Sammanfattning på Svenska
Målsättningen med denna avhandling är att undersöka vilken betydelse olika faktorer relaterade till hur sjukvården är organiserad har för hur det går för patienter som behandlas för tjocktarmscancer och ändtarmscancer. Sådana faktorer är t.ex. sjukhusstorlek, hur många liknande operationer varje kirurg gör per år, vilken grad av formell specialisering kirurgen som opererar har och huruvida enskilda patienters behandling diskuteras i dedikerade multidisci-plinära grupper.
Behandlingen av tjocktarmscancer och ändtarmscancer har genomgått stora framsteg sedan början av åttiotalet. Dessa framsteg rör både strålbehandling, cellgiftsbehandling och kirurgisk teknik. Den största förändringen inom ki-rurgisk teknik är att kirurger numera noggrannare följer specifika anatomiska begränsningar som man vet styr hur tumörer sprids. På detta sätt kan man minska risken för återfall och samtidigt minska risken att omgivande strukturer skadas i onödan. Detta gäller framförallt ändtarmscancer där denna teknik kallas total mesorektal excision (TME). Under den senare delen av denna tidsperiod har även multidisciplinära team introducerats i rutincancervård. Resurserna dessa tar i anspråk är stora och nyttan av dem är dåligt utredd. En stor andel av de som opereras för tjocktarmscancer, mer än var femte, opereras akut. För dessa är prognosen fortfarande mycket sämre än för de som operaras planerat. Varför det förhåller sig så vet man inte.
I första arbetet använde vi oss av en databas från Uppsala/Örebroregionen. Från denna tog vi fram data från sex sjukhus för alla patienter som opererats för tjocktarmscancer mellan 1997-2006 och för ändtarmscancer mellan 1995-2006. Vi gick igenom journalerna för alla dessa patienter för att komplettera registren med uppgifter om hur många operationer varje kirurg gjort per år, vilken formell grad av specialisering varje kirurg har samt andra data som sak-nades i registret. Specialisering delades upp i läkare under inlärning, specialist i kirurgi, specialist i kirurgi med inriktning mot tarmkirurgi samt kirurger som genomgått formell ackreditering i tarmkirurgi. Vi kunde i denna studie inte finna att varken antalet operationer per år eller specialiseringen hade någon mätbar betydelse för överlevnaden för dessa patienter.
I det andra arbetet använde vi oss av samma patienter som i första studien men koncentrerade oss på de som opererats för cancer i högra delen av tjocktarmen. Denna operation sker på ett standardiserat sätt. Eftersom man vet att patienter med ett större antal analyserade lokala lymfkörtlar från tarmseglet har bättre överlevnad anses det viktigt att minst tolv lymfkörtlar skall analyseras för varje patient. Antalet kan påverkas av hur noggrann den patolog som undersöker
SAMANFATTNING PÅ SVENSKA
det som opererats bort (preparatet) är när hen söker efter lymfkörtlar. Det kan också bero på hur mycket av tarmseglet (d.v.s. tarmens fäste där lymfkört-larna finns) som opereras bort och därför har många kirurger börjat ta med så mycket som möjligt av detta. Att ta bort en större del kan dock ge ökad risk för komplikationer. I denna studie fann vi att kirurger som genomgått formell ackreditering i tarmkirurgi hade fler lymfkörtlar i sina preparat vilket kan vara ett tecken på att de är mer radikala i sina operationer.
I det tredje arbetet använde vi oss av det register som finns för alla patienter som opereras för tjocktarms- och ändtarmscancer i Sverige (SCRCR). Enligt de riklinjer som finns i Sverige skall alla som behandlas för ändtarmscancer diskuteras av ett MDT (Multi Disciplinärt Team) innan behandling. Bland alla patienter som opererades för ändtarmscancer 2007–2010 diskuterades endast 78% vid MDT konferens. Vi fann att de sjuhus som hade få operationer för ändtarmscancer hade en betydligt lägre andel av patienterna som diskuterades av ett MDT innan behandling. Vi undersökte vidare två grupper av patienter som utifrån de tumörkaraktäristika som fanns i den bortopererade tumören (preparatet) enligt nationella vårdprogrammet borde ha fått strålbehandling innan operationen. Vi fann att de som diskuterats av ett MDT innan behandling i mycket högre andel fått sådan behandling.
