7164 784 9

Quality and Efficiency in Swedish Cancer Care

Regional Comparisons

2011

Quality and E

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Regional Comparisons 2011

Swedish Association of Local Authorities and Regions Swedish National Board of Health and Welfare

1 000 copies

Production: Ordförrådet AB

Printing: Åtta.45, Solna


Order or download from

Swedish National Board of Health and Welfare Beställningsservice, SE-120 88 Stockholm

E-mail: [email protected] Fax: +46 8 779 96 67www.socialstyrelsen.se/publicationsArt. no: 2012-3-15

or

Swedish Association of Local Authorities and Regions SE-118 82 Stockholm

www.skl.se/publikationerPhone: +46 20 31 32 30, fax: +46 20 31 32 40E-mail: [email protected] 978-91-7164-784-9

Foreword

Each year the Swedish National Board of Health and Welfare (NBHW) and the Swedish Association of Local Authorities and Regions (SALAR) publish a joint re-port entitled Quality and Efficiency in Swedish Health Care – Regional Comparisons. The Government has now mandated the NBHW to collaborate with SALAR on a special edition for cancer care.

The joint organisation created by the NBHW and SALAR to develop and promote open comparisons of the healthcare system has assumed responsibility for compil-ing the report.

The dual purpose of the report is to provide supporting data for decision makers at various levels who are attempting to improve cancer care while offering the general public insight into what publicly financed cancer care is accomplishing.

The project coordinator at the NBHW has been Mona Heurgren. The project manag-ers have been Göran Zetterström (NBHW) and Katarina Wiberg Hedman (SALAR).

The project has been accompanied by a dialogue with contacts at each of the 21 county councils.

Many of the indicators proceed from external databases and other sources, prima-rily national quality registers for cancer care. Our special gratitude goes to repre-sentatives of the registers, the regional cancer centres, and others who contributed to the report.

Lars Erik Holm Håkan Sörman

Director-General Executive Director

Swedish National Board Swedish Association of of Health and Welfare Local Authorities and Regions

Summary

This is the first time that open comparisons have been presented that reflect care quality for ten common forms of cancer in Sweden. The report compares the vari-ous counties in terms of medical outcomes, patient experience and waiting times.

Survival rates among cancer patients are increasingThe percentage of cancer deaths has declined over the past 40 years, while survival rates have risen. The relative five-year survival rate among men increased from just over 50 per cent in 1990–1994 to almost 70 per cent in 2005–2009. For women, the survival rate increased from 60 to 68 per cent.

Patients with breast cancer and malignant melanoma had the highest survival rates. The relative five-year survival rate among breast cancer patients was 87 per cent in 2005–2009. The survival rate for malignant melanoma was 93 per cent among women and 86 per cent among men during the period.

Lung cancer claims more Swedish lives each year than any other form of the disease. Relative survival rates are low but have increased, particularly the one-year rate, since the early 1990s. The relative five-year survival rate is approximately 15 per cent among women and 12 per cent among men.

No county consistently stands out in terms of survival rates for multiple types of cancer as well as for both sexes. However, lung cancer and bladder cancer show ma-jor variations between counties.

The frequency of multidisciplinary team meetings variesMultidisciplinary team meetings are often important for assessing a patient’s medi-cal needs and setting up an individual treatment plan. The report demonstrates that the number of new patients who receive such an assessment varies from 4 to 100 per cent between the different counties, as well as between the different forms of cancer. Multidisciplinary team meetings are not indicated or expedient prior to emergency surgery for colon cancer and in certain other situations.

Waiting times vary significantlyThe report shows that waiting times vary significantly among counties and forms of cancer. For instance, the median waiting time from receipt of a referral until the initial appointment with a specialist ranged from 17 to 43 days.

A concerted effort has been made in recent years to shorten healthcare waiting times. The waiting times presented in this report cover a period when this effort was beginning but had not been fully implemented. The data can now be used for future comparisons.

Diagnostic methods are more effective in some areasAssessment and diagnosis of cancer has improved in some areas. Here are a few examples:

• The number of patients who underwent bone scintigraphy for low-risk localised prostate cancer decreased from 38 to 4.5 per cent in 2000–2009 (few such pa-tients actually need the examination)

• A total of 83 per cent of all kidney cancer patients had CT scans, which is very close to the clinical practice guidelines target

• Almost all counties met the lung cancer guidelines that biopsies be performed for 99 per cent of patients

Some cancer care outcomesMost indicators in the report reflect medical quality, such as the use of various treat-ment options, as well as postoperative outcomes and complications. Following are some examples:

• The number of patients with medium to high-risk prostate cancer who received curative treatment increased from 48 per cent in 2000 to 68 per cent in 2009

• Use of the sentinel node technique to identify breast cancer cases in which com-plete removal of lymph nodes from the armpit area is indicated rose to 80 per cent in 2009

• A total of 1.5 per cent of breast cancer cases were reoperated in 2009 due to bleeding, infection or other complications; the percentage has remained essen-tially unchanged in recent years

• A total of 8.7 per cent of colon cancer cases and 10.8 per cent of rectal cancer cases were reoperated in 2007–2009

Open comparisons offer a snapshotThis report is descriptive in nature and strives to present a snapshot of current cancer care.

The dual purpose of the report is to provide supporting data for decision makers at various levels who are attempting to improve cancer care while offering the general public some insight into what publicly financed cancer care is accomplishing.

County outcomes for each of the indicators are shown in ranked diagrams, but no weighted ranking of the counties based on overall quality and efficiency is pre-

sented. The choice is intentional, given that no nationally confirmed method of weighting indicators has yet been devised. The outcomes should be interpreted in light of data quality and the other considerations discussed in connection with each indicator.

The report omits certain areas, including rehabilitation, nursing and psychosocial care, as well as patient experience of health and disease after treatment (patient-reported outcome measures). Registers, other data sources and indicators need to be developed for these areas before they can be included in future comparisons.

Contents

Introduction 10

GeneralIndicators 151 Cancersurvivalrates................................................................................................. 16

PalliaTivE CanCER CaRE

2 PercentageofpatientsforwhomVAS/NRSwasusedtoassesspainseverityduringthelastweekoflife.......................................... 17

3 On-demandprescriptionsforpainattheendoflife.................................................. 18

PaTiEnT ExPERiEnCE

Indicatorsspecifictoparticularformsofcancer 22

BREaST CanCER

9 Breastcancer–relativesurvivalrates....................................................................... 2310 Multidisciplinaryteammeetingspriortotratment..................................................... 2411 Multidisciplinaryteammeetingsaftersurgery........................................................... 2412 Waitingtimefrominitialappointmentwithaspecialistuntilsurgery......................... 2513 Waitingtimefromsurgerytotestresults.................................................................. 2514 Definitivepreoperativediagnosis............................................................................... 2715 Sentinelnodesurgery................................................................................................ 2816 ReoperationafterPAD............................................................................................... 2917 Reoperationwithinfourweeksduetocomplications................................................ 30

OvaRian CanCER

18 Survivalrateforovariancancer................................................................................. 3219 Waitingtimefromdiagnosisuntildecisiontotreat.................................................... 3320 Waitingtimefromdecisiontotreatuntilcommencementofchemotherapy............. 3321 Percentageofbiopsiesassessedbyasubspecialisedpathologist......................... 34

KiDnEy CanCER

22 Kidneycancer–survivalrates................................................................................... 3623 Waitingtimefromreferraltotheinitialappointmentwithaspecialist....................... 3724 Waitingtimefromdecisiontotreatuntilsurgery...................................................... 3825 PrimaryassessmentbasedonpreoperativethoracicCTscan................................. 39

BlaDDER CanCER

26 Bladdercancer–survivalrates.................................................................................. 4127 Waitingtimefromreceiptofthereferral

totheinitialappointmentwithaurologist.................................................................. 4228 Waitingtimefrominitialappointmentwitha

urologistuntiltransurethralresection........................................................................ 4329 IntravesicaltherapyforT1tumoursofthebladder.................................................... 4430 CurativetreatmentofT2–T4tumours....................................................................... 45

PROSTaTE CanCER

31 Waitingtimefortheinitialappointmentwithaurologist............................................ 4632 Bonescintigraphyforlow-riskprostatecancer........................................................ 4833 Activesurveillanceoflow-riskprostatecancer........................................................ 4934 Curativetreatmentformediumandhigh-riskprostatecancer................................. 5035 Treatmentoflocallyadvancedprostatecancer........................................................ 51

COlOn CanCER

36 Coloncancer–relativefive-yearsurvivalrates......................................................... 5337 Multidisciplinaryteammeetingspriortotreatment................................................... 5538 Multidisciplinaryteammeetingsaftersurgery........................................................... 5539 Atleasttwelvelymphnodesexaminedinthetumoursample.................................. 5840 Perforationofthecolonduringsurgery..................................................................... 6041 Morethan15daysofhospitalisationaftersurgery................................................... 6242 Reoperationduetocomplicationswithin30daysofprimarysurgery...................... 6543 Deathswithin30and90daysofsurgery.................................................................. 66

RECTal CanCER

44 Rectalcancer–relativefive-yearsurvivalrates......................................................... 6945 Multidisciplinaryteammeetingspriortotreatment................................................... 7146 Multidisciplinaryteammeetingsaftersurgery........................................................... 7147 Atleasttwelvelymphnodesexaminedinthetumoursample.................................. 7448 Preoperativeradiotherapy........................................................................................ 7849 Perforationoftherectumduringsurgery................................................................... 8050 Anastomosisinsufficiencyaftersurgery.................................................................... 8351 Morethan21daysofhospitalisationaftersurgery................................................... 8552 Reoperationduetocomplicationswithin30daysofprimarysurgery...................... 8753 Newcancerofthepelviswithinfiveyearsofsurgery................................................ 9154 Deathswithin30and90daysofsurgery.................................................................. 93

lung CanCER

55 Lungcancer–relativeone-year,two-yearandfive-yearsurvivalrates..................... 9856 Multidisciplinaryteammeetingpriortotreatment..................................................... 9957 Waitingtimefromreceiptofareferral

bythespecialistclinicuntildecisiontotreat........................................................... 10058 Lungcancerconfirmedbyabiopsy........................................................................ 10159 CombinedPET/CTscanpriortocurativetreatment.............................................. 10260 CurativesurgeryforstageIandIInon-small-celllungcancer................................ 10361 PalliativeradiotherapyforstageIIIBandIVlungcancer......................................... 10562 Palliativechemotherapyforincurablelungcancer.................................................. 107

HEaD anD nECK CanCER

63 Headandneckcancer–five-yearsurvivalrates..................................................... 10964 Multidisciplinaryteammeetingpriortotreatment.................................................. 11065 Waitingtimefromreceiptofareferraluntildecisiontotreat................................... 11166 Waitingtimefromreceiptofareferraluntilcommencementoftreatment.............. 112

MalignanT MElanOMa

67 Malignantmelanoma–relativefive-yearsurvivalrates........................................... 11468 Waitingtimefrominitialdoctor’sappointmentuntilprimarysurgery..................... 11669 Waitingtimefromsampletakinguntilnotificationofthediagnosis........................ 11770 Malignantmelanoma1.0millimetreorthinner......................................................... 118

Projectorganisation 121

10 QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011

Introduction

Open comparisons of cancer careEach year the Swedish National Board of Health and Welfare (NBHW) and the Swedish Association of Local Authorities and Regions (SALAR) publish a joint report entitled Quality and Efficiency in Swedish Health Care – Regional Compari-sons based on a series of indicators. The report compares counties with respect to medical outcomes, patient experience, waiting times and costs. Available national healthcare statistics provide the basic data for the report.

In 2010, the Government mandated the NBHW to collaborate with SALAR on a special edition for cancer care.

The overall purpose of the report is to promote local, regional and national im-provement efforts by comparing the quality of cancer care throughout the country. The comparisons should encourage the counties to perform in-depth analyses of their outcomes in order to further improve the quality and efficiency of the cancer care they provide. The report offers healthcare decision makers and administrators data and knowledge support for managing and monitoring the activities of their or-ganisations. It is also intended to provide the general public with insight into what publicly financed cancer care is accomplishing.

The Government’s national cancer strategy has taken the initiative for the imple-mentation of several new measures, including an emphasis on knowledge support and monitoring of cancer care outcomes. Open comparisons represent one approach to collecting and presenting data that can be used for follow-up and improvement purposes.

Knowledge support includes national guidelines to promote the adoption of evi-dence-based methods by the healthcare system. Sweden has national guidelines for breast, colon, rectal, prostate and lung cancer.

The report covers the following ten forms of cancer:

• breast • colon

• ovarian • rectal

• kidney • lung

• bladder • head and neck

• prostate • malignant melanoma

A total of 70 indicators are presented, 4–10 for each form of cancer.

QuALIty ANd EFFICIENCy IN SWEdISH CANCER CARE 2011 11

All ten forms are very uncommon in children and adolescents. Thus, the report does not cover this population.

Open comparisons should include the entire care chain in order to ensure an over-all perspective. However, this report does not examine nursing, rehabilitation and certain other methods for treatment and care of cancer patients. Nor do any of the indicators reflect patient-reported outcome measures (PROMs).

Data sources The conditions for register-based performance measurement are unique in Sweden. Thanks to the identity number assigned to each Swedish resident, various national healthcare databases can be linked to each other and provide access to comparative outcome data.

The data sources used in the report are presented along with the description of out-comes. Further on in this chapter is a separate chart of the data sources that have been used.

The medical quality indicators are based primarily on data from the Swedish cancer register – which started in 1958 – as well as national quality registers. Information about these sources is available at www.socialstyrelsen.se and www.kvalitetsregister.se/cancer All data about patient experience are taken from the National Patient Survey (www.skl.se/nationellpatientenkat). The health data registers (Swedish Cancer Register, National Patient Register, etc.) and national quality registers con-tain data about individuals and unique care events. Reporting is mandatory to the health data registries and optional to the quality registers.

SWEDENHASADECENTRALISEDHEALTHCARESYSTEMTwentycountiesandregions,aswellasonemunicipality,areresponsibleforprovidingtheircitizenswithhospital,primary,psychiatricandotherhealthcareservices.Acountycounciltaxsupplementedbyagovernmentgrantisthemainmeansoffinancingthehealthcaresystem.Inaddition,smalluserfeesarepaidatthepointofuse.Long-termcarefortheelderlyisfinancedandorganizedbythemunicipalities.Eachcountyandregionisgovernedbyapoliticalassembly,whoserepresentativesareelectedforfouryearsingeneralelections.

Thecountiesandregionsareofdifferentsize.Withpopulationsbetweenoneandtwomillioneach,Stockholm,VästraGötalandandSkåneareconsiderablylargerthantherest.Gotlandissmallest,withabout60000inhabitants.Mostoftheothercountieshavepopulationsbetween200000and300000.

Withintheframeworkofnationallegislationandvaryinghealthcarepolicyinitiativesbythenationalgovernment,thecountiesandregionshavesubstantialdecisionmakingpowersandobligationstotheircitizens.TheSwedishhealthcaresystemisdecentral-ised.Thus,focusingontheperformanceoftheindividualcountiesandregionsisalogicalapproach.


Remarks on regional comparisons Every indicator is accompanied by a diagram and brief description. The diagrams are generally horizontal bar charts on which the counties appear in descending or-der. The national average is also presented in a separate colour. The counties at the top of the diagram have usually shown the best outcomes. Outcomes and therefore rankings can be affected by poor data quality and small differences between coun-ties whose data lack statistical significance.

Ranking is easy to justify when it comes to mortality, complications and certain other indicators, but additional factors – such as the health of the general popula-tion and case mix at the hospitals – must always be taken into consideration. Coun-ty populations were age standardised for some indicators to ensure more compara-ble outcomes. Such standardisation corrects for regional variations in age structure. However, no corrections were made for differences in health status or morbidity that do not correlate with age.

The report identifies regional variations in outcomes as measured by a series of quality indicators. The variations may be due to superior organisation and admin-istration of health care by certain counties; such observations can be used as a basis

DATASouRCES

Swedish national Board of Health and Welfare SwedishCancerRegisterNationalPatientRegisterSwedishPrescribedDrugRegisterCauseofDeathRegister

Swedish association of local authorities and RegionsNationalCaseCostingDatabaseNationalPatientSurvey

national Quality RegistersSwedishRegisterofPalliativeCareNationalBreastCancerRegisterNationalQualityRegisterforGynecologicalOnkologyNationalSwedishKidneyCancerRegisterSwedishBladderCancerRegisterNationalProstateCancerRegisterNationalColonCancerRegisterNationalRectalCancerRegisterNationalLungCancerRegisterSwedishHeadandNeckCancerRegisterSwedishMelanomaRegister


for improvement efforts. Variations may also stem from differences in terms of population health status or case mix, not to mention random fluctuations. Most of the diagrams show a 95 per cent confidence interval with a black line by the bar of each region. The lines represent the statistical uncertainty associated with the region’s actual performance.

Thus, ranking the counties in the diagrams consistently presents certain difficul-ties. If unreliable data quality or other interpretation problems call the ranking into question, the description of the indicator mentions or discusses it.

Some indicators have access to national guidelines or other material for evaluating outcomes. The discussion of such indicators contains an assessment of whether the outcomes as a whole meet the recommendations of the guidelines or their equiva-lent. With the exception of lung cancer, the national guidelines do not include for-mal targets. Any targets set by a medical speciality association or the like are speci-fied for the indicator in question.

The national average is not a yardstickThe diagrams usually rank the counties without explicit targets but highlight the national average. Viewing the average as a standard for an acceptable or passable outcome would be a misconception.

The national average is not a yardstick for evaluating regional outcomes. A region may have performed very well even though its outcome was far below average. The most important conclusion in such cases is that the outcomes for all counties are favourable. The converse is true as well. If the national average is low relative to individual Swedish hospitals, other countries or potential outcomes, a county may perform poorly and still end up at the top of the diagram.

If one or more large counties perform poorly, the national average may be far below the median. It may be better under such circumstances to base comparisons on the median county; outcomes must nevertheless be compared from a broader point of view than the national average or the median.

In other words, readers should not assume that the national average or the median represent a good or optimum outcome. Regardless of rank, outcomes should be ana-lysed in relation to performance over time or in comparison with other counties as a means of identifying potential for improvement.


ADDITIoNALMATERIALANDCoNTACTSThisreportmaybedownloadedinPDFformatfromwww.skl.se/compareorwww.socialstyrelsen.se/publications

ForinformationaboutthereportandtheongoingworkofthejointprojectQuality and Efficiency in Swedish Health Care – Regional Comparisons,writeto

BodilKlintberg,SwedishAssociationofLocalAuthoritiesandRegions([email protected])

MonaHeurgren,SwedishNationalBoardofHealthandWelfare([email protected]).


GeneralIndicators

One out of every three Swedes has cancer at some point in their life. The disease occurs with approximately equal frequency in both sexes, but women and men de-velop different forms. Prostate cancer is most common in men and breast cancer in women. Prostate, breast, lung, colon and rectal cancer account for half of all new cases in the adult population.

