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  • 1.
    Birgisson, H
    et al.
    Department of Surgery, Akademiska Sjukhuset, S-75185 Uppsala, Sweden.
    Talbäck, M
    Gunnarsson, Ulf
    Department of Surgery, Akademiska Sjukhuset, S-75185 Uppsala, Sweden.
    Påhlman, L
    Glimelius, B
    Improved survival in cancer of the colon and rectum in Sweden.2005Ingår i: European Journal of Surgical Oncology, ISSN 0748-7983, E-ISSN 1532-2157, Vol. 31, nr 8, s. 845-53Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    AIMS: To analyse time-trends in survival of patients with colon and rectal cancer in Sweden.

    PATIENTS AND METHODS: Data including all patients diagnosed with adenocarcinoma of the colon and rectum between 1960 and 1999, from the Swedish Cancer Registry, were analysed. The observed and relative survival rates were calculated according to the Hakulinen cohort method.

    RESULTS: Five-year relative survival rate for cancer of the colon improved significantly from 39.6% in 1960--1964 to 57.2% in 1995--1999 and for rectal cancer from 36.1 to 57.6%, respectively. Corresponding observed survival improved from 31.2 to 44.3% for colon cancer and from 28.4 to 45.4% for rectal cancer. The largest improvement of survival were seen during the later part of the period observed.

    CONCLUSION: The survival of patients with colon and rectal cancer in Sweden continues to improve, especially in rectal cancer, which now has a 5-year observed and relative survival rate comparable to that for colon cancer. The survival improvement in rectal cancer is probably a result of the implementation of total mesorectal excision and pre-operative radiotherapy.

  • 2. Breugom, A. J.
    et al.
    Bastiaannet, E.
    Boelens, P. G.
    Van Eycken, E.
    Iversen, L. H.
    Martling, A.
    Johansson, Robert
    Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper, Onkologi.
    Evans, T.
    Lawton, S.
    O'Brien, K. M.
    Ortiz, H.
    Janciauskiene, R.
    Dekkers, O. M.
    Rutten, H. J. T.
    Liefers, G. J.
    Lemmens, V. E. P. P.
    van de Velde, C. J. H.
    Oncologic treatment strategies and relative survival of patients with stage I-III rectal cancer - A EURECCA international comparison between the Netherlands, Belgium, Denmark, Sweden, England, Ireland, Spain, and Lithuania2018Ingår i: European Journal of Surgical Oncology, ISSN 0748-7983, E-ISSN 1532-2157, Vol. 44, nr 9, s. 1338-1343Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Introduction: The aim of this EURECCA international comparison is to compare oncologic treatment strategies and relative survival of patients with stage I-III rectal cancer between European countries.

    Material and methods: Population-based national cohort data from the Netherlands (NL), Belgium (BE), Denmark (DK), Sweden (SE), England (ENG), Ireland (IE), Spain (ES), and single-centre data from Lithuania (LT) were obtained. All operated patients with (y)pTNM stage I-III rectal cancer diagnosed between 2004 and 2009 were included. Oncologic treatment strategies and relative survival were calculated and compared between neighbouring countries.

    Results: We included 57,120 patients. Treatment strategies differed between NL and BE (p < 0.001), DK and SE (p < 0.001), and ENG and IE (p < 0.001). More preoperative radiotherapy as single treatment before surgery was administered in NL compared with BE (59.7% vs. 13.1%), in SE compared with DK (55.1% vs. 10.4%), and in ENG compared with IE (15.2% vs. 9.6%). Less postoperative chemotherapy was given in NL (9.6% vs. 39.1%), in SE (7.9% vs. 14.1%), and in IE (12.6% vs. 18.5%) compared with their neighbouring country. In ES, 55.1% of patients received preoperative chemoradiation and 62.3% post-operative chemotherapy. There were no significant differences in relative survival between neighbouring countries.

    Conclusion: Large differences in oncologic treatment strategies for patients with (y)pTNM I-III rectal cancer were observed across European countries. No clear relation between oncologic treatment strategies and relative survival was observed. Further research into selection criteria for specific treatments could eventually lead to individualised and optimal treatment for patients with non-metastasised rectal cancer. 

