Quality and Efficiency in Swedish Cancer Care Regional Comparisons 2011
Quality and Efficiency in Swedish Cancer Care
Regional Comparisons
2011
Quality and E
fficiency in Sw
edish Cancer C
are Reg
ional C
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ns 2011
Quality and Efficiency in Swedish Cancer Care
Regional Comparisons 2011
Swedish Association of Local Authorities and Regions Swedish National Board of Health and Welfare
1 000 copies
Production: Ordförrådet AB
Printing: Åtta.45, Solna
Quality and Efficiency in Swedish Cancer Care
Order or download from
Swedish National Board of Health and Welfare Beställningsservice, SE-120 88 Stockholm
E-mail: [email protected] Fax: +46 8 779 96 67www.socialstyrelsen.se/publicationsArt. no: 2012-3-15
or
Swedish Association of Local Authorities and Regions SE-118 82 Stockholm
www.skl.se/publikationerPhone: +46 20 31 32 30, fax: +46 20 31 32 40E-mail: [email protected] 978-91-7164-784-9
Foreword
Each year the Swedish National Board of Health and Welfare (NBHW) and the Swedish Association of Local Authorities and Regions (SALAR) publish a joint re-port entitled Quality and Efficiency in Swedish Health Care – Regional Comparisons. The Government has now mandated the NBHW to collaborate with SALAR on a special edition for cancer care.
The joint organisation created by the NBHW and SALAR to develop and promote open comparisons of the healthcare system has assumed responsibility for compil-ing the report.
The dual purpose of the report is to provide supporting data for decision makers at various levels who are attempting to improve cancer care while offering the general public insight into what publicly financed cancer care is accomplishing.
The project coordinator at the NBHW has been Mona Heurgren. The project manag-ers have been Göran Zetterström (NBHW) and Katarina Wiberg Hedman (SALAR).
The project has been accompanied by a dialogue with contacts at each of the 21 county councils.
Many of the indicators proceed from external databases and other sources, prima-rily national quality registers for cancer care. Our special gratitude goes to repre-sentatives of the registers, the regional cancer centres, and others who contributed to the report.
Lars Erik Holm Håkan Sörman
Director-General Executive Director
Swedish National Board Swedish Association of of Health and Welfare Local Authorities and Regions
Summary
This is the first time that open comparisons have been presented that reflect care quality for ten common forms of cancer in Sweden. The report compares the vari-ous counties in terms of medical outcomes, patient experience and waiting times.
Survival rates among cancer patients are increasingThe percentage of cancer deaths has declined over the past 40 years, while survival rates have risen. The relative five-year survival rate among men increased from just over 50 per cent in 1990–1994 to almost 70 per cent in 2005–2009. For women, the survival rate increased from 60 to 68 per cent.
Patients with breast cancer and malignant melanoma had the highest survival rates. The relative five-year survival rate among breast cancer patients was 87 per cent in 2005–2009. The survival rate for malignant melanoma was 93 per cent among women and 86 per cent among men during the period.
Lung cancer claims more Swedish lives each year than any other form of the disease. Relative survival rates are low but have increased, particularly the one-year rate, since the early 1990s. The relative five-year survival rate is approximately 15 per cent among women and 12 per cent among men.
No county consistently stands out in terms of survival rates for multiple types of cancer as well as for both sexes. However, lung cancer and bladder cancer show ma-jor variations between counties.
The frequency of multidisciplinary team meetings variesMultidisciplinary team meetings are often important for assessing a patient’s medi-cal needs and setting up an individual treatment plan. The report demonstrates that the number of new patients who receive such an assessment varies from 4 to 100 per cent between the different counties, as well as between the different forms of cancer. Multidisciplinary team meetings are not indicated or expedient prior to emergency surgery for colon cancer and in certain other situations.
Waiting times vary significantlyThe report shows that waiting times vary significantly among counties and forms of cancer. For instance, the median waiting time from receipt of a referral until the initial appointment with a specialist ranged from 17 to 43 days.
A concerted effort has been made in recent years to shorten healthcare waiting times. The waiting times presented in this report cover a period when this effort was beginning but had not been fully implemented. The data can now be used for future comparisons.
Diagnostic methods are more effective in some areasAssessment and diagnosis of cancer has improved in some areas. Here are a few examples:
• The number of patients who underwent bone scintigraphy for low-risk localised prostate cancer decreased from 38 to 4.5 per cent in 2000–2009 (few such pa-tients actually need the examination)
• A total of 83 per cent of all kidney cancer patients had CT scans, which is very close to the clinical practice guidelines target
• Almost all counties met the lung cancer guidelines that biopsies be performed for 99 per cent of patients
Some cancer care outcomesMost indicators in the report reflect medical quality, such as the use of various treat-ment options, as well as postoperative outcomes and complications. Following are some examples:
• The number of patients with medium to high-risk prostate cancer who received curative treatment increased from 48 per cent in 2000 to 68 per cent in 2009
• Use of the sentinel node technique to identify breast cancer cases in which com-plete removal of lymph nodes from the armpit area is indicated rose to 80 per cent in 2009
• A total of 1.5 per cent of breast cancer cases were reoperated in 2009 due to bleeding, infection or other complications; the percentage has remained essen-tially unchanged in recent years
• A total of 8.7 per cent of colon cancer cases and 10.8 per cent of rectal cancer cases were reoperated in 2007–2009
Open comparisons offer a snapshotThis report is descriptive in nature and strives to present a snapshot of current cancer care.
The dual purpose of the report is to provide supporting data for decision makers at various levels who are attempting to improve cancer care while offering the general public some insight into what publicly financed cancer care is accomplishing.
County outcomes for each of the indicators are shown in ranked diagrams, but no weighted ranking of the counties based on overall quality and efficiency is pre-
sented. The choice is intentional, given that no nationally confirmed method of weighting indicators has yet been devised. The outcomes should be interpreted in light of data quality and the other considerations discussed in connection with each indicator.
The report omits certain areas, including rehabilitation, nursing and psychosocial care, as well as patient experience of health and disease after treatment (patient-reported outcome measures). Registers, other data sources and indicators need to be developed for these areas before they can be included in future comparisons.
Contents
Introduction 10
GeneralIndicators 151 Cancersurvivalrates................................................................................................. 16
PalliaTivE CanCER CaRE
2 PercentageofpatientsforwhomVAS/NRSwasusedtoassesspainseverityduringthelastweekoflife.......................................... 17
3 On-demandprescriptionsforpainattheendoflife.................................................. 18
PaTiEnT ExPERiEnCE
Indicatorsspecifictoparticularformsofcancer 22
BREaST CanCER
9 Breastcancer–relativesurvivalrates....................................................................... 2310 Multidisciplinaryteammeetingspriortotratment..................................................... 2411 Multidisciplinaryteammeetingsaftersurgery........................................................... 2412 Waitingtimefrominitialappointmentwithaspecialistuntilsurgery......................... 2513 Waitingtimefromsurgerytotestresults.................................................................. 2514 Definitivepreoperativediagnosis............................................................................... 2715 Sentinelnodesurgery................................................................................................ 2816 ReoperationafterPAD............................................................................................... 2917 Reoperationwithinfourweeksduetocomplications................................................ 30
OvaRian CanCER
18 Survivalrateforovariancancer................................................................................. 3219 Waitingtimefromdiagnosisuntildecisiontotreat.................................................... 3320 Waitingtimefromdecisiontotreatuntilcommencementofchemotherapy............. 3321 Percentageofbiopsiesassessedbyasubspecialisedpathologist......................... 34
KiDnEy CanCER
22 Kidneycancer–survivalrates................................................................................... 3623 Waitingtimefromreferraltotheinitialappointmentwithaspecialist....................... 3724 Waitingtimefromdecisiontotreatuntilsurgery...................................................... 3825 PrimaryassessmentbasedonpreoperativethoracicCTscan................................. 39
BlaDDER CanCER
26 Bladdercancer–survivalrates.................................................................................. 4127 Waitingtimefromreceiptofthereferral
totheinitialappointmentwithaurologist.................................................................. 4228 Waitingtimefrominitialappointmentwitha
urologistuntiltransurethralresection........................................................................ 4329 IntravesicaltherapyforT1tumoursofthebladder.................................................... 4430 CurativetreatmentofT2–T4tumours....................................................................... 45
PROSTaTE CanCER
31 Waitingtimefortheinitialappointmentwithaurologist............................................ 4632 Bonescintigraphyforlow-riskprostatecancer........................................................ 4833 Activesurveillanceoflow-riskprostatecancer........................................................ 4934 Curativetreatmentformediumandhigh-riskprostatecancer................................. 5035 Treatmentoflocallyadvancedprostatecancer........................................................ 51
COlOn CanCER
36 Coloncancer–relativefive-yearsurvivalrates......................................................... 5337 Multidisciplinaryteammeetingspriortotreatment................................................... 5538 Multidisciplinaryteammeetingsaftersurgery........................................................... 5539 Atleasttwelvelymphnodesexaminedinthetumoursample.................................. 5840 Perforationofthecolonduringsurgery..................................................................... 6041 Morethan15daysofhospitalisationaftersurgery................................................... 6242 Reoperationduetocomplicationswithin30daysofprimarysurgery...................... 6543 Deathswithin30and90daysofsurgery.................................................................. 66
RECTal CanCER
44 Rectalcancer–relativefive-yearsurvivalrates......................................................... 6945 Multidisciplinaryteammeetingspriortotreatment................................................... 7146 Multidisciplinaryteammeetingsaftersurgery........................................................... 7147 Atleasttwelvelymphnodesexaminedinthetumoursample.................................. 7448 Preoperativeradiotherapy........................................................................................ 7849 Perforationoftherectumduringsurgery................................................................... 8050 Anastomosisinsufficiencyaftersurgery.................................................................... 8351 Morethan21daysofhospitalisationaftersurgery................................................... 8552 Reoperationduetocomplicationswithin30daysofprimarysurgery...................... 8753 Newcancerofthepelviswithinfiveyearsofsurgery................................................ 9154 Deathswithin30and90daysofsurgery.................................................................. 93
lung CanCER
55 Lungcancer–relativeone-year,two-yearandfive-yearsurvivalrates..................... 9856 Multidisciplinaryteammeetingpriortotreatment..................................................... 9957 Waitingtimefromreceiptofareferral
bythespecialistclinicuntildecisiontotreat........................................................... 10058 Lungcancerconfirmedbyabiopsy........................................................................ 10159 CombinedPET/CTscanpriortocurativetreatment.............................................. 10260 CurativesurgeryforstageIandIInon-small-celllungcancer................................ 10361 PalliativeradiotherapyforstageIIIBandIVlungcancer......................................... 10562 Palliativechemotherapyforincurablelungcancer.................................................. 107
HEaD anD nECK CanCER
63 Headandneckcancer–five-yearsurvivalrates..................................................... 10964 Multidisciplinaryteammeetingpriortotreatment.................................................. 11065 Waitingtimefromreceiptofareferraluntildecisiontotreat................................... 11166 Waitingtimefromreceiptofareferraluntilcommencementoftreatment.............. 112
MalignanT MElanOMa
67 Malignantmelanoma–relativefive-yearsurvivalrates........................................... 11468 Waitingtimefrominitialdoctor’sappointmentuntilprimarysurgery..................... 11669 Waitingtimefromsampletakinguntilnotificationofthediagnosis........................ 11770 Malignantmelanoma1.0millimetreorthinner......................................................... 118
Projectorganisation 121
10 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
Introduction
Open comparisons of cancer careEach year the Swedish National Board of Health and Welfare (NBHW) and the Swedish Association of Local Authorities and Regions (SALAR) publish a joint report entitled Quality and Efficiency in Swedish Health Care – Regional Compari-sons based on a series of indicators. The report compares counties with respect to medical outcomes, patient experience, waiting times and costs. Available national healthcare statistics provide the basic data for the report.
In 2010, the Government mandated the NBHW to collaborate with SALAR on a special edition for cancer care.
The overall purpose of the report is to promote local, regional and national im-provement efforts by comparing the quality of cancer care throughout the country. The comparisons should encourage the counties to perform in-depth analyses of their outcomes in order to further improve the quality and efficiency of the cancer care they provide. The report offers healthcare decision makers and administrators data and knowledge support for managing and monitoring the activities of their or-ganisations. It is also intended to provide the general public with insight into what publicly financed cancer care is accomplishing.
The Government’s national cancer strategy has taken the initiative for the imple-mentation of several new measures, including an emphasis on knowledge support and monitoring of cancer care outcomes. Open comparisons represent one approach to collecting and presenting data that can be used for follow-up and improvement purposes.
Knowledge support includes national guidelines to promote the adoption of evi-dence-based methods by the healthcare system. Sweden has national guidelines for breast, colon, rectal, prostate and lung cancer.
The report covers the following ten forms of cancer:
• breast • colon
• ovarian • rectal
• kidney • lung
• bladder • head and neck
• prostate • malignant melanoma
A total of 70 indicators are presented, 4–10 for each form of cancer.
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 11
All ten forms are very uncommon in children and adolescents. Thus, the report does not cover this population.
Open comparisons should include the entire care chain in order to ensure an over-all perspective. However, this report does not examine nursing, rehabilitation and certain other methods for treatment and care of cancer patients. Nor do any of the indicators reflect patient-reported outcome measures (PROMs).
Data sources The conditions for register-based performance measurement are unique in Sweden. Thanks to the identity number assigned to each Swedish resident, various national healthcare databases can be linked to each other and provide access to comparative outcome data.
The data sources used in the report are presented along with the description of out-comes. Further on in this chapter is a separate chart of the data sources that have been used.
The medical quality indicators are based primarily on data from the Swedish cancer register – which started in 1958 – as well as national quality registers. Information about these sources is available at www.socialstyrelsen.se and www.kvalitetsregister.se/cancer All data about patient experience are taken from the National Patient Survey (www.skl.se/nationellpatientenkat). The health data registers (Swedish Cancer Register, National Patient Register, etc.) and national quality registers con-tain data about individuals and unique care events. Reporting is mandatory to the health data registries and optional to the quality registers.
SWEDENHASADECENTRALISEDHEALTHCARESYSTEMTwentycountiesandregions,aswellasonemunicipality,areresponsibleforprovidingtheircitizenswithhospital,primary,psychiatricandotherhealthcareservices.Acountycounciltaxsupplementedbyagovernmentgrantisthemainmeansoffinancingthehealthcaresystem.Inaddition,smalluserfeesarepaidatthepointofuse.Long-termcarefortheelderlyisfinancedandorganizedbythemunicipalities.Eachcountyandregionisgovernedbyapoliticalassembly,whoserepresentativesareelectedforfouryearsingeneralelections.
Thecountiesandregionsareofdifferentsize.Withpopulationsbetweenoneandtwomillioneach,Stockholm,VästraGötalandandSkåneareconsiderablylargerthantherest.Gotlandissmallest,withabout60000inhabitants.Mostoftheothercountieshavepopulationsbetween200000and300000.
Withintheframeworkofnationallegislationandvaryinghealthcarepolicyinitiativesbythenationalgovernment,thecountiesandregionshavesubstantialdecisionmakingpowersandobligationstotheircitizens.TheSwedishhealthcaresystemisdecentral-ised.Thus,focusingontheperformanceoftheindividualcountiesandregionsisalogicalapproach.
12 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
Remarks on regional comparisons Every indicator is accompanied by a diagram and brief description. The diagrams are generally horizontal bar charts on which the counties appear in descending or-der. The national average is also presented in a separate colour. The counties at the top of the diagram have usually shown the best outcomes. Outcomes and therefore rankings can be affected by poor data quality and small differences between coun-ties whose data lack statistical significance.
Ranking is easy to justify when it comes to mortality, complications and certain other indicators, but additional factors – such as the health of the general popula-tion and case mix at the hospitals – must always be taken into consideration. Coun-ty populations were age standardised for some indicators to ensure more compara-ble outcomes. Such standardisation corrects for regional variations in age structure. However, no corrections were made for differences in health status or morbidity that do not correlate with age.
The report identifies regional variations in outcomes as measured by a series of quality indicators. The variations may be due to superior organisation and admin-istration of health care by certain counties; such observations can be used as a basis
DATASouRCES
Swedish national Board of Health and Welfare SwedishCancerRegisterNationalPatientRegisterSwedishPrescribedDrugRegisterCauseofDeathRegister
Swedish association of local authorities and RegionsNationalCaseCostingDatabaseNationalPatientSurvey
national Quality RegistersSwedishRegisterofPalliativeCareNationalBreastCancerRegisterNationalQualityRegisterforGynecologicalOnkologyNationalSwedishKidneyCancerRegisterSwedishBladderCancerRegisterNationalProstateCancerRegisterNationalColonCancerRegisterNationalRectalCancerRegisterNationalLungCancerRegisterSwedishHeadandNeckCancerRegisterSwedishMelanomaRegister
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 13
for improvement efforts. Variations may also stem from differences in terms of population health status or case mix, not to mention random fluctuations. Most of the diagrams show a 95 per cent confidence interval with a black line by the bar of each region. The lines represent the statistical uncertainty associated with the region’s actual performance.
Thus, ranking the counties in the diagrams consistently presents certain difficul-ties. If unreliable data quality or other interpretation problems call the ranking into question, the description of the indicator mentions or discusses it.
Some indicators have access to national guidelines or other material for evaluating outcomes. The discussion of such indicators contains an assessment of whether the outcomes as a whole meet the recommendations of the guidelines or their equiva-lent. With the exception of lung cancer, the national guidelines do not include for-mal targets. Any targets set by a medical speciality association or the like are speci-fied for the indicator in question.
The national average is not a yardstickThe diagrams usually rank the counties without explicit targets but highlight the national average. Viewing the average as a standard for an acceptable or passable outcome would be a misconception.
The national average is not a yardstick for evaluating regional outcomes. A region may have performed very well even though its outcome was far below average. The most important conclusion in such cases is that the outcomes for all counties are favourable. The converse is true as well. If the national average is low relative to individual Swedish hospitals, other countries or potential outcomes, a county may perform poorly and still end up at the top of the diagram.
If one or more large counties perform poorly, the national average may be far below the median. It may be better under such circumstances to base comparisons on the median county; outcomes must nevertheless be compared from a broader point of view than the national average or the median.
In other words, readers should not assume that the national average or the median represent a good or optimum outcome. Regardless of rank, outcomes should be ana-lysed in relation to performance over time or in comparison with other counties as a means of identifying potential for improvement.
14 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
ADDITIoNALMATERIALANDCoNTACTSThisreportmaybedownloadedinPDFformatfromwww.skl.se/compareorwww.socialstyrelsen.se/publications
ForinformationaboutthereportandtheongoingworkofthejointprojectQuality and Efficiency in Swedish Health Care – Regional Comparisons,writeto
BodilKlintberg,SwedishAssociationofLocalAuthoritiesandRegions([email protected])
MonaHeurgren,SwedishNationalBoardofHealthandWelfare([email protected]).
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 15
GeneralIndicators
One out of every three Swedes has cancer at some point in their life. The disease occurs with approximately equal frequency in both sexes, but women and men de-velop different forms. Prostate cancer is most common in men and breast cancer in women. Prostate, breast, lung, colon and rectal cancer account for half of all new cases in the adult population.
Statistics for 2009 Women Men
Numberofdiagnoses 25721 28890
Prevalence,total 228665 183294
Relativefive-yearsurvivalrates 67.6% 69.2%
Numberofdeaths 10769 11686
16 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
Figure 1Sweden
Cancer, relative five-year survival rates. Trend, 1990–2009. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare
Percent
0
20
40
60
80
100
2005-20092000-20041995-19991990-1994
Women
Total
Men
Figure 1Total
Cancer, relative five-year survival rates. Patients diagnosed in 2000–2004. Patients age 30–89 at the time of diagnosis. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare
Confidence interval calculated using Taylor series Percent
72.672.070.970.369.669.568.968.868.467.867.567.567.567.367.366.866.766.265.965.465.363.4
0 20 40 60 80 100
GävleborgVästernorrland
BlekingeÖstergötland
NorrbottenJämtlandSörmland
DalarnaÖrebro
VästerbottenUppsala
VärmlandVästmanland
GotlandSWEDEN
SkåneKronoberg
Västra GötalandKalmar
StockholmJönköping
Halland
1 Cancer survival ratesThe percentage of cancer deaths has declined over the past 40 years, while survival rates have risen. One reason for the improvement is that the healthcare system is better able to make early diagnoses and offer effective treatment.
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 17
PALLIATIvECANCERCAREThe NBHW national guidelines for breast, colorectal and prostate cancer care in-clude palliative care. The guidelines assign top priority to estimating and assessing pain severity, prescribing opioids on demand at the end of life and certain other measures. They also contain indicators for those two particular measures. Data have been taken from the Swedish Register of Palliative Care , which started in 2005 and covered 42 per cent of all deaths after the first quarter of 2011. The participation rate was higher (over 57 per cent) for expected cancer deaths.
2 Percentage of patients for whom vaS/nRS was used to assess pain severity during the last week of life
Proper alleviation of pain requires structured treatment, including uniform assess-ment methods. Routine, structured assessments enable effective treatment. The Visual Analogue Scale (VAS) and Numeric Rating Scale (NRS) are recommended instruments for assessing pain.
The results should be interpreted with caution given that the register generally had a limited participation rate in 2010, while some counties had a low participation rate and few reported cases.
Figure 2Total
Percentage of cancer patients at the end of life who assessed pain intensity on the VAS/NRS scale, 2010. Source: Swedish Register of Palliative Care
2009 Percent
Participation rate 2010
41.438.927.023.520.519.918.817.215.213.913.513.011.4
9.58.58.48.17.36.75.85.43.9
76626951443857468769727451546061448256515850
0 10 20 30 40 50
VästmanlandVärmland
Västra GötalandÖrebro
DalarnaBlekingeUppsala
KronobergVästerbotten
NorrbottenSörmland
GävleborgGotlandKalmar
SkåneSWEDEN
VästernorrlandHalland
JönköpingJämtland
StockholmÖstergötland
18 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
3 On-demand prescriptions for pain at the end of lifeMost patients who die of cancer experience pain during the last week of life. Much of the pain can be alleviated by means of opioid treatment as soon as it develops. The national guidelines specify that options for administering drugs be prescribed in advance. The Swedish Register of Palliative Care contains the number of patients who received an on-demand prescription up to 24 hours before death.
Figure 3Total
Percentage of cancer patients who were prescribed opioids on an on-demand basis at the end of life, 2010. Source: Swedish Register of Palliative Care
2009 Percent
Participation rate 2010
97.597.397.096.996.596.496.196.096.095.995.895.795.495.494.994.593.593.292.992.091.591.2
56444669625451385061517660578269445172745887
0 20 40 60 80 100
KalmarVärmlandSörmland
GävleborgNorrbotten
BlekingeJämtlandDalarna
SWEDENKronoberg
ÖstergötlandVästra Götaland
UppsalaVästmanland
VästernorrlandJönköping
VästerbottenStockholm
GotlandSkåne
HallandÖrebro
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 19
PATIENTExPERIENCESALAR conducts the National Patient Survey on behalf of Sweden’s county coun-cils and regions. This report presents the results of the survey with respect to spe-cialised medical care during appointments at oncology clinics or stays at oncology departments in 2010. The survey contains questions about the information patients received, the caregiver attitudes they encountered and their degree of participation in the care process. Patients were given the opportunity to describe their appoint-ment or stay and to grade their experience.
