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Zhang FG, Sheni R, Zhang C, Viswanathan S, Fiori K, Mehta V. Association Between Social Determinants of Health and Cancer Treatment Delay in an Urban Population. JCO Oncol Pract 2024:OP2400118. [PMID: 38959443 DOI: 10.1200/op.24.00118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 04/14/2024] [Accepted: 05/21/2024] [Indexed: 07/05/2024] Open
Abstract
PURPOSE Delays in oncologic time to treatment initiation (TTI) independently and adversely affect disease-specific mortality. Social Determinants of Health (SDoH) are increasingly recognized as significant contributors to patients' disease management and health outcomes. Our academic center has validated a 10-item SDoH screener, and we elucidated which specific needs may be predictive of delayed TTI. METHODS This is a retrospective cohort study at an urban academic center of patients with a SDoH screening and diagnosis of breast, colorectal, endocrine/neuroendocrine, GI, genitourinary, gynecologic, head and neck, hematologic, hepatobiliary, lung, or pancreatic cancer from 2018 to 2022. Variables of interest included household income, tumor stage, and emergency department (ED) or inpatient admission 30 days before diagnosis. Factors associated with delayed TTI ≥45 days were assessed using multivariable logistic regression. RESULTS Among 2,328 patients (mean [standard deviation] age, 64.0 (12.8) years; 66.6% female), having >1 unmet social need was associated with delayed TTI (odds ratio [OR], 1.68; 95% CI, 1.54 to 1.82). The disparities most associated with delay were legal help, transportation, housing stability, and needing to provide care for others. Those with ED (OR, 0.49; 95% CI, 0.44 to 0.54) or inpatient (OR, 0.54; 95% CI, 0.50 to 0.58) admission 30 days before diagnosis were less likely to experience delay. CONCLUSION Delays in oncologic TTI ≥45 days are independently associated with unmet social needs. ED or inpatient admissions before diagnosis increase care coordination, leading to improved TTI. Although limitations included the retrospective nature of the study and self-reporting bias, these findings more precisely identify targets for intervention that may more effectively decrease delay. Patients with SDoH barriers are at higher risk of treatment delay and could especially benefit from legal, transportation, caregiver, and housing assistance.
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Affiliation(s)
| | - Risha Sheni
- Albert Einstein College of Medicine, Bronx, NY
| | - Chenxin Zhang
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - Shankar Viswanathan
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - Kevin Fiori
- Department of Family and Social Medicine, Department of Pediatrics, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Vikas Mehta
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
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2
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Donnelly C, Or M, Toh J, Thevaraja M, Janssen A, Shaw T, Pathma-Nathan N, Harnett P, Chiew KL, Vinod S, Sundaresan P. Measurement that matters: A systematic review and modified Delphi of multidisciplinary colorectal cancer quality indicators. Asia Pac J Clin Oncol 2024; 20:259-274. [PMID: 36726222 DOI: 10.1111/ajco.13917] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 12/19/2022] [Accepted: 12/26/2022] [Indexed: 02/03/2023]
Abstract
AIM To develop a priority set of quality indicators (QIs) for use by colorectal cancer (CRC) multidisciplinary teams (MDTs). METHODS The review search strategy was executed in four databases from 2009-August 2019. Two reviewers screened abstracts/manuscripts. Candidate QIs and characteristics were extracted using a tailored abstraction tool and assessed for scientific soundness. To prioritize candidate indicators, a modified Delphi consensus process was conducted. Consensus was sought over two rounds; (1) multidisciplinary expert workshops to identify relevance to Australian CRC MDTs, and (2) an online survey to prioritize QIs by clinical importance. RESULTS A total of 93 unique QIs were extracted from 118 studies and categorized into domains of care within the CRC patient pathway. Approximately half the QIs involved more than one discipline (52.7%). One-third of QIs related to surgery of primary CRC (31.2%). QIs on supportive care (6%) and neoadjuvant therapy (6%) were limited. In the Delphi Round 1, workshop participants (n = 12) assessed 93 QIs and produced consensus on retaining 49 QIs including six new QIs. In Round 2, survey participants (n = 44) rated QIs and prioritized a final 26 QIs across all domains of care and disciplines with a concordance level > 80%. Participants represented all MDT disciplines, predominantly surgical (32%), radiation (23%) and medical (20%) oncology, and nursing (18%), across six Australian states, with an even spread of experience level. CONCLUSION This study identified a large number of existing CRC QIs and prioritized the most clinically relevant QIs for use by Australian MDTs to measure and monitor their performance.