  • 3. Claassen, Y. H. M.
    et al.
    Bastiaannet, E.
    van Eycken, E.
    Van Damme, N.
    Martling, A.
    Johansson, R.
    Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper, Onkologi.
    Iversen, L. H.
    Ingeholm, P.
    Lemmens, V. E. P. P.
    Liefers, G. J.
    Holman, F. A.
    Dekker, J. W. T.
    Portielje, J. E. A.
    Rutten, H. J.
    van de Velde, C. J. H.
    Time trends of short-term mortality for octogenarians undergoing a colorectal resection in North Europe2019Ingår i: European Journal of Surgical Oncology, ISSN 0748-7983, E-ISSN 1532-2157, Vol. 45, nr 8, s. 1396-1402Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Decreased cancer specific survival in older colorectal patients is mainly due to mortality in the first year, emphasizing the importance of the first postoperative year. This study aims to gain an overview and time trends of short-term mortality in octogenarians (>= 80 years) with colorectal cancer across four North European countries. Methods: Patients of 80 years or older, operated for colorectal cancer (stage I-Ill) between 2005 and 2014, were included. Population-based cohorts from Belgium, Denmark, the Netherlands, and Sweden were collected. Separately for colon- and rectal cancer, 30-day, 90-day, one-year, and excess one-year mortality were calculated. Also, short-term mortality over three time periods (2005-2008, 2009-2011, 2012-2014) was analyzed. Results: In total, 35,158 colon cancer patients and 10,144 rectal cancer patients were included. For colon cancer, 90-day mortality rate was highest in Denmark (15%) and lowest in Sweden (8%). For rectal cancer, 90-day mortality rate was highest in Belgium (11%) and lowest in Sweden (7%). One-year excess mortality rate of colon cancer patients decreased from 2005 to 2008 to 2012-2014 for all countries (Belgium: 17%-11%, Denmark: 21%-15%, the Netherlands: 18%-10%, and Sweden: 10%-8%). For rectal cancer, from 2005 to 2008 to 2012-2014 one-year excess mortality rate decreased in the Netherlands from 16% to 7% and Sweden: 8%-2%). Conclusions: Short-term mortality rates were high in octogenarians operated for colorectal cancer. Short-term mortality rates differ across four North European countries, but decreased over time for both colon and rectal cancer patients in all countries.

  • 4.
    Gunnarsson, Ulf
    Department of Surgical Sciences, University Hospital, Uppsala, Sweden.
    Quality assurance in surgical oncology: Colorectal cancer as an example2003Ingår i: European Journal of Surgical Oncology, ISSN 0748-7983, E-ISSN 1532-2157, Vol. 29, nr 1, s. 89-94Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Quality assurance in surgical oncology is a field of growing importance. National, regional and local systems have been built up in many countries. Often the quality assurance projects are linked to different registers. The advantage of such a link is the possibility of obtaining population-based data from unselected health care institutions. Few discussions of results from such projects have been published. Quality assurance of colorectal cancer surgery implies the development and use of systems for improvement all the way from detection of the cancer to the outcome as survival and patient satisfaction. To achieve this we must know what methods are being used and the outcome of our treatments. Designing processes for improvement necessitates careful planning, including decisions about end-points. Some crucial issues are discussed step-by-step in the present paper. In addition to auditing and providing collegial feedback, quality assurance is a tool for closing the gap between clinical practice and evidence based medicine and for creating new evidences as well as monitoring the introduction of new techniques and their effects.

  • 5.
    Jestin, Pia
    et al.
    Department of Surgical Sciences, University Hospital, Uppsala, SE 75185 Uppsala, .
    Heurgren, M
    Påhlman, L
    Glimelius, B
    Gunnarsson, Ulf
    Department of Surgical Sciences, University Hospital, Uppsala, Sweden.
    Elective surgery for colorectal cancer in a defined Swedish population.2004Ingår i: European Journal of Surgical Oncology, ISSN 0748-7983, E-ISSN 1532-2157, Vol. 30, nr 1, s. 26-33Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    AIMS: The aim of this study was to describe variability in compliance to clinical guidelines in colorectal cancer surgery related to hospital structure.

