Adjuvant radiation for rectal cancer: do we measure up to the standard of care? An epidemiologic analysis of trends over 25 years in the United States

Predictors of Long-Term Quality of Life for Survivors of Stage II/III Rectal Cancer in the Cancer Care Outcomes Research and Surveillance Consortium

PURPOSE

Many patients do not receive guideline-recommended neoadjuvant chemoradiotherapy for resectable rectal cancer. Little is known regarding long-term quality of life (QOL) associated with various treatment approaches. Our objective was to determine patient characteristics and subsequent QOL associated with treatment approach.

METHODS

Our study was a geographically diverse population- and health system-based cohort study that included adults age 21 years or older with newly diagnosed stage II/III rectal cancer who were recruited from 2003 to 2005. Eligible patients were contacted 1 to 4 months after diagnosis and asked to participate in a telephone survey and to consent to medical record review, with separate follow-up QOL surveys conducted 1 and 7 years after diagnosis.

RESULTS

Two hundred thirty-nine patients with stage II/III rectal cancer were included in this analysis. Younger age (< 65 v ≥ 65 years: odds ratio, 2.49; 95% CI, 1.33 to 4.65) was significantly associated with increased odds of receiving neoadjuvant or adjuvant chemoradiotherapy. The adjuvant chemoradiotherapy group had significantly worse mean EuroQol-5D (range, 0 to 1) and Short Form-12 physical health component scores (standardized mean, 50) at 1-year follow-up than the neoadjuvant chemoradiotherapy group (0.75 v 0.85; P = .002; 37.2 v 43.3; P = .01, respectively) and the group that received only one or neither form of treatment (0.75 v 0.85; P = .02; 37.2 v 45.1; P = .008, respectively).

CONCLUSION

Neoadjuvant treatment may result in better QOL and functional status 1 year after diagnosis. Further evaluation of patient and provider reasons for not pursuing neoadjuvant therapy is necessary to determine how and where to target process improvement and/or education efforts to ensure that patients have access to recommended treatment options.

Physicians' beliefs about the benefits and risks of adjuvant therapies for stage II and stage III colorectal cancer

BACKGROUND

Adjuvant therapy plays a major role in treating colorectal cancer, and physicians' views of its effectiveness influence treatment decisions. We assessed physicians' views of the relative benefits and risks of adjuvant chemotherapy and radiotherapy for stages II and III colon and rectal cancers.

METHODS

The Cancer Care Outcomes Research and Surveillance Consortium surveyed a geographically dispersed population of medical oncologists, radiation oncologists, and surgeons in the United States about the benefits and risks of adjuvant therapies for colorectal cancer. We used logistic regression to assess the association of physician and practice characteristics with beliefs about adjuvant therapies.

RESULTS

Among 1,296 respondents, > 90% believed the benefits of adjuvant therapies for stage III colorectal cancer outweigh the risks. Only 21.9%, 50%, and 50.4% believed in the net benefit of chemotherapy for stage II colon cancer, chemotherapy for stage II rectal cancer, and radiation for stage II rectal cancer, respectively. Younger physicians were less likely than others to perceive adjuvant therapy for stage II colorectal cancer as beneficial. Medical oncologists were more likely than surgeons and radiation oncologists to endorse the benefits of adjuvant chemotherapy and radiation for stage II rectal cancer, but less likely for stage II colon cancer.

CONCLUSIONS

Physicians largely agreed that the benefits of adjuvant chemotherapy for stage III colon cancer, as well as chemotherapy, and radiation for stage III rectal cancer, outweigh the risks, consistent with strong evidence, but were divided over the net benefit of adjuvant therapies for stage II colorectal cancer, where evidence is inconsistent.

High-Priority Topics for Cancer Quality Measure Development: Results of the 2012 American Society of Clinical Oncology Collaborative Cancer Measure Summit

Addressing the high-priority topics identified by this effort will help fill the gaps left by existing cancer quality measures, including care coordination and transitions, quality of life, safety, experience of care, and outcomes.

Patterns of colorectal cancer care in the United States and Canada: a systematic review

Colorectal cancer is the third most common cancer in the United States and Canada. Given the high incidence and increased survival of colorectal cancer patients, prevalence is increasing over time in both countries. Using MEDLINE, we conducted a systematic review of the literature published between 2000 and 2010 to describe patterns of colorectal cancer care. Specifically we examined data sources used to obtain treatment information and compared patterns of cancer-directed initial care, post-diagnostic surveillance care, and end-of-life care among colorectal cancer patients diagnosed in the United States and Canada. Receipt of initial treatment for colorectal cancer was associated with the anatomical position of the tumor and extent of disease at diagnosis, in accordance with consensus-based guidelines. Overall, care trends were similar between the United States and Canada; however, we observed differences with respect to data sources used to measure treatment receipt. Differences were also present between study populations within country, further limiting direct comparisons. Findings from this review will allow researchers, clinicians, and policy makers to evaluate treatment receipt by patient, clinical, or system characteristics and identify emerging trends over time. Furthermore, comparisons between health-care systems in the United States and Canada can identify disparities in care, allow the evaluation of different models of care, and highlight issues regarding the utility of existing data sources to estimate national patterns of care.

