Fracture and embolization of an implantable venous access device in patient with atrial septal defect.

Totally implantable venous access devices (TIVADs) are frequently used for the administration of chemotherapy or parenteral nutrition and have proved to be safe and improve patient quality of life during treatment. Catheter-related infections are the most common complication, whereas catheter fracture and embolization is rarely seen. We present a case of a 61-year-old cancer patient in which the TIVAD fractured and embolized to the patient's left knee 18 months after its initial placement. An endovascular procedure with intraoperative imaging revealed that the catheter had embolized to the popliteal artery and was successfully removed, the only explanation being the presence of an atrial septal defect. A bubble echocardiogram was unsuccessful in confirming the diagnosis. The catheter fracture could be related to an intravascular procedure that was performed 18 months prior to remove fibrin sheaths as a cause of port malfunction, or it could be a case of pinch-off syndrome.

Potentially curative radiotherapy for non-small-cell lung cancer in Norway: a population-based study of survival.

PURPOSE: The efficacy of curative irradiation in the treatment of non-small-cell lung cancer patients is considered limited. The purpose of this study was to evaluate long-term survival in a population-based approach. METHODS AND MATERIALS: Cases of non-small-cell lung cancer diagnosed from 1993 to 2001 were identified in the Cancer Registry of Norway. Electronic linkage with national data from the hospitals' radiotherapy verification systems identified those who received potentially curative doses (≥ 50 Gy). Hospital records were reviewed for all patients. RESULTS: A total of 497 patients (336 men) were identified with a radiation dose of ≥ 50 Gy delivered to the lung region. Of these, 41% received 60 Gy or more. The majority (70%) of patients included had advanced stage disease: 24% Stage IIIA and 46% Stage IIIB. The overall 1-, 3-, and 5-year observed survival rates were 53%, 16%, and 9%, respectively. Multivariable analyses identified stage and chemotherapy, but not radiation dose, as significant independent prognostic variables for survival. However, 68% of patients treated with chemotherapy participated in prospective studies with inclusion criteria that excluded patients with less favorable prognostic factors, leading to a selection bias. The number of fractions and the radiation doses varied widely among different hospitals. CONCLUSION: The long-term prognosis after radiation therapy is poor. More sophisticated, targeted, and uniform delivery of radiation therapy is needed. The apparent benefit of chemotherapy may in part be due to selection of patients with more favorable prognostic factors for this therapy.

[The function of hallway patients in Norwegian hospitals]. / Korridorpasientenes funksjon i norsk sykehusvesen.

BACKGROUND: Accommodation of patients in hospital hallways has been practiced in Norway for a long time. Provision of adequate patient care in a hospital corridor is challenging; both patients and staff suffer from this practice. Numerous analyses and interventions have been initiated, but have not improved the situation. MATERIAL AND METHODS: The magnitude and distribution of the hallway patient phenomenon was analyzed with data from official Norwegian statistics, and a simple model for calculating hospital financial gains of having hallway patients was developed. RESULTS: Norwegian hospitals had an average of 256 hallway patients per night (five patients per hospital [2%], ranging from zero to 52 [0-10% of active beds]) from 1.5. 2006 to 31.8. 2006, according to data from the Norwegian Patient Registry. The model showed that to render the arrangement of having two or more patients accommodated in hallways unprofitable, hospitals would have to pay more than NOK 10,000 per night/hallway accommodated patient. A negative diagnosis related group (within the system of activity based financing of Norwegian hospitals) has been proposed for hallway accommodation of patients. INTERPRETATION: Hallway accommodation of patients is very profitable for hospital owners within the current financing system, and it is unlikely that this practice will be eliminated without strong financial stimuli.

Structured electronic template for histopathology reports on colorectal carcinomas: a joint project by the Cancer Registry of Norway and the Norwegian Society for Pathology.