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Affiliation(s)
- Candice Donnelly
- Faculty of Medicine and Health, University of Sydney, Camperdown, Australia
| | - Michelle Or
- Radiation Oncology Network, Western Sydney Local Health District, Westmead, Australia
| | - James Toh
- Department of Surgery, Westmead Hospital, Westmead, Australia
- Westmead Clinical School, University of Sydney, Sydney, Australia
| | | | - Anna Janssen
- Faculty of Medicine and Health, University of Sydney, Camperdown, Australia
| | - Tim Shaw
- Faculty of Medicine and Health, University of Sydney, Camperdown, Australia
| | | | - Paul Harnett
- Westmead Clinical School, University of Sydney, Sydney, Australia
- Crown Princess Mary Cancer Centre, Western Sydney Local Health District, Westmead, Australia
| | - Kim-Lin Chiew
- Ingham Institute for Applied Medical Research, Liverpool, Australia
- Liverpool Cancer Therapy Centre, South Western Sydney Local Health District, Liverpool, Australia
- South Western Clinical School, University of New South Wales, Randwick, Australia
- Princess Alexandra Hospital, Division of Cancer Services, Brisbane, Australia
| | - Shalini Vinod
- Liverpool Cancer Therapy Centre, South Western Sydney Local Health District, Liverpool, Australia
- South Western Clinical School, University of New South Wales, Randwick, Australia
| | - Puma Sundaresan
- Radiation Oncology Network, Western Sydney Local Health District, Westmead, Australia
- Westmead Clinical School, University of Sydney, Sydney, Australia
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3
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Drosdowsky A, Lamb KE, Karahalios A, Bergin RJ, Milley K, Boyd L, IJzerman MJ, Emery JD. The effect of time before diagnosis and treatment on colorectal cancer outcomes: systematic review and dose-response meta-analysis. Br J Cancer 2023; 129:993-1006. [PMID: 37528204 PMCID: PMC10491798 DOI: 10.1038/s41416-023-02377-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 06/28/2023] [Accepted: 07/24/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND This systematic review and meta-analysis aimed to evaluate existing evidence on the relationship between diagnostic and treatment intervals and outcomes for colorectal cancer. METHODS Four databases were searched for English language articles assessing the role of time before initial treatment in colorectal cancer on any outcome, including stage and survival. Two reviewers independently screened articles for inclusion and data were synthesised narratively. A dose-response meta-analysis was performed to examine the association between treatment interval and survival. RESULTS One hundred and thirty papers were included in the systematic review, eight were included in the meta-analysis. Forty-five different intervals were considered in the time from first symptom to treatment. The most common finding was of no association between the length of intervals on any outcome. The dose-response meta-analysis showed a U-shaped association between the treatment interval and overall survival with the nadir at 45 days. CONCLUSION The review found inconsistent, but mostly a lack of, association between interval length and colorectal cancer outcomes, but study design and quality were heterogeneous. Meta-analysis suggests survival becomes increasingly poorer for those commencing treatment more than 45 days after diagnosis. REGISTRATION This review was registered, and the protocol is available, in PROSPERO, the international database of systematic reviews, with the registration ID CRD42021255864.
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Affiliation(s)
- Allison Drosdowsky
- Department of General Practice and Centre for Cancer Research, The University of Melbourne, Parkville, VIC, Australia.