Approximately 200 000 questionnaires were sent to a random sample of people who had received outpatient or inpatient medical care during specific weeks in spring 2010. Approximately 88 000 outpatients and 34 000 inpatients responded. The na-tional response rate was 61 per cent among outpatients and 67 per cent among in-patients.
Neither the Stockholm nor Norrbotten County Council were included but are par-ticipating in the 2011 survey.
The data for this report have been taken from the National Patient Survey, but only a few hospitals are able to provide outcomes for their oncology clinics or depart-ments. The response rate was 75 per cent for both clinics and departments. This report does not cover cancer patients who had an appointment with a non-onco-logical outpatient clinic or were admitted to a non-oncological department during the period. However, those who had not been diagnosed with cancer but went to an oncology clinic or department were included.
The indicators in this report that are based on the National Patient Survey reflect caregiver attitudes, patient participation and information received in both outpa-tient (clinic) and inpatient (department) care. Outcomes are also presented with re-spect to the physician in charge of inpatient care, as well as planning for continued outpatient care. The outcomes are shown at the hospital level for those that report an oncology clinic or department separately.
Outcomes that are based on the National Patient Survey are presented as weighted patient-reported quality. An ascending scale of 1 to 100 has been used.
Figure 4AHospital,clinic
"Did you feel that you were treated respectfully and considerately?" Patient-reported quality at an oncology clinic or department, spring 2010.Source: National Patient Survey, Swedish Association of Local Authorities and Regions
97.597.095.694.696.699.296.196.596.895.094.896.997.4
RegionUppsala
SörmlandÖstergötland
JönköpingKalmar
GotlandSkåne
VärmlandÖrebro
VästmanlandGävleborg
VästernorrlandVästerbotten
PUK
0 20 40 60 80 100
Norrlands Universitetssjukhus, UmeåLänssjukhuset Sundsvall-Härnösand
Gävle sjukhusVästerås lasarett
Universitetssjukhuset ÖrebroCentralsjukhuset i KarlstadSkånes universitetssjukhus
Visby lasarettLänssjukhuset i Kalmar
Länssjukhuset Ryhov, JönköpingUniversitetssjukhuset, Linköping
Mälarsjukhuset, Eskilstuna/Nyköpings sjukhusAkademiska sjukhuset, Uppsala
Figure 4BHospital,department
"Did you feel that you were treated respectfully and considerately?" Patient-reported quality at an oncology clinic or department, spring 2010.Source: National Patient Survey, Swedish Association of Local Authorities and Regions
92.493.992.395.696.596.3
RegionUppsala
JönköpingSkåne
Västra GötalandÖrebro
Västerbotten
PUK
0 20 40 60 80 100
Norrlands Universitetssjukhus, UmeåUniversitetssjukhuset Örebro
Sahlgrenska universitetssjukhusetSkånes universitetssjukhus
Länssjukhuset Ryhov, JönköpingAkademiska sjukhuset, Uppsala
Figure 5AHospital,clinic
"Did you feel as though you participated in your care and treatment as much as you wanted?" Patient-reported quality at an oncology clinic or department, spring 2010. Source: National Patient Survey, Swedish Association of Local Authorities and Regions
84.677.383.084.987.587.183.881.686.482.982.787.187.5
RegionUppsala
SörmlandÖstergötland
JönköpingKalmar
GotlandSkåne
VärmlandÖrebro
VästmanlandGävleborg
VästernorrlandVästerbotten
PUK
0 20 40 60 80 100
Norrlands Universitetssjukhus, UmeåLänssjukhuset Sundsvall-Härnösand
Gävle sjukhusVästerås lasarett
Universitetssjukhuset ÖrebroCentralsjukhuset i KarlstadSkånes universitetssjukhus
Visby lasarettLänssjukhuset i Kalmar
Länssjukhuset Ryhov, JönköpingUniversitetssjukhuset, Linköping
Mälarsjukhuset, Eskilstuna/Nyköpings sjukhusAkademiska sjukhuset, Uppsala
Figure 5BHospital,department
"Did you feel as though you participated in your care and treatment as much as you wanted?" Patient-reported quality at an oncology clinic or department, spring 2010. Source: National Patient Survey, Swedish Association of Local Authorities and Regions
77.182.183.581.186.683.9
RegionUppsala
JönköpingSkåne
Västra GötalandÖrebro
Västerbotten
PUK
0 20 40 60 80 100
Norrlands Universitetssjukhus, UmeåUniversitetssjukhuset Örebro
Sahlgrenska universitetssjukhusetSkånes universitetssjukhus
Länssjukhuset Ryhov, JönköpingAkademiska sjukhuset, Uppsala
Figure 6AHospital,clinic
"Did you receive enough information about your condition?" Patient-reported quality at an oncology clinic or department, spring 2010.Source: National Patient Survey, Swedish Association of Local Authorities and Regions
1 Fewer than 30 cases
87.084.583.084.187.587.586.185.587.785.286.0
89.6
RegionUppsala
SörmlandÖstergötland
JönköpingKalmar
GotlandSkåne
VärmlandÖrebro
VästmanlandGävleborg
VästernorrlandVästerbotten
PUK
0 20 40 60 80 100
Norrlands Universitetssjukhus, UmeåLänssjukhuset Sundsvall-Härnösand 1
Gävle sjukhusVästerås lasarett
Universitetssjukhuset ÖrebroCentralsjukhuset i KarlstadSkånes universitetssjukhus
Visby lasarettLänssjukhuset i Kalmar
Länssjukhuset Ryhov, JönköpingUniversitetssjukhuset, Linköping
Mälarsjukhuset, Eskilstuna/Nyköpings sjukhusAkademiska sjukhuset, Uppsala
Figure 6BHospital,department
"Did you receive enough information about your condition?" Patient-reported quality at an oncology clinic or department, spring 2010.Source: National Patient Survey, Swedish Association of Local Authorities and Regions
83.081.886.682.686.084.8
RegionUppsala
JönköpingSkåne
Västra GötalandÖrebro
Västerbotten
PUK
0 20 40 60 80 100
Norrlands Universitetssjukhus, UmeåUniversitetssjukhuset Örebro
Sahlgrenska universitetssjukhusetSkånes universitetssjukhus
Länssjukhuset Ryhov, JönköpingAkademiska sjukhuset, Uppsala
Figure 7Hospital,clinic
“Were any plans made for your ongoing care during the appointment?” Patient-reported quality at an oncology clinic or department, spring 2010.Source: National Patient Survey, Swedish Association of Local Authorities and Regions
82.190.183.984.492.593.688.185.786.881.291.793.890.8
RegionUppsala
SörmlandÖstergötland
JönköpingKalmar
GotlandSkåne
VärmlandÖrebro
VästmanlandGävleborg
VästernorrlandVästerbotten
PUK
0 20 40 60 80 100
Norrlands Universitetssjukhus, UmeåLänssjukhuset Sundsvall-Härnösand
Gävle sjukhusVästerås lasarett
Universitetssjukhuset ÖrebroCentralsjukhuset i KarlstadSkånes universitetssjukhus
Visby lasarettLänssjukhuset i Kalmar
Länssjukhuset Ryhov, JönköpingUniversitetssjukhuset, Linköping
Mälarsjukhuset, Eskilstuna/Nyköpings sjukhusAkademiska sjukhuset, Uppsala
Figure 8Hospital,department
“Do you know which doctor was responsible for your care?” Patient-reported quality at an oncology clinic or department, spring 2010. Source: National Patient Survey, Swedish Association of Local Authorities and Regions
65.480.478.988.469.982.8
RegionUppsala
JönköpingSkåne
Västra GötalandÖrebro
Västerbotten
PUK
0 20 40 60 80 100
Norrlands Universitetssjukhus, UmeåUniversitetssjukhuset Örebro
Sahlgrenska universitetssjukhusetSkånes universitetssjukhus
Länssjukhuset Ryhov, JönköpingAkademiska sjukhuset, Uppsala
22 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
Indicatorsspecifictoparticularformsofcancer
This chapter presents the indicators for the ten forms of cancer covered by the re-port. The comparisons include both general indicators – cancer survival rates, wait-ing times, frequency of multidisciplinary team meetings, etc. – and those that are specific to particular forms of cancer.
The section on each form of cancer starts off with a brief overview of its frequency in 2009, the last year for which data are available from the cancer register and cause of death register. The next segment presents the outcomes for the various indicators.
BREASTCANCER
Statistics for 2009 Women
Numberofdiagnoses 7380
Percentageofallcancercases 29%
Prevalence,total 88825
Relativefive-yearsurvivalrate 87%
Numberofdeaths 1378
Breast cancer is the most common form of the disease in middle-aged women. A total of 7 380 women were diagnosed with breast cancer in 2009, and Sweden cur-rently has approximately 88 800 survivors. The average age at the time of diagnosis was 60. A total of 1 378 women died of breast cancer in 2009.
In very rare cases (30 in 2009), men develop breast cancer as well. This report covers women only.
Almost all breast cancer in Sweden is operable. The breast cancer register’s follow-up for 2008 showed that 93 per cent, a figure that varied by only 1–2 per cent among the different counties, of patients had undergone surgery.
This report presents nine breast cancer indicators, four of which concern the qual-ity of surgery. One indicator reflects survival, two reflect the frequency of multidis-ciplinary team meetings and two reflect waiting times. With the exception of the survival rate indicator, which used the Swedish Cancer Register , data were taken from the National Breast Cancer Register.
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 23
The Swedish Association for Breast Cancer Surgery (SFBK) has put together guide-lines that contain both process and outcome measures. The SFBK proposes specific targets for indicators for which ranges have been set up.
9 Breast cancer – relative survival ratesRelative survival rates for breast cancer patients have been high since the early 1990s. Figure 9 shows that the relative five-year survival rate rose from approxi-
Figure 9 Sweden
Breast cancer – relative five-year survival rates. Trend, 1990–2009. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare
Percent
0
20
40
60
80
100
2005-20092000-20041995-19991990-1994
Figure 9Women
Breast cancer – relative five-year survival rates. Patients diagnosed in 2000– 2004. Patients age 30–89 at the time of diagnosis. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare
Confidence interval calculated using Taylor series Percent
90.389.589.088.588.487.787.687.187.187.086.586.386.186.085.785.785.385.384.884.484.082.3
0 20 40 60 80 100
GotlandGävleborg
VästerbottenVärmland
ÖrebroVästernorrland
VästmanlandBlekinge
SkåneSörmland
DalarnaKalmar
SWEDENVästra Götaland
HallandJämtland
ÖstergötlandStockholmJönköping
UppsalaNorrbottenKronoberg
24 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
mately 80 per cent in 1990–1994 to 87 per cent in 2005–2009. The regional differ-ences were negligible – 97.0–97.7 per cent for one-year survival and 85.9–88.3 per cent for five-year survival. As indicated by Figure 9, the gap between counties was somewhat wider.
The relative five-year survival rate was 65 per cent in the mid-1960s. The number rose to 84 per cent for patients diagnosed in the 1990s and to 87 per cent in 2005–2009.
The most interesting observation about this indicator is that outcomes have been both uniform and impressive throughout the country.
10–11 Multidisciplinary team meetingsPrimary breast cancer treatment may be preceded by a multidisciplinary team meeting, a comprehensive assessment for the purpose of optimising the interven-tion. Surgery, oncology, radiology and pathology specialists, as well as nurses, may participate. The NBHW national guidelines for breast cancer care recommend a multidisciplinary team meeting both before commencement of treatment and postoperatively.
Figure 10Women
Percentage of patients who had a multidisciplinary team meeting prior to decision to treat breast cancer, 2009. Source: National Breast Cancer Register
1 No data available 2008 Percent
100.099.398.798.698.397.597.196.896.496.296.095.594.692.091.591.189.886.980.951.442.1
0 20 40 60 80 100
Örebro 1
ÖstergötlandJönköping
KalmarVästernorrland
BlekingeVästerbotten
GävleborgSWEDEN
NorrbottenVästra Götaland
GotlandJämtlandUppsalaHalland
StockholmSkåne
SörmlandDalarna
KronobergVärmland
Västmanland
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 25
The comparison finds excellent outcomes for the great majority of counties. Both pre- and postoperative multidisciplinary team meetings are much more frequent for breast cancer than for most other forms of the disease.
12 Waiting time from initial appointment with a specialist until surgeryThe SFBK, which advocates for a rapid care process, argues that more than 90 per cent of all patients with verified breast cancer should be offered surgery within three weeks and 100 per cent within four weeks. The indicator reflects the waiting time from the initial appointment with a specialist (surgeon) until surgery. Waiting time is affected by the local structure of the breast cancer care chain. In some coun-ties, an assessment has begun or has already been completed before the patient is referred to a specialist clinic for treatment.
13 Waiting time from surgery to test results A postoperative pathological anatomical diagnosis of the tumour, along with the surrounding tissue, is performed. The indicator shows the waiting time from sur-gery until the patient is notified of the test results. The SFBK targets waiting time of no more than one week. Waiting time is affected by the availability of patholo-gists, as well as procedures for handling tests and results.
Figure 11Women
Percentage of patients who had a multidisciplinary team meeting prior to breast cancer surgery, 2009. Source: National Breast Cancer Register
2008 Percent
100.0100.0100.0
99.999.799.699.599.599.599.399.199.199.099.098.696.495.895.688.988.464.737.4
0 20 40 60 80 100
KalmarÖstergötland
JönköpingBlekinge
VästernorrlandSWEDEN
ÖrebroUppsala
Västra GötalandGävleborg
HallandJämtland
KronobergVästerbottenVästmanland
DalarnaVärmlandStockholm
SkåneSörmland
NorrbottenGotland
26 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
Figure 12Women
Waiting time from initial appointment with a specialist until breast cancer surgery, 2009.Source: National Breast Cancer Register
Value first quartile Median Value third quartileDays
13131515151617192021212122222222232425262728
0 10 20 30 40 50
GävleborgSörmland
DalarnaVästerbotten
JämtlandKalmar
StockholmSkåne
VärmlandGotland
SWEDENVästra Götaland
VästernorrlandÖstergötland
BlekingeÖrebro
JönköpingHalland
KronobergVästmanland
UppsalaNorrbotten
Figure 13Women
Waiting time from breast cancer surgery until patient received results of PAD, 2009. Source: National Breast Cancer Register
Value first quartile Median Value third quartileDays
13151516161920202021212222222224252728283134
0 10 20 30 40 50
SörmlandÖstergötland
VästernorrlandJönköping
KalmarVästerbotten
HallandVästmanland
BlekingeSWEDEN
Västra GötalandStockholmVärmland
UppsalaSkåne
DalarnaGotland
GävleborgNorrbotten
ÖrebroKronoberg
Jämtland
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 27
14 Definitive preoperative diagnosisTo minimise the risk of reoperation, assessments of changes in breast tissue when malignancy is suspected should strive to provide patients with as accurate a preop-erative diagnosis as possible. The NBHW national guidelines for breast cancer care highlight definitive preoperative diagnosis of malignancy as an important indicator to monitor. According to the association, at least 90 per cent of patients should re-ceive a definitive preoperative diagnosis.
Figure 14Women
Percentage of patients with confirmed diagnosis prior to breast cancer surgery, 2009. Source: National Breast Cancer Register
2008 Percent
97.997.096.295.694.494.294.093.791.190.890.489.889.389.088.688.085.785.684.982.481.477.6
0 20 40 60 80 100
JönköpingÖstergötland
GävleborgVästernorrland
UppsalaGotlandKalmar
HallandSkåne
VästerbottenSWEDEN
ÖrebroStockholm
Västra GötalandVästmanland
NorrbottenVärmland
BlekingeJämtlandDalarna
SörmlandKronoberg
28 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
15 Sentinel node surgerySentinel node surgery involves removal of the potentially malignant first lymph node. A tracer that is injected in the breast locates the sentinel node and shows up during surgery. The node is analysed microscopically for signs of metastasis. The procedure reduces the number of patients who undergo complete removal of lymph nodes from the armpit area, thereby reducing the risk of annoying postoperative swelling there.
According to the NBHW national guidelines, the sentinel node technique may be indicated for tumours that are up to four centimetres in diameter. It should be used in patients with invasive breast cancer, i.e., when the tumour has formed cell lines in the surrounding normal tissue. The technique has been used in Sweden since 1997 and is currently available at one or more hospitals in most counties. When it is not offered, primarily at small hospitals, the patient can go to another hospital nearby.
Figure 15Women
Percentage of invasive breast cancer patients who underwent surgery with the sentinel node technique, 2009. Refers to tumours 4 cm or smaller. Source: National Breast Cancer Register
2008 Percent
84.884.184.083.082.482.382.182.181.781.280.980.880.680.678.277.676.176.173.770.869.065.4
0 20 40 60 80 100
DalarnaBlekinge
KronobergÖrebroKalmar
HallandGävleborg
VästerbottenÖstergötland
JämtlandVästernorrland
SWEDENUppsala
VärmlandGotland
SörmlandVästra Götaland
NorrbottenJönköping
VästmanlandStockholm
Skåne
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 29
16 Reoperation after PaDA postoperative pathological anatomical diagnosis (PAD) of the tumour, along with surrounding tissue (such as lymph nodes), is performed. If the analysis shows re-maining tumour cells or cancer within a larger area than previously known, reop-eration is recommended to minimise the risk of recurrence. The second operation may involve additional physical suffering.
The NBHW national guidelines for breast cancer care identify the percentage of re-operations after PAD as an important indicator to monitor. The indicator measures both the quality of the preoperative malignancy assessment and how successful the surgeon is in removing the tumour.
The data are based on relatively few cases, generating a broad confidence interval. Errors may also occur because not all hospitals report reoperations to the breast cancer register. Outcomes should also be related to the degree to which breast-pre-serving surgery, which increases the risk of reoperation, has been performed – and whether the purpose of primary surgery was to confirm a cancer diagnosis.
In the view of the Swedish Association for Breast Cancer Surgery, treatment should be as definitive as possible in order to avoid reoperation and PAD should lead to re-operation in fewer than 10 per cent of all cases. The comparison demonstrates that only five counties remained below the recommended level.
Figure 16Women
Percentage of breast cancer patients who underwent reoperation due to tumour data, 2009.Source: National Breast Cancer Register
2008 Percent
1.77.27.87.98.4
10.110.510.710.811.111.511.811.912.314.314.314.815.616.616.917.624.3
0 10 20 30 40
KronobergÖrebro
JönköpingSkåne
VärmlandKalmar
UppsalaGotland
VästernorrlandSWEDEN
VästerbottenDalarna
StockholmÖstergötlandVästmanland
GävleborgBlekinge
SörmlandHalland
NorrbottenVästra Götaland
Jämtland
30 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
17 Reoperation within four weeks due to complicationsMore than 90 per cent of breast cancer patients undergo surgery. The scope of sur-gery varies according to the location and microscopic presentation of the tumour, as well the patient’s general state of health. Complications may require relatively prompt reoperation. Among such complications are bleeding, which usually occurs within 24 hours, or infection, whose symptoms appear within a week. The second operation may involve additional physical suffering. Follow-up by the breast can-cer register indicates that most reoperations are due to bleeding within the first 24 hours. Given that breast cancer operations are regarded as clean surgery, infection should be rare; in fact, very few reoperations are performed as the result of surgical site infection. However, infections that do not lead to reoperations are not entered in the register.
The NBHW national guidelines for breast cancer care identify the percentage of re-operations within 30 days due to complications as an important indicator to monitor.
The data are based on relatively few cases, generating a broad confidence interval. Moreover, some hospitals may fail to report reoperations to the breast cancer reg-ister. It goes without saying that the percentage of reoperations due to unforeseen events should be as low as possible. A national average of one or two percentage points is a good target.
Figure 17Women
Percentage of breast cancer patients who underwent reoperation within 30 days due to complications, 2009. Source: National Breast Cancer Register
2008 Percent
0.50.50.50.80.91.01.31.31.41.51.51.61.61.61.92.22.22.93.94.85.56.1
0 10 20 30 40
JämtlandBlekingeGotland
NorrbottenDalarna
JönköpingKalmar
VästmanlandVärmland
ÖrebroVästernorrland
Västra GötalandSWEDEN
KronobergHalland
ÖstergötlandStockholmSörmland
SkåneVästerbotten
UppsalaGävleborg
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 31
ovARIANCANCER
Statistics for 2009 Women
Numberofdiagnoses 780
Percentageofallcancercases 3%
Prevalence,total 8752
Relativefive-yearsurvivalrate 44.0%
Numberofdeaths 675
Approximately 800 women develop ovarian cancer every year. The prognosis is fair-ly poor and the relative five-year survival rate is 44 per cent. A total of 675 Swedes died of ovarian cancer in 2009. Due partially to the protective effect of oral contra-ceptives, the incidence has declined since 1975.
Many forms of cancer are broken down into four stages according to how far the tumour has spread. In this case, malignancy is limited to the ovaries during the first stage and has metastasised outside the abdominal cavity by the fourth stage. The disease has an insidious course and is often diagnosed late because it does not cause any symptoms early on. Approximately 60 per cent of cases are in the third or fourth stage when diagnosed.
This report presents four indicators: one for survival rate, one for the care proc-ess, and two for waiting time. Five-year survival rates by county are based on data from the Swedish Cancer Register. The other indicators are taken from the National Quality Register for Gynecological Onkology and presented at the regional level. The register started in 2008. This report generally presents indicators at the county level, but representatives of the quality register believe that this data cannot yet be accounted for other than at the regional level.
32 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
18 Survival rate for ovarian cancerSurvival rates, particularly for one or two years, among ovarian cancer patients have risen since 1990. The five-year survival rate also increased somewhat to 44 per cent in 2005–2009 (see Figure 18). Some regional differences exist, but the confidence intervals are broad and the role of chance cannot be ruled out.
Figure 18Women
Ovarian cancer – relative five-year survival rates. Patients diagnosed in 2000– 2004. Patients age 30–89 at the time of diagnosis. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare
Confidence interval calculated using Taylor series Percent
55.150.047.847.446.645.244.944.744.144.043.843.843.643.442.240.540.439.238.938.638.334.9
0 20 40 60 80
JämtlandGotlandHalland
KronobergGävleborgSörmland
ÖrebroUppsala
NorrbottenKalmar
Västra GötalandSkåne
SWEDENVästernorrland
DalarnaVärmlandStockholm
BlekingeÖstergötlandVästerbotten
JönköpingVästmanland
Figure 18Sweden
Ovarian cancer – relative five-year survival rates. Trend, 1990–2009. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare
Percent
0
20
40
60
80
100
2005-20092000-20041995-19991990-1994
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 33
Healthcare region
Figure 19Women
Waiting time from confirmed diagnosis until decision to treat for ovarian cancer patients, 2009. Source: National Quality Register for Gynecological Cancer
Value first quartile Median Value third quartileDays
20242529293442
0 10 20 30 40 50 60
Norra Stockholm-Gotland
SWEDENSödra
Uppsala-ÖrebroVästra
Sydöstra
Healthcare region
Figure 20Women
Waiting time from decision to treat until commencement of chemotherapy for ovarian cancer patients, 2009. Source: National Quality Register for Gynecological Cancer
Value first quartile Median Value third quartileDays
16667
1417
0 5 10 15 20 25 30
Västra Sydöstra
SWEDENUppsala-Örebro
Södra Stockholm-Gotland
Norra
19 Waiting time from diagnosis until decision to treatOvarian cancer is often detected late when it has already reached a serious stage. Thus, minimising the waiting time from diagnosis until decision to treat is particu-larly important.