Both individual patient treatment and cancer registries depend on adequate histopathology reports. To ensure the quality of these reports, professional organizations have published guidelines on minimum data sets for various cancer types. Norway has a population of 4.6 million, and all individuals have a unique identification number. As required by law, relevant information on cancer is submitted to the Cancer Registry of Norway. A closed, national health data network has been established facilitating electronic transferal between various institutions. The Cancer Registry and the Norwegian Society for Pathology have jointly established a nationwide project to (i) develop standardized templates in database format for histopathology reports on cancer resection specimens and (ii) develop an Extensible Markup Language (XML) standard to facilitate future electronic transfer of cancer reports from hospitals to the Cancer Registry. A minimum data set template for reporting colorectal carcinoma resection specimens and the Extensible Markup Language standard have been established. The template is based on international guidelines and classification systems. For most key parameters, pull-down menus with predefined alternatives have been constructed. The template is fully integrated into software being used by all pathology laboratories in Norway. Since the introduction of the template in April 2005, the template had been used for reporting 430 (93%) of 462 colorectal resections at 2 pilot laboratories (Akershus University Hospital [Lørenskog, Norway] and Stavanger, University Hospital [Stavanger, Norway]), demonstrating that high and consistent quality can be ascertained. Pathologists have found the template both time saving and user friendly. The template is now gradually implemented nationwide.

Resected synchronous primary malignant lung tumors: a population-based study.

BACKGROUND: Synchronous lung tumors with a histology indicating primary lung carcinomas detected preoperatively or at surgery may represent intrapulmonary metastases from a primary tumor or two or more simultaneously occurring primary tumors. The situation is rare. This study was conducted to assess the characteristics and outcome for this patient group. METHODS: All clinical and pathology departments in Norway submit standardized reports on cancer patients to the Cancer Registry of Norway. The registry also has a law-regulated authority to collect supplemental information on diagnosis, treatment, and outcome for all cancer patients from hospitals. During the period 1993 to 2000, lung cancer was diagnosed in 15,308 patients, of whom 2528 underwent resection in 24 hospitals. This investigation included all patients with histology demonstrating primary lung carcinoma in more than one tumor in the resected specimen. RESULTS: Synchronous malignant tumors were found in 94 patients: 66 had two tumors and the remaining 28 had three or more. The tumors were of similar histology in 85 cases. The tumors were diagnosed preoperatively in 11 patients and peroperatively or in the resected specimen in the other 83. The 5-year relative survival rate was 31.4% for patients with squamous cell carcinomas, 23.2% for adenocarcinomas, and 42.7% for patients with tumors of other histology (two carcinoids). CONCLUSIONS: Survival in patients with synchronous lung tumors is good compared with historical reports on patients with distant metastases or other variants of T4 tumors; thus, they should be considered for surgery.

Risk factors for 30-day mortality after resection of lung cancer and prediction of their magnitude.

BACKGROUND: There is considerable variability in reported postoperative mortality and risk factors for mortality after surgery for lung cancer. Population-based data provide unbiased estimates and may aid in treatment selection. METHODS: All patients diagnosed with lung cancer in Norway from 1993 to the end of 2005 were reported to the Cancer Registry of Norway (n = 26 665). A total of 4395 patients underwent surgical resection and were included in the analysis. Data on demographics, tumour characteristics and treatment were registered. A subset of 1844 patients was scored according to the Charlson co-morbidity index. Potential factors influencing 30-day mortality were analysed by logistic regression. RESULTS: The overall postoperative mortality rate was 4.4% within 30 days with a declining trend in the period. Male sex (OR 1.76), older age (OR 3.38 for age band 70-79 years), right-sided tumours (OR 1.73) and extensive procedures (OR 4.54 for pneumonectomy) were identified as risk factors for postoperative mortality in multivariate analysis. Postoperative mortality at high-volume hospitals (> or = 20 procedures/year) was lower (OR 0.76, p = 0.076). Adjusted ORs for postoperative mortality at individual hospitals ranged from 0.32 to 2.28. The Charlson co-morbidity index was identified as an independent risk factor for postoperative mortality (p = 0.017). A prediction model for postoperative mortality is presented. CONCLUSIONS: Even though improvements in postoperative mortality have been observed in recent years, these findings indicate a further potential to optimise the surgical treatment of lung cancer. Hospital treatment results varied but a significant volume effect was not observed. Prognostic models may identify patients requiring intensive postoperative care.

