Surgeon-Level Variation in Utilization of Local Staging and Neoadjuvant Therapy for Stage II-III Rectal Adenocarcinoma

Lack of Complete Pretreatment Staging Is Associated With Omission of Neoadjuvant Therapy for Rectal Cancer: A Statewide Study

BACKGROUND

Standardized local staging and neoadjuvant therapy are rectal cancer management quality measures supported by the Commission on Cancer and National Accreditation Program for Rectal Cancer for the management of rectal cancer. Previous studies suggested that up to 25% of patients with stage II/III rectal cancer patients do not receive neoadjuvant therapy. We hypothesized that failure to receive neoadjuvant therapy may be caused by failure to properly stage patients before surgery.

OBJECTIVE

This study aimed to determine whether lack of local rectal cancer staging is associated with underutilization of neoadjuvant therapy and to determine risk factors for omission of neoadjuvant therapy.

DESIGN

Retrospective cohort study. Bivariate and multivariable analyses were performed on patient, tumor, and 30-day outcome factors associated with neoadjuvant therapy and staging.

SETTINGS

hospitals participated in the Michigan Surgical Quality Collaborative Colorectal Cancer Project from January 2014 to December 2019.

PATIENTS

Elective, clinical stage II/III, mid-to-low rectal cancer resections. Patients with upper rectal cancer were excluded.

MAIN OUTCOME MEASURES

Percentage of patients receiving neoadjuvant therapy.

RESULTS

The final cohort included 350 patients with clinical stage II/III mid or low rectal cancer-80.9% of patients who had received neoadjuvant therapy and 83.2% of patients who had MRI and/or endoscopic ultrasound. A significant association was found between receiving neoadjuvant therapy and MRI/endorectal ultrasound staging ( p < 0.0001). Eighty-seven percent of patients who had MRI/endorectal ultrasound received neoadjuvant chemoradiotherapy; 49% of patients who did not have MRI/endorectal ultrasound staging received neoadjuvant chemoradiotherapy. Multivariate analysis revealed that risk factors for the omission of neoadjuvant therapy were older age and incomplete staging.

LIMITATIONS

Observational study with the possibility of unmeasured confounding variables.

CONCLUSIONS

Neoadjuvant therapy is underused in patients with stage II/III rectal cancer. Omission of pretreatment staging with MRI/endorectal ultrasound is associated with omission of neoadjuvant therapy. These data suggest the need for regional and national quality improvement strategies to standardize the multidisciplinary management of rectal cancer. See Video Abstract at http://links.lww.com/DCR/B923 .

LA FALTA DE ESTADIFICACIN COMPLETA PREVIA AL TRATAMIENTO SE ASOCIA CON LA OMISIN DE LA TERAPIA NEOADYUVANTE PARA EL CNCER DE RECTO UN ESTUDIO ESTATAL