20 Waiting time from decision to treat until commencement of chemotherapy
Approximately 80 per cent of all ovarian cancer cases should be treated with chem-otherapy – as soon as possible, considering the course of the disease. According to the national healthcare guarantee, treatment is to commence within 90 days after the decision.
Based on data for 452 patients, Figure 20 shows the number of days that 25, 50 and 75 per cent of patients waited between the decision to treat and commencement of chemotherapy. Fifty per cent of patients nationwide began chemotherapy within a week and 75 per cent within 19 days. Seventy-five per cent of patients in the north-ern region started within two days.
34 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
The National Quality Register for Gynecological Onkology contains waiting time data for 60 per cent of patients who were entered based on a decision to treat in accordance with Indicator 19 above. The relatively large percentage of unreported cases affects the outcomes for this indicator.
21 Percentage of biopsies assessed by a subspecialised pathologist Diagnosis and decision to treat ovarian cancer cases are based on the pathologist’s assessment of the biopsy. The National Quality Register for Gynecological Onkol-ogy has performed follow-ups indicating that a fairly large number of diagnoses would be re-evaluated if the biopsy were also assessed by a subspecialised gynaeco-logical pathologist. The assessment influences the prognosis and can be crucial to ongoing treatment.
Figure 21Women
Percentage of ovarian cancer patients whose biopsies were examined by a subspecialised pathologist prior to decision to treat, 2008–2009.Source: National Quality Register for Gynecological Cancer
Percent
45.544.137.329.228.920.811.8
0 10 20 30 40 50 60
Uppsala-ÖrebroSydöstra
SWEDENVästraSödra
Stockholm-GotlandNorra
Healthcare region
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 35
KIDNEYCANCER
Statistics for 2009 Women Men
Numberofdiagnoses 342 517
Percentageofallcancercases 1% 2%
Prevalence,total 3555 4529
Relativefive-yearsurvivalrate 66.1% 63.7%
Numberofdeaths 198 344
Approximately 2 per cent of all cancer cases among Swedish adults are of the kidney. Men account for approximately 60 per cent of the diagnoses. Incidence has declined over the past two decades, and no major differences between healthcare counties have been reported. Almost 900 people, most of them over 65, are diagnosed with kidney cancer every year. The causes have not been fully determined, but smoking and renal failure are two known risk factors.
The prognosis has improved over the past decade. The five-year survival rate is 90-95 per cent for patients with small tumours that do not yet extend through the renal capsule. The overall five-year survival rate for both sexes is better than 60 per cent.
The report presents outcomes for four indicators, three of which are based on data from the National Swedish Kidney Cancer Register. One indicator concerns surviv-al rates in accordance with data from the Swedish Cancer Register, and two reflect waiting times at various links in the care chain. The fourth indicator presents the percentage of patients who have been assessed on the basis of thoracic CT scans as recommended by the clinical practice guidelines.
36 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
22 Kidney cancer – survival ratesAfter having held steady in the 1990s, the relative five-year survival rate increased for both women and men in the early 2000s. Figure 22 shows that the rate was higher than 66 per cent for women and almost 64 per cent for men in 2005–2009. The various counties range from 49.4 to 75.7 per cent.
Figure 22Total
Kidney cancer – relative five-year survival rates. Patients diagnosed in 2000– 2004. Patients age 30–89 at the time of diagnosis. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare
Confidence interval calculated using Taylor series Percent
75.774.372.670.869.869.467.265.665.565.465.364.563.461.761.260.560.359.458.955.554.449.4
0 20 40 60 80 100
DalarnaUppsala
SörmlandÖstergötland
GotlandNorrbottenKronoberg
Västra GötalandJönköping
JämtlandSWEDEN
SkåneVästernorrland
KalmarÖrebro
VästerbottenStockholm
VästmanlandHalland
GävleborgVärmland
Blekinge
Figure 22 Sweden
Kidney cancer – relative five-year survival rates. Trend, 1990–2009. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare
Percent
0
20
40
60
80
100
2005-20092000-20041995-19991990-1994
Women
Total
Men
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 37
Figure 23Total
Waiting time from receipt of referral until the initial appointment with a specialist for assessment of kidney cancer, 2009. Source: National Swedish Kidney Cancer Register
1 Fewer than 10 cases Value first quartile Median Value third quartileDays
Number of patients
89
10101314141516171717171920212121252526
24182031261230
129262223
781110
2619
1392319192435
0 20 40 60 80
Gotland 1
ÖstergötlandVästmanland
JämtlandVärmland
KronobergStockholm
DalarnaGävleborg
SkåneSWEDEN
VästerbottenÖrebro
HallandVästra Götaland
SörmlandBlekingeUppsala
NorrbottenKalmar
VästernorrlandJönköping
23 Waiting time from referral to the initial appointment with a specialist
The goal is to minimise the waiting time from a referral due to suspicion of cancer until an appointment with a specialist. The waiting time has been reported to the register since 2009.
38 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
24 Waiting time from decision to treat until surgery The waiting time from decision to treat until surgery should be as short as possible. The indicator reflects the healthcare system’s resources and organisational capacity. The waiting time has been reported to the register since 2009.
Figure 24Total
Waiting time from decision to treat until surgery for kidney cancer, 2009. Source: National Swedish Kidney Cancer Register
1 Fewer than 10 cases Value first quartile Median Value third quartileDays
Number of patients
102021222323242526262727272828282829303641
11232821182020
127140
212321
7613015
1112334252420
0 20 40 60 80
Gotland 1
DalarnaVärmland
KronobergÖstergötland
GävleborgSkåne
JämtlandSörmlandSWEDEN
UppsalaÖrebro
VästerbottenStockholm
Västra GötalandHalland
VästernorrlandKalmar
VästmanlandNorrbottenJönköping
Blekinge
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 39
Figure 25Sweden
Percentage of patients who underwent thoracic CT scan prior to kidney cancer surgery. Trend, 2005–2009. Source: National Swedish Kidney Cancer Register
Percent
0
20
40
60
80
100
20092008200720062005
Women
Total
Men
Figure 25Total
Percentage of patients who underwent thoracic CT scan prior to kidney cancer surgery, 2008–2009. Source: National Swedish Kidney Cancer Register
2006–2007 Percent
95.993.892.792.391.490.689.885.983.883.383.382.681.580.480.278.978.678.478.472.568.665.5
0 20 40 60 80 100
HallandKalmar
DalarnaUppsala
SörmlandJämtland
NorrbottenSkåne
JönköpingVästra Götaland
SWEDENStockholm
BlekingeGävleborg
ÖstergötlandKronobergVärmland
VästerbottenGotlandÖrebro
VästernorrlandVästmanland
25 Primary assessment based on preoperative thoracic CT scanDistant metastases from kidney cancer are often located in the lungs. A decisive pr-eoperative assessment, best performed on the basis of a thoracic CT scan, is whether the malignancy has metastasised to the lungs. According to the clinical practice guidelines, 85 per cent of all cases should be assessed on the basis of thoracic CT scans.
40 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
BLADDERCANCER
Statistics for 2009 Women Men
Numberofdiagnoses 587 1667
Percentageofallcancercases 2% 6%
Prevalence,total 5397 15119
Relativefive-yearsurvivalrate 73.0% 76.0%
Numberofdeaths 214 473
More than 2 000 Swedes, three-quarters of whom are men, develop bladder cancer every year. Many patients see their doctor for presumed urinary tract infection due to blood in the urine. The number of cases started to rise significantly in the 1960s but appears to have levelled off in the 2000s. The average age at diagnosis is approxi-mately 70; smoking is the most important known risk factor.
Bladder cancers are broken down into three different groups: Tis, Ta and T1–T4; Tis, Ta and T1 are non-muscle invasive. Approximately three-quarters of all cases are non-muscle invasive although there is some variation among the healthcare coun-ties.
The report presents outcomes for five indicators. The first indicator concerns sur-vival rates. Two indicators reflect waiting times. The last two indicators show the percentage of patients who received one or more of the treatments in question de-pending on the stage of the tumour. With the exception of the survival indicator, which is based on the the Swedish Cancer Register, the data were taken from the Swedish Bladder Cancer Register.
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 41
26 Bladder cancer – survival ratesFigure 26 shows the relative five-year survival rate for bladder cancer patients. The national average for 2005–2009 was 75.2 per cent, with a regional variation of 65.1–81.1 per cent. The higher the age at the time of diagnosis, the lower the survival rate.
Figure 26 Sweden
Bladder cancer – relative five-year survival rates. Trend, 1990–2009. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare
Percent
0
20
40
60
80
100
2005-20092000-20041995-19991990-1994
Women
Total
Men
Figure 26Total
Bladder cancer – relative five-year survival rates. Patients diagnosed in 2000– 2004. Patients age 30–89 at the time of diagnosis. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare
Confidence interval calculated using Taylor series Percent
81.179.879.178.378.378.377.977.376.775.375.274.974.774.574.271.971.870.568.967.065.465.1
0 20 40 60 80 100
DalarnaJämtland
GävleborgUppsala
VärmlandSörmland
HallandVästernorrland
KronobergNorrbottenStockholmSWEDEN
VästerbottenVästra Götaland
KalmarSkåne
JönköpingBlekinge
ÖstergötlandÖrebro
VästmanlandGotland
42 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
27 Waiting time from receipt of the referral to the initial appointment with a urologist
When bladder cancer is suspected, the urologist usually performs a cystoscopy of the urethra and bladder at the first appointment. In most cases, the examination suf-fices for detecting a tumour and making a decision to treat. The indicator concerns waiting time from receipt of a referral until the first appointment with a urologist.
Figure 27Total
Waiting time from receipt of the referral until the initial appointment with a urologist for bladder cancer, 2009. Source: Swedish Bladder Cancer Register
Value first quartile Median Value third quartileDays
17181920202020202121222222232626272730333541
0 10 20 30 40 50 60
JämtlandGotland
GävleborgDalarnaUppsala
ÖstergötlandVärmlandJönköping
VästmanlandVästerbotten
Västra GötalandNorrbotten
BlekingeSWEDENSörmland
KronobergSkåne
KalmarÖrebro
StockholmHalland
Västernorrland
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 43
Figure 28Total
Waiting time from initial appointment with a urologist until transurethral resection (TUR) for bladder cancer, 2009. Source: Swedish Bladder Cancer Register
Value first quartile Median Value third quartileDays
16182020202021212222222324262627272729303334
0 10 20 30 40 50 60
JämtlandVästerbotten
GotlandUppsalaÖrebro
GävleborgNorrbotten
VärmlandÖstergötland
VästernorrlandSörmland
KalmarVästra Götaland
KronobergSWEDEN
VästmanlandBlekinge
SkåneHallandDalarna
JönköpingStockholm
28 Waiting time from initial appointment with a urologist until transurethral resection
Based on the cystoscopy, the urologist determines whether a transurethral resection – which often serves as both a diagnostic tool and surgical procedure – is called for. The indicator presents waiting times from the initial appointment with a urologist until a transurethral resection is performed.
Thus the two waiting times in tandem reflect how long it takes from the point at which the patient is given a referral until actual treatment. However, it says nothing about the total waiting time that starts when the patient first schedules an appoint-ment for primary care.
Much of the data used by the indicator have been reported to the Swedish Bladder Cancer Register. This indicator is not based on exactly the same data as the previous indicator and is more representative.
44 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
29 intravesical therapy for T1 tumours of the bladderNearly all tumours of the bladder are treated with a transurethral resection. Though non-invasive, T1 tumours belong to a high-risk category. According to the guidelines of the European Association of Urology, most patients with a T1 tumour should also be offered intravesical chemotherapy or immunotherapy to prevent recurrence and progression. Possible exceptions are patients with comorbidity and very advanced age.
The data for the indicator in Figure 29 cover two years in order to ensure more reliable outcomes at the regional level. Some counties have so few cases that the outcomes are uncertain nonetheless. However, the figures point to notable regional differences.
Figure 29Total
Percentage of patients with bladder cancer who underwent intravesical therapy, 2008–2009. Refers to stage T1. Source: Swedish Bladder Cancer Register
1 Fewer than 10 cases Percent
Number of patients
73.363.262.160.956.350.050.048.047.945.444.442.433.326.723.821.220.020.019.218.811.9
15192923323028
171140205
27963
273021332520261642
0 20 40 60 80 100
Gotland 1
DalarnaJämtland
VärmlandKalmar
GävleborgHalland
SörmlandUppsala
KronobergSWEDEN
NorrbottenSkåne
Västra GötalandStockholm
VästernorrlandBlekingeÖrebro
VästerbottenÖstergötlandVästmanland
Jönköping
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 45
Figure 30Total
Percentage of patients with bladder cancer who underwent curative primary treatment, 2008–2009. Refers to stage T2–T4. Source: Swedish Bladder Cancer Register
1 Fewer than 10 cases Percent
71.464.562.958.355.655.054.854.850.050.050.048.044.443.843.841.539.637.931.319.2
0 20 40 60 80 100
Gotland 1
Jönköping 1
KronobergVärmland
BlekingeSörmland
StockholmUppsala
JämtlandVästra Götaland
SWEDENKalmar
HallandDalarna
ÖstergötlandVästerbotten
NorrbottenSkåne
VästernorrlandGävleborg
VästmanlandÖrebro
Number of patients
35313524
133203142505030
1 029171
1632
17153293226
30 Curative treatment of T2–T4 tumours A T2-T4 tumour has invaded the muscle and the options for curative treatment are cystectomy (removal of the bladder), with or without systemic chemotherapy, or radiotherapy. Due to comorbidity, advanced age or certain other factors, a decision may be made not to attempt a cure.
Approximately 500 Swedes are diagnosed with T2-T4 tumours of the bladder every year. The percentage of patients who receive curative treatment varies considerably from county to county. Given the low incidence, the indicator is not broken down by gender. The diagram contains data for two years in order to ensure more reliable outcomes. Nevertheless, some counties have so few cases that uncertainty remains.
46 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
PRoSTATECANCER
Statistics for 2009 Men
Numberofdiagnoses 10317
Percentageofallcancercases 36%
Prevalence,total 75753
Relativefive-yearsurvivalrate 86.5%
Numberofdeaths 2424
Prostate cancer is the most common form of the disease in Sweden and accounts for more than 36 per cent of cases in men. A total of 10 317 patients were diagnosed with prostate cancer in 2009, and Sweden currently has approximately 75 700 preva-lent cases. The disease is rare before the age of 50. The median age at diagnosis has decreased to 70.
The number of new cases was stable in 1990–1995, rising substantially through 2005 and then levelling off for several years. There was a spike again in 2009, largely due to the growing number of symptom-free men who take a prostate-specific antigen (PSA) blood test and the fact that patients with elevated PSA levels (about 10 per cent of those who are symptom-free) undergo a biopsy. The greater use of the test explains why prostate cancer is detected at earlier stages and why the age at diagno-sis has decreased.
The risk of death depends on the stage and degree of the tumour. Because men are increasingly diagnosed with small, well-differentiated tumours, the relative five-year survival rate has risen to 86.5 per cent. A total of 2 424 Swedes died of prostate cancer in 2009.
This report presents outcomes for five indicators. Four of the indicators reflect in-terventions at various stages and grades of prostate cancer – from tumours with low risk of metastasis to those with high risk, which often grow rapidly and aggressively. The fifth indicator concerns waiting times. The data have been taken from the Na-tional Prostate Cancer Register.
31 Waiting time for the initial appointment with a urologistUsually a general practitioner makes an assessment or, at the patient’s request, a PSA test is performed as part of a routine check-up. If the GP suspects cancer, the patient is referred to a urologist.
According to the national healthcare guarantee, the initial appointment with a spe-cialist is to take place within 90 days after the referral is sent. Since tumours of the prostate tend to grow slowly, waiting time is rarely decisive to treatment outcome. The PSA level, which reflects proliferation of the tumour, is useful in determining
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 47
the need for rapid assessment. Be that as it may, a long waiting time causes unneces-sary anxiety and should be avoided.
The comparison is based on how long it takes from the time that the clinic receives a referral or is contacted by the patient until the initial appointment with a urolo-gist.
There were major regional variations. Halland, for example, had the shortest me-dian waiting time and only 25 per cent of patients waited for more than 34 days. Because no waiting time had been reported for 26 per cent of the cases, the data are inconclusive.
In seven counties, at least 25 per cent of patients waited longer than three months. Thus it would appear that many counties lacked the capacity in 2009 to meet the national care guarantee’s 90-day deadline.
This report does not consider the possibility that a patient was offered an appoint-ment at a second urology clinic during the waiting period but turned it down.
The column on the right side of the diagram indicates the percentage of patients included in the comparison. The counties exhibited large variations; a high percent-age of unreported cases can affect the waiting time data.
Figure 31Men
Waiting time from referral until the initial appointment with a urologist for assessment of prostate cancer, 2009. Source: National Prostate Cancer Register
Value first quartile Median Value third quartileDays
Participation rate 2009
24363839404041424344454646474854586365697695
74728294846782577672927582858388918792876782
0 30 60 90 120 150 180
JämtlandKronoberg
DalarnaÖstergötland
GävleborgVästerbotten
KalmarBlekinge
JönköpingÖrebro
VästernorrlandNorrbotten
VärmlandSWEDENStockholm
VästmanlandRegion Skåne
UppsalaGotland
Västra GötalandSörmland
Halland
48 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
32 Bone scintigraphy for low-risk prostate cancer Bone scintigraphy involves the injection of a radioisotope in order to detect bone changes, including metastases from prostate cancer. The examination can be used to determine whether prostate cancer has spread to the skeletal system, ordinarily the spinal column or pelvis. Low-risk localised tumours rarely require bone scintig-raphy. Thus, the NBHW national guidelines for prostate cancer care and the clini-
Figure 32Men
Percentage of patients with localised prostate cancer who underwent skeletal scintigraphy, 2009. Refers to low-risk tumours. Source: National Prostate Cancer Register
1 Fewer than 10 cases in 2003 2003 Percent
0.01.72.32.32.52.73.03.54.24.54.74.95.15.66.06.17.17.48.9
10.911.611.6
0 20 40 60 80
NorrbottenGävleborg
DalarnaSörmlandVärmlandJönköpingKronoberg
ÖrebroVästerbottenÖstergötland
VästernorrlandBlekinge
SWEDENKalmar
StockholmSkåne
Västra GötalandVästmanland
HallandUppsala
JämtlandGotland 1
Figure 32Sweden
Percentage of patients with localised prostate cancer who underwent skeletal scintigraphy. Refers to low-risk tumours. Trend, 2000–2009. Source: National Prostate Cancer Register
Percent
0
20
40
60
80
100
2009200820072006200520042003200220012000
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 49
cal practice guidelines of every region specify that patients with low-risk tumours should not be given bone scintigraphy. However, a few patients may experience symptoms in the skeletal system that call for the examination to be used.
33 active surveillance of low-risk prostate cancer Only 3 per cent of low-risk prostate cancer patients die of the disease within 10 years. The first-line treatment strategy recommended by the NBHW national guidelines is active surveillance for patients with a remaining life expectancy of 10–20 years and prostatectomy or radiotherapy for those with a remaining life expectancy of more than 20 years. Active surveillance involves frequent PSA tests and occasional biopsies. Any indication that the tumour is growing triggers prostatectomy or ra-diotherapy. Since the guidelines were drawn up, the quality register has further nar-rowed the criteria for low-risk cancer for which active surveillance is indicated; thus fewer patients are now included in this population.
Swedish urologists disagree about the optimum treatment for low-risk prostate can-cer. Active surveillance reduces the number of patients who are overtreated, but at the risk of treating some too late.
Because the quality register revised its reporting methods in 2009, no comparison with previous outcomes is possible.
Figure 33Men
Percentage of patients with prostate cancer who received active surveillance, 2009. Refers to patients age 75 and younger with low-risk tumours. Source: National Prostate Cancer Register
1 Fewer than 10 cases Percent
80.077.376.073.467.764.763.662.160.058.758.457.153.352.951.450.049.447.637.926.7
0 20 40 60 80 100
Norrbotten 1
Gotland 1
GävleborgKronoberg
KalmarStockholm
VästerbottenJönköpingVärmlandSörmlandJämtland
SWEDENVästra Götaland
DalarnaÖrebro
BlekingeVästmanland
HallandSkåne
VästernorrlandUppsala
Östergötland
50 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
34 Curative treatment for medium and high-risk prostate cancer Given that medium and high-risk prostate cancer poses a significantly higher risk of death, patients are normally offered the possibility of curative treatment, which involves one of various prostatectomy or radiotherapy techniques. Such treatment is indicated only if the tumour is localised, i.e., has not metastasised beyond the
Figure 34Men
Percentage of patients with prostate cancer who received curative treatment, 2009. Refers to patients age 75 and younger medium and high-risk tumours. Source: National Prostate Cancer Register
2003 Percent
83.082.977.577.575.373.172.772.572.172.171.269.268.466.562.562.462.161.260.059.757.550.6
0 20 40 60 80 100
JönköpingGävleborg
Västra GötalandÖrebro
NorrbottenVästmanland
VästernorrlandDalarna
ÖstergötlandSWEDEN
HallandSörmland
GotlandVärmlandStockholm
JämtlandUppsala
SkåneKronoberg
KalmarBlekinge
Västerbotten
Figure 34Sweden
Percentage of patients with prostate cancer who received curative treatment. Refers to patients age 75 and younger medium and high-risk tumours. Trend, 2000–2009. Source: National Prostate Cancer Register
Percent
0
20
40
60
80
100
2009200820072006200520042003200220012000
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 51
prostate. This report presents a follow-up of patients under age 75, since they usu-ally have a remaining life expectancy of more than ten years.
Some counties are almost 70 per cent below the national average, suggesting under-treatment of this patient population.
35 Treatment of locally advanced prostate cancer Locally advanced prostate cancer grows aggressively and can metastasise. The condi-tion poses a large risk of premature death within five years of the diagnosis.
Various curative treatment methods are available to these patients. The NBHW national guidelines for prostate cancer care assign top priority to neoadjuvant hor-mone therapy followed by external radiotherapy. The combined treatment is rec-ommended for patients with remaining life expectancy of more than five years. Patients with limited remaining life expectancy may instead be prescribed medica-tion to delay progression of the disease; the guidelines favour antiandrogen therapy with bicalutamide to block the stimulating effect of testosterone on cancer cells.
Figure 35Men
Percentage of patients with prostate cancer who received neoadjuvant hormone therapy and radiotherapy or bicalutamide as monotherapy, 2008–2009. Refers to patients age 75 and younger with high-risk tumours. Source: National Prostate Cancer Register
2006–2007
Percentage who received neoadjuvant hormone therapy and radiotherapy
Percentage who received bicalutamide as monotherapy
Percent
62.662.056.155.954.553.853.351.251.250.048.848.446.743.742.538.334.733.732.728.627.227.0
0 20 40 60 80 100
KalmarVästra Götaland
HallandBlekinge
SörmlandSkåne
ÖstergötlandSWEDENStockholm
GotlandJämtlandUppsala
JönköpingÖrebro
VärmlandNorrbotten
VästmanlandDalarna
VästerbottenVästernorrland
KronobergGävleborg
52 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
Figure 35Sweden
Percentage of patients with prostate cancer who received neoadjuvant hormone therapy and radiotherapy or bicalutamide as monotherapy. Refers to patients age 75 and younger with high-risk tumours. Trend, 2000–2009.Source: National Prostate Cancer Register
Percent
0
20
40
60
80
100
2009200820072006200520042003200220012000
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 53
CoLoNCANCER
Statistics for 2009 Women Men
Numberofdiagnoses 2036 2023
Percentageofallcancercases 8% 7%
Prevalence,total 15745 12594
Relativefive-yearsurvivalrate 65.4% 60.9%
Numberofdeaths 907 886
Colon cancer is the third most common form of the disease in both women and men. A total of 4 059 Swedes – 2 036 women and 2 023 men – developed colon can-cer in 2009. More than 28 000 Swedes now alive have had the disease. Colon cancer is uncommon before the age of 49 and approximately 75 per cent of patients are over 65 at the time of diagnosis. The number of new cases has been stable since 1990, with a small upward trend. One reason is that the population has aged.
