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Background: Differences in the prognosis after colorectal cancer (CRC) by socioeconomic position (SEP) have been reported previously; however, most studies focused on survival differences at a particular time since diagnosis. We quantified the lifetime impact of CRC and its variation by SEP, using individualised income to conceptualise SEP. Methods: Data included all adults with a first-time diagnosis of colon or rectal cancers in Sweden between 2008 and 2021. The analysis was done separately for colon and rectal cancers using flexible parametric models. For each cancer and income group, we estimated the life expectancy in the absence of cancer, the life expectancy in the presence of cancer and the loss in life expectancy (LLE). Results: We found large income disparities in life expectancy after a cancer diagnosis, with larger differences among the youngest patients. Higher income resulted in more years lost following a cancer diagnosis. For example, 40-year-old females with colon cancer lost 17.64 years if in the highest-income group and 13.68 years if in the lowest-income group. Rectal cancer resulted in higher LLE compared with colon cancer. Males lost a larger proportion of their lives. All patients, including the oldest, lost more than 30% of their remaining life expectancy. Based on the number of colon and rectal cancer diagnoses in 2021, colon cancer results in almost double the number of years lost compared with rectal cancer (24 669 and 12 105 years, respectively). Conclusion: While our results should be interpreted in line with what individualised income represents, they highlight the need to address inequalities.

QC 20231121

Objectives: The present study aimed to investigate if and how the panorama of acute cholecystitis changed in 2020 in Sweden. Seven aspects were identified, the incidence of cholecystitis, the Tokyo grade, the timing of diagnosis and treatment, the proportion treated with early surgery, the proportion of patients treated with delayed surgery, and new complications from gallstones.Design Retrospective multicentre cohort study. Setting: 3 hospitals in Sweden, covering 675 000 inhabitants.Participants 1634 patients with cholecystitis.Outcomes The incidence, treatment choice and diagnostic and treatment delay were investigated by comparing prepandemic and pandemic patients. Results: Patients diagnosed with cholecystitis during the pandemic were more comorbid (American Society of Anesthesiologists 2-5, 86% vs 81%, p=0.01) and more often had a diagnostic CT (67% vs 59%, p=0.01). There were variations in the number of patients corresponding with the pandemic waves, but there was no overall increase in the number of patients with cholecystitis (78 vs 76 cases/100 000 inhabitants, p=0.7) or the proportion of patients treated with surgery during the pandemic (50% vs 50%, p=0.4). There was no increase in time to admission from symptoms (both median 1 day, p=0.7), or surgery from admission (both median 1 day, p=0.9). The proportion of grades 2-3 cholecystitis was not higher during the pandemic (46% vs 44%, p=0.9). The median time to elective surgery increased (184 days vs 130 days, p=0.04), but there was no increase in new gallstone complications (35% vs 39%, p=0.3). Conclusion: Emergency surgery for cholecystitis was not impacted by the pandemic in Sweden. Patients were more comorbid but did not have more severe cholecystitis nor was there a delay in seeking care. Fewer patients non-operatively managed had elective surgery within 6 months of their initial diagnosis but there was no corresponding increase in gallstone complications.

Colon cancer is the fourth most common cancer worldwide with approximately 1.2 million yearly cases. Developments in the standard of care have improved prognosis. In Paper I the recurrence risk was investigated in a national material consisting of 14,325 colon cancer patients. Three fourths of stage II patients have a risk of approximately 11%, indicating that adjuvant chemotherapy can marginally improve prognosis. In stage III, one fifth of the patients have such a low risk of recurrence that the addition of a second chemotherapeutic drug, oxaliplatin with its risk for late toxicity, may be questioned. In Paper II emerging risk factors were investigated in a thoroughly staged and described material of 416 colon cancer patients from one county. All emerging risk factors correlated with an increased recurrence risk. Adjusting for established risk factors, pN-substage and postoperative carcinoembryonic antigen (CEA) correlated independently with recurrence. Paper III investigated the completeness and correctness of recurrences in the Swedish Colorectal Cancer registry in 2,893 patients from two counties. In patients operated more than 5 years ago 2% of recurrences were not registered. In Paper IV a nomogram for clinicians was developed using registry data to aid the interpretation of the recurrence risk and discussion with patients about treatment choices. It was validated in Norwegian cancer registry data and performed better than other available nomograms. Future investigations of the cohort from paper II are planned with immunohistochemistry, tumour-normal tissue sequencing and biomarkers. In summary, recurrence rates have decreased since the early 2000s and a large proportion of patients can probably be spared some or all adjuvant treatment. Established risk factors describe a large part of the risk, but there is room for improvement. The biomarker CEA taken after surgery could aid in the selection of patients to receive adjuvant treatment and guide follow-up., Tjock- och ändtarmscancer är den tredje vanligaste cancern i Sverige och drabbar årligen cirka 6 000 personer, varav 4 000 har tjocktarmscancer. Hälften av patienterna med tjocktarmscancer har måttlig till hög risk för återfall (cancerstadie II och III). Behandlingen är kirurgi och eventuellt efterföljande cellgiftsbehandling, vilken minskar risken för återfall och ökar överlevnaden, men behandlingen är inte biverkningsfri. Den kirurgiska samt onkologiska behandlingen har senaste åren förbättrats avsevärt och det finns indikationer på att studier som gjordes i början av 2000-talet beskriver en högre risk för återfall och död i tjocktarmscancer än vad som är aktuellt idag.Cirka 14 000 patienter från det svenska tjock- och ändtarmscancerregistret (SCRCR) utgjorde grunden för den första studien (artikel I) där risken för återfall idag beskrivs. Vid större tumör, men utan spridning till lymfan (stadie II), har 3/4 av patienterna en låg risk för återfall. Vid spridning till lymfan (stadie III) är risken högre, men 1/5 har så låg risk att de sannolikt inte tjänar tillräckligt på intensiva cellgifter. Risken för återfall beskrevs bra av de faktorer som används kliniskt och som varit kända sedan länge.Ytterligare riskfaktorer undersöktes hos en mindre grupp patienter som alla bodde i Uppsala län (artikel II). Om CEA, ett protein som används som tumörmarkör och mäts i blod, var förhöjt efter kirurgin var det en riskfaktor för återfall men huvuddelen av risken beskrevs av de redan kända faktorerna.För att vara säkra på att risken för återfall var så låg som i artikel I granskades alla journaler från patienter som opererats för tjock- och ändtarmscancer i två regioner. Nästan 2% av återfallen saknades i SCRCR hos patienter som opererats för mer än 5 år sedan. Risken för återfall, när alla återfall var medräknade i de två regionerna, var dock lägre än i artikel I vilket talar för att siffrorna som presenterats stämmer väl med verkligheten. För att underlätta för läkare att föru