[Waiting time for surgery of lung cancer]. / Ventetid på operasjon for lungekreft.

BACKGROUND: Surgical resection is the mainstay of curative treatment for lung cancer. It is important that the resection is done as soon as the disease is diagnosed. The waiting time in Norway can be longer than desirable. MATERIAL AND METHODS: Patients who underwent resection for primary lung cancer in the period 1998-2001 were identified in the Cancer Registry of Norway. When malignancy was confirmed preoperatively by histopathology or cytology, the time interval from diagnostic procedure to the pathologist's answer was calculated as response time and further the time from diagnosis to surgery was calculated as waiting time. Covariates important for waiting time were analysed by univariable and multivariable regression analyses. RESULTS: Of the 1351 patients that were operated in the period, 924 had a positive cytological or histological preoperative diagnosis. Pathology response time was median 3 days and waiting time for surgery was median 26 days (range 0-406 days). Multivariable regression analysis demonstrated that disease stage, histology and patient referral between hospitals contributed to waiting time from diagnosis to operation. Patients undergoing investigation and surgery at the same hospital had a median 9 days shorter waiting time than those referred from other hospitals. INTERPRETATION: Our investigation revealed a longer waiting time than desired. A high proportion of patients did not have a positive preoperative biopsy or cytology.

Multiple primary malignancies in patients with renal cell carcinoma: a national population-based cohort study.

OBJECTIVE: To determine the possibly greater occurrence of multiple malignancies in patients with renal cell carcinoma (RCC). PATIENTS AND METHODS: In the 7-year period 1987-93, all 1425 patients aged 15-70 years with registered histopathologically verified RCC in Norway were included in the study. All clinical and histopathology reports were checked manually, to verify the registered diagnosis and to ensure that no tumour was a metastasis from another. After this process, 257 patients (287 tumours other than RCC) with multiple primary malignancies were identified. The primary tumours other than RCC were classified as antecedent, synchronous and subsequent. For the subsequently occurring tumours, the expected number of different tumour types was calculated according to age group, gender and observation time. RESULTS: Of the 1425 patients, 228 (16%) had one, 23 (1.6%) had two, three (0.2%) had three and one (0.07%) had four other primary malignancies. In all, 100 (34.8%) of the other tumours were diagnosed as antecedent, 53 (18.7%) as synchronous and 134 (46.7%) as subsequent to the RCC. Cancer in the prostate, bladder, lung, breast, colon and rectal cancer, malignant melanomas (MM) and non-Hodgkin's lymphomas (NHL) were the most common other malignancies. The observed overall number of subsequent other malignant tumours was 22% higher than the expected number. The observed number of subsequent tumours was significantly higher for bladder cancer, NHL and MM. The estimated 15-year cumulative risk for patients with RCC and no previous or synchronous other malignancy for developing a later second cancer was 26.6% in men, and 15.5% in women (statistically significant, P = 0.04). Patients with antecedent or synchronous other cancer had significantly poorer overall survival than those without. CONCLUSIONS: Patients with RCC seem to have a significantly higher risk of developing other subsequent primary malignancies. This should be considered during the follow-up of patients with RCC.

Lung cancer surgery: the first 60 days. A population-based study.

