M. Sharmin1, A. Berthelsen1, M. Morgan2, A. Fowler3, S. Avery1

1SWSLHD Clinical Cancer Registry, Liverpool Hospital, 2Division of Surgery, Bankstown Hospital, 3Cancer Therapy Centre, SWSLHD

BACKGROUND AND SCOPE

Colorectal cancer is the second most commonly diagnosed cancer in females and the third in males, with over 1.2 million new cancer

cases diagnosed per year worldwide. The highest incidence rates are found in Australia/ New Zealand, Europe, and North America [1].

The latest national figures available reveals colorectal cancer was the second most common cancer in New South Wales (NSW),

comprising 13% of all cancers diagnosed in NSW and 12.8% in the South Western Sydney Local Health District (SWSLHD) [2].

South Western Sydney is a large metropolitan area in NSW, Australia, covering an area of 6237km2. SWSLHD is one of the most

populous area health districts in NSW providing healthcare to over 819,000 residents [3].

Rectal cancer represents approximately 35% of all colorectal cancers diagnosed and/treated in SWSLHD and approximately 4.5% of

all malignant cancers in the district [4].

Guidelines have been introduced for management of rectal cancer internationally and in Australia. In 2005, the National Health &

Medical Research Council (NHMRC) published the update of the 1999 document 'Clinical practice guidelines for the prevention, early

detection and management of colorectal cancer' which was developed by the Australian Cancer Network. These guidelines are

evidence-based. They have been produced by a multidisciplinary team and are proposed as basis for sound decision making [5].

NHMRC’s guidelines have recommended adjuvant radiotherapy (RT) for patients with stage II and III rectal cancer. Previous clinical

studies indicate that utilisation of RT in rectal cancer remains low and there seems to be a correlation between patients’ age and

utilisation of RT [6].

Figure 1: Age-Standardized Colorectal Cancer Incidence Rates by Gender

and World Area, 2008 [1].

60 40 20 0 20 40

South-Eastern Asia

Micronesia/ Polynesia

Southern Africa

Eastern Asia

Central and Eastern Europe

Northern America

Northern Europe

Southern Europe

Western Europe

Australia/ New Zealand

Males Females

0.3%

0.8%

1.3%

1.6%

2.8%

2.9%

3.6%

4.2%

7.5%

7.7%

8.7%

11.1%

12.1%

12.8%

22.7%

Eye

Bone and connective…

Myelodysplasia

Neurological

Ill Defined and…

Head and Neck

Thyroid/Endocrine

Gynaecological

Skin

Lymphohaematopoietic

Upper GI

Respiratory

Breast

Colorectal

Urogenital

The objective of this investigation is to examine the incidence, demographics, stage and preoperative or postoperative status

of radiotherapy in newly diagnosed and treated rectal cancer patients within the SWSLHD over a 12 year period.

MATERIALS AND METHOD

The data on newly diagnosed rectal cancer cases used in this analysis were collected from the

SWSLHD Clinical Cancer Registry (ClinCR).

ClinCR collects a minimum data set for each new cancer and the colorectal dataset extension

for each new colorectal case that is diagnosed and/or treated within the SWSLHD public

facilities [see figure 3].

• The core dataset describes cancer type, staging, treatment and quality of care.

• The dataset extension captures additional measures and indicators specific to the

tumour stream.

Figure 3: South Western Sydney Local Health District. Eligibility:

Patients identified for inclusion in this investigation were drawn from the SWSLHD ClinCR database according to the following criteria:

• A diagnosis of primary rectal cancer between January 1997 and December 2008.

• Patients with previously diagnosed rectal cancers or secondary malignancies were excluded.

• Recto-sigmoid cancers were excluded.

• Diagnosed and/ or treated within SWSLHD public facilities. RT is provided by Liverpool and Macarthur Cancer Therapy Centres.

• Treatments analysed were only the first course treatment provided in SWSLHD public facilities.

Staging:

The American Joint Committee on Cancer (AJCC) TNM staging system was used in this study. For the purpose of this study, the staging of

some patients has been modified to incorporate the pre-operative staging for patients receiving preoperative chemoradiation. In instances

where patients did not have preoperative treatment, the pathological stage became the final stage regardless of initial clinical stage.

Treatment guidelines:

• National Guideline on rectal cancer:

NHMRC guidelines (2005) for rectal cancer patients recommend RT for high risk patients with stage II (T3/T4) and stage III (node

positive) disease [6].

