Original article

Colon cancer management and outcome in relation

to individual hospitals in a defined population
A. Sjövall1 , T. Holm1 , T. Singnomklao2 , F. Granath3 , B. Glimelius4 and B. Cedermark1
1
Department of Surgery, Karolinska University Hospital, Solna, Karolinska Institutet, 2 Oncologic Centre, 3 Department of Medicine, Clinical
Epidemiology Unit, Karolinska Institutet and 4 Department of Oncology and Pathology, Karolinska University Hospital, Solna, Karolinska Institutet,
Stockholm, Sweden
Correspondence to: Dr A. Sjövall, Department of Surgery, P9:03, Karolinska Hospital, S171 76 Stockholm, Sweden (e-mail: annika.sjovall@karolinska.se)

Background: The Stockholm and Gotland region in Sweden has a common management protocol for
the treatment of colon cancer. The aim of this study was to assess the management and treatment of
colon cancer in the region and to try to identify ways to improve the outcome further.
Methods: Clinical data on all patients diagnosed with colon cancer in the region’s nine hospitals between
January 1996 and December 2000 were prospectively collected. Patients were followed until December
2004, and their management and outcome analysed.
Results: Colon cancer was diagnosed in 2775 patients. An elective operation was performed in 2116
(76·3 per cent) patients and an emergency procedure in 590 (21·3 per cent). Emergency surgery was an
independent risk factor for death. The crude overall cumulative 5-year survival was 46·2 per cent. A
multivariable analysis of risk of dying and risk of local recurrence showed significant differences between
hospitals. The number of lymph nodes examined in the specimens also differed between hospitals.
Conclusion: Differences in the management and outcome of colon cancer in the nine hospitals, despite
a common management protocol, indicate a need for improving collaboration between hospitals and
multidisciplinary management.

Paper accepted 20 December 2006

Published online 29 January 2007 in Wiley InterScience (www.bjs.co.uk). DOI: 10.1002/bjs.5455

Introduction of total mesorectal excision and the introduction of

Since 1980, The Stockholm Colorectal Cancer Study
Group has been committed to improving the management
and outcome of colorectal cancer. It has accomplished
two large randomized trials on preoperative radiotherapy
in rectal cancer (Stockholm I and II trials), an adjuvant
chemotherapy trial in colorectal cancer and an educational
project on multidisciplinary management in patients with
rectal cancer, including the concept of total mesorectal
excision1 – 4 . In addition, the group has established
management protocols for colorectal cancer since 1980.
Since 1996, as part of these protocols, all patients within
the Stockholm population with colorectal cancer have been
prospectively registered, and their follow-up data recorded.
As a result of these efforts, local control and survival
in patients with rectal cancer has improved in the region
as well as in other parts of Sweden in the past decade.
A similar effect on outcome has become evident in other
countries as a result of the widespread implementation
preoperative radiotherapy5 – 7 . Recent population-based
data from Sweden show that patients with rectal cancer now
have a better prognosis than those with colon cancer8,9 .
From a population of 1·9 million, about 550 new
patients with colon cancer are registered in the region
annually. Although the management protocol established
in Stockholm includes patients with colon cancer, no
specific efforts have been made to improve outcome in
these patients. Thus in 2004 the Stockholm Colorectal
Cancer Study Group initiated the Colon Cancer Project
in Stockholm in an attempt to improve the outcome for
this large group of patients. The initial task was to analyse
the prospective data on almost 3000 patients with colon
cancer registered between 1996 and 2000 and followed
until December 2004.
The aim of this study was to assess the overall
management and outcome in these patients, to establish
whether the management and prognosis was related to