| | - Karen E Lamb
- Melbourne School of Population and Global Health, The University of Melbourne, Parkville, VIC, Australia
| | - Amalia Karahalios
- Melbourne School of Population and Global Health, The University of Melbourne, Parkville, VIC, Australia
| | - Rebecca J Bergin
- Department of General Practice and Centre for Cancer Research, The University of Melbourne, Parkville, VIC, Australia
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, VIC, Australia
| | - Kristi Milley
- Department of General Practice and Centre for Cancer Research, The University of Melbourne, Parkville, VIC, Australia
- Primary Care Collaborative Cancer Clinical Trials Group (PC4), Carlton, VIC, Australia
| | - Lucy Boyd
- Department of General Practice and Centre for Cancer Research, The University of Melbourne, Parkville, VIC, Australia
| | - Maarten J IJzerman
- Melbourne School of Population and Global Health, The University of Melbourne, Parkville, VIC, Australia
| | - Jon D Emery
- Department of General Practice and Centre for Cancer Research, The University of Melbourne, Parkville, VIC, Australia
- Primary Care Collaborative Cancer Clinical Trials Group (PC4), Carlton, VIC, Australia
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4
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Drosdowsky A, Lamb KE, Bergin RJ, Boyd L, Milley K, IJzerman MJ, Emery JD. A systematic review of methodological considerations in time to diagnosis and treatment in colorectal cancer research. Cancer Epidemiol 2023; 83:102323. [PMID: 36701982 DOI: 10.1016/j.canep.2023.102323] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 01/06/2023] [Accepted: 01/09/2023] [Indexed: 01/26/2023]
Abstract
Research focusing on timely diagnosis and treatment of colorectal cancer is necessary to improve outcomes for people with cancer. Previous attempts to consolidate research on time to diagnosis and treatment have noted varied methodological approaches and quality, limiting the comparability of findings. This systematic review was conducted to comprehensively assess the scope of methodological issues in this field and provide recommendations for future research. Eligible articles had to assess the role of any interval up to treatment, on any outcome in colorectal cancer, in English, with no limits on publication time. Four databases were searched (Ovid Medline, EMBASE, EMCARE and PsycInfo). Papers were screened by two independent reviewers using a two-stage process of title and abstract followed by full text review. In total, 130 papers were included and had data extracted on specific methodological and statistical features. Several methodological problems were identified across the evidence base. Common issues included arbitrary categorisation of intervals (n = 107, 83%), no adjustment for potential confounders (n = 65, 50%), and lack of justification for included covariates where there was adjustment (n = 40 of 65 papers that performed an adjusted analysis, 62%). Many articles introduced epidemiological biases such as immortal time bias (n = 37 of 80 papers that used survival as an outcome, 46%) and confounding by indication (n = 73, 56%), as well as other biases arising from inclusion of factors outside of their temporal sequence. However, determination of the full extent of these problems was hampered by insufficient reporting. Recommendations include avoiding artificial categorisation of intervals, ensuring bias has not been introduced due to out-of-sequence use of key events and increased use of theoretical frameworks to detect and reduce bias. The development of reporting guidelines and domain-specific risk of bias tools may aid in ensuring future research can reliably contribute to recommendations regarding optimal timing and strengthen the evidence base.
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Affiliation(s)
- Allison Drosdowsky
- Department of General Practice and Centre for Cancer Research, The University of Melbourne, Parkville, Australia.
| | - Karen E Lamb
- Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Australia
| | - Rebecca J Bergin
- Department of General Practice and Centre for Cancer Research, The University of Melbourne, Parkville, Australia; Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Australia
| | - Lucy Boyd
- Department of General Practice and Centre for Cancer Research, The University of Melbourne, Parkville, Australia
| | - Kristi Milley
- Department of General Practice and Centre for Cancer Research, The University of Melbourne, Parkville, Australia; Primary Care Collaborative Cancer Clinical Trials Group (PC4), Carlton, Australia
| | - Maarten J IJzerman
- Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Australia
| | - Jon D Emery
- Department of General Practice and Centre for Cancer Research, The University of Melbourne, Parkville, Australia; Primary Care Collaborative Cancer Clinical Trials Group (PC4), Carlton, Australia
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5
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Sheni R, Qin J, Viswanathan S, Castellucci E, Kalnicki S, Mehta V. Predictive Factors for Cancer Treatment Delay in a Racially Diverse and Socioeconomically Disadvantaged Urban Population. JCO Oncol Pract 2023:OP2200779. [DOI: 10.1200/op.22.00779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
PURPOSE Incremental delays in time to treatment initiation (TTI) have been shown to cause a proportional, increased independent risk of disease-specific mortality for breast cancer, colorectal cancer (CRC), head and neck cancer (HNC), non–small-cell lung cancer (NSCLC), and pancreatic cancer. Studies suggest that delays are associated with racial and socioeconomic disparities. We evaluated associations between patient factors and TTI to identify those associated with delay. MATERIALS AND METHODS This is a retrospective cohort study at an urban community-based academic center of patients diagnosed with or referred for curative-intent treatment of breast cancer, CRC, HNC, NSCLC, and pancreatic cancer from January 2019 to December 2021. Variables of interest included Charlson Comorbidity Index (CCI) score, insurance type, language preference, and inpatient admission 30 days before diagnosis. Factors associated with TTI delay, defined as TTI ≥ 30 days, were assessed using multivariable logistic regression. RESULTS Among 2,543 patients (69% female), the mean age was 63.4 years and the median TTI was 25 days (IQR, 6-44). Within multivariable models, patients treated as outpatient and not admitted 30 days before diagnosis experienced statistically significant greater delay for CRC (odds ratio [OR], 2.82; 95% CI, 1.71 to 4.66) and NSCLC (OR, 2.11; 95% CI, 1.31 to 3.39). Higher CCI score was associated with delay for HNC (OR, 2.63; 95% CI, 1.04 to 6.66) and NSCLC (OR, 1.75; 95% CI, 1.14 to 2.71). For breast cancer, uninsured and Spanish-speaking patients (OR, 1.79; 95% CI, 1.21 to 2.67) experienced increased TTI. CONCLUSION Care coordination/compliance (eg, inpatient 30 days before diagnosis), clinical (eg, medical comorbidities), and socioeconomic (eg, uninsured status) predictors for delayed TTI were identified and may inform delay minimizing interventions. Our data support evidence that TTI delays are associated with demographic and socioeconomic disparities. Existing disparities are likely exacerbated by delays that disproportionately affect patients with care coordination/compliance issues, multiple comorbidities, and lower socioeconomic status.