Statistics for 2009 Women Men

Numberofdiagnoses 25721 28890

Prevalence,total 228665 183294

Relativefive-yearsurvivalrates 67.6% 69.2%

Numberofdeaths 10769 11686


Figure 1Sweden

Cancer, relative five-year survival rates. Trend, 1990–2009. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare

Percent

0

20

40

60

80

100

2005-20092000-20041995-19991990-1994

Women

Total

Men

Figure 1Total

Cancer, relative five-year survival rates. Patients diagnosed in 2000–2004. Patients age 30–89 at the time of diagnosis. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare

Confidence interval calculated using Taylor series Percent

72.672.070.970.369.669.568.968.868.467.867.567.567.567.367.366.866.766.265.965.465.363.4

0 20 40 60 80 100

GävleborgVästernorrland

BlekingeÖstergötland

NorrbottenJämtlandSörmland

DalarnaÖrebro

VästerbottenUppsala

VärmlandVästmanland

GotlandSWEDEN

SkåneKronoberg

Västra GötalandKalmar

StockholmJönköping

Halland

1 Cancer survival ratesThe percentage of cancer deaths has declined over the past 40 years, while survival rates have risen. One reason for the improvement is that the healthcare system is better able to make early diagnoses and offer effective treatment.


PALLIATIvECANCERCAREThe NBHW national guidelines for breast, colorectal and prostate cancer care in-clude palliative care. The guidelines assign top priority to estimating and assessing pain severity, prescribing opioids on demand at the end of life and certain other measures. They also contain indicators for those two particular measures. Data have been taken from the Swedish Register of Palliative Care , which started in 2005 and covered 42 per cent of all deaths after the first quarter of 2011. The participation rate was higher (over 57 per cent) for expected cancer deaths.

2 Percentage of patients for whom vaS/nRS was used to assess pain severity during the last week of life

Proper alleviation of pain requires structured treatment, including uniform assess-ment methods. Routine, structured assessments enable effective treatment. The Visual Analogue Scale (VAS) and Numeric Rating Scale (NRS) are recommended instruments for assessing pain.

The results should be interpreted with caution given that the register generally had a limited participation rate in 2010, while some counties had a low participation rate and few reported cases.

Figure 2Total

Percentage of cancer patients at the end of life who assessed pain intensity on the VAS/NRS scale, 2010. Source: Swedish Register of Palliative Care

2009 Percent

Participation rate 2010

41.438.927.023.520.519.918.817.215.213.913.513.011.4

9.58.58.48.17.36.75.85.43.9

76626951443857468769727451546061448256515850

0 10 20 30 40 50

VästmanlandVärmland

Västra GötalandÖrebro

DalarnaBlekingeUppsala

KronobergVästerbotten

NorrbottenSörmland

GävleborgGotlandKalmar

SkåneSWEDEN

VästernorrlandHalland

JönköpingJämtland

StockholmÖstergötland


3 On-demand prescriptions for pain at the end of lifeMost patients who die of cancer experience pain during the last week of life. Much of the pain can be alleviated by means of opioid treatment as soon as it develops. The national guidelines specify that options for administering drugs be prescribed in advance. The Swedish Register of Palliative Care contains the number of patients who received an on-demand prescription up to 24 hours before death.

Figure 3Total

Percentage of cancer patients who were prescribed opioids on an on-demand basis at the end of life, 2010. Source: Swedish Register of Palliative Care

2009 Percent


97.597.397.096.996.596.496.196.096.095.995.895.795.495.494.994.593.593.292.992.091.591.2

56444669625451385061517660578269445172745887

0 20 40 60 80 100

KalmarVärmlandSörmland

GävleborgNorrbotten

BlekingeJämtlandDalarna

SWEDENKronoberg

ÖstergötlandVästra Götaland

UppsalaVästmanland

VästernorrlandJönköping

VästerbottenStockholm

GotlandSkåne

HallandÖrebro


PATIENTExPERIENCESALAR conducts the National Patient Survey on behalf of Sweden’s county coun-cils and regions. This report presents the results of the survey with respect to spe-cialised medical care during appointments at oncology clinics or stays at oncology departments in 2010. The survey contains questions about the information patients received, the caregiver attitudes they encountered and their degree of participation in the care process. Patients were given the opportunity to describe their appoint-ment or stay and to grade their experience.

Approximately 200 000 questionnaires were sent to a random sample of people who had received outpatient or inpatient medical care during specific weeks in spring 2010. Approximately 88 000 outpatients and 34 000 inpatients responded. The na-tional response rate was 61 per cent among outpatients and 67 per cent among in-patients.

Neither the Stockholm nor Norrbotten County Council were included but are par-ticipating in the 2011 survey.

The data for this report have been taken from the National Patient Survey, but only a few hospitals are able to provide outcomes for their oncology clinics or depart-ments. The response rate was 75 per cent for both clinics and departments. This report does not cover cancer patients who had an appointment with a non-onco-logical outpatient clinic or were admitted to a non-oncological department during the period. However, those who had not been diagnosed with cancer but went to an oncology clinic or department were included.

The indicators in this report that are based on the National Patient Survey reflect caregiver attitudes, patient participation and information received in both outpa-tient (clinic) and inpatient (department) care. Outcomes are also presented with re-spect to the physician in charge of inpatient care, as well as planning for continued outpatient care. The outcomes are shown at the hospital level for those that report an oncology clinic or department separately.

Outcomes that are based on the National Patient Survey are presented as weighted patient-reported quality. An ascending scale of 1 to 100 has been used.

Figure 4AHospital,clinic

"Did you feel that you were treated respectfully and considerately?" Patient-reported quality at an oncology clinic or department, spring 2010.Source: National Patient Survey, Swedish Association of Local Authorities and Regions

97.597.095.694.696.699.296.196.596.895.094.896.997.4

RegionUppsala

SörmlandÖstergötland

JönköpingKalmar

GotlandSkåne

VärmlandÖrebro

VästmanlandGävleborg

VästernorrlandVästerbotten

PUK

0 20 40 60 80 100

Norrlands Universitetssjukhus, UmeåLänssjukhuset Sundsvall-Härnösand

Gävle sjukhusVästerås lasarett

Universitetssjukhuset ÖrebroCentralsjukhuset i KarlstadSkånes universitetssjukhus

Visby lasarettLänssjukhuset i Kalmar

Länssjukhuset Ryhov, JönköpingUniversitetssjukhuset, Linköping

Mälarsjukhuset, Eskilstuna/Nyköpings sjukhusAkademiska sjukhuset, Uppsala

Figure 4BHospital,department

"Did you feel that you were treated respectfully and considerately?" Patient-reported quality at an oncology clinic or department, spring 2010.Source: National Patient Survey, Swedish Association of Local Authorities and Regions

92.493.992.395.696.596.3

RegionUppsala

JönköpingSkåne


Västerbotten

PUK

0 20 40 60 80 100

Norrlands Universitetssjukhus, UmeåUniversitetssjukhuset Örebro

Sahlgrenska universitetssjukhusetSkånes universitetssjukhus

Länssjukhuset Ryhov, JönköpingAkademiska sjukhuset, Uppsala


"Did you feel as though you participated in your care and treatment as much as you wanted?" Patient-reported quality at an oncology clinic or department, spring 2010. Source: National Patient Survey, Swedish Association of Local Authorities and Regions

84.677.383.084.987.587.183.881.686.482.982.787.187.5

RegionUppsala


JönköpingKalmar

GotlandSkåne

VärmlandÖrebro



PUK

0 20 40 60 80 100








"Did you feel as though you participated in your care and treatment as much as you wanted?" Patient-reported quality at an oncology clinic or department, spring 2010. Source: National Patient Survey, Swedish Association of Local Authorities and Regions

77.182.183.581.186.683.9

RegionUppsala

JönköpingSkåne


Västerbotten

PUK

0 20 40 60 80 100





"Did you receive enough information about your condition?" Patient-reported quality at an oncology clinic or department, spring 2010.Source: National Patient Survey, Swedish Association of Local Authorities and Regions

1 Fewer than 30 cases

87.084.583.084.187.587.586.185.587.785.286.0

89.6

RegionUppsala


JönköpingKalmar

GotlandSkåne

VärmlandÖrebro



PUK

0 20 40 60 80 100

Norrlands Universitetssjukhus, UmeåLänssjukhuset Sundsvall-Härnösand 1







"Did you receive enough information about your condition?" Patient-reported quality at an oncology clinic or department, spring 2010.Source: National Patient Survey, Swedish Association of Local Authorities and Regions

83.081.886.682.686.084.8

RegionUppsala

JönköpingSkåne


Västerbotten

PUK

0 20 40 60 80 100




Figure 7Hospital,clinic

“Were any plans made for your ongoing care during the appointment?” Patient-reported quality at an oncology clinic or department, spring 2010.Source: National Patient Survey, Swedish Association of Local Authorities and Regions

82.190.183.984.492.593.688.185.786.881.291.793.890.8

RegionUppsala


JönköpingKalmar

GotlandSkåne

VärmlandÖrebro



PUK

0 20 40 60 80 100







Figure 8Hospital,department

“Do you know which doctor was responsible for your care?” Patient-reported quality at an oncology clinic or department, spring 2010. Source: National Patient Survey, Swedish Association of Local Authorities and Regions

65.480.478.988.469.982.8

RegionUppsala

JönköpingSkåne


Västerbotten

PUK

0 20 40 60 80 100





Indicatorsspecifictoparticularformsofcancer

This chapter presents the indicators for the ten forms of cancer covered by the re-port. The comparisons include both general indicators – cancer survival rates, wait-ing times, frequency of multidisciplinary team meetings, etc. – and those that are specific to particular forms of cancer.

The section on each form of cancer starts off with a brief overview of its frequency in 2009, the last year for which data are available from the cancer register and cause of death register. The next segment presents the outcomes for the various indicators.

BREASTCANCER

Statistics for 2009 Women

Numberofdiagnoses 7380

Percentageofallcancercases 29%

Prevalence,total 88825

Relativefive-yearsurvivalrate 87%

Numberofdeaths 1378

Breast cancer is the most common form of the disease in middle-aged women. A total of 7 380 women were diagnosed with breast cancer in 2009, and Sweden cur-rently has approximately 88 800 survivors. The average age at the time of diagnosis was 60. A total of 1 378 women died of breast cancer in 2009.

In very rare cases (30 in 2009), men develop breast cancer as well. This report covers women only.

Almost all breast cancer in Sweden is operable. The breast cancer register’s follow-up for 2008 showed that 93 per cent, a figure that varied by only 1–2 per cent among the different counties, of patients had undergone surgery.

This report presents nine breast cancer indicators, four of which concern the qual-ity of surgery. One indicator reflects survival, two reflect the frequency of multidis-ciplinary team meetings and two reflect waiting times. With the exception of the survival rate indicator, which used the Swedish Cancer Register , data were taken from the National Breast Cancer Register.


The Swedish Association for Breast Cancer Surgery (SFBK) has put together guide-lines that contain both process and outcome measures. The SFBK proposes specific targets for indicators for which ranges have been set up.

9 Breast cancer – relative survival ratesRelative survival rates for breast cancer patients have been high since the early 1990s. Figure 9 shows that the relative five-year survival rate rose from approxi-

Figure 9 Sweden

Breast cancer – relative five-year survival rates. Trend, 1990–2009. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare

Percent

0

20

40

60

80

100

2005-20092000-20041995-19991990-1994

Figure 9Women

Breast cancer – relative five-year survival rates. Patients diagnosed in 2000– 2004. Patients age 30–89 at the time of diagnosis. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare


90.389.589.088.588.487.787.687.187.187.086.586.386.186.085.785.785.385.384.884.484.082.3

0 20 40 60 80 100

GotlandGävleborg

VästerbottenVärmland

ÖrebroVästernorrland

VästmanlandBlekinge

SkåneSörmland

DalarnaKalmar

SWEDENVästra Götaland

HallandJämtland

ÖstergötlandStockholmJönköping

UppsalaNorrbottenKronoberg


mately 80 per cent in 1990–1994 to 87 per cent in 2005–2009. The regional differ-ences were negligible – 97.0–97.7 per cent for one-year survival and 85.9–88.3 per cent for five-year survival. As indicated by Figure 9, the gap between counties was somewhat wider.

The relative five-year survival rate was 65 per cent in the mid-1960s. The number rose to 84 per cent for patients diagnosed in the 1990s and to 87 per cent in 2005–2009.

The most interesting observation about this indicator is that outcomes have been both uniform and impressive throughout the country.

10–11 Multidisciplinary team meetingsPrimary breast cancer treatment may be preceded by a multidisciplinary team meeting, a comprehensive assessment for the purpose of optimising the interven-tion. Surgery, oncology, radiology and pathology specialists, as well as nurses, may participate. The NBHW national guidelines for breast cancer care recommend a multidisciplinary team meeting both before commencement of treatment and postoperatively.

Figure 10Women

Percentage of patients who had a multidisciplinary team meeting prior to decision to treat breast cancer, 2009. Source: National Breast Cancer Register

1 No data available 2008 Percent

100.099.398.798.698.397.597.196.896.496.296.095.594.692.091.591.189.886.980.951.442.1

0 20 40 60 80 100

Örebro 1

ÖstergötlandJönköping

KalmarVästernorrland

BlekingeVästerbotten

GävleborgSWEDEN

NorrbottenVästra Götaland

GotlandJämtlandUppsalaHalland

StockholmSkåne

SörmlandDalarna

KronobergVärmland

Västmanland


The comparison finds excellent outcomes for the great majority of counties. Both pre- and postoperative multidisciplinary team meetings are much more frequent for breast cancer than for most other forms of the disease.

12 Waiting time from initial appointment with a specialist until surgeryThe SFBK, which advocates for a rapid care process, argues that more than 90 per cent of all patients with verified breast cancer should be offered surgery within three weeks and 100 per cent within four weeks. The indicator reflects the waiting time from the initial appointment with a specialist (surgeon) until surgery. Waiting time is affected by the local structure of the breast cancer care chain. In some coun-ties, an assessment has begun or has already been completed before the patient is referred to a specialist clinic for treatment.

13 Waiting time from surgery to test results A postoperative pathological anatomical diagnosis of the tumour, along with the surrounding tissue, is performed. The indicator shows the waiting time from sur-gery until the patient is notified of the test results. The SFBK targets waiting time of no more than one week. Waiting time is affected by the availability of patholo-gists, as well as procedures for handling tests and results.

Figure 11Women

Percentage of patients who had a multidisciplinary team meeting prior to breast cancer surgery, 2009. Source: National Breast Cancer Register

2008 Percent

100.0100.0100.0

99.999.799.699.599.599.599.399.199.199.099.098.696.495.895.688.988.464.737.4

0 20 40 60 80 100

KalmarÖstergötland

JönköpingBlekinge

VästernorrlandSWEDEN

ÖrebroUppsala

Västra GötalandGävleborg

HallandJämtland

KronobergVästerbottenVästmanland

DalarnaVärmlandStockholm

SkåneSörmland

NorrbottenGotland


Figure 12Women

Waiting time from initial appointment with a specialist until breast cancer surgery, 2009.Source: National Breast Cancer Register

Value first quartile Median Value third quartileDays

13131515151617192021212122222222232425262728

0 10 20 30 40 50

GävleborgSörmland

DalarnaVästerbotten

JämtlandKalmar

StockholmSkåne

VärmlandGotland


VästernorrlandÖstergötland

BlekingeÖrebro

JönköpingHalland

KronobergVästmanland

UppsalaNorrbotten

Figure 13Women

Waiting time from breast cancer surgery until patient received results of PAD, 2009. Source: National Breast Cancer Register


13151516161920202021212222222224252728283134

0 10 20 30 40 50



KalmarVästerbotten

HallandVästmanland

BlekingeSWEDEN

Västra GötalandStockholmVärmland

UppsalaSkåne

DalarnaGotland


ÖrebroKronoberg

Jämtland


14 Definitive preoperative diagnosisTo minimise the risk of reoperation, assessments of changes in breast tissue when malignancy is suspected should strive to provide patients with as accurate a preop-erative diagnosis as possible. The NBHW national guidelines for breast cancer care highlight definitive preoperative diagnosis of malignancy as an important indicator to monitor. According to the association, at least 90 per cent of patients should re-ceive a definitive preoperative diagnosis.

Figure 14Women

Percentage of patients with confirmed diagnosis prior to breast cancer surgery, 2009. Source: National Breast Cancer Register

2008 Percent

97.997.096.295.694.494.294.093.791.190.890.489.889.389.088.688.085.785.684.982.481.477.6

0 20 40 60 80 100

JönköpingÖstergötland


UppsalaGotlandKalmar

HallandSkåne

VästerbottenSWEDEN

ÖrebroStockholm

Västra GötalandVästmanland

NorrbottenVärmland

BlekingeJämtlandDalarna

SörmlandKronoberg


15 Sentinel node surgerySentinel node surgery involves removal of the potentially malignant first lymph node. A tracer that is injected in the breast locates the sentinel node and shows up during surgery. The node is analysed microscopically for signs of metastasis. The procedure reduces the number of patients who undergo complete removal of lymph nodes from the armpit area, thereby reducing the risk of annoying postoperative swelling there.

According to the NBHW national guidelines, the sentinel node technique may be indicated for tumours that are up to four centimetres in diameter. It should be used in patients with invasive breast cancer, i.e., when the tumour has formed cell lines in the surrounding normal tissue. The technique has been used in Sweden since 1997 and is currently available at one or more hospitals in most counties. When it is not offered, primarily at small hospitals, the patient can go to another hospital nearby.

Figure 15Women

Percentage of invasive breast cancer patients who underwent surgery with the sentinel node technique, 2009. Refers to tumours 4 cm or smaller. Source: National Breast Cancer Register

2008 Percent

84.884.184.083.082.482.382.182.181.781.280.980.880.680.678.277.676.176.173.770.869.065.4

0 20 40 60 80 100

DalarnaBlekinge

KronobergÖrebroKalmar

HallandGävleborg

VästerbottenÖstergötland

JämtlandVästernorrland

SWEDENUppsala

VärmlandGotland

SörmlandVästra Götaland

NorrbottenJönköping

VästmanlandStockholm

Skåne


16 Reoperation after PaDA postoperative pathological anatomical diagnosis (PAD) of the tumour, along with surrounding tissue (such as lymph nodes), is performed. If the analysis shows re-maining tumour cells or cancer within a larger area than previously known, reop-eration is recommended to minimise the risk of recurrence. The second operation may involve additional physical suffering.

The NBHW national guidelines for breast cancer care identify the percentage of re-operations after PAD as an important indicator to monitor. The indicator measures both the quality of the preoperative malignancy assessment and how successful the surgeon is in removing the tumour.

The data are based on relatively few cases, generating a broad confidence interval. Errors may also occur because not all hospitals report reoperations to the breast cancer register. Outcomes should also be related to the degree to which breast-pre-serving surgery, which increases the risk of reoperation, has been performed – and whether the purpose of primary surgery was to confirm a cancer diagnosis.