Copyright  2007 British Journal of Surgery Society Ltd British Journal of Surgery 2007; 94: 491–499
Published by John Wiley & Sons Ltd
492 A. Sjövall, T. Holm, T. Singnomklao, F. Granath, B. Glimelius and B. Cedermark
individual hospitals and to try to identify ways of improving
management and outcome.
Patients and methods
In Sweden, all patients with cancer are reported to
the National Cancer Registry by the physician and the
pathologist at diagnosis. Causes of death are reported to the
Cause of Death Registry at the National Board of Health
and Welfare. The Stockholm County Council keeps
record of all healthcare consumption including diagnoses
according to the International Classification of Diseases of
the World Health Organization. The registration uses an
identification number unique to each resident of Sweden.
Since 1996, all patients with colon cancer in the
Stockholm region have been registered with the Oncologic
Centre in Stockholm. The database includes information
on age, sex, tumour location and stage, emergency or
elective surgery, type of surgery performed, postoperative
mortality, radiotherapy, chemotherapy, the histopathology
of the tumour and follow-up data on recurrence and
survival.
The colon is defined as the large bowel above 15 cm
from the anal verge, excluding the appendix. Tumours are
classified as being in the right, transverse or left colon
or as being multiple (more than one synchronous tumour
or later diagnosis of a new tumour) or unknown location
(when the location of the primary tumour is impossible to
establish). The right colon includes the caecum, ascending
colon and hepatic flexure, while the left colon includes the
splenic flexure, descending colon and the sigmoid.
Surgery is defined as ‘curative’ if no distant metastases
are present and the primary resection is locally complete
according to both the surgeon and the pathologist, as
‘uncertain’ when there are no distant metastases but the
local completeness of the resection is uncertain according
to either the surgeon or the pathologist, and as ‘incomplete’
if the resection is locally incomplete according to the
surgeon or the pathologist, or if they both assess the
completeness of the resection as uncertain. A fourth patient
group is defined for those who have distant metastases at
primary surgery or in whom the primary tumour is not
resected. The Oncologic Centre database is continuously
validated and updated using the registries above, and all
patients with an invasive adenocarcinoma of the colon are
included.
This study included all patients from the Stockholm pop-
ulation diagnosed with a primary invasive adenocarcinoma
of the colon between January 1996 and December 2000.
The patients were followed until December 2004. The
region had nine hospitals and five pathology departments.
Copyright  2007 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd
Hospitals 1 and 2 were university hospitals associated
with Karolinska Institutet, 3 and 4 were large community
hospitals that also had medical students and 5–9 were com-
munity hospitals without medical students (see Table 1). All
had emergency rooms except Hospital 6.
In addition to the information in the Oncologic Centre
database, details of healthcare consumption for all patients
after the diagnosis were taken from the Stockholm County
Council registry. In patients without a reported recurrence
at the end of follow-up, an analysis of medical records was
performed to ensure that no patient with a diagnosed cancer
recurrence had been missed. Data on patients from the
Stockholm population who had been treated in hospitals
outside the region were also collected through medical
records. In the few patients who moved out of the region
during the study, data on tumour recurrence were not
available. However, in patients who died during follow-up,
information on the date and cause of death was retrieved
and recorded.
In addition to the analysis of management and outcome
in the total number of patients within the region, results
were analysed separately for the nine different hospitals. In
these analyses, only abdominal operations were included.
The institutions outside the region where patients had
had emergency surgery were for the purpose of this study
merged and defined as hospital 10. Patients treated in
this group were excluded from the comparative analyses
regarding outcome in relation to hospital, but they were
included in the descriptive part of this study, to avoid
selection of patients.
During the study, a randomized trial assessed the value
of adjuvant chemotherapy to patients with stage II or III
colon cancer, and some of the patients in this study were
included in that trial4 .
Statistical analysis
The survival time was calculated from the date of the
primary surgery until the date of death or the end of
follow-up. In non-operated patients, the survival time was
calculated from the date of diagnosis until the time of death
or end of follow-up. Comparisons of survival times between
patient groups were made with the Kaplan–Meier method
and log rank test. The χ2 test was used for comparisons of
differences in proportions.
A proportional hazards regression model was used to
assess survival after elective versus emergency abdominal
surgery. The risk of death and recurrence in the
different hospitals was also calculated in a proportional
hazards regression model. In these multivariable analyses,
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 Colon cancer management

Table 1 Patient characteristics of 2775 patients diagnosed with colon cancer in nine hospitals in the Stockholm and Gotland region, 1996–2000

Published by John Wiley & Sons Ltd

Hospital

Characteristics 1 2 3 4 5 6 7 8 9 10† Total

Male 156 (50·0) 184 (51·8) 216 (47·8) 206 (49·8) 193 (46·8) 210 (46·8) 55 (48·2) 55 (49·1) 48 22 1345 (48·5)