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6
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Franssen RFW, Strous MTA, Bongers BC, Vogelaar FJ, Janssen-Heijnen MLG. The Association Between Treatment Interval and Survival in Patients With Colon or Rectal Cancer: A Systematic Review. World J Surg 2021; 45:2924-2937. [PMID: 34175967 PMCID: PMC8322003 DOI: 10.1007/s00268-021-06188-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Surgery for colon or rectal cancer is associated with a high incidence of complications, especially in patients with a low aerobic fitness. Those patients might benefit from a comprehensive preoperative workup including prehabilitation. However, time between diagnosis and treatment is often limited due to current treatment guidelines. To date, it is unclear whether the treatment interval can be extended without compromising survival. METHODS A systematic review concerning the association between treatment intervals and survival in patients who underwent elective curative surgery for colon or rectal cancer was performed. A search up to December 2020 was conducted in PubMed, Cinahl and Embase. Original research articles were eligible. Quality assessment was performed using the Downs and Black checklist. RESULTS Eleven observational studies were included (897 947 patients). In colon cancer, treatment intervals that were statistically significant associated with reduced overall survival or cancer-specific survival ranged between > 30 and > 84 days. In rectal cancer, only one out of four studies showed that treatment intervals > 49 days was associated with reduced cancer-specific survival. CONCLUSIONS This systematic review identified that studies investigating the association between treatment intervals and survival are heterogeneous with regard to treatment interval definitions, treatment interval time intervals and used outcome measures. These aspects need standardization before a reliable estimate of an optimal treatment interval can be made. In addition, further research should focus on establishing optimal treatment intervals in patients at high risk for postoperative complications, as particularly these patients might benefit from extended diagnosis to treatment intervals permitting comprehensive preoperative preparation.
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Affiliation(s)
- Ruud F W Franssen
- Department of Clinical Physical Therapy, VieCuri Medical Center, Venlo Tegelseweg, Venlo, 210 5912BL, The Netherlands.
- Department of Epidemiology, GROW School for Oncology and Developmental Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.
| | - Maud T A Strous
- Department of Epidemiology, GROW School for Oncology and Developmental Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Surgery, VieCuri Medical Center, Venlo, The Netherlands
| | - Bart C Bongers
- Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - F Jeroen Vogelaar
- Department of Surgery, VieCuri Medical Center, Venlo, The Netherlands
| | - Maryska L G Janssen-Heijnen
- Department of Epidemiology, GROW School for Oncology and Developmental Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Epidemiology, VieCuri Medical Center, Venlo, The Netherlands
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7
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Garcia-Botello S, Martín-Arevalo J, Cozar-Lozano C, Benitez-Riesco A, Moro-Valdezate D, Pla-Martí V, Espí-Macías A. Does delaying curative surgery for colorectal cancer influence long-term disease-free survival? A cohort study. Langenbecks Arch Surg 2021; 406:2383-2390. [PMID: 34247257 PMCID: PMC8272683 DOI: 10.1007/s00423-021-02251-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 06/16/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Surgical wait list time is a major problem in many health-care systems and its influence on survival is unclear. The aim of this study is to assess the impact of wait list time on long-term disease-free survival in patients scheduled for colorectal cancer resection. MATERIALS AND METHODS A prospective study was carried out in patients with colorectal cancer scheduled for surgery at a tertiary care center. Wait list time was defined as the time from completion of diagnostic workup to definitive surgery and divided into 2-week intervals from 0 to 6 weeks. The outcome variables were 2-year and 5-year disease-free survival. RESULTS A total of 602 patients, 364 (60.5%) male, median age 73 years (range = 71) were defined. The median wait list time was 28 days (range = 99). Two and 5-year disease-free survival rates were 521 (86.5%) and 500 (83.1%) respectively. There were no differences in 2-year or 5-year disease-free survival for the whole cohort or by tumor stage between wait list time intervals except for AJCC stage II tumors which showed a higher 5-year disease-free survival for the 2-4 and 4-6-week wait list time interval (p = 0.021). CONCLUSIONS Time from diagnosis to definitive surgery up to 6 weeks is not associated with a decrease in 2-year or 5-year disease-free survival (DFS) in AJCC stage I through III colorectal cancer patients. These are important findings in the light of the COVID-19 pandemic and offer a window of opportunity for preoperative optimization and prehabilitation.