Raman spectroscopy demonstrates prolonged alteration of bone chemical composition following extremity localized irradiation

INTRODUCTION

Radiotherapy to the appendicular skeleton can cause an increased risk of developing catastrophic fractures with delayed bone healing or non-union, and may subsequently require multiple procedures and amputation. Biomechanical studies suggest that irradiated bone is more brittle, but the cause is unclear and cannot be explained by changes to bone structure or quantity, suggesting that there are crucial changes in irradiated bone material properties. Raman spectroscopy provides a means to assess the chemical properties of the mineral and matrix constituents of bone, which could help explain post-radiation embrittlement. In this study we use a murine tibial model with focal irradiation and perform Raman spectroscopy to test the hypothesis that changes in bone chemistry following irradiation is consistent with reduced bone quality and persists in the long term after irradiation.

METHODS

Female BALB/F mice aged 12weeks were subjected to unilateral, localized hindlimb irradiation in 4 daily 5Gy fractions (4×5Gy) totaling 20Gy, and were euthanized at 1, 4, 8, 12, and 26weeks post-irradiation (n=6/group). The irradiated (right) and non-irradiated contralateral control (left) tibiae were explanted and assessed by non-polarized and polarized Raman spectroscopy over the proximal cortical bone surface. Raman parameters used included the mineral/matrix ratio, mineral crystallinity, carbonate/phosphate ratio, collagen cross-link ratio, and depolarization ratio.

RESULTS

Significantly increased collagen cross-link ratio and decreased depolarization ratio of matrix were evident at 1week after irradiation and this persisted through 26weeks. A similar significant decrease was observed for depolarization ratio of mineral at all time points except 8 and 26weeks. At 4weeks after irradiation there was a significantly increased mineral/matrix ratio, increased mineral crystallinity, and decreased carbonate/phosphate ratio compared to controls. However, at 12weeks after irradiation these parameters had moved in the opposite direction, resulting in a significantly decreased mineral/matrix ratio, decreased crystallinity and increased carbonate/phosphate ratio compared to controls. At 26weeks, mineral/matrix, crystallinity and carbonate/phosphate ratios had returned to normal.

DISCUSSION

In this mouse model, Raman spectroscopy reports both bone mineral and collagen cross-link radiation-induced abnormalities that are evident as early as one week after irradiation and persists for 26weeks. The picture is one of extensive damage, after which there is an attempt at remodeling. We hypothesize that pathological cross-links formed by radiation damage to collagen are poorly resorbed during the altered remodeling process, so that new tissue is formed on a defective scaffold, resulting in increased bone brittleness.

In search of synergy: strategies for combining interventions at multiple levels

The social ecological perspective provides a compelling justification for multilevel intervention. Yet, it offers little guidance for selecting interventions that work together in complementary or synergistic ways. Using a causal modeling framework, we describe five strategies for increasing potential complementarity or synergy among interventions that operate at different levels of influence: accumulation, amplification, facilitation, cascade, and convergence. We illustrate these strategies with examples of multilevel interventions to improve the quality of cancer treatment.

Racial and ethnic disparities in outcomes with radiation therapy for rectal adenocarcinoma

BACKGROUND

Race/ethnicity may modify cancer outcomes and manifest as survival disparities for patients with rectal cancer. Our objective was to determine whether disparate rectal cancer outcomes result from variable efficacy of radiation therapy for major racial/ethnic groups.

METHODS

The Los Angeles County Cancer Surveillance Program (CSP) identified patients with rectal adenocarcinoma between the years 1988 and 2006. Patients who underwent curative-intent surgery were grouped by race/ethnicity and by receipt (yes vs. no) and timing (neoadjuvant vs. adjuvant) of radiation therapy. The impact of receipt and timing of radiation therapy on overall survival was then assessed.

RESULTS

Of 4,961 patients in CSP, 2,229 (45%) received radiation therapy. Overall, there was no difference in survival among patients according to receipt of radiation therapy. We then examined the radiation cohort, wherein 919 (41%) and 1,310 (59%) patients received neoadjuvant or adjuvant radiation, respectively. Overall, patients who received neoadjuvant compared to adjuvant radiation had improved survival (median survival (MS), 9.4 vs. 6.8 years, respectively; p < 0.001). Among those patients who received neoadjuvant radiation, whites, Hispanics, and Asians had significantly longer survival than blacks (MS, 10.4, 10.4, and 10.4 vs. 4.4 years, respectively; p = 0.003). On multivariate analysis, race/ethnicity was an independent predictor of survival (p = 0.001).

CONCLUSIONS

To our knowledge, this is the first study examining the efficacy of radiation therapy for racial/ethnic groups with rectal cancer. Disparate outcomes were observed for the administration of radiation therapy for select racial/ethnic groups. The reasons for these disparities in outcomes should be investigated to better optimize radiation therapy for patients with rectal cancer.