In the view of the Swedish Association for Breast Cancer Surgery, treatment should be as definitive as possible in order to avoid reoperation and PAD should lead to re-operation in fewer than 10 per cent of all cases. The comparison demonstrates that only five counties remained below the recommended level.

Figure 16Women

Percentage of breast cancer patients who underwent reoperation due to tumour data, 2009.Source: National Breast Cancer Register

2008 Percent

1.77.27.87.98.4

10.110.510.710.811.111.511.811.912.314.314.314.815.616.616.917.624.3

0 10 20 30 40

KronobergÖrebro

JönköpingSkåne

VärmlandKalmar

UppsalaGotland


VästerbottenDalarna

StockholmÖstergötlandVästmanland

GävleborgBlekinge

SörmlandHalland


Jämtland


17 Reoperation within four weeks due to complicationsMore than 90 per cent of breast cancer patients undergo surgery. The scope of sur-gery varies according to the location and microscopic presentation of the tumour, as well the patient’s general state of health. Complications may require relatively prompt reoperation. Among such complications are bleeding, which usually occurs within 24 hours, or infection, whose symptoms appear within a week. The second operation may involve additional physical suffering. Follow-up by the breast can-cer register indicates that most reoperations are due to bleeding within the first 24 hours. Given that breast cancer operations are regarded as clean surgery, infection should be rare; in fact, very few reoperations are performed as the result of surgical site infection. However, infections that do not lead to reoperations are not entered in the register.

The NBHW national guidelines for breast cancer care identify the percentage of re-operations within 30 days due to complications as an important indicator to monitor.

The data are based on relatively few cases, generating a broad confidence interval. Moreover, some hospitals may fail to report reoperations to the breast cancer reg-ister. It goes without saying that the percentage of reoperations due to unforeseen events should be as low as possible. A national average of one or two percentage points is a good target.

Figure 17Women

Percentage of breast cancer patients who underwent reoperation within 30 days due to complications, 2009. Source: National Breast Cancer Register

2008 Percent

0.50.50.50.80.91.01.31.31.41.51.51.61.61.61.92.22.22.93.94.85.56.1

0 10 20 30 40

JämtlandBlekingeGotland

NorrbottenDalarna

JönköpingKalmar



Västra GötalandSWEDEN

KronobergHalland

ÖstergötlandStockholmSörmland

SkåneVästerbotten

UppsalaGävleborg


ovARIANCANCER

Statistics for 2009 Women




Relativefive-yearsurvivalrate 44.0%

Numberofdeaths 675

Approximately 800 women develop ovarian cancer every year. The prognosis is fair-ly poor and the relative five-year survival rate is 44 per cent. A total of 675 Swedes died of ovarian cancer in 2009. Due partially to the protective effect of oral contra-ceptives, the incidence has declined since 1975.

Many forms of cancer are broken down into four stages according to how far the tumour has spread. In this case, malignancy is limited to the ovaries during the first stage and has metastasised outside the abdominal cavity by the fourth stage. The disease has an insidious course and is often diagnosed late because it does not cause any symptoms early on. Approximately 60 per cent of cases are in the third or fourth stage when diagnosed.

This report presents four indicators: one for survival rate, one for the care proc-ess, and two for waiting time. Five-year survival rates by county are based on data from the Swedish Cancer Register. The other indicators are taken from the National Quality Register for Gynecological Onkology and presented at the regional level. The register started in 2008. This report generally presents indicators at the county level, but representatives of the quality register believe that this data cannot yet be accounted for other than at the regional level.


18 Survival rate for ovarian cancerSurvival rates, particularly for one or two years, among ovarian cancer patients have risen since 1990. The five-year survival rate also increased somewhat to 44 per cent in 2005–2009 (see Figure 18). Some regional differences exist, but the confidence intervals are broad and the role of chance cannot be ruled out.

Figure 18Women

Ovarian cancer – relative five-year survival rates. Patients diagnosed in 2000– 2004. Patients age 30–89 at the time of diagnosis. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare


55.150.047.847.446.645.244.944.744.144.043.843.843.643.442.240.540.439.238.938.638.334.9

0 20 40 60 80

JämtlandGotlandHalland

KronobergGävleborgSörmland

ÖrebroUppsala

NorrbottenKalmar

Västra GötalandSkåne

SWEDENVästernorrland

DalarnaVärmlandStockholm

BlekingeÖstergötlandVästerbotten

JönköpingVästmanland

Figure 18Sweden

Ovarian cancer – relative five-year survival rates. Trend, 1990–2009. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare

Percent

0

20

40

60

80

100

2005-20092000-20041995-19991990-1994


Healthcare region

Figure 19Women

Waiting time from confirmed diagnosis until decision to treat for ovarian cancer patients, 2009. Source: National Quality Register for Gynecological Cancer


20242529293442

0 10 20 30 40 50 60

Norra Stockholm-Gotland

SWEDENSödra

Uppsala-ÖrebroVästra

Sydöstra

Healthcare region

Figure 20Women

Waiting time from decision to treat until commencement of chemotherapy for ovarian cancer patients, 2009. Source: National Quality Register for Gynecological Cancer


16667

1417

0 5 10 15 20 25 30

Västra Sydöstra

SWEDENUppsala-Örebro

Södra Stockholm-Gotland

Norra

19 Waiting time from diagnosis until decision to treatOvarian cancer is often detected late when it has already reached a serious stage. Thus, minimising the waiting time from diagnosis until decision to treat is particu-larly important.

20 Waiting time from decision to treat until commencement of chemotherapy

Approximately 80 per cent of all ovarian cancer cases should be treated with chem-otherapy – as soon as possible, considering the course of the disease. According to the national healthcare guarantee, treatment is to commence within 90 days after the decision.

Based on data for 452 patients, Figure 20 shows the number of days that 25, 50 and 75 per cent of patients waited between the decision to treat and commencement of chemotherapy. Fifty per cent of patients nationwide began chemotherapy within a week and 75 per cent within 19 days. Seventy-five per cent of patients in the north-ern region started within two days.


The National Quality Register for Gynecological Onkology contains waiting time data for 60 per cent of patients who were entered based on a decision to treat in accordance with Indicator 19 above. The relatively large percentage of unreported cases affects the outcomes for this indicator.

21 Percentage of biopsies assessed by a subspecialised pathologist Diagnosis and decision to treat ovarian cancer cases are based on the pathologist’s assessment of the biopsy. The National Quality Register for Gynecological Onkol-ogy has performed follow-ups indicating that a fairly large number of diagnoses would be re-evaluated if the biopsy were also assessed by a subspecialised gynaeco-logical pathologist. The assessment influences the prognosis and can be crucial to ongoing treatment.

Figure 21Women

Percentage of ovarian cancer patients whose biopsies were examined by a subspecialised pathologist prior to decision to treat, 2008–2009.Source: National Quality Register for Gynecological Cancer

Percent

45.544.137.329.228.920.811.8

0 10 20 30 40 50 60

Uppsala-ÖrebroSydöstra

SWEDENVästraSödra

Stockholm-GotlandNorra

Healthcare region


KIDNEYCANCER



Percentageofallcancercases 1% 2%


Relativefive-yearsurvivalrate 66.1% 63.7%


Approximately 2 per cent of all cancer cases among Swedish adults are of the kidney. Men account for approximately 60 per cent of the diagnoses. Incidence has declined over the past two decades, and no major differences between healthcare counties have been reported. Almost 900 people, most of them over 65, are diagnosed with kidney cancer every year. The causes have not been fully determined, but smoking and renal failure are two known risk factors.

The prognosis has improved over the past decade. The five-year survival rate is 90-95 per cent for patients with small tumours that do not yet extend through the renal capsule. The overall five-year survival rate for both sexes is better than 60 per cent.

The report presents outcomes for four indicators, three of which are based on data from the National Swedish Kidney Cancer Register. One indicator concerns surviv-al rates in accordance with data from the Swedish Cancer Register, and two reflect waiting times at various links in the care chain. The fourth indicator presents the percentage of patients who have been assessed on the basis of thoracic CT scans as recommended by the clinical practice guidelines.


22 Kidney cancer – survival ratesAfter having held steady in the 1990s, the relative five-year survival rate increased for both women and men in the early 2000s. Figure 22 shows that the rate was higher than 66 per cent for women and almost 64 per cent for men in 2005–2009. The various counties range from 49.4 to 75.7 per cent.

Figure 22Total

Kidney cancer – relative five-year survival rates. Patients diagnosed in 2000– 2004. Patients age 30–89 at the time of diagnosis. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare


75.774.372.670.869.869.467.265.665.565.465.364.563.461.761.260.560.359.458.955.554.449.4

0 20 40 60 80 100

DalarnaUppsala


GotlandNorrbottenKronoberg

Västra GötalandJönköping

JämtlandSWEDEN

SkåneVästernorrland

KalmarÖrebro


VästmanlandHalland

GävleborgVärmland

Blekinge

Figure 22 Sweden

Kidney cancer – relative five-year survival rates. Trend, 1990–2009. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare

Percent

0

20

40

60

80

100

2005-20092000-20041995-19991990-1994

Women

Total

Men


Figure 23Total

Waiting time from receipt of referral until the initial appointment with a specialist for assessment of kidney cancer, 2009. Source: National Swedish Kidney Cancer Register

1 Fewer than 10 cases Value first quartile Median Value third quartileDays

Number of patients

89

10101314141516171717171920212121252526

24182031261230

129262223

781110

2619

1392319192435

0 20 40 60 80

Gotland 1

ÖstergötlandVästmanland

JämtlandVärmland

KronobergStockholm

DalarnaGävleborg

SkåneSWEDEN

VästerbottenÖrebro

HallandVästra Götaland

SörmlandBlekingeUppsala

NorrbottenKalmar


23 Waiting time from referral to the initial appointment with a specialist

The goal is to minimise the waiting time from a referral due to suspicion of cancer until an appointment with a specialist. The waiting time has been reported to the register since 2009.


24 Waiting time from decision to treat until surgery The waiting time from decision to treat until surgery should be as short as possible. The indicator reflects the healthcare system’s resources and organisational capacity. The waiting time has been reported to the register since 2009.

Figure 24Total

Waiting time from decision to treat until surgery for kidney cancer, 2009. Source: National Swedish Kidney Cancer Register

1 Fewer than 10 cases Value first quartile Median Value third quartileDays

Number of patients

102021222323242526262727272828282829303641

11232821182020

127140

212321

7613015

1112334252420

0 20 40 60 80

Gotland 1

DalarnaVärmland

KronobergÖstergötland

GävleborgSkåne

JämtlandSörmlandSWEDEN

UppsalaÖrebro


Västra GötalandHalland

VästernorrlandKalmar

VästmanlandNorrbottenJönköping

Blekinge


Figure 25Sweden

Percentage of patients who underwent thoracic CT scan prior to kidney cancer surgery. Trend, 2005–2009. Source: National Swedish Kidney Cancer Register

Percent

0

20

40

60

80

100

20092008200720062005

Women

Total

Men

Figure 25Total

Percentage of patients who underwent thoracic CT scan prior to kidney cancer surgery, 2008–2009. Source: National Swedish Kidney Cancer Register

2006–2007 Percent

95.993.892.792.391.490.689.885.983.883.383.382.681.580.480.278.978.678.478.472.568.665.5

0 20 40 60 80 100

HallandKalmar

DalarnaUppsala

SörmlandJämtland

NorrbottenSkåne

JönköpingVästra Götaland

SWEDENStockholm

BlekingeGävleborg

ÖstergötlandKronobergVärmland

VästerbottenGotlandÖrebro

VästernorrlandVästmanland

25 Primary assessment based on preoperative thoracic CT scanDistant metastases from kidney cancer are often located in the lungs. A decisive pr-eoperative assessment, best performed on the basis of a thoracic CT scan, is whether the malignancy has metastasised to the lungs. According to the clinical practice guidelines, 85 per cent of all cases should be assessed on the basis of thoracic CT scans.


BLADDERCANCER







More than 2 000 Swedes, three-quarters of whom are men, develop bladder cancer every year. Many patients see their doctor for presumed urinary tract infection due to blood in the urine. The number of cases started to rise significantly in the 1960s but appears to have levelled off in the 2000s. The average age at diagnosis is approxi-mately 70; smoking is the most important known risk factor.

Bladder cancers are broken down into three different groups: Tis, Ta and T1–T4; Tis, Ta and T1 are non-muscle invasive. Approximately three-quarters of all cases are non-muscle invasive although there is some variation among the healthcare coun-ties.

The report presents outcomes for five indicators. The first indicator concerns sur-vival rates. Two indicators reflect waiting times. The last two indicators show the percentage of patients who received one or more of the treatments in question de-pending on the stage of the tumour. With the exception of the survival indicator, which is based on the the Swedish Cancer Register, the data were taken from the Swedish Bladder Cancer Register.


26 Bladder cancer – survival ratesFigure 26 shows the relative five-year survival rate for bladder cancer patients. The national average for 2005–2009 was 75.2 per cent, with a regional variation of 65.1–81.1 per cent. The higher the age at the time of diagnosis, the lower the survival rate.

Figure 26 Sweden

Bladder cancer – relative five-year survival rates. Trend, 1990–2009. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare

Percent

0

20

40

60

80

100

2005-20092000-20041995-19991990-1994

Women

Total

Men

Figure 26Total

Bladder cancer – relative five-year survival rates. Patients diagnosed in 2000– 2004. Patients age 30–89 at the time of diagnosis. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare


81.179.879.178.378.378.377.977.376.775.375.274.974.774.574.271.971.870.568.967.065.465.1

0 20 40 60 80 100

DalarnaJämtland

GävleborgUppsala

VärmlandSörmland

HallandVästernorrland

KronobergNorrbottenStockholmSWEDEN

VästerbottenVästra Götaland

KalmarSkåne

JönköpingBlekinge

ÖstergötlandÖrebro

VästmanlandGotland


27 Waiting time from receipt of the referral to the initial appointment with a urologist

When bladder cancer is suspected, the urologist usually performs a cystoscopy of the urethra and bladder at the first appointment. In most cases, the examination suf-fices for detecting a tumour and making a decision to treat. The indicator concerns waiting time from receipt of a referral until the first appointment with a urologist.

Figure 27Total

Waiting time from receipt of the referral until the initial appointment with a urologist for bladder cancer, 2009. Source: Swedish Bladder Cancer Register


17181920202020202121222222232626272730333541

0 10 20 30 40 50 60

JämtlandGotland

GävleborgDalarnaUppsala

ÖstergötlandVärmlandJönköping

VästmanlandVästerbotten

Västra GötalandNorrbotten

BlekingeSWEDENSörmland

KronobergSkåne

KalmarÖrebro

StockholmHalland

Västernorrland


Figure 28Total

Waiting time from initial appointment with a urologist until transurethral resection (TUR) for bladder cancer, 2009. Source: Swedish Bladder Cancer Register


16182020202021212222222324262627272729303334

0 10 20 30 40 50 60

JämtlandVästerbotten

GotlandUppsalaÖrebro


VärmlandÖstergötland

VästernorrlandSörmland

KalmarVästra Götaland

KronobergSWEDEN

VästmanlandBlekinge

SkåneHallandDalarna

JönköpingStockholm

28 Waiting time from initial appointment with a urologist until transurethral resection

Based on the cystoscopy, the urologist determines whether a transurethral resection – which often serves as both a diagnostic tool and surgical procedure – is called for. The indicator presents waiting times from the initial appointment with a urologist until a transurethral resection is performed.

Thus the two waiting times in tandem reflect how long it takes from the point at which the patient is given a referral until actual treatment. However, it says nothing about the total waiting time that starts when the patient first schedules an appoint-ment for primary care.

Much of the data used by the indicator have been reported to the Swedish Bladder Cancer Register. This indicator is not based on exactly the same data as the previous indicator and is more representative.


29 intravesical therapy for T1 tumours of the bladderNearly all tumours of the bladder are treated with a transurethral resection. Though non-invasive, T1 tumours belong to a high-risk category. According to the guidelines of the European Association of Urology, most patients with a T1 tumour should also be offered intravesical chemotherapy or immunotherapy to prevent recurrence and progression. Possible exceptions are patients with comorbidity and very advanced age.

The data for the indicator in Figure 29 cover two years in order to ensure more reliable outcomes at the regional level. Some counties have so few cases that the outcomes are uncertain nonetheless. However, the figures point to notable regional differences.

Figure 29Total

Percentage of patients with bladder cancer who underwent intravesical therapy, 2008–2009. Refers to stage T1. Source: Swedish Bladder Cancer Register

1 Fewer than 10 cases Percent

Number of patients

73.363.262.160.956.350.050.048.047.945.444.442.433.326.723.821.220.020.019.218.811.9

15192923323028

171140205

27963

273021332520261642

0 20 40 60 80 100

Gotland 1

DalarnaJämtland

VärmlandKalmar

GävleborgHalland

SörmlandUppsala

KronobergSWEDEN

NorrbottenSkåne

Västra GötalandStockholm

VästernorrlandBlekingeÖrebro

VästerbottenÖstergötlandVästmanland

Jönköping


Figure 30Total

Percentage of patients with bladder cancer who underwent curative primary treatment, 2008–2009. Refers to stage T2–T4. Source: Swedish Bladder Cancer Register


71.464.562.958.355.655.054.854.850.050.050.048.044.443.843.841.539.637.931.319.2

0 20 40 60 80 100

Gotland 1

Jönköping 1

KronobergVärmland

BlekingeSörmland

StockholmUppsala

JämtlandVästra Götaland

SWEDENKalmar

HallandDalarna

ÖstergötlandVästerbotten

NorrbottenSkåne

VästernorrlandGävleborg

VästmanlandÖrebro

Number of patients

35313524

133203142505030

1 029171

1632

17153293226

30 Curative treatment of T2–T4 tumours A T2-T4 tumour has invaded the muscle and the options for curative treatment are cystectomy (removal of the bladder), with or without systemic chemotherapy, or radiotherapy. Due to comorbidity, advanced age or certain other factors, a decision may be made not to attempt a cure.

Approximately 500 Swedes are diagnosed with T2-T4 tumours of the bladder every year. The percentage of patients who receive curative treatment varies considerably from county to county. Given the low incidence, the indicator is not broken down by gender. The diagram contains data for two years in order to ensure more reliable outcomes. Nevertheless, some counties have so few cases that uncertainty remains.


PRoSTATECANCER

Statistics for 2009 Men




Relativefive-yearsurvivalrate 86.5%

Numberofdeaths 2424

Prostate cancer is the most common form of the disease in Sweden and accounts for more than 36 per cent of cases in men. A total of 10 317 patients were diagnosed with prostate cancer in 2009, and Sweden currently has approximately 75 700 preva-lent cases. The disease is rare before the age of 50. The median age at diagnosis has decreased to 70.