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Affiliation(s)
- Stephanie Garcia-Botello
- Colorectal Surgery Unit, Biomedical Research Institute INCLIVA, Hospital Clinico Universitario, Valencia, Spain. .,Department of Surgery, Universidad de Valencia, Valencia, Spain.
| | - J Martín-Arevalo
- Colorectal Surgery Unit, Biomedical Research Institute INCLIVA, Hospital Clinico Universitario, Valencia, Spain
| | - C Cozar-Lozano
- Colorectal Surgery Unit, Biomedical Research Institute INCLIVA, Hospital Clinico Universitario, Valencia, Spain
| | - A Benitez-Riesco
- Colorectal Surgery Unit, Biomedical Research Institute INCLIVA, Hospital Clinico Universitario, Valencia, Spain
| | - D Moro-Valdezate
- Colorectal Surgery Unit, Biomedical Research Institute INCLIVA, Hospital Clinico Universitario, Valencia, Spain.,Department of Surgery, Universidad de Valencia, Valencia, Spain
| | - V Pla-Martí
- Colorectal Surgery Unit, Biomedical Research Institute INCLIVA, Hospital Clinico Universitario, Valencia, Spain.,Department of Surgery, Universidad de Valencia, Valencia, Spain
| | - A Espí-Macías
- Colorectal Surgery Unit, Biomedical Research Institute INCLIVA, Hospital Clinico Universitario, Valencia, Spain.,Department of Surgery, Universidad de Valencia, Valencia, Spain
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8
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Horsey ML, Sparks AD, Simkins A, Kim G, Ng M, Obias VJ. Comparing outcomes for non-metastatic rectal cancer in academic vs. community centers: A propensity-matched analysis of the National Cancer Database. Am J Surg 2021; 222:989-997. [PMID: 34024628 DOI: 10.1016/j.amjsurg.2021.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 04/26/2021] [Accepted: 05/07/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Little is known regarding the impact of hospital academic status on outcomes following rectal cancer surgery. We compare these outcomes for nonmetastatic rectal adenocarcinoma at academic versus community institutions. METHODS The National Cancer Database (2010-2016) was queried for patients with nonmetastatic rectal adenocarcinoma who underwent resection. Propensity score matching was performed across facility cohorts to balance confounding covariates. Kaplan-Meier estimation and Cox-proportional hazards regression were used to analyze survival, other short and long-term outcomes were analyzed by way of logistic regression. RESULTS After matching, 15,096 patients were included per cohort. Academic centers were associated with significantly decreased odds of conversion and positive margins with significantly increased odds of ≥12 regional nodes examined. Academic programs also had decreased odds of 30 and 90-day mortality and decreased 5-year mortality hazard. After matching for facility volume, no significant differences in outcomes between centers was seen. CONCLUSIONS No difference between academic and community centers in outcomes following surgery for non-metastatic rectal cancer was seen after matching for facility procedural volume.
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Affiliation(s)
- Michael L Horsey
- Walter Reed National Military Medical Center, Bethesda, MD, USA.