Use of primary radiotherapy for rectal cancer in the Netherlands between 1997 and 2008: a population-based study

AIMS

To describe variation in the utilisation rates of primary radiotherapy for patients with rectal cancer in the Netherlands, focusing on time trends and age effects.

MATERIALS AND METHODS

Data on primary non-metastatic rectal cancer were derived from the population-based cancer registries of four comprehensive cancer centres (regions) in the Netherlands (1997-2008, n=13,055).

RESULTS

An increase in the utilisation rate was noted for the four regions, from 37-46% in 1997 to 66-76% in 2008, for both genders. This increase was found predominately for preoperative radiotherapy (from 13-31% to 58-67%) and (unsurprisingly) was most pronounced for stage T2-3 patients (from 9-27% to 68-80%). The probability of receiving radiotherapy decreased with age: the odds of receiving preoperative radiotherapy was reduced in patients aged 65 years and older, as well as the odds of receiving postoperative radiotherapy in those aged 75 years and older, which remained significant after adjustment for stage, gender and region. Regional differences persisted in multivariable analyses, i.e. the odds of receiving preoperative radiotherapy was reduced in two regions: odds ratio: 0.4 (95% confidence interval: 0.4-0.5) and 0.7 (0.6-0.8). The odds of receiving postoperative radiotherapy was significantly increased in these regions [odds ratio: 2.6 (2.2-3.2) and 1.6 (1.3-1.9), respectively] and reduced in another [odds ratio 0.8 (0.6-0.96)].

CONCLUSIONS

The utilisation rate of radiotherapy for rectal cancer increased significantly over time, particularly for preoperative radiotherapy and was most pronounced for T2-3 patients. Due to national multidisciplinary treatment guidelines, regional differences became limited in recent years after adjustment for age and stage of the disease. A low utilisation rate of radiotherapy was seen in women and elderly patients.

Temporal and regional variations in the use of preoperative radiation therapy for rectal cancer

OBJECTIVE

Preoperative (preop) chemoradiation therapy improves local control and reduces toxicity for stage II/III rectal cancer better than postoperative (postop) chemoradiation therapy. We examined the temporal and regional variations in the use of preop radiotherapy (RT) across the United States.

METHODS

Patients with stage II/III rectal cancer diagnosed between 1998 and 2005 who had a primary site resection were identified from the SEER database. The rate of preop RT use over time was plotted. Regression models were used to analyze regional variations.

RESULTS

From 1998 to 2005, an increase of 1.7 in the ratio of preop RT/postoperative RT was noted, whereas the ratio of RT/no RT increased only by 0.7. The ratio of preop RT/postop RT increased from 0.5 to 1 in 5 years (1998-2003) but from 1 to 1.5 in 2 years (2003-2005). Multivariate regression analysis showed: patients with stage II disease were more likely than those with stage III disease, younger patients were more likely than older patients, and males were more likely than females to receive preop RT. Whites were more likely to receive preop RT than nonwhites for stage III disease only. Patients treated in the San Francisco region, Hawaii, New Mexico, Seattle, and Los Angeles were more likely to receive preop RT than were patients in the Connecticut, Detroit, Iowa, Utah, Atlanta, and San Jose/Monterey regions.

CONCLUSIONS

The increasing use of preop RT varies across US regions and patient subgroups. Further studies should evaluate potentially modifiable factors contributing to these variations.

Adoption of preoperative radiation therapy for rectal cancer from 2000 to 2006: a Surveillance, Epidemiology, and End Results Patterns-of-Care Study

PURPOSE

The German rectal study determined that preoperative radiation therapy (RT) as a component of combined-modality therapy decreased local tumor recurrence, increased sphincter preservation, and decreased treatment toxicity compared with postoperative RT for rectal cancer. We evaluated the use of preoperative RT after the presentation of the landmark German rectal study results and examined the impact of tumor and sociodemographic factors on receiving preoperative RT.

METHODS AND MATERIALS

In total, 20,982 patients who underwent surgical resection for T3-T4 and/or node-positive rectal adenocarcinoma diagnosed from 2000 through 2006 were identified from the Surveillance, Epidemiology, and End Results tumor registries. We analyzed trends in preoperative RT use before and after publication of the findings from the German rectal study. We also performed multivariate logistic regression to identify factors associated with receiving preoperative RT.

RESULTS

Among those treated with RT, the proportion of patients treated with preoperative RT increased from 33.3% in 2000 to 63.8% in 2006. After adjustment for age; gender; race/ethnicity; marital status; Surveillance, Epidemiology, and End Results registry; county-level education; T stage; N stage; tumor size; and tumor grade, there was a significant association between later year of diagnosis and an increase in preoperative RT use (adjusted odds ratio, 1.26/y increase; 95% confidence interval, 1.23-1.29). When we compared the years before and after publication of the German rectal study (2000-2003 vs. 2004-2006), patients were more likely to receive preoperative RT than postoperative RT in 2004-2006 (adjusted odds ratio, 2.35; 95% confidence interval, 2.13-2.59). On multivariate analysis, patients who were older, who were female, and who resided in counties with lower educational levels had significantly decreased odds of receiving preoperative RT.