ANTECEDENTES: La estadificación local estandarizada y la terapia neoadyuvante son medidas de calidad de la Comisión sobre el Cáncer y el Programa Nacional de Acreditación para el Cáncer de Recto para el tratamiento del cáncer de recto. Estudios previos sugirieron que hasta el 25% de los pacientes con cáncer de recto en estadio II/III no reciben terapia neoadyuvante. Planteamos la hipótesis de que la falla en recibir la terapia neoadyuvante puede deberse a la falla en la estadificación adecuada de los pacientes antes de la cirugía.OBJETIVO: El propósito de este estudio es determinar si la falta de estadificación local del cáncer de recto está asociada con la infrautilización de la terapia neoadyuvante y determinar los factores de riesgo para la omisión de la terapia neoadyuvante.DISEÑO: Estudio de cohorte retrospectivo. Se realizaron análisis bivariados y multivariados sobre el paciente, el tumor y los factores de resultado a los 30 días asociados con la terapia neoadyuvante y la estadificación.AJUSTE: Un total de 31 hospitales que participaron en el Proyecto Quirugico Colaborativo de Cáncer Colorrectal de Calidad de Michigan desde enero de 2014 hasta diciembre de 2019.PACIENTES: Resecciones electivas, en estadio clínico II/III, de cáncer de recto medio a bajo. Se excluyeron los pacientes con cáncer de recto superior.MEDIDA DE RESULTADO PRINCIPAL: Porcentaje de pacientes que reciben terapia neoadyuvante. Porcentaje de pacientes que reciben terapia neoadyuvante.RESULTADOS: La cohorte final fue de 350 casos con cáncer de recto medio o bajo en estadio clínico II/III. El 80,9% tenía terapia neoadyuvante y el 83,2%, resonancia magnética y/o ultrasonido endoscópico. Hubo una asociación significativa entre recibir terapia neoadyuvante y la estadificación MRI/ERUS ( p < 0,0001). El 87% de los pacientes a los que se les realizaron imágenes con MRI/ERUS recibieron NT, mientras que el 49% de los pacientes a los que no se les realizó la estadificación con MRI/ERUS tuvieron NT. El análisis multivariante reveló que los factores de riesgo para la omisión de la terapia neoadyuvante fueron la edad avanzada y la estadificación incompleta.LIMITACIONES: Estudio observacional con posibilidad de confusión de variables no medidas.CONCLUSIONES: La terapia neoadyuvante está infrautilizada en pacientes con cáncer de recto en estadio II/III. La omisión de la estadificación previa al tratamiento con MRI/ERUS se asocia con la omisión de la terapia neoadyuvante. Estos datos sugieren la necesidad de estrategias regionales y nacionales de mejora de la calidad para estandarizar el manejo multidisciplinario del cáncer de recto. Consulte Video Resumen en http://links.lww.com/DCR/B923 . (Traducción-Dr Yolanda Colorado ).

Analysis of Patterns of Compliance with Accreditation Standards of National Accreditation Program for Rectal Cancer

BACKGROUND

We identified commonly deficient standards across rectal cancer programs that underwent accreditation review by the National Accreditation Program for Rectal Cancer to evaluate for patterns of noncompliance.

STUDY DESIGN

With the use of the internal database of the American College of Surgeons, programs that underwent accreditation review from 2018 to 2020 were evaluated. The occurrence and frequency of noncompliance with the standards, using the 2017 standards manual, were evaluated. Programs were further stratified based on the year of review, annual rectal cancer volume, and Commission on Cancer classification.

RESULTS

A total of 25 programs with annual rectal cancer volume from 14 to more than 200 cases per year underwent accreditation review. Only 2 programs achieved 100% compliance with all standards. Compliance with standards ranged from 48% to 100%. The 2 standards with the lowest level of compliance included standard 2.5 and standard 2.11 that require all patients with rectal cancer to be discussed at a multidisciplinary team meeting before the initiation of definitive treatment and within 4 weeks after definitive surgical therapy, respectively. Patterns of noncompliance persisted when programs were stratified on the basis oof the year of survey, annual rectal cancer volume, and Commission on Cancer classification. The corrective action process allowed all programs to ultimately become successfully accredited.

CONCLUSION

During this initial phase of the National Accreditation Program for Rectal Cancer accreditation, the majority of programs undergoing review did not achieve 100% compliance and went through a corrective action process. Although the minimal multidisciplinary team meeting attendance requirements were simplified in the 2021 revised standards, noncompliance related to presentation of all patients at the multidisciplinary team meeting before and after definitive treatment highlights the need for programs seeking accreditation to implement optimized and standardized workflows to achieve compliance.

Evaluating disparities in delivery of neoadjuvant guideline-based chemoradiation for rectal cancer: A multicenter, propensity score-weighted cohort study

BACKGROUND

Despite guideline recommendations, some patients still receive care inappropriate for their clinical stage of disease. Identification of factors that contribute to variation in guideline base care may help eradicate disparities in the treatment of early and locally advanced rectal cancer.