| | - Andrew D Sparks
- Department of Surgery, George Washington University Medical Faculty Associates, Washington, DC, USA
| | - Aron Simkins
- Department of Hematology & Oncology, George Washington University Hospital, Washington, DC, USA
| | - George Kim
- Department of Hematology & Oncology, George Washington University Hospital, Washington, DC, USA
| | - Matthew Ng
- Department of Colon and Rectal Surgery at the George Washington University Hospital, Washington, DC, USA
| | - Vincent J Obias
- Department of Colon and Rectal Surgery at the George Washington University Hospital, Washington, DC, USA
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9
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DE Rosa M, Pasculli A, Rondelli F, Mariani L, Avenia S, Ceccarelli G, Testini M, Avenia N, Bugiantella W. Could diagnostic and therapeutic delay affect the prognosis of gastrointestinal primary malignancies in the COVID-19 pandemic era? A literature review. Minerva Surg 2021; 76:467-476. [PMID: 33890444 DOI: 10.23736/s2724-5691.21.08736-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Emergency situations, as the Covid-19 pandemic that is striking the world nowadays, stress the national health systems which are forced to rapidly reorganizing their sources. Therefore, many elective diagnostic and surgical procedures are being suspended or significantly delayed. Moreover, patients might find it difficult to refer to physicians and delay the diagnostic and even the therapeutic procedures because of emotional or logistic problems. The effect of diagnostic and therapeutic delay on survival in patients affected by gastrointestinal malignancies is still unclear. METHODS We carried out a review of the available literature, in order to determine whether the delay in performing diagnosis and curative-intent surgical procedures affects the oncological outcomes in patients with oesophageal, gastric, colorectal cancers, and colorectal liver metastasis. RESULTS The findings indicate that for oesophageal, gastric and colon cancers delaying surgery up to 2 months after the end of the staging process does not worsen the oncological outcomes. Oesophageal cancer should undergo surgery within 7-8 weeks after the end of neoadjuvant chemoradiation. Rectal cancers should undergo surgery within 31 days after the diagnostic process and within 12 weeks after neoadjuvant therapy. Adjuvant therapy should start within 4 weeks after surgery, especially in gastric cancer; a delay up to 42 days may be allowed for oesophageal cancer undergoing adjuvant radiotherapy. CONCLUSIONS Gastrointestinal malignancies can be safely managed taking into account that reasonable delays of planned treatments appear a generally safe approach, not having a significant impact on long-term oncological outcome.
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Affiliation(s)
- Michele DE Rosa
- General Surgery, San Giovanni Battista Hospital, USL Umbria 2, Foligno, Perugia, Italy
| | - Alessandro Pasculli
- Department of Biomedical Sciences and Human Oncology - Unit Of Endocrine, Digestive And Emergency Surgery, University A. Moro of Bari, Polyclinic of Bari, Bari, Italy
| | - Fabio Rondelli
- General and Specialized Surgery, Santa Maria Hospital, Terni, Italy.,Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Lorenzo Mariani
- General Surgery, San Giovanni Battista Hospital, USL Umbria 2, Foligno, Perugia, Italy
| | - Stefano Avenia
- Postgraduate School of General Surgery, University of Perugia, Perugia, Italy
| | - Graziano Ceccarelli
- General Surgery, San Giovanni Battista Hospital, USL Umbria 2, Foligno, Perugia, Italy
| | - Mario Testini
- Department of Biomedical Sciences and Human Oncology - Unit Of Endocrine, Digestive And Emergency Surgery, University A. Moro of Bari, Polyclinic of Bari, Bari, Italy
| | - Nicola Avenia
- General and Specialized Surgery, Santa Maria Hospital, Terni, Italy.,Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Walter Bugiantella
- General Surgery, San Giovanni Battista Hospital, USL Umbria 2, Foligno, Perugia, Italy -
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10
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Molenaar CJL, Janssen L, van der Peet DL, Winter DC, Roumen RMH, Slooter GD. Conflicting Guidelines: A Systematic Review on the Proper Interval for Colorectal Cancer Treatment. World J Surg 2021; 45:2235-2250. [PMID: 33813632 DOI: 10.1007/s00268-021-06075-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Timely treatment for colorectal cancer (CRC) is a quality indicator in oncological care. However, patients with CRC might benefit more from preoperative optimization rather than rapid treatment initiation. The objectives of this study are (1) to determine the definition of the CRC treatment interval, (2) to study international recommendations regarding this interval and (3) to study whether length of the interval is associated with outcome. METHODS We performed a systematic search of the literature in June 2020 through MEDLINE, EMBASE and Cochrane databases, complemented with a web search and a survey among colorectal surgeons worldwide. Full-text papers including subjects with CRC and a description of the treatment interval were included. RESULTS Definition of the treatment interval varies widely in published studies, especially due to different starting points of the interval. Date of diagnosis is often used as start of the interval, determined with date of pathological confirmation. The end of the interval is rather consistently determined with date of initiation of any primary treatment. Recommendations on the timeline of the treatment interval range between and within countries from two weeks between decision to treat and surgery, to treatment within seven weeks after pathological diagnosis. Finally, there is no decisive evidence that a longer treatment interval is associated with worse outcome. CONCLUSIONS The interval from diagnosis to treatment for CRC treatment could be used for prehabilitation to benefit patient recovery. It may be that this strategy is more beneficial than urgently proceeding with treatment.