This report presents outcomes for eight indicators. Considering that most patients undergo surgery, five of the indicators reflect outcomes during and after the opera-tion. One indicator concerns survival rates and two concern multidisciplinary team meetings. Seven of the indicators are based on data from the National Colon Cancer Register, which started in 2007, and the eighth indicator is based on data from the Swedish Cancer Register. The comparison period covers 2–3 years, nearly the entire lifetime of the national quality register. Thus, comparison with outcomes from pre-vious years is out of the question.
36 Colon cancer – relative five-year survival ratesThe relative five-year survival rate among colon cancer patients rose to 65.4 per cent for women and 60.9 per cent for men in 2005–2009. Figure 36 reveals that there are
Figure 36 Sweden
Colon cancer – relative five-year survival rates. Trend, 1990–2009. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare
Percent
0
20
40
60
80
100
2005-20092000-20041995-19991990-1994
Women
Total
Men
54 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
Figure 36Women
Colon cancer – relative five-year survival rates. Patients diagnosed in 2000– 2004. Patients age 30–89 at the time of diagnosis. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare
Confidence interval calculated using Taylor series Percent
70.669.769.568.368.267.867.265.465.264.263.463.163.062.962.562.362.161.761.361.261.160.5
0 20 40 60 80 100
SörmlandJämtland
VästmanlandNorrbotten
ÖrebroÖstergötland
KalmarJönköping
UppsalaVärmland
DalarnaGävleborgKronoberg
Västra GötalandSWEDEN
VästerbottenSkåne
StockholmHallandGotlandBlekinge
Västernorrland
Figure 36Men
Colon cancer – relative five-year survival rates. Patients diagnosed in 2000– 2004. Patients age 30–89 at the time of diagnosis. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare
Confidence interval calculated using Taylor series Percent
68.967.265.763.963.562.262.261.660.960.760.560.359.359.358.558.457.357.256.156.055.950.2
0 20 40 60 80 100
GotlandÖrebro
NorrbottenBlekinge
VästernorrlandJämtland
VästerbottenVärmland
KronobergGävleborg
Västra GötalandStockholm
DalarnaSWEDENJönköping
SkåneKalmar
SörmlandHalland
VästmanlandÖstergötland
Uppsala
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 55
large regional differences for men: 50.2–68.9 per cent, as opposed to 60.5–70.6 per cent for women.
37–38 Multidisciplinary team meetingsPrimary colon cancer treatment may be preceded by a multidisciplinary team meet-ing, a comprehensive assessment for the purpose of optimising the intervention. Surgery, oncology, radiology, pathology and other specialists, as well as nurses, may participate. A postoperative multidisciplinary team meeting looks at the patho-logical anatomical data (PAD) and plans ongoing treatment. The NBHW national guidelines for colon cancer care recommend a multidisciplinary team meeting both before commencement of treatment for newly diagnosed cases and postoperatively.
The National Colon Cancer Register targets multidisciplinary assessments for at least 90 per cent of patients, both at commencement of treatment and postopera-tively.
Certain regional differences in reporting of multidisciplinary team meetings affect the outcomes in the diagram. In the first place, there is no uniform definition of the specialists who need to participate in order for a multidisciplinary team meeting to take place. Some counties report only meetings attended by all of the various types of specialists and are thereby underrepresented in the register. In the second place,
Figure 36Total
Colon cancer – relative five-year survival rates. Patients diagnosed in 2000– 2004. Patients age 30–89 at the time of diagnosis. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare
Confidence interval calculated using Taylor series Percent
66.565.864.964.464.364.263.763.362.962.862.462.362.262.262.061.961.761.059.859.058.358.1
0 20 40 60 80 100
GotlandNorrbotten
ÖrebroJämtland
VärmlandDalarna
SörmlandKronobergGävleborgJönköping
KalmarBlekinge
Västra GötalandVästerbotten
SWEDENVästmanlandÖstergötland
VästernorrlandStockholm
SkåneUppsalaHalland
56 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
Figure 37Total
Percentage of patients who had a multidisciplinary team meeting prior to treatment for colon cancer, 2008–2009. Source: National Colon Cancer Register
Percent
Percentage of emergency operations
57.655.048.938.234.232.832.632.428.626.424.923.722.921.321.118.415.913.012.812.011.9
4.4
15171713201815192127161821282021261829182118
0 20 40 60 80 100
HallandVästernorrland
JönköpingGävleborg
VästerbottenJämtland
KalmarBlekinge
VärmlandÖrebro
SörmlandUppsala
ÖstergötlandSkåne
SWEDENKronoberg
VästmanlandVästra Götaland
GotlandDalarna
NorrbottenStockholm
Figure 38Total
Percentage of patients who had a multidisciplinary team meeting after colon cancer surgery, 2008–2009. Source: National Colon Cancer Register
Percent
Percentage of emergency operations
96.690.080.480.178.476.272.568.763.262.561.861.559.254.046.542.440.335.633.031.825.911.8
20172030151429222118163021221919232319252018
0 20 40 60 80 100
HallandJönköping
JämtlandVästerbotten
BlekingeSkåne
VästernorrlandSörmland
KalmarSWEDEN
ÖstergötlandKronoberg
UppsalaVästra Götaland
ÖrebroVärmland
GotlandStockholmGävleborg
NorrbottenDalarna
Västmanland
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 57
the patient populations that need a multidisciplinary team meeting are identified differently from county to county.
The column of figures on the right side of the diagram shows the percentage of emergency operations per county. Because multidisciplinary team meetings are not feasible when the patient’s condition is acute, the two variables are related. How-ever, the percentage of postoperative multidisciplinary team meetings should not be affected by whether the operation was scheduled or emergency.
Figure 37Hospitals
Percentage of patients who had a multidisciplinary team meeting prior to treatment for colon cancer, 2008–2009. Source: National Colon Cancer Register
82.181.280.170.634.47.0
56.02.4
28.322.323.046.18.36.3
17.78.81.9
47.414.423.835.920.866.322.316.917.910.21.64.28.5
51.78.9
24.46.38.2
75.613.67.0
32.42.0
18.915.424.432.259.323.39.2
20.04.6
10.616.015.57.5
18.56.00.0
29.466.0
83
1515162223221416223916162212231119251321212030162326123018245411201619182741301321191618312723212026231714202417
RegionStockholm
UppsalaSörmland
Östergötland
Jönköping
Kronoberg
Kalmar
GotlandBlekinge
Skåne
Halland
Västra Götaland
Värmland
Örebro
VästmanlandDalarna
Gävleborg
Västernorrland
JämtlandVästerbotten
Norrbotten
Percent
Percentage of emergency operations
0 20 40 60 80 100
Sunderbyns sjukhusKiruna lasarett
Gällivare lasarettSkellefteå lasarett
Norrlands Universitetssjukhus, UmeåLycksele lasarett
Östersunds sjukhusÖrnsköldsviks sjukhus
Sundsvalls sjukhusSollefteå sjukhus
Hudiksvalls sjukhusGävle sjukhusMora lasarettFalu lasarett
Västerås lasarettUniversitetssjukhuset Örebro
Lindesbergs lasarettKarlskoga lasarett
Torsby sjukhusCentralsjukhuset i Karlstad
Arvika sjukhusSÄ-sjukvården
SU Östra, GöteborgSkaraborgs sjukhus, Skövde
Skaraborgs sjukhus, LidköpingSahlgrenska universitetssjukhuset
NU-sjukvårdenKungälvs sjukhusAlingsås lasarett
Varbergs sjukhusLänssjukhuset i Halmstad
Ystads lasarettUniversitetssjukhuset MAS
Universitetssjukhuset i LundKristianstads sjukhusHelsingborgs lasarett
BlekingesjukhusetVisby lasarett
Västerviks sjukhusLänssjukhuset Kalmar
Växjö lasarettLjungby lasarett
Värnamo sjukhusLänssjukhuset Ryhov, Jönköping
Höglandssjukhuset, EksjöVrinnevisjukhuset i Norrköping
Universitetssjukhuset i LinköpingNyköpings sjukhus
Mälarsjukhuset, EskilstunaAkademiska sjukhuset, Uppsala
Södertälje sjukhusSödersjukhuset, Stockholm
S:t Görans sjukhus, StockholmNorrtälje sjukhusKarolinska, Solna
Karolinska, HuddingeErsta sjukhus, Stockholm
Danderyds sjukhus
58 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
39 at least twelve lymph nodes examined in the tumour sampleAfter primary surgery for colon cancer, the intestinal tissue and tumour that have been removed are sent to a pathology lab for microscopic and macroscopic examina-tion. The purpose of the examinations is to offer a definitive assessment of the type and stage of the tumour. Correctly classifying the malignancy is integral to predict-ing progression of the disease and prescribing proper treatment. Scientific studies indicate that acceptable diagnostic quality requires examination of at least twelve
Figure 38Hospitals
Percentage of patients who had a multidisciplinary team meeting after colon cancer surgery, 2008–2009. Source: National Colon Cancer Register
95.794.390.092.977.434.496.120.063.652.832.887.739.019.126.637.714.092.054.355.275.635.470.324.716.538.048.911.27.8
54.654.219.855.272.189.693.830.856.690.331.357.916.790.296.690.492.376.983.947.646.034.931.722.932.637.041.240.092.5
62
1918162622201616234418172613241021281524242133172326122517266910221622192744291422201717342424171926231815242720
RegionStockholm
UppsalaSörmland
Östergötland
Jönköping
Kronoberg
Kalmar
GotlandBlekinge
Skåne
Halland
Västra Götaland
Värmland
Örebro
VästmanlandDalarna
Gävleborg
Västernorrland
JämtlandVästerbotten
Norrbotten
Percent
Percentage of emergency operations
0 20 40 60 80 100
Sunderbyns sjukhusKiruna lasarett
Gällivare lasarettSkellefteå lasarett
Norrlands Universitetssjukhus, UmeåLycksele lasarett
Östersunds sjukhusÖrnsköldsviks sjukhus
Sundsvalls sjukhusSollefteå sjukhus
Hudiksvalls sjukhusGävle sjukhusMora lasarettFalu lasarett
Västerås lasarettUniversitetssjukhuset Örebro
Lindesbergs lasarettKarlskoga lasarett
Torsby sjukhusCentralsjukhuset i Karlstad
Arvika sjukhusSÄ-sjukvården
SU Östra, GöteborgSkaraborgs sjukhus, Skövde
Skaraborgs sjukhus, LidköpingSahlgrenska universitetssjukhuset
NU-sjukvårdenKungälvs sjukhusAlingsås lasarett
Varbergs sjukhusLänssjukhuset i Halmstad
Ystads lasarettUniversitetssjukhuset MAS
Universitetssjukhuset i LundKristianstads sjukhusHelsingborgs lasarett
BlekingesjukhusetVisby lasarett
Västerviks sjukhusLänssjukhuset Kalmar
Växjö lasarettLjungby lasarett
Värnamo sjukhusLänssjukhuset Ryhov, Jönköping
Höglandssjukhuset, EksjöVrinnevisjukhuset i Norrköping
Universitetssjukhuset i LinköpingNyköpings sjukhus
Mälarsjukhuset, EskilstunaAkademiska sjukhuset, Uppsala
Södertälje sjukhusSödersjukhuset, Stockholm
S:t Görans sjukhus, StockholmNorrtälje sjukhusKarolinska, Solna
Karolinska, HuddingeErsta sjukhus, Stockholm
Danderyds sjukhus
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 59
Figure 39Total
Percentage of patients who had at least twelve lymph nodes examined after colon cancer surgery, 2008–2009. Source: National Colon Cancer Register
Percent
97.691.991.490.178.578.178.077.277.276.775.473.973.871.170.470.168.565.864.163.561.754.7
0 20 40 60 80 100
JämtlandVästernorrland
VärmlandÖrebro
GävleborgVästerbottenÖstergötland
BlekingeJönköping
DalarnaSörmland
SkåneNorrbotten
UppsalaSWEDEN
HallandKalmar
StockholmVästra Götaland
KronobergGotland
Västmanland
Figure 39Pathology lab
Percentage of patients who had at least twelve lymph nodes examined after colon cancer surgery, 2008–2009. Source: National Colon Cancer Register
67.589.787.872.076.879.373.270.170.891.378.669.890.986.756.669.878.392.691.890.479.363.865.196.872.965.861.054.069.375.5
RegionStockholm
UppsalaSörmland
ÖstergötlandJönköpingKronoberg
KalmarBlekinge
Skåne
HallandVästra Götaland
VärmlandÖrebro
VästmanlandDalarna
GävleborgVästernorrland
JämtlandVästerbotten
Norrbotten
Percent
0 20 40 60 80 100
Sunderbyns sjukhusNorrlands Universitetssjukhus, Umeå
Östersunds sjukhusSundsvalls sjukhus
Gävle sjukhusFalu lasarett
Västerås lasarettUniversitetssjukhuset Örebro
Centralsjukhuset i KarlstadSÄ-sjukvården, Borås
Skaraborgs sjukhus, SkövdeSahlgrenska universitetssjukhusetNU-sjukvården, Trollhättan/NÄL
Länssjukhuset i HalmstadUniversitetssjukhuset MAS
Universitetssjukhuset i LundKristianstads sjukhusHelsingborgs lasarett
Blekingesjukhuset, KarlskronaLänssjukhuset Kalmar
Växjö lasarettLänssjukhuset Ryhov, JönköpingUniversitetssjukhuset i Linköping
Mälarsjukhuset, EskilstunaAkademiska sjukhuset, Uppsala
Täby MedilabS:t Görans sjukhus, Stockholm
Karolinska, SolnaKarolinska, Huddinge
Danderyds sjukhus
60 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
lymph nodes. The quality of the examinations is affected by whether the surgeon removes sufficient tissue, as well as the pathologist’s analytical skills.
According to an analysis of 2008 data by the National Colon Cancer Register, the number of lymph nodes examined was not related to whether surgery had been per-formed on a scheduled or emergency basis. Given that surgery is fairly standardised, the quality of the results appeared to depend more on the ability of the pathologist to analyse at least twelve nodes than on the size of the sample.
The comparison covers a two-year period. With the exception of the large counties, however, the quality register contained few cases – as reflected in the broad confi-dence intervals.
Counties that were below 95 per cent should review their resources, particularly when it comes to pathologists.
40 Perforation of the colon during surgeryOne important complication that can occur during surgery is perforation of the colon. Such a development increases the risk of tumour recurrence and therefore suffering on the part of the patient. The risk of perforation is greater when surgery is performed on an emergency basis.
Figure 40Total
Percentage of patients with perforated colon during colon cancer surgery, 2007–2009. Source: National Colon Cancer Register
Percent
Percentage of emergency operations
0.41.01.51.51.61.72.02.12.22.22.32.52.52.63.03.03.33.64.44.64.74.9
17201321262221172325191829152020231720222123
0 5 10 15 20
BlekingeVästra Götaland
JämtlandVästerbotten
KronobergSkåne
SWEDENJönköpingStockholm
ÖstergötlandHalland
SörmlandVärmland
KalmarDalarna
VästernorrlandÖrebro
GävleborgNorrbotten
GotlandUppsala
Västmanland
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 61
Figure 40Hospitals
Percentage of patients with perforated colon during colon cancer surgery, 2007–2009. Source: National Colon Cancer Register
1.00.36.84.80.03.93.12.01.31.82.11.73.34.23.60.04.83.02.60.01.55.03.51.33.73.83.12.32.22.81.02.4
22.40.05.96.52.02.82.41.61.41.91.60.41.72.41.02.40.01.44.23.93.85.53.83.50.01.3
82
1715152520231917234317172414261222271423241932192122152415255011221720192338251323181617282231201822262014172222
RegionStockholm
UppsalaSörmland
Östergötland
Jönköping
Kronoberg
Kalmar
GotlandBlekinge
Skåne
Halland
Västra Götaland
Värmland
Örebro
VästmanlandDalarna
Gävleborg
Västernorrland
JämtlandVästerbotten
Norrbotten
Percent
Percentage of emergency operations
0 10 20 30 40 50
Sunderbyns sjukhus Kiruna lasarett
Gällivare lasarettSkellefteå lasarett
Norrlands Universitetssjukhus, UmeåLycksele lasarett
Östersunds sjukhusÖrnsköldsviks sjukhus
Sundsvalls sjukhusSollefteå sjukhus
Hudiksvalls sjukhusGävle sjukhusMora lasarettFalu lasarett
Västerås lasarettUniversitetssjukhuset Örebro
Lindesbergs lasarettKarlskoga lasarett
Torsby sjukhusCentralsjukhuset i Karlstad
Arvika sjukhusSÄ-sjukvården
SU Östra, GöteborgSkaraborgs sjukhus, Skövde
Skaraborgs sjukhus, LidköpingSahlgrenska universitetssjukhuset
NU-sjukvårdenKungälvs sjukhusAlingsås lasarett
Varbergs sjukhusLänssjukhuset i Halmstad
Ystads lasarettUniversitetssjukhuset MAS
Universitetssjukhuset i LundKristianstads sjukhusHelsingborgs lasarett
BlekingesjukhusetVisby lasarett
Västerviks sjukhusLänssjukhuset Kalmar
Växjö lasarettLjungby lasarett
Värnamo sjukhusLänssjukhuset Ryhov, Jönköping
Höglandssjukhuset, EksjöVrinnevisjukhuset i Norrköping
Universitetssjukhuset i LinköpingNyköpings sjukhus
Mälarsjukhuset, EskilstunaAkademiska sjukhuset, Uppsala
Södertälje sjukhusSödersjukhuset, Stockholm
S:t Görans sjukhus, StockholmNorrtälje sjukhusKarolinska, Solna
Karolinska, HuddingeErsta sjukhus, Stockholm
Danderyds sjukhus
One goal is to minimise the number of complications that are due to healthcare interventions, in this case injury during the course of an operation. Perforations during surgery cannot be wholly eliminated given that they can also be caused by acute volvulus and other conditions.
62 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
41 More than 15 days of hospitalisation after surgeryAssuming no complications occur, hospitalisation after surgery should not exceed 15 days. The goal is based on a 2008 follow-up by the National Colon Cancer Register showing that the median hospitalisation period following surgery was 7 days for patients discharged to home and 14 days for those who were discharged to another institution.
The comparison does not take the possible effects of comorbidity or the patient’s preoperative condition into consideration.
Figure 41Total
Percentage of patients with more than 15 days of hospitalisation after colon cancer surgery, 2008–2009. Source: National Colon Cancer Register
Percentage discharged to home Percentage discharged to another institution Percent
Percentage of emergency operations
6.69.5
10.911.211.212.212.713.113.913.914.914.915.015.117.417.918.018.119.820.221.223.3
19142015302018202129211718222319301622232519
0 10 20 30 40 50
SörmlandJämtland
SkåneKalmar
KronobergGävleborg
VästerbottenBlekingeÖrebro
UppsalaDalarna
SWEDENVärmland
Västra GötalandJönköping
HallandVästmanlandÖstergötland
StockholmNorrbotten
GotlandVästernorrland
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 63
Figure 41Hospitals
Percentage of patients with more than 15 days of hospitalisation after colon cancer surgery, 2008–2009. Source: National Colon Cancer Register
Percentage discharged to home Percentage discharged to another institution
5.36.7
16.722.319.412.09.5
10.714.831.110.98.4
13.610.513.318.924.014.922.915.59.8
16.226.913.319.519.918.916.49.49.1
28.914.334.510.313.510.812.315.113.216.718.419.411.513.616.210.819.216.19.55.87.0
20.725.713.021.711.86.7
11.2
62
1918162622201616234418172613241021281524242133172326122517266910221622192744291422201717342424171926231815242720
RegionStockholm
UppsalaSörmland
Östergötland
Jönköping
Kronoberg
Kalmar
GotlandBlekinge
Skåne
Halland
Västra Götaland
Värmland
Örebro
VästmanlandDalarna
Gävleborg
Västernorrland
JämtlandVästerbotten
Norrbotten
Percent
Percentage of emergency operations
0 10 20 30 40 50 60
Sunderbyns sjukhusKiruna lasarett
Gällivare lasarettSkellefteå lasarett
Norrlands Universitetssjukhus, UmeåLycksele lasarett
Östersunds sjukhusÖrnsköldsviks sjukhus
Sundsvalls sjukhusSollefteå sjukhus
Hudiksvalls sjukhusGävle sjukhusMora lasarettFalu lasarett
Västerås lasarettUniversitetssjukhuset Örebro
Lindesbergs lasarettKarlskoga lasarett
Torsby sjukhusCentralsjukhuset i Karlstad
Arvika sjukhusSÄ-sjukvården
SU Östra, GöteborgSkaraborgs sjukhus, Skövde
Skaraborgs sjukhus, LidköpingSahlgrenska universitetssjukhuset
NU-sjukvårdenKungälvs sjukhusAlingsås lasarett
Varbergs sjukhusLänssjukhuset i Halmstad
Ystads lasarettUniversitetssjukhuset MAS
Universitetssjukhuset i LundKristianstads sjukhusHelsingborgs lasarett
BlekingesjukhusetVisby lasarett
Västerviks sjukhusLänssjukhuset Kalmar
Växjö lasarettLjungby lasarett
Värnamo sjukhusLänssjukhuset Ryhov, Jönköping
Höglandssjukhuset, EksjöVrinnevisjukhuset i Norrköping
Universitetssjukhuset i LinköpingNyköpings sjukhus
Mälarsjukhuset, EskilstunaAkademiska sjukhuset, Uppsala
Södertälje sjukhusSödersjukhuset, Stockholm
S:t Görans sjukhus, StockholmNorrtälje sjukhusKarolinska, Solna
Karolinska, HuddingeErsta sjukhus, Stockholm
Danderyds sjukhus
64 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
Figure 42Women
Percentage of patients with reoperation within 30 days after primary surgery, 2007–2009. Source: National Colon Cancer Register
Percent
Percentage of emergency operations
1.22.93.43.53.64.14.25.76.56.56.66.77.17.47.47.67.67.88.38.98.99.8
20142215181229252321222123212216222215192025
0 10 20 30 40
BlekingeKronobergSörmland
HallandJämtlandUppsala
StockholmGävleborg
KalmarVästernorrland
ÖrebroVästra Götaland
SWEDENSkåne
VärmlandÖstergötlandVästmanlandVästerbotten
DalarnaJönköping
GotlandNorrbotten
Figure 42Men
Percentage of patients with reoperation within 30 days after primary surgery, 2007–2009. Source: National Colon Cancer Register
Percent
Percentage of emergency operations
3.65.56.36.97.17.68.48.58.89.19.4
10.911.011.712.112.613.513.814.214.516.219.6
22181319202425172130222019302121231715132222
0 10 20 30 40
BlekingeJämtland
StockholmKronobergJönköping
ÖrebroVästerbotten
HallandGävleborg
Västra GötalandSWEDEN
SkåneÖstergötland
NorrbottenDalarna
VärmlandKalmar
VästernorrlandSörmland
GotlandUppsala
Västmanland
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 65
42 Reoperation due to complications within 30 days of primary surgery
Approximately 95 per cent of all colon cancer patients undergo surgery. The location and size of the tumour, as well as the patient’s general condition, affect the scope and riskiness of the operation. Bleeding, infection, leakage or another complication may require relatively prompt reoperation, which entails additional suffering for the patient and increases the risk of further complications.
