title: Time trends, improvements and national auditing of rectal cancer management over an 18-year period.
abstract: OBJECTIVE
  The main aims were to explore time trends in the management and outcome of patients with rectal cancer in a national cohort and to evaluate the possible impact of national auditing on overall outcomes. A secondary aim was to provide population-based data for appraisal of external validity in selected patient series.
  
  
  METHODS
  Data from the Swedish ColoRectal Cancer Registry with virtually complete national coverage were utilized in this cohort study on 29 925 patients with rectal cancer diagnosed between 1995 and 2012. Of eligible patients, nine were excluded.
  
  
  RESULTS
  During the study period, overall, relative and disease-free survival increased. Postoperative mortality after 30 and 90 days decreased to 1.7% and 2.9%. The 5-year local recurrence rate dropped to 5.0%. Resection margins improved, as did peri-operative blood loss despite more multivisceral resections being performed. Fewer patients underwent palliative resection and the proportion of non-operated patients increased. The proportions of temporary and permanent stoma formation increased. Preoperative radiotherapy and chemoradiotherapy became more common as did multidisciplinary team conferences. Variability in rectal cancer management between healthcare regions diminished over time when new aspects of patient care were audited.
  
  
  CONCLUSIONS
  There have been substantial changes over time in the management of patients with rectal cancer, reflected in improved outcome. Much indirect evidence indicates that auditing matters, but without a control group it is not possible to draw firm conclusions regarding the possible impact of a quality control registry on faster shifts in time trends, decreased variability and improvements. Registry data were made available for reference.
authors.affiliation: Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
authors.forename: K
authors.initials: K
authors.lastname: Kodeda
authors.affiliation: Department of Radiation Sciences, Oncology, Umeå University, Umeå, Sweden.
authors.forename: R
authors.initials: R
authors.lastname: Johansson
authors.affiliation: Department of Surgery, Ryhov County Hospital, Jönköping, Sweden.
authors.forename: N
authors.initials: N
authors.lastname: Zar
authors.affiliation: Department of Surgical Science, Uppsala University, Uppsala, Sweden.
authors.forename: H
authors.initials: H
authors.lastname: Birgisson
authors.affiliation: Department of Surgery and Perioperative Sciences, Umeå University, Umeå, Sweden.
authors.forename: M
authors.initials: M
authors.lastname: Dahlberg
authors.affiliation: Department of Surgery, Skaraborg Hospital - Skövde, Skövde, Sweden.
authors.forename: S
authors.initials: S
authors.lastname: Skullman
authors.affiliation: Department of Surgery, Helsingborg Hospital/Lund University, Helsingborg, Sweden.
authors.forename: G
authors.initials: G
authors.lastname: Lindmark
authors.affiliation: Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden.
authors.forename: B
authors.initials: B
authors.lastname: Glimelius
authors.affiliation: Department of Surgical Science, Uppsala University, Uppsala, Sweden.
authors.forename: L
authors.initials: L
authors.lastname: Påhlman
authors.affiliation: Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
authors.forename: A
authors.initials: A
authors.lastname: Martling
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016063:Blood Loss, Surgical; D059186:Chemoradiotherapy, Adjuvant / Q000639:trends; D015331:Cohort Studies; D003131:Combined Modality Therapy / Q000639:trends*; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D020360:Neoadjuvant Therapy / Q000639:trends; D010030:Ostomy / Q000639:trends; D010166:Palliative Care / Q000639:trends; D010348:Patient Care Team / Q000639:trends; D011183:Postoperative Complications / Q000453:epidemiology*; D018714:Radiotherapy, Adjuvant / Q000639:trends; D012004:Rectal Neoplasms / Q000401:mortality / Q000628:therapy*; D015996:Survival Rate / Q000639:trends*; D013548:Sweden / Q000453:epidemiology
keywords: Rectal neoplasms; quality control; registries; surgery; therapy