The number of new cases was stable in 1990–1995, rising substantially through 2005 and then levelling off for several years. There was a spike again in 2009, largely due to the growing number of symptom-free men who take a prostate-specific antigen (PSA) blood test and the fact that patients with elevated PSA levels (about 10 per cent of those who are symptom-free) undergo a biopsy. The greater use of the test explains why prostate cancer is detected at earlier stages and why the age at diagno-sis has decreased.

The risk of death depends on the stage and degree of the tumour. Because men are increasingly diagnosed with small, well-differentiated tumours, the relative five-year survival rate has risen to 86.5 per cent. A total of 2 424 Swedes died of prostate cancer in 2009.

This report presents outcomes for five indicators. Four of the indicators reflect in-terventions at various stages and grades of prostate cancer – from tumours with low risk of metastasis to those with high risk, which often grow rapidly and aggressively. The fifth indicator concerns waiting times. The data have been taken from the Na-tional Prostate Cancer Register.

31 Waiting time for the initial appointment with a urologistUsually a general practitioner makes an assessment or, at the patient’s request, a PSA test is performed as part of a routine check-up. If the GP suspects cancer, the patient is referred to a urologist.

According to the national healthcare guarantee, the initial appointment with a spe-cialist is to take place within 90 days after the referral is sent. Since tumours of the prostate tend to grow slowly, waiting time is rarely decisive to treatment outcome. The PSA level, which reflects proliferation of the tumour, is useful in determining


the need for rapid assessment. Be that as it may, a long waiting time causes unneces-sary anxiety and should be avoided.

The comparison is based on how long it takes from the time that the clinic receives a referral or is contacted by the patient until the initial appointment with a urolo-gist.

There were major regional variations. Halland, for example, had the shortest me-dian waiting time and only 25 per cent of patients waited for more than 34 days. Because no waiting time had been reported for 26 per cent of the cases, the data are inconclusive.

In seven counties, at least 25 per cent of patients waited longer than three months. Thus it would appear that many counties lacked the capacity in 2009 to meet the national care guarantee’s 90-day deadline.

This report does not consider the possibility that a patient was offered an appoint-ment at a second urology clinic during the waiting period but turned it down.

The column on the right side of the diagram indicates the percentage of patients included in the comparison. The counties exhibited large variations; a high percent-age of unreported cases can affect the waiting time data.

Figure 31Men

Waiting time from referral until the initial appointment with a urologist for assessment of prostate cancer, 2009. Source: National Prostate Cancer Register



24363839404041424344454646474854586365697695

74728294846782577672927582858388918792876782

0 30 60 90 120 150 180

JämtlandKronoberg

DalarnaÖstergötland

GävleborgVästerbotten

KalmarBlekinge

JönköpingÖrebro

VästernorrlandNorrbotten

VärmlandSWEDENStockholm

VästmanlandRegion Skåne

UppsalaGotland

Västra GötalandSörmland

Halland


32 Bone scintigraphy for low-risk prostate cancer Bone scintigraphy involves the injection of a radioisotope in order to detect bone changes, including metastases from prostate cancer. The examination can be used to determine whether prostate cancer has spread to the skeletal system, ordinarily the spinal column or pelvis. Low-risk localised tumours rarely require bone scintig-raphy. Thus, the NBHW national guidelines for prostate cancer care and the clini-

Figure 32Men

Percentage of patients with localised prostate cancer who underwent skeletal scintigraphy, 2009. Refers to low-risk tumours. Source: National Prostate Cancer Register

1 Fewer than 10 cases in 2003 2003 Percent

0.01.72.32.32.52.73.03.54.24.54.74.95.15.66.06.17.17.48.9

10.911.611.6

0 20 40 60 80

NorrbottenGävleborg

DalarnaSörmlandVärmlandJönköpingKronoberg

ÖrebroVästerbottenÖstergötland

VästernorrlandBlekinge

SWEDENKalmar

StockholmSkåne


HallandUppsala

JämtlandGotland 1

Figure 32Sweden

Percentage of patients with localised prostate cancer who underwent skeletal scintigraphy. Refers to low-risk tumours. Trend, 2000–2009. Source: National Prostate Cancer Register

Percent

0

20

40

60

80

100

2009200820072006200520042003200220012000


cal practice guidelines of every region specify that patients with low-risk tumours should not be given bone scintigraphy. However, a few patients may experience symptoms in the skeletal system that call for the examination to be used.

33 active surveillance of low-risk prostate cancer Only 3 per cent of low-risk prostate cancer patients die of the disease within 10 years. The first-line treatment strategy recommended by the NBHW national guidelines is active surveillance for patients with a remaining life expectancy of 10–20 years and prostatectomy or radiotherapy for those with a remaining life expectancy of more than 20 years. Active surveillance involves frequent PSA tests and occasional biopsies. Any indication that the tumour is growing triggers prostatectomy or ra-diotherapy. Since the guidelines were drawn up, the quality register has further nar-rowed the criteria for low-risk cancer for which active surveillance is indicated; thus fewer patients are now included in this population.

Swedish urologists disagree about the optimum treatment for low-risk prostate can-cer. Active surveillance reduces the number of patients who are overtreated, but at the risk of treating some too late.

Because the quality register revised its reporting methods in 2009, no comparison with previous outcomes is possible.

Figure 33Men

Percentage of patients with prostate cancer who received active surveillance, 2009. Refers to patients age 75 and younger with low-risk tumours. Source: National Prostate Cancer Register


80.077.376.073.467.764.763.662.160.058.758.457.153.352.951.450.049.447.637.926.7

0 20 40 60 80 100

Norrbotten 1

Gotland 1

GävleborgKronoberg

KalmarStockholm

VästerbottenJönköpingVärmlandSörmlandJämtland


DalarnaÖrebro

BlekingeVästmanland

HallandSkåne

VästernorrlandUppsala

Östergötland


34 Curative treatment for medium and high-risk prostate cancer Given that medium and high-risk prostate cancer poses a significantly higher risk of death, patients are normally offered the possibility of curative treatment, which involves one of various prostatectomy or radiotherapy techniques. Such treatment is indicated only if the tumour is localised, i.e., has not metastasised beyond the

Figure 34Men

Percentage of patients with prostate cancer who received curative treatment, 2009. Refers to patients age 75 and younger medium and high-risk tumours. Source: National Prostate Cancer Register

2003 Percent

83.082.977.577.575.373.172.772.572.172.171.269.268.466.562.562.462.161.260.059.757.550.6

0 20 40 60 80 100

JönköpingGävleborg


NorrbottenVästmanland

VästernorrlandDalarna

ÖstergötlandSWEDEN

HallandSörmland

GotlandVärmlandStockholm

JämtlandUppsala

SkåneKronoberg

KalmarBlekinge

Västerbotten

Figure 34Sweden

Percentage of patients with prostate cancer who received curative treatment. Refers to patients age 75 and younger medium and high-risk tumours. Trend, 2000–2009. Source: National Prostate Cancer Register

Percent

0

20

40

60

80

100

2009200820072006200520042003200220012000


prostate. This report presents a follow-up of patients under age 75, since they usu-ally have a remaining life expectancy of more than ten years.

Some counties are almost 70 per cent below the national average, suggesting under-treatment of this patient population.

35 Treatment of locally advanced prostate cancer Locally advanced prostate cancer grows aggressively and can metastasise. The condi-tion poses a large risk of premature death within five years of the diagnosis.

Various curative treatment methods are available to these patients. The NBHW national guidelines for prostate cancer care assign top priority to neoadjuvant hor-mone therapy followed by external radiotherapy. The combined treatment is rec-ommended for patients with remaining life expectancy of more than five years. Patients with limited remaining life expectancy may instead be prescribed medica-tion to delay progression of the disease; the guidelines favour antiandrogen therapy with bicalutamide to block the stimulating effect of testosterone on cancer cells.

Figure 35Men

Percentage of patients with prostate cancer who received neoadjuvant hormone therapy and radiotherapy or bicalutamide as monotherapy, 2008–2009. Refers to patients age 75 and younger with high-risk tumours. Source: National Prostate Cancer Register

2006–2007

Percentage who received neoadjuvant hormone therapy and radiotherapy

Percentage who received bicalutamide as monotherapy

Percent

62.662.056.155.954.553.853.351.251.250.048.848.446.743.742.538.334.733.732.728.627.227.0

0 20 40 60 80 100

KalmarVästra Götaland

HallandBlekinge

SörmlandSkåne

ÖstergötlandSWEDENStockholm

GotlandJämtlandUppsala

JönköpingÖrebro

VärmlandNorrbotten

VästmanlandDalarna

VästerbottenVästernorrland

KronobergGävleborg


Figure 35Sweden

Percentage of patients with prostate cancer who received neoadjuvant hormone therapy and radiotherapy or bicalutamide as monotherapy. Refers to patients age 75 and younger with high-risk tumours. Trend, 2000–2009.Source: National Prostate Cancer Register

Percent

0

20

40

60

80

100

2009200820072006200520042003200220012000


CoLoNCANCER







Colon cancer is the third most common form of the disease in both women and men. A total of 4 059 Swedes – 2 036 women and 2 023 men – developed colon can-cer in 2009. More than 28 000 Swedes now alive have had the disease. Colon cancer is uncommon before the age of 49 and approximately 75 per cent of patients are over 65 at the time of diagnosis. The number of new cases has been stable since 1990, with a small upward trend. One reason is that the population has aged.

This report presents outcomes for eight indicators. Considering that most patients undergo surgery, five of the indicators reflect outcomes during and after the opera-tion. One indicator concerns survival rates and two concern multidisciplinary team meetings. Seven of the indicators are based on data from the National Colon Cancer Register, which started in 2007, and the eighth indicator is based on data from the Swedish Cancer Register. The comparison period covers 2–3 years, nearly the entire lifetime of the national quality register. Thus, comparison with outcomes from pre-vious years is out of the question.

36 Colon cancer – relative five-year survival ratesThe relative five-year survival rate among colon cancer patients rose to 65.4 per cent for women and 60.9 per cent for men in 2005–2009. Figure 36 reveals that there are

Figure 36 Sweden

Colon cancer – relative five-year survival rates. Trend, 1990–2009. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare

Percent

0

20

40

60

80

100

2005-20092000-20041995-19991990-1994

Women

Total

Men


Figure 36Women

Colon cancer – relative five-year survival rates. Patients diagnosed in 2000– 2004. Patients age 30–89 at the time of diagnosis. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare


70.669.769.568.368.267.867.265.465.264.263.463.163.062.962.562.362.161.761.361.261.160.5

0 20 40 60 80 100

SörmlandJämtland

VästmanlandNorrbotten

ÖrebroÖstergötland

KalmarJönköping

UppsalaVärmland

DalarnaGävleborgKronoberg


VästerbottenSkåne

StockholmHallandGotlandBlekinge

Västernorrland

Figure 36Men



68.967.265.763.963.562.262.261.660.960.760.560.359.359.358.558.457.357.256.156.055.950.2

0 20 40 60 80 100

GotlandÖrebro

NorrbottenBlekinge

VästernorrlandJämtland

VästerbottenVärmland

KronobergGävleborg


DalarnaSWEDENJönköping

SkåneKalmar

SörmlandHalland

VästmanlandÖstergötland

Uppsala


large regional differences for men: 50.2–68.9 per cent, as opposed to 60.5–70.6 per cent for women.

37–38 Multidisciplinary team meetingsPrimary colon cancer treatment may be preceded by a multidisciplinary team meet-ing, a comprehensive assessment for the purpose of optimising the intervention. Surgery, oncology, radiology, pathology and other specialists, as well as nurses, may participate. A postoperative multidisciplinary team meeting looks at the patho-logical anatomical data (PAD) and plans ongoing treatment. The NBHW national guidelines for colon cancer care recommend a multidisciplinary team meeting both before commencement of treatment for newly diagnosed cases and postoperatively.

The National Colon Cancer Register targets multidisciplinary assessments for at least 90 per cent of patients, both at commencement of treatment and postopera-tively.

Certain regional differences in reporting of multidisciplinary team meetings affect the outcomes in the diagram. In the first place, there is no uniform definition of the specialists who need to participate in order for a multidisciplinary team meeting to take place. Some counties report only meetings attended by all of the various types of specialists and are thereby underrepresented in the register. In the second place,

Figure 36Total



66.565.864.964.464.364.263.763.362.962.862.462.362.262.262.061.961.761.059.859.058.358.1

0 20 40 60 80 100

GotlandNorrbotten

ÖrebroJämtland

VärmlandDalarna

SörmlandKronobergGävleborgJönköping

KalmarBlekinge

Västra GötalandVästerbotten

SWEDENVästmanlandÖstergötland

VästernorrlandStockholm

SkåneUppsalaHalland


Figure 37Total

Percentage of patients who had a multidisciplinary team meeting prior to treatment for colon cancer, 2008–2009. Source: National Colon Cancer Register

Percent

Percentage of emergency operations

57.655.048.938.234.232.832.632.428.626.424.923.722.921.321.118.415.913.012.812.011.9

4.4

15171713201815192127161821282021261829182118

0 20 40 60 80 100

HallandVästernorrland

JönköpingGävleborg

VästerbottenJämtland

KalmarBlekinge

VärmlandÖrebro

SörmlandUppsala

ÖstergötlandSkåne

SWEDENKronoberg

VästmanlandVästra Götaland

GotlandDalarna

NorrbottenStockholm

Figure 38Total

Percentage of patients who had a multidisciplinary team meeting after colon cancer surgery, 2008–2009. Source: National Colon Cancer Register

Percent


96.690.080.480.178.476.272.568.763.262.561.861.559.254.046.542.440.335.633.031.825.911.8

20172030151429222118163021221919232319252018

0 20 40 60 80 100

HallandJönköping


BlekingeSkåne


KalmarSWEDEN

ÖstergötlandKronoberg

UppsalaVästra Götaland

ÖrebroVärmland

GotlandStockholmGävleborg

NorrbottenDalarna

Västmanland


the patient populations that need a multidisciplinary team meeting are identified differently from county to county.

The column of figures on the right side of the diagram shows the percentage of emergency operations per county. Because multidisciplinary team meetings are not feasible when the patient’s condition is acute, the two variables are related. How-ever, the percentage of postoperative multidisciplinary team meetings should not be affected by whether the operation was scheduled or emergency.

Figure 37Hospitals

Percentage of patients who had a multidisciplinary team meeting prior to treatment for colon cancer, 2008–2009. Source: National Colon Cancer Register

82.181.280.170.634.47.0

56.02.4

28.322.323.046.18.36.3

17.78.81.9

47.414.423.835.920.866.322.316.917.910.21.64.28.5

51.78.9

24.46.38.2

75.613.67.0

32.42.0

18.915.424.432.259.323.39.2

20.04.6

10.616.015.57.5

18.56.00.0

29.466.0

83

1515162223221416223916162212231119251321212030162326123018245411201619182741301321191618312723212026231714202417

RegionStockholm

UppsalaSörmland

Östergötland

Jönköping

Kronoberg

Kalmar

GotlandBlekinge

Skåne

Halland

Västra Götaland

Värmland

Örebro

VästmanlandDalarna

Gävleborg

Västernorrland


Norrbotten

Percent


0 20 40 60 80 100

Sunderbyns sjukhusKiruna lasarett

Gällivare lasarettSkellefteå lasarett

Norrlands Universitetssjukhus, UmeåLycksele lasarett

Östersunds sjukhusÖrnsköldsviks sjukhus

Sundsvalls sjukhusSollefteå sjukhus

Hudiksvalls sjukhusGävle sjukhusMora lasarettFalu lasarett

Västerås lasarettUniversitetssjukhuset Örebro

Lindesbergs lasarettKarlskoga lasarett

Torsby sjukhusCentralsjukhuset i Karlstad

Arvika sjukhusSÄ-sjukvården

SU Östra, GöteborgSkaraborgs sjukhus, Skövde

Skaraborgs sjukhus, LidköpingSahlgrenska universitetssjukhuset

NU-sjukvårdenKungälvs sjukhusAlingsås lasarett

Varbergs sjukhusLänssjukhuset i Halmstad

Ystads lasarettUniversitetssjukhuset MAS

Universitetssjukhuset i LundKristianstads sjukhusHelsingborgs lasarett

BlekingesjukhusetVisby lasarett

Västerviks sjukhusLänssjukhuset Kalmar

Växjö lasarettLjungby lasarett

Värnamo sjukhusLänssjukhuset Ryhov, Jönköping

Höglandssjukhuset, EksjöVrinnevisjukhuset i Norrköping

Universitetssjukhuset i LinköpingNyköpings sjukhus

Mälarsjukhuset, EskilstunaAkademiska sjukhuset, Uppsala

Södertälje sjukhusSödersjukhuset, Stockholm

S:t Görans sjukhus, StockholmNorrtälje sjukhusKarolinska, Solna

Karolinska, HuddingeErsta sjukhus, Stockholm

Danderyds sjukhus


39 at least twelve lymph nodes examined in the tumour sampleAfter primary surgery for colon cancer, the intestinal tissue and tumour that have been removed are sent to a pathology lab for microscopic and macroscopic examina-tion. The purpose of the examinations is to offer a definitive assessment of the type and stage of the tumour. Correctly classifying the malignancy is integral to predict-ing progression of the disease and prescribing proper treatment. Scientific studies indicate that acceptable diagnostic quality requires examination of at least twelve

Figure 38Hospitals

Percentage of patients who had a multidisciplinary team meeting after colon cancer surgery, 2008–2009. Source: National Colon Cancer Register

95.794.390.092.977.434.496.120.063.652.832.887.739.019.126.637.714.092.054.355.275.635.470.324.716.538.048.911.27.8

54.654.219.855.272.189.693.830.856.690.331.357.916.790.296.690.492.376.983.947.646.034.931.722.932.637.041.240.092.5

62

1918162622201616234418172613241021281524242133172326122517266910221622192744291422201717342424171926231815242720

RegionStockholm

UppsalaSörmland

Östergötland

Jönköping

Kronoberg

Kalmar

GotlandBlekinge

Skåne

Halland

Västra Götaland

Värmland

Örebro

VästmanlandDalarna

Gävleborg

Västernorrland


Norrbotten

Percent


0 20 40 60 80 100



























Danderyds sjukhus


Figure 39Total

Percentage of patients who had at least twelve lymph nodes examined after colon cancer surgery, 2008–2009. Source: National Colon Cancer Register

Percent

97.691.991.490.178.578.178.077.277.276.775.473.973.871.170.470.168.565.864.163.561.754.7

0 20 40 60 80 100

JämtlandVästernorrland

VärmlandÖrebro

GävleborgVästerbottenÖstergötland

BlekingeJönköping

DalarnaSörmland

SkåneNorrbotten

UppsalaSWEDEN

HallandKalmar

StockholmVästra Götaland

KronobergGotland

Västmanland

Figure 39Pathology lab

Percentage of patients who had at least twelve lymph nodes examined after colon cancer surgery, 2008–2009. Source: National Colon Cancer Register

67.589.787.872.076.879.373.270.170.891.378.669.890.986.756.669.878.392.691.890.479.363.865.196.872.965.861.054.069.375.5

RegionStockholm

UppsalaSörmland

ÖstergötlandJönköpingKronoberg

KalmarBlekinge

Skåne


VärmlandÖrebro

VästmanlandDalarna



Norrbotten

Percent

0 20 40 60 80 100

Sunderbyns sjukhusNorrlands Universitetssjukhus, Umeå

Östersunds sjukhusSundsvalls sjukhus

Gävle sjukhusFalu lasarett


Centralsjukhuset i KarlstadSÄ-sjukvården, Borås

Skaraborgs sjukhus, SkövdeSahlgrenska universitetssjukhusetNU-sjukvården, Trollhättan/NÄL

Länssjukhuset i HalmstadUniversitetssjukhuset MAS


Blekingesjukhuset, KarlskronaLänssjukhuset Kalmar

Växjö lasarettLänssjukhuset Ryhov, JönköpingUniversitetssjukhuset i Linköping


Täby MedilabS:t Görans sjukhus, Stockholm

Karolinska, SolnaKarolinska, Huddinge

Danderyds sjukhus


lymph nodes. The quality of the examinations is affected by whether the surgeon removes sufficient tissue, as well as the pathologist’s analytical skills.