    METHODS: All patients registered in the databases of the Regional Oncologic Centre, operated upon electively for colon cancer between the start of the register in 1997 until 2000 (n=1771) and for rectal cancer between the start of the register in 1995 until 2000 (n=1841) were selected for analysis.

    RESULTS: There was no difference in 5-year survival rate between colon and rectal cancer (mean follow-up 2.6 and 3.0 years, respectively; p=0.22). There was a significant difference in frequency of preoperative liver scan depending on hospital category with an increase in colon cancer from 39 to 46% (p=0.02) and in rectal cancer from 42 to 64% (p<0.001). For colon cancer there was no difference, according to hospital category, in quotient sigmoid and high anterior resection to left-sided resection. Furthermore, high anterior resection was more common at university and general district hospitals (8%) compared with district hospitals (4%) (p=0.01). Sphincter-saving surgery was more common at university hospitals and district general hospitals than at district hospitals (low anterior/abdomino-perineal resection quotients 2.3, 2.4 and 1.6, respectively; p<0.001).

    CONCLUSIONS: Population-based audit forms an appropriate and valuable basis for quality assurance projects. In addition to describing compliance to guidelines and pointing to process steps that can be improved, such investigations may also indicate changes due to scientific development. Linked to case-costing data, such results may form an important basis for decisions about modifications in health care.

  • 6. Klevebro, F.
    et al.
    Johnsen, G.
    Johnson, E.
    Viste, A.
    Myrnäs, T.
    Szabo, E.
    Jacobsen, A. -B.
    Friesland, S.
    Tsai, J. A.
    Persson, S.
    Lindblad, M.
    Lundell, L.
    Nilsson, M.
    Morbidity and mortality after surgery for cancer of the oesophagus and astro-oesophageal junction: a randomized clinical trial of neoadjuvant hemotherapy vs. neoadjuvant chemoradiation2015Ingår i: European Journal of Surgical Oncology, ISSN 0748-7983, E-ISSN 1532-2157, Vol. 41, nr 7, s. 920-926Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective: To compare the incidence and severity of postoperative omplications after oesophagectomy for carcinoma of the oesophagus and astro-oesophageal junction (GOJ) after randomized accrual to eoadjuvant chemotherapy (nCT) or neoadjuvant chemoradiotherapy (nCRT). ackground: Neoadjuvant therapy improves long-term survival after esophagectomy. To date, evidence is insufficient to determine whether ombined nCT, or nCRT alone, is the most beneficial. ethods: Patients with carcinoma of the oesophagus or GOJ, resectable ith a curative intention, were enrolled in this multicenter trial onducted at seven centres in Sweden and Norway. Study participants re andomized to nCT or nCRT followed by surgery with two-field ymphadenectomy. Three cycles of cisplatin/5-fluorouracil was dministered in all patients, while 40 Gy of concomitant radiotherapy as administered in the nCRT group. esults: Of the randomized 181 patients, 91 were assigned to nCT and 90 o nCRT. One-hundred-and-fifty-five patients, 78 nCT and 77 nCRT, nderwent resection. There was no statistically significant difference etween the groups in the incidence of surgical or nonsurgical omplications (P-value = 0.69 and 0.13, respectively). There was no 0-day mortality, while the 90-day mortality was 3% (2/78) in the nCT roup and 6% (5/77) in the nCRT group (P = 0.24). The median lavien-Dindo complication severity grade was significantly higher in he nCRT. group (P = 0.001). onclusion: There was no significant difference in the incidence of omplications between patients randomized to nCT and nCRT. However, omplications were significantly more severe after nCRT. Registration rial database: The trial was registered in the Clinical Trials tabase registration number NCT01362127). 

