Treatment of rectal cancer varies enormously between different European countries

The European Registration of Cancer Care (EURECCA) study, initiated by ECCO -- the European CanCer Organisation -- compared the treatment of 6,597 patients in Sweden, Norway, Denmark and The Netherlands who were diagnosed with rectal cancer between 2008 and 2009. It also compared the numbers of deaths 30 days after surgery.

In a presentation to the 2011 European Multidisciplinary Cancer Congress, Dr Colette van den Broek MD, a PhD student and research fellow at Leiden University Medical Centre (Leiden, The Netherlands), explained that by using the results from the EURECCA study, she and the other researchers involved in the project, hoped to identify those aspects of cancer care that played a role in improving clinical practice, treatments, survival, and the limiting of undesired side effects. Then, they would be able to develop recommendations for treatment that could lead to more standardised clinical practice across Europe.

The project started three years ago, and the data presented now, which have been obtained from comparisons of cancer registries in the four countries, show that the use of radiotherapy, or radiotherapy combined with chemotherapy, varied enormously between the countries, despite the fact that the patients had comparable stages of disease.

"The use of radiotherapy or chemotherapy or both was the lowest in Denmark at 25 percent, followed by Norway at 50 percent, Sweden at nearly 61 percent and the highest in The Netherlands at 81 percent," said Dr Van den Broek. "Its use varied depending on the stage of the disease in each country. For instance, in Denmark and The Netherlands, patients with stage I, II and III disease received radiotherapy, chemotherapy or both most often; in Sweden it was patients with stage II or III disease, and in Norway patients with stage IV disease, who received it most often."

At present, the researchers are comparing the deaths within 30 days after surgery between countries. "We will be able to compare treatment strategies, radiotherapy, chemotherapy, or both, for different stages of disease," said Dr Van den Broek.

"It is clear from our results so far, that different countries in Europe have different guidelines for treating rectal cancer patients. An earlier study has shown that radiotherapy, delivered before surgery, reduces local recurrences of the disease. But, in The Netherlands, we use radiotherapy for almost all stages, while in Denmark, for example, they use a combination of radiotherapy and chemotherapy. The differences in treatment do not necessarily cause big differences in survival, and recent research has shown that, although radiotherapy decreases deaths from cancer, it increases deaths due to other causes. So we have to find the right balance between the 'gain and pain' of radiotherapy and between under- and over-treatment. With this study we hope to be able to give an answer to the ongoing discussion about this and it is a first step towards a single guideline that can be used in different countries."

The EURECCA project is looking at a number of cancers in addition to rectal cancer, and Dr Van den Broek says that the researchers are hoping to look at long-term survival as well. "This is just a first step in the process," she concluded.

ECCO president, Professor Michael Baumann, said: "Cancer professionals know well that treatment practice varies widely in Europe. These differences have many reasons, such as regional experience and expertise as well as available infrastructure. To some extent differences in approach may, therefore, be quite appropriate. On the other hand it appears unlikely that all different approaches could be equally effective and equally well tolerable. Comparison of outcome after different approaches in large cohorts is an evidence-based way to identify shortcomings in specific services. For this reason, ECCO and several of its member societies strongly support the EURECCA study, which provides a show-case on what can be achieved for improved cancer care by such multidisciplinary, multinational clinical research projects."

Professor David Kerr, president of ESMO and Professor of Cancer Medicine at the University of Oxford, said: "This important study gives an insight into one aspect of the reasons underpinning variation in recurrence and survival from rectal cancer -- access to optimal treatment around the time of diagnosis. Although heterogeneity in the biology of cancer is accepted and the subject of much research, unwarranted variation in clinical outcome may be related to lack of knowledge, lack of funding, inadequate healthcare systems or failure to apply effective treatment protocols. This report serves as a wake-up call to the European cancer community that further work needs to be done to find how widespread this phenomenon is."