According to an analysis of 2008 data by the National Colon Cancer Register, the number of lymph nodes examined was not related to whether surgery had been per-formed on a scheduled or emergency basis. Given that surgery is fairly standardised, the quality of the results appeared to depend more on the ability of the pathologist to analyse at least twelve nodes than on the size of the sample.

The comparison covers a two-year period. With the exception of the large counties, however, the quality register contained few cases – as reflected in the broad confi-dence intervals.

Counties that were below 95 per cent should review their resources, particularly when it comes to pathologists.

40 Perforation of the colon during surgeryOne important complication that can occur during surgery is perforation of the colon. Such a development increases the risk of tumour recurrence and therefore suffering on the part of the patient. The risk of perforation is greater when surgery is performed on an emergency basis.

Figure 40Total

Percentage of patients with perforated colon during colon cancer surgery, 2007–2009. Source: National Colon Cancer Register

Percent


0.41.01.51.51.61.72.02.12.22.22.32.52.52.63.03.03.33.64.44.64.74.9

17201321262221172325191829152020231720222123

0 5 10 15 20

BlekingeVästra Götaland


KronobergSkåne

SWEDENJönköpingStockholm

ÖstergötlandHalland

SörmlandVärmland

KalmarDalarna

VästernorrlandÖrebro


GotlandUppsala

Västmanland


Figure 40Hospitals

Percentage of patients with perforated colon during colon cancer surgery, 2007–2009. Source: National Colon Cancer Register

1.00.36.84.80.03.93.12.01.31.82.11.73.34.23.60.04.83.02.60.01.55.03.51.33.73.83.12.32.22.81.02.4

22.40.05.96.52.02.82.41.61.41.91.60.41.72.41.02.40.01.44.23.93.85.53.83.50.01.3

82

1715152520231917234317172414261222271423241932192122152415255011221720192338251323181617282231201822262014172222

RegionStockholm

UppsalaSörmland

Östergötland

Jönköping

Kronoberg

Kalmar

GotlandBlekinge

Skåne

Halland

Västra Götaland

Värmland

Örebro

VästmanlandDalarna

Gävleborg

Västernorrland


Norrbotten

Percent


0 10 20 30 40 50

Sunderbyns sjukhus Kiruna lasarett


























Danderyds sjukhus

One goal is to minimise the number of complications that are due to healthcare interventions, in this case injury during the course of an operation. Perforations during surgery cannot be wholly eliminated given that they can also be caused by acute volvulus and other conditions.


41 More than 15 days of hospitalisation after surgeryAssuming no complications occur, hospitalisation after surgery should not exceed 15 days. The goal is based on a 2008 follow-up by the National Colon Cancer Register showing that the median hospitalisation period following surgery was 7 days for patients discharged to home and 14 days for those who were discharged to another institution.

The comparison does not take the possible effects of comorbidity or the patient’s preoperative condition into consideration.

Figure 41Total

Percentage of patients with more than 15 days of hospitalisation after colon cancer surgery, 2008–2009. Source: National Colon Cancer Register

Percentage discharged to home Percentage discharged to another institution Percent


6.69.5

10.911.211.212.212.713.113.913.914.914.915.015.117.417.918.018.119.820.221.223.3

19142015302018202129211718222319301622232519

0 10 20 30 40 50

SörmlandJämtland

SkåneKalmar

KronobergGävleborg

VästerbottenBlekingeÖrebro

UppsalaDalarna

SWEDENVärmland


HallandVästmanlandÖstergötland

StockholmNorrbotten

GotlandVästernorrland


Figure 41Hospitals

Percentage of patients with more than 15 days of hospitalisation after colon cancer surgery, 2008–2009. Source: National Colon Cancer Register

Percentage discharged to home Percentage discharged to another institution

5.36.7

16.722.319.412.09.5

10.714.831.110.98.4

13.610.513.318.924.014.922.915.59.8

16.226.913.319.519.918.916.49.49.1

28.914.334.510.313.510.812.315.113.216.718.419.411.513.616.210.819.216.19.55.87.0

20.725.713.021.711.86.7

11.2

62

1918162622201616234418172613241021281524242133172326122517266910221622192744291422201717342424171926231815242720

RegionStockholm

UppsalaSörmland

Östergötland

Jönköping

Kronoberg

Kalmar

GotlandBlekinge

Skåne

Halland

Västra Götaland

Värmland

Örebro

VästmanlandDalarna

Gävleborg

Västernorrland


Norrbotten

Percent


0 10 20 30 40 50 60



























Danderyds sjukhus


Figure 42Women

Percentage of patients with reoperation within 30 days after primary surgery, 2007–2009. Source: National Colon Cancer Register

Percent


1.22.93.43.53.64.14.25.76.56.56.66.77.17.47.47.67.67.88.38.98.99.8

20142215181229252321222123212216222215192025

0 10 20 30 40

BlekingeKronobergSörmland

HallandJämtlandUppsala

StockholmGävleborg

KalmarVästernorrland

ÖrebroVästra Götaland

SWEDENSkåne

VärmlandÖstergötlandVästmanlandVästerbotten

DalarnaJönköping

GotlandNorrbotten

Figure 42Men


Percent


3.65.56.36.97.17.68.48.58.89.19.4

10.911.011.712.112.613.513.814.214.516.219.6

22181319202425172130222019302121231715132222

0 10 20 30 40

BlekingeJämtland

StockholmKronobergJönköping

ÖrebroVästerbotten

HallandGävleborg


SkåneÖstergötland

NorrbottenDalarna

VärmlandKalmar


GotlandUppsala

Västmanland


42 Reoperation due to complications within 30 days of primary surgery

Approximately 95 per cent of all colon cancer patients undergo surgery. The location and size of the tumour, as well as the patient’s general condition, affect the scope and riskiness of the operation. Bleeding, infection, leakage or another complication may require relatively prompt reoperation, which entails additional suffering for the patient and increases the risk of further complications.

The NBHW national guidelines for colon cancer care identify reoperation after 30 days of primary surgery as an important indicator to monitor.

One source of error in comparing data is that some hospitals report minor interven-tions as reoperations and some do not. The percentage of reoperations is also related to the way that primary surgery was performed and the patient’s condition at the time.

Figure 42Total


Percent


3.94.55.66.36.56.66.97.17.57.97.98.08.48.78.79.5

10.010.210.811.612.114.7

17132117202925212319232020202126221815172223

0 10 20 30 40

BlekingeJämtland

KronobergStockholm

HallandÖrebro

GävleborgVästra Götaland

SWEDENJönköping

VästerbottenSkåne

SörmlandKalmar

VästernorrlandVärmland

ÖstergötlandUppsalaDalarna

NorrbottenGotland

Västmanland


Figure 42Hospitals


9.48.7

11.919.213.59.3

11.95.96.76.1

12.55.17.96.99.59.1

16.78.26.0

13.93.0

13.67.37.15.5

10.29.38.7

11.75.65.7

10.712.110.210.28.94.18.38.01.68.5

11.59.53.95.96.17.7

12.80.08.18.3

10.913.28.35.13.55.65.9

82

1715152520231917234317172414261222271423241932192122152415255011221720192338251323181617282231201822262014172222

RegionStockholm

UppsalaSörmland

Östergötland

Jönköping

Kronoberg

Kalmar

GotlandBlekinge

Skåne

Halland

Västra Götaland

Värmland

Örebro

VästmanlandDalarna

Gävleborg

Västernorrland


Norrbotten

Percent


0 10 20 30 40













Nu-sjukvårdenKungälvs sjukhusAlingsås lasarett














Danderyds sjukhus

43 Deaths within 30 and 90 days of surgeryThe NBHW national guidelines for colon cancer care identify the percentage of deaths within 30 and 90 days of surgery as an important indicator for monitoring healthcare quality. The indicator reflects the selection of patients for surgery, as well as the care they receive before, during and after the operation.

Age, gender, and severity of the malignancy also affect the percentage of deaths. Table 1 presents the odds ratio by county, adjusted for age, gender and tumour stage.


Figure 43Total

Percentage of deaths within 30 and 90 days after colon cancer surgery, 2007–2009. Source: National Colon Cancer Register

Percentage of deaths within 30 days Percentage of deaths within 90 days Percent


1.52.24.14.44.54.54.75.05.55.55.65.66.06.46.56.56.76.97.87.88.39.3

12172117222015182228202023182321222518192622

0 5 10 15 20 25 30

JämtlandGävleborgSörmland

JönköpingVärmland

VästernorrlandVästra Götaland

KalmarKronoberg


SWEDENÖstergötland

ÖrebroHalland

StockholmUppsala

SkåneDalarna


Gotland

Table 1

County council

Odds ratio

95 % confidence interval

County council

Odds ratio

95 % confidence interval

Stockholm 0.96 0.74–1.23 V.Götaland 1.11 0.88–1.40

Uppsala 0.91 0.51–1.62 Värmland 1.29 0.83–2.00

Sörmland 1.26 0.77–2.06 Örebro 1.01 0.60–1.72

Östergötland 0.94 0.61–1.43 Västmanland 0.41 0.17–1.03

Jönköping 1.23 0.83–1.84 Dalarna 0.92 0.53–1.61

Kronoberg 0.95 0.54–1.67 Gävleborg 1.46 0.94–2.25

Kalmar 0.96 0.60–1.55 Västernorrland 1.27 0.75–2.16

Gotland 0.30 0.04–2.21 Jämtland 1.78 0.95–3.33

Blekinge 1.07 0.58–1.96 Västerbotten 1.05 0.61–1.81

RegionSkåne 0.79 0.60–1.05 Norrbotten 0.70 0.34–1.45

Halland 0.76 0.45–1.29

A value of 1 is assigned to the national average of patients who die within 90 days of surgery. A value less than 1 represents a percentage below the national average and a value greater than 1 represents a percentage above the national average.


Figure 43Hospitals

Percentage of deaths within 30 and 90 days after colon cancer surgery, 2007–2009. Source: National Colon Cancer Register

Percentage of deaths within 30 days Percentage of deaths within 90 days

3.11.39.36.35.85.75.15.14.0

10.93.27.24.38.56.68.16.26.17.54.01.56.13.57.24.34.53.55.54.47.38.86.95.48.99.04.55.65.66.97.97.00.06.52.23.57.68.49.6

15.44.28.67.95.95.66.83.60.04.7

91

1616152520211917244117172214271223251223241928192023152316255212221720202338251424181718282238211722252015182222

RegionStockholm

UppsalaSörmland

Östergötland

Jönköping

Kronoberg

Kalmar

GotlandBlekinge

Skåne

Halland

Västra Götaland

Värmland

Örebro

VästmanlandDalarna

Gävleborg

Västernorrland


Norrbotten

Percent


0 10 20 30 40



























Danderyds sjukhus


RECTALCANCER







Rectal cancer is more common among men than women. A total of 888 women and 2 121 men were diagnosed with the disease in 2009. More than 16 400 Swedes now alive have had the disease. Rectal cancer is fairly uncommon before the age of 50.

This report presents outcomes for eleven indicators. Seven of them reflect outcomes during and after surgery. Given that most rectal cancer patients undergo surgery, the selection of indicators sheds a great deal of light on the quality of the operations. The other four indicators concern survival rates, frequency of recurrence within five years of surgery, and the use of multidisciplinary team meetings. Two of the indicators are based on the National Rectal Cancer Register, which started in 1995. One indicator contains data from the Swedish Cancer Register.

44 Rectal cancer – relative five-year survival ratesThe relative five-year survival rate has increased among both female and male rectal cancer patients since the early 1990s. Figure 44 shows that the rate was 64.1 per cent for women and 60.9 per cent for men in 2005–2009. However, there were large re-gional differences: the figure ranged from 48.6 to 81.8 per cent for women and from 55.2 to 77.5 per cent for men.

Figure 44 Sweden

Rectal cancer – relative five-year survival rates. Trend, 1990–2009. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare

Percent

0

20

40

60

80

100

2005-20092000-20041995-19991990-1994

Women

Total

Men


Figure 44Women

Rectal cancer – relative five-year survival rates. Patients diagnosed in 2000– 2004. Patients age 30–89 at the time of diagnosis. Age-standardised values.Source: Swedish Cancer Register, Swedish National Board of Health and Welfare

1 Fewer than 10 cases. Confidence interval calculated using Taylor series Percent

81.867.967.366.466.266.164.764.764.564.164.164.063.763.663.062.461.961.459.255.148.6

0 20 40 60 80 100

Gotland 1

JämtlandNorrbotten

HallandKronoberg


ÖstergötlandVästernorrland

SörmlandVästerbotten

SWEDENKalmar

UppsalaSkåne

StockholmGävleborg

DalarnaVärmland

ÖrebroJönköping

Blekinge

Figure 44Men



77.570.369.167.566.565.863.062.262.161.761.461.361.161.060.960.960.960.858.055.855.355.2

0 20 40 60 80 100

GävleborgÖstergötland



VästerbottenSWEDENJämtland

StockholmVärmland

SkåneBlekingeDalarna

SörmlandKronoberg

KalmarNorrbottenJönköping

UppsalaVästmanland

Gotland


Figure 44Total



72.469.466.966.866.464.464.263.963.763.062.962.862.361.861.761.661.461.160.059.157.456.7

0 20 40 60 80 100

HallandJämtland




KronobergSWEDENStockholm

SkåneSörmland

ÖrebroDalarnaKalmar

VärmlandVästmanland

UppsalaJönköping

BlekingeGotland

45–46 Multidisciplinary team meetingsPrimary rectal cancer treatment may be preceded by a multidisciplinary team meet-ing, a comprehensive assessment for the purpose of optimising the intervention. Surgical, oncology, radiology, pathology and other specialists, as well as nurses, may participate. A postoperative multidisciplinary team meeting looks at the patho-logical anatomical data (PAD) and plans ongoing treatment. The NBHW national guidelines for rectal cancer care recommend a multidisciplinary team meeting both before commencement of treatment for newly diagnosed cases and postoperatively.

The long-term target of the National Rectal Cancer Register is that at least 90 per cent of patients receive a multidisciplinary assessment, both at commencement of treatment and postoperatively.

A follow-up performed by the register in 2009 found that only 58 per cent of pa-tients age 85 and older were given a multidisciplinary assessment before commence-ment of treatment for a newly diagnosed malignancy.


Figure 45Total

Percentage of patients who had a multidisciplinary team meeting prior to treatment for rectal cancer, 2008–2009. Source: National Rectal Cancer Register

Percent

93.892.992.591.691.688.388.285.985.784.083.179.979.879.278.276.075.170.166.053.151.719.1

0 20 40 60 80 100

HallandBlekinge

JönköpingJämtland

KronobergÖstergötland

KalmarVärmlandSWEDENSörmland

Västra GötalandSkåne


StockholmÖrebro

GävleborgDalarna


UppsalaGotland

Figure 46Total

Percentage of patients who had a multidisciplinary team meeting after rectal cancer surgery, 2008–2009. Source: National Rectal Cancer Register

Percent

97.996.896.696.492.991.590.988.881.881.473.971.670.869.160.459.050.041.839.236.031.421.2

0 20 40 60 80 100

HallandJämtlandBlekinge

JönköpingSkåne


KalmarSörmland

KronobergSWEDEN


GotlandStockholm

UppsalaÖrebro

DalarnaVärmland

VästmanlandNorrbottenGävleborg


Certain regional differences in reporting of multidisciplinary team meetings affect the outcomes in the diagram. In the first place, there is no uniform definition of the specialists who need to participate in order for a multidisciplinary team meeting to take place. Some counties report only meetings attended by all of the various types of specialists and are thereby underrepresented in the register. In the second place, the patient populations for whom a multidisciplinary team meeting is indicated are identified differently from region to region.

Figure 45Hospitals

Percentage of patients who had a multidisciplinary team meeting prior to treatment for rectal cancer, 2008–2009. Source: National Rectal Cancer Register

92.996.788.992.183.346.093.935.792.785.368.689.854.248.470.433.322.990.473.381.891.752.991.484.489.574.010.822.656.083.882.383.375.991.249.487.987.992.590.196.786.195.853.391.588.965.291.965.291.6

RegionStockholm

UppsalaSörmland

Östergötland

Jönköping

Kronoberg

Kalmar

GotlandBlekinge

Skåne

Halland

Västra Götaland

VärmlandÖrebro

VästmanlandDalarna

Gävleborg

Västernorrland


Norrbotten

Percent

0 20 40 60 80 100

Sunderbyns sjukhusSkellefteå lasarett

Norrlands Universitetssjukhus, UmeåÖstersunds sjukhus

Örnsköldsviks sjukhusSundsvalls sjukhus

Sollefteå sjukhusHudiksvalls sjukhus

Gävle sjukhusMora lasarettFalu lasarett


Centralsjukhuset i KarlstadSÄ-sjukvården


Skaraborgs sjukhus, LidköpingNU-sjukvården

Kungälvs sjukhusAlingsås lasarett


Universitetssjukhuset MASUniversitetssjukhuset i Lund

Kristianstads sjukhusHelsingborgs lasarett











Danderyds sjukhus


47 at least twelve lymph nodes examined in the tumour sampleAfter primary surgery for rectal cancer, the intestinal tissue and tumour that have been removed are sent to a pathology lab for microscopic and macroscopic examina-tion. The purpose of the examinations is to offer a definitive assessment of the type and stage of the tumour. Correctly classifying the malignancy is integral to predict-ing progression of the disease and prescribing proper treatment. Scientific studies indicate that acceptable diagnostic quality requires examination of at least twelve lymph nodes. The quality of the examinations is affected by whether the surgeon removes sufficient tissue, as well as the pathologist’s analytical skills.