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Affiliation(s)
- Charlotte J L Molenaar
- Department of Surgery, Máxima MC, De Run 4600, P.O. Box 7777, 5504 DB, Veldhoven, The Netherlands.
| | - Loes Janssen
- Department of Surgery, Máxima MC, De Run 4600, P.O. Box 7777, 5504 DB, Veldhoven, The Netherlands
| | - Donald L van der Peet
- Department of Surgery, Amsterdam UMC, Location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Desmond C Winter
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin, D04T6F4, Ireland
| | - Rudi M H Roumen
- Department of Surgery, Máxima MC, De Run 4600, P.O. Box 7777, 5504 DB, Veldhoven, The Netherlands
| | - Gerrit D Slooter
- Department of Surgery, Máxima MC, De Run 4600, P.O. Box 7777, 5504 DB, Veldhoven, The Netherlands
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11
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Molenaar CJL, Winter DC, Slooter GD. Contradictory guidelines for colorectal cancer treatment intervals. Lancet Oncol 2021; 22:167-168. [PMID: 33539739 DOI: 10.1016/s1470-2045(20)30738-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 12/02/2020] [Accepted: 12/03/2020] [Indexed: 01/19/2023]
Affiliation(s)
| | - Desmond C Winter
- Department of Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - Gerrit D Slooter
- Department of Surgery, Máxima MC, 5504 DB Veldhoven, Netherlands.
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12
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Yoshida M, Nakaya Y, Shimizu K, Tatsumi N, Tsutsumi M, Fuseya H, Horiuchi M, Yoshimura T, Hayashi Y, Nakao T, Inoue T, Yamane T. Importance of diagnosis-to-treatment interval in newly diagnosed patients with diffuse large B-cell lymphoma. Sci Rep 2021; 11:2837. [PMID: 33531642 PMCID: PMC7854577 DOI: 10.1038/s41598-021-82615-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 01/22/2021] [Indexed: 11/09/2022] Open
Abstract
Treatment of patients with malignancy sometimes be delayed due to various reasons. Several studies revealed that an influence of diagnosis-to-treatment interval (DTI) on outcomes differs depending on the type of malignancy. In this study, we evaluated the influence of DTI on clinical outcomes in newly diagnosed patients with diffuse large B-cell lymphoma (DLBCL). A total of 199 patients were identified with a median DTI of 22 days. At 2 years, patients with short DTI (0–22 days) showed significantly poorer OS (62.7% vs 86.4%) and PFS (55.1% vs 75.9%) compared to those with long DTI (over 22 days). Although short DTI was strongly correlated with several known adverse factors, it remained to be an independent prognostic factor by multivariate analysis. In conclusion, our study confirmed the importance of DTI in patients with DLBCL. Researchers should consider DTI as one of the important prognostic factors and plan clinical trials to be able to enroll patients with aggressive disease requiring urgent treatment.
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Affiliation(s)
- Masahiro Yoshida
- Department of Hematology, Osaka City General Hospital, Osaka, Japan.