  • 7.
    Kverneng Hultberg, Daniel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Kirurgi.
    Angenete, E.
    Lydrup, M. -L
    Rutegård, Jörgen
    Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Kirurgi.
    Matthiessen, P.
    Rutegård, Martin
    Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Kirurgi.
    Nonsteroidal anti-inflammatory drugs and the risk of anastomotic leakage after anterior resection for rectal cancer2017Ingår i: European Journal of Surgical Oncology, ISSN 0748-7983, E-ISSN 1532-2157, Vol. 43, nr 10, s. 1908-1914Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Nonsteroidal anti-inflammatory drugs (NSAIDs) have been widely used in colorectal surgery due to their opioid-sparing effect. However, several studies have indicated an increased risk of anastomotic leakage following NSAID treatment, although conflicting results exist. The primary goal of this study was to further examine whether postoperative NSAIDs are independently associated with anastomotic leakage after anterior resection for rectal cancer. Methods: Patients who underwent anterior resection for rectal cancer during 2007-2013 in 15 different hospitals in three healthcare regions in Sweden were included in the study. Registry data and information from patient records were retrieved. The association between NSAID treatment (for at least two days in the first postoperative week) and symptomatic anastomotic leakage (within 90 days) was evaluated with multiple logistic regression, with adjustment for pertinent confounding factors. Results: Some 1495 patients were included in the study. Of these, 27% received postoperative NSAIDs for at least two days in the first postoperative week. Symptomatic anastomotic leakage occurred in 11% and 14% in the NSAID and non-NSAID group, respectively. With adjustment for confounders, the odds ratio for leakage among patients who received NSAIDs compared with those who did not was 0.88 (95% CI 0.65-1.20). No differences were seen between non-selective and COX-2-selective NSAIDs. Conclusion: Postoperative NSAID treatment does not seem to increase the risk of symptomatic anastomotic leakage after anterior resection for rectal cancer. NSAID use appears to be safe, but a well-powered randomized clinical trial is warranted.

  • 8. Martling, A
    et al.
    Granath, F
    Cedermark, B
    Johansson, Robert
    Holm, T
    Gender differences in the treatment of rectal cancer: a population based study2009Ingår i: European Journal of Surgical Oncology, ISSN 0748-7983, E-ISSN 1532-2157, Vol. 35, nr 4, s. 427-433Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Aims: Colorectal cancer is the second most common type of cancer in both women and men in Sweden. A National Quality Register for rectal adenocarcinoma in Sweden has included 97% of all rectal cancer patients since 1995. A previous study, based on data from the treatment program register in the Stockholm-Gotland region. found that women in Stockholm received preoperative radiotherapy (RT) less often than men [Martling A. Rectal cancer: staging, radiotherapy and surgery, ISBN: 91-7349-461-5. Stockholm: Karolinska Institute: 2003].(1) The aim of this study was to assess if women and men with rectal cancer receive equal treatment oil a national level, and whether any potential dissimilarity causes measurable consequences in Outcome. regarding postoperative morbidity and mortality, turnout, recurrence and Survival.

    Methods: All patients with rectal cancer included in the National Quality Register between 1995 and 2002 (11 774 patients) were analysed. Gender was correlated to treatment, postoperative morbidity and mortality, local recurrence and death.

    Results: The proportion of women selected for preoperative RT was significantly lower than that of men (42.5% vs. 50.1%, p < 0.001). After adjustment for other prognostic factors, the significant difference in the treatment strategy among women and men persisted. Postoperative mortality was significantly higher in men than in women and the gender difference was most pronounced in irradiated patients. RT improved local control significantly in both women and men but it had no effect oil cancer specific survival.

    Conclusions: For unknown reasons women less often received adjuvant RT than men. The opposite appeared to be a more adequate alternative. There is a need of improved selection criteria for RT in both men and women with rectal cancer.

  • 9.
    Nyström, Hanna
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Kirurgi.
    Naredi, Peter
    Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Kirurgi.
    Hafström, Larsolof
    Sund, Malin
    Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Kirurgi.
    Type IV collagen as a tumour marker for colorectal liver metastases2011Ingår i: European Journal of Surgical Oncology, ISSN 0748-7983, E-ISSN 1532-2157, Vol. 37, nr 7, s. 611-617Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: About 50% of patients with primary colorectal cancer (CRC) will develop liver metastases (CLM). Currently, carcinoembryonic antigen (CEA) is the most common tumour marker for CRC and CLM. However, the sensitivity and specificity of this marker is not optimal, as almost 50% of patients have tumours that do not produce CEA. Therefore there is a need for better markers for CRC and CLM.

