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Introduction: Sex and gender are modulators of health and disease and may have impact on treatment allocation and survival in patients with cancer. In this study, we analyzed the impact of sex and gender on treatment allocation and overall survival in patients with stage I-III pancreatic cancer., Methods: Patients with stage I-III pancreatic cancer diagnosed between 2015 and 2020 were selected from the nationwide Netherlands Cancer Registry. Associations between sex and gender and the probability of receiving surgical and/or systemic treatment were examined with multivariable logistic regression analyses. Overall survival was assessed with log rank test and multivariable Cox proportional hazard analysis., Results: Among 6855 patients, 51.2 % were female. Multivariable logistic regression analyses with adjustment for known confounders (age, performance status, comorbidities, tumor location, tumor stage and previous malignancies) showed that females less often received systemic chemotherapy compared to males (OR 0.799, 95 %CI 0.703-0.909, p < .001). No difference was found in the probability for undergoing surgical resection. Furthermore, females had worse overall survival compared to males (median OS 8.5 and 9.2 months respectively, 95 %CI 8.669-9.731)., Conclusion: This nationwide study found that female patients with stage I-III pancreatic cancer significantly less often received systemic treatment and had worse overall survival as compared to males. Disparities in pancreatic cancer care can be decreased by recognizing and resolving potential obstacles or biases in treatment decision-making., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Importance: Implementation of new cancer treatment strategies as recommended by evidence-based guidelines is often slow and suboptimal., Objective: To improve the implementation of guideline-based best practices in the Netherlands in pancreatic cancer care and assess the impact on survival., Design, Setting, and Participants: This multicenter, stepped-wedge cluster randomized trial compared enhanced implementation of best practices with usual care in consecutive patients with all stages of pancreatic cancer. It took place from May 22, 2018 through July 9, 2020. Data were analyzed from April 1, 2022, through February 1, 2023. It included all patients in the Netherlands with pathologically or clinically diagnosed pancreatic ductal adenocarcinoma. This study reports 1-year follow-up (or shorter in case of deceased patients)., Intervention: The 5 best practices included optimal use of perioperative chemotherapy, palliative chemotherapy, pancreatic enzyme replacement therapy (PERT), referral to a dietician, and use of metal stents in patients with biliary obstruction. A 6-week implementation period was completed, in a randomized order, in all 17 Dutch networks for pancreatic cancer care., Main Outcomes and Measures: The primary outcome was 1-year survival. Secondary outcomes included adherence to best practices and quality of life (European Organisation for Research and Treatment of Cancer [EORTC] global health score)., Results: Overall, 5887 patients with pancreatic cancer (median age, 72.0 [IQR, 64.0-79.0] years; 50% female) were enrolled, 2641 before and 2939 after implementation of best practices (307 during wash-in period). One-year survival was 24% vs 23% (hazard ratio, 0.98, 95% CI, 0.88-1.08). There was no difference in the use of neoadjuvant chemotherapy (11% vs 11%), adjuvant chemotherapy (48% vs 51%), and referral to a dietician (59% vs 63%), while the use of palliative chemotherapy (24% vs 30%; odds ratio [OR], 1.38; 95% CI, 1.10-1.74), PERT (34% vs 45%; OR, 1.64; 95% CI, 1.28-2.11), and metal biliary stents increased (74% vs 83%; OR, 1.78; 95% CI, 1.13-2.80). The EORTC global health score did not improve (area under the curve, 43.9 vs 42.8; median difference, -1.09, 95% CI, -3.05 to 0.94)., Conclusions and Relevance: In this randomized clinical trial, implementation of 5 best practices in pancreatic cancer care did not improve 1-year survival and quality of life. The finding that most patients received no tumor-directed treatment paired with the poor survival highlights the need for more personalized treatment options., Trial Registration: ClinicalTrials.gov Identifier: NCT03513705.

Background: Most data on the treatment and outcomes of intrahepatic cholangiocarcinoma (iCCA) derives from expert centers. This study aimed to investigate the treatment and outcomes of all patients diagnosed with iCCA in a nationwide cohort., Methods: Data on all patients diagnosed with iCCA between 2010 and 2018 were obtained from the Netherlands Cancer Registry., Results: In total, 1747 patients diagnosed with iCCA were included. Resection was performed in 292 patients (17%), 548 patients (31%) underwent palliative systemic treatment, and 867 patients (50%) best supportive care (BSC). The OS median and 1-, and 3-year OS were after resection: 37.5 months (31.0-44.0), 79.2%, and 51.6%,; with systemic therapy, 10.0 months (9.2-10.8), 38.4%, and 5.1%, and with BSC 2.2 months (2.0-2.5), 10.4%, and 1.3% respectively. The resection rate for patients who first presented in academic centers was 33% (96/292) compared to 13% (195/1454) in non-academic centers (P < 0.001)., Discussion: Half of almost 1750 patients with iCCA over an 8 year period did not receive any treatment with a 1-year OS of 10.4%. Three-year survival was about 50% after resection, while long-term survival was rare after palliative treatment. The resection rate was higher in academic centers compared to non-academic centers., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction: - This population-based study aimed to investigate incidence, risk factors, treatment, and survival of synchronous peritoneal metastases (PM) of hepatobiliary origin., Methods: - All Dutch patients diagnosed with hepatobiliary cancer between 2009 and 2018 were selected. Factors associated with PM were identified with logistic regression analyses. Treatments for patients with PM were categorized into local therapy, systemic therapy, and best supportive care (BSC). Overall survival (OS) was investigated using log-rank test., Results: - In total, 12 649 patients were diagnosed with hepatobiliary cancer of whom 8% (n = 1066) were diagnosed with synchronous PM (12% [n = 882/6519] in biliary tract cancer [BTC] vs. 4% [n = 184/5248] in hepatocellular carcinoma [HCC]). Factors that were positively associated with PM were the female sex (OR 1.18, 95% CI 1.03-1.35), BTC (OR 2.93, 95% CI 2.46-3.50), diagnosis in more recent years (2013-2015: OR 1.42, 95% CI 1.20-1.68; 2016-2018: OR 1.48, 95% CI 1.26-1.75), T3/T4 stage (OR 1.84, 95% CI 1.55-2.18), N1/N2 stage (OR 1.31, 95% CI 1.12-1.53) and other synchronous systemic metastases (OR 1.85, 95% CI 1.62-2.12). Of all PM patients, 723 (68%) received BSC only. Median OS was 2.7 months (IQR 0.9-8.2) in PM patients., Conclusion: - Synchronous PM were found in 8% of all hepatobiliary cancer patients and occurred more often in BTC than in HCC. Most patients with PM received BSC only. Given the high incidence and dismal prognosis of PM patients, extended research in hepatobiliary PM is needed to achieve better outcome in these patients., Competing Interests: Declaration of competing interest IHJTdH: An unrestricted research grant for unrelated research from RanD Biotech and ROCHE, paid to the institute. JdV has served as a consultant for Amgen, AstraZeneca, MSD, Pierre Fabre, and Servier, and has received institutional research funding from Servier. HJK: has served in an advisory board for Jansen, IPSEN and Astra Zeneca, paid to institute. Has received speakers fee from Medtalks and CCO, paid to institute. All outside the submitted work. The other authors declare no conflicts of interest., (Copyright © 2023 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Background & Aims: Recent pancreatic cancer surveillance programs of high-risk individuals have reported improved outcomes. This study assessed to what extent outcomes of pancreatic ductal adenocarcinoma (PDAC) in patients with a CDKN2A/p16 pathogenic variant diagnosed under surveillance are better as compared with patients with PDAC diagnosed outside surveillance., Methods: In a propensity score matched cohort using data from the Netherlands Cancer Registry, we compared resectability, stage, and survival between patients diagnosed under surveillance with non-surveillance patients with PDAC. Survival analyses were adjusted for potential effects of lead time., Results: Between January 2000 and December 2020, 43,762 patients with PDAC were identified from the Netherlands Cancer Registry. Thirty-one patients with PDAC under surveillance were matched in a 1:5 ratio with 155 non-surveillance patients based on age at diagnosis, sex, year of diagnosis, and tumor location. Outside surveillance, 5.8% of the patients had stage I cancer, as compared with 38.7% of surveillance patients with PDAC (odds ratio [OR], 0.09; 95% confidence interval [CI], 0.04-0.19). In total, 18.7% of non-surveillance patients vs 71.0% of surveillance patients underwent a surgical resection (OR, 10.62; 95% CI, 4.56-26.63). Patients in surveillance had a better prognosis, reflected by a 5-year survival of 32.4% and a median overall survival of 26.8 months vs 4.3% 5-year survival and 5.2 months median overall survival in non-surveillance patients (hazard ratio, 0.31; 95% CI 0.19-0.50). For all adjusted lead times, survival remained significantly longer in surveillance patients than in non-surveillance patients., Conclusion: Surveillance for PDAC in carriers of a CDKN2A/p16 pathogenic variant results in earlier detection, increased resectability, and improved survival as compared with non-surveillance patients with PDAC., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Centralization of pancreatic cancer surgery aims to improve postoperative outcomes. Consequently, patients with pancreatic cancer may undergo pancreatic surgery in an expert centre and adjuvant chemotherapy in a local hospital (network treatment). The aim of this study was to assess whether network treatment has an impact on time to chemotherapy, failure to complete adjuvant chemotherapy, and survival. Second, whether these parameters varied between pancreatic networks was studied., Methods: This retrospective study included all patients diagnosed with non-metastatic pancreatic ductal adenocarcinoma who underwent pancreatic surgery and adjuvant chemotherapy, registered in the Netherlands Cancer Registry (2015-2020). Time to chemotherapy was defined as the time between surgery and the start of adjuvant chemotherapy. Completion of adjuvant chemotherapy was defined as the receipt of 12 cycles of FOLFIRINOX or six cycles of gemcitabine. Analysis was performed with linear mixed models and multilevel logistic regression models. Cox regression analyses were performed for survival., Results: In total, 1074 patients were included. Network treatment was observed in 468 patients (43.6 per cent) and was not associated with longer time to chemotherapy (0.77 days, standard error (s.e.) 1.14, P = 0.501), failure to complete adjuvant chemotherapy (odds ratio (OR) = 1.140, 95 per cent c.i. 0.86 to 1.52, P = 0.349), and overall survival (hazards ratio (HR) = 1.04, 95 per cent c.i. 0.88 to 1.22, P = 0.640). Significant variation between the networks was observed for time to chemotherapy (range 40.5-63 days, P < 0.0001) and completion of adjuvant chemotherapy (range 19-52 per cent, P = 0.030). Adjusted for case mix, time to chemotherapy significantly differed between networks., Conclusion: In this nationwide analysis, network treatment in patients with resected pancreatic cancer was not associated with longer time to chemotherapy, failure to complete adjuvant chemotherapy, and worse survival. Significant variation between pancreatic cancer networks was found for time to chemotherapy., (© The Author(s) 2023. Published by Oxford University Press on behalf of BJS Society Ltd.)

