This study was designed to examine the outcome of cancer of the lower rectum, particularly the rates of local recurrence and survival for tumors located in this area that have been treated by anterior or abdominoperineal resections. A prospective, observational, national, cohort study which is part of the Norwegian Rectal Cancer Project. The present cohort includes all patients undergoing total mesorectal excision in 47 hospitals during the period November 1993 to December 1999. A total of 2,136 patients with rectal cancer within 12 cm of the anal verge were analyzed; there were 1,315 (62 percent) anterior resections and 821 (38 percent) abdominoperineal resections. The lower edge of the tumor was located 0 to 5 cm from the anal verge in 791 patients, 6 to 8 cm in 558 patients, and 9 to 12 cm in 787 patients. According to the TNM classification, there were 33 percent Stage I, 35 percent Stage II, and 32 percent Stage III. Univariate analyses: The five-year local recurrence rate was 15 percent in the lower level, 13 percent in the intermediate level, and 9 percent in the upper level (P=0.014). It was 10 percent local recurrence after anterior resection and 15 percent after abdominoperineal resection (P=0.008). The five-year survival rate was 59 percent in the lower level, 62 percent in the intermediate level, and 69 percent in the upper level (P<0.001), respectively, and it was 68 percent in the anterior-resection group and 55 percent in the abdominoperineal-resection group (P<0.001). Multivariate analyses: The level of the tumor influenced the risk of local recurrence (hazard ratio, 1.8; 95 percent confidence interval, 1.1-2.3), but the operative procedure, anterior resection vs. abdominoperineal resection, did not (hazard ratio, 1.2; 95 percent confidence interval, 0.7-1.8). On the contrary, operative procedure influenced survival (hazard ratio, 1.3; 95 percent confidence interval, 1-1.6), but tumor level did not (hazard ratio, 1.1; 95 percent confidence interval, 0.9-1.5). In addition to patient and tumor characteristics (T4 tumors), intraoperative bowel perforation and tumor involvement of the circumferential margin were identified as significant prognostic factors, which were more common in the lower rectum, explaining the inferior prognosis for tumors in this region. T4 tumors, R1 resections, and/or intraoperative perforation of the tumor or bowel wall are main features of low rectal cancers, causing inferior oncologic outcomes for tumors in this area. If surgery is optimized, preventing intraoperative perforation and involvement of the circumferential resection margin, the prognosis for cancers of the lower rectum seems not to be inherently different from that for tumors at higher levels. In that case, the level of the tumor or the type of resection will not be indicators for selecting patients for radiotherapy.

Increased attention is being paid to the long-term health and well-being of people living with a history of cancer. Of particular concern is cancer’s effect on productivity and work ability, which in turn is important for persons’ financial situation, life satisfaction, and social relationships. We explored the extent to which Norwegian cancer survivors stay affiliated to working life compared to the cancer-free population, and quantified cancer-associated earning declines. Logistic regression models were estimated to explore the impact of cancer on employment using register data covering the entire Norwegian population in 2001, 567,000 men and 549,300 women 40–59 years old, of whom 34,000 were diagnosed with cancer. These analyses revealed that a cancer diagnosis was strongly associated with not being employed. Log-linear regression models were used to estimate the effect of cancer on labor earnings in 2001 for those employed. Cancer was associated with a 12% decline in earnings overall. Leukemia, lymphomas, lung, brain, bone, colorectal, and head-and-neck cancer resulted in the largest reductions in employment and earnings. Earning declines were strongly associated with educational level. In addition, linear regression models were used to estimate differentials in earnings before and after cancer. These results accorded well with those from cross-sectional models. Cancer survivors are less likely to be employed than the cancer-free population, and undertake modifications in their employment, e.g. reduce work-hours or hold lower-wage jobs, which result in reduced earnings. A social class gradient is present and must be addressed to accommodate appropriate intervention from welfare societies.

Background: Inadvertent perforation of the bowel or tumour is a relatively common complication during resection of rectal cancer. The purpose of this study was to examine intraoperative perforation following the introduction of mesorectal excision as a standard surgical technique in Norway. Methods: This was a prospective national cohort study of 2873 patients undergoing major resection of rectal carcinoma at 54 Norwegian hospitals from November 1993 to December 1999. Results: The overall perforation rate was 8·1 per cent (234 of 2873 patients). In a multivariate analysis, the risk of perforation was significantly greater in patients undergoing abdominoperineal resection (odds ratio (OR) 5·6 (95 per cent confidence interval (c.i.) 3·5 to 8·8)) and in those aged 80 years or more (OR 2·0 (95 per cent c.i. 1·2 to 3·5)). The 5-year local recurrence rate was 28·8 per cent following perforation, compared with 9·9 per cent in patients with no perforation (P < 0·001); survival rates were 41·5 and 67·1 per cent respectively (P < 0·001). Conclusion: The risk of intraoperative perforation was significantly greater in patients with rectal cancer undergoing abdominoperineal resection and in those aged 80 years or more. The high local recurrence rates and reduced survival following perforation call for increased attention to avoid this complication.

Earlier hospital discharge: a challenge for Norwegian municipalities