Figure 46Hospitals

Percentage of patients who had a multidisciplinary team meeting after rectal cancer surgery, 2008–2009. Source: National Rectal Cancer Register


100.098.4

100.096.7

31.798.826.390.782.127.392.248.242.940.529.420.8

100.057.964.3

37.380.031.913.345.117.09.5

68.065.284.887.590.294.935.197.391.496.691.095.0

100.094.4

50.066.725.065.328.696.8

RegionStockholm

UppsalaSörmland

Östergötland

Jönköping

Kronoberg

Kalmar

GotlandBlekinge

Skåne

Halland

Västra Götaland

VärmlandÖrebro

VästmanlandDalarna

Gävleborg

Västernorrland


Norrbotten

Percent

0 20 40 60 80 100



Örnsköldsviks sjukhusSundsvalls sjukhusSollefteå sjukhus 1










BlekingesjukhusetVisby lasarett 1








S:t Görans sjukhus, StockholmNorrtälje sjukhus 1


Ersta sjukhus, StockholmDanderyds sjukhus


Figure 47Women

Percentage of patients who had at least twelve lymph nodes examined after rectal cancer surgery, 2008–2009.Source: National Rectal Cancer Register

1 Fewer than 10 cases, 2006-2007 2 Fewer than 10 cases, both periods 2006–2007 Percent

87.579.676.973.270.666.765.264.163.258.857.956.754.652.652.050.046.744.243.835.132.0

0 20 40 60 80 100

Gotland 2

VästerbottenVärmlandGävleborg


ÖrebroJönköping

NorrbottenJämtland 1

HallandDalarna

KronobergKalmar

SWEDENBlekingeUppsala

SkåneStockholmSörmland


Figure 47Men


1 Fewer than 10 cases 2006–2007 Percent

88.487.282.275.673.770.669.368.868.867.365.364.664.363.658.757.153.952.743.943.336.6

0 20 40 60 80 100

Gotland 1

VästernorrlandVästerbottenÖstergötland

VärmlandHalland

KronobergÖrebro

NorrbottenJönköpingGävleborg

KalmarDalarnaUppsala

SWEDENStockholm

SkåneJämtlandBlekinge


Sörmland


Figure 47Total


2006–2007 Percent

84.484.184.171.970.970.667.866.966.764.463.460.059.759.657.956.355.355.145.744.040.938.2

0 20 40 60 80 100


ÖstergötlandVärmland

HallandÖrebro

GävleborgKronobergNorrbottenJönköping

GotlandDalarnaKalmar

JämtlandSWEDEN

UppsalaSkåne

StockholmBlekinge

SörmlandVästra Götaland

Västmanland

Figure 47Sweden

Percentage of patients who have at least twelve lymph nodes examined after rectal cancer surgery. Trend, 2003–2009. Source: National Rectal Cancer Register

Percent

0

20

40

60

80

100

2009200820072006200520042003

Women

Total

Men


Figure 47Pathology lab


53.786.873.660.661.166.282.545.460.057.964.071.985.768.954.773.951.688.691.281.261.347.854.785.963.957.536.861.540.760.8

RegionStockholm

UppsalaSörmland

ÖstergötlandJönköping Kronoberg

KalmarBlekinge

Skåne


VärmlandÖrebro

VästmanlandDalarna



Norrbotten

Percent

0 20 40 60 80 100

Sunderbyns sjukhusNorrlands Universitetssjukhus, Umeå

Östersunds sjukhusSundsvalls sjukhus

Gävle sjukhusFalu lasarett



Skaraborgs sjukhus, SkövdeSahlgrenska universitetssjukhusetNU-sjukvården, Trollhättan/NÄL

Länssjukhuset i HalmstadUniversitetssjukhuset MAS


Blekingesjukhuset, KarlskronaLänssjukhuset Kalmar

Växjö lasarettLänssjukhuset Ryhov, JönköpingUniversitetssjukhuset i Linköping


Täby MedilabS:t Görans sjukhus, Stockholm


Danderyds sjukhus

The comparison covers a two-year period. With the exception of the large counties, however, the quality register contained few cases – as reflected in the broad confi-dence intervals.


48 Preoperative radiotherapy Preoperative radiotherapy may be indicated to reduce the risk of local recurrence and occasionally to limit tumour extension as well. The NBHW national guidelines for rectal cancer care assign relatively high priority to the intervention, particularly if the tumour is difficult to remove. If the malignancy is small enough, however, the risk of recurrence is smaller than the risks associated with radiotherapy.

A follow-up by the rectal cancer register in 2009 showed that fewer patients over 80 were receiving preoperative radiotherapy.

Figure 48Total

Percentage of patients who received radiotherapy prior to rectal cancer surgery, 2008–2009. Source: National Rectal Cancer Register

2006–2007 Percent

82.881.680.379.878.273.972.972.770.867.266.766.065.565.362.461.660.654.454.053.951.441.8

0 20 40 60 80 100

JönköpingJämtlandHalland


ÖrebroVärmland

SkåneDalarna

SWEDENKalmar


KronobergGotland

StockholmÖstergötland


UppsalaVästmanland

Gävleborg


Figure 48Sweden

Percentage of patients who received radiotherapy prior to rectal cancer surgery. Trend, 2000–2009. Source: National Rectal Cancer Register

Percent

0

20

40

60

80

100

2009200820072006200520042003200220012000

Women

Total

Men

Figure 48Hospitals

Percentage of patients who received radiotherapy prior to rectal cancer surgery, 2008–2009. Source: National Rectal Cancer Register


67.971.170.385.0

56.176.563.280.082.177.371.476.852.438.141.266.775.665.867.9

65.384.451.462.051.058.547.636.047.854.441.749.253.975.461.662.483.065.750.075.994.4

87.057.146.967.471.454.0

RegionStockholm

UppsalaSörmland

Östergötland

Jönköping

Kronoberg

Kalmar

GotlandBlekinge

Skåne

Halland

Västra Götaland

VärmlandÖrebro

VästmanlandDalarna

Gävleborg

Västernorrland


Norrbotten

Percent

0 20 40 60 80 100

























49 Perforation of the rectum during surgeryOne important complication that can occur during surgery is perforation of the rectum. Such a development increases the risk of tumour recurrence and therefore suffering on the part of the patient.

One goal is to minimise the number of complications that are due to healthcare interventions, in this case injury during the course of an operation. Perforations during surgery cannot be wholly eliminated given that they can also be caused by the patient’s general condition.

Figure 49Total

Percentage of patients with perforated rectum during rectal cancer surgery, 2007–2009. Source: National Rectal Cancer Register

2004–2006 Percent

0.01.51.51.92.12.22.93.84.04.64.85.25.45.66.27.17.47.77.98.4

10.110.3

0 5 10 15 20 25 30

ÖrebroBlekinge


ÖstergötlandVästerbotten

JönköpingGävleborgSWEDEN

SkåneVärmland

DalarnaKronoberg

KalmarStockholm


NorrbottenUppsala

SörmlandVästmanland

Gotland


Figure 49Sweden

Percentage of patients with perforated rectum during rectal cancer surgery. Trend, 2000–2009. Source: National Rectal Cancer Register

Percent

0

5

10

15

20

25

30

2009200820072006200520042003200220012000

Women

Total

Men

Figure 49Hospitals

Percentage of patients with perforated rectum during rectal cancer surgery, 2007–2009. Source: National Rectal Cancer Register

4.01.66.05.60.06.51.89.14.11.13.56.4

10.88.38.53.13.35.33.62.70.0

10.11.56.15.18.89.57.55.67.43.73.5

19.09.82.44.6

11.21.44.13.33.25.90.03.30.02.37.5

10.02.1

RegionStockholm

UppsalaSörmland

Östergötland

Jönköping

Kronoberg

Kalmar

GotlandBlekinge

Skåne

Halland

Västra Götaland

VärmlandÖrebro

VästmanlandDalarna

Gävleborg

Västernorrland


Norrbotten

Percent

0 5 10 15 20 25 30
























Danderyds sjukhus


Figure 50Women

Percentage of patients with anastomosis insufficiency after rectal cancer surgery, 2007–2009. Source: National Rectal Cancer Register

1 Fewer than 10 cases in 2007–2009 2 Fewer than 10 cases, both periods 2004–2006 Percent

0.00.00.03.64.64.84.95.36.36.76.77.6

10.312.513.314.315.415.817.125.0

0 10 20 30 40 50 60


KronobergGävleborg


SörmlandVärmlandSWEDEN


KalmarSkåne

Västra GötalandDalarnaUppsalaHalland

VästmanlandNorrbottenJönköpingJämtland 1

Gotland 2

Figure 50Men


1 Fewer than 10 cases in 2007–2009 2 Fewer than 10 cases, both periods 2004–2006 Percent

1.73.84.66.57.07.17.18.78.89.4

10.510.710.811.912.215.715.816.719.421.7

0 10 20 30 40 50 60

NorrbottenÖrebro

BlekingeJönköpingStockholm

ÖstergötlandSörmland


SWEDENKalmar

UppsalaSkåne

VärmlandJämtland

Västra GötalandGävleborgKronoberg

HallandVästmanland

Västernorrland 1

Gotland 2


Figure 50Total


1 Fewer than 10 cases in 2004–2006 2004–2006 Percent

1.23.76.27.17.37.88.48.69.19.39.49.59.8

10.010.512.112.213.214.415.621.427.3

0 10 20 30 40 50 60

Gotland 1

ÖrebroBlekinge

ÖstergötlandNorrbottenStockholmSörmland

GävleborgJämtland

KronobergVästernorrland

SWEDENVästerbotten

JönköpingDalarna

VärmlandKalmar

SkåneUppsala


Västmanland

50 anastomosis insufficiency after surgerySurgery involves removal of the tumour, followed in approximately 50 per cent of cases by one of several methods to reconnect the two ends of the bowel. The area that has been reconnected is referred to as anastomosis. A serious postoperative complication is anastomosis insufficiency – leakage of faeces into the abdomen – which can cause peritonitis (inflammation) and sepsis (blood poisoning). The con-dition is life-threatening, requiring reoperation and posing the risk of a permanent stoma (opening). The NBHW national guidelines for rectal cancer care identity the percentage of patients who develop anastomosis insufficiency after surgery as an important indicator to monitor.

The outcome is affected to some extent by whether and when the patient received preoperative radiotherapy. The comparison does not take case mix, age, tumour stage, or the patient’s condition into consideration. Such factors can affect the oc-currence of anastomosis insufficiency.


Figure 50Sweden

Percentage of patients with anastomosis insufficiency after rectal cancer surgery. Trend, 2000–2009. Source: National Rectal Cancer Register

Percent

0

5

10

15

20

25

30

2009200820072006200520042003200220012000

Women

Total

Men

Figure 50Hospitals



7.514.421.112.59.12.2

12.318.26.8

10.318.28.2

20.50.06.1

18.218.88.06.3

12.5

15.95.18.2

12.54.00.08.30.00.03.20.0

11.19.44.18.6

22.21.29.86.72.9

20.0

10.58.3

13.2

RegionStockholm

UppsalaSörmland

Östergötland

Jönköping

Kronoberg

Kalmar

GotlandBlekinge

Skåne

Halland

Västra Götaland

VärmlandÖrebro

VästmanlandDalarna

Gävleborg

Västernorrland


Norrbotten

Percent

0 10 20 30 40 50

Sunderbyns sjukhusSkellefteå lasarett 1


Örnsköldsviks sjukhus 1

Sundsvalls sjukhus 1

Sollefteå sjukhus 1




















Danderyds sjukhus


51 More than 21 days of hospitalisation after surgeryAssuming no complications occur, hospitalisation after surgery should not exceed 21 days. The goal is based on a follow-up by the National Rectal Cancer Register for 1995–2009 showing that the median hospitalisation period following surgery was fewer than 13 days for patients discharged to home and fewer than 21 days for those who were discharged to another institution (a different department or special housing). Only a few years deviated from that pattern. Thus, patients who were discharged to another institution had generally been hospitalised longer.

The comparison does not take the possible effects of comorbidity or the patient’s preoperative condition into consideration.

Figure 51Total

Percentage of patients with more than 21 days of hospitalisation after rectal cancer surgery, 2008–2009. Source: National Rectal Cancer Register

Percentage discharged to another institution

Percentage discharged to home

2006–2007 Percent

3.96.16.47.78.39.19.29.9

10.110.711.511.511.712.312.513.213.915.118.219.827.428.6

0 10 20 30 40 50 60

JämtlandSörmland

SkåneUppsala

GävleborgKronoberg

KalmarVärmlandSWEDEN

ÖrebroJönköping

VästerbottenBlekinge


VästmanlandGotland


NorrbottenDalarnaHalland


Figure 51Sweden

Percentage of patients with more than 21 days of hospitalisation after rectal cancer surgery. Trend, 2000–2009. Source: National Rectal Cancer Register

Percent

0

5

10

15

20

25

30

2009200820072006200520042003200220012000

Women

Total

Men

Figure 51Hospitals

Percentage of patients with more than 21 days of hospitalisation after rectal cancer surgery, 2008–2009. Source: National Rectal Cancer Register

Percentage discharged to another institution

Percentage discharged to home


3.86.6

16.212.5

2.416.110.514.737.54.63.9

14.65.09.5

11.825.07.39.2

25.0

10.726.75.6

25.719.00.07.34.0

26.16.5

12.513.19.0

12.311.611.810.24.5

10.015.513.9

4.44.8

31.310.214.36.4

RegionStockholm

UppsalaSörmland

Östergötland

Jönköping

Kronoberg

Kalmar

GotlandBlekinge

Skåne

Halland

Västra Götaland

VärmlandÖrebro

VästmanlandDalarna

Gävleborg

Västernorrland


Norrbotten

Percent

0 10 20 30 40 50 60

























52 Reoperation due to complications within 30 days of primary surgery

Approximately 82 per cent of all rectal cancer surgery involves removal of the entire tumour. The location and size of the tumour, as well as the patient’s general condi-tion, affect the scope and riskiness of the operation. Relatively prompt reoperation may be required due to bleeding, infection, leakage or another complication. Reop-eration entails additional suffering for the patient and increases the risk of further complications.

The NBHW national guidelines for rectal cancer care identify reoperation within 30 days of primary surgery as an important indicator to monitor.

One source of error in comparing data is that some hospitals report minor interven-tions as reoperations and some do not. The percentage of reoperations is also related to the way that primary surgery was performed and the patient’s condition at the time.

Figure 52Total

Percentage of patients with reoperation within 30 days after primary rectal cancer surgery, 2005–2009.Source: National Rectal Cancer Register

2003–2007 Percent

3.94.25.56.27.89.09.79.9

10.410.410.810.911.011.212.212.212.612.612.612.714.014.0

0 5 10 15 20 25 30

JämtlandJönköping

KalmarVärmland

KronobergStockholm

Västra GötalandVästernorrland


ÖrebroSWEDEN

VästerbottenSkåne

HallandBlekinge

ÖstergötlandSörmland

DalarnaUppsalaGotland

Västmanland


Figure 52Women


1 Fewer than 10 cases 2003–2007 Percent

4.64.95.65.66.77.68.08.18.39.29.69.89.9

10.110.510.610.711.411.513.313.7

0 5 10 15 20 25 30

KronobergJämtland

JönköpingVästernorrland

SkåneÖrebro

NorrbottenSörmland


VästerbottenSWEDEN

ÖstergötlandKalmar

BlekingeGävleborgVärmland

VästmanlandDalarnaUppsalaHalland

Gotland 1

Figure 52Men


2003–2007 Percent

3.05.66.06.56.79.6

10.210.810.911.011.211.911.912.813.113.613.814.314.515.215.616.8

0 5 10 15 20 25 30

VärmlandJönköping

KalmarStockholm

JämtlandVästra Götaland

GävleborgHalland


KronobergNorrbotten

ÖrebroVästerbotten

BlekingeSkåne

ÖstergötlandDalarna

SörmlandUppsalaGotland

Västmanland


Figure 52Sweden

Percentage of patients with reoperation within 30 days after primary rectal cancer surgery. Trend, 1995–2009. Source: National Rectal Cancer Register

Percent

0

5

10

15

20

25

30

090807060504030201009998979695

Women

Total

Men

Figure 52Hospitals


8.510.311.59.89.19.1

12.89.06.17.17.38.26.4

15.010.718.821.58.7

11.511.06.1

14.99.36.3

10.07.7

14.27.1

12.314.09.1

15.38.3

11.513.011.513.511.23.97.9

13.38.0

21.223.56.15.9

10.310.613.011.7

RegionStockholm

UppsalaSörmland

Östergötland

Jönköping

Kronoberg

Kalmar

GotlandBlekinge

Skåne

Halland

Västra Götaland

VärmlandÖrebro

VästmanlandDalarna

Gävleborg

Västernorrland


Norrbotten

Percent

0 10 20 30 40









Skaraborgs sjukhus, LidköpingNU-sjukvården, Uddevalla





Blekingesjukhuset, KarlskronaBlekingesjukhuset, Karlshamn

Visby lasarettVästerviks sjukhus

Länssjukhuset KalmarVäxjö lasarett

Ljungby lasarettVärnamo sjukhus

Länssjukhuset Ryhov, JönköpingHöglandssjukhuset, Eksjö

Vrinnevisjukhuset i NorrköpingUniversitetssjukhuset i Linköping

Nyköpings sjukhusMälarsjukhuset, Eskilstuna

Akademiska sjukhuset, UppsalaSödertälje sjukhus

Södersjukhuset, StockholmS:t Görans sjukhus, Stockholm

Norrtälje sjukhusKarolinska, Solna


Danderyds sjukhus


Figure 53Women

Percentage of patients with relapse of cancer of the pelvis within five years after rectal cancer surgery. Patients who underwent surgery in 2001–2004 with follow-up through 2009. Source: National Rectal Cancer Register


0.01.82.73.73.94.24.36.16.46.86.87.17.78.08.39.09.39.59.7

15.023.4

0 10 20 30 40

HallandKalmar

SörmlandSkåne

BlekingeStockholm

Västra GötalandJönköpingSWEDEN

KronobergNorrbotten

VärmlandVästernorrland


JämtlandDalarna

VästerbottenÖrebro

UppsalaVästmanland

Gotland 1

Figure 53Men


Percent

1.01.11.42.93.03.54.24.37.17.37.47.47.47.67.98.39.39.59.6

10.511.811.9

0 10 20 30 40

HallandKronoberg

SkåneVärmlandStockholm

JämtlandÖrebro

NorrbottenVästerbotten

Västra GötalandDalarnaBlekinge

SWEDENGotland


KalmarGävleborgJönköping

UppsalaVästmanlandÖstergötland


53 new cancer of the pelvis within five years of surgeryRelapse refers to the recurrence of a malignancy in an area that was previously treated by surgery or radiotherapy. The result is a very high risk of incurable disease or extensive surgery, chemotherapy or radiotherapy. The NBHW national guide-lines for rectal cancer care identify the percentage of relapses in the pelvis within two years after surgery as an important indicator to monitor. The rectal cancer reg-ister monitors tumour recurrence for five years after surgery, as presented in this comparison.

The result is affected to some extent by the patient’s preoperative condition.