METHODS

The American College of Surgeons National Cancer Database from 2010 to 2015 was analyzed with propensity score weighting to identify factors associated with delivery and omission of neoadjuvant guideline-based chemoradiation (GBC) for those with early and locally advanced rectal cancer.

RESULTS

Only 74% of patients with rectal cancer received stage-appropriate neoadjuvant chemoradiation; 4544 (88%) of those with early stage disease and 8675 (68%) in locally advanced disease. Chemotherapy and radiotherapy were not planned in 27% and 34% respectively, of those who did not receive GBC. Factors associated with receipt of non-guideline-based neoadjuvant chemoradiation were age >65 years, Medicare insurance, treatment at a community facility, West-South-Central geography, having locally advanced disease, and Charlson-Deyo score >3. Receipt of ideal guideline-based neoadjuvant chemoradiation conferred a survival benefit at 5 years.

CONCLUSION

Patient and non-patient factors contribute to disparities in guideline-based delivery of neoadjuvant chemoradiation in the treatment of rectal cancer. Identification of these risk factors are important to help standardize care and improve survival outcomes.

Quality indicator selection for the Canadian Partnership against Cancer rectal cancer project: A modified Delphi study

AIM

It is well established that (i) magnetic resonance imaging, (ii) multidisciplinary cancer conference (MCCs), (iii) preoperative radiotherapy, (iv) total mesorectal excision surgery and (v) pathological assessment as described by Quirke are key processes necessary for high quality, rectal cancer care. The objective was to select a set of multidisciplinary quality indicators to measure the uptake of these clinical processes in clinical practice.

METHOD

A multidisciplinary panel was convened and a modified two-phase Delphi method was used to select a set of quality indicators. Phase 1 included a literature review with written feedback from the panel. Phase 2 included an in-person workshop with anonymous voting. The selection criteria for the indicators were strength of evidence, ease of capture and usability. Indicators for which ≥90% of the panel members voted 'to keep' were selected as the final set of indicators.

RESULTS

During phase 1, 68 potential indicators were generated from the literature and an additional four indicators were recommended by the panel. During phase 2, these 72 indicators were discussed; 48 indicators met the 90% inclusion threshold and included eight pathology, five radiology, 11 surgical, six radiation oncology and 18 MCC indicators.

CONCLUSION

A modified Delphi method was used to select 48 multidisciplinary quality indicators to specifically measure the uptake of key processes necessary for high quality care of patients with rectal cancer. These quality indicators will be used in future work to identify and address gaps in care in the uptake of these clinical processes.

Fragmented Care in the Treatment of Rectal Cancer and Time to Definitive Therapy

BACKGROUND

The National Accreditation Program for Rectal Cancer (NAPRC) emphasizes a multidisciplinary approach for treating rectal cancer and has developed performance measures to ensure that patients receive standardized care. We hypothesized that rectal cancer patients receiving care at multiple centers would be less likely to receive timely and appropriate care.

STUDY DESIGN

A single institution retrospective review of a prospectively maintained database was performed. All patients undergoing proctectomy and ≤1 other treatment modality (eg radiation and/or chemotherapy) for Stage II/III rectal adenocarcinoma were included. Unified care was defined as receiving all modalities of care at our institution, and fragmented care was defined as having at least 1 treatment modality at another institution.

RESULTS

From 2009 to 2019, 415 patients met inclusion criteria, with 197 (47.5%) receiving fragmented care and 218 (52.5%) receiving unified care. The unified cohort patients were more likely to see a colorectal surgeon before starting treatment (89.0% vs 78.7%, p < 0.01) and start definitive treatment within 60 days of diagnosis (89.0% vs 79.7%, p = 0.01). On adjusted analysis, unified care patients were 2.78 times more likely to see a surgeon before starting treatment (95% CI 1.47-5.24) and 2.63 times more likely to start treatment within 60 days (95% CI 1.35-5.13). There was no difference in 90-day mortality or 5-year disease-free survival.