Background: Due to the centralization of pancreatic surgery, patients with suspected pancreatic cancer may undergo diagnostic workup in both a non-pancreatic centre and a pancreatic centre, i.e. multicentre workup. This retrospective study assessed whether multicentre diagnostic workup is associated with repeated diagnostics, delayed time-to-diagnosis, delayed time-to-treatment, survival and whether variation existed among pancreatic cancer networks., Methods: This nationwide study included all patients diagnosed with non-metastatic pancreatic ductal adenocarcinoma (PDAC) in 2015, registered by the Netherlands Cancer Registry. A delayed time-to-diagnosis was defined as ≥3 weeks from initial hospital visit to final diagnosis. A delayed time-to-treatment was defined as ≥6 weeks from the first hospital visit to start of first tumour treatment. Multilevel logistic regression analyses and survival analyses were performed., Results: In total, 931 patients with non-metastatic PDAC were included. Overall, 175 patients (19%) underwent a multicentre diagnostic workup, which was significantly associated with repeated diagnostic investigations (OR = 6.31, 95% CI 4.13-9.64, P < 0.0001), a delayed time-to-diagnosis (OR = 2.66 95% CI 1.74-4.06, P < 0.001), and a delayed time-to-treatment (OR = 1.93 95% CI 1.12-3.31, P = 0.02), but not with decreased survival (HR = 1.09 95% CI 0.83-1.44; P = 0.532). Variation in outcomes per network was observed, especially for time-to-treatment, though the ICC was not statistically significant (P = 0.065)., Conclusion: Multicentre diagnostic workup for patients with PDAC is associated with repeated diagnostic investigations, a delayed time-to-diagnosis and delayed time-to-treatment compared to patients with monocentre workup. To reduce costs and improve treatment times, efforts should be made to improve network coordination, for example via network care pathways., Competing Interests: Declaration of competing interest Judith de Vos-Geelen has served as a consultant for Amgen, AstraZeneca, MSD, Pierre Fabre, and Servier, and has received institutional research funding from Servier. All outside the submitted work. Lodewijk Brosens served as a paid consultant for Bristol-Myers Squibb. The other authors have no interests to declare., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Periampullary adenocarcinoma consists of pancreatic adenocarcinoma (PDAC), distal cholangiocarcinoma (DC), ampullary cancer (AC), and duodenal adenocarcinoma (DA). The aim of this study was to assess treatment modalities and overall survival by tumor origin., Methods: Patients diagnosed with non-metastatic periampullary cancer in 2012-2018 were identified from the Netherlands Cancer Registry. OS was studied with Kaplan-Meier analysis and multivariable Cox regression analyses, stratified by origin., Results: Among the 8758 patients included, 68% had PDAC, 13% DC, 12% AC, and 7% DA. Resection was performed in 35% of PDAC, 56% of DC, 70% of AC, and 59% of DA. Neoadjuvant and/or adjuvant therapy was administered in 22% of PDAC, 7% of DC, 7% of AC, and 12% of DA. Three-year OS was highest for AC (37%) and DA (34%), followed by DC (21%) and PDAC (11%). Adjuvant therapy was associated with improved OS among PDAC (HR = 0.62; 95% CI 0.55-0.69) and DC (HR = 0.69; 95% CI 0.48-0.98), but not AC (HR = 0.87; 95% CI 0.62-1.22) and DA (HR = 0.85; 95% CI 0.48-1.50)., Conclusion: This retrospective study identified considerable differences in treatment modalities and OS between the four periampullary cancer origins in daily clinical practice. An improved OS after adjuvant chemotherapy could not be demonstrated in patients with AC and DA., (Copyright © 2022 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

The added value of capecitabine to adjuvant gemcitabine monotherapy (GEM) in pancreatic ductal adenocarcinoma (PDAC) was shown by the ESPAC-4 trial. Real-world data on the effectiveness of gemcitabine plus capecitabine (GEMCAP), in patients ineligible for mFOLFIRINOX, are lacking. Our study assessed whether adjuvant GEMCAP is superior to GEM in a nationwide cohort. Patients treated with adjuvant GEMCAP or GEM after resection of PDAC without preoperative treatment were identified from The Netherlands Cancer Registry (2015-2019). The primary outcome was overall survival (OS), measured from start of chemotherapy. The treatment effect of GEMCAP vs GEM was adjusted for sex, age, performance status, tumor size, lymph node involvement, resection margin and tumor differentiation in a multivariable Cox regression analysis. Secondary outcome was the percentage of patients who completed the planned six adjuvant treatment cycles. Overall, 778 patients were included, of whom 21.1% received GEMCAP and 78.9% received GEM. The median OS was 31.4 months (95% CI 26.8-40.7) for GEMCAP and 22.1 months (95% CI 20.6-25.0) for GEM (HR: 0.71, 95% CI 0.56-0.90; logrank P = .004). After adjustment for prognostic factors, survival remained superior for patients treated with GEMCAP (HR: 0.73, 95% CI 0.57-0.92, logrank P = .009). Survival with GEMCAP was superior to GEM in most subgroups of prognostic factors. Adjuvant chemotherapy was completed in 69.5% of the patients treated with GEMCAP and 62.7% with GEM (P = .11). In this nationwide cohort of patients with PDAC, adjuvant GEMCAP was associated with superior survival as compared to GEM monotherapy and number of cycles was similar., (© 2021 The Authors. International Journal of Cancer published by John Wiley & Sons Ltd on behalf of UICC.)

Background: Various prognostic factors are associated with overall survival (OS) after resection of distal cholangiocarcinoma (dCCA). The objective of this study was to develop and validate a prediction model for 3-year OS after pancreatoduodenectomy for dCCA., Methods: The derivation cohort consisted of all patients who underwent pancreatoduodenectomy for dCCA in the Netherlands (2009-2016). Clinically relevant variables were selected based on the Akaike information criterion using a multivariate Cox proportional hazards regression model, with model performance being assessed by concordance index (C-index) and calibration plots. External validation was performed using patients from the Belgium Cancer Registry (2008-2016), and patients from two university hospitals of Southampton (U.K.) and Verona (Italy)., Results: Independent prognostic factors for OS in the derivation cohort of 454 patients after pancreatoduodenectomy for dCCA were age (HR 1.02, 95% CI 1.01-1.03), pT (HR 1.43, 95% CI 1.07-1.90) and pN category (pN1: HR 1.78, 95% CI 1.37-2.32; pN2: HR 2.21, 95% CI 1.63-3.01), resection margin status (HR 1.79, 95% CI 1.39-2.29) and tumour differentiation (HR 2.02, 95% CI 1.62-2.53). The prediction model was based on these prognostic factors. The optimism-adjusted C-indices were similar in the derivation cohort (0.69), and in the Belgian (0.66) and Southampton-Verona (0.68) validation cohorts. Calibration was accurate in the Belgian validation cohort (slope = 0.93, intercept = 0.12), but slightly less optimal in the Southampton-Verona validation cohort (slope = 0.88, intercept = 0.32). Based on this model, three risk groups with different prognoses were identified (3-year OS of 65.4%, 33.2% and 11.8%)., Conclusions: The prediction model for 3-year OS after resection of dCCA had reasonable performance in both the derivation and geographically external validation cohort. Calibration slightly differed between validation cohorts. The model is readily available via www. pancreascalculator.com to inform patients from Western European countries on their prognosis, and may be used to stratify patients for clinical trials., (© 2022. The Author(s), under exclusive licence to Springer Nature Limited.)