Copyright  2007 British Journal of Surgery Society Ltd

Female 156 (50·0) 171 (48·2) 236 (52·2) 208 (50·2) 219 (53·2) 239 (53·2) 59 (51·8) 57 (50·9) 57 28 1430 (51·5)
Median age (years)* 72 (30–95) 74 (22–93) 75 (30–94) 75 (29–97) 76 (35–97) 74 (27–94) 73 (32–93) 75 (24–97) 74 (32–90) 71 (29–91) 74 (22–97)
Tumour location
Right 151 (48·4) 156 (43·9) 182 (40·3) 184 (44·4) 187 (45·4) 186 (41·4) 42 46 41 20 1195 (43·1)
Transverse 33 35 42 42 59 (14·3) 37 6 10 13 4 281 (10·1)
Left 124 (39·7) 155 (43·7) 214 (47·3) 180 (43·5) 157 (38·1) 215 (47·9) 59 (51·8) 51 (45·6) 49 24 1228 (44·3)
Multiple 4 8 13 7 9 11 7 3 2 1 65 (2·3)
Unknown 0 1 1 1 0 0 0 2 0 1 6
No surgery 13 4 9 14 4 6 2 11 1 5 69 (2·5)
Elective surgery 246 (78·8) 270 (76·0) 297 (65·7) 300 (72·5) 295 (71·6) 435 (96·9) 83 (72·8) 80 (71·4) 79 (75·2) 31 2116 (76·3)
Emergency surgery 53 (17·0) 81 (22·8) 146 (32·3) 100 (24·2) 113 (27·4) 8 29 21 25 14 590 (21·3)
Curative surgery 187 (59·9) 208 (58·6) 288 (63·7) 296 (71·5) 297 (72·1) 362 (80·6) 77 (67·5) 78 (69·6) 76 (72·4) 32 1901 (68·5)
Tumour stage
I 29 44 39 57 (13·8) 37 82 (18·3) 9 17 8 10 332 (12·0)

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II 108 (34·6) 138 (38·9) 153 (33·8) 163 (39·4) 165 (40·0) 171 (38·1) 46 (40·4) 53 (47·3) 32 14 1043 (37·6)
III 84 (26·9) 85 (23·9) 145 (32·1) 112 (27·0) 125 (30·3) 113 (25·2) 27 (23·7) 11 (9·8) 41 10 753 (27·1)
IV 78 (25·0) 83 (23·4) 108 (23·9) 77 (18·6) 79 (19·2) 61 (13·6) 31 (27·2) 25 (22·3) 18 12 572 (20·6)
Unknown 13 5 7 5 6 22 1 6 6 4 75 (2·7)
30-day mortality
Emergency surgery 4 6 20 17 10 0 5 3 1 0 66 (11·2)
Elective surgery 11 9 12 6 10 8 3 1 2 1 63 (3·1)

Values in parentheses are percentages or *ranges. †Refers to patients who had surgery outside the Stockholm and Gotland region or those who did not visit a department of surgery.