CONCLUSIONS

This retrospective cohort study suggests patients with rectal cancer receiving fragmented care are at an increased risk of delays in care without any impact on disease-free survival. These findings need to be considered within the context of ongoing regionalization of rectal cancer care to ensure all patients receive optimal care, irrespective of whether care is delivered across multiple institutions.

The Canadian Partnership Against Cancer Rectal Cancer Project: Protocol for a Pan-Canadian, Multidisciplinary Quality Improvement Initiative to Optimize the Quality of Rectal Cancer Care

BACKGROUND

Over the last 2 decades, the use of multimodal strategies, including total mesorectal excision (TME) surgery, preoperative chemotherapy, multidisciplinary case conference, pelvic magnetic resonance imaging, and pathologic assessment using Quirke method, has led to significant improvements in oncologic outcomes for patients with rectal cancer. Although the literature supports claims on the effectiveness of these multimodal strategies, the uptake of these multimodal strategies varies considerably among centers, suggesting that the best evidence is not always implemented into clinical practice.

OBJECTIVE

This study aims to perform a quality improvement initiative to (1) identify existing gaps in care for these multimodal strategies and (2) implement knowledge translation (KT) interventions to close these gaps to optimize quality of care for patients with rectal cancer across high-volume centers in Canada.

METHODS

Process indicators for the selected multimodal strategies to optimize rectal cancer care will be selected and prospectively collected for all patients with stages 1 to 3 rectal cancer undergoing TME surgery. KT interventions, including audit and feedback, opinion leaders, and community of practice, will be implemented to increase the uptake of these clinical strategies.

RESULTS

The uptake of the process indicators over time and the effect of the uptake of the process indicators on short- and long-term oncologic outcomes will be evaluated for each multimodal strategy.

CONCLUSIONS

This quality improvement initiative will identify existing gaps in care for the selected multimodal strategies and implement KT interventions to close these gaps. The results of this study will inform further efforts to optimize rectal cancer care.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/15535.

Facility Variation in Local Staging of Rectal Adenocarcinoma and its Contribution to Underutilization of Neoadjuvant Therapy

BACKGROUND

Guidelines recommend neoadjuvant therapy (NT) for clinical stage II-III (locally advanced) rectal adenocarcinoma, but utilization remains suboptimal. The causes of NT omission remain poorly understood.

METHODS

The main outcomes in this study of patients with resected clinically non-metastatic rectal adenocarcinoma in the 2010-2015 National Cancer Database were local staging utilization in patients with non-metastatic tumors (i.e., undocumented clinical stage/pathologic stage I-III) and NT utilization for locally advanced tumors. Multivariable regression was used to examine predictors of these outcomes. Facility-specific risk- and reliability-adjusted local staging and NT rates were calculated. Positive margins and overall survival (OS) were examined as secondary outcomes.

RESULTS

Local staging was omitted in 7737/43,819 (17.7%) patients with clinically non-metastatic tumors and NT was omitted in 5199/31,632 (16.4%) patients with locally advanced tumors. NT was utilized in 24,826 (91.1%) locally advanced patients who had local staging vs. 1607 (36.6%) patients who did not; 2785 (53.6%) locally advanced patients with NT omitted also had local staging omitted. Treatment at facilities with lowest quintile local staging rates was associated with NT omission (relative risk 2.41, 95% confidence interval 2.11, 2.75). Adjusted facility local staging rates varied sixfold (16.1-98.0%), facility NT rates varied twofold (43.9-95.9%), and they were correlated (r = 0.58; P < 0.001). Local staging omission and NT omission were independently associated with positive margins and decreased OS.

CONCLUSIONS

Local staging omission is a common care process in over half of cases of omitted NT. These data emphasize the need for quality improvement efforts directed at providing facilities feedback about their local staging rates.