampulla (ICD-9 154.1), recorded in Côte- 05), Faculté de Medecine, 7 peutic approaches including an increase in the boulevard Jeanne d’Arc, use of surgery in elderly patients,3 the develop- d’Or (n=862) and Calvados (n=1116), was 21033 Dijon Cedex, France. ment of an eVective adjuvant therapy,4–6 the Accepted for publication increase in the proportion of sphincter preser- Abbreviations used in this paper: CI, confidence 1 October 1998 vation procedures,78and the general improve- interval; RR, relative risk; OR, odds ratio. 378 Finn-Faivre, Maurel, Benhamiche, et al survival were studied on a four year basis using, Calvados whenever possible, the logarithm of the pro- portion according to a linear regression. The percentages of variation of those proportions are given together with the 95% confidence Gut: first published as 10.1136/gut.44.3.377 on 1 March 1999. Downloaded from interval (CI). A non-conditional logistic regression was used to obtain odds ratios asso- Cote-d'Or ciated with the probability of tumour resection and with the probability of sphincter saving resection for each period adjusted for the other variables. The computations were performed using the BMDP software package.10 Relative survival rates were computed using the Relsurv 1.0 program for relative survival (Guy Hedelin, Strasburg, France). It is defined as the ratio of the observed survival rate to the expected sur- Figure 1 Location of the two regions involved in the vival rate of an age, sex, geographical area, and study. period matched cohort estimated from popula- considered for this study. We define rectal tion life tables. It provides an estimate of cancer as cancer arising from the rectal patient survival which is corrected for the effect ampulla only—that is, cancers located within of the causes of death independent of rectal 15 cm of the anal verge. cancer itself. Multivariate analysis was per- formed using a relative survival model with STUDIED VARIABLES proportional hazard applied to the net mor- For all patients, the studied variables included tality by interval. This model makes it possible sex, age at diagnosis, place of residence, date at to calculate relative risks in comparison with a diagnosis, stage at diagnosis, and treatment. baseline which is the cumulative net hazard Patients were categorised in two age groups: calculated from a priori defined intervals.11 The under 75 years of age (n=1313) and those 75 last study period (1990–1993) has not been years of age and over at time of diagnosis considered in the survival analysis because the (n=665). Place of residence was coded as uni- five year follow up is not yet available for all versity hospital towns (Caen and Dijon), other patients. urban areas (towns of more than 2000 inhabit- ants), and rural areas. Cancer extension at the Results time of diagnosis was classified for resected TIME TRENDS IN THERAPEUTIC APPROACH cancers, according to Dukes,9 as limited to the The resection rate increased progressively from digestive wall (Dukes’ A; n=436), extension 66.0% during the 1978–1981 period to 76.3% http://gut.bmj.com/ beyond the digestive wall (Dukes’ B; n=417), during the 1982–1985 period, to 77.8% during or lymph node involvement (Dukes’ C; the 1986–1989 period, and finally to 80.1% n=444). Advanced stages (n=639) included: during the 1990–1993 period (corresponding patients with visceral metastasis, operated to a mean four year increase of +6.2% patients without resection of the tumour, and (CI=−2.8, 15.2; p=0.10). The increase in non-operated patients. Those who underwent resection rate was higher in patients aged 75 resection but were not staged were classified as and over (from 44.5% during the 1978–1981 unknown (n=42). Treatment procedures were period to 69.4% during the 1990–1993 period) on October 1, 2021 by guest. Protected copyright. classified as: I, resection of the tumour compared with younger patients (80.3% and (curative or palliative) (n=1488); II, bypass 89.0% respectively). This increase in the surgery and laparotomy (n=122); and III, non- proportion of patients having their cancers surgical palliative treatment (n=254) including resected was associated both with a corre- exclusive medical treatment, chemotherapy, sponding decrease in the proportion of patients and radiotherapy. Surgical resections were treated surgically but without resection divided into continence preserving or non- (−14.9% per four years; CI=−49.6, 18.7; preserving procedures. Radiotherapy treat- p=0.20) and in the proportion of patients not ment was divided into adjuvant treatment operated on (−30.9% per four years; (preoperative or postoperative) or palliative CI=−56.9, −4.9; p=0.03).