I det fjärde arbetet undersökte vi olika faktorers betydelse för risken för can-ceråterfall i operationsområdet hos patienter som opererats akut för tjock-tarmscancer. För de som opererats akut finns specifika riskfaktorer som kan påverkas av sjukvårdsorganisationen, exempelvis om operationen sker på dagen eller natten eller hur lång tid det tar från inläggning till operation. Bland de riskfaktorer som analyserades var det dock bara cancer-stadium och orsaken till att operationen skedde akut som innebär någon påvisbar riskökning. De som opererades akut för att tarmen hade spruckit hade en högre risk för can-ceråterfall i operationsområdet än övriga.
Sammanfattningsvis tycks varken antalet operationer per år eller graden av specialisering ha någon mätbar betydelse för överlevnaden hos dessa patienter trots att det fanns tecken på att de kirurger som genomgått formell ackredite-ring i tarmkirurgi var mer radikala i sina operationer. Detta kan innebära att det finns andra organisationsrelaterade faktorer som har större betydelse och MDT skulle kunna vara en sådan. Ingen av de organisationsrelaterade faktorer vi undersökte tycks ha någon betydelse för risken att få canceråterfall i opera-tionsområdet för de som opereras akut för tjocktarmscancer.
ACKNOWLEDGEMENT
Acknowledgements
A Ph.D. thesis cannot be written without the help of others. I would therefore like to take the opportunity to thank those who have helped me along the way. First I would like to thank my supervisor Ulf Gunnarsson for including me in his excellent research group. I am grateful for his patience and trust he has shown by letting me wander with my thoughts and ideas, yet still managing to steer me in the right direction, helping me choose the ideas that actually formed the basis for this thesis. I am thankful for his leadership that creates a friendly and creative atmosphere that is a joy to work in, and for being a true friend. I am also grateful to my co-supervisors Pia Jestin and Peter Matthiessen for the support and help they have given over all these years. I would like to thank everyone in the research group especially Ursula Dahlstrand and Ambatchew Gurmu with whom I have worked closely both in research and clinically. Mar-gareta Michanek, Eva Köhn and Linda Olsson have been most helpful in solving both possible and impossible administrative problems in an effective manner. I am grateful to the organisers and participants of the Gastrointestinal Oncology Course 2010. In particular I would like to thank Malin Mörner, Jon
Bjerre-gaard, Anders Winbladh, Mef Nilbert, Arthur Revhaugand Gunnar Wagenius
for working with me in Study 3 in this thesis, and for introducing me to many new perspectives in science and research.
I would also like to thank the managers of the Swedish ColoRectal Cancer Register and the registers at Uppsala/Örebro and Stockholm for granting me access to data, and Peter Cox for excellent proof reading.
I also take this opportunity to thank my wonderful surgical colleagues, nurses and all other personnel at Hudiksvall Hospital for giving me a firm basis in the field of surgery without which this thesis would not have been possible – my time there was indeed an enjoyable one. Thanks also to my previous co-workers at Karolinska Hospital in Stockholm and my current co-workers at Norrlands Universitetssjukhus in Umeå, for making it fun to go to work every day, espe-cially Karin Strigård who is always a reliable source of sound clinical advice. I want to thank my parents Anna-Lena and Anders for their unwavering support in good times and bad throughout my life. Also great thanks to my brother Erik, Frida, Viktor and Klara for always being there for me. To Kristina, Åsa, Moa, Per and Doris for making my life so much richer. To Christopher, Soheil, Per, David, Tobias, Micael and all other friends who have been with me for a such a
ACKNOWLEDGEMENT
long time, and to my cousins, aunts and uncles who I really should have listed since they all remain a great part of my life. But most of all I would like to thank Karin, Viola and Solveig who are the joy and meaning of my life.
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