OBJECTIVE: The postoperative mortality following lung cancer surgery is relatively high. The purpose of the present study was to identify preoperative risk factors as well as fatal complications in 27 Norwegian hospitals. METHODS: In Norway, all clinical and pathologic departments submit reports on cancer patients to the Cancer Registry of Norway. The Registry also has a law-regulated authority to collect supplemental information regarding diagnosis, treatment, and outcome for all cancer patients from the hospitals in charge. This investigation included all patients who died within 30 and 60 days after resection of lung cancer in the period 1993-2002. RESULTS: During the investigation lung cancer was diagnosed in 19,582 patients, 3224 (16.5%) were treated by surgery. The resection rate was almost similar in the two sexes, but postoperative mortality in women was less than half compared to men. Total mortality was 5% and 8% after 30 and 60 days, respectively. Bilobectomy and pneumonectomy were most risky with a mortality rate of about 10% within 60 days. In patients more than 70 years of age, there was a considerably higher frequency of pneumonectomy in men compared to women. Dominating causes of death were pneumonia with respiratory failure and cardiac events. Other identifiable causes were surgical hemorrhage and bronchopleural fistula. CONCLUSIONS: In this population-based, unselected series, the postoperative mortality was relatively high, and increased markedly in patients older than 70 years. Pneumonectomy in patients older than 70 years should only be performed when heart-lung function is found to be acceptable following full pulmonary function testing and thorough preoperative assessment of cardiovascular risk factors.

[Curative treatment of prostatic cancer in Norway in 1998 and 2001]. / Kurativ behandling av prostatakreft i Norge i 1998 og 2001.

BACKGROUND: The two major therapeutic options for early diagnosed prostate cancer are radical prostatectomy or radiation therapy. The National Program for Prostate Cancer in Norway conducted this study in order to document the use of treatment with curative intention in five geographical regions in Norway. MATERIAL AND METHODS: The study is based on data from the Cancer Registry of Norway on patients diagnosed with prostate cancer in 1998 and 2001. The departments of oncology have provided relevant information about radiation therapy. Treatment with curative intention is defined as radical prostatectomy or radiation therapy with > or = 64 Gy. RESULTS: About one third of all patients under the age of 75 years with recently diagnosed prostate cancer were treated with curative intention in 1998 and 2001 (1998: 28%, 2001: 33%); the total number increased from 440 in 1998 to 556 in 2001. There were marked variations between the geographical regions in the use of treatment with curative intention and in the use of radical prostatectomy versus radiation therapy. INTERPRETATION: The fact that no more than one third of the patients were treated with curative intention is probably due to uncertainty about the therapeutic benefit in relation to side effects. The regional variations probably reflect different opinions on the true effect of early diagnosis and treatment.

Estimated prevalence of hereditary cancers and the need for surveillance in a Norwegian county, Telemark.

OBJECTIVE: The aim of the study was to estimate the prevalence of hereditary cancers and the need for surveillance in Telemark county, Norway. MATERIAL AND METHODS: All persons attending the Norwegian Colorectal Cancer Prevention (NORCCAP) trial in Telemark were interviewed about cases of cancer in the family. Diagnoses were verified, pedigrees constructed and families classified according to preset criteria aiming at identifying hereditary cancer. Mutation analyses were performed in kindreds at risk for breast cancers when possible. Immunohistochemistry of tumors in assumed inherited colorectal cancer families was undertaken. RESULTS: The screening examination was attended by 7,224 persons among whom 2,866 had cancer in the family. Of these, 2,479 had no suspicion of any known inherited cancer syndrome. Family information questionnaires were mailed to 387 persons and returned by 191. Sixty-four of these 191 met the clinical criteria for familial cancer by family history after verification of diagnoses. Observed prevalences for being at risk for hereditary breast and breast-ovarian cancer (HBOC) or hereditary non-polyposis colorectal cancer (HNPCC) were 2.8 per thousand and 0.77 per thousand, respectively. CONCLUSIONS: The number of colonoscopies and mammograms obtained per year serving those who needed them was limited and reduced by clinical genetic work-up from 2,866 with a family history of cancer to 64 proven cases. Continued surveillance of an unnecessarily high number leads to unjustified cancer worry, is costly and uses up health-care facilities. Genetic work-up is a one-time job that reduces input numbers to surveillance programs, provides a starting-point for mutation testing and is economically cost beneficial if inherited cancers are prevented or cured by the health-care programs offered.

Is there an association between SV40 contaminated polio vaccine and lymphoproliferative disorders? An age-period-cohort analysis on Norwegian data from 1953 to 1997.