Figure 53Total


Percent

0.61.62.54.55.15.35.35.95.96.36.57.27.47.47.57.88.28.39.39.7

10.116.9

0 10 20 30 40

HallandSkåne

KronobergStockholmVärmland


JämtlandSWEDEN

NorrbottenKalmar


DalarnaÖrebro

JönköpingGotland

VästernorrlandGävleborg

ÖstergötlandUppsala

Västmanland


Figure 53Hospitals



12.07.48.49.24.07.89.0

24.33.28.02.04.10.04.54.89.38.0

10.310.35.66.38.46.7

10.3

9.113.919.73.43.37.05.04.09.9

11.09.44.00.76.45.82.5

10.95.66.03.27.76.75.64.1

RegionStockholm

UppsalaSörmland

Östergötland

Jönköping

Kronoberg

Kalmar

GotlandBlekinge

Skåne

Halland

Västra Götaland

VärmlandÖrebro

VästmanlandDalarna

Gävleborg

Västernorrland


Norrbotten

Percent

0 10 20 30 40












Universitetssjukhuset MASUniversitetssjukhuset i Lund 1












Danderyds sjukhus


54 Deaths within 30 and 90 days of surgeryThe NBHW national guidelines for rectal cancer care identify the percentage of deaths within 30 days of surgery as an important indicator for monitoring health-care quality. The indicator reflects the selection of patients for surgery, as well as the care they receive before, during and after the operation. Given that patients who experience complications generally survive the first 30 days thanks to intensive care and other interventions, this comparison also presents those who die within 90 days.

Age, gender, and severity of the malignancy also affect the percentage of deaths. Table 2 shows the odds ratio by county, adjusted for age, gender and tumour stage. A value of 1 is assigned to the national average of patients who die within 90 days of surgery. A value less than 1 represents a percentage below the national average and a value greater than 1 represents a percentage above the national average.

Figure 54Sweden

Percentage of deaths within 90 days after rectal cancer surgery. Trend, 2000–2009. Source: National Rectal Cancer Register

Percent

0

5

10

15

20

25

30

2009200820072006200520042003200220012000

Women

Total

Men


Figure 54Women

Percentage of deaths within 30 and 90 days after rectal cancer surgery, 2007–2009.Source: National Rectal Cancer Register


Percentage of deaths within 30 days

Percentage of deaths within 31-90 days

2002–2006 Percent

0.00.00.00.01.61.62.02.02.02.22.32.42.52.52.73.83.95.45.55.77.1

0 5 10 15 20 25 30

BlekingeKalmarÖrebro

NorrbottenSörmland


SkåneStockholm

UppsalaÖstergötland

VästernorrlandVästmanland

JönköpingDalarna

VärmlandGävleborg

VästerbottenKronoberg

JämtlandHalland

Gotland 1

Figure 54Men


2002–2006



Percent

0.00.01.82.32.52.63.23.23.33.63.84.14.44.44.44.65.35.35.75.96.1

12.5

0 5 10 15 20 25 30

JämtlandKalmar


JönköpingKronoberg

SkåneVärmland

ÖrebroHalland

SWEDENSörmland

VästerbottenNorrbotten

UppsalaDalarna

StockholmGävleborg

VästmanlandVästernorrland

GotlandBlekinge


Figure 54Total




2002–2006 Percent

0.02.02.12.12.22.32.62.62.82.93.33.33.63.73.94.04.14.34.84.95.98.7

0 5 10 15 20 25 30

JämtlandKalmar


ÖstergötlandNorrbottenJönköpingSörmland

SkåneSWEDEN

KronobergVärmland

UppsalaDalarnaHalland

StockholmBlekinge

VästmanlandVästerbotten


Gotland

Table 2

Countycouncil

Odds ratio

95 % Confidence interval

Countycouncil

Odds ratio

95 % Confidence interval

Stockholm 0.84 0.51–1.39 V.Götaland 1.37 0.90–2.09

Uppsala 0.58 0.14–2.41 Värmland 0.93 0.37–2.32

Sörmland 1.18 0.46–2.99 Örebro 1.25 0.56–2.81

Östergötland 1.33 0.63–2.82 Västmanland 0.74 0.23–2.38

Jönköping 1.08 0.42–2.73 Dalarna 0.74 0.27–2.08

Kronoberg 0.85 0.26–2.83 Gävleborg 0.40 0.10–1.65

Kalmar 1.57 0.77–3.23 Västernorrland 0.68 0.16–2.80

Gotland 0.00 Jämtland 2.34 0.80–6.81

Blekinge 0.69 0.17–2.88 Västerbotten 0.52 0.13–2.18

RegionSkåne 1.09 0.68–1.76 Norrbotten 1.23 0.44–3.43

Halland 0.30 0.07–1.23


Figure 54Hospitals


Percentage of deaths within 30 days Percentage of deaths within 31-90 days

2.01.73.03.97.13.20.04.82.53.46.93.75.10.03.59.43.13.57.12.70.02.32.37.04.02.01.44.55.4

11.13.06.98.34.52.43.44.92.23.13.32.22.07.11.70.09.31.53.54.1

RegionStockholm

UppsalaSörmland

Östergötland

Jönköping

Kronoberg

Kalmar

GotlandBlekinge

Skåne

Halland

Västra Götaland

VärmlandÖrebro

VästmanlandDalarna

Gävleborg

Västernorrland


Norrbotten

Percent

0 5 10 15 20 25 30
























Danderyds sjukhus


LuNGCANCER





Relativeone-yearsurvivalrate 43% 37.7%


As the fifth most common form of the disease, lung cancer was diagnosed in 1 772 women and 1 696 men in 2009. Approximately half of newly diagnosed patients are over 70 and fewer than 1 per cent are below 40. Lung cancer claims approximately 3 500 Swedish lives every year, more than any other form of the disease. The most frequent cause by far is smoking.

The number of cases has decreased among men since the 1980s and increased among women, most probably due to changes in women’s smoking habits since the 1950s. The number of smokers has decreased in recent decades, but the steady growth of cases among women reflects their smoking habits 20 years ago and earlier.

Lung cancer is aggressive but can be cured if it has not metastasised. There are two different types of the disease: small-cell and non-small-cell. Approximately 80 per cent of all lung cancer is non-small-cell, 15 per cent small-cell and 5 per cent indeter-minate. Stages I and II of non-small-cell cancer are amenable to surgery, assuming that the patient does not have reduced lung capacity, poor general health or other diseases that present obstacles. Stage III non-small-cell lung cancer is limited to the thoracic cavity and may be operable. Stage IV non-small-cell cancer has metasta-sised and cannot be cured through surgery.

Approximately 70 per cent of patients are at stages III or IV at the time of diagnosis and usually cannot be cured. Some 75 per cent of them die within a year. The various palliative treatment methods (drug therapy, radiotherapy or other means of allevi-ating symptoms) all focus on improving the quality of life of these patients.

This report presents outcomes for eight indicators that reflect either curative or palliative interventions. The indicators look at survival rates, diagnosis, curative surgery, palliative treatment, multidisciplinary team meetings and waiting times. Seven of the indicators are based on data from the National Lung Cancer Register, whereas the survival indicator is taken from the Swedish Cancer Register.

The national guidelines for lung cancer care published by the NBHW in 2011 con-tain targets for several of the indicators. The project to formulate the targets in spring 2011 collected data from the National Lung Cancer Register on everyone who had been diagnosed in 2002–2009. The subsequent statistical method chose the


90th percentile of the nationwide results as the target. Thus, the target is realistic in the sense that some counties have already attained it.

The comparisons that are presented are for 2002–2009 when no targets had yet been set. Along with the outcomes for each indicator, however, the discussion speci-fies the future targets that can now be used to find potential for improvement in lung cancer treatment and care.

The same sample from the National Lung Cancer Register has been used as during the project to formulate the targets. Thus, the outcomes cover a longer period than is typical for this report.

55 lung cancer – relative one-year, two-year and five-year survival rates

Relative survival rates for lung cancer are low but somewhat higher among women than men. Survival rates, particularly for one or two years, have trended upwards since the early 1990s. More women develop and die of lung cancer before the age of 60, whereas the majority of older patients are men.

Figure 55 indicates that the relative one-year survival rate among men rose by al-most 10 per cent from 1990-1994 to 2005–2009. The increase among women was somewhat greater. Men had a relative one-year survival rate of 37.7 per cent and a

Figure 55Total

Lung cancer – relative one-year survival rates. Patients diagnosed in 2000– 2004. Patients age 30–89 at the time of diagnosis. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare


47.546.745.044.444.342.641.741.240.540.338.238.138.037.636.536.135.735.535.534.233.732.9

0 20 40 60 80


VärmlandÖrebro

VästmanlandSörmland

VästerbottenKronoberg

KalmarBlekinge

GävleborgSkåne

SWEDENDalarna


ÖstergötlandStockholm

UppsalaNorrbotten

GotlandHalland


two-year rate of 20.9 per cent in 2005–2009, as opposed to 43 per cent and 27 per cent respectively for women. There were significant regional differences: anywhere from 32.9 to 47.5 per cent. The older the patient at the time of diagnosis, the lower the survival rate.

The relative five-year survival rate is approximately 12 per cent among men and 15 per cent among women.

56 Multidisciplinary team meeting prior to treatmentPrimary lung cancer treatment may be preceded by a multidisciplinary team meet-ing, a comprehensive assessment for the purpose of optimising the intervention. Surgery, oncology, pulmonary, radiology, pathology and other specialists, as well as nurses, may participate A multidisciplinary team meeting is particularly important when the benefit of surgery, radiotherapy or drug therapy is difficult to assess; mul-timodal treatment may be indicated. The NBHW national guidelines for lung can-

Figure 55 Sweden

Lung cancer – relative one-year survival rates. Trend, 1990–2009. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare

Percent

0

20

40

60

80

100

2005-20092000-20041995-19991990-1994

Women

Total

Men

Figure 56Sweden

Percentage of patients who have a multidisciplinary team meeting prior to primary treatment for lung cancer. Trend, 2002–2009. Source: National Lung Cancer Register

Percent

0

20

40

60

80

100

20092008200720062005200420032002

Women

Total

Men


cer care assign high priority to a multidisciplinary team meeting before commence-ment of treatment of a newly diagnosed case. The guidelines target meetings in 74 per cent of the cases, but few counties reach that level. The idea is that all counties should be able to do so and that the level be even higher eventually.

Certain regional differences in reporting of multidisciplinary team meetings affect the outcomes in the diagram. For one thing, there is no uniform definition of the specialists who need to participate in order for a multidisciplinary team meeting to take place. Some counties report only meetings attended by all of the various types of specialists and are thereby underrepresented in the register.

57 Waiting time from receipt of a referral by the specialist clinic until decision to treat

A key indicator of lung cancer care is the amount of time that transpires between the date that a specialist clinic receives a referral – or is contacted by the patient – and decision to treat. The waiting time includes assessment and diagnosis until a decision is made at a multidisciplinary team meeting or in some other manner. The clinic ordinarily specialises in either pulmonary medicine or oncology. According to the Swedish Lung Cancer Group, the waiting time should be 28 days or less for at least 80 per cent of patients.

Figure 56Total

Percentage of patients who had a multidisciplinary team meeting prior to primary treatment for lung cancer, 2002–2009. Source: National Lung Cancer Register

Percent

80.578.873.371.165.762.350.446.846.746.644.343.942.339.837.836.535.332.525.723.519.911.8

0 20 40 60 80 100

DalarnaGotlandHalland

VästmanlandKronoberg

BlekingeSkåne

JönköpingUppsala

Västra GötalandVästernorrland

JämtlandÖrebro

NorrbottenKalmar

SWEDENSörmland


VärmlandStockholm

Västerbotten


Figure 57Total

Waiting time from receipt of a referral by the specialist clinic until decision to treat lung cancer, 2009. Source: National Lung Cancer Register


15222323252727282829303131333334373840434748

0 20 40 60 80 100 120

JönköpingGotland

ÖstergötlandKalmar

StockholmVästra Götaland

JämtlandSWEDEN

DalarnaBlekinge

VästernorrlandKronoberg

SkåneVästerbotten

SörmlandGävleborgVärmland

NorrbottenUppsala

VästmanlandHallandÖrebro

58 lung cancer confirmed by a biopsyA biopsy is required to confirm the diagnosis of lung cancer, determine what type is involved and ensure that it is primary and not metastasis from another tumour. Such an assessment sets the stage for correct and optimum treatment and care. The NBHW national guidelines for lung cancer care assign very high priority to a biopsy.

Figure 58Sweden

Percentage of lung cancer diagnoses confirmed by a biopsy Trend, 2002–2009. Source: National Lung Cancer Register

Percent

0

20

40

60

80

100

20092008200720062005200420032002

Women

Total

Men


Figure 58Total

Percentage of lung cancer diagnoses confirmed by a biopsy, 2002–2009. Source: National Lung Cancer Register

Percent

98.998.598.498.398.397.997.897.397.096.696.596.596.396.395.395.194.793.691.391.288.787.0

0 20 40 60 80 100

VästmanlandÖrebro

GävleborgUppsala

SörmlandStockholmSWEDEN

SkåneVästra Götaland

DalarnaVärmlandJönköping

VästernorrlandBlekingeHalland

JämtlandÖstergötland

NorrbottenGotlandKalmar


The guidelines target biopsies in 99 per cent of cases, a level that most counties are close to attaining. The figure may be lower for some counties because they do not report all of their cases – particularly elderly patients and those with comorbidity – to the lung cancer register.

59 Combined PET/CT scan prior to curative treatment Providing the best possible treatment requires as exact a determination as possible of the location of the malignancy. Lung cancer assessments include examining the upper abdomen by means of X-rays, CT scans, etc. Combined positron emission tomography (PET) and computer tomography (CT) in patients with stage IB-IIIB non-small-cell lung cancer can help decide whether curative treatment is indicated by means of either surgery, chemotherapy or radiotherapy. The NBHW national guidelines assign very high priority to PET/CT scans for this patient population.

Because this is a new variable in the National Lung Cancer Register, data are pre-sented for 2007–2009 only. Even though the sample is small, the guidelines indicate that at least 82 per cent of cases should be assessed with a PET/CT scan.

The benefit of the diagnostic method was not generally known during the compari-son period and the counties were still in the process of adopting it.


60 Curative surgery for stage i and ii non-small-cell lung cancerSurgery cures more cases of non-small-cell lung cancer by far than any other meth-od. Whether the disease is operable depends on the location and size of the malig-nancy, as well as whether it has metastasised to other organs. Curative surgery is indicated primarily for patients in stages I or II. The NBHW national guidelines for lung cancer care identify curative surgery as an important indicator to monitor. Un-derutilisation of the method may reflect missed opportunities to cure the disease.

This indicator measures treatment interventions by county for people in an early stage of lung cancer. The comparison presents the percentage of patients who are scheduled for curative surgery. A follow-up by the lung cancer register showed that surgery was performed 90 per cent of the time.

The target of the NBHW national guidelines for 2011 is that 79 per cent of patients in stage I or II of non-small-cell lung cancer receive curative surgery.

Figure 59Total

Percentage of patients with non-small-cell lung cancer who underwent PET/CT scan prior to commencement of curative treatment, 2007–2009. Refers to stage IB-IIIB. Source: National Lung Cancer Register


83.374.374.367.364.059.458.349.145.844.444.142.941.434.133.329.223.114.711.1

9.16.4

0 20 40 60 80 100

Gotland 1

GävleborgSörmland


VästernorrlandBlekingeUppsala

VärmlandDalarna

VästerbottenNorrbotten

ÖrebroJämtland

SWEDENKronobergJönköping

HallandÖstergötland

KalmarStockholm

Skåne


Figure 60Women

Percentage of patients with non-small-cell lung cancer scheduled for curative surgery, 2002–2009. Refers to stage I and II. Source: National Lung Cancer Register

Percent

82.881.880.377.877.576.976.575.074.774.674.572.271.870.770.068.766.166.063.863.158.853.0

0 20 40 60 80 100

NorrbottenDalarna


VästerbottenKalmar


UppsalaSWEDEN


GävleborgSkåne

StockholmHalland

KronobergSörmlandJämtland

JönköpingGotlandBlekinge

Figure 60Men


Percent

80.477.475.672.171.269.968.265.665.564.764.463.662.161.560.659.558.958.557.454.853.652.6

0 20 40 60 80 100

GotlandVärmland


NorrbottenVästernorrland

UppsalaVästra Götaland


HallandJämtlandSörmland

GävleborgSWEDENJönköping

SkåneStockholm

BlekingeVästmanland

KronobergÖrebro


61 Palliative radiotherapy for stage iiiB and iv lung cancerThe purpose of palliative radiotherapy is to damage the cancer cells and prevent the tumour from growing, thereby delaying or alleviating the symptoms. The NBHW national guidelines assign high priority to the method for patients in stage IIIB or IV of incurable lung cancer who are experiencing pain, coughing, haemoptysis (ex-pectoration of blood) or dyspnoea (breathlessness) from the thoracic organs. Given

Figure 60Total


Percent

77.677.276.473.573.473.172.172.170.370.169.468.667.065.164.563.763.361.961.457.756.655.7

0 20 40 60 80 100

NorrbottenDalarna


VästerbottenGotlandKalmar

Västra GötalandUppsala

ÖstergötlandSWEDENJämtland

GävleborgHalland

SkåneSörmland

StockholmVästmanland

JönköpingBlekinge

KronobergÖrebro

Figure 60Sweden

Percentage of patients with non-small-cell lung cancer scheduled for curative surgery. Refers to stage I and II. Trend, 2002–2009. Source: National Lung Cancer Register

Percent

0

20

40

60

80

100

20092008200720062005200420032002

Women

Total

Men


that the adverse effects of radiotherapy can cause deterioration of a patient’s gen-eral condition, it is not indicated in all cases. Some patients decline the treatment for other reasons.

The indicator reflects whether patients with incurable stage IIIB and IV lung cancer are actively offered palliative radiotherapy; large regional differences may suggest

Figure 61Total

Percentage of patients with incurable lung cancer who were offered radiotherapy for palliative purposes, 2002–2009. Refers to stage IIIB and IV. Source: National Lung Cancer Register

Percent

27.523.122.920.216.015.014.213.313.112.712.511.911.610.3

8.47.47.36.85.04.94.82.4

0 10 20 30 40

GotlandHallandÖrebro

BlekingeDalarnaUppsala


KronobergGävleborgStockholm

NorrbottenSkåne

SWEDENJönköping

VästmanlandKalmar

Västra GötalandÖstergötland


Värmland

Figure 61Sweden

Percent

0

5

10

15

20

25

30

20092008200720062005200420032002

Women

Total

Men

Percentage of patients with incurable lung cancer who were offered radiotherapy for palliative purposes, 2002–2009. Refers to stage IIIB and IV. Trend 2002–2009. Source: National Lung Cancer Register


discrepancies in care quality. The counties also varied substantially, anywhere from 2.4 to 27.5 per cent.

Given that the guidelines target 22 per cent, a number of counties should consider the possibility that they are underutilising palliative radiotherapy.