    METHODS: The circulating levels of type IV collagen were measured in patients with CLM, primary CRC and in healthy controls. The expression pattern of type IV collagen was studied by immunofluorescence in CLM and normal liver tissue. The metastatic volume of CLM in the liver was estimated from CT.

    RESULTS: In CLM tissue type IV collagen is highly expressed in the areas of desmoplasia. Patients with primary CRC (Dukes' A-C) did not show any increase in circulating type IV collagen compared to healthy controls. However, patients with CLM have significantly elevated levels of circulating type IV collagen when compared to patients with primary CRC and healthy controls. The levels of type IV collagen decreased during chemotherapy and increased at the time of disease progression. The circulating levels of type IV collagen seem to reflect the tumour burden in the liver.

    CONCLUSIONS: Type IV collagen has the potential to be used as tumour associated biomarker for CLM. These results indicate the importance of interaction between cancer cells and the stroma in the tumour microenvironment.

  • 10.
    Påhlman, Lars
    et al.
    Colorectal Unit, Section of Surgery, Department of Surgical Sciences, University Hospital, SE-751 85 Uppsala, Sweden.
    Gunnarsson, Ulf
    Colorectal Unit, Section of Surgery, Department of Surgical Sciences, University Hospital, SE-751 85 Uppsala, Sweden.
    Karlbom, U
    Colorectal Unit, Section of Surgery, Department of Surgical Sciences, University Hospital, SE-751 85 Uppsala, Sweden.
    The influence on treatment outcome of structuring rectal cancer care.2005Ingår i: European Journal of Surgical Oncology, ISSN 0748-7983, E-ISSN 1532-2157, Vol. 31, nr 6, s. 645-649Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Clinical trials and registers data for quality assurance have been mandatory to achieve the good results and the enormous evolution which has been involved in rectal cancer surgery during the past 20 years. The whole business came into focus when local recurrences were considered as a matter of tumour biology and radiotherapy was introduced in many countries as a standard treatment in rectal cancer patients to reduce the local recurrence rate and to improve survival. During the last 30 years more than 8000 patients have been randomized in trials using pre- or post-operative radiotherapy. Those data are summarized in two good meta-analyses. In short, a summary of those meta-analyses has shown that radiotherapy reduces the local recurrence rate with 50%. Moreover, it has been revealed that pre-operative radiotherapy is better than post-operative radiotherapy in attempt to reduce the local recurrence rate and finally that there is a survival benefit with this reduction of the local recurrence rate.

  • 11.
    Rutegård, Martin
    et al.
    Upper Gastrointestinal Research, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
    Lagergren, P
    Rouvelas, I
    Mason, R
    Lagergren, J
    Surgical complications and long-term survival after esophagectomy for cancer in a nationwide Swedish cohort study2012Ingår i: European Journal of Surgical Oncology, ISSN 0748-7983, E-ISSN 1532-2157, Vol. 38, nr 7, s. 555-561Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    AIMS: Acute surgical complications after esophageal resection for cancer may decrease the long-term survival. Previous results on this topic are conflicting and no population-based studies are available.

    METHODS: A prospective, nationwide Swedish study was conducted in 2001-2010. Eligible patients comprised those afflicted by esophageal or cardia cancer and underwent surgical resection in Sweden in 2001-2005. Details concerning patient and tumor characteristics, surgical procedures, and postoperative surgical complications were collected prospectively. Follow-up for mortality, starting from 90 days after the surgery, was done until May 2010. Cox proportional-hazards regression was performed to estimate hazard ratios (HRs) and 95% confidence intervals (CIs), adjusted for age, tumor stage, sex, histology, comorbidity, surgical approach and surgical radicality.

    RESULTS: Among 567 included patients who survived at least 90 days postoperatively, 130 (22.9%) sustained a predefined surgical complication within 30 days of surgery. The adjusted HR of mortality was increased in patients who sustained surgical complications, compared to patients without such complications (HR 1.29, 95% CI 1.02-1.63).

    CONCLUSIONS: The occurrence of surgical complications might be an independent predictor for poorer long-term survival in patients resected for esophageal cancer, even in patients who survived the postoperative period.