Between 1955 and 1963, an estimated number of 150 million people in various parts of the world, including Norway, received poliomyelitis vaccine possibly contaminated with infectious simian virus 40 (SV40). Human studies have investigated the hypothesised association between SV40 and various cancers, but the results have so far been contradicting. The aim of the present study was to examine Norwegian cancer incidence data to assess a possible association between birth cohorts assumed to have been subjected to the vaccine and the incidence rate of lymphoproliferative disorders (excluding Hodgkin's lymphoma), further subdivided into non-Hodgkin's lymphoma (NHL), lymphocytic leukemia and plasma cell neoplasms. Between 1953 and 1997, the incidence rate of lymphoproliferative diseases combined increased about 3-fold in both males and females. Subgroup analysis showed that this increase was largely attributable to NHL. Age-period-cohort modelling of the subgroups, as well as of all groups combined, showed that the cohort effect was more prominent than the period effect. However, the variations in incidence patterns across the birth cohorts did not fit with the trends that would be expected if a SV40 contaminated vaccine did play a causative role. Thus, our data do not support the hypothesis of an association between the vaccine and any subgroup of lymphoproliferative diseases.

[Teenage smoking and lung cancer incidence in early adult age, 1954-1998]. / Tenåringsrøyking og lungekreft i tidlig voksen alder, 1954-98.

OBJECTIVE: To describe national trends in Norway in lung cancer incidence among young adults and its relationship to adolescent smoking. MATERIAL AND METHODS: Between 1954 and 1998, a total of 1108 non-carcinoid lung cancers in individuals aged 20-44 were reported to the Cancer Registry of Norway. Temporal variations were studied in age and sex-specific rates, in age-adjusted rates, and in cohort specific rates. The association between cancer incidence and smoking prevalence was evaluated. RESULTS: The incidence among women aged 40-44 in Norway continued to increase into the most recent time interval (1994-1998) whereas the rate among men aged 40-44 was essentially constant after 1970. Consequently, the incidence rates converged among male and female young adults. The incidence at age 40-44 was highly correlated with smoking prevalence at age 15-19 in males (r = 0.88) and females (r = 0.82) within the same birth cohort. INTERPRETATION: The lung cancer incidence in young Norwegian women now equals that of men. The risk at age 40-44 was closely associated with teenage smoking, indicating that duration and age of onset are important.

[Breast-conserving surgery and sentinel node procedure in Norway, 1993-2001]. / Brystbevarende kirurgi og vaktpostlymfeknuteprosedyre ved brystkreft i Norge 1993-2001.

BACKGROUND: The aim of the present study is to describe the development in the use of breast-conserving surgery and sentinel node procedures in Norway from 1993 to 2001, with special emphasis on geographical variations and possible relationships with the mammography screening programme. MATERIAL AND METHODS: The Cancer Registry of Norway registers diagnosis and treatment of all cases of cancer in Norway. All women diagnosed with breast cancer in the period 1993-2001 who received surgical treatment were included in the study except those with distant metastases at diagnosis. RESULTS: During the period, there were 18,564 surgically treated female breast cancer patients without evidence of distant metastases. Breast-conserving surgery was applied in 4203 (22%) out of 19,408 cases. The proportion increased from 14% in 1993 to 36% in 2001. In most counties with mammography screening, the proportion of breast-conserving surgery in women aged 50-69 rose to 40% or more in 2001. Utilisation of sentinel node biopsy in breast-conserving surgery increased from 2% in 1998 to 55% in 2001. INTERPRETATION: Over the 1993-2001 period, there was a strong increase in the extent of utilisation of breast-conserving surgery and sentinel node biopsy in breast cancer in Norway.

Results of pulmonary resection for lung cancer in Norway, patients older than 70 years.