Background: The impact of pancreatic and periampullary cancer treatment on health-related quality of life (HRQoL) is unclear., Methods: This study merged data from the Netherlands Cancer Registry with EORTC QLQ-C30 and -PAN26 questionnaires at baseline and three-months follow-up of pancreatic and periampullary cancer patients (2015-2018). Propensity score matching (1:3) of group without to group with treatment was performed. Linear mixed model regression analyses were performed to investigate the association between cancer treatment and HRQoL at follow-up., Results: After matching, 247 of 629 available patients remained (68 (27.5%) no treatment, 179 (72.5%) treatment). Treatment consisted of resection (n = 68 (27.5%)), chemotherapy only (n = 111 (44.9%)), or both (n = 40 (16.2%)). At follow-up, cancer treatment was associated with better global health status (Beta-coefficient 4.8, 95% confidence-interval 0.0-9.5) and less constipation (Beta-coefficient -7.6, 95% confidence-interval -13.8-1.4) compared to no cancer treatment. Median overall survival was longer for the cancer treatment group compared to the no treatment group (15.4 vs. 6.2 months, p < 0.001)., Conclusion: Patients undergoing treatment for pancreatic and periampullary cancer reported slight improvement in global HRQoL and less constipation at three months-follow up compared to patients without cancer treatment, while overall survival was also improved., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Metastatic pancreatic ductal adenocarcinoma (PDAC) is characterized by a poor survival rate, which can be improved by systemic treatment. Consensus on the most optimal first- and second-line palliative systemic treatment is lacking. The aim of this study was to describe the use of first- and second-line systemic treatment, overall survival (OS), and time to failure (TTF) of first- and second-line treatment in metastatic PDAC in a real-world setting., Patients and Methods: Patients with synchronous metastatic PDAC diagnosed between 2015 and 2018 who received systemic treatment were selected from the nationwide Netherlands Cancer Registry. OS and TTF were evaluated using Kaplan-Meier curves with log-rank test and multivariable Cox proportional hazard analyses., Results: The majority of 1,586 included patients received FOLFIRINOX (65%), followed by gemcitabine (18%), and gemcitabine + nab-paclitaxel (13%) in the first line. Median OS for first-line FOLFIRINOX, gemcitabine + nab-paclitaxel, and gemcitabine monotherapy was 6.6, 4.7, and 2.9 months, respectively. Compared to FOLFIRINOX, gemcitabine + nab-paclitaxel showed significantly inferior OS after adjustment for confounders (hazard ratio [HR], 1.20; 95% CI, 1.02-1.41), and gemcitabine monotherapy was independently associated with a shorter OS and TTF (HR, 1.98; 95% CI, 1.71-2.30 and HR, 2.31; 95% CI, 1.88-2.83, respectively). Of the 121 patients who received second-line systemic treatment, 33% received gemcitabine + nab-paclitaxel, followed by gemcitabine (31%) and FOLFIRINOX (10%)., Conclusions: Based on population-based data in patients with metastatic PDAC, treatment predominantly consists of FOLFIRINOX in the first line and gemcitabine with or without nab-paclitaxel in the second line. FOLFIRINOX in the first line shows superior OS compared with gemcitabine with or without nab-paclitaxel.

Background: Perihilar cholangiocarcinoma (pCCA) is a rare tumour that requires complex multidisciplinary management. All known data are almost exclusively derived from expert centres. This study aimed to analyse the outcomes of patients with pCCA in a nationwide cohort., Methods: Data on all patients diagnosed with pCCA in the Netherlands between 2010 and 2018 were obtained from the Netherlands Cancer Registry. Data included type of hospital of diagnosis and the received treatment. Outcomes included the type of treatment and overall survival., Results: A total of 2031 patients were included and the median overall survival for the overall cohort was 5.2 (95% CI 4.7-5.7) months. Three-hundred-ten (15%) patients underwent surgical resection, 271 (13%) underwent palliative systemic treatment, 21 (1%) palliative local anti-cancer treatment and 1429 (70%) underwent best supportive care. These treatments resulted in a median overall survival of 29.6 (95% CI 25.2-34.0), 12.2 (95% CI 11.0-13.3), 14.5 (95%CI 8.2-20.8) and 2.9 (95% CI 2.6-3.2) months respectively. Resection rate was 13% in patients who were diagnosed in non-academic and 32% in academic centres (P < .001), which resulted in a survival difference in favour of academic centres. Median overall survival was 9.7 (95% CI 7.7-11.7) months in academic centres compared to 4.9 (95% CI 4.3-5.4) months in non-academic centres (P < .001)., Conclusions: In patients with pCCA, resection rate and overall survival were higher for patients who were diagnosed in academic centres. These results show population-based outcomes of pCCA and highlight the importance of regional collaboration in the treatment of these patients., (© 2021 The Authors. Liver International published by John Wiley & Sons Ltd.)

Introduction: Ampullary cancer is rare and as a result epidemiological data are scarce. The aim of this population-based study was to determine the trends in incidence, treatment and overall survival (OS) in patients with ampullary adenocarcinoma in the Netherlands between 1989 and 2016., Methods: Patients diagnosed with ampullary adenocarcinoma were identified from the Netherlands Cancer Registry. Incidence rates were age-adjusted to the European standard population. Trends in treatment and OS were studied over (7 years) period of diagnosis, using Kaplan-Meier and Cox regression analyses for OS and stratified by the presence of metastatic disease., Results: In total, 3840 patients with ampullary adenocarcinoma were diagnosed of whom, 55.0% were male and 87.1% had non-metastatic disease. The incidence increased from 0.59 per 100,000 in 1989-1995 to 0.68 per 100,000in 2010-2016. In non-metastatic disease, the resection rate increased from 49.5% in 1989-1995 to 63.9% in 2010-2016 (p < 0.001). The rate of adjuvant therapy increased from 3.1% to 7.9%. In non-metastatic disease, five-year OS (95% CI) increased from 19.8% (16.9-22.8) in 1989-1995 to 29.1% (26.0-31.2) in 2010-2016 (logrank p < 0.001). In patients with metastatic disease, median OS did not significantly improve (from 4.4 months (3.6-5.0) to 5.9 months (4.7-7.1); logrank p = 0.06). Cancer treatment was an independent prognostic factor for OS among all patients., Conclusion: Both incidence and OS of ampullary cancer increased from 1989 to 2016 which is most likely related to the observed increased resection rates and use of adjuvant therapy., Competing Interests: Declaration of competing interest Drs. de Vos-Geelen reports grants, personal fees and non-financial support from Servier, personal fees from AstraZeneca, personal fees from MSD, personal fees from Pierre Fabre, personal fees from Amgen, outside the submitted work. Dr. ir. Geurts reports grants from Roche, grants from Pfizer, grants from Novartis, grants from Eisai, grants from Lilly, outside the submitted work. Dr. Haj Mohammad reports non-financial support from Servier, non-financial support from MSD, non-financial support from BMS, non-financial support from Eli Lily, non-financial support from Astra Zeneca, outside the submitted work. Dr. van Laarhoven reports grants and non-financial support from BMS, grants and non-financial support from Celgene, grants and non-financial support from Lilly, grants and non-financial support from Nordic, grants and non-financial support from Servier, grants from Bayer, grants from Merck Serono, grants from MSD, grants from Philips, outside the submitted work. Dr. Tjan-Heijnen reports grants and personal fees from Roche, grants and personal fees from Novartis, grants and personal fees from Pfizer, grants and personal fees from Lilly, personal fees from Accord Healthcare, grants from AstraZeneca, grants from Eisai, grants from Daiichi Sankyo, outside the submitted work. Dr. Valkenburg-van Iersel reports non-financial support from Servier, non-financial support from Pierre Fabre, non-financial support from Roche, outside the submitted work. Dr. Wilmink reports grants and non-financial support from Servier, non-financial support from MSD, non-financial support from AstraZeneca, grants and non-financial support from Celgene, grants from Halozyme, grants from Merck, grants from Roche, grants from Pfizer, grants from Amgen, grants from Novartis, outside the submitted work. The other authors have declared no conflicts of interests., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: The aim of the study was to gain insight in the incidence, treatment, and survival of patients with synchronous pancreatic peritoneal metastases., Methods: All patients diagnosed with pancreatic cancer between 2008 and 2018 in the Netherlands Cancer Registry were evaluated. The patients were subcategorized as (1) synchronous peritoneal metastases, (2) synchronous systemic metastases, and (3) no metastases., Results: In total, 25,334 patients with pancreatic cancer were included. Among them, 3524 (14%) presented with synchronous peritoneal metastases, 10,659 (42%) with systemic metastases, and 11,151 (44%) without metastases at the time of diagnosis. The proportion of the patients diagnosed with peritoneal metastases increased over time (11%, 2008; 16%, 2018; P < 0.001). Of these patients, 964 (27%) received cancer treatment and 2560 (73%) received best supportive care. The median overall survival in patients with peritoneal metastases, systemic metastases, and without metastases was 1.9, 2.4, and 8.0 months, respectively (P < 0.001). In the patients with peritoneal metastases, the median overall survival was 5.0 months when undergoing cancer treatment and 1.3 months with best supportive care (P < 0.001)., Conclusions: Patients with pancreatic cancer are increasingly diagnosed with synchronous peritoneal metastases. Given the current dismal prognosis, research to improve treatment is designated for this patient category., Competing Interests: I.H.J.T.d.H. received an unrestricted research grant for unrelated research from RanD Biotech and ROCHE, paid to the institute. J.d.V.-G. has served as a consultant for AstraZeneca, MSD, Pierre Fabre, and Servier and has received institutional research funding from Servier (all outside the submitted work). The other authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Identification of metastatic pancreatic cancer (mPC) patients with the worst prognosis could help to tailor therapy. We evaluated readily available biomarkers for the prediction of 90-day mortality in a nationwide cohort of mPC patients., Methods: Patients with synchronous mPC were included from the Netherlands Cancer Registry (2015-2017). Baseline CA19-9, albumin, CRP, LDH, CRP/albumin ratio, and (modified) Glasgow Prognostic Score ((m)GPS composed of albumin and CRP) were evaluated. Multivariable logistic regression analyses were performed to identify predictors of 90-day mortality. Prognostic value per predictor was quantified by Nagelkerke's partial R 2 ., Results: Overall, 4248 patients were included. Median overall survival was 2.2 months and 90-day mortality was 59.4% (n = 1629). All biomarkers predicted 90-day mortality in univariable analysis, and remained statistically significant after adjustment for clinically relevant factors and all other biomarkers (all p  < 0.001). The prognostic value of the biomarkers combined was similar to WHO performance status. Patients who received chemotherapy had better outcomes than those who did not, regardless of biomarker levels., Conclusions: In mPC patients, albumin, CA19-9, CRP, LDH, CRP/albumin ratio, and (m)GPS are prognostic for poor survival. Biomarkers did not predict response to chemotherapy. These readily available biomarkers can be used to better inform patients and to stratify in clinical trials.