Background: Prediction models are useful tools in the clinical management of colon cancer patients, particularly when estimating the recurrence rate and, thus, the need for adjuvant treatment. However, the most used models (MSKCC, ACCENT) are based on several decades-old patient series from clinical trials, likely overestimating the current risk of recurrence, especially in low-risk groups, as outcomes have improved over time. The aim was to develop and validate an updated model for the prediction of recurrence within 5 years after surgery using routinely collected clinicopathologic variables. Material and methods: A population-based cohort from the Swedish Colorectal Cancer Registry of 16,134 stage I–III colon cancer cases was used. A multivariable model was constructed using Cox proportional hazards regression. Three-quarters of the cases were used for model development and one quarter for internal validation. External validation was performed using 12,769 stage II–III patients from the Norwegian Colorectal Cancer Registry. The model was compared to previous nomograms. Results: The nomogram consisted of eight variables: sex, sidedness, pT-substages, number of positive and found lymph nodes, emergency surgery, lymphovascular and perineural invasion. The area under the curve (AUC) was 0.78 in the model, 0.76 in internal validation, and 0.70 in external validation. The model calibrated well, especially in low-risk patients, and performed better than existing nomograms in the Swedish registry data. The new nomogram’s AUC was equal to that of the MSKCC but the calibration was better. Conclusion: The nomogram based on recently operated patients from a population registry predicts recurrence risk more accurately than previous nomograms. It performs best in the low-risk groups where the risk-benefit ratio of adjuvant treatment is debatable and the need for an accurate prediction model is the largest.

BACKGROUND: The completeness and accuracy of the registration of synchronous metastases and recurrences in the Swedish Colorectal Cancer Registry has not been investigated. Knowing how accurate these parameters are in the registry is a prerequisite to adequately measure the current recurrence risk. METHODS: All charts for patients diagnosed with stage I-III colorectal cancer (CRC) in two regions were reviewed. In one of the regions, all registrations of synchronous metastases were similarly investigated. After the database had been corrected, recurrence risk in colon cancer was calculated stratified by risk group as suggested by ESMO in 2020. RESULTS: In patients operated upon more than five years ago (N = 1235), there were 20 (1.6%) recurrences not reported. In more recent patients, more recurrences were unreported (4.0%). Few synchronous metastases were wrongly registered (3.6%) and, likewise, few synchronous metastases were not registered (about 1%). The five-year recurrence risk in stage II was 6% for low-risk, 11% for intermediate risk, and 23% for high-risk colon cancer patients. In stage III, it was 25% in low- and 45% in high-risk patients. Incorporation of risk factors in stage III modified the risks substantially even if this is not considered by ESMO. Adjuvant chemotherapy lowered the risk in stage III but not to any relevant extent in stage II. CONCLUSION: The registration of recurrences in the registry after 5 years is accurate to between 1 and 2% but less accurate earlier. A small number of unreported recurrences and falsely reported recurrences were discovered in the chart review. The recurrence risk in this validated and updated patient series matches what has been recently reported, except for the risk of recurrence in stage II low risk colon cancers which seem to be even a few percentage points lower (6 vs. 9%).

The value of adjuvant chemotherapy in elderly patients has been the subject of many overviews, with opinions varying from "not effective", since randomized trials have not been performed, to "as effective as in young individuals", based upon many retrospective analyses of randomized trials that have included patients of all ages. In the absence of randomized trials performed specifically with elderly patients, retrospective analyses demonstrate that the influence on the time to tumour recurrence (TTR) may be the same as in young individuals, but that endpoints that include death for any reason, such as recurrence-free survival (RFS), disease-free survival (DFS), and overall survival (OS), are poorer in the elderly. This is particularly true if oxaliplatin has been part of the treatment. The need for adjuvant chemotherapy after colorectal cancer surgery in elderly patients is basically the same as that in younger patients. The reduction in recurrence risks may be similar, provided the chosen treatment is tolerated but survival gains are less. Adding oxaliplatin to a fluoropyrimidine is probably not beneficial in individuals above a biological age of approximately 70 years. If an oxaliplatin combination is administered to elderly patients, three months of therapy is in all probability the most realistic goal.