The NBHW national guidelines for colon cancer care identify reoperation after 30 days of primary surgery as an important indicator to monitor.
One source of error in comparing data is that some hospitals report minor interven-tions as reoperations and some do not. The percentage of reoperations is also related to the way that primary surgery was performed and the patient’s condition at the time.
Figure 42Total
Percentage of patients with reoperation within 30 days after primary surgery, 2007–2009. Source: National Colon Cancer Register
Percent
Percentage of emergency operations
3.94.55.66.36.56.66.97.17.57.97.98.08.48.78.79.5
10.010.210.811.612.114.7
17132117202925212319232020202126221815172223
0 10 20 30 40
BlekingeJämtland
KronobergStockholm
HallandÖrebro
GävleborgVästra Götaland
SWEDENJönköping
VästerbottenSkåne
SörmlandKalmar
VästernorrlandVärmland
ÖstergötlandUppsalaDalarna
NorrbottenGotland
Västmanland
66 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
Figure 42Hospitals
Percentage of patients with reoperation within 30 days after primary surgery, 2007–2009. Source: National Colon Cancer Register
9.48.7
11.919.213.59.3
11.95.96.76.1
12.55.17.96.99.59.1
16.78.26.0
13.93.0
13.67.37.15.5
10.29.38.7
11.75.65.7
10.712.110.210.28.94.18.38.01.68.5
11.59.53.95.96.17.7
12.80.08.18.3
10.913.28.35.13.55.65.9
82
1715152520231917234317172414261222271423241932192122152415255011221720192338251323181617282231201822262014172222
RegionStockholm
UppsalaSörmland
Östergötland
Jönköping
Kronoberg
Kalmar
GotlandBlekinge
Skåne
Halland
Västra Götaland
Värmland
Örebro
VästmanlandDalarna
Gävleborg
Västernorrland
JämtlandVästerbotten
Norrbotten
Percent
Percentage of emergency operations
0 10 20 30 40
Sunderbyns sjukhusKiruna lasarett
Gällivare lasarettSkellefteå lasarett
Norrlands Universitetssjukhus, UmeåLycksele lasarett
Östersunds sjukhusÖrnsköldsviks sjukhus
Sundsvalls sjukhusSollefteå sjukhus
Hudiksvalls sjukhusGävle sjukhusMora lasarettFalu lasarett
Västerås lasarettUniversitetssjukhuset Örebro
Lindesbergs lasarettKarlskoga lasarett
Torsby sjukhusCentralsjukhuset i Karlstad
Arvika sjukhusSÄ-sjukvården
SU Östra, GöteborgSkaraborgs sjukhus, Skövde
Skaraborgs sjukhus, LidköpingSahlgrenska universitetssjukhuset
Nu-sjukvårdenKungälvs sjukhusAlingsås lasarett
Varbergs sjukhusLänssjukhuset i Halmstad
Ystads lasarettUniversitetssjukhuset MAS
Universitetssjukhuset i LundKristianstads sjukhusHelsingborgs lasarett
BlekingesjukhusetVisby lasarett
Västerviks sjukhusLänssjukhuset Kalmar
Växjö lasarettLjungby lasarett
Värnamo sjukhusLänssjukhuset Ryhov, Jönköping
Höglandssjukhuset, EksjöVrinnevisjukhuset i Norrköping
Universitetssjukhuset i LinköpingNyköpings sjukhus
Mälarsjukhuset, EskilstunaAkademiska sjukhuset, Uppsala
Södertälje sjukhusSödersjukhuset, Stockholm
S:t Görans sjukhus, StockholmNorrtälje sjukhusKarolinska, Solna
Karolinska, HuddingeErsta sjukhus, Stockholm
Danderyds sjukhus
43 Deaths within 30 and 90 days of surgeryThe NBHW national guidelines for colon cancer care identify the percentage of deaths within 30 and 90 days of surgery as an important indicator for monitoring healthcare quality. The indicator reflects the selection of patients for surgery, as well as the care they receive before, during and after the operation.
Age, gender, and severity of the malignancy also affect the percentage of deaths. Table 1 presents the odds ratio by county, adjusted for age, gender and tumour stage.
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 67
Figure 43Total
Percentage of deaths within 30 and 90 days after colon cancer surgery, 2007–2009. Source: National Colon Cancer Register
Percentage of deaths within 30 days Percentage of deaths within 90 days Percent
Percentage of emergency operations
1.52.24.14.44.54.54.75.05.55.55.65.66.06.46.56.56.76.97.87.88.39.3
12172117222015182228202023182321222518192622
0 5 10 15 20 25 30
JämtlandGävleborgSörmland
JönköpingVärmland
VästernorrlandVästra Götaland
KalmarKronoberg
BlekingeVästerbotten
SWEDENÖstergötland
ÖrebroHalland
StockholmUppsala
SkåneDalarna
NorrbottenVästmanland
Gotland
Table 1
County council
Odds ratio
95 % confidence interval
County council
Odds ratio
95 % confidence interval
Stockholm 0.96 0.74–1.23 V.Götaland 1.11 0.88–1.40
Uppsala 0.91 0.51–1.62 Värmland 1.29 0.83–2.00
Sörmland 1.26 0.77–2.06 Örebro 1.01 0.60–1.72
Östergötland 0.94 0.61–1.43 Västmanland 0.41 0.17–1.03
Jönköping 1.23 0.83–1.84 Dalarna 0.92 0.53–1.61
Kronoberg 0.95 0.54–1.67 Gävleborg 1.46 0.94–2.25
Kalmar 0.96 0.60–1.55 Västernorrland 1.27 0.75–2.16
Gotland 0.30 0.04–2.21 Jämtland 1.78 0.95–3.33
Blekinge 1.07 0.58–1.96 Västerbotten 1.05 0.61–1.81
RegionSkåne 0.79 0.60–1.05 Norrbotten 0.70 0.34–1.45
Halland 0.76 0.45–1.29
A value of 1 is assigned to the national average of patients who die within 90 days of surgery. A value less than 1 represents a percentage below the national average and a value greater than 1 represents a percentage above the national average.
68 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
Figure 43Hospitals
Percentage of deaths within 30 and 90 days after colon cancer surgery, 2007–2009. Source: National Colon Cancer Register
Percentage of deaths within 30 days Percentage of deaths within 90 days
3.11.39.36.35.85.75.15.14.0
10.93.27.24.38.56.68.16.26.17.54.01.56.13.57.24.34.53.55.54.47.38.86.95.48.99.04.55.65.66.97.97.00.06.52.23.57.68.49.6
15.44.28.67.95.95.66.83.60.04.7
91
1616152520211917244117172214271223251223241928192023152316255212221720202338251424181718282238211722252015182222
RegionStockholm
UppsalaSörmland
Östergötland
Jönköping
Kronoberg
Kalmar
GotlandBlekinge
Skåne
Halland
Västra Götaland
Värmland
Örebro
VästmanlandDalarna
Gävleborg
Västernorrland
JämtlandVästerbotten
Norrbotten
Percent
Percentage of emergency operations
0 10 20 30 40
Sunderbyns sjukhusKiruna lasarett
Gällivare lasarettSkellefteå lasarett
Norrlands Universitetssjukhus, UmeåLycksele lasarett
Östersunds sjukhusÖrnsköldsviks sjukhus
Sundsvalls sjukhusSollefteå sjukhus
Hudiksvalls sjukhusGävle sjukhusMora lasarettFalu lasarett
Västerås lasarettUniversitetssjukhuset Örebro
Lindesbergs lasarettKarlskoga lasarett
Torsby sjukhusCentralsjukhuset i Karlstad
Arvika sjukhusSÄ-sjukvården
SU Östra, GöteborgSkaraborgs sjukhus, Skövde
Skaraborgs sjukhus, LidköpingSahlgrenska universitetssjukhuset
NU-sjukvårdenKungälvs sjukhusAlingsås lasarett
Varbergs sjukhusLänssjukhuset i Halmstad
Ystads lasarettUniversitetssjukhuset MAS
Universitetssjukhuset i LundKristianstads sjukhusHelsingborgs lasarett
BlekingesjukhusetVisby lasarett
Västerviks sjukhusLänssjukhuset Kalmar
Växjö lasarettLjungby lasarett
Värnamo sjukhusLänssjukhuset Ryhov, Jönköping
Höglandssjukhuset, EksjöVrinnevisjukhuset i Norrköping
Universitetssjukhuset i LinköpingNyköpings sjukhus
Mälarsjukhuset, EskilstunaAkademiska sjukhuset, Uppsala
Södertälje sjukhusSödersjukhuset, Stockholm
S:t Görans sjukhus, StockholmNorrtälje sjukhusKarolinska, Solna
Karolinska, HuddingeErsta sjukhus, Stockholm
Danderyds sjukhus
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 69
RECTALCANCER
Statistics for 2009 Women Men
Numberofdiagnoses 888 1233
Percentageofallcancercases 3% 4%
Prevalence,total 7991 8426
Relativefive-yearsurvivalrate 64.1% 60.9%
Numberofdeaths 344 451
Rectal cancer is more common among men than women. A total of 888 women and 2 121 men were diagnosed with the disease in 2009. More than 16 400 Swedes now alive have had the disease. Rectal cancer is fairly uncommon before the age of 50.
This report presents outcomes for eleven indicators. Seven of them reflect outcomes during and after surgery. Given that most rectal cancer patients undergo surgery, the selection of indicators sheds a great deal of light on the quality of the operations. The other four indicators concern survival rates, frequency of recurrence within five years of surgery, and the use of multidisciplinary team meetings. Two of the indicators are based on the National Rectal Cancer Register, which started in 1995. One indicator contains data from the Swedish Cancer Register.
44 Rectal cancer – relative five-year survival ratesThe relative five-year survival rate has increased among both female and male rectal cancer patients since the early 1990s. Figure 44 shows that the rate was 64.1 per cent for women and 60.9 per cent for men in 2005–2009. However, there were large re-gional differences: the figure ranged from 48.6 to 81.8 per cent for women and from 55.2 to 77.5 per cent for men.
Figure 44 Sweden
Rectal cancer – relative five-year survival rates. Trend, 1990–2009. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare
Percent
0
20
40
60
80
100
2005-20092000-20041995-19991990-1994
Women
Total
Men
70 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
Figure 44Women
Rectal cancer – relative five-year survival rates. Patients diagnosed in 2000– 2004. Patients age 30–89 at the time of diagnosis. Age-standardised values.Source: Swedish Cancer Register, Swedish National Board of Health and Welfare
1 Fewer than 10 cases. Confidence interval calculated using Taylor series Percent
81.867.967.366.466.266.164.764.764.564.164.164.063.763.663.062.461.961.459.255.148.6
0 20 40 60 80 100
Gotland 1
JämtlandNorrbotten
HallandKronoberg
VästmanlandVästra Götaland
ÖstergötlandVästernorrland
SörmlandVästerbotten
SWEDENKalmar
UppsalaSkåne
StockholmGävleborg
DalarnaVärmland
ÖrebroJönköping
Blekinge
Figure 44Men
Rectal cancer – relative five-year survival rates. Patients diagnosed in 2000– 2004. Patients age 30–89 at the time of diagnosis. Age-standardised values.Source: Swedish Cancer Register, Swedish National Board of Health and Welfare
Confidence interval calculated using Taylor series Percent
77.570.369.167.566.565.863.062.262.161.761.461.361.161.060.960.960.960.858.055.855.355.2
0 20 40 60 80 100
GävleborgÖstergötland
HallandVästra Götaland
ÖrebroVästernorrland
VästerbottenSWEDENJämtland
StockholmVärmland
SkåneBlekingeDalarna
SörmlandKronoberg
KalmarNorrbottenJönköping
UppsalaVästmanland
Gotland
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 71
Figure 44Total
Rectal cancer – relative five-year survival rates. Patients diagnosed in 2000– 2004. Patients age 30–89 at the time of diagnosis. Age-standardised values.Source: Swedish Cancer Register, Swedish National Board of Health and Welfare
Confidence interval calculated using Taylor series Percent
72.469.466.966.866.464.464.263.963.763.062.962.862.361.861.761.661.461.160.059.157.456.7
0 20 40 60 80 100
HallandJämtland
ÖstergötlandVästra Götaland
GävleborgNorrbotten
VästerbottenVästernorrland
KronobergSWEDENStockholm
SkåneSörmland
ÖrebroDalarnaKalmar
VärmlandVästmanland
UppsalaJönköping
BlekingeGotland
45–46 Multidisciplinary team meetingsPrimary rectal cancer treatment may be preceded by a multidisciplinary team meet-ing, a comprehensive assessment for the purpose of optimising the intervention. Surgical, oncology, radiology, pathology and other specialists, as well as nurses, may participate. A postoperative multidisciplinary team meeting looks at the patho-logical anatomical data (PAD) and plans ongoing treatment. The NBHW national guidelines for rectal cancer care recommend a multidisciplinary team meeting both before commencement of treatment for newly diagnosed cases and postoperatively.
The long-term target of the National Rectal Cancer Register is that at least 90 per cent of patients receive a multidisciplinary assessment, both at commencement of treatment and postoperatively.
A follow-up performed by the register in 2009 found that only 58 per cent of pa-tients age 85 and older were given a multidisciplinary assessment before commence-ment of treatment for a newly diagnosed malignancy.
72 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
Figure 45Total
Percentage of patients who had a multidisciplinary team meeting prior to treatment for rectal cancer, 2008–2009. Source: National Rectal Cancer Register
Percent
93.892.992.591.691.688.388.285.985.784.083.179.979.879.278.276.075.170.166.053.151.719.1
0 20 40 60 80 100
HallandBlekinge
JönköpingJämtland
KronobergÖstergötland
KalmarVärmlandSWEDENSörmland
Västra GötalandSkåne
VästerbottenVästernorrland
StockholmÖrebro
GävleborgDalarna
NorrbottenVästmanland
UppsalaGotland
Figure 46Total
Percentage of patients who had a multidisciplinary team meeting after rectal cancer surgery, 2008–2009. Source: National Rectal Cancer Register
Percent
97.996.896.696.492.991.590.988.881.881.473.971.670.869.160.459.050.041.839.236.031.421.2
0 20 40 60 80 100
HallandJämtlandBlekinge
JönköpingSkåne
VästernorrlandVästerbotten
KalmarSörmland
KronobergSWEDEN
ÖstergötlandVästra Götaland
GotlandStockholm
UppsalaÖrebro
DalarnaVärmland
VästmanlandNorrbottenGävleborg
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 73
Certain regional differences in reporting of multidisciplinary team meetings affect the outcomes in the diagram. In the first place, there is no uniform definition of the specialists who need to participate in order for a multidisciplinary team meeting to take place. Some counties report only meetings attended by all of the various types of specialists and are thereby underrepresented in the register. In the second place, the patient populations for whom a multidisciplinary team meeting is indicated are identified differently from region to region.
Figure 45Hospitals
Percentage of patients who had a multidisciplinary team meeting prior to treatment for rectal cancer, 2008–2009. Source: National Rectal Cancer Register
92.996.788.992.183.346.093.935.792.785.368.689.854.248.470.433.322.990.473.381.891.752.991.484.489.574.010.822.656.083.882.383.375.991.249.487.987.992.590.196.786.195.853.391.588.965.291.965.291.6
RegionStockholm
UppsalaSörmland
Östergötland
Jönköping
Kronoberg
Kalmar
GotlandBlekinge
Skåne
Halland
Västra Götaland
VärmlandÖrebro
VästmanlandDalarna
Gävleborg
Västernorrland
JämtlandVästerbotten
Norrbotten
Percent
0 20 40 60 80 100
Sunderbyns sjukhusSkellefteå lasarett
Norrlands Universitetssjukhus, UmeåÖstersunds sjukhus
Örnsköldsviks sjukhusSundsvalls sjukhus
Sollefteå sjukhusHudiksvalls sjukhus
Gävle sjukhusMora lasarettFalu lasarett
Västerås lasarettUniversitetssjukhuset Örebro
Centralsjukhuset i KarlstadSÄ-sjukvården
SU Östra, GöteborgSkaraborgs sjukhus, Skövde
Skaraborgs sjukhus, LidköpingNU-sjukvården
Kungälvs sjukhusAlingsås lasarett
Varbergs sjukhusLänssjukhuset i Halmstad
Universitetssjukhuset MASUniversitetssjukhuset i Lund
Kristianstads sjukhusHelsingborgs lasarett
BlekingesjukhusetVisby lasarett
Västerviks sjukhusLänssjukhuset Kalmar
Växjö lasarettLjungby lasarett
Värnamo sjukhusLänssjukhuset Ryhov, Jönköping
Höglandssjukhuset, EksjöVrinnevisjukhuset i Norrköping
Universitetssjukhuset i LinköpingNyköpings sjukhus
Mälarsjukhuset, EskilstunaAkademiska sjukhuset, Uppsala
Södertälje sjukhusSödersjukhuset, Stockholm
S:t Görans sjukhus, StockholmNorrtälje sjukhusKarolinska, Solna
Karolinska, HuddingeErsta sjukhus, Stockholm
Danderyds sjukhus
74 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
47 at least twelve lymph nodes examined in the tumour sampleAfter primary surgery for rectal cancer, the intestinal tissue and tumour that have been removed are sent to a pathology lab for microscopic and macroscopic examina-tion. The purpose of the examinations is to offer a definitive assessment of the type and stage of the tumour. Correctly classifying the malignancy is integral to predict-ing progression of the disease and prescribing proper treatment. Scientific studies indicate that acceptable diagnostic quality requires examination of at least twelve lymph nodes. The quality of the examinations is affected by whether the surgeon removes sufficient tissue, as well as the pathologist’s analytical skills.
Figure 46Hospitals
Percentage of patients who had a multidisciplinary team meeting after rectal cancer surgery, 2008–2009. Source: National Rectal Cancer Register
1 Fewer than 10 cases
100.098.4
100.096.7
31.798.826.390.782.127.392.248.242.940.529.420.8
100.057.964.3
37.380.031.913.345.117.09.5
68.065.284.887.590.294.935.197.391.496.691.095.0
100.094.4
50.066.725.065.328.696.8
RegionStockholm
UppsalaSörmland
Östergötland
Jönköping
Kronoberg
Kalmar
GotlandBlekinge
Skåne
Halland
Västra Götaland
VärmlandÖrebro
VästmanlandDalarna
Gävleborg
Västernorrland
JämtlandVästerbotten
Norrbotten
Percent
0 20 40 60 80 100
Sunderbyns sjukhusSkellefteå lasarett
Norrlands Universitetssjukhus, UmeåÖstersunds sjukhus
Örnsköldsviks sjukhusSundsvalls sjukhusSollefteå sjukhus 1
Hudiksvalls sjukhusGävle sjukhusMora lasarettFalu lasarett
Västerås lasarettUniversitetssjukhuset Örebro
Centralsjukhuset i KarlstadSÄ-sjukvården
SU Östra, GöteborgSkaraborgs sjukhus, Skövde
Skaraborgs sjukhus, LidköpingNU-sjukvården
Kungälvs sjukhusAlingsås lasarett
Varbergs sjukhusLänssjukhuset i Halmstad
Universitetssjukhuset MASUniversitetssjukhuset i Lund
Kristianstads sjukhusHelsingborgs lasarett
BlekingesjukhusetVisby lasarett 1
Västerviks sjukhusLänssjukhuset Kalmar
Växjö lasarettLjungby lasarett
Värnamo sjukhusLänssjukhuset Ryhov, Jönköping
Höglandssjukhuset, EksjöVrinnevisjukhuset i Norrköping
Universitetssjukhuset i LinköpingNyköpings sjukhus
Mälarsjukhuset, EskilstunaAkademiska sjukhuset, Uppsala
Södertälje sjukhusSödersjukhuset, Stockholm
S:t Görans sjukhus, StockholmNorrtälje sjukhus 1
Karolinska, SolnaKarolinska, Huddinge
Ersta sjukhus, StockholmDanderyds sjukhus
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 75
Figure 47Women
Percentage of patients who had at least twelve lymph nodes examined after rectal cancer surgery, 2008–2009.Source: National Rectal Cancer Register
1 Fewer than 10 cases, 2006-2007 2 Fewer than 10 cases, both periods 2006–2007 Percent
87.579.676.973.270.666.765.264.163.258.857.956.754.652.652.050.046.744.243.835.132.0
0 20 40 60 80 100
Gotland 2
VästerbottenVärmlandGävleborg
ÖstergötlandVästernorrland
ÖrebroJönköping
NorrbottenJämtland 1
HallandDalarna
KronobergKalmar
SWEDENBlekingeUppsala
SkåneStockholmSörmland
Västra GötalandVästmanland
Figure 47Men
Percentage of patients who had at least twelve lymph nodes examined after rectal cancer surgery, 2008–2009.Source: National Rectal Cancer Register
1 Fewer than 10 cases 2006–2007 Percent
88.487.282.275.673.770.669.368.868.867.365.364.664.363.658.757.153.952.743.943.336.6
0 20 40 60 80 100
Gotland 1
VästernorrlandVästerbottenÖstergötland
VärmlandHalland
KronobergÖrebro
NorrbottenJönköpingGävleborg
KalmarDalarnaUppsala
SWEDENStockholm
SkåneJämtlandBlekinge
VästmanlandVästra Götaland
Sörmland
76 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
Figure 47Total
Percentage of patients who had at least twelve lymph nodes examined after rectal cancer surgery, 2008–2009.Source: National Rectal Cancer Register
2006–2007 Percent
84.484.184.171.970.970.667.866.966.764.463.460.059.759.657.956.355.355.145.744.040.938.2
0 20 40 60 80 100
VästerbottenVästernorrland
ÖstergötlandVärmland
HallandÖrebro
GävleborgKronobergNorrbottenJönköping
GotlandDalarnaKalmar
JämtlandSWEDEN
UppsalaSkåne
StockholmBlekinge
SörmlandVästra Götaland
Västmanland
Figure 47Sweden
Percentage of patients who have at least twelve lymph nodes examined after rectal cancer surgery. Trend, 2003–2009. Source: National Rectal Cancer Register
Percent
0
20
40
60
80
100
2009200820072006200520042003
Women
Total
Men
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 77
Figure 47Pathology lab
Percentage of patients who had at least twelve lymph nodes examined after rectal cancer surgery, 2008–2009.Source: National Rectal Cancer Register
53.786.873.660.661.166.282.545.460.057.964.071.985.768.954.773.951.688.691.281.261.347.854.785.963.957.536.861.540.760.8
RegionStockholm
UppsalaSörmland
ÖstergötlandJönköping Kronoberg
KalmarBlekinge
Skåne
HallandVästra Götaland
VärmlandÖrebro
VästmanlandDalarna
GävleborgVästernorrland
JämtlandVästerbotten
Norrbotten
Percent
0 20 40 60 80 100
Sunderbyns sjukhusNorrlands Universitetssjukhus, Umeå
Östersunds sjukhusSundsvalls sjukhus
Gävle sjukhusFalu lasarett
Västerås lasarettUniversitetssjukhuset Örebro
Centralsjukhuset i KarlstadSÄ-sjukvården, Borås
Skaraborgs sjukhus, SkövdeSahlgrenska universitetssjukhusetNU-sjukvården, Trollhättan/NÄL
Länssjukhuset i HalmstadUniversitetssjukhuset MAS
Universitetssjukhuset i LundKristianstads sjukhusHelsingborgs lasarett
Blekingesjukhuset, KarlskronaLänssjukhuset Kalmar
Växjö lasarettLänssjukhuset Ryhov, JönköpingUniversitetssjukhuset i Linköping
Mälarsjukhuset, EskilstunaAkademiska sjukhuset, Uppsala
Täby MedilabS:t Görans sjukhus, Stockholm
Karolinska, SolnaKarolinska, Huddinge
Danderyds sjukhus
The comparison covers a two-year period. With the exception of the large counties, however, the quality register contained few cases – as reflected in the broad confi-dence intervals.