Background: Compliance with national guidelines on pancreatic cancer management could improve patient outcomes. Early compliance with the Dutch guideline was poor. The aim was to assess compliance with this guideline during six years after publication., Materials and Methods: Nationwide guideline compliance was investigated for three subsequent time periods (2012-2013 vs. 2014-2015 vs. 2016-2017) in patients with pancreatic cancer using five quality indicators in the Netherlands Cancer Registry: 1) discussion in multidisciplinary team meeting (MDT), 2) maximum 3-week interval from final MDT to start of treatment, 3) preoperative biliary drainage when bilirubin >250 μmol/L, 4) use of adjuvant chemotherapy, and 5) chemotherapy for inoperable disease (non-metastatic and metastatic)., Results: In total, 14 491 patients were included of whom 2290 (15.8%) underwent resection and 4561 (31.5%) received chemotherapy. Most quality indicators did not change over time: overall, 88.8% of patients treated with curative intent were discussed in a MDT, 42.7% were treated with curative intent within the 3-week interval, 62.7% with a resectable head tumor and bilirubin >250 μmol/L underwent preoperative biliary drainage, 57.2% received chemotherapy after resection, and 36.6% with metastatic disease received chemotherapy. Only use of chemotherapy for non-metastatic, non-resected disease improved over time (23.4% vs. 25.6% vs. 29.7%)., Conclusion: Nationwide compliance to five quality indicators for the guideline on pancreatic cancer management showed little to no improvement during six years after publication. Besides critical review of the current quality indicators, these outcomes may suggest that a nationwide implementation program is required to increase compliance to guideline recommendations., Competing Interests: Declaration of competing interest The authors report no conflicts of interest. MDT = multidisciplinary team. Preop = preoperative. CT = chemotherapy. M1 = metastatic disease. M0-NR = non-metastatic, non-resected disease. Bold p-values indicate statistical significance. Indicator 1: discussion in a MDT meeting for pancreatic cancer treated with curative intent. Indicator 2: maximum transit time until start of treatment with curative intent (2A: maximum 3-week interval between final MDT meeting and start of treatment; 2B: maximum 6-week interval between first contact and start of treatment). Indicator 3: preoperative biliary drainage for pancreatic head cancer with bilirubin >250 μmol/L. Indicator 4: adjuvant chemotherapy after resection of pancreatic cancer. Indicator 5: chemotherapy for inoperable pancreatic cancer (5A: metastatic disease, non-resected; 5B: non-metastatic disease, non-resected). MDT = multidisciplinary team. Preop = preoperative. CT = chemotherapy. M1 = metastatic disease. M0-NR = non-metastatic, non-resected disease. Bold p-values indicate statistical significance. Indicator 1: discussion in a MDT meeting for pancreatic cancer treated with curative intent. Indicator 2: maximum transit time until start of treatment with curative intent (2A: maximum 3-week interval between final MDT meeting and start of treatment; 2B: maximum 6-week interval between first contact and start of treatment). Indicator 3: preoperative biliary drainage for pancreatic head cancer with bilirubin >250 μmol/L. Indicator 4: adjuvant chemotherapy after resection of pancreatic cancer. Indicator 5: chemotherapy for inoperable pancreatic cancer (5A: metastatic disease, non-resected; 5B: non-metastatic disease, non-resected)., (Copyright © 2020 IAP and EPC. Published by Elsevier B.V. All rights reserved.)

Background: Dutch guidelines indicate that treatment of pancreatic head and periampullary malignancies should be started within 3 weeks of the multidisciplinary team (MDT) meeting. This study aimed to assess the impact of time to surgery on oncological outcomes., Methods: This was a retrospective population-based cohort study of patients with pancreatic head and periampullary malignancies included in the Netherlands Cancer Registry. Patients scheduled for pancreatoduodenectomy and who were discussed in an MDT meeting from May 2012 to December 2016 were eligible. Time to surgery was defined as days between the final preoperative MDT meeting and surgery, categorized in tertiles (short interval, 18 days or less; intermediate, 19-32 days; long, 33 days or more). Oncological outcomes included overall survival, resection rate and R0 resection rate., Results: A total of 2027 patients were included, of whom 677, 665 and 685 had a short, intermediate and long time interval to surgery respectively. Median time to surgery was 25 (i.q.r. 14-36) days. Longer time to surgery was not associated with overall survival (hazard ratio 0·99, 95 per cent c.i. 0·87 to 1·13; P = 0·929), resection rate (relative risk (RR) 0·96, 95 per cent c.i. 0·91 to 1·01; P = 0·091) or R0 resection rate (RR 1·01, 0·94 to 1·09; P = 0·733). Patients with pancreatic ductal adenocarcinoma and a long time interval had a lower resection rate (RR 0·92, 0·85 to 0·99; P = 0·029)., Discussion: A longer time interval between the last MDT meeting and pancreatoduodenectomy did not decrease overall survival., (© 2020 The Authors. BJS Open published by John Wiley & Sons Ltd on behalf of British Journal of Surgery Society.)

Background: A relationship between quality of life (QoL) and survival has been shown for several types of cancer, mostly in clinical trials with highly selected patient groups. The relationship between QoL and survival for patients with pancreatic or periampullary cancer is unclear., Methods: This study analyzed QoL data from a prospective multicenter patient-reported outcome registry in patients with pancreatic or periampullary carcinoma registered in the nationwide Netherlands Cancer Registry (2015-2018). Baseline and delta QoL, between baseline and 3-month follow-up, were assessed with the Happiness, EORTC Quality of Life Questionnaire-Core 30 (QLQ-C30), and QLQ-PAN26 questionnaires. The relationship between QoL and survival was assessed using Cox regression models, and additional prognostic value of separate items was assessed using Nagelkerke R2 (explained variance)., Results: For the baseline and delta analyses, 233 and 148 patients were available, respectively. Most were diagnosed with pancreatic adenocarcinoma (n=194; 83.3%) and had stage III disease (n=77; 33.0%), with a median overall survival of 13.6 months. Multivariate analysis using baseline scores indicated several scales to be of prognostic value for the total cohort (ie, happiness today, role functioning, diarrhea, pancreatic pain, and body image; hazard ratios all P<.05) and for patients without resection (ie, overall satisfaction with life, physical and cognitive functioning, QLQ-C30 summary score, fatigue, pain, constipation, diarrhea, and body image; hazard ratios all P<.05). Except for diarrhea, all QoL items accounted for >5% of the additional explained variance and were of added prognostic value. Multivariate analysis using delta QoL revealed that only constipation was of prognostic value for the total cohort, whereas no association with survival was found for subgroups with or without resection., Conclusions: In a multicenter cohort of patients with pancreatic or periampullary carcinoma, QoL scores predicted survival regardless of patient, tumor, and treatment characteristics. QoL scores may thus be used for shared decision-making regarding disease management and treatment choice.

Background: Pancreatic cancer has a very poor prognosis. Best practices for the use of chemotherapy, enzyme replacement therapy, and biliary drainage have been identified but their implementation in daily clinical practice is often suboptimal. We hypothesized that a nationwide program to enhance implementation of these best practices in pancreatic cancer care would improve survival and quality of life., Methods/design: PACAP-1 is a nationwide multicenter stepped-wedge cluster randomized controlled superiority trial. In a per-center stepwise and randomized manner, best practices in pancreatic cancer care regarding the use of (neo)adjuvant and palliative chemotherapy, pancreatic enzyme replacement therapy, and metal biliary stents are implemented in all 17 Dutch pancreatic centers and their regional referral networks during a 6-week initiation period. Per pancreatic center, one multidisciplinary team functions as reference for the other centers in the network. Key best practices were identified from the literature, 3 years of data from existing nationwide registries within the Dutch Pancreatic Cancer Project (PACAP), and national expert meetings. The best practices follow the Dutch guideline on pancreatic cancer and the current state of the literature, and can be executed within daily clinical practice. The implementation process includes monitoring, return visits, and provider feedback in combination with education and reminders. Patient outcomes and compliance are monitored within the PACAP registries. Primary outcome is 1-year overall survival (for all disease stages). Secondary outcomes include quality of life, 3- and 5-year overall survival, and guideline compliance. An improvement of 10% in 1-year overall survival is considered clinically relevant. A 25-month study duration was chosen, which provides 80% statistical power for a mortality reduction of 10.0% in the 17 pancreatic cancer centers, with a required sample size of 2142 patients, corresponding to a 6.6% mortality reduction and 4769 patients nationwide., Discussion: The PACAP-1 trial is designed to evaluate whether a nationwide program for enhanced implementation of best practices in pancreatic cancer care can improve 1-year overall survival and quality of life., Trial Registration: ClinicalTrials.gov, NCT03513705. Trial opened for accrual on 22th May 2018.