CONCLUSIONS

After the publication of the landmark German rectal study, there was widespread, rapid adoption of preoperative RT for locally advanced rectal cancer. However, preoperative RT may be underused in certain sociodemographic groups.

Colorectal cancer: epidemiology, risk factors, and health services

Colorectal carcinoma is the third most common cancer in the United States in both men and women but still remains the second leading cause of cancer-related deaths. The risk of developing colorectal cancer increases with age. Additional risk factors include family history of colorectal cancer, heredity conditions such as polyposis and hereditary nonpolyposis colorectal cancer, and personal history of inflammatory bowel disease, polyps, and cancers. Health services is a new scientific discipline that examines the quality of care, often at the population level, and may examine parts or the entire spectrum of care.

Focal dose escalation using FDG-PET-guided intensity-modulated radiation therapy boost for postoperative local recurrent rectal cancer: a planning study with comparison of DVH and NTCP

Background

To evaluate the safety of focal dose escalation to regions with standardized uptake value (SUV) >2.0 using intensity-modulated radiation therapy (IMRT) by comparison of radiotherapy plans using dose-volume histograms (DVHs) and normal tissue complication probability (NTCP) for postoperative local recurrent rectal cancer

Methods

First, we performed conventional radiotherapy with 40 Gy/20 fr. (CRT 40 Gy) for 12 patients with postoperative local recurrent rectal cancer, and then we performed FDG-PET/CT radiotherapy planning for those patients. We defined the regions with SUV > 2.0 as biological target volume (BTV) and made three boost plans for each patient: 1) CRT boost plan, 2) IMRT without dose-painting boost plan, and 3) IMRT with dose-painting boost plan. The total boost dose was 20 Gy. In IMRT with dose-painting boost plan, we increased the dose for BTV+5 mm by 30% of the prescribed dose. We added CRT boost plan to CRT 40 Gy (summed plan 1), IMRT without dose-painting boost plan to CRT 40 Gy (summed plan 2) and IMRT with dose-painting boost plan to CRT 40 Gy (summed plan 3), and we compared those plans using DVHs and NTCP.

Results

D_mean of PTV-PET and that of PTV-CT were 26.5 Gy and 21.3 Gy, respectively. V₅₀ of small bowel PRV in summed plan 1 was significantly higher than those in other plans ((summed plan 1 vs. summed plan 2 vs. summed plan 3: 47.11 ± 45.33 cm³ vs. 40.63 ± 39.13 cm³ vs. 41.25 ± 39.96 cm³(p < 0.01, respectively)). There were no significant differences in V₃₀, V₄₀, V₆₀, D_mean or NTCP of small bowel PRV.

Conclusions

FDG-PET-guided IMRT can facilitate focal dose-escalation to regions with SUV above 2.0 for postoperative local recurrent rectal cancer.

An evaluation of the relationship between lymph node number and staging in pT3 colon cancer using population-based data

PURPOSE

The number of lymph nodes examined has been proposed as a quality benchmark for colon cancer surgery, although it is unknown whether this strategy reduces understaging.

METHODS

We identified 11,044 patients who underwent surgery for colon cancer with pT3 wall penetration between 1988 and 2003 from the Surveillance, Epidemiology and End Results cancer registry. We determined the proportion of patients who were node positive for each node count. We used logistic regression to predict the odds of being node positive by node count after adjusting for confounders. We used joinpoint analysis to determine whether there was a consistent relationship between node count and the odds of being node positive.

RESULTS

The proportion of patients found to be node positive increased with node count at low counts (<or=5-6 nodes), but patients with 7 nodes identified were as likely to be node positive as patients with 30 or more nodes (odds ratio = 0.97; 95% CI = 0.90-1.05). Joinpoint analysis demonstrated a dramatic increase in odds of node positivity with increasing node count to 5 nodes (slope = 0.2; P < .0001). Between 6 and 13 nodes there was a marginal increase in odds of positive nodes (slope = 0.03; P = .006), but when more nodes were evaluated, odds of node positivity actually declined (slope = -0.01; P = .04).

CONCLUSIONS

Staging of pT3 colon cancer improves with increasing node count, but only when the node count is low (<5-7 nodes). At higher counts, an increased node count has marginal effects on staging.