British Journal of Surgery 2007; 94: 491–499

493
494
adjustment was made for case mix including age, sex and
tumour node metastasis stages. For comparisons between
hospitals, adjustment was also made for elective and
emergency surgery.
Results
A total of 2855 patients were diagnosed with colon cancer
during the study period. In 80, the tumour was diagnosed
at autopsy, and these patients were excluded from further
analysis. Clinical characteristics of the remaining 2775 in
relation to treatment hospital are shown in Table 1. There
were 1345 (48·5 per cent) men and 1430 (51·5 per cent)
women, and the median age at diagnosis was 73 years in
men and 76 years in women. There were no significant
differences between hospitals regarding sex, but hospital 1
patients had a lower median age and hospital 5 patients a
higher median age. Patient and tumour characteristics did
not change over time (data not shown).
Diagnosis and tumour location
The diagnosis was verified by histopathology in 2745
patients (98·9 per cent) and by unequivocal radiology
or endoscopy findings alone with no subsequent colon
resection in 30 (1·1 per cent). Right-sided tumours were
significantly more common in women: 669 of 1430
(46·8 per cent) versus 526 of 1345 (39·1 per cent) in men
(P < 0·001), while left-sided tumours were more common
in men; 651 of 1345 (48·4 per cent) versus 577 of 1430
(40·3 per cent) in women (P < 0·001). The proportion of
tumours in the transverse colon was similar in men and in
women, 9·9 and 10·6 per cent respectively.
Synchronous distant metastases were found in 572
patients (20·6 per cent). Liver metastases were present
in 398 patients and peritoneal carcinomatosis in 130.
Other less common locations of distant spread were lung,
intra-abdominal lymph nodes and ovaries. Synchronous
metastases in multiple locations were diagnosed in 89
patients.
Surgery
Surgery was performed in 2706 patients (97·5 per cent)
(Table 2). An abdominal procedure was performed in
2649, which was elective in 2059 (77·7 per cent) and
an emergency in 590 (22·2 per cent). Of patients who
had a bowel resection, right hemicolectomy and sigmoid
resection were the most common procedures. In 188
patients, another organ was resected at the same time
as the bowel, most commonly the spleen or an ovary. In
Copyright  2007 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd
A. Sjövall, T. Holm, T. Singnomklao, F. Granath, B. Glimelius and B. Cedermark
Table 2 Surgical procedures in 2706 patients with colon cancer in
the Stockholm and Gotland region, 1996–2000
Procedure n
Ileocaecal resection 58 (2·1)
Right hemicolectomy 1177 (43·5)
Resection of transverse colon 115 (4·2)
Left hemicolectomy 242 (8·9)
Resection of sigmoid colon 694 (25·6)
Anterior resection* 114 (4·2)
Hartmann’s procedure 48
Subtotal colectomy† 84 (3·1)
Endoscopic polypectomy 57 (2·1)
Exploratory laparotomy 117 (4·3)
Values in parentheses are percentages. *Patients with sigmoid cancer;
†patients with multiple tumours, previous colorectal cancer or
inflammatory bowel disease.
53 of 57 patients who had an endoscopic polypectomy,
the tumour was located in the sigmoid colon. Laparotomy
without bowel resection was performed in 117 patients.
The operation was considered potentially cura-
tive in 1901 patients (70·3 per cent). Of those, 1549
(81·5 per cent) had an elective and 352 (18·5 per cent) an
emergency operation. In 184 patients, the local complete-
ness was uncertain. Of those, 132 (71·7 per cent) had an
elective and 52 (28·3 per cent) an emergency procedure. In
621 patients, the operation was considered non-curative
owing to locally incomplete resection or synchronous
distant metastases. Of these, 435 (70·0 per cent) had an
elective operation.
Reoperation within 30 days of surgery was performed in
88 (4·2 per cent) patients after elective and 32 (5·4 per cent)
patients after emergency surgery. The two most common
causes for reoperations were anastomotic leakage and
abdominal wall dehiscence.
Mortality within 30 days of surgery was significantly
higher after emergency surgery than elective surgery: 66
of 590 (11·2 per cent) versus 63 of 2059 (3·1 per cent)
(P < 0·001).
Histopathology
The tumours were classified as stage I in 332 (12·0 per cent)
patients, stage II in 1043 (37·6 per cent) patients, stage
III in 753 (27·1 per cent) patients and stage IV in
572 (20·6 per cent) patients (Table 1). In 75 patients, the
tumour stage was unknown because no surgery had been
performed or no lymph nodes had been found or examined.
Hospital 6 had a significantly higher proportion of stage I
tumours and a lower proportion of stage IV tumours than
the other hospitals, whereas hospital 8 had fewer stage III
www.bjs.co.uk British Journal of Surgery 2007; 94: 491–499
Colon cancer management 495

tumours and hospital 9 significantly more stage III tumours Curative

(Table 1). 100 Uncertain
Incomplete
The median number of lymph nodes examined was six Palliative
90
(range 0–36), and 12 or more lymph nodes were examined
in only 385 (15·4 per cent) of the specimens (Table 3). 80
The numbers of specimens having at least 12 lymph nodes
examined improved over time: in 2000, 12 or more lymph 70

Cumulative survival (%)

nodes were examined in 22 per cent of patients compared 60
with 8 per cent in 1996. The median number of lymph
nodes examined ranged from five to seven in the nine 50
hospitals. The number of patients having 12 or more
40
nodes examined ranged from 19 of 365 (5·2 per cent) in
hospital 4 to 95 of 418 (22·7 per cent) in hospital 6. 30