Background: Re-resection for incidental gallbladder cancer (iGBC) is associated with improved survival but little is known about residual disease (RD) and prognostic factors. In this study, survival after re-resection, RD, and prognostic factors are analyzed., Methods: Patients with iGBC were identified from the Netherlands Cancer Registry, and pathology reports of re-resected patients were reviewed. Survival and prognostic factors were analyzed., Results: Overall, 463 patients were included; 24% (n = 110) underwent re-resection after a median interval of 66 days. RD was present in 35% of patients and was most frequently found in the lymph nodes (23%). R0 resection was achieved in 93 patients (92%). Median overall survival (OS) of patients without re-resection was 13.7 (95% confidence interval [CI] 11.6-15.6), compared with 52.6 months (95% CI 36.3-68.8) in re-resected patients (p < 0.001). After re-resection, median OS was superior in patients without RD versus patients with RD (not reached vs. 23.1 months; p < 0.001). In patients who underwent re-resection, RD in the liver (hazard ratio [HR] 5.54; p < 0.001) and lymph nodes (HR 2.35; p = 0.005) were the only significant prognostic factors in multivariable analysis. Predictive factors for the presence of RD were pT3 stage (HR 25.3; p = 0.003) and pN1 stage (HR 23.0; p = 0.022)., Conclusion: Re-resection for iGBC is associated with improved survival but remains infrequently used and is often performed after the optimal timing interval. RD is the only significant prognostic factor for survival after re-resection and can be predicted by pT and pN stages.

Background: Population-based data on distal cholangiocarcinoma (DCC) from the Western world are not available, albeit essential to identify areas for improvement. This study investigated the incidence, treatment and outcomes, including time trends and predictors for survival, in a nationwide cohort of DCC. Methods: This is a retrospective cohort study of patients diagnosed with DCC (2009-2016) derived from the Netherlands Cancer Registry. Overall survival (OS) and its predictors were analyzed using Kaplan-Meier and Cox regression analysis. Time trends (2009-2012 versus 2013-2016) were assessed. Results: Overall, 1338 patients with DCC were included, with 1-, 3- and 5-year OS of 46%, 18%, and 11%. Incidence of DCC was 0.55-0.90 per 100.000 per year. Median OS was 10.4 months across all stages; 21.9 months for resected ( n  = 620, 46.3%), 6.7 months for unresected nonmetastatic ( n  = 445, 33.3%), and 3.6 months for metastatic DCC ( n  = 273, 20.4%) ( p  < .001). After resection, 30-day mortality was 4.8% and 90-day mortality 7.7%. Patients with metastatic DCC who received chemotherapy (n = 78, 28.6%) had a median OS of 8.2 versus 2.8 months for those not treated ( p  < .001). Over time, resection rates (53.6% to 61.7%, p  = .008) and use of palliative chemotherapy in metastatic DCC (22.3% to 32.9%, p  = .05) increased, without improvement in OS (10.3 vs 10.6 months, p  = .55). Independent poor prognostic factors for OS in resected disease were increasing age, pT3/T4 stage, higher lymph node ratio, poor differentiation, and R1 resection. Conclusions: In a nationwide cohort of DCC, resection rates and the use of chemotherapy increased whereas OS remained stable at 10.4 months.

Background: Decisions about palliative systemic treatment are key elements of palliative and end-of-life care. Such decisions must often be made in complex, clinical situations., Aim: To explore the content of medical records of patients with advanced non-small cell lung cancer and pancreatic cancer with specific emphasis on doctors' notes about decisions on palliative systemic treatment., Design: Medical record review (2009-2012) of 147 cancer patients containing 276 notes about palliative systemic treatment. We described the proportion of notes/medical records containing pre-specified items relevant to palliative systemic treatment. We selected patients using the nationwide Netherlands Cancer Registry., Setting: Hospital based., Results: About 75% of all notes reported doctors' considerations to start/continue palliative systemic treatment, including information about the prognosis (47%), possible survival gain (22%), patients' wish for palliative systemic treatment (33%), impact on quality of life (8%), and patient's age (3%). Comorbidity (82%), smoking status (78%) and drinking behaviour (63%) were more often documented than patients' performance status (16%). Conversations with the patient/family about palliative systemic treatment were reported in 49% of all notes. Response measurements and dose adaptations were documented in 75% and 71% of patients who received palliative systemic treatment respectively., Conclusion: Medical records provide insight into the decision-making process about palliative systemic treatment. The content and detail of doctors' notes, however, widely varies especially concerning their palliative systemic treatment considerations. Registries that aim to measure the quality of (end-of-life) care must be aware of this outcome. Future research should further explore how medical records can best assist in evaluating the quality of the decision-making process in the patient's final stage of life.

Background: In the Netherlands, like in many other European countries, pancreatic cancer mortality was found to be systematically higher than the incidence. This suggests that there is an underestimation of the reported incidence of pancreatic cancer., Aim: We aimed to study the incidence of pancreatic cancer in the Rotterdam area and to compare this with the national level., Methods: This study is embedded in the Rotterdam Study (RS), an ongoing population-based prospective cohort study of people aged 45 years and above, enrolled between 1989 till 2006. Details on incident pancreatic cancer cases were available until 2013. Age-specific incidence rates were calculated and compared with data available in the Netherlands Cancer Registry., Results: At baseline 14,922 participants were at risk of developing pancreatic cancer. Median follow-up time was 16.4 person years per person. In total, 113 participants developed pancreatic cancer. Rates increased with age with an incidence rate of 109.9 (95% confidence interval [CI]; 85.7-138.8) per 100,000 person years for people older than 75. This is higher than the currently reported 55.9-89.2 per 100,000 person year. Of the 113 cases identified in the RS, only 67.3% was reported as pancreatic cancer in the Netherlands Cancer Registry. Cases that were not registered were significantly older and had significantly poorer survival., Conclusion: The incidence of pancreatic cancer, as registered by the Netherlands Cancer Registry, is an underestimation. Patients, not registered by the cancer registry, have a significantly poorer survival. Consequently, we probably overestimate the already poor survival of pancreatic cancer., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

The influence of socioeconomic inequalities in pancreatic cancer patients and especially its effect in patients who had a resection is not known. Hospital type in which resection is performed might also influence outcome. Patients diagnosed with pancreatic cancer from 1989 to 2011 (n = 34,757) were selected from the population-based Netherlands Cancer Registry. Postal code was used to determine SES. Multivariable survival analyses using Cox regression were conducted to discriminate independent risk factors for death. Patients living in a high SES neighborhood more often underwent resection and more often were operated in a university hospital. After adjustment for clinicopathological factors, risk of dying was increased independently for patients with intermediate and low SES compared to patients with high SES. After resection, no survival difference was found among patients in the three SES groups. However, survival was better for patients treated in university hospitals compared to patients treated in non-university hospitals. Low SES was an independent risk factor for poor survival in patients with pancreatic cancer. SES was not an adverse risk factor after resection. Resection in non-university hospitals was associated with a worse prognosis., Competing Interests: The authors have declared that no competing interests exist.

As the value of palliative primary tumor resection in stage IV colorectal cancer (CRC) is still under debate, the purpose of this population-based study was to investigate if palliative primary tumor resection as the initial treatment after diagnosis was associated with improved overall survival. All patients with stage IV colorectal adenocarcinoma (2008-2011) were selected from the Netherlands Cancer Registry, and patients undergoing treatment with curative intent (i.e., metastasectomy, radiofrequency ablation and/or hyperthermic intraperitoneal chemotherapy), or best supportive care were excluded. After propensity score matching, a multivariable Cox proportional hazard model was performed to determine the association between treatment strategy and mortality. From a total group of 10,371 patients with stage IV CRC, 2,746 patients (26%) underwent an elective palliative resection of the primary tumor, whether or not followed by systemic therapy, and 3,345 patients (32%) were initially treated with palliative systemic therapy. After propensity score matching, median overall survival in these groups was 17.2 months (95% CI 16.3-18.1) and 11.5 months (95% CI 11.0-12.0), respectively. In Cox regression analysis, primary tumor resection was significantly associated with improved overall survival (hazard ratio of death = 0.44 [95% CI 0.35-0.55], p < 0.001). This large population-based study shows an overall survival benefit for patients with incurable stage IV CRC who underwent primary tumor resection as the initial treatment after diagnosis, compared to patients who started systemic therapy with the primary tumor in situ. This result is an argument in favor of resection of the primary tumor, even when patients have little to no symptoms., (© 2016 UICC.)