OBJECTIVE: Surgical resection for lung cancer is the mainstay of curative treatment, but studies regarding postoperative results and long term outcome in the elderly have differed. The purpose of the present study was to assess the early and long-term results of surgical resection in patients more than 70 years of age. METHODS: In Norway all clinical and pathologic departments submit reports on cancer patients to the Cancer Registry of Norway. This investigation included all patients more than 70 years of age resected for lung cancer in the time period 1993-2000. For results of long-time follow-up only patients operated on between 1993 and 1998 were included. RESULTS: A total of 763 patients (541 men) were identified aged 71-87 years. Postoperative mortality rate was 9%, highest after bilobectomy and pneumonectomy. The most commonly reported causes of postoperative death were pneumonia and cardiac complications. The majority of patients had tumor categorized as clinical stage (cStage) Ia and Ib. More than 100 in each of these groups proved to have more advanced disease postoperatively (pStage). The 5-year relative survival rate was significantly better in patients with disease in pStage I compared to higher stages. Women had a significantly better 5-year survival rate compared to men, 62.8 and 35.7%, respectively. CONCLUSIONS: Lung cancer surgery appears to be a relatively safe procedure even in the elderly. There is a high postoperative mortality after bilobectomy and pneumonectomy. However, when old people survive the postoperative period the long term prognosis seems favorable.

Small cell lung cancer in Norway. Should more patients have been offered surgical therapy?

OBJECTIVE: The final outcome of patients with small cell lung cancer (SCLC) is poor with an overall 5-year survival rate of less than 10%. Therefore, the question of surgery in patients with a technically-operable solitary tumor has been raised. The purpose of this study was to identify the proportion of patients with operable SCLC and to assess the prognosis of different treatment strategies. For patients who were operated, we compared the resection specimens from patients with more than 5-year survival with those with shorter survival to see whether the specimens belonged to different subclasses of SCLC. METHODS: In Norway all clinical and pathologic departments submit reports on cancer patients to the Cancer Registry. The Registry also has a law-regulated authority to collect supplemental information regarding diagnosis, treatment and outcome for all cancer patients from the hospitals in charge. All reports on patients diagnosed as having SCLC in limited disease or unknown stage during the time interval 1993-1999 were reviewed. Patients with a T2-tumor, in whom a pneumonectomy would have to be performed, were classified as potentially operable. Five-year relative survival was calculated for patients diagnosed in 1993-1997. RESULTS: During the actual period 2442 individuals with SCLC were identified. The majority was treated with conventional chemotherapy or concurrent chemoradiotherapy while 38 underwent surgical therapy. Following reclassification of 697 patients reported to have limited disease or unknown stage 180 were judged to be in stage I. In addition to the 38 resected patients 14 were considered fit for surgery technically and medically while 97 were found to be potentially operable treatment modalities apart from surgery yielded a 5-year survival rate <7%. For stage I (N=96) the rate was 11.3% in conventionally treated patients compared to 44.9% for those who underwent surgical resection. By pathological review of surgical specimens a diagnosis of SCLC was confirmed in all patients treated by surgery in the groups with long and short survival. CONCLUSION: This investigation demonstrates that patients with SCLC having a peripherally located tumor should be referred to surgery, as long time survival is far better than for conventionally treated patients.

Adolescent smoking and trends in lung cancer incidence among young adults in Norway 1954-1998.

OBJECTIVE: To describe the national trends in lung cancer incidence among young adults and the relationship to adolescent smoking. METHODS: Between 1954 and 1998, a total of 1108 non-carcinoid lung cancers were reported to the Cancer Registry of Norway in individuals aged 20-44 years. Temporal variations were studied in age and sex specific rates, in age-adjusted rates, and by means of age-period-cohort modelling. The association between cancer incidence and smoking prevalence was evaluated. RESULTS: The lung cancer incidence rate among women aged 40-44 in Norway continued to increase into the most recent time interval (1994-1998) whereas the rate among men aged 40-44 was essentially constant after 1970. Consequently, lung cancer incidence rates converged among male and female young adults. Lung cancer incidence rates at age 40-44 were highly correlated with smoking prevalence at age 15-19 in males ( r = 0.88) and females ( r = 0.82) within the same birth cohort. CONCLUSIONS: The lung cancer incidence rate in young Norwegian women now equals that of men. The risk at age 40-44 was closely associated with teenage smoking, indicating that duration and age of onset are important.

