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Quality control on surgery, radiotherapy, and pathology has been introduced in trials, followed

by incorporation in the general care.91,92 _{Furthermore, there have been several improvements}

by introducing high volume clinics.93,94 _{As an alternative to volume based referral, hospitals}

and surgeons can also improve their results by learning from their own outcome statistics and those from colleagues treating a similar patient group. An audit is a quality instrument that collects detailed clinical data from different healthcare providers, which can be adjusted for baseline risk and subsequently fed back to individual hospitals or surgeons. In this way, ‘best practices’ can be identified, communicated, and broadly adopted. After case-mix adjustments, a fair judgement can be made on the quality of cancer treatments. Hospitals and surgeons can be faced with their own results compared to those of colleagues treating the same patient category. Another important advantage is the fact that audit registries include the entire patient population which makes it possible to perform research on patient groups that are usually excluded from clinical trials (such as elderly patients and patients with comorbidities). Although all these national and regional audit structures have achieved excellent results, dif- ferences in outcome between European countries remain which cannot be easily explained.

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A joined international network has been initiated to generate the best care for all cancer patients, founded as the European Registration of Cancer Care (EURECCA). EURECCA was initi- ated in colorectal cancer, but has expended to Upper GI, breast, and hepatic, pancreatic, and biliary cancer. The initiative and the first results of a comparison between treatment strategies for rectal cancer are described in this thesis. Next, the selection of patients receiving adjuvant chemotherapy in colon stage II and rectal cancer will be compared across the countries. In the future EURECCA wants to expand to other cancer types, and the ultimate goal would be to achieve an European audit with feedback to the countries, hospitals, and clinicians about their results in comparison with other countries, after case-mix adjustment.

cOnclusiOn AnD future PersPectives

For the past two decades both colon and rectal cancer have been a subject of research. This resulted in several diagnostic and treatment improvements for both colon and rectal can- cer, which led to improved outcome. Even though, several further improvements are to be expected in the coming decades. First of all, screening will be initiated in the Netherlands, possibly leading to a detection of more early tumours, which might need a different approach. Secondly, elderly patients and patients with comorbidities, which will be a growing group of patients in the next ten years, will probably need different care since not all treatments will be tolerated and fewer side effects might be accepted. Furthermore, the past five to ten years have led to significant advances in the understanding of biological, molecular, genetics, and pathogenesis. Genetic based tumour markers will lead to further characterised cancer, and will be accompanied by tailored treatment. Already the genetic testing for KRAS, and several other similar RAS mutations, are being implemented clinically to determine which patients should undergo treatment with monoclonal antibodies against EGFR. In parallel with these advances in understanding colorectal cancer, DNA sequencing has increased exponentially. By examining tumours and identifying common genetic mutations and molecular pathway perturbations, cancer development will be better understood. This will allow the development of more accurate screening tests, diagnostic tests, and identification of new and specialised treatments. Overall, these advances will lead to more complex treatment strategies which need to be individualised based on patient- and tumour characteristics.

Trials are important to answer specific research questions, but for individualised patient care trials will probably not provide the needed information. Large population based datasets can provide the needed information by identifying the optimal treatment strategy for certain subgroups. An audit is a quality instrument that collects detailed clinical data from different healthcare providers, which can be adjusted for baseline risk and subsequently fed back to individual hospitals or clinicians. The audit structure will include all patients. Audits have achieved excellent results on national level. A next step will be to combine these national

audits. The combined audit structure will provide a network in which ‘best practices’ can be compared and identified, including for certain subgroups.

To achieve optimal care for all patients, multidisciplinary care is the only way. Current and future research will lead to advances in colorectal cancer screening, diagnosing, treatment, and outcome. By comparing multidisciplinary audit structures across countries, optimal treat- ment strategies within subgroups can be identified. Furthermore, optimal communication between clinicians and between patient and clinician will be the optimal strategy to achieve shared decision making in combination with personalised medicine.

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summArY

In the Western World, colorectal cancer is a major health problem. The incidence is high and

expected to grow even further in the upcoming years.5 _{Besides, the incidence increases with}

increasing age, which makes it a disease of the older patient. Together, it is anticipated that the number of elderly patients with colorectal cancer will grow during the coming years, while there are no specific clinical guidelines for the elderly. Evidence from population-based studies clearly demonstrates that older patients are more often inadequately staged, undergo

fewer elective operations95 _{and are less likely to receive adjuvant chemotherapy and/}

or radiotherapy than their younger counterparts96-100_{. Current guidelines are derived from}

(randomised) trials in which elderly patients or patients with severe comorbidity are excluded

or underrepresented.100,101