Adjuvant chemotherapy after pancreatoduodenectomy for pancreatic cancer is currently considered standard of care. In this nationwide study, we investigated which characteristics determine the likelihood of receiving adjuvant chemotherapy and its effect on overall survival. The data were obtained from the Netherlands Cancer Registry. All patients alive 90 days after pancreatoduodenectomy for M 0 -pancreatic cancer between 2008 and 2013 in the Netherlands were included in this study. The likelihood to receive adjuvant chemotherapy was analyzed by multilevel logistic regression analysis and differences in time-to-first-chemotherapy were tested for significance by Mann-Whitney U test. Overall survival was assessed by Kaplan-Meier method and Cox regression analysis. Of the 1195 patients undergoing a pancreatoduodenectomy for pancreatic cancer, 642 (54%) patients received adjuvant chemotherapy. Proportions differed significantly between the 19 pancreatic centers, ranging from 26% to 74% (P < 0.001). Median time-to-first-chemotherapy was 6.7 weeks and did not differ between centers. Patients with a higher tumor stage, younger age, and diagnosed more recently were more likely to receive adjuvant treatment. The 5-year overall survival was significantly prolonged in patients treated with adjuvant chemotherapy-23% versus 17%, log-rank = 0.01. In Cox regression analysis, treatment with adjuvant chemotherapy significantly prolonged survival compared with treatment without adjuvant chemotherapy. The finding that elderly patients and patients with a low tumor stage are less likely to undergo treatment needs further attention, especially since adjuvant treatment is known to prolong survival in most of these patients., (© 2016 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Purpose: Many apparent differences exist in aetiology, genetics, anatomy and treatment response between colon cancer (CC) and rectal cancer (RC). This study examines the differences in patient characteristics, prevalence of complications and their effect on short-term survival, long-term survival and the rate of recurrence between RC and CC., Methods: For all stage II-III CC and RC patients who underwent resection with curative intent (2006-2008) in five hospitals in the Netherlands, occurrence of complications, crude survival, relative survival and recurrence rates were compared., Results: A total of 767 CC and 272 RC patients underwent resection. Significant differences were found for age, gender, emergency surgery, T-stage and grade. CC patients experienced fewer complications compared to RC (p = 0.019), but CC patients had worse short-term mortality rates (1.5 versus 6.7 % for 30-day mortality, p = 0.001 and 5.2 versus 9.5 % for 90-day mortality, p = 0.032). The adjusted HR (overall survival) for CC patients with complications was 1.57 (1.23-2.01; p < 0.001) as compared to patients without complications; for RC, the HR was 1.79 (1.12-2.87; p = 0.015). Relative survival analyses showed high excess mortality in the first months after surgery and a sustained, prolonged negative effect on both CC and RC. Complications were associated with a higher recurrence rate for both CC and RC; adjusted analyses showed a trend towards a significant association., Conclusion: Large differences exist in patient characteristics and clinical outcomes between CC and RC. CC patients have a significantly higher short-term mortality compared to RC patients due to a more severe effect of complications., Competing Interests: Compliance with ethical standards Funding There was no funding for this study. Conflict of interest The authors declare that they have no conflict of interest.

Background: The purpose of this study was to identify the ten most frequent complications after surgery for stage I-III colon cancer and to assess the association between these complications and overall survival, conditional overall survival, and recurrences., Methods: All patients who underwent surgery for stage I-III colon cancer in five hospitals in the Western region of the Netherlands were identified. Crude and adjusted Cox proportional hazards models were used to study the association between complications and 1-year overall survival, 5-year overall survival, 5-year conditional overall survival, and 5-year disease-free period., Results: Data from 761 patients were used for the analyses. Complications were associated with decreased 1-year overall survival (hazard ratio (HR) 2.87, 95 % confidence interval (CI) 1.82-4.51; p < 0.001), 5-year overall survival (HR 1.59, 95 % CI 1.25-2.04; p < 0.001), and 5-year conditional overall survival (HR 1.34, 95 % CI 1.06-1.69; p = 0.016), whereas an increasing number of complications had no additional impact. Anastomotic leakage, excessive blood loss, and (abdominal) sepsis were associated with reduced 1-year overall survival, anastomotic leakage, delirium, abscess, and (abdominal) sepsis with reduced 5-year overall survival, and anastomotic leakage, delirium, and abscess with reduced 5-year conditional overall survival. Anastomotic leakage, electrolyte disorders, and abscess were risk factors for recurrence within five years., Conclusions: Our results demonstrate the serious impact of the most frequent complications after surgery for colon cancer on short-term and long-term outcomes. This study confirms the prolonged impact of surgery and demonstrates that complications result not only in reduced 1-year survival, but also in reduced long-term outcomes.

Background: Series from expert centers suggest that pancreas cancer surgery is safe for elderly patients but nationwide data, taking hospital volume into account, are lacking., Methods: From the Netherlands Cancer Registry, all 3420 patients who underwent pancreatoduodenectomy (PD) for primary pancreatic or periampullary carcinoma in 2005-2013 were selected. Associations between age (<75, ≥75 years), hospital volume (tertiles), and postoperative mortality (30, 90 day) were evaluated by χ (2) tests and logistic regression analyses. Overall survival was investigated by means of Kaplan-Meier and Cox proportional hazard regression analyses., Results: The proportion of elderly patients (≥75 years) undergoing PD increased from 15 % in 2005-2007 to 20 % in 2011-2013 (p = 0.009). In low (<15 per year), medium (15-28 per year), and high (>28 per year) hospital volume tertiles, the proportion of elderly patients was 16, 20, and 17 %, respectively (p = 0.10). With increasing hospital volume, 30-day postoperative mortality was 6.0-4.5-2.9 % (p = 0.002) and 90-day mortality 9.3-8.0-5.3 % (p = 0.001), respectively. Within each volume tertile, adjusted 30- and 90-day mortality of elderly patients was 1.6-2.5 times higher compared to outcomes of younger patients. Adjusted 30-day mortality in elderly patients was higher in low-volume hospitals (odds ratio = 2.87, 95 % confidence interval 1.15-7.17) compared to high-volume hospitals. Similarly, elderly patients had a worse overall survival in low-volume hospitals (hazard ratio = 1.28, 95 % confidence interval 1.01-1.63). Postoperative mortality of elderly patients in high-volume hospitals was similar to mortality of younger patients in low- and medium-volume hospitals., Conclusions: Elderly patients benefit from centralization by undergoing PD in high-volume hospitals, both with respect to postoperative mortality and survival. It would seem reasonable to place elderly patients into a high-risk category; they should only undergo surgery in the highest-tertile-volume hospitals.

Background: Volume-outcome relationships in pancreatic surgery are well established, but an optimal volume remains to be determined. Studies analyzing outcomes in volume categories exceeding 20 procedures annually are lacking., Study Design: A consecutive 3420 patients underwent PD for primary pancreatic or periampullary carcinoma (2005-2013) and were registered in the Netherlands Cancer Registry. Relationships between hospital volume (< 5, 5-19, 20-39 and ≥ 40 PDs/year) and mortality and survival were explored., Results: There was a non-significant decrease in 90-day mortality from 8.1 to 6.7% during the study period (p = 0.23). Ninety-day mortality was 9.7% in centers performing < 5 PDs/year (n = 185 patients), 8.9% for 5-19 PDs/year (n = 1432), 7.3% for 20-39 PDs/year (n = 240) and 4.3% for ≥ 40 PDs/year (n = 562, p = 0.004). Within volume categories, 90-day mortality did not change over time. After adjustment for confounding factors, significantly lower mortality was found in the ≥ 40 category compared to 20-39 PDs/year (OR = 1.72 (1.08-2.74)). Overall survival adjusted for confounding factors was better in the ≥ 40 category compared to categories under 20 PDs/year: HR (≥ 40 vs 5-19/year) = 1.24 (1.09-1.42). In the ≥ 40 category significantly more patients received adjuvant chemotherapy and had > 10 lymph nodes retrieved compared to lower volume categories., Conclusions: Volume-outcome relationships in pancreatic surgery persist in centers performing ≥ 40 PDs annually, regarding both mortality and survival. The volume plateau for pancreatic surgery has yet to be determined., (Copyright © 2016 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: Comprehensive geriatric assessment (CGA) is a multidimensional method to detect frailty in elderly patients. Time saving could be accomplished by identifying those individual items that classify elderly cancer patients at risk for feasibility of chemotherapy and for mortality., Material and Methods: Patients older than 70 years of age were assessed before the first chemotherapy administration. GA consisted of the Mini Nutritional Assessment (MNA), Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), Groningen Frailty Indicator (GFI) and Mini Mental State Examination (MMSE). Predictive individual items for feasibility of chemotherapy and mortality were entered in the multivariable logistic regression and Cox-regression models, and a three-item sum scale was constructed: the Geriatric Prognostic Index (GPI)., Results: The 494 patients had a median age of 75 years (range 70-92 years). The majority of the patients had malignancies of the digestive tract (41.7%) followed by hematological tumors (22.3%). Three items of the MNA ('psychological distress or acute disease in the past three months', 'neuropsychological problems' and 'using > 3 prescript drugs') independently predicted for feasibility of chemotherapy. Two items of the MNA and one of the GFI ('declining food intake in past 3 months', 'using > 3 prescript drugs', and 'dependence in shopping') independently predicted for mortality. In comparison with patients without any positive item on the three-item GPI, patients with one, two or three positive items had hazard ratios (HRs) of 1.58, 2.32, and 5.58, respectively (all p < 0.001)., Conclusions: With only three items of the MNA, feasibility of chemotherapy can be predicted. The three-item GPI may help to identify elderly cancer patients at elevated risk for mortality.

Background: At a national level, it is unknown to what degree elderly patients with pancreatic or periampullary carcinoma benefit from surgical treatment compared to their younger counterparts. We investigated resection rates and outcomes after surgical treatment among elderly patients., Methods: From the Netherlands Cancer Registry, 20 005 patients diagnosed with primary pancreatic or periampullary cancer in 2005-2013 were selected. The associations between age (<70, 70-74, 75-79, ≥80 years) and resection rates were investigated using χ(2) tests, and surgical outcomes (30-, 90-day mortality) were evaluated using logistic regression analysis. Overall survival after resection was investigated by means of Kaplan-Meier and Cox proportional hazard regression analysis., Results: During the study period, resection rates increased in all age groups (<70 years: 20-30%, p < 0.001; ≥80 years: 2-8%, p < 0.001). Of 3845 patients who underwent tumour resection for pancreatic or periampullary carcinoma, the proportion of octogenarians increased from 3.5% to 5.5% (p = 0.03), whereas postoperative mortality did not increase (30-day: 6-3%, p = 0.06; 90-day: 9-8%, p = 0.21). With rising age, 30-day postoperative mortality increased (4-5-7-8%, respectively, p < 0.001), while 90-day mortality was 6-10-13-12% (p < 0.001) and three-year overall survival rates after surgery were 35-33-28-31%, respectively (p < 0.001). After adjustment for confounding factors, octogenarians who survived 90 days postoperative exhibited an overall survival close to younger patients [hazard ratio (≥80 vs. <70 years) = 1.21, 95% confidence interval (0.99-1.47), p = 0.07]., Conclusion: Despite higher short-term mortality, octogenarians who underwent pancreatic resection showed long-term survival similar to younger patients. With careful patient screening and counselling of elderly patients, a further increase of resection rates may be combined with improved outcomes.