• International Guideline on rectal cancer:

Commission on Cancer (CoC) Quality of care measures states, RT should be considered or administered within 6 months (180 days) of

diagnosis for patients under the age of 80 with clinical or pathologic AJCC T4N0M0 or Stage III receiving surgical resection for rectal

cancer [9].

Figure 2: Top 14 Groups, Incidence, Persons, South Western Sydney, 2008 [4].

RESULTS

n = 1031 (%)

Gender

Female 341 (33)

Male 690 (67)

Age Range

20 - 29 4 (<1)

30 - 39 17 (2)

40 – 49 80 (8)

50 – 59 239 (23)

60 – 69 278 (27)

70 – 79 267 (26)

80 + 146 (14)

Country of Birth

Australia 471 (46)

Overseas 560 (54)

Socioeconomic status

1st quintile 134 (13)

2nd quintile 2 (<1)

3rd quintile 320 (31)

4th quintile 282 (27)

5th quintile 225 (22)

Overseas or Outside

SWSLHD 68 (7)

Residence on diagnosis (LGA)

Bankstown 250 (24)

Camden 56 (5)

Campbelltown 145 (14)

Fairfield 224 (22)

Liverpool 170 (16)

Wingecarribee 28 (3)

Wollondilly 38 (4)

Other 120 (12)

AJCC/TNM Stage

Stage I 223 (22)

Stage II 314 (30)

Stage III 318 (31)

Stage IV 159 (15)

Indeterminate 17 (2)

Given radiotherapy

Yes 469 (45)

No 562 (55)

• 1031 rectal cancer cases were

identified according to the

inclusion criteria.

• The median age of patients at

diagnosis was 66 years; the

range was from 22 to 101

years.

• Majority of the patients were

less than 80 years of age with

a clear male predominance

(67%).

• At least 54% of patients were

born overseas. Amongst those

born overseas, 25% were from

Europe, 10% were from South-

East Asia, 6% were from UK

and 5% were from Middle East.

• 13% of patients were classified

within the highest socioeconomic

status quintile for SWSLHD,

while majority of patients (58%)

were within the 3rd and 4th

quintile.

• A large number of patients

diagnosed with rectal cancer

resided either in Bankstown

(24%) or Fairfield (22%) at the

time of diagnosis. 12% of all

patients resided outside the

local government area

boundaries for the local health

district.

• 45% of patients received RT

alone or with other treatment

modalities and, the remaining

55% did not receive RT.

• Of those patients that received RT, 96%

received RT with other treatment

modalities. Amongst those patients, 79%

had a combined treatment of surgery,

chemotherapy and RT.

• 56% of patients received RT

preoperatively and 35% postoperatively.

This is consistent with other studies and

clinical treatment practice favouring

preoperative RT [6, 7, 8].

14%

79%

4% 3%

S + R

S + R + C

R

R + C

• Studies have indicated that patients with

lower third rectal tumours were more likely

to receive RT than those in upper third [6].

As shown in figure 6, 40% of lower third

rectal tumours vs 15% of upper third

rectal tumours received RT.

• 433 stage II and III cancers of the mid and

lower third of the rectum were identified.

Of these, 79% received RT with other

treatment modalities.

21%

26% 39%

14%

40%

42%

15%

3%

Lower third Middle third Upper third Not measured

RT not given

RT given

Figure 5: Rectal tumour site and RT distribution.

Figure 4: RT given with other treatment modalities in SWSLHD.

Table 1: Patient characteristics.

0%

25%

50%

75%

100%

RT Not Given RT Given

Figure 6: AJCC/TNM stage by RT in SWSLHD.

• 61% of stage II and 72% of stage III

patients received RT within Liverpool and

Macarthur Cancer Therapy Centres.

• According to the Australian National

Colorectal Cancer Survey, SWSLHD is

proportionately treating more patients.

• Survey indicates that only 36% of stage II

and 55% of stage III rectal cancers

received RT [7].

0

10

20

30

40

50

60

70

80

Stage I

Stage II

Stage III

Stage IV

• RT for rectal cancer patients

declined with increasing age at

diagnosis, particularly in

patients aged 80 years and

over [see figure 7].

• Only 8% of patients 80 years

and over received RT.

Figure 7: RT by Stage and Age group within SWSLHD.