[Causes of postoperative mortality after lung cancer surgery]. / Arsaker til mortalitet etter reseksjon for lungekreft.

BACKGROUND: There is a relatively high postoperative mortality after lung cancer surgery. However, the alternative is almost 100% mortality within five years if surgery is not performed. MATERIAL AND METHODS: This study is based on data in the Cancer Registry of Norway and information from hospitals where the patients had been treated. From 1993 to 2000, 2528 patients with lung cancer were operated with lung resection. RESULTS: A total of 188 patients died within 60 days. In 54 of them the cause of death was respiratory failure or pneumonia. There were nine cases with serious intraoperative bleeding with seven deaths, six on the table. Further postoperative bleeding occurred in 27 cases, most often after pneumonectomy. Of these, 10 died because of the bleeding. For 15 patients the cause of death was bronchopleural fistula, of which 13 had been operated with pneumonectomy. Myocardial infarction or cardiac failure caused the death of 32 patients. An additional 70 patients died from other complications. INTERPRETATION: Postoperative fatal complications after lung resection for cancer are too high.

[Is the treatment of lung cancer in Norway adequate?]. / Er behandlingen av lungekreft i Norge god nok?

BACKGROUND: Almost 2,000 new cases of lung cancer are reported in Norway every year. Only 16-17% are operated upon with resection. MATERIAL AND METHODS: Over the 1995-98 period, 1,035 not resected cases with localized lung cancer were reported to the Cancer Registry of Norway; 166 cases were excluded for various reasons. Records from the Cancer Registry with additional information from clinicians were revised by the authors with regard to staging and operability. RESULTS: Of 869 evaluable patients, 386 were inoperable due to advanced disease, and in 86 the situation was not adequately clarified. Of the remaining 397, 270 were classified as being operable and 127 possibly operable. Of the operable patients, small cell lung cancer was considered as the sole contraindication to surgery in 61 patients despite being in stage 1. Poor lung function was noted as contraindication to surgery in 50 patients. However, most of them were inadequately investigated. In 124 patients one or more other risk factors were considered as contraindications, but the impact of some of them seemed to have been overestimated. INTERPRETATION: The study showed that the information about stage routinely submitted to the Cancer Registry was unsatisfactory. We believe that more patients with localized disease in the present series should have been operated on.

A national strategic change in treatment policy for rectal cancer--implementation of total mesorectal excision as routine treatment in Norway. A national audit.

INTRODUCTION: Rectal cancer surgery has been characterized by a high incidence of local recurrence, an occurrence which influences survival negatively. In Norway there was a growing recognition that local recurrence rates were related to surgeon performance and that surgeons applying a standardized surgical technique in the form of total mesorectal excision could achieve better results. This contrasts with the prevailing argument voiced by many opinion leaders that local recurrence rates and possibly survival rates can only be improved by adjuvant or neoadjuvant treatment strategies. The Norwegian Rectal Cancer Project-initiated in 1993-aimed at improving the outcome of patients with rectal cancer by implementing total mesorectal excision as the standard rectal resection technique. METHODS: This observational national cohort study covers all new patients (3,319) with rectal cancer from a population of 4.5 million treated between November 1993 and August 1997. The main outcome measures were local recurrence, survival, and postoperative mortality and morbidity rates. The technique of total mesorectal excision was compared with conventional surgery. RESULTS: The proportion of patients undergoing total mesorectal excision was 78 percent in 1994, increasing to 92 percent in 1997. The observed local recurrence rate for patients undergoing a curative resection was 6 percent in the group treated by total mesorectal excision and 12 percent in the conventional surgery group. Four-year survival rate was 73 percent after total mesorectal excision and 60 percent after conventional surgery. Postoperative mortality rate was 3 percent and the anastomotic dehiscence rate was 10 percent. Radiotherapy was given to 5 percent and chemotherapy to 3 percent of the patients in the curative resection group. CONCLUSION: A refinement of the surgical resection technique for rectal cancer can be achieved on a national level, the technique of total mesorectal excision can be widely distributed, and surgery alone can give good results.