Background: We evaluated national compliance to selected quality indicators from the Dutch multidisciplinary evidence-based guideline on pancreatic and periampullary carcinoma and identified areas for improvement., Methods: Compliance to 3 selected quality indicators from the guideline was evaluated before and after implementation of the guideline in 2011: 1) adjuvant chemotherapy after tumor resection for pancreatic carcinoma, 2) discussion of the patient within a multidisciplinary team (MDT) meeting and 3) a maximum 3-week interval between final MDT meeting and start of treatment., Results: In total 5086 patients with pancreatic or periampullary carcinoma were included. In 2010, 2522 patients were included and in 2012, 2564 patients. 1) Use of adjuvant chemotherapy following resection for pancreatic carcinoma increased significantly from 45% (120 out of 268) in 2010 to 54% (182 out of 336) in 2012 which was mainly caused by an increase in patients aged <75 years. 2) In 2012, 64% (896 of 1396) of patients suspected of a pancreatic or periampullary carcinoma was discussed within a MDT meeting which was higher in patients aged <75 years and patients starting treatment with curative intent. 3) In 2012, the recommended 3 weeks between final MDT meeting and start of treatment was met in 39% (141 of 363) of patients which was not influenced by patient and tumor characteristics., Conclusion: Compliance to three selected quality indicators in pancreatic cancer care was low in 2012. Areas for improvement were identified. Future compliance will be investigated through structured audit and feedback from the Dutch Pancreatic Cancer Audit., (Copyright © 2015 IAP and EPC. Published by Elsevier India Pvt Ltd. All rights reserved.)

Background and Objective: Despite an increase in recent years, hepatocellular carcinoma remains uncommon in the Netherlands. The aim of the current study is to explore potential effects of hospital type and volume on outcomes after resection or sorafenib in patients with hepatocellular carcinoma., Methods: Initial treatment and survival of patients with hepatocellular carcinoma diagnosed in the period 2005-2011 were based on data of the Netherlands Cancer Registration. Potential risk factors (including hospital type and volume) for 30-days postoperative and long-term mortality in patients who underwent resection and in patients treated with sorafenib were evaluated by uni- and multivariate analyses., Results: In the period 2005-2011, 2402 patients were diagnosed with hepatocellular carcinoma: 12% received resection and 9% sorafenib. Postoperative mortality was higher in non-university hospitals (13% versus 4%; P=0.01). Resection in non-university hospitals was associated with higher postoperative mortality (odds ratio 3.38, 95% confidence interval 1.37-10.68) and long-term mortality (hazard ratio 1.21, 95% confidence interval 1.04-1.40). Sorafenib treatment in non-university hospitals was also associated with higher long-term mortality (hazard ratio 1.39, 95% confidence interval 1.06-1.82). Hospital volume was not independent predictor for outcome., Conclusion: In low incidence countries, outcome after resection or sorafenib for hepatocellular carcinoma may differ between various hospital types., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

The aim of this study was to determine trends in incidence, treatment and survival of colorectal cancer (CRC) patients with synchronous metastases (Stage IV) in the Netherlands. This nationwide population-based study included 160,278 patients diagnosed with CRC between 1996 and 2011. We evaluated changes in stage distribution, location of synchronous metastases and treatment in four consecutive periods, using Chi square tests for trend. Median survival in months was determined, using Kaplan-Meier analysis. The proportion of Stage IV CRC patients (n = 33,421) increased from 19 % (1996-1999) to 23 % (2008-2011, p < 0.001). This was predominantly due to a major increase in the incidence of lung metastases (1.7-5.0 % of all CRC patients). During the study period, the primary tumor was resected less often in Stage IV patients (65-46 %) and the use of systemic treatment has increased (29-60 %). Also an increase in metastasectomy was found in patients with one metastatic site, especially in patients with liver-only disease (5-18 %, p < 0.001). Median survival of all Stage IV CRC patients increased from 7 to 12 months. Especially in patients with metastases confined to the liver or lungs this improvement in survival was apparent (9-16 and 12-24 months respectively, both p < 0.001). In the last two decades, more lung metastases were detected and an increasing proportion of Stage IV CRC patients was treated with systemic therapy and/or metastasectomy. Survival of patients has significantly improved. However, the prognosis of Stage IV patients becomes increasingly diverse.

The age-adjusted International Prognostic Index (IPI) is an important prognostic factor for patients with non-Hodgkin lymphoma (NHL). We investigated whether a geriatric assessment (GA) is of additional prognostic value in NHL. In this prospective cohort study of 44 patients aged 70 years or older with NHL receiving rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP), a GA was administered before the start of chemotherapy. GA was composed of the Mini Nutritional Assessment (MNA), Groningen Frailty Indicator (GFI), Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), Mini Mental State Examination (MMSE) and levels of albumin, creatinine, lactate dehydrogenase (LDH) and hemoglobin. Multivariate analyses were performed using logistic regression and the Cox regression model. After adjustment for sex, age, comorbidity and univariate laboratory values with p ≤ 0.1, abnormal MNA and GFI scores and low hemoglobin level were associated with not being able to complete the intended chemotherapy: odds ratio (OR) 8.29 (95% confidence interval [CI]: 1.24-55.6; p = 0.03), 9.17 (95% CI: 1.51-55.8; p = 0.02) and 5.41 (95% CI: 0.99-29.8; p = 0.05), respectively. Adjusted for sex, age, comorbidity, age-adjusted IPI and univariate laboratory values with p ≤ 0.1, frailty by GFI and low hemoglobin were associated with worse survival, with a hazard ratio (HR) of mortality of 2.55 (95% CI: 1.07-6.10; p = 0.04) and 4.90 (95% CI: 1.76-13.7; p = 0.002), respectively. We conclude that (risk of) malnutrition, measured with the MNA, frailty, measured with the GFI, and low hemoglobin level had additional predictive value for early treatment withdrawal, and GFI and hemoglobin were, independent of the age-adjusted IPI, predictive for an increased mortality risk.

Background: This study was designed to define a statistically sound and clinically meaningful cutoff point for annual hospital volume for esophagectomy. Higher hospital volumes are associated with improved outcomes after esophagectomy. However, reported optimal volumes in literature vary, and minimal volume standards in different countries show considerable variation. So far, there has been no research on the noncategorical, nonlinear, volume-outcome relationship in esophagectomy., Methods: Data were derived from the Netherlands Cancer Registry. Restricted cubic splines were used to investigate the nonlinear effects of annual hospital volume on 6 month and 2 year mortality rates. Outcomes were adjusted for year of diagnosis, case-mix, and (neo)adjuvant treatment., Results: Between 1989 and 2009, 10,025 patients underwent esophagectomy for cancer in the Netherlands. Annual hospital volumes varied between 1 and 83 year, increasing over time. Increasing annual hospital volume showed a continuous, nonlinear decrease in hazard ratio (HR) for mortality along the curve. Increasing hospital volume from 20 year (baseline, HR = 1.00) to 40 and 60 year was associated with decreasing 6 month mortality, with a HR of 0.73 (95 % confidence interval (0.65-0.83) and 0.67 (0.58-0.77) respectively. Beyond 60 year, no further decrease was detected. Higher hospital volume also was associated with decreasing 2 year mortality until 50 esophagectomies year with a HR of 0.86 (0.79-0.93)., Conclusions: Centralization of esophagectomy to a minimum of 20 resections/year has been effectively introduced in the Netherlands. Increasing annual hospital volume was associated with a nonlinear decrease in mortality up to 40-60 esophagectomies/year, after which a plateau was reached. This finding may guide quality improvement efforts worldwide.

Background: The 1-year mortality after colorectal cancer surgery is high and explains age related differences in colorectal cancer survival. To gain better insight in its etiology, cause of death for these patients was studied., Methods: All 1924 patients who had a resection for stage I-III colorectal cancer from 2006 to 2008 in the Western region of the Netherlands were identified. Data were merged with cause of death data from the Central Bureau of Statistics Netherlands. To calculate excess mortality as compared to the general population, national data were used., Results: Overall 13.2% of patients died within the first postoperative year. One-year mortality increased with age. It was as high as 43% in elderly patients that underwent emergency surgery. In 75% of patients, death was attributed to the colorectal cancer. In 25% of all patients, registered deaths were attributed to postoperative complications. Elderly patients with comorbidity more frequently died due to complications (p < 0.01). Death of other causes was similar to background mortality according to age group., Conclusion: In the presently studied cohort of patients that died within one year of surgery, cause of death was predominantly attributed to colorectal cancer. However, because it is not to be expected that in this cohort the number of deaths from recurrences is very high, the excess 1-year mortality indicates a prolonged impact of the surgery, especially in elderly patients. Therefore, in these patients we should focus on limiting the physiological impact of the surgery and be more involved in the post-hospital period., (Copyright © 2014. Published by Elsevier Ltd.)

