Total mesorectal excision for rectal cancer--what can be achieved by a national audit?

The results of rectal cancer surgery in Norway have been poor. In a national audit for the period 1986-88, 28% of the patients developed local recurrence (LR) following treatment with a curative intent. Five-year overall survival was 55% for patients younger than 75 years. The aim of this study is to report how an initiative focusing on better surgery can improve the prognosis for rectal cancer patients on a national level.

In 1994, the Norwegian Rectal Cancer Group was founded. The aim of this initiative was to improve the surgical standard by implementing total mesorectal excision (TME) on a national level and to evaluate the results. A number of courses were arranged to teach the surgeons the TME technique, and pathologists were trained to increase the standard of both macroscopic and microscopic assessment of specimens. A rectal cancer registry was established, and all surgical departments treating rectal cancer were invited to transfer their clinical data to this registry. Each department regularly receives its own results together with the national average for comparison and quality control.

The Rectal Cancer Registry includes all patients with rectal cancer diagnosed since November 1993. From then until December 1999, 5382 patients had a tumour located within 16 cm from the anal verge, and 3432 patients underwent rectal resection with a curative intent. Of these, 9% had adjuvant radiotherapy, and 2% were given chemotherapy. There was a rapid implementation of the new technique, as 78% underwent TME in 1994, increasing to 96% in 1998. After 39 months mean follow-up the rate of local recurrence was 8%, and 5-year overall survival was 71% for patients younger than 75 years.

An optimized surgical technique (TME) for rectal cancer can reduce the rate of local recurrence and increase overall survival. This improved surgical treatment can be implemented on a national level within a few years. Specialization of surgeons, feedback of results and a separate rectal cancer registry are thought to be major contributors to the improved treatment.