Rectal cancer

Surgery is the cornerstone of rectal cancer treatment. Oncological cure and overall survival continue to be the main goals, but sparing of the anal sphincter mechanism and functional results are also important. The modern management of rectal cancer is a multidisciplinary approach, and pre-operative staging is of crucial importance when planning treatment in these patients. Pre-operative staging is used to determine the indication for neoadjuvant therapy prior to surgical resection or to determine whether local excision is an option in carefully selected patients with early rectal cancer. Surgery in the form of total mesorectal excision (TME) has become the standard of care for mid and distal rectal cancers. Early rectal cancers do not require neoadjuvant therapy. For locally advanced cancers of the lower two-thirds of the rectum, the combination of surgical resection with chemoradiotherapy decreases local recurrence rates and probably improves overall survival. Whereas in the past local excision was only contemplated in patients who were unfit for radical surgery or for local palliation in cases of metastatic disease, over the last number of years there has been increasing interest in local treatment with curative intent in early rectal cancer.

Death after bowel resection: patient disease, not surgeon error

INTRODUCTION

Although bowel resection is associated with a significant mortality rate, little is known about the demographics of the patients and how often surgical error is the primary cause of death. We sought to use a rigorous prospective quality database incorporating standardized peer review, to define how often patients die from provider-related causes.

MATERIALS AND METHODS

All patients undergoing bowel resection with anastomosis at a university hospital from July 2003 to June 2006 were entered into a prospectively maintained quality database. Patients were seen daily with house staff by a specially trained nurse practitioner who recorded demographics and complications. Clinical case reviews were conducted monthly. Five hundred sixty-six patients underwent bowel resection with anastomosis during the study period.

DISCUSSION

One hundred ninety-three patients suffered at least one complication (34.1%) and there were 20 deaths (3.5%). In 17 cases, death was deemed unavoidable due to patient disease; most occurred in patients who developed ischemic bowel while hospitalized for a serious concomitant illness. In only one case did death appear clearly related to a surgical complication (0.17%). Death after bowel resection typically reflects the need for urgent surgery in extreme circumstances and not surgeon error. Postoperative mortality rate in this population appears to be poor indicator of surgical quality.

Residual treatment disparities after oncology referral for rectal cancer

BACKGROUND

Black patients with rectal cancer are considerably less likely than white patients to receive adjuvant therapy. We examined the hypothesis that the lower treatment rate for blacks is due to underreferral to medical and radiation oncologists.

METHODS

We used 1992-1999 Surveillance, Epidemiology, and End Results-Medicare data to identify elderly (> or = 66 years of age) patients who had been hospitalized for resection of stage II or III rectal cancer (n = 2716). We used chi(2) tests to examine associations between race and 1) consultation with an oncologist and 2) receipt of adjuvant therapy. We then used logistic regression to analyze the influence of sociodemographic and clinical characteristics (age at diagnosis, sex, marital status, median income and education in area of residence, comorbidity, and cancer stage) on black-white differences in the receipt of adjuvant therapy. All statistical tests were two-sided.

RESULTS

There was no statistically significant difference between the 134 black patients and the 2582 white patients in the frequency of consultation with a medical oncologist (73.1% for blacks vs 74.9% for whites, difference = 1.8%, 95% confidence interval [CI] = > 5.9% to 9.5%, P = .64) or radiation oncologist (56.7% vs 64.8%, difference = 8.1%, 95% CI = > 0.5% to 16.7%, P = .06), but blacks were less likely than whites to consult with both a medical oncologist and a radiation oncologist (49.2% vs 58.8%, difference = 9.6%, 95% CI = 0.9% to 18.2%, P = .03). Among patients who saw an oncologist, black patients were less likely than white patients to receive chemotherapy (54.1% vs 70.2%, difference = 16.1%, 95% CI = 6.0% to 26.2%, P = .006), radiation therapy (73.7% vs 83.4%, difference = 9.7%, 95% CI = 0.4% to 19.8%, P = .06), or both (60.6% vs 76.9%, difference = 16.3%, 95% CI = 4.3% to 28.3%, P = .008). Patient and provider characteristics had minimal influence on the racial disparity in the use of adjuvant therapy.

CONCLUSION

Racial differences in oncologist consultation rates do not explain disparities in the use of adjuvant treatment for rectal cancer. A better understanding of patient preferences, patient-provider interactions, and potential influences on provider decision making is necessary to develop strategies to increase the use of adjuvant treatment for rectal cancer among black patients.

Residual treatment disparities after oncology referral for rectal cancer

BACKGROUND

Black patients with rectal cancer are considerably less likely than white patients to receive adjuvant therapy. We examined the hypothesis that the lower treatment rate for blacks is due to underreferral to medical and radiation oncologists.

METHODS

We used 1992-1999 Surveillance, Epidemiology, and End Results-Medicare data to identify elderly (> or = 66 years of age) patients who had been hospitalized for resection of stage II or III rectal cancer (n = 2716). We used chi(2) tests to examine associations between race and 1) consultation with an oncologist and 2) receipt of adjuvant therapy. We then used logistic regression to analyze the influence of sociodemographic and clinical characteristics (age at diagnosis, sex, marital status, median income and education in area of residence, comorbidity, and cancer stage) on black-white differences in the receipt of adjuvant therapy. All statistical tests were two-sided.