20
Neoadjuvant and adjuvant treatment
10
Preoperative chemotherapy or radiotherapy or both was
given to 25 patients, all because of advanced disease. In 0
0 1 2 3 4 5
the 1901 patients operated on with a curative intent, 246
Time after primary surgery or diagnosis (years)
had postoperative adjuvant chemotherapy, 198 of whom
No. at risk
had stage III tumours. During the study period there was
Curative 1901 1732 1550 1409 1146 798
a significant increase in the use of adjuvant treatment to Uncertain 184 133 104 87 72 53
patients with stage III disease and a decrease to those with Incomplete 99 59 39 32 24 17
stage II disease. The proportion of patients with stage Palliative 591 187 80 38 23 8
III tumours, younger than 76 years and having adjuvant
treatment after curative surgery ranged from 40 per cent Fig. 1Crude survival in 2775 patients diagnosed with colon
in hospital 5 to 69 per cent in hospital 6 (data not shown). cancer in Stockholm and Gotland, 1996–2000, analysed by
definition of surgery (curative procedure, uncertain, incomplete
resection or palliative procedure in patients with distant
Recurrence and survival metastases or non-resected tumour) (P < 0·001, log rank test)

The median survival time for all 2775 patients, including

patients who died within 30 days of surgery, was 50 (range
0–110) months. The crude cumulative 5-year survival was
46·2 per cent. At the end of follow-up, 1145 (41·3 per cent)
patients were alive after a median follow-up time of 75
(range 49–110) months.
The overall survival times for all 2775 patients in relation
to the definition of the surgery are shown in Fig. 1.
Distant metastases, locoregional recurrence or both were
found after a median follow-up of 18 months in 386 of
1901 (20·3 per cent) patients operated on for cure. The
crude cumulative 5-year survival after curative surgery was
61·1 per cent.
In patients where the local completeness of the resection
was uncertain, 87 of 184 (47·3 per cent) patients were

Table 3 Number of lymph nodes examined after abdominal colon resection in five pathology departments and nine hospitals (n = 2494)

Pathology Department Hospital 1–6 nodes 7–11 nodes > 11 nodes Data missing Total

A 1 122 (43·9) 80 (28·8) 46 30 278

B 2 172 (51·3) 75 (22·4) 59 (17·6) 29 335
3 185 (44·7) 127 (30·7) 86 (20·8) 16 414
7 58 (55·8) 23 16 7 104
C 5 221 (56·2) 107 (27·2) 38 27 393
D 6 184 (44·0) 125 (29·9) 95 (22·7) 14 418
9 38 36 19 4 97
E 4 254 (69·6) 86 (23·6) 19 6 365
8 60 (67) 22 7 1 90

Values in parentheses are percentages.

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496 A. Sjövall, T. Holm, T. Singnomklao, F. Granath, B. Glimelius and B. Cedermark

diagnosed with a tumour recurrence after a median 100

time of 10 months. The cumulative 5-year survival was
90
39·3 per cent.
In 99 patients with an incomplete primary tumour 80
resection, 50 (51 per cent) were diagnosed with progressive
disease after a median of 10 months and the cumulative 70

Cumulative survival (%)

5-year survival was 24·2 per cent.
In 591 patients, including those with synchronous distant 60

metastases and those where the tumour was not resected

50
owing to extensive tumour growth, the cumulative 5-year
survival was 2·9 per cent. 40
Excluding patients who died within 30 days of surgery
and after adjusting for age, sex and tumour stage, the 30
Hospital 1 Hospital 5
relative risk of overall death was significantly higher after Hospital 2 Hospital 6
20
emergency than after elective surgery (hazard ratio (HR) Hospital 3 Hospital 7
1·68, 95 per cent confidence interval (c.i.) 1·45 to 1·96, 10 Hospital 4 Hospital 8
Hospital 9
P < 0·001). After adjusting for local completeness of the
surgery, the risk of death was still significantly higher 0 1 2 3 4
after emergency surgery (HR 1·62, 95 per cent c.i. 1·37 to Time after surgery (years)
1·90, P < 0·001). In order to exclude all deaths related to No. at risk
postoperative complications, an analysis was performed for 292 223 185 164 134
Hospital 1
patients who survived for more than 180 days. This still Hospital 2 347 258 204 171 141
showed a higher relative risk of dying after emergency than Hospital 3 439 314 254 224 186
elective surgery, with an HR of 1·79 (95 per cent c.i. 1·50 Hospital 4 397 314 265 229 180
Hospital 5 404 303 255 218 168
to 2·13, P < 0·001).
Hospital 6 424 373 339 310 259
Hospital 7 111 80 61 55 38
Hospital 8 95 76 68 61 51
Outcome differences between hospitals Hospital 9 99 73 59 56 43