62 Palliative chemotherapy for incurable lung cancerChemotherapy involves drug therapy to kill cancer cells or prevent them from mul-tiplying. A number of different drugs can be used, often in combination, with equal efficacy. However, the adverse effects may vary somewhat. The clinical practice guidelines recommend that chemotherapy be tried for the purpose of alleviating symptoms in patients with incurable lung cancer. The NBHW national guidelines for lung cancer care identify palliative chemotherapy in stage IIIB and IV patients with a performance status of 0–2 as a key indicator to monitor. Although not all stage IV patients should receive the treatment, the indicator is relevant to a com-parison of regional variations and may suggest quality differences.

Performance status (PS) grades a patient’s level of functioning on a scale of 0-4. PS 0 refers to a fully active person, while PS 2 is assigned to people who can perform normal activities and are out of bed for more than half the day, though with reduced

Figure 61Total

Percentage of patients with incurable lung cancer who were offered radiotherapy for palliative purposes, 2002–2009. Refers to stage IIIB and IV. Source: National Lung Cancer Register

Percent

27.523.122.920.216.015.014.213.313.112.712.511.911.610.3

8.47.47.36.85.04.94.82.4

0 10 20 30 40

GotlandHallandÖrebro

BlekingeDalarnaUppsala


KronobergGävleborgStockholm

NorrbottenSkåne

SWEDENJönköping

VästmanlandKalmar

Västra GötalandÖstergötland


Värmland

Figure 62Total

Percentage of patients with lung cancer who were offered chemotherapy for palliative purposes, 2002–2009. Refers to stage IIIB and IV. Source: National Lung Cancer Register

Percent

87.980.774.873.472.269.869.469.265.965.163.863.563.263.262.561.057.957.656.054.545.743.1

0 20 40 60 80 100

SörmlandVärmland

VästerbottenUppsala


KronobergJämtland

SWEDENSkåne

VästmanlandStockholmGävleborg

KalmarNorrbotten

BlekingeJönköping


HallandDalarnaGotland


strength. PS is important for assessing whether a patient can handle and benefit from chemotherapy.

The target of the NBHW national guidelines is that 78 per cent of this patient pop-ulation be offered palliative chemotherapy. The target considers the fact that cura-tive radiotherapy or chemotherapy is indicated instead for some stage IIIB patients.

The outcomes for individual hospitals may be affected by their having recorded the stages of the disease in different ways or underreported elderly patients to the qual-ity register. Furthermore, some hospitals may have a larger percentage of patients with performance status 3–4, i.e., unable to handle chemotherapy. While some of the regional variation may be due to these factors, the data suggest that a certain degree of undertreatment is likely.

Figure 62Sweden

Percentage of patients with lung cancer who were offered chemotherapy for palliative purposes. Refers to stage IIIB and IV. Trend, 2002–2009. Source: National Lung Cancer Register

Percent

0

20

40

60

80

100

20092008200720062005200420032002

Women

Total

Men


HEADANDNECKCANCER





Relativefive-yearsurvivalrate 65% 60%


Head and neck cancer refers to malignancies of the lip, mouth, throat, larynx, nose, sinus cavities and salivary glands. Assessment, treatment and diagnostic methods for the various forms of the disease vary greatly. Approximately 10 000 Swedes cur-rently alive have or have had head or neck cancer. The overall five-year survival rate is 65 per cent for women and 60 per cent for men. The disease is more common among men and people over 60 years of age.

Head and neck cancer can cause a great deal of suffering by making it difficult to breathe or eat, as well as affecting speech, vision, hearing, smell and other impor-tant functions.

This report presents four indicators. The first indicator concerns survival rates, fol-lowed by one that reflects multidisciplinary team meetings and two that measure waiting times. Five-year survival rates are broken down by county and are based on data from the Swedish Cancer Register. The other data are taken from the Swedish Head and Neck Cancer Register. The register, which has been in existence since 2008, covers surgery, chemotherapy and radiotherapy alike.

Approximately 90 per cent of treatment for head and neck cancer is provided at the regional level, whereas county hospitals perform assessments until decision to treat. Most decisions are made by a multidisciplinary team meeting at the regional level. Thus, we have chosen to present the percentage of patients assessed by means of a multidisciplinary team meeting by region and waiting times by both region and county.

63 Head and neck cancer – five-year survival ratesFive-year survival rates are presented collectively for all forms of head and neck can-cer even though there are major differences between them. The survival rate has in-creased somewhat for women since 1990 but remained constant for men. Figure 63 shows that the five-year survival rate was 62 per cent in 2005–2009. Some regional differences exist, but the confidence intervals are broad and the role of chance can-not be ruled out.


64 Multidisciplinary team meeting prior to treatment Primary treatment for head and neck cancer may be preceded by a multidiscipli-nary team meeting, a comprehensive assessment for the purpose of optimising the intervention. ENT surgery, oncology, radiology, pathology and other specialists may participate.

Figure 63Total

Head and neck cancer – five-year survival rates Patients diagnosed in 2000– 2004. Patients age 30–89 at the time of diagnosis. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare


69.068.266.164.463.563.563.263.163.062.662.462.161.961.861.461.360.958.557.256.552.249.5

0 20 40 60 80 100


VästernorrlandKalmarÖrebro

NorrbottenSkåne

JönköpingSWEDEN

Västra GötalandVärmland

ÖstergötlandKronobergStockholmGävleborgSörmland

DalarnaGotlandHalland

VästmanlandUppsalaBlekinge

Figure 63Sweden

Head and neck cancer – five-year survival rates Trend, 1990–2009. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare

Percent

0

20

40

60

80

100

2005-20092000-20041995-19991990-1994

Women

Total

Men


Figure 64Total

Percentage of patients who had a multidisciplinary team meeting prior to decision to treat head and neck cancer, 2009-2010. Source: Swedish Head and Neck Cancer Register

Percent

96.492.191.289.087.482.374.1

0 20 40 60 80 100

NorraSödra

SydöstraSWEDEN

Uppsala-ÖrebroVästra

Stockholm-Gotland

Healthcare region

65 Waiting time from receipt of a referral until decision to treatThis indicator was presented in the 2010 edition of Quality and Efficiency in Swedish Health Care – Regional Comparisons. Assessment of suspected cancer must be com-pleted quickly so that treatment can commence before the malignancy gets bigger or metastasises. The way that the assessment is planned and the resources that are at the disposal of the units that must be utilised determine the amount of time that passes from the day that a clinic receives a referral or is contacted by the patient until decision to treat.

Figure 65Total

Median waiting time from receipt of a referral by an ear, nose and throat clinic until decision to treat for patients with malignant head and neck tumours, 2009–2010. Source: Swedish Head and Neck Cancer Register


22293030323334353535363637373941414851525355

0 20 40 60 80 100

VästernorrlandJönköpingVärmland

ÖstergötlandJämtland

NorrbottenHallandKalmar



SWEDENBlekinge

StockholmSörmland

GotlandVästmanland

DalarnaGävleborg

SkåneUppsala


Differences both within and between the various regions are relatively large. Simi-larly, the northern (Norra) and south-east (Sydöstra) regions have longer waiting times than the other regions.

66 Waiting time from receipt of a referral until commencement of treatment

The waiting time from receipt of a referral until commencement of treatment illu-minates an additional step in the process and reflects a variable that is central to the

Days

32333435374444

0 20 40 60 80 100

SydöstraNorraVästra

SWEDENStockholm-Gotland

Uppsala-ÖrebroSödra

Healthcare region

Figure 65Total

Median waiting time from receipt of a referral by an ear, nose and throat clinic until decision to treat for patients with malignant head and neck tumours, 2009–2010. Source: Swedish Head and Neck Cancer Register

Value first quartile Median Value third quartile

Figure 66Total

Median waiting time from receipt of a referral by an ear, nose and throat clinic until commencement of treatment for patients with malignant head and neck tumours, 2008–2009. Source: Swedish Head and Neck Cancer Register


36395051525253565757575961626367697072747682

0 20 40 60 80 100 120

VästernorrlandJönköpingVärmland

KalmarHalland

ÖstergötlandJämtland

KronobergNorrbotten

VästerbottenVästmanland


SkåneSörmland

ÖrebroDalarnaBlekinge

GävleborgStockholm

UppsalaGotland


ongoing progress of the disease. It is also important to patients that they can quickly start on prescribed treatment.

There is a large variation within and between the various counties.

The south-east (Sydöstra) and northern (Norra) regions have longer waiting times for commencement of treatment than the other regions. The difference is presum-ably due to the period after receipt of the referral.

Figure 66Total

Median waiting time from receipt of a referral by an ear, nose and throat clinic until commencement of treatment for patients with malignant head and neck tumours, 2008–2009. Source: Swedish Head and Neck Cancer Register


49555757586771

0 20 40 60 80 100 120

SydöstraNorraSödra

VästraSWEDEN

Uppsala-ÖrebroStockholm-Gotland

Healthcare region


MALIGNANTMELANoMA







Malignant melanoma is the most serious of the three common forms of skin cancer. It accounts for 5 per cent of all cancer in both women and men. A total of 2 819 people – 1 411 women and 1 408 men – were diagnosed with malignant melanoma in 2009. More than 30 500 Swedes now alive have had the disease. After having held fairly steady in the 1990s, the incidence has risen by nearly 5 per cent every year in the 2000s. Generally speaking, however, malignant melanoma is more common in southern than northern Sweden. Mortality rates have also increased: from approxi-mately 4 per cent to approximately 5 per cent. Excessive exposure to ultraviolet rays constitutes the biggest risk factor for the disease.

A melanoma that is detected at an early stage (1 millimetre thick or less) can usually be cured with simple surgery. However, a melanoma that is thicker than 4 millime-tres carries a considerable risk of recurrence and death.

The median age at diagnosis is 64 in men and 60 in women, but young people can also develop the disease. However, it is very uncommon in children. Approximately 40 per cent of women and 30 per cent of men are younger than 55 when they are diagnosed.

This report presents outcomes for four indicators, three of which are based on data from the Swedish Melanoma Register. Two indicators measure the waiting times that are important from the patient’s point of view and one indicator measures the percentage of thin malignant melanomas (1.0 millimetre or less). The survival data have been taken from the Swedish Cancer Register.

67 Malignant melanoma – relative five-year survival ratesFigure 67 shows that the relative five-year survival rate for 2005–2009 was 86.0 per cent for men and 92.6 per cent for women. Men’s survival rate increased in the 1990s and then retreated somewhat, whereas women’s has risen modestly since the 1990s. There are certain differences between various parts of the country.


Figure 67Women

Malignant melanoma – relative five-year survival rates. Patients diagnosed in 2000–2004. Patients age 30–89 at the time of diagnosis. Age-standardised values.Source: Swedish Cancer Register, Swedish National Board of Health and Welfare

Confidence interval calculated using Taylor series 1 Fewer than 15 cases Percent

97.395.895.395.094.794.393.192.892.692.191.591.291.190.690.390.390.189.788.786.085.6

0 20 40 60 80 100

Gotland 1


VärmlandKronoberg


SörmlandSkåne

UppsalaHalland

JönköpingNorrbotten

SWEDENGävleborg


DalarnaVästra Götaland

KalmarVästmanland

Jämtland

Figure 67Men



90.889.989.489.189.088.588.186.586.085.384.784.584.184.083.982.381.581.480.472.572.3

0 20 40 60 80 100

Gotland 1

GävleborgVärmlandSörmland


ÖrebroSkåne

JämtlandKronoberg

ÖstergötlandBlekinge

JönköpingSWEDEN

HallandKalmar


DalarnaVästmanland

UppsalaNorrbotten


68 Waiting time from initial doctor’s appointment until primary surgery The melanoma register has been set up for entry of waiting times since 2009. How-ever, there is still a high percentage of nonreporting and only half of the county councils can account for waiting times from the initial doctor’s appointment until primary surgery (removal of the skin change that has been sent for histopathologi-

Figure 67Total



92.792.391.991.691.591.491.289.889.389.388.387.987.487.387.187.085.885.884.082.282.1

0 20 40 60 80 100

Gotland 1


GävleborgBlekinge

SörmlandKronoberg


SkåneJönköping

VästerbottenHalland

SWEDENUppsala

JämtlandKalmar

StockholmVästmanland

Västra GötalandDalarna

Norrbotten

Figure 67Sweden

Malignant melanoma – relative five-year survival rates. Trend, 1990–2009. Age-standardised values. Source: Swedish Cancer Register, Swedish National Board of Health and Welfare

Percent

0

20

40

60

80

100

2005-20092000-20041995-19991990-1994

Women

Total

Men


cal diagnosis). The indicator is measured on a regional basis to ensure more reliable outcomes.

A large percentage of patients undergo primary surgery during their first appoint-ment at the community health centre. This comparison concerns only the relatively small percentage of the patient population who are referred to a specialist clinic. Figure 68 shows that their median waiting time in 2009 ranged from 19 to 28 days for the various regions. Regional routines and referral procedures can affect waiting times, not to mention the possibility that a specialist clinic will pass a referral on to another one. The national median was 25 days.

The fact that the variable was relatively new to the register rendered complete as-sessments that much more difficult.

69 Waiting time from sample taking until notification of the diagnosisFigure 69 indicates that the median waiting time from the date that a sample was taken until the patient received a diagnosis was 21 days, with a regional variation of 13–30 days. The waiting time also covers the period from the date that the sample is taken until a histopathological diagnosis is performed and the referring doctor receives the results. As of 2011, the waiting time until the diagnosis has been com-pleted is also analysed. Only the Stockholm and Gotland Regions, which started their registration process late, were unable to report data.

Figure 68Total

Waiting time from initial doctor’s appointment at a community health centre until primary surgery (sample taking for histopathological diagnosis) for malignant melanoma, 2009. Source: Swedish Melanoma Register

Value first quartile Median Value third quartile1 No data available Days

192525262828

0 20 40 60 80

Stockholm-Gotland1

Uppsala-ÖrebroNorraSödra

SydöstraSWEDEN

VästraHealthcare region


70 Malignant melanoma 1.0 millimetre or thinnerThe indicator is a yardstick of people’s general awareness of the need to see a doctor when they suspect skin cancer. It also measures the ability of doctors to correctly assess the seriousness of a skin change. Detecting melanoma at an early stage (1 mil-limetre or thinner) is important; the survival rate at that point is excellent. This in-dicator reflects the percentage of patients with a melanoma that is no more than 1.0 millimetre thick. Five years of data have been combined to ensure greater reliability.

A comparison between 1990–1999 and 2000–2008 shows a decline in the percentage of melanomas that were thin at the time of diagnosis – which obviously represents a negative trend. The gap between women and men appears to be narrowing.

Figure 69Total

Waiting time from sample taking for malignant melanoma until patient received diagnosis, 2009. Source: Swedish Melanoma Register

1 No data available Value first quartile Median Value third quartileDays

Waiting time data not available, %

1313141718192021212121212122232323242430

2715281731111715201630492415371511264911

0 10 20 30 40 50 60

Stockholm 1

Gotland 1

ÖstergötlandHalland

GävleborgJönköpingSörmland

SkåneUppsala

VästernorrlandVästra Götaland

SWEDENKalmar

VästerbottenVästmanland

NorrbottenÖrebro

VärmlandBlekingeDalarna

KronobergJämtland


Figure 70Women

Percentage of patients with a malignant melanoma 1.0 mm or thinner, 2005–2009. Source: Swedish Melanoma Register

2000–2004 Percent

58.757.757.456.856.855.254.954.354.354.254.154.053.953.753.450.849.749.448.847.446.340.8

0 20 40 60 80

NorrbottenUppsalaGotland

VästerbottenHallandÖrebro

SörmlandJönköping

VästernorrlandKalmar

VästmanlandDalarna

JämtlandKronobergGävleborgSWEDEN

SkåneStockholm


ÖstergötlandVärmland

Figure 70Men


2000–2004 Percent

50.949.949.449.248.948.848.046.646.646.444.143.143.042.542.042.041.540.439.538.936.232.8

0 20 40 60 80

JämtlandBlekinge


VästerbottenDalarna

VästernorrlandKronoberg

HallandUppsala


ÖstergötlandSWEDEN

SkåneGotland

JönköpingVästra Götaland

KalmarSörmland

StockholmÖrebro


Figure 70Total


2000–2004 Percent

Participation rate 2005–2009

53.453.252.151.551.451.050.950.850.350.147.947.847.747.747.546.646.545.744.744.443.340.2

94909996979794939895929685989696917688949199

0 20 40 60 80

NorrbottenJämtland

VästerbottenUppsalaHalland

GävleborgBlekinge

VästmanlandVästernorrland

GotlandDalarna

KronobergSörmland

ÖrebroSWEDEN

SkåneJönköpingVärmland




Projectorganisation

Steering committeeStefan Ackerby, Swedish Association of Local Authorities and Regions (SALAR)

Mona Heurgren, Swedish National Board of Health and Welfare (NBHW)

Marie Lawrence, NBHW

Roger Molin, SALAR

Task forceCecilia Dahlgren, NBHW

Camilla Eriksson, SALAR

Behzad Koucheki, NBHW

Birgitta Lindelius, NBHW

Katarina Wiberg Hedman, Project Manager, SALAR

Göran Zetterström, Project Manager, NBHW

Other participantsMats Fernström, NBHW

Gunilla Gunnarsson, SALAR

Staffan Khan, NBWH

Åsa Klint, NBHW

Bodil Klintberg, SALAR

Max Köster, NBHW

Pinelopi Lundqvist, NBHW

Lisbeth Serdén, NBHW

Sofia Tullberg, SALAR

Fredrik Westander, Consultant

Medical specialistsJan Adolfsson

Gunilla Gunnarsson

Lars Holmberg


This special edition of Quality and Efficiency in Swedish Health Care – Regional Comparisons – examines cancer care only. The report, which includes ten forms of cancer and 70 indicators, is a joint project of the Swedish National Board of Health and Welfare and the Swedish Association of Local Authorities and Regions. The indicators reflect different aspects of cancer care, including medical outcomes, patient experience and waiting times.

The overall purpose of the report is to promote local, regional and national improvement efforts by comparing the quality of cancer care throughout the country. It is also intended to provide the general public with insight into what publicly financed cancer care is accomplishing.

While the majority of the indicators are presented at the county level, some of them are of necessity limited to a regional perspective. The indicators for certain types of cancer are also shown at the hospital level. A number of the indicators are broken down between women and men in order to capture potential gender differences.

Swedish Association of Local Authorities and Regions ISBN 978-91-7164-784-9

Swedish National Board of Health and Welfare Art. nr. 2012-3-15

Quality and E

fficiency in Sw

edish Cancer C

are Reg

ional C

om

pariso

ns 2011

Swedish Association of Local Authorities and Regions

SE-118 82 Stockholm+46 8 452 70 00 www.skl.se

Swedish National Board of Health and Welfare

SE-106 30 Stockholm+46 75 247 30 00 www.socialstyrelsen.se

7164 784 9

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