RESULTS

There was no statistically significant difference between the 134 black patients and the 2582 white patients in the frequency of consultation with a medical oncologist (73.1% for blacks vs 74.9% for whites, difference = 1.8%, 95% confidence interval [CI] = > 5.9% to 9.5%, P = .64) or radiation oncologist (56.7% vs 64.8%, difference = 8.1%, 95% CI = > 0.5% to 16.7%, P = .06), but blacks were less likely than whites to consult with both a medical oncologist and a radiation oncologist (49.2% vs 58.8%, difference = 9.6%, 95% CI = 0.9% to 18.2%, P = .03). Among patients who saw an oncologist, black patients were less likely than white patients to receive chemotherapy (54.1% vs 70.2%, difference = 16.1%, 95% CI = 6.0% to 26.2%, P = .006), radiation therapy (73.7% vs 83.4%, difference = 9.7%, 95% CI = 0.4% to 19.8%, P = .06), or both (60.6% vs 76.9%, difference = 16.3%, 95% CI = 4.3% to 28.3%, P = .008). Patient and provider characteristics had minimal influence on the racial disparity in the use of adjuvant therapy.

CONCLUSION

Racial differences in oncologist consultation rates do not explain disparities in the use of adjuvant treatment for rectal cancer. A better understanding of patient preferences, patient-provider interactions, and potential influences on provider decision making is necessary to develop strategies to increase the use of adjuvant treatment for rectal cancer among black patients.

Survival benefits and trends in use of adjuvant therapy among elderly stage II and III rectal cancer patients in the general population

BACKGROUND

This study examined elderly stage II and III rectal cancer patients' adjuvant chemoradiation therapy adherence, trends in adherence over time, and the relation of levels of adherence to mortality.

METHODS

The authors studied 2886 stage II and III rectal cancer patients who had surgical resection and who appeared in 1992-1999 linked SEER-Medicare claims data. The authors compared measures of adjuvant radiation and chemotherapy receipt and completion between stage II and III patients. Adjusted risk of cancer-related 5-year mortality was calculated by multivariate logistic regression for different levels of chemoradiation adherence among stage II and III patients.

RESULTS

Of the 2886 patients, 45.4% received both adjuvant radiation and chemotherapy. Stage III patients were more likely to receive chemoradiation than stage II patients. The receipt of chemoradiation by stage II patients increased significantly from 1992 to 1999. Stage III patients were more likely to complete radiation therapy (96.6%), chemotherapy (68.2%), and both modalities (67.5%) than stage II patients (91.5%, 49.8%, 47.6%, respectively). Only a complete course of both radiation and chemotherapy for both stage II (relative risk [RR] 0.74; 95% CI, 0.54, 0.97) and III (RR 0.80; 95% CI, 0.65, 0.96) decreased the adjusted 5-year cancer mortality risk compared with counterparts with no adjuvant therapy.

CONCLUSIONS

Even though stage II rectal cancer patients were less likely than stage III patients to receive and complete adjuvant chemoradiation, both patient groups in the general population had lower cancer-related mortality if they completed chemoradiation. These patients deserve support and encouragement to complete treatment.

Assessing the quality of colorectal cancer care: do we have appropriate quality measures? (A systematic review of literature)

RATIONALE, AIMS AND OBJECTIVES

The burden of illness from colorectal cancer (CRC) can be reduced by improving the quality of care. Identifying appropriate quality measures is the first step in this direction. We identified process measures currently available to assess the quality of diagnosis and management of CRC. We also evaluated the extent to which these measures are ready to be implemented in clinical practice, and identified areas for future research.

METHODS

We searched MEDLINE, Cochrane Database of Systematic Reviews, and relevant grey literature. We identified 3771 abstracts and reviewed 74 articles that included quality measures for diagnosis or management of CRC. Measures from traditional quality improvement literature, and from epidemiological and other studies that included quality measures as part of their research agenda, were considered. In addition, we devised a summary rating scale (IST) to appraise the extent of a measure's importance and usability, scientific acceptability and extent of testing.

RESULTS

The coverage of general process measures in CRC is extensive. Most measures are important, but need to be developed and field-tested. The best available measures relate to pathology and chemotherapy. No measures are available for assessing quality of management of stage IV rectal cancer and hepatic metastasis; chemotherapy for stage II colon cancer; and procedure notes.

CONCLUSIONS

There is an urgent need to refine existing measures and to develop scientifically accurate quality measures for a comprehensive assessment of the quality of CRC care. The role of the federal government and professional societies is critical in pursuing this goal.

Adjuvant therapy for resected gastric cancer--rapid, yet incomplete adoption following results of intergroup 0116 trial

PURPOSE

The Southwest Oncology Group/Intergroup 0116 (INT-0116) trial showed that adjuvant chemoradiotherapy improves survival in high-risk gastric adenocarcinoma patients. This study examined the adoption of adjuvant treatment following the trial results and the factors associated with its use.