The crude survival after an abdominal operation in relation Fig. 2Crude survival in 2608 patients after abdominal operation
to treating hospital is shown in Fig. 2. The proportion for colon cancer in nine hospitals in the Stockholm and Gotland
of patients having emergency surgery differed between region
the hospitals, but the differences in survival persisted
also when only patients who had an elective procedure
were included. The pattern of hospital performance was Table 4 Overall death after abdominal surgery for colon cancer in
consistent throughout the study period. the nine hospitals in the Stockholm and Gotland region,
The population in the catchment area of hospital 1 was 1996–2000, adjusted for age, sex, tumour node metastasis
considered representative of the region and this hospital (TNM) stage and type of surgery (emergency or elective)
was chosen as the reference (HR 1·0). In the multivariable (n = 2608)
analysis, the relative risk for death was significantly lower
No. of No. of 95% confidence
in hospital 6 and higher in hospital 2, as shown in Table 4. Hospital events patients Hazard ratio interval
These results were also consistent throughout the study
1 170 292 1·00
period.
2 220 347 1·24 1·00–1·54
In patients who had an abdominal resection with curative 3 267 439 0·98 0·79–1·20
intent, the local recurrence rate was 6·2 per cent (113 of 4 234 397 1·06 0·86–1·32
1826). The local recurrence rate was also analysed in 5 264 404 0·96 0·78–1·19
6 185 424 0·79 0·63–0·99
relation to individual hospitals (Table 5), and patients who 7 73 111 1·20 0·90–1·61
had surgery in hospital 4 had a relatively high risk of 8 49 95 0·93 0·66–1·31
local recurrence (HR 2·78, 95 per cent c.i. 1·20 to 6·43, 9 60 99 1·11 0·82–1·51
P = 0·017). There was no significant difference in the risk
of having distant metastases between the nine different
hospitals (data not shown).

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Colon cancer management 497

Table 5 Locoregional recurrence after abdominal potentially volume per surgeon. The lack of an emergency room in
curative surgery for colon cancer in the nine hospitals in the this hospital could also have resulted in the selection of
Stockholm and Gotland region, 1996–2000, adjusted for age, fewer patients with concomitant diseases that might have
sex, tumour node metastasis (TNM) stage and type of surgery affected the outcome.
(emergency or elective) (n = 1826)
In the current management protocol, the recommended
No. of No. of 95% confidence number of examined lymph nodes for correct staging is at
Hospital events patients Hazard ratio interval least 12 nodes20,21 . The number of lymph nodes examined
1 8 181 1.00
after abdominal colon resections in this study is low and
2 15 206 2.32 0·94–5·74 signals a suboptimal histopathological examination of the
3 15 285 1.29 0·52–3·20 specimen and possibly less than optimal surgery. Previous
4 27 293 2.78 1·20–6·43
authors have reported similar problems with harvesting of
5 25 294 2.23 0·95–5·24
6 10 346 0.89 0·34–2·38 lymph nodes22 – 24 .
7 7 76 2.81 0·98–8·09 The management protocol, introduced in 1996, aimed at
8 2 73 0.96 0·20–4·68 achieving similar results in all hospitals in the region. Most
9 4 72 1.30 0·38–4·50
of the differences in this study were not significant, but
were consistent throughout the study period, indicating
that they were not random. However, there are potential
Discussion
confounders to consider. The database lacks information
The management of rectal cancer within defined pop- on concomitant diseases; differences in survival could also
ulations has been studied extensively in recent years, be affected by socioeconomic differences. Regarding the
mainly thanks to randomized radiotherapy trials, educa- risk for local recurrence, the low number of events makes
tional projects and quality audits, and the treatment results it hard to draw firm conclusions from the interhospital
have improved accordingly1 – 3,5 – 7,10,11 . differences.
However, few studies have addressed colon cancer It is questionable whether a region of this size should
treatment specifically, and recent large population-based have colon cancer surgery performed in nine different
audits are scarce12 . Owing to the prospective registration hospitals. The six larger institutions had a volume of 60–90
of all patients with colorectal cancer within the Stockholm patients with colon cancer per year, while three hospitals
population since 1996, the outcome has now been assessed had volumes of less than 25 per year. This study did not
in almost 3000 patients with colon cancer followed for at show a difference in survival related to hospital volume
least 4 years. as reported by previous authors25 – 28 , so a high hospital
The outcome in this large group of patients has improved volume is not a guarantee for good results. The standard
in Sweden during the past four decades, but it is notable of the surgical team as well as pre- and postoperative
that survival after treatment for rectal cancer is now better management are very important29 , although the present
than for colon cancer8 . The proportion of non-operated study cannot determine the most important factors.
patients, emergency or elective procedures and potentially After surgery for rectal cancer, the proportion of local
curative surgery has not changed markedly from previous recurrences is considered a measure of the quality of the
population-based Swedish studies13,14 . surgery. As for colon cancer, the risk of local recurrence
The worse prognosis for patients who have emergency in a population-based survey has not, to the authors’
rather than elective surgery has been reported15 – 18 . It is knowledge, been previously assessed. Indeed, there is
not clear whether this is caused by patient-related factors no established definition of local recurrence after colon
or by poor surgery in the emergency setting. Biondo cancer surgery, and in the evaluation in this study, data
et al.19 show no differences in overall survival between on locoregional recurrence as reported to the database by
elective and emergency patients after curative resection the surgeon or oncologist was used. The different risks of
of stage II colon cancer. However, in the Stockholm and locoregional recurrences among the hospitals may reflect a
Gotland population, the proportion of patients in whom true difference in surgical quality. Data on the competence
a locally complete resection could be accomplished was and experience of the surgeon in charge of each operation
lower in emergency than in elective procedures. Hospital were not available for this study, and therefore a more
6, which has essentially no emergency surgery, showed the detailed study of the factors responsible for differences in
best results in elective surgery compared with the other outcome was not possible.
hospitals. This might be because hospital 6 is small, with During the study period, the management protocol for
dedicated colorectal surgeons and a large colorectal cancer colon cancer did not include a compulsory preoperative