78 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
48 Preoperative radiotherapy Preoperative radiotherapy may be indicated to reduce the risk of local recurrence and occasionally to limit tumour extension as well. The NBHW national guidelines for rectal cancer care assign relatively high priority to the intervention, particularly if the tumour is difficult to remove. If the malignancy is small enough, however, the risk of recurrence is smaller than the risks associated with radiotherapy.
A follow-up by the rectal cancer register in 2009 showed that fewer patients over 80 were receiving preoperative radiotherapy.
Figure 48Total
Percentage of patients who received radiotherapy prior to rectal cancer surgery, 2008–2009. Source: National Rectal Cancer Register
2006–2007 Percent
82.881.680.379.878.273.972.972.770.867.266.766.065.565.362.461.660.654.454.053.951.441.8
0 20 40 60 80 100
JönköpingJämtlandHalland
NorrbottenVästra Götaland
ÖrebroVärmland
SkåneDalarna
SWEDENKalmar
BlekingeVästerbotten
KronobergGotland
StockholmÖstergötland
VästernorrlandSörmland
UppsalaVästmanland
Gävleborg
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 79
Figure 48Sweden
Percentage of patients who received radiotherapy prior to rectal cancer surgery. Trend, 2000–2009. Source: National Rectal Cancer Register
Percent
0
20
40
60
80
100
2009200820072006200520042003200220012000
Women
Total
Men
Figure 48Hospitals
Percentage of patients who received radiotherapy prior to rectal cancer surgery, 2008–2009. Source: National Rectal Cancer Register
1 Fewer than 10 cases
67.971.170.385.0
56.176.563.280.082.177.371.476.852.438.141.266.775.665.867.9
65.384.451.462.051.058.547.636.047.854.441.749.253.975.461.662.483.065.750.075.994.4
87.057.146.967.471.454.0
RegionStockholm
UppsalaSörmland
Östergötland
Jönköping
Kronoberg
Kalmar
GotlandBlekinge
Skåne
Halland
Västra Götaland
VärmlandÖrebro
VästmanlandDalarna
Gävleborg
Västernorrland
JämtlandVästerbotten
Norrbotten
Percent
0 20 40 60 80 100
Sunderbyns sjukhusSkellefteå lasarett
Norrlands Universitetssjukhus, UmeåÖstersunds sjukhus
Örnsköldsviks sjukhusSundsvalls sjukhusSollefteå sjukhus 1
Hudiksvalls sjukhusGävle sjukhusMora lasarettFalu lasarett
Västerås lasarettUniversitetssjukhuset Örebro
Centralsjukhuset i KarlstadSÄ-sjukvården
SU Östra, GöteborgSkaraborgs sjukhus, Skövde
Skaraborgs sjukhus, LidköpingNU-sjukvården
Kungälvs sjukhusAlingsås lasarett
Varbergs sjukhusLänssjukhuset i Halmstad
Universitetssjukhuset MASUniversitetssjukhuset i Lund
Kristianstads sjukhusHelsingborgs lasarett
BlekingesjukhusetVisby lasarett 1
Västerviks sjukhusLänssjukhuset Kalmar
Växjö lasarettLjungby lasarett
Värnamo sjukhusLänssjukhuset Ryhov, Jönköping
Höglandssjukhuset, EksjöVrinnevisjukhuset i Norrköping
Universitetssjukhuset i LinköpingNyköpings sjukhus
Mälarsjukhuset, EskilstunaAkademiska sjukhuset, Uppsala
Södertälje sjukhusSödersjukhuset, Stockholm
S:t Görans sjukhus, StockholmNorrtälje sjukhus 1
Karolinska, SolnaKarolinska, Huddinge
Ersta sjukhus, StockholmDanderyds sjukhus
80 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
49 Perforation of the rectum during surgeryOne important complication that can occur during surgery is perforation of the rectum. Such a development increases the risk of tumour recurrence and therefore suffering on the part of the patient.
One goal is to minimise the number of complications that are due to healthcare interventions, in this case injury during the course of an operation. Perforations during surgery cannot be wholly eliminated given that they can also be caused by the patient’s general condition.
Figure 49Total
Percentage of patients with perforated rectum during rectal cancer surgery, 2007–2009. Source: National Rectal Cancer Register
2004–2006 Percent
0.01.51.51.92.12.22.93.84.04.64.85.25.45.66.27.17.47.77.98.4
10.110.3
0 5 10 15 20 25 30
ÖrebroBlekinge
Västra GötalandHalland
ÖstergötlandVästerbotten
JönköpingGävleborgSWEDEN
SkåneVärmland
DalarnaKronoberg
KalmarStockholm
VästernorrlandJämtland
NorrbottenUppsala
SörmlandVästmanland
Gotland
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 81
Figure 49Sweden
Percentage of patients with perforated rectum during rectal cancer surgery. Trend, 2000–2009. Source: National Rectal Cancer Register
Percent
0
5
10
15
20
25
30
2009200820072006200520042003200220012000
Women
Total
Men
Figure 49Hospitals
Percentage of patients with perforated rectum during rectal cancer surgery, 2007–2009. Source: National Rectal Cancer Register
4.01.66.05.60.06.51.89.14.11.13.56.4
10.88.38.53.13.35.33.62.70.0
10.11.56.15.18.89.57.55.67.43.73.5
19.09.82.44.6
11.21.44.13.33.25.90.03.30.02.37.5
10.02.1
RegionStockholm
UppsalaSörmland
Östergötland
Jönköping
Kronoberg
Kalmar
GotlandBlekinge
Skåne
Halland
Västra Götaland
VärmlandÖrebro
VästmanlandDalarna
Gävleborg
Västernorrland
JämtlandVästerbotten
Norrbotten
Percent
0 5 10 15 20 25 30
Sunderbyns sjukhusSkellefteå lasarett
Norrlands Universitetssjukhus, UmeåÖstersunds sjukhus
Örnsköldsviks sjukhusSundsvalls sjukhus
Sollefteå sjukhusHudiksvalls sjukhus
Gävle sjukhusMora lasarettFalu lasarett
Västerås lasarettUniversitetssjukhuset Örebro
Centralsjukhuset i KarlstadSÄ-sjukvården
SU Östra, GöteborgSkaraborgs sjukhus, Skövde
Skaraborgs sjukhus, LidköpingNU-sjukvården
Kungälvs sjukhusAlingsås lasarett
Varbergs sjukhusLänssjukhuset i Halmstad
Universitetssjukhuset MASUniversitetssjukhuset i Lund
Kristianstads sjukhusHelsingborgs lasarett
BlekingesjukhusetVisby lasarett
Västerviks sjukhusLänssjukhuset Kalmar
Växjö lasarettLjungby lasarett
Värnamo sjukhusLänssjukhuset Ryhov, Jönköping
Höglandssjukhuset, EksjöVrinnevisjukhuset i Norrköping
Universitetssjukhuset i LinköpingNyköpings sjukhus
Mälarsjukhuset, EskilstunaAkademiska sjukhuset, Uppsala
Södertälje sjukhusSödersjukhuset, Stockholm
S:t Görans sjukhus, StockholmNorrtälje sjukhusKarolinska, Solna
Karolinska, HuddingeErsta sjukhus, Stockholm
Danderyds sjukhus
82 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
Figure 50Women
Percentage of patients with anastomosis insufficiency after rectal cancer surgery, 2007–2009. Source: National Rectal Cancer Register
1 Fewer than 10 cases in 2007–2009 2 Fewer than 10 cases, both periods 2004–2006 Percent
0.00.00.03.64.64.84.95.36.36.76.77.6
10.312.513.314.315.415.817.125.0
0 10 20 30 40 50 60
ÖrebroÖstergötland
KronobergGävleborg
VästernorrlandBlekinge
SörmlandVärmlandSWEDEN
VästerbottenStockholm
KalmarSkåne
Västra GötalandDalarnaUppsalaHalland
VästmanlandNorrbottenJönköpingJämtland 1
Gotland 2
Figure 50Men
Percentage of patients with anastomosis insufficiency after rectal cancer surgery, 2007–2009. Source: National Rectal Cancer Register
1 Fewer than 10 cases in 2007–2009 2 Fewer than 10 cases, both periods 2004–2006 Percent
1.73.84.66.57.07.17.18.78.89.4
10.510.710.811.912.215.715.816.719.421.7
0 10 20 30 40 50 60
NorrbottenÖrebro
BlekingeJönköpingStockholm
ÖstergötlandSörmland
DalarnaVästerbotten
SWEDENKalmar
UppsalaSkåne
VärmlandJämtland
Västra GötalandGävleborgKronoberg
HallandVästmanland
Västernorrland 1
Gotland 2
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 83
Figure 50Total
Percentage of patients with anastomosis insufficiency after rectal cancer surgery, 2007–2009. Source: National Rectal Cancer Register
1 Fewer than 10 cases in 2004–2006 2004–2006 Percent
1.23.76.27.17.37.88.48.69.19.39.49.59.8
10.010.512.112.213.214.415.621.427.3
0 10 20 30 40 50 60
Gotland 1
ÖrebroBlekinge
ÖstergötlandNorrbottenStockholmSörmland
GävleborgJämtland
KronobergVästernorrland
SWEDENVästerbotten
JönköpingDalarna
VärmlandKalmar
SkåneUppsala
Västra GötalandHalland
Västmanland
50 anastomosis insufficiency after surgerySurgery involves removal of the tumour, followed in approximately 50 per cent of cases by one of several methods to reconnect the two ends of the bowel. The area that has been reconnected is referred to as anastomosis. A serious postoperative complication is anastomosis insufficiency – leakage of faeces into the abdomen – which can cause peritonitis (inflammation) and sepsis (blood poisoning). The con-dition is life-threatening, requiring reoperation and posing the risk of a permanent stoma (opening). The NBHW national guidelines for rectal cancer care identity the percentage of patients who develop anastomosis insufficiency after surgery as an important indicator to monitor.
The outcome is affected to some extent by whether and when the patient received preoperative radiotherapy. The comparison does not take case mix, age, tumour stage, or the patient’s condition into consideration. Such factors can affect the oc-currence of anastomosis insufficiency.
84 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
Figure 50Sweden
Percentage of patients with anastomosis insufficiency after rectal cancer surgery. Trend, 2000–2009. Source: National Rectal Cancer Register
Percent
0
5
10
15
20
25
30
2009200820072006200520042003200220012000
Women
Total
Men
Figure 50Hospitals
Percentage of patients with anastomosis insufficiency after rectal cancer surgery, 2007–2009. Source: National Rectal Cancer Register
1 Fewer than 10 cases
7.514.421.112.59.12.2
12.318.26.8
10.318.28.2
20.50.06.1
18.218.88.06.3
12.5
15.95.18.2
12.54.00.08.30.00.03.20.0
11.19.44.18.6
22.21.29.86.72.9
20.0
10.58.3
13.2
RegionStockholm
UppsalaSörmland
Östergötland
Jönköping
Kronoberg
Kalmar
GotlandBlekinge
Skåne
Halland
Västra Götaland
VärmlandÖrebro
VästmanlandDalarna
Gävleborg
Västernorrland
JämtlandVästerbotten
Norrbotten
Percent
0 10 20 30 40 50
Sunderbyns sjukhusSkellefteå lasarett 1
Norrlands Universitetssjukhus, UmeåÖstersunds sjukhus
Örnsköldsviks sjukhus 1
Sundsvalls sjukhus 1
Sollefteå sjukhus 1
Hudiksvalls sjukhusGävle sjukhusMora lasarettFalu lasarett
Västerås lasarettUniversitetssjukhuset Örebro
Centralsjukhuset i KarlstadSÄ-sjukvården
SU Östra, GöteborgSkaraborgs sjukhus, Skövde
Skaraborgs sjukhus, LidköpingNU-sjukvården
Kungälvs sjukhusAlingsås lasarett
Varbergs sjukhusLänssjukhuset i Halmstad
Universitetssjukhuset MASUniversitetssjukhuset i Lund
Kristianstads sjukhusHelsingborgs lasarett
BlekingesjukhusetVisby lasarett 1
Västerviks sjukhusLänssjukhuset Kalmar
Växjö lasarettLjungby lasarett
Värnamo sjukhusLänssjukhuset Ryhov, Jönköping
Höglandssjukhuset, EksjöVrinnevisjukhuset i Norrköping
Universitetssjukhuset i LinköpingNyköpings sjukhus
Mälarsjukhuset, EskilstunaAkademiska sjukhuset, Uppsala
Södertälje sjukhusSödersjukhuset, Stockholm
S:t Görans sjukhus, StockholmNorrtälje sjukhusKarolinska, Solna
Karolinska, HuddingeErsta sjukhus, Stockholm
Danderyds sjukhus
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 85
51 More than 21 days of hospitalisation after surgeryAssuming no complications occur, hospitalisation after surgery should not exceed 21 days. The goal is based on a follow-up by the National Rectal Cancer Register for 1995–2009 showing that the median hospitalisation period following surgery was fewer than 13 days for patients discharged to home and fewer than 21 days for those who were discharged to another institution (a different department or special housing). Only a few years deviated from that pattern. Thus, patients who were discharged to another institution had generally been hospitalised longer.
The comparison does not take the possible effects of comorbidity or the patient’s preoperative condition into consideration.
Figure 51Total
Percentage of patients with more than 21 days of hospitalisation after rectal cancer surgery, 2008–2009. Source: National Rectal Cancer Register
Percentage discharged to another institution
Percentage discharged to home
2006–2007 Percent
3.96.16.47.78.39.19.29.9
10.110.711.511.511.712.312.513.213.915.118.219.827.428.6
0 10 20 30 40 50 60
JämtlandSörmland
SkåneUppsala
GävleborgKronoberg
KalmarVärmlandSWEDEN
ÖrebroJönköping
VästerbottenBlekinge
Västra GötalandStockholm
VästmanlandGotland
ÖstergötlandVästernorrland
NorrbottenDalarnaHalland
86 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
Figure 51Sweden
Percentage of patients with more than 21 days of hospitalisation after rectal cancer surgery. Trend, 2000–2009. Source: National Rectal Cancer Register
Percent
0
5
10
15
20
25
30
2009200820072006200520042003200220012000
Women
Total
Men
Figure 51Hospitals
Percentage of patients with more than 21 days of hospitalisation after rectal cancer surgery, 2008–2009. Source: National Rectal Cancer Register
Percentage discharged to another institution
Percentage discharged to home
1 Fewer than 10 cases
3.86.6
16.212.5
2.416.110.514.737.54.63.9
14.65.09.5
11.825.07.39.2
25.0
10.726.75.6
25.719.00.07.34.0
26.16.5
12.513.19.0
12.311.611.810.24.5
10.015.513.9
4.44.8
31.310.214.36.4
RegionStockholm
UppsalaSörmland
Östergötland
Jönköping
Kronoberg
Kalmar
GotlandBlekinge
Skåne
Halland
Västra Götaland
VärmlandÖrebro
VästmanlandDalarna
Gävleborg
Västernorrland
JämtlandVästerbotten
Norrbotten
Percent
0 10 20 30 40 50 60
Sunderbyns sjukhusSkellefteå lasarett
Norrlands Universitetssjukhus, UmeåÖstersunds sjukhus
Örnsköldsviks sjukhusSundsvalls sjukhusSollefteå sjukhus 1
Hudiksvalls sjukhusGävle sjukhusMora lasarettFalu lasarett
Västerås lasarettUniversitetssjukhuset Örebro
Centralsjukhuset i KarlstadSÄ-sjukvården
SU Östra, GöteborgSkaraborgs sjukhus, Skövde
Skaraborgs sjukhus, LidköpingNU-sjukvården
Kungälvs sjukhusAlingsås lasarett
Varbergs sjukhusLänssjukhuset i Halmstad
Universitetssjukhuset MASUniversitetssjukhuset i Lund
Kristianstads sjukhusHelsingborgs lasarett
BlekingesjukhusetVisby lasarett 1
Västerviks sjukhusLänssjukhuset Kalmar
Växjö lasarettLjungby lasarett
Värnamo sjukhusLänssjukhuset Ryhov, Jönköping
Höglandssjukhuset, EksjöVrinnevisjukhuset i Norrköping
Universitetssjukhuset i LinköpingNyköpings sjukhus
Mälarsjukhuset, EskilstunaAkademiska sjukhuset, Uppsala
Södertälje sjukhusSödersjukhuset, Stockholm
S:t Görans sjukhus, StockholmNorrtälje sjukhus 1
Karolinska, SolnaKarolinska, Huddinge
Ersta sjukhus, StockholmDanderyds sjukhus
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 87
52 Reoperation due to complications within 30 days of primary surgery
Approximately 82 per cent of all rectal cancer surgery involves removal of the entire tumour. The location and size of the tumour, as well as the patient’s general condi-tion, affect the scope and riskiness of the operation. Relatively prompt reoperation may be required due to bleeding, infection, leakage or another complication. Reop-eration entails additional suffering for the patient and increases the risk of further complications.
The NBHW national guidelines for rectal cancer care identify reoperation within 30 days of primary surgery as an important indicator to monitor.
One source of error in comparing data is that some hospitals report minor interven-tions as reoperations and some do not. The percentage of reoperations is also related to the way that primary surgery was performed and the patient’s condition at the time.
Figure 52Total
Percentage of patients with reoperation within 30 days after primary rectal cancer surgery, 2005–2009.Source: National Rectal Cancer Register
2003–2007 Percent
3.94.25.56.27.89.09.79.9
10.410.410.810.911.011.212.212.212.612.612.612.714.014.0
0 5 10 15 20 25 30
JämtlandJönköping
KalmarVärmland
KronobergStockholm
Västra GötalandVästernorrland
GävleborgNorrbotten
ÖrebroSWEDEN
VästerbottenSkåne
HallandBlekinge
ÖstergötlandSörmland
DalarnaUppsalaGotland
Västmanland
88 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
Figure 52Women
Percentage of patients with reoperation within 30 days after primary rectal cancer surgery, 2005–2009.Source: National Rectal Cancer Register
1 Fewer than 10 cases 2003–2007 Percent
4.64.95.65.66.77.68.08.18.39.29.69.89.9
10.110.510.610.711.411.513.313.7
0 5 10 15 20 25 30
KronobergJämtland
JönköpingVästernorrland
SkåneÖrebro
NorrbottenSörmland
Västra GötalandStockholm
VästerbottenSWEDEN
ÖstergötlandKalmar
BlekingeGävleborgVärmland
VästmanlandDalarnaUppsalaHalland
Gotland 1
Figure 52Men
Percentage of patients with reoperation within 30 days after primary rectal cancer surgery, 2005–2009.Source: National Rectal Cancer Register
2003–2007 Percent
3.05.66.06.56.79.6
10.210.810.911.011.211.911.912.813.113.613.814.314.515.215.616.8
0 5 10 15 20 25 30
VärmlandJönköping
KalmarStockholm
JämtlandVästra Götaland
GävleborgHalland
VästernorrlandSWEDEN
KronobergNorrbotten
ÖrebroVästerbotten
BlekingeSkåne
ÖstergötlandDalarna
SörmlandUppsalaGotland
Västmanland
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 89
Figure 52Sweden
Percentage of patients with reoperation within 30 days after primary rectal cancer surgery. Trend, 1995–2009. Source: National Rectal Cancer Register
Percent
0
5
10
15
20
25
30
090807060504030201009998979695
Women
Total
Men
Figure 52Hospitals
Percentage of patients with reoperation within 30 days after primary rectal cancer surgery, 2005–2009.Source: National Rectal Cancer Register
8.510.311.59.89.19.1
12.89.06.17.17.38.26.4
15.010.718.821.58.7
11.511.06.1
14.99.36.3
10.07.7
14.27.1
12.314.09.1
15.38.3
11.513.011.513.511.23.97.9
13.38.0
21.223.56.15.9
10.310.613.011.7
RegionStockholm
UppsalaSörmland
Östergötland
Jönköping
Kronoberg
Kalmar
GotlandBlekinge
Skåne
Halland
Västra Götaland
VärmlandÖrebro
VästmanlandDalarna
Gävleborg
Västernorrland
JämtlandVästerbotten
Norrbotten
Percent
0 10 20 30 40
Sunderbyns sjukhusSkellefteå lasarett
Norrlands Universitetssjukhus, UmeåÖstersunds sjukhus
Örnsköldsviks sjukhusSundsvalls sjukhus
Sollefteå sjukhusHudiksvalls sjukhus
Gävle sjukhusMora lasarettFalu lasarett
Västerås lasarettUniversitetssjukhuset Örebro
Centralsjukhuset i KarlstadSÄ-sjukvården, Borås
SU Östra, GöteborgSkaraborgs sjukhus, Skövde
Skaraborgs sjukhus, LidköpingNU-sjukvården, Uddevalla
Kungälvs sjukhusAlingsås lasarett
Varbergs sjukhusLänssjukhuset i Halmstad
Universitetssjukhuset MASUniversitetssjukhuset i Lund
Kristianstads sjukhusHelsingborgs lasarett
Blekingesjukhuset, KarlskronaBlekingesjukhuset, Karlshamn
Visby lasarettVästerviks sjukhus
Länssjukhuset KalmarVäxjö lasarett
Ljungby lasarettVärnamo sjukhus
Länssjukhuset Ryhov, JönköpingHöglandssjukhuset, Eksjö
Vrinnevisjukhuset i NorrköpingUniversitetssjukhuset i Linköping
Nyköpings sjukhusMälarsjukhuset, Eskilstuna
Akademiska sjukhuset, UppsalaSödertälje sjukhus
Södersjukhuset, StockholmS:t Görans sjukhus, Stockholm
Norrtälje sjukhusKarolinska, Solna
Karolinska, HuddingeErsta sjukhus, Stockholm
Danderyds sjukhus
90 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
Figure 53Women
Percentage of patients with relapse of cancer of the pelvis within five years after rectal cancer surgery. Patients who underwent surgery in 2001–2004 with follow-up through 2009. Source: National Rectal Cancer Register
1 Fewer than 10 cases Percent
0.01.82.73.73.94.24.36.16.46.86.87.17.78.08.39.09.39.59.7
15.023.4
0 10 20 30 40
HallandKalmar
SörmlandSkåne
BlekingeStockholm
Västra GötalandJönköpingSWEDEN
KronobergNorrbotten
VärmlandVästernorrland
GävleborgÖstergötland
JämtlandDalarna
VästerbottenÖrebro
UppsalaVästmanland
Gotland 1
Figure 53Men
Percentage of patients with relapse of cancer of the pelvis within five years after rectal cancer surgery. Patients who underwent surgery in 2001–2004 with follow-up through 2009. Source: National Rectal Cancer Register
Percent
1.01.11.42.93.03.54.24.37.17.37.47.47.47.67.98.39.39.59.6
10.511.811.9
0 10 20 30 40
HallandKronoberg
SkåneVärmlandStockholm
JämtlandÖrebro
NorrbottenVästerbotten
Västra GötalandDalarnaBlekinge
SWEDENGotland
VästernorrlandSörmland
KalmarGävleborgJönköping
UppsalaVästmanlandÖstergötland
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 91
53 new cancer of the pelvis within five years of surgeryRelapse refers to the recurrence of a malignancy in an area that was previously treated by surgery or radiotherapy. The result is a very high risk of incurable disease or extensive surgery, chemotherapy or radiotherapy. The NBHW national guide-lines for rectal cancer care identify the percentage of relapses in the pelvis within two years after surgery as an important indicator to monitor. The rectal cancer reg-ister monitors tumour recurrence for five years after surgery, as presented in this comparison.