METHODS AND MATERIALS

Between 1996 and 2003, patients aged 18-85 years with resected gastric adenocarcinoma were identified in the Surveillance, Epidemiology, and End Results (SEER) database and classified as diagnosed before (January 1996 to April 2000) or after (May 2000 to December 2003) presentation of the INT-0116 trial findings. Univariate and multivariable models were used to determine the factors associated with use of adjuvant radiotherapy (RT).

RESULTS

Of 10,230 patients studied, 14.6% were given adjuvant RT before the INT-0116 trial, increasing to 30.4% afterward (p<0.001). Significant increases in adjuvant RT from before to after INT-0116 were seen in all demographic categories. Younger patients were significantly more likely to receive adjuvant RT (44.5%, 18-59 years; 31.0%, 60-74 years; and 12.6%, 75-85 years, p<0.0001). Married patients were significantly more likely to receive adjuvant RT (30.9%) than were unmarried patients (23.6%, p<0.001). A greater depth of tumor invasion, worse nodal status, and more lymph nodes assessed were associated with adjuvant RT (p<0.0001). The rate of adjuvant RT varied from 22.9-44.2% across SEER regions. On multiple logistic regression analysis, age, SEER region, marital status, assessed lymph nodes, tumor depth, and nodal status were all significant independent predictors of the use of adjuvant RT.

CONCLUSION

Use of adjuvant RT doubled after the INT-0116 trial results became public; however, the fraction of patients receiving adjuvant RT is still low. Additional examination of the statistically significant and clinically relevant variability between different SEER regions, tumor characteristics, and patient demographics is warranted.

The status of radical proctectomy and sphincter-sparing surgery in the United States

PURPOSE

Worldwide, "centers of excellence" in rectal cancer surgery report high rates of anal sphincter-sparing surgery (70-90 percent) after proctectomy. The rate of sphincter-sparing surgery with reestablishment of intestinal continuity in the general population of the United Stares is unknown.

METHODS

We used data from the Nationwide Inpatient Sample, a 20 percent stratified random sample of patients admitted to hospitals in the United States. We identified patients with rectal cancer from 1988 through 2003 who underwent sphincter-sparing surgery with reestablishment of intestinal continuity or proctectomy with colostomy. To determine predictors of sphincter-sparing surgery with reestablishment of intestinal continuity, we constructed a multivariate model that analyzed patients' age, gender, race, insurance status, and income level.

RESULTS

During our 16-year study period, radical extirpative procedures were performed in 41,631 patients: 16,510 (39.7 percent) sphincter-sparing surgery with reestablishment of intestinal continuity, and 25,121 (60.3 percent) sphincter-sacrificing procedures. The proportion of sphincter-sparing procedures increased from 26.9 percent in 1988 to 48.3 percent in 2003 (P < 0.001). There has been no significant change in the rate of sphincter-sparing surgery since 1999 (P = not significant). Logistic regression revealed that patients who were older, male, black, used Medicaid insurance, or lived in lower-income zip codes were less likely to have sphincter-sparing surgery with reestablishment of intestinal continuity (P < 0.001).

CONCLUSIONS

Despite a significant increase in the rate of sphincter-sparing surgery with reestablishment of intestinal continuity, most radical resections for rectal cancer in hospitals in the United States result in a colostomy. Patients vulnerable to proctectomy without sphincter preservation were older, male, black, used Medicaid insurance, or lived in lower income zip codes.

Postoperative irradiation for rectal cancer increases the risk of small bowel obstruction after surgery

OBJECTIVE

To determine the risk of small bowel obstruction (SBO) after irradiation (RT) for rectal cancer

BACKGROUND

: SBO is a frequent complication after standard resection of rectal cancer. Although the use of RT is increasing, the effect of RT on risk of SBO is unknown.

METHODS

We conducted a retrospective cohort study using Surveillance, Epidemiology, and End Results cancer registry data linked to Medicare claims data to determine the effect of RT on risk of SBO. Patients 65 years of age and older diagnosed with nonmetastatic invasive rectal cancer treated with standard resection from 1986 through 1999 were included. We determined whether patients had undergone RT and evaluated the effect of RT and timing of RT on the incidence of admission to hospital for SBO, adjusting for potential confounders using a proportional hazards model.

RESULTS

We identified a total of 5606 patients who met our selection criteria: 1994 (36%) underwent RT, 74% postoperatively. Patients were followed for a mean of 3.8 years. A total of 614 patients were admitted for SBO over the study period; 15% of patients in the RT group and 9% of patients in the nonirradiated group (P < 0.001). After controlling for age, sex, race, diagnosis year, type of surgery, and stage, we found that patients who underwent postoperative RT were at higher risk of SBO, hazard ratio 1.69 (95% CI, 1.3-2.1). However, the long-term risk associated with preoperative irradiation was not statistically significant (hazard ratio, 0.89; 95% CI, 0.55-1.46).

CONCLUSIONS

Postoperative but not preoperative RT after standard resection of rectal cancer results in an increased risk of SBO over time.