  • 12.
    Saraste, D
    et al.
    Division of Surgery, CLINTEC, Karolinska Institutet, Department of Surgical Gastroenterology, Karolinska University Hospital, Huddinge, Sweden.
    Gunnarsson, Ulf
    Division of Surgery, CLINTEC, Karolinska Institutet, Department of Surgical Gastroenterology, Karolinska University Hospital, Huddinge, Sweden.
    Janson, M
    Division of Surgery, CLINTEC, Karolinska Institutet, Department of Surgical Gastroenterology, Karolinska University Hospital, Huddinge, Sweden.
    Local excision in early rectal cancer-outcome worse than expected: a population based study2013Ingår i: European Journal of Surgical Oncology, ISSN 0748-7983, E-ISSN 1532-2157, Vol. 39, nr 6, s. 634-639Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Considering the morbidity and mortality after abdominal surgery for rectal cancer, our aim was to determine whether local excision in Stage I rectal cancer provides long-term survival equivalent to TME surgery, particularly in elderly patients.

    METHODS: Data on 3694 consecutive patients with Stage I rectal cancer operated 1995-2006, were collected from the Swedish Rectal Cancer Register, a population-based, prospectively sampled data-base. Risk factors for death within 5 years after surgery, local recurrence rates, cumulative relative and overall survival rates were calculated for patients ≥ and <80 years-of-age. ASA grading related to surgical technique was analysed in a separate sample.

    RESULTS: Local excision (LE) was associated with an increased mortality risk both ≥80 (HR 1.55) and <80 years-of-age (HR 1.45). After LE the 5-year local recurrence rate was 11.2% and the total and relative cumulative 5-year survival was 0.62 and 0.81 respectively. Hartmann's procedure (HA) showed an increased mortality risk only in younger patients (HR 2.15). The overall local recurrence rate was 7.2% with HA. Male gender (HR 1.70) and age (HR 1.06) were associated with a significantly increased mortality risk in all age groups. The ASA-grade was higher among patients operated with LE compared to Anterior Resection/Abdominoperineal resection.

    CONCLUSION: Local excision has a poor outcome in the elderly. A negative selection bias towards old age and high co-morbidity could explain this. Hartmann's procedure has a high risk for mortality and local recurrence in younger patients.

  • 13. Van den Broek, C. B. M.
    et al.
    van Gijn, W.
    Bastiaannet, E.
    Møller, B.
    Johansson, Robert
    Umeå universitet, Medicinska fakulteten, Institutionen för strålningsvetenskaper, Onkologi.
    Elferink, M. A. G.
    Wibe, A.
    Påhlman, L.
    Iversen, L. H.
    Penninckx, F.
    Valentini, V.
    van de Velde, C. J. H.
    Differences in pre-operative treatment for rectal cancer between Norway, Sweden, Denmark, Belgium and the Netherlands2014Ingår i: European Journal of Surgical Oncology, ISSN 0748-7983, E-ISSN 1532-2157, Vol. 40, nr 12, s. 1789-1796Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Several studies have shown remarkable differences in colorectal cancer survival across Europe. Most of these studies lacked information about stage and treatment. In this study we compared short-term survival as well as differences in tumour stage and treatment strategies between five European countries: Norway, Sweden, Denmark, Belgium, and the Netherlands. For this retrospective cohort study all patients aged 18 years or older and operated on adenocarcinoma of the rectum without distant metastases and diagnosed in 2008 and 2009 were selected in national audit registries from Norway, Sweden, Denmark, Belgium, and the Netherlands. Differences in pre-operative treatment between the countries were compared using univariable and multivariable logistic regression. One year relative survival and one year relative excess risk of death (RER) were compared between the five countries. Large variation in the use of preoperative radiotherapy and chemoradiation was found between the countries. Even though, there was little variation in relative survival between the countries, except Sweden, which had a significant better one year RER of death among the elderly patients after adjustment. The differences in survival are expected to be caused by differences in pen-operative care, selection of patients, and especially management of elderly patients. The effects of preoperative treatment are expected to be seen on long term follow-up. 

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