The result is affected to some extent by the patient’s preoperative condition.
Figure 53Total
Percentage of patients with relapse of cancer of the pelvis within five years after rectal cancer surgery. Patients who underwent surgery in 2001–2004 with follow-up through 2009. Source: National Rectal Cancer Register
Percent
0.61.62.54.55.15.35.35.95.96.36.57.27.47.47.57.88.28.39.39.7
10.116.9
0 10 20 30 40
HallandSkåne
KronobergStockholmVärmland
BlekingeVästra Götaland
JämtlandSWEDEN
NorrbottenKalmar
SörmlandVästerbotten
DalarnaÖrebro
JönköpingGotland
VästernorrlandGävleborg
ÖstergötlandUppsala
Västmanland
92 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
Figure 53Hospitals
Percentage of patients with relapse of cancer of the pelvis within five years after rectal cancer surgery. Patients who underwent surgery in 2001–2004 with follow-up through 2009. Source: National Rectal Cancer Register
1 Fewer than 10 cases
12.07.48.49.24.07.89.0
24.33.28.02.04.10.04.54.89.38.0
10.310.35.66.38.46.7
10.3
9.113.919.73.43.37.05.04.09.9
11.09.44.00.76.45.82.5
10.95.66.03.27.76.75.64.1
RegionStockholm
UppsalaSörmland
Östergötland
Jönköping
Kronoberg
Kalmar
GotlandBlekinge
Skåne
Halland
Västra Götaland
VärmlandÖrebro
VästmanlandDalarna
Gävleborg
Västernorrland
JämtlandVästerbotten
Norrbotten
Percent
0 10 20 30 40
Sunderbyns sjukhusSkellefteå lasarett
Norrlands Universitetssjukhus, UmeåÖstersunds sjukhus
Örnsköldsviks sjukhusSundsvalls sjukhus
Sollefteå sjukhusHudiksvalls sjukhus
Gävle sjukhusMora lasarettFalu lasarett
Västerås lasarettUniversitetssjukhuset Örebro
Centralsjukhuset i KarlstadSÄ-sjukvården
SU Östra, GöteborgSkaraborgs sjukhus, Skövde
Skaraborgs sjukhus, LidköpingNU-sjukvården
Kungälvs sjukhusAlingsås lasarett
Varbergs sjukhusLänssjukhuset i Halmstad
Universitetssjukhuset MASUniversitetssjukhuset i Lund 1
Kristianstads sjukhusHelsingborgs lasarett
BlekingesjukhusetVisby lasarett
Västerviks sjukhusLänssjukhuset Kalmar
Växjö lasarettLjungby lasarett
Värnamo sjukhusLänssjukhuset Ryhov, Jönköping
Höglandssjukhuset, EksjöVrinnevisjukhuset i Norrköping
Universitetssjukhuset i LinköpingNyköpings sjukhus
Mälarsjukhuset, EskilstunaAkademiska sjukhuset, Uppsala
Södertälje sjukhusSödersjukhuset, Stockholm
S:t Görans sjukhus, StockholmNorrtälje sjukhusKarolinska, Solna
Karolinska, HuddingeErsta sjukhus, Stockholm
Danderyds sjukhus
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 93
54 Deaths within 30 and 90 days of surgeryThe NBHW national guidelines for rectal cancer care identify the percentage of deaths within 30 days of surgery as an important indicator for monitoring health-care quality. The indicator reflects the selection of patients for surgery, as well as the care they receive before, during and after the operation. Given that patients who experience complications generally survive the first 30 days thanks to intensive care and other interventions, this comparison also presents those who die within 90 days.
Age, gender, and severity of the malignancy also affect the percentage of deaths. Table 2 shows the odds ratio by county, adjusted for age, gender and tumour stage. A value of 1 is assigned to the national average of patients who die within 90 days of surgery. A value less than 1 represents a percentage below the national average and a value greater than 1 represents a percentage above the national average.
Figure 54Sweden
Percentage of deaths within 90 days after rectal cancer surgery. Trend, 2000–2009. Source: National Rectal Cancer Register
Percent
0
5
10
15
20
25
30
2009200820072006200520042003200220012000
Women
Total
Men
94 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
Figure 54Women
Percentage of deaths within 30 and 90 days after rectal cancer surgery, 2007–2009.Source: National Rectal Cancer Register
1 Fewer than 10 cases
Percentage of deaths within 30 days
Percentage of deaths within 31-90 days
2002–2006 Percent
0.00.00.00.01.61.62.02.02.02.22.32.42.52.52.73.83.95.45.55.77.1
0 5 10 15 20 25 30
BlekingeKalmarÖrebro
NorrbottenSörmland
Västra GötalandSWEDEN
SkåneStockholm
UppsalaÖstergötland
VästernorrlandVästmanland
JönköpingDalarna
VärmlandGävleborg
VästerbottenKronoberg
JämtlandHalland
Gotland 1
Figure 54Men
Percentage of deaths within 30 and 90 days after rectal cancer surgery, 2007–2009.Source: National Rectal Cancer Register
2002–2006
Percentage of deaths within 30 days
Percentage of deaths within 31-90 days
Percent
0.00.01.82.32.52.63.23.23.33.63.84.14.44.44.44.65.35.35.75.96.1
12.5
0 5 10 15 20 25 30
JämtlandKalmar
ÖstergötlandVästra Götaland
JönköpingKronoberg
SkåneVärmland
ÖrebroHalland
SWEDENSörmland
VästerbottenNorrbotten
UppsalaDalarna
StockholmGävleborg
VästmanlandVästernorrland
GotlandBlekinge
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 95
Figure 54Total
Percentage of deaths within 30 and 90 days after rectal cancer surgery, 2007–2009.Source: National Rectal Cancer Register
Percentage of deaths within 30 days
Percentage of deaths within 31-90 days
2002–2006 Percent
0.02.02.12.12.22.32.62.62.82.93.33.33.63.73.94.04.14.34.84.95.98.7
0 5 10 15 20 25 30
JämtlandKalmar
Västra GötalandÖrebro
ÖstergötlandNorrbottenJönköpingSörmland
SkåneSWEDEN
KronobergVärmland
UppsalaDalarnaHalland
StockholmBlekinge
VästmanlandVästerbotten
GävleborgVästernorrland
Gotland
Table 2
Countycouncil
Odds ratio
95 % Confidence interval
Countycouncil
Odds ratio
95 % Confidence interval
Stockholm 0.84 0.51–1.39 V.Götaland 1.37 0.90–2.09
Uppsala 0.58 0.14–2.41 Värmland 0.93 0.37–2.32
Sörmland 1.18 0.46–2.99 Örebro 1.25 0.56–2.81
Östergötland 1.33 0.63–2.82 Västmanland 0.74 0.23–2.38
Jönköping 1.08 0.42–2.73 Dalarna 0.74 0.27–2.08
Kronoberg 0.85 0.26–2.83 Gävleborg 0.40 0.10–1.65
Kalmar 1.57 0.77–3.23 Västernorrland 0.68 0.16–2.80
Gotland 0.00 Jämtland 2.34 0.80–6.81
Blekinge 0.69 0.17–2.88 Västerbotten 0.52 0.13–2.18
RegionSkåne 1.09 0.68–1.76 Norrbotten 1.23 0.44–3.43
Halland 0.30 0.07–1.23
96 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
Figure 54Hospitals
Percentage of deaths within 30 and 90 days after rectal cancer surgery, 2007–2009.Source: National Rectal Cancer Register
Percentage of deaths within 30 days Percentage of deaths within 31-90 days
2.01.73.03.97.13.20.04.82.53.46.93.75.10.03.59.43.13.57.12.70.02.32.37.04.02.01.44.55.4
11.13.06.98.34.52.43.44.92.23.13.32.22.07.11.70.09.31.53.54.1
RegionStockholm
UppsalaSörmland
Östergötland
Jönköping
Kronoberg
Kalmar
GotlandBlekinge
Skåne
Halland
Västra Götaland
VärmlandÖrebro
VästmanlandDalarna
Gävleborg
Västernorrland
JämtlandVästerbotten
Norrbotten
Percent
0 5 10 15 20 25 30
Sunderbyns sjukhusSkellefteå lasarett
Norrlands Universitetssjukhus, UmeåÖstersunds sjukhus
Örnsköldsviks sjukhusSundsvalls sjukhus
Sollefteå sjukhusHudiksvalls sjukhus
Gävle sjukhusMora lasarettFalu lasarett
Västerås lasarettUniversitetssjukhuset Örebro
Centralsjukhuset i KarlstadSÄ-sjukvården
SU Östra, GöteborgSkaraborgs sjukhus, Skövde
Skaraborgs sjukhus, LidköpingNU-sjukvården
Kungälvs sjukhusAlingsås lasarett
Varbergs sjukhusLänssjukhuset i Halmstad
Universitetssjukhuset MASUniversitetssjukhuset i Lund
Kristianstads sjukhusHelsingborgs lasarett
BlekingesjukhusetVisby lasarett
Västerviks sjukhusLänssjukhuset Kalmar
Växjö lasarettLjungby lasarett
Värnamo sjukhusLänssjukhuset Ryhov, Jönköping
Höglandssjukhuset, EksjöVrinnevisjukhuset i Norrköping
Universitetssjukhuset i LinköpingNyköpings sjukhus
Mälarsjukhuset, EskilstunaAkademiska sjukhuset, Uppsala
Södertälje sjukhusSödersjukhuset, Stockholm
S:t Görans sjukhus, StockholmNorrtälje sjukhusKarolinska, Solna
Karolinska, HuddingeErsta sjukhus, Stockholm
Danderyds sjukhus
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 97
LuNGCANCER
Statistics for 2009 Women Men
Numberofdiagnoses 1772 1696
Percentageofallcancercases 7% 6%
Prevalence,total 4248 3419
Relativeone-yearsurvivalrate 43% 37.7%
Numberofdeaths 1656 1830
As the fifth most common form of the disease, lung cancer was diagnosed in 1 772 women and 1 696 men in 2009. Approximately half of newly diagnosed patients are over 70 and fewer than 1 per cent are below 40. Lung cancer claims approximately 3 500 Swedish lives every year, more than any other form of the disease. The most frequent cause by far is smoking.
The number of cases has decreased among men since the 1980s and increased among women, most probably due to changes in women’s smoking habits since the 1950s. The number of smokers has decreased in recent decades, but the steady growth of cases among women reflects their smoking habits 20 years ago and earlier.
Lung cancer is aggressive but can be cured if it has not metastasised. There are two different types of the disease: small-cell and non-small-cell. Approximately 80 per cent of all lung cancer is non-small-cell, 15 per cent small-cell and 5 per cent indeter-minate. Stages I and II of non-small-cell cancer are amenable to surgery, assuming that the patient does not have reduced lung capacity, poor general health or other diseases that present obstacles. Stage III non-small-cell lung cancer is limited to the thoracic cavity and may be operable. Stage IV non-small-cell cancer has metasta-sised and cannot be cured through surgery.
Approximately 70 per cent of patients are at stages III or IV at the time of diagnosis and usually cannot be cured. Some 75 per cent of them die within a year. The various palliative treatment methods (drug therapy, radiotherapy or other means of allevi-ating symptoms) all focus on improving the quality of life of these patients.
This report presents outcomes for eight indicators that reflect either curative or palliative interventions. The indicators look at survival rates, diagnosis, curative surgery, palliative treatment, multidisciplinary team meetings and waiting times. Seven of the indicators are based on data from the National Lung Cancer Register, whereas the survival indicator is taken from the Swedish Cancer Register.
The national guidelines for lung cancer care published by the NBHW in 2011 con-tain targets for several of the indicators. The project to formulate the targets in spring 2011 collected data from the National Lung Cancer Register on everyone who had been diagnosed in 2002–2009. The subsequent statistical method chose the
98 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
90th percentile of the nationwide results as the target. Thus, the target is realistic in the sense that some counties have already attained it.
The comparisons that are presented are for 2002–2009 when no targets had yet been set. Along with the outcomes for each indicator, however, the discussion speci-fies the future targets that can now be used to find potential for improvement in lung cancer treatment and care.
The same sample from the National Lung Cancer Register has been used as during the project to formulate the targets. Thus, the outcomes cover a longer period than is typical for this report.
55 lung cancer – relative one-year, two-year and five-year survival rates
Relative survival rates for lung cancer are low but somewhat higher among women than men. Survival rates, particularly for one or two years, have trended upwards since the early 1990s. More women develop and die of lung cancer before the age of 60, whereas the majority of older patients are men.
Figure 55 indicates that the relative one-year survival rate among men rose by al-most 10 per cent from 1990-1994 to 2005–2009. The increase among women was somewhat greater. Men had a relative one-year survival rate of 37.7 per cent and a
Figure 55Total
Lung cancer – relative one-year survival rates. Patients diagnosed in 2000– 2004. Patients age 30–89 at the time of diagnosis. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare
Confidence interval calculated using Taylor series Percent
47.546.745.044.444.342.641.741.240.540.338.238.138.037.636.536.135.735.535.534.233.732.9
0 20 40 60 80
VästernorrlandJämtland
VärmlandÖrebro
VästmanlandSörmland
VästerbottenKronoberg
KalmarBlekinge
GävleborgSkåne
SWEDENDalarna
Västra GötalandJönköping
ÖstergötlandStockholm
UppsalaNorrbotten
GotlandHalland
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 99
two-year rate of 20.9 per cent in 2005–2009, as opposed to 43 per cent and 27 per cent respectively for women. There were significant regional differences: anywhere from 32.9 to 47.5 per cent. The older the patient at the time of diagnosis, the lower the survival rate.
The relative five-year survival rate is approximately 12 per cent among men and 15 per cent among women.
56 Multidisciplinary team meeting prior to treatmentPrimary lung cancer treatment may be preceded by a multidisciplinary team meet-ing, a comprehensive assessment for the purpose of optimising the intervention. Surgery, oncology, pulmonary, radiology, pathology and other specialists, as well as nurses, may participate A multidisciplinary team meeting is particularly important when the benefit of surgery, radiotherapy or drug therapy is difficult to assess; mul-timodal treatment may be indicated. The NBHW national guidelines for lung can-
Figure 55 Sweden
Lung cancer – relative one-year survival rates. Trend, 1990–2009. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare
Percent
0
20
40
60
80
100
2005-20092000-20041995-19991990-1994
Women
Total
Men
Figure 56Sweden
Percentage of patients who have a multidisciplinary team meeting prior to primary treatment for lung cancer. Trend, 2002–2009. Source: National Lung Cancer Register
Percent
0
20
40
60
80
100
20092008200720062005200420032002
Women
Total
Men
100 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
cer care assign high priority to a multidisciplinary team meeting before commence-ment of treatment of a newly diagnosed case. The guidelines target meetings in 74 per cent of the cases, but few counties reach that level. The idea is that all counties should be able to do so and that the level be even higher eventually.
Certain regional differences in reporting of multidisciplinary team meetings affect the outcomes in the diagram. For one thing, there is no uniform definition of the specialists who need to participate in order for a multidisciplinary team meeting to take place. Some counties report only meetings attended by all of the various types of specialists and are thereby underrepresented in the register.
57 Waiting time from receipt of a referral by the specialist clinic until decision to treat
A key indicator of lung cancer care is the amount of time that transpires between the date that a specialist clinic receives a referral – or is contacted by the patient – and decision to treat. The waiting time includes assessment and diagnosis until a decision is made at a multidisciplinary team meeting or in some other manner. The clinic ordinarily specialises in either pulmonary medicine or oncology. According to the Swedish Lung Cancer Group, the waiting time should be 28 days or less for at least 80 per cent of patients.
Figure 56Total
Percentage of patients who had a multidisciplinary team meeting prior to primary treatment for lung cancer, 2002–2009. Source: National Lung Cancer Register
Percent
80.578.873.371.165.762.350.446.846.746.644.343.942.339.837.836.535.332.525.723.519.911.8
0 20 40 60 80 100
DalarnaGotlandHalland
VästmanlandKronoberg
BlekingeSkåne
JönköpingUppsala
Västra GötalandVästernorrland
JämtlandÖrebro
NorrbottenKalmar
SWEDENSörmland
GävleborgÖstergötland
VärmlandStockholm
Västerbotten
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 101
Figure 57Total
Waiting time from receipt of a referral by the specialist clinic until decision to treat lung cancer, 2009. Source: National Lung Cancer Register
Value first quartile Median Value third quartileDays
15222323252727282829303131333334373840434748
0 20 40 60 80 100 120
JönköpingGotland
ÖstergötlandKalmar
StockholmVästra Götaland
JämtlandSWEDEN
DalarnaBlekinge
VästernorrlandKronoberg
SkåneVästerbotten
SörmlandGävleborgVärmland
NorrbottenUppsala
VästmanlandHallandÖrebro
58 lung cancer confirmed by a biopsyA biopsy is required to confirm the diagnosis of lung cancer, determine what type is involved and ensure that it is primary and not metastasis from another tumour. Such an assessment sets the stage for correct and optimum treatment and care. The NBHW national guidelines for lung cancer care assign very high priority to a biopsy.
Figure 58Sweden
Percentage of lung cancer diagnoses confirmed by a biopsy Trend, 2002–2009. Source: National Lung Cancer Register
Percent
0
20
40
60
80
100
20092008200720062005200420032002
Women
Total
Men
102 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
Figure 58Total
Percentage of lung cancer diagnoses confirmed by a biopsy, 2002–2009. Source: National Lung Cancer Register
Percent
98.998.598.498.398.397.997.897.397.096.696.596.596.396.395.395.194.793.691.391.288.787.0
0 20 40 60 80 100
VästmanlandÖrebro
GävleborgUppsala
SörmlandStockholmSWEDEN
SkåneVästra Götaland
DalarnaVärmlandJönköping
VästernorrlandBlekingeHalland
JämtlandÖstergötland
NorrbottenGotlandKalmar
KronobergVästerbotten
The guidelines target biopsies in 99 per cent of cases, a level that most counties are close to attaining. The figure may be lower for some counties because they do not report all of their cases – particularly elderly patients and those with comorbidity – to the lung cancer register.
59 Combined PET/CT scan prior to curative treatment Providing the best possible treatment requires as exact a determination as possible of the location of the malignancy. Lung cancer assessments include examining the upper abdomen by means of X-rays, CT scans, etc. Combined positron emission tomography (PET) and computer tomography (CT) in patients with stage IB-IIIB non-small-cell lung cancer can help decide whether curative treatment is indicated by means of either surgery, chemotherapy or radiotherapy. The NBHW national guidelines assign very high priority to PET/CT scans for this patient population.
Because this is a new variable in the National Lung Cancer Register, data are pre-sented for 2007–2009 only. Even though the sample is small, the guidelines indicate that at least 82 per cent of cases should be assessed with a PET/CT scan.
The benefit of the diagnostic method was not generally known during the compari-son period and the counties were still in the process of adopting it.
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 103
60 Curative surgery for stage i and ii non-small-cell lung cancerSurgery cures more cases of non-small-cell lung cancer by far than any other meth-od. Whether the disease is operable depends on the location and size of the malig-nancy, as well as whether it has metastasised to other organs. Curative surgery is indicated primarily for patients in stages I or II. The NBHW national guidelines for lung cancer care identify curative surgery as an important indicator to monitor. Un-derutilisation of the method may reflect missed opportunities to cure the disease.
This indicator measures treatment interventions by county for people in an early stage of lung cancer. The comparison presents the percentage of patients who are scheduled for curative surgery. A follow-up by the lung cancer register showed that surgery was performed 90 per cent of the time.
The target of the NBHW national guidelines for 2011 is that 79 per cent of patients in stage I or II of non-small-cell lung cancer receive curative surgery.
Figure 59Total
Percentage of patients with non-small-cell lung cancer who underwent PET/CT scan prior to commencement of curative treatment, 2007–2009. Refers to stage IB-IIIB. Source: National Lung Cancer Register
1 Fewer than 10 cases Percent
83.374.374.367.364.059.458.349.145.844.444.142.941.434.133.329.223.114.711.1
9.16.4
0 20 40 60 80 100
Gotland 1
GävleborgSörmland
VästmanlandVästra Götaland
VästernorrlandBlekingeUppsala
VärmlandDalarna
VästerbottenNorrbotten
ÖrebroJämtland
SWEDENKronobergJönköping
HallandÖstergötland
KalmarStockholm
Skåne
104 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
Figure 60Women
Percentage of patients with non-small-cell lung cancer scheduled for curative surgery, 2002–2009. Refers to stage I and II. Source: National Lung Cancer Register
Percent
82.881.880.377.877.576.976.575.074.774.674.572.271.870.770.068.766.166.063.863.158.853.0
0 20 40 60 80 100
NorrbottenDalarna
VärmlandVästernorrland
VästerbottenKalmar
Västra GötalandVästmanland
UppsalaSWEDEN
ÖstergötlandÖrebro
GävleborgSkåne
StockholmHalland
KronobergSörmlandJämtland
JönköpingGotlandBlekinge
Figure 60Men
Percentage of patients with non-small-cell lung cancer scheduled for curative surgery, 2002–2009. Refers to stage I and II. Source: National Lung Cancer Register
Percent
80.477.475.672.171.269.968.265.665.564.764.463.662.161.560.659.558.958.557.454.853.652.6
0 20 40 60 80 100
GotlandVärmland
DalarnaVästerbotten
NorrbottenVästernorrland
UppsalaVästra Götaland
KalmarÖstergötland
HallandJämtlandSörmland
GävleborgSWEDENJönköping
SkåneStockholm
BlekingeVästmanland
KronobergÖrebro
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 105
61 Palliative radiotherapy for stage iiiB and iv lung cancerThe purpose of palliative radiotherapy is to damage the cancer cells and prevent the tumour from growing, thereby delaying or alleviating the symptoms. The NBHW national guidelines assign high priority to the method for patients in stage IIIB or IV of incurable lung cancer who are experiencing pain, coughing, haemoptysis (ex-pectoration of blood) or dyspnoea (breathlessness) from the thoracic organs. Given
Figure 60Total
Percentage of patients with non-small-cell lung cancer scheduled for curative surgery, 2002–2009. Refers to stage I and II. Source: National Lung Cancer Register
Percent
77.677.276.473.573.473.172.172.170.370.169.468.667.065.164.563.763.361.961.457.756.655.7
0 20 40 60 80 100
NorrbottenDalarna
VärmlandVästernorrland
VästerbottenGotlandKalmar
Västra GötalandUppsala
ÖstergötlandSWEDENJämtland
GävleborgHalland
SkåneSörmland
StockholmVästmanland
JönköpingBlekinge
KronobergÖrebro
Figure 60Sweden
Percentage of patients with non-small-cell lung cancer scheduled for curative surgery. Refers to stage I and II. Trend, 2002–2009. Source: National Lung Cancer Register
Percent
0
20
40
60
80
100
20092008200720062005200420032002
Women
Total
Men
106 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
that the adverse effects of radiotherapy can cause deterioration of a patient’s gen-eral condition, it is not indicated in all cases. Some patients decline the treatment for other reasons.