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Published by John Wiley & Sons Ltd
498 A. Sjövall, T. Holm, T. Singnomklao, F. Granath, B. Glimelius and B. Cedermark
assessment of the local extent of the primary tumour. This
could have an impact on the risk of unexpected findings
during colon resection, and might increase the risk of
the resection being incomplete during primary surgery.
It is generally accepted that a complete resection is a
crucial factor in predicting the outcome for patients with
colorectal cancer, and the results of this study support this.
As can be seen in Fig. 1, the survival of patients where
both the surgeon and the pathologist agreed on a locally
complete resection was significantly better than if either
expressed uncertainty as to the resection margins or, even
worse, if both expressed uncertainty or one reported an
incomplete resection. This supports a previous report on
prognosis after rectal cancer surgery30 .
Colon cancer surgery is considered less demanding than
rectal cancer surgery, appropriate for general surgeons
without a specific colorectal interest and often for residents.
There is no established policy in the Stockholm and
Gotland region on supervision of trainees in surgery,
and a right hemicolectomy has generally been considered
suitable for residents with or without the help of a
colorectal surgeon. As survival for patients with rectal
cancer in Sweden is now better than for those with
colon cancer, after intense efforts in clinical research
on adjuvant radiotherapy and educational initiatives on
surgery, it is time for action to improve management of
patients with colon cancer. It seems crucial to increase
the multidisciplinary collaboration between surgeons and
radiologists for better preoperative staging. In addition,
educational initiatives to improve surgery are needed. For
example, a better survival than in the current study is
reported after extensive and meticulous dissection of the
mesocolic lymph nodes31 . A complete removal of the
intact mesocolon to the affected colonic segment may
be important in the case of colon cancer, as is now
accepted in the total mesorectal excision technique in rectal
cancer surgery. Also, the histopathological examination of
the specimen should be optimized for quality control of
the surgery performed and for correct staging. Adjuvant
treatment should always be considered in multidisciplinary
conferences, and given according to continuously updated
clinical guidelines when indicated. If these measures can be
adopted, more patients with colon cancer should be cured.
Acknowledgements
The Colon Cancer Project in Stockholm is supported by
Tyco Healthcare. The present study was supported by
the Stockholm Cancer Society. The authors also thank the
Stockholm Colorectal Cancer Study Group who made the
registers available for this study.
Copyright  2007 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd
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