8%

2%

<1%

23%

67%

RT not recommended

Patient declined RT

Patient wishes to betreated outside SWSLHD

Patient was not referred toSWSLHD Cancer TherapyCentres

RT given

Figure 8: Stage II and Stage III disease by RT treatment within SWSLHD.

• Overall, 67% of patients with

stage II and stage III disease

received RT in SWSLHD.

• 33% of patients with stage II and

stage III did not receive RT. Of

those, 10% had a reason for no

RT (RT was not recommended due

to poor performance status or

patient declined RT or patient

wishes to be treated elsewhere)

and 23% of patients were not

referred to SWSLHD cancer

therapy centres [see figure 8].

DISCUSSION AND CONCLUSION • Patterns remained broadly similar to other studies. Over the 12 years it was noted that RT utilisation declined with increasing age at

diagnosis, particularly in patients aged 70 – 80+ years.

• 23% of patients under 80 years of age who did not receive RT with Stage II or III disease, majority had a stage IIA disease. Also, these

patients were not referred to SWSLHD Cancer Therapy Centres, it is believed some were possibly treated outside SWSLHD. The SWSLHD

ClinCR program’s scope is limited to collecting minimum dataset for new cancer cases that are diagnosed and/or treated within the

SWSLHD public facilities. However, the Cancer Institute NSW - Centre for Health Record linkage projects offers a means to close this

information gap.

• This data offers opportunities for quality projects that further investigate the individual circumstances around those patients who did not

receive RT with Stage II or III disease.

• Introduction of the NHMRC guidelines made a difference to RT utilisation in Stage II rectal cancer patients in SWSLHD, with an increase of

9% of patients receiving RT.

• Results identified will inform local clinicians about RT utilisation in rectal cancer patients in SWSLHD.

• Further research into treatment patterns, referral rates and patient outcomes will enhance clinical practice and service provision.

REFERENCES

1. Jemal, A et al. Global Cancer Statistics. A Cancer Journal for Clinicians 2011; 61 (2): 69-90.

2. Cancer Institute NSW. Cancer in NSW: Incidence Mortality Report 2008. Cancer Institute NSW, Sydney, 2010.

3. NSW Health Population Projection Series 1. 2009. Department of Planning & State-wide Services Development

Branch, NSW Health March 2009.

4. Cancer Institute NSW. Online statistics module. Cancer Institute NSW, Sydney, 2011. Available at:

http://www.cancerinstitute.org.au/data-and-statistics/cancer-statistics/online-statistics-module (accessed August

2011).

5. Australian Cancer Network Revision Committee. Clinical Practice Guidelines for the Prevention, Early Detection, and

Management of Colorectal Cancer. National Health and Medical Research Council, Canberra 2005.

6. Hegi-Johnson, F et al. Utilisation of radiotherapy for rectal cancer in Greater Western Sydney 1994 - 2001. Asia

Pacific Journal of Clinical Oncology 2007; 3: 134-142.

7. National Cancer Control Initiative. The National Colorectal Care Survey. Cancer Australia, Canberra 2003.

8. Wong SK et al. Surgical Management of Colorectal Cancer in South-Western Sydney 1997-2001: A prospective

series of 1293 unselected cases from six public hospitals 2005; ANZ. Surg. 75: 776-782.

9. Commission on Caner. Coc Quality of care Measure. American College of Surgeons, Cancer Program, Chicago,

2011. Available at: http://www.facs.org/cancer/ncdb/rectalmeasure.pdf (accessed August 2011).

All correspondence to:

Mahbuba Sharmin BMedSci, BSci(HIM), MBA

Cancer information Manager

SWSLHD Clinical Cancer Registry

Locked Bag 7103, Liverpool BC 1871

(02) 9612 0619

mahbuba.sharmin@sswahs.nsw.gov.au

http://intranet.sswahs.nsw.gov.au/sswahs/cancer/

Treatment

• Of those, 23% of patients who did not have RT, 67 cases (61%) had stage IIA disease.

• Introduction of the NHMRC guidelines in 2005 made a difference to RT utilisation in stage II

rectal cancer patients in SWSLHD, with an increase of 9% of patients receiving RT.

• Patterns remained broadly similar with other studies for stage III patients with no significant

difference in RT utilisation. This is consistent with experience in both North America and

Europe [6].

• According to the CoC guideline, SWSLHD results indicate that 97% of patients received RT

within 6 months of diagnosis.

Population

Eligibility

Staging

Treatment Guidelines