The indicator reflects whether patients with incurable stage IIIB and IV lung cancer are actively offered palliative radiotherapy; large regional differences may suggest
Figure 61Total
Percentage of patients with incurable lung cancer who were offered radiotherapy for palliative purposes, 2002–2009. Refers to stage IIIB and IV. Source: National Lung Cancer Register
Percent
27.523.122.920.216.015.014.213.313.112.712.511.911.610.3
8.47.47.36.85.04.94.82.4
0 10 20 30 40
GotlandHallandÖrebro
BlekingeDalarnaUppsala
VästernorrlandJämtland
KronobergGävleborgStockholm
NorrbottenSkåne
SWEDENJönköping
VästmanlandKalmar
Västra GötalandÖstergötland
SörmlandVästerbotten
Värmland
Figure 61Sweden
Percent
0
5
10
15
20
25
30
20092008200720062005200420032002
Women
Total
Men
Percentage of patients with incurable lung cancer who were offered radiotherapy for palliative purposes, 2002–2009. Refers to stage IIIB and IV. Trend 2002–2009. Source: National Lung Cancer Register
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 107
discrepancies in care quality. The counties also varied substantially, anywhere from 2.4 to 27.5 per cent.
Given that the guidelines target 22 per cent, a number of counties should consider the possibility that they are underutilising palliative radiotherapy.
62 Palliative chemotherapy for incurable lung cancerChemotherapy involves drug therapy to kill cancer cells or prevent them from mul-tiplying. A number of different drugs can be used, often in combination, with equal efficacy. However, the adverse effects may vary somewhat. The clinical practice guidelines recommend that chemotherapy be tried for the purpose of alleviating symptoms in patients with incurable lung cancer. The NBHW national guidelines for lung cancer care identify palliative chemotherapy in stage IIIB and IV patients with a performance status of 0–2 as a key indicator to monitor. Although not all stage IV patients should receive the treatment, the indicator is relevant to a com-parison of regional variations and may suggest quality differences.
Performance status (PS) grades a patient’s level of functioning on a scale of 0-4. PS 0 refers to a fully active person, while PS 2 is assigned to people who can perform normal activities and are out of bed for more than half the day, though with reduced
Figure 61Total
Percentage of patients with incurable lung cancer who were offered radiotherapy for palliative purposes, 2002–2009. Refers to stage IIIB and IV. Source: National Lung Cancer Register
Percent
27.523.122.920.216.015.014.213.313.112.712.511.911.610.3
8.47.47.36.85.04.94.82.4
0 10 20 30 40
GotlandHallandÖrebro
BlekingeDalarnaUppsala
VästernorrlandJämtland
KronobergGävleborgStockholm
NorrbottenSkåne
SWEDENJönköping
VästmanlandKalmar
Västra GötalandÖstergötland
SörmlandVästerbotten
Värmland
Figure 62Total
Percentage of patients with lung cancer who were offered chemotherapy for palliative purposes, 2002–2009. Refers to stage IIIB and IV. Source: National Lung Cancer Register
Percent
87.980.774.873.472.269.869.469.265.965.163.863.563.263.262.561.057.957.656.054.545.743.1
0 20 40 60 80 100
SörmlandVärmland
VästerbottenUppsala
ÖstergötlandVästra Götaland
KronobergJämtland
SWEDENSkåne
VästmanlandStockholmGävleborg
KalmarNorrbotten
BlekingeJönköping
ÖrebroVästernorrland
HallandDalarnaGotland
108 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
strength. PS is important for assessing whether a patient can handle and benefit from chemotherapy.
The target of the NBHW national guidelines is that 78 per cent of this patient pop-ulation be offered palliative chemotherapy. The target considers the fact that cura-tive radiotherapy or chemotherapy is indicated instead for some stage IIIB patients.
The outcomes for individual hospitals may be affected by their having recorded the stages of the disease in different ways or underreported elderly patients to the qual-ity register. Furthermore, some hospitals may have a larger percentage of patients with performance status 3–4, i.e., unable to handle chemotherapy. While some of the regional variation may be due to these factors, the data suggest that a certain degree of undertreatment is likely.
Figure 62Sweden
Percentage of patients with lung cancer who were offered chemotherapy for palliative purposes. Refers to stage IIIB and IV. Trend, 2002–2009. Source: National Lung Cancer Register
Percent
0
20
40
60
80
100
20092008200720062005200420032002
Women
Total
Men
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 109
HEADANDNECKCANCER
Statistics for 2009 Women Men
Numberofdiagnoses 426 789
Percentageofallcancercases 2% 3%
Prevalence,total 3777 6258
Relativefive-yearsurvivalrate 65% 60%
Numberofdeaths 115 234
Head and neck cancer refers to malignancies of the lip, mouth, throat, larynx, nose, sinus cavities and salivary glands. Assessment, treatment and diagnostic methods for the various forms of the disease vary greatly. Approximately 10 000 Swedes cur-rently alive have or have had head or neck cancer. The overall five-year survival rate is 65 per cent for women and 60 per cent for men. The disease is more common among men and people over 60 years of age.
Head and neck cancer can cause a great deal of suffering by making it difficult to breathe or eat, as well as affecting speech, vision, hearing, smell and other impor-tant functions.
This report presents four indicators. The first indicator concerns survival rates, fol-lowed by one that reflects multidisciplinary team meetings and two that measure waiting times. Five-year survival rates are broken down by county and are based on data from the Swedish Cancer Register. The other data are taken from the Swedish Head and Neck Cancer Register. The register, which has been in existence since 2008, covers surgery, chemotherapy and radiotherapy alike.
Approximately 90 per cent of treatment for head and neck cancer is provided at the regional level, whereas county hospitals perform assessments until decision to treat. Most decisions are made by a multidisciplinary team meeting at the regional level. Thus, we have chosen to present the percentage of patients assessed by means of a multidisciplinary team meeting by region and waiting times by both region and county.
63 Head and neck cancer – five-year survival ratesFive-year survival rates are presented collectively for all forms of head and neck can-cer even though there are major differences between them. The survival rate has in-creased somewhat for women since 1990 but remained constant for men. Figure 63 shows that the five-year survival rate was 62 per cent in 2005–2009. Some regional differences exist, but the confidence intervals are broad and the role of chance can-not be ruled out.
110 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
64 Multidisciplinary team meeting prior to treatment Primary treatment for head and neck cancer may be preceded by a multidiscipli-nary team meeting, a comprehensive assessment for the purpose of optimising the intervention. ENT surgery, oncology, radiology, pathology and other specialists may participate.
Figure 63Total
Head and neck cancer – five-year survival rates Patients diagnosed in 2000– 2004. Patients age 30–89 at the time of diagnosis. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare
Confidence interval calculated using Taylor series Percent
69.068.266.164.463.563.563.263.163.062.662.462.161.961.861.461.360.958.557.256.552.249.5
0 20 40 60 80 100
JämtlandVästerbotten
VästernorrlandKalmarÖrebro
NorrbottenSkåne
JönköpingSWEDEN
Västra GötalandVärmland
ÖstergötlandKronobergStockholmGävleborgSörmland
DalarnaGotlandHalland
VästmanlandUppsalaBlekinge
Figure 63Sweden
Head and neck cancer – five-year survival rates Trend, 1990–2009. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare
Percent
0
20
40
60
80
100
2005-20092000-20041995-19991990-1994
Women
Total
Men
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 111
Figure 64Total
Percentage of patients who had a multidisciplinary team meeting prior to decision to treat head and neck cancer, 2009-2010. Source: Swedish Head and Neck Cancer Register
Percent
96.492.191.289.087.482.374.1
0 20 40 60 80 100
NorraSödra
SydöstraSWEDEN
Uppsala-ÖrebroVästra
Stockholm-Gotland
Healthcare region
65 Waiting time from receipt of a referral until decision to treatThis indicator was presented in the 2010 edition of Quality and Efficiency in Swedish Health Care – Regional Comparisons. Assessment of suspected cancer must be com-pleted quickly so that treatment can commence before the malignancy gets bigger or metastasises. The way that the assessment is planned and the resources that are at the disposal of the units that must be utilised determine the amount of time that passes from the day that a clinic receives a referral or is contacted by the patient until decision to treat.
Figure 65Total
Median waiting time from receipt of a referral by an ear, nose and throat clinic until decision to treat for patients with malignant head and neck tumours, 2009–2010. Source: Swedish Head and Neck Cancer Register
Value first quartile Median Value third quartileDays
22293030323334353535363637373941414851525355
0 20 40 60 80 100
VästernorrlandJönköpingVärmland
ÖstergötlandJämtland
NorrbottenHallandKalmar
Västra GötalandÖrebro
KronobergVästerbotten
SWEDENBlekinge
StockholmSörmland
GotlandVästmanland
DalarnaGävleborg
SkåneUppsala
112 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
Differences both within and between the various regions are relatively large. Simi-larly, the northern (Norra) and south-east (Sydöstra) regions have longer waiting times than the other regions.
66 Waiting time from receipt of a referral until commencement of treatment
The waiting time from receipt of a referral until commencement of treatment illu-minates an additional step in the process and reflects a variable that is central to the
Days
32333435374444
0 20 40 60 80 100
SydöstraNorraVästra
SWEDENStockholm-Gotland
Uppsala-ÖrebroSödra
Healthcare region
Figure 65Total
Median waiting time from receipt of a referral by an ear, nose and throat clinic until decision to treat for patients with malignant head and neck tumours, 2009–2010. Source: Swedish Head and Neck Cancer Register
Value first quartile Median Value third quartile
Figure 66Total
Median waiting time from receipt of a referral by an ear, nose and throat clinic until commencement of treatment for patients with malignant head and neck tumours, 2008–2009. Source: Swedish Head and Neck Cancer Register
Value first quartile Median Value third quartileDays
36395051525253565757575961626367697072747682
0 20 40 60 80 100 120
VästernorrlandJönköpingVärmland
KalmarHalland
ÖstergötlandJämtland
KronobergNorrbotten
VästerbottenVästmanland
Västra GötalandSWEDEN
SkåneSörmland
ÖrebroDalarnaBlekinge
GävleborgStockholm
UppsalaGotland
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 113
ongoing progress of the disease. It is also important to patients that they can quickly start on prescribed treatment.
There is a large variation within and between the various counties.
The south-east (Sydöstra) and northern (Norra) regions have longer waiting times for commencement of treatment than the other regions. The difference is presum-ably due to the period after receipt of the referral.
Figure 66Total
Median waiting time from receipt of a referral by an ear, nose and throat clinic until commencement of treatment for patients with malignant head and neck tumours, 2008–2009. Source: Swedish Head and Neck Cancer Register
Value first quartile Median Value third quartileDays
49555757586771
0 20 40 60 80 100 120
SydöstraNorraSödra
VästraSWEDEN
Uppsala-ÖrebroStockholm-Gotland
Healthcare region
114 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
MALIGNANTMELANoMA
Statistics for 2009 Women Men
Numberofdiagnoses 1411 1408
Percentageofallcancercases 5% 5%
Prevalence,total 17119 13401
Relativefive-yearsurvivalrate 92.6% 86.0%
Numberofdeaths 217 282
Malignant melanoma is the most serious of the three common forms of skin cancer. It accounts for 5 per cent of all cancer in both women and men. A total of 2 819 people – 1 411 women and 1 408 men – were diagnosed with malignant melanoma in 2009. More than 30 500 Swedes now alive have had the disease. After having held fairly steady in the 1990s, the incidence has risen by nearly 5 per cent every year in the 2000s. Generally speaking, however, malignant melanoma is more common in southern than northern Sweden. Mortality rates have also increased: from approxi-mately 4 per cent to approximately 5 per cent. Excessive exposure to ultraviolet rays constitutes the biggest risk factor for the disease.
A melanoma that is detected at an early stage (1 millimetre thick or less) can usually be cured with simple surgery. However, a melanoma that is thicker than 4 millime-tres carries a considerable risk of recurrence and death.
The median age at diagnosis is 64 in men and 60 in women, but young people can also develop the disease. However, it is very uncommon in children. Approximately 40 per cent of women and 30 per cent of men are younger than 55 when they are diagnosed.
This report presents outcomes for four indicators, three of which are based on data from the Swedish Melanoma Register. Two indicators measure the waiting times that are important from the patient’s point of view and one indicator measures the percentage of thin malignant melanomas (1.0 millimetre or less). The survival data have been taken from the Swedish Cancer Register.
67 Malignant melanoma – relative five-year survival ratesFigure 67 shows that the relative five-year survival rate for 2005–2009 was 86.0 per cent for men and 92.6 per cent for women. Men’s survival rate increased in the 1990s and then retreated somewhat, whereas women’s has risen modestly since the 1990s. There are certain differences between various parts of the country.
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 115
Figure 67Women
Malignant melanoma – relative five-year survival rates. Patients diagnosed in 2000–2004. Patients age 30–89 at the time of diagnosis. Age-standardised values.Source: Swedish Cancer Register, Swedish National Board of Health and Welfare
Confidence interval calculated using Taylor series 1 Fewer than 15 cases Percent
97.395.895.395.094.794.393.192.892.692.191.591.291.190.690.390.390.189.788.786.085.6
0 20 40 60 80 100
Gotland 1
VästernorrlandBlekinge
VärmlandKronoberg
ÖstergötlandÖrebro
SörmlandSkåne
UppsalaHalland
JönköpingNorrbotten
SWEDENGävleborg
VästerbottenStockholm
DalarnaVästra Götaland
KalmarVästmanland
Jämtland
Figure 67Men
Malignant melanoma – relative five-year survival rates. Patients diagnosed in 2000–2004. Patients age 30–89 at the time of diagnosis. Age-standardised values.Source: Swedish Cancer Register, Swedish National Board of Health and Welfare
Confidence interval calculated using Taylor series 1 Fewer than 15 cases Percent
90.889.989.489.189.088.588.186.586.085.384.784.584.184.083.982.381.581.480.472.572.3
0 20 40 60 80 100
Gotland 1
GävleborgVärmlandSörmland
VästerbottenVästernorrland
ÖrebroSkåne
JämtlandKronoberg
ÖstergötlandBlekinge
JönköpingSWEDEN
HallandKalmar
Västra GötalandStockholm
DalarnaVästmanland
UppsalaNorrbotten
116 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
68 Waiting time from initial doctor’s appointment until primary surgery The melanoma register has been set up for entry of waiting times since 2009. How-ever, there is still a high percentage of nonreporting and only half of the county councils can account for waiting times from the initial doctor’s appointment until primary surgery (removal of the skin change that has been sent for histopathologi-
Figure 67Total
Malignant melanoma – relative five-year survival rates. Patients diagnosed in 2000–2004. Patients age 30–89 at the time of diagnosis. Age-standardised values.Source: Swedish Cancer Register, Swedish National Board of Health and Welfare
Confidence interval calculated using Taylor series 1 Fewer than 15 cases Percent
92.792.391.991.691.591.491.289.889.389.388.387.987.487.387.187.085.885.884.082.282.1
0 20 40 60 80 100
Gotland 1
VärmlandVästernorrland
GävleborgBlekinge
SörmlandKronoberg
ÖrebroÖstergötland
SkåneJönköping
VästerbottenHalland
SWEDENUppsala
JämtlandKalmar
StockholmVästmanland
Västra GötalandDalarna
Norrbotten
Figure 67Sweden
Malignant melanoma – relative five-year survival rates. Trend, 1990–2009. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare
Percent
0
20
40
60
80
100
2005-20092000-20041995-19991990-1994
Women
Total
Men
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 117
cal diagnosis). The indicator is measured on a regional basis to ensure more reliable outcomes.
A large percentage of patients undergo primary surgery during their first appoint-ment at the community health centre. This comparison concerns only the relatively small percentage of the patient population who are referred to a specialist clinic. Figure 68 shows that their median waiting time in 2009 ranged from 19 to 28 days for the various regions. Regional routines and referral procedures can affect waiting times, not to mention the possibility that a specialist clinic will pass a referral on to another one. The national median was 25 days.
The fact that the variable was relatively new to the register rendered complete as-sessments that much more difficult.
69 Waiting time from sample taking until notification of the diagnosisFigure 69 indicates that the median waiting time from the date that a sample was taken until the patient received a diagnosis was 21 days, with a regional variation of 13–30 days. The waiting time also covers the period from the date that the sample is taken until a histopathological diagnosis is performed and the referring doctor receives the results. As of 2011, the waiting time until the diagnosis has been com-pleted is also analysed. Only the Stockholm and Gotland Regions, which started their registration process late, were unable to report data.
Figure 68Total
Waiting time from initial doctor’s appointment at a community health centre until primary surgery (sample taking for histopathological diagnosis) for malignant melanoma, 2009. Source: Swedish Melanoma Register
Value first quartile Median Value third quartile1 No data available Days
192525262828
0 20 40 60 80
Stockholm-Gotland1
Uppsala-ÖrebroNorraSödra
SydöstraSWEDEN
VästraHealthcare region
118 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
70 Malignant melanoma 1.0 millimetre or thinnerThe indicator is a yardstick of people’s general awareness of the need to see a doctor when they suspect skin cancer. It also measures the ability of doctors to correctly assess the seriousness of a skin change. Detecting melanoma at an early stage (1 mil-limetre or thinner) is important; the survival rate at that point is excellent. This in-dicator reflects the percentage of patients with a melanoma that is no more than 1.0 millimetre thick. Five years of data have been combined to ensure greater reliability.
A comparison between 1990–1999 and 2000–2008 shows a decline in the percentage of melanomas that were thin at the time of diagnosis – which obviously represents a negative trend. The gap between women and men appears to be narrowing.
Figure 69Total
Waiting time from sample taking for malignant melanoma until patient received diagnosis, 2009. Source: Swedish Melanoma Register
1 No data available Value first quartile Median Value third quartileDays
Waiting time data not available, %
1313141718192021212121212122232323242430
2715281731111715201630492415371511264911
0 10 20 30 40 50 60
Stockholm 1
Gotland 1
ÖstergötlandHalland
GävleborgJönköpingSörmland
SkåneUppsala
VästernorrlandVästra Götaland
SWEDENKalmar
VästerbottenVästmanland
NorrbottenÖrebro
VärmlandBlekingeDalarna
KronobergJämtland
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 119
Figure 70Women
Percentage of patients with a malignant melanoma 1.0 mm or thinner, 2005–2009. Source: Swedish Melanoma Register
2000–2004 Percent
58.757.757.456.856.855.254.954.354.354.254.154.053.953.753.450.849.749.448.847.446.340.8
0 20 40 60 80
NorrbottenUppsalaGotland
VästerbottenHallandÖrebro
SörmlandJönköping
VästernorrlandKalmar
VästmanlandDalarna
JämtlandKronobergGävleborgSWEDEN
SkåneStockholm
BlekingeVästra Götaland
ÖstergötlandVärmland
Figure 70Men
Percentage of patients with a malignant melanoma 1.0 mm or thinner, 2005–2009. Source: Swedish Melanoma Register
2000–2004 Percent
50.949.949.449.248.948.848.046.646.646.444.143.143.042.542.042.041.540.439.538.936.232.8
0 20 40 60 80
JämtlandBlekinge
GävleborgNorrbotten
VästerbottenDalarna
VästernorrlandKronoberg
HallandUppsala
VästmanlandVärmland
ÖstergötlandSWEDEN
SkåneGotland
JönköpingVästra Götaland
KalmarSörmland
StockholmÖrebro
120 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
Figure 70Total
Percentage of patients with a malignant melanoma 1.0 mm or thinner, 2005–2009. Source: Swedish Melanoma Register
2000–2004 Percent
Participation rate 2005–2009
53.453.252.151.551.451.050.950.850.350.147.947.847.747.747.546.646.545.744.744.443.340.2
94909996979794939895929685989696917688949199
0 20 40 60 80
NorrbottenJämtland
VästerbottenUppsalaHalland
GävleborgBlekinge
VästmanlandVästernorrland
GotlandDalarna
KronobergSörmland
ÖrebroSWEDEN
SkåneJönköpingVärmland
KalmarÖstergötland
Västra GötalandStockholm
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 121
Projectorganisation
Steering committeeStefan Ackerby, Swedish Association of Local Authorities and Regions (SALAR)
Mona Heurgren, Swedish National Board of Health and Welfare (NBHW)
Marie Lawrence, NBHW
Roger Molin, SALAR
Task forceCecilia Dahlgren, NBHW
Camilla Eriksson, SALAR
Behzad Koucheki, NBHW
Birgitta Lindelius, NBHW
Katarina Wiberg Hedman, Project Manager, SALAR
Göran Zetterström, Project Manager, NBHW
Other participantsMats Fernström, NBHW
Gunilla Gunnarsson, SALAR
Staffan Khan, NBWH
Åsa Klint, NBHW
Bodil Klintberg, SALAR
Max Köster, NBHW
Pinelopi Lundqvist, NBHW
Lisbeth Serdén, NBHW
Sofia Tullberg, SALAR
Fredrik Westander, Consultant
Medical specialistsJan Adolfsson
Gunilla Gunnarsson
Lars Holmberg
122 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 123
124 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011
Quality and Efficiency in Swedish Cancer Care
This special edition of Quality and Efficiency in Swedish Health Care – Regional Comparisons – examines cancer care only. The report, which includes ten forms of cancer and 70 indicators, is a joint project of the Swedish National Board of Health and Welfare and the Swedish Association of Local Authorities and Regions. The indicators reflect different aspects of cancer care, including medical outcomes, patient experience and waiting times.
The overall purpose of the report is to promote local, regional and national improvement efforts by comparing the quality of cancer care throughout the country. It is also intended to provide the general public with insight into what publicly financed cancer care is accomplishing.
While the majority of the indicators are presented at the county level, some of them are of necessity limited to a regional perspective. The indicators for certain types of cancer are also shown at the hospital level. A number of the indicators are broken down between women and men in order to capture potential gender differences.
Swedish Association of Local Authorities and Regions ISBN 978-91-7164-784-9
Swedish National Board of Health and Welfare Art. nr. 2012-3-15
Quality and E
fficiency in Sw
edish Cancer C
are Reg
ional C
om
pariso
ns 2011
Swedish Association of Local Authorities and Regions
SE-118 82 Stockholm+46 8 452 70 00 www.skl.se
Swedish National Board of Health and Welfare
SE-106 30 Stockholm+46 75 247 30 00 www.socialstyrelsen.se