Teaching efforts to spread TME surgery in Sweden

The whole infrastructure of rectal cancer treatment in Sweden has changed dramatically due to the awareness of the local recurrence rate, good surgical technique, and selective use of radiotherapy. Surgeons have been trained in a proper way, and it has been proven that the outcome has improved enormously in our country [14]. Due to repeated reports from the SRCR to each unit, it is possible for every surgeon to follow the process. It has been shown that the outcome for not only colon cancer but also rectal cancer has improved dramatically during the last 40 years, and there is a marked improvement in survival from approximately 40% in the early 1960s to almost 60% in the late 1990s [15]. An interesting phenomenon is that the relative 5-year survival rate has, during the 5-year cohort, been better for patients with colon cancer compared to those with rectal cancer. For the last two 5-year cohorts in Sweden, 1990-1995 and 1996-2000, the results for rectal cancer patients have improved, and in the most recent cohort, rectal cancer patients are actually doing better than colon cancer patients in terms of relative survival [16]. This increase has been interpreted to be a result of much better surgery, a more selective use of radiotherapy, but most of all an awareness of the results and focus on good auditing. This quality assurance and quality control of rectal cancer surgery is important and will be mandatory in the future for all units to not only know the results but also be able to present them in a way that patients can understand. We are facing a new generation of young patients who are familiar with the Internet and find all types of information before having surgery. It is obvious that only the best units will survive in such a competition, and the only way to be able to compete is to show good results within a good and validated population-based quality registration, as is the situation for many different diseases in Sweden today. A tremendous change has been seen in our country over the last two decades, and it is in part a result of registration and quality auditing, where the results are displayed to the surgeons.