Racial disparities in late survival after rectal cancer surgery

BACKGROUND

African-American patients experience higher mortality than Caucasian patients after surgery for most common cancer types. Whether longterm survival after rectal cancer surgery varies by race is less clear.

STUDY DESIGN

Using 1992 to 2003 Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we examined race and longterm survival among African-American and Caucasian rectal cancer patients undergoing resection. We identified racial differences in patient characteristics, structure, and processes of care. We then assessed mortality using a Cox proportional hazards model, sequentially adding variables to explore the extent to which they attenuated the association between race and mortality.

RESULTS

African-American patients had a substantially poorer overall survival rate than Caucasian patients did. Five-year survival rates were 41% and 50%, respectively (p < 0.0001). African Americans were younger (p=0.006), more likely to reside in low income areas (p < 0.0001), and had more baseline comorbid disease (p < 0.0001). They were also more likely to be diagnosed emergently (p < 0.001) and with more advanced cancer (p < 0.001). Accounting for demographic and clinical characteristics reduced the mortality difference, although it remained pronounced (hazard ratio=1.13, CI=1.01 to 1.26). African Americans were more likely to be treated by low volume surgeons and less likely to receive adjuvant therapy (48.6% versus 60.9%, p < 0.0001). After adjusting for provider variables, the hazard ratio for mortality by race was additionally attenuated and became statistically nonsignificant (hazard ratio=1.05, CI=0.92 to 1.20).

CONCLUSIONS

Poorer longterm survival after rectal cancer surgery among African Americans is explained by measurable differences in processes of care and patient characteristics. These data suggest that outcomes disparities could be reduced by strategies targeting earlier diagnosis and increasing adjuvant therapy use among African-American patients.

Impact of radiotherapy on local recurrence of rectal cancer in Norway

Background

The purpose of this study was to analyse the impact of radiotherapy on local recurrence of rectal cancer in Norway after the national implementation of total mesorectal excision (TME).

Methods

This was a prospective national cohort study of 4113 patients undergoing major resection of rectal carcinoma between November 1993 and December 2001.

Results

The proportion of patients who had radiotherapy before or after operation increased from 4·6 per cent in 1994 to 23·0 per cent in 2001. The cumulative 5-year local recurrence rate decreased from 16·2 to 10·7 per cent. Multivariable analysis showed that preoperative radiotherapy significantly reduced local recurrence (hazard ratio 0·59 (95 per cent confidence interval 0·39 to 0·87)). The use of preoperative radiotherapy in patients from a local hospital offering radiotherapy was 50 per cent higher than that for patients from a hospital without such services (P = 0·003); cumulative 5-year local recurrence rates for these patients were 10·6 and 15·8 per cent respectively (P &lt; 0·001).

Conclusion

Following national implementation of TME for rectal cancer, increased use of preoperative radiotherapy appeared to reduce recurrence rates further.

Colorectal Cancer: Epidemiology and Health Services Research

The causes of colorectal carcinoma are multifactorial. Numerous lines of epidemiologic evidence support the role of dietary factors, with strong associations revealed for folate and calcium, more equivocal evidence exists for dietary antioxidants. Lifestyle factors such as physical activity, alcohol in-take, and tobacco use are also positively correlated with the risk of colorectal carcinoma. Health services research examines epidemiologic issues,clinical evidence regarding prevention and treatment, patient preferences,and other factors with the goal of improving the quality of care. Observations based on epidemiologic studies and health services research will in the future provide the basis for reducing personal and social burdens caused by colorectal carcinoma.

The New England Colorectal Cancer Quality Project: A Prospective Multi-Institutional Feasibility Study

BACKGROUND

The need for risk-adjusted databases to benchmark quality is well recognized. Data entry is typically performed by physician surrogates who are variably involved in patient care and might be unable to capture key elements of patient care known only to the operating surgeon. The primary purpose of this study was to assess the feasibility of developing a multi-institutional, prospective, surgeon-initiated database and, secondarily, to compare the data collected with chart review.

STUDY DESIGN

The New England Colorectal Society project registry was a prospective, multi-institutional regional database of consecutive patients undergoing operation for colorectal cancer at 13 participating institutions from July 2003 to June 2004. Three sites were chosen for case entry compliance and a random 10% sampling of cases was selected for chart review.

RESULTS

Five hundred sixty-nine patients were entered by 26 surgeons at 13 study sites. Two hundred nineteen complications were reported in 168 patients including 6 deaths (1.1%). Case entry compliance ranged from 45% to 100% by site and 25.5% to 100% by surgeon. There was at least one discrepancy between surgeon entry and chart review in 96% of cases; intraoperative complications and key surgical details reported by the surgeon were frequently absent from the chart.

CONCLUSIONS

Surgeons will participate in a collaborative, multi-institutional quality database. Compliance was variable, indicating that surgeon data entry cannot reliably replace other means of data collection. The surgeon might be able to provide key pieces of data, not otherwise available, that can be critical to understanding and improving outcomes.