This is an investigation of factors determining hospital delay until treatment in an unrestricted population of colorectal cancer patients in the western part of the Netherlands. All patients with newly diagnosed colon (n=2146) and rectal carcinoma (n=1036) in the period 2006-2008 were included in analyses of inhospital delay (first hospital visit until first treatment >35 days). One-third of all patients were also available for analyses of prehospital delay (enrollment until first hospital visit >7 days). Patient, tumour and process factors predicting delay were examined in logistic regression models. The median prehospital and inhospital time intervals were 2 days [(p25-p75) 0-16] and 32 days (17-49), respectively, for colon cancer patients and 7 days (1-21) and 43 days (33-60) for rectal cancer patients. After adjustment for patient and tumour factors, colon and rectal cancer patients with first hospital visit before histological confirmation of cancer, complete diagnostic assessment or discussed in a multidisciplinary meeting had a higher probability of increased inhospital delay. Furthermore, first hospital visit before histological confirmation of cancer was associated with decreased prehospital delay in colon and rectal cancer patients. A guidelines-based diagnostic process (considered high quality of care) and multidisciplinary collaboration were associated with increased hospital delay in colorectal cancer patients.

Objective: To evaluate trends in the distribution of care for patients with hepatocellular carcinoma (HCC) in the past decade., Design: Retrospective study., Method: We collected data on diagnostic testing and initial treatment of patients with HCC in the period 2003-2011 from the Dutch Cancer Registry., Results: In the period 2003-2011, 2915 patients were diagnosed with HCC. The proportion of patients given palliative treatment increased significantly, whereas the proportion of patients treated by resection remained stable (approximately 10%). Tumour biopsies were performed in virtually all hospitals. Despite a significant decrease seen in the period studied, tumour biopsy was still performed in more than 50% of cases. The number of hospitals where any treatment was performed increased significantly (from 33% to 62% of all hospitals) and the contribution of treatments in academic hospitals decreased significantly (from 83% to 75%). Transarterial chemoembolization (TACE), radiofrequency ablation (RFA) and resection were mainly performed in academic hospitals (99%, 95% and 79% respectively), whereas about half of the initial sorafenib treatments were given in non-academic hospitals. Only in a few academic hospitals were a minimum of five resections performed annually and (only during the last three years of the period studied) were a minimum of five patients started on sorafenib annually. Significant differences existed between regions in the use of RFA or TACE - both p < 0.001, after case-mix correction., Conclusion: In the past decade there was no trend towards centralization of diagnostic testing and treatments for patients with HCC.

Introduction: The prognostic value of geriatric assessment in older patients with breast cancer treated with chemotherapy is largely unknown., Methods: Fifty-five patients with advanced breast cancer aged 70 years or older were assessed by Mini Nutritional Assessment (MNA), Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), Groningen Frailty Indicator (GFI) and Mini Mental State Examination (MMSE). Levels of albumin, hemoglobin, creatinine and lactate dehydrogenase were measured. Patients completing at least four cycles of chemotherapy were reassessed by GFI and MMSE and mortality was evaluated using Cox regression analysis., Results: The mean age was 76 year (SD 4.8). Inferior MNA and GFI scores were associated with increased hazard ratios for mortality: 3.05 (95% confidence interval [CI]: 1.44-6.45; p = 0.004) and 3.40 (95% CI: 1.62-7.10; p = 0.001), respectively. Physical aspects of frailty worsened during the course of chemotherapy. Laboratory values were not associated with assessment scores nor were they predictive for mortality., Conclusions: Malnutrition and frailty, rather than cognitive impairment and laboratory values, were associated with an increased mortality risk in these elderly breast cancer patients with advanced breast cancer., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Introduction: In general, geriatric assessment (GA) provides the combined information on comorbidity and functional, nutritional and psychosocial status and may be predictive for mortality outcome of cancer patients. The impact of geriatric assessment on the outcome of older patients with colorectal cancer treated with chemotherapy is largely unknown., Methods: In a prospective study, 143 patients with colorectal cancer who were 70years and older were assessed before chemotherapy by Mini Nutritional Assessment (MNA), Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), Groningen Frailty Indicator (GFI) and Mini Mental State Examination (MMSE)., Results: Fifty-four (38%) patients received adjuvant chemotherapy and 89 (62%) patients received palliative chemotherapy. Malnutrition and frailty were prevalent in 39 (27%, assessed by MNA) and 34 (24%, by GFI) patients, respectively; whereas cognitive impairment was prevalent in 19 (13%, by IQCODE) and 11 (8%, by MMSE) patients, respectively. In patients with palliative chemotherapy, poor MNA scores were associated with receiving less than 4cycles of chemotherapy (p=0.008). Poor MNA and GFI scores were associated with increased hazard ratios (HR) for mortality for patients with palliative chemotherapy: HR=2.76 (95% confidence interval [CI]: 1.60-4.77; p<0.001) and HR=2.72 (95% CI: 1.58-4.69; p<0.001), respectively, after adjustment for several clinical parameters., Conclusions: Malnutrition and frailty were strongly associated with an increased mortality risk in patients who underwent palliative chemotherapy. Furthermore, a poor score on MNA was predictive for less tolerance of chemotherapy. Our findings may help the oncologist in future decision making and advice for elderly patients with colorectal cancer., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: In several European countries, centralization of oesophagogastric cancer surgery has been realized and clinical audits initiated. The present study was designed to evaluate differences in resection rates, outcomes and annual hospital volumes between these countries, and to analyse the relationship between hospital volume and outcomes., Methods: National data were obtained from cancer registries or clinical audits in the Netherlands, Sweden, Denmark and England. Differences in outcomes were analysed between countries and between hospital volume categories, adjusting for available case-mix factors., Results: Between 2004 and 2009, 10 854 oesophagectomies and 9010 gastrectomies were registered. Resection rates in England were 18·2 and 21·6 per cent for oesophageal and gastric cancer respectively, compared with 28·5-29·9 and 41·4-41·9 per cent in the Netherlands and Denmark (P < 0·001). The adjusted 30-day mortality rate after oesophagectomy was lowest in Sweden (1·9 per cent). After gastrectomy, the adjusted 30-day mortality rate was significantly higher in the Netherlands (6·9 per cent) than in Sweden (3·5 per cent; P = 0·017) and Denmark (4·3 per cent; P = 0·029). Increasing hospital volume was associated with a lower 30-day mortality rate after oesophagectomy (odds ratio 0·55 (95 per cent confidence interval 0·42 to 0·72) for at least 41 versus 1-10 procedures per year) and gastrectomy (odds ratio 0·64 (0·41 to 0·99) for at least 21 versus 1-10 procedures per year)., Conclusion: Hospitals performing larger numbers of oesophagogastric cancer resections had a lower 30-day mortality rate. Differences in outcomes between several European countries could not be explained by differences in hospital volumes. To understand these differences in outcomes and resection rates, with reliable case-mix adjustments, a uniform European upper gastrointestinal cancer audit with recording of standardized data is warranted., (Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

Aim: The study included investigation of factors determining suboptimal adjuvant chemotherapy of patients diagnosed with Stage III colon cancer., Method: All 606 patients diagnosed with Stage III colon cancer between 2006 and 2008 in the western part of the Netherlands were included. Patient [gender, age, comorbidity and socio-economic status (SES)], tumour (location, stage and grade) and treatment (emergency surgery, laparoscopic surgery, reoperation, hospital stay and multidisciplinary meeting) factors were examined in logistic regression analyses predicting a complicated postoperative period and omission, delay and discontinuation of adjuvant chemotherapy., Results: Overall, 27% of all patients experienced a complicated postoperative period, which was independently associated with emergency surgery, older age, multiple comorbidity, male gender and poor tumour grade. Of patients who survived this period, 60% received chemotherapy. Chemotherapy was omitted more often in women, the elderly and in patients with Stage IIIB, reoperation, prolonged hospital stay and (borderline) after open surgery. Of patients who received chemotherapy, 86% started within 8 weeks after surgery. Patients with a higher SES, reoperation and prolonged hospital stay had a higher probability of a delayed start. Sixty-seven per cent of patients completed their chemotherapy. For women, elderly patients and patients with prolonged hospital stay a higher probability of discontinuation was noted., Conclusion: Age was the most important predictive factor for receiving adjuvant chemotherapy. However, at all ages, complicated postoperative recovery negatively influenced the administration of chemotherapy to Stage III colon cancer patients, as well as a timely start and completion of chemotherapy., (Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland.)

Aims: Comorbidity affects outcomes after colorectal cancer surgery. However, it's importance in risk adjustment is unclear and different measures are being used. This study aims to assess its impact on post-operative outcomes., Methods: All 2204 patients who were operated on for stage I-III colorectal cancer in the Midwestern region of the Netherlands between January 1, 2006 and December 31, 2008 were analyzed. A multivariate two-step enter-model was used to evaluate the effect of the American Society of Anaesthesiologists Physical Status classification (ASA) score, the sum of diseased organ systems (SDOS), the Charlson Comorbidity Index (CCI) and a combination of specific comorbidities on 30-day mortality, surgical complications and a prolonged length of stay (LOS). For each retrieved model, and for a model without comorbidity, a ROC curve was made., Results: High ASA score, SDOS, CCI, pulmonary disease and previous malignancy were all strongly associated with 30-day mortality and a prolonged LOS. High ASA score and gastro-intestinal comorbidity were risk factors for surgical complications. Predictive values for all comorbidity measures were similar with regard to all adverse post-operative outcomes. Omitting comorbidity only had a marginal effect on the predictive value of the model., Conclusion: Irrespective of the measure used, comorbidity is an independent risk factor for adverse outcome after colorectal surgery. However, the importance of comorbidity in risk-adjustment models is limited. Probably the work and costs of data collection for auditing can be reduced, without compromising risk-adjustment., (Copyright © 2012. Published by Elsevier Ltd.)