| | - Yosuke Nakaya
- Department of Hematology, Osaka City General Hospital, Osaka, Japan
| | - Katsujun Shimizu
- Department of Hematology, Osaka City General Hospital, Osaka, Japan
| | - Naoko Tatsumi
- Department of Hematology, Osaka City General Hospital, Osaka, Japan
| | - Minako Tsutsumi
- Department of Hematology, Osaka City General Hospital, Osaka, Japan
| | - Hoyuri Fuseya
- Department of Hematology, Osaka City General Hospital, Osaka, Japan
| | - Mirei Horiuchi
- Department of Hematology, Osaka City General Hospital, Osaka, Japan
| | - Takuro Yoshimura
- Department of Hematology, Osaka City General Hospital, Osaka, Japan
| | - Yoshiki Hayashi
- Department of Hematology, Osaka City General Hospital, Osaka, Japan
| | - Takafumi Nakao
- Department of Hematology, Osaka City General Hospital, Osaka, Japan
| | - Takeshi Inoue
- Department of Pathology, Osaka City General Hospital, Osaka, Japan
| | - Takahisa Yamane
- Department of Hematology, Osaka City General Hospital, Osaka, Japan
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13
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Medina-Lara A, Grigore B, Lewis R, Peters J, Price S, Landa P, Robinson S, Neal R, Hamilton W, Spencer AE. Cancer diagnostic tools to aid decision-making in primary care: mixed-methods systematic reviews and cost-effectiveness analysis. Health Technol Assess 2020; 24:1-332. [PMID: 33252328 PMCID: PMC7768788 DOI: 10.3310/hta24660] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Tools based on diagnostic prediction models are available to help general practitioners diagnose cancer. It is unclear whether or not tools expedite diagnosis or affect patient quality of life and/or survival. OBJECTIVES The objectives were to evaluate the evidence on the validation, clinical effectiveness, cost-effectiveness, and availability and use of cancer diagnostic tools in primary care. METHODS Two systematic reviews were conducted to examine the clinical effectiveness (review 1) and the development, validation and accuracy (review 2) of diagnostic prediction models for aiding general practitioners in cancer diagnosis. Bibliographic searches were conducted on MEDLINE, MEDLINE In-Process, EMBASE, Cochrane Library and Web of Science) in May 2017, with updated searches conducted in November 2018. A decision-analytic model explored the tools' clinical effectiveness and cost-effectiveness in colorectal cancer. The model compared patient outcomes and costs between strategies that included the use of the tools and those that did not, using the NHS perspective. We surveyed 4600 general practitioners in randomly selected UK practices to determine the proportions of general practices and general practitioners with access to, and using, cancer decision support tools. Association between access to these tools and practice-level cancer diagnostic indicators was explored. RESULTS Systematic review 1 - five studies, of different design and quality, reporting on three diagnostic tools, were included. We found no evidence that using the tools was associated with better outcomes. Systematic review 2 - 43 studies were included, reporting on prediction models, in various stages of development, for 14 cancer sites (including multiple cancers). Most studies relate to QCancer® (ClinRisk Ltd, Leeds, UK) and risk assessment tools. DECISION MODEL In the absence of studies reporting their clinical outcomes, QCancer and risk assessment tools were evaluated against faecal immunochemical testing. A linked data approach was used, which translates diagnostic accuracy into time to diagnosis and treatment, and stage at diagnosis. Given the current lack of evidence, the model showed that the cost-effectiveness of diagnostic tools in colorectal cancer relies on demonstrating patient survival benefits. Sensitivity of faecal immunochemical testing and specificity of QCancer and risk assessment tools in a low-risk population were the key uncertain parameters. SURVEY Practitioner- and practice-level response rates were 10.3% (476/4600) and 23.3% (227/975), respectively. Cancer decision support tools were available in 83 out of 227 practices (36.6%, 95% confidence interval 30.3% to 43.1%), and were likely to be used in 38 out of 227 practices (16.7%, 95% confidence interval 12.1% to 22.2%). The mean 2-week-wait referral rate did not differ between practices that do and practices that do not have access to QCancer or risk assessment tools (mean difference of 1.8 referrals per 100,000 referrals, 95% confidence interval -6.7 to 10.3 referrals per 100,000 referrals). LIMITATIONS There is little good-quality evidence on the clinical effectiveness and cost-effectiveness of diagnostic tools. Many diagnostic prediction models are limited by a lack of external validation. There are limited data on current UK practice and clinical outcomes of diagnostic strategies, and there is no evidence on the quality-of-life outcomes of diagnostic results. The survey was limited by low response rates. CONCLUSION The evidence base on the tools is limited. Research on how general practitioners interact with the tools may help to identify barriers to implementation and uptake, and the potential for clinical effectiveness. FUTURE WORK Continued model validation is recommended, especially for risk assessment tools. Assessment of the tools' impact on time to diagnosis and treatment, stage at diagnosis, and health outcomes is also recommended, as is further work to understand how tools are used in general practitioner consultations. STUDY REGISTRATION This study is registered as PROSPERO CRD42017068373 and CRD42017068375. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology programme and will be published in full in Health Technology Assessment; Vol. 24, No. 66. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Antonieta Medina-Lara
- Health Economics Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Bogdan Grigore
- Exeter Test Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Ruth Lewis
- North Wales Centre for Primary Care Research, Bangor University, Bangor, UK
| | - Jaime Peters
- Exeter Test Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Sarah Price
- Primary Care Diagnostics, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Paolo Landa
- Health Economics Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Sophie Robinson
- Peninsula Technology Assessment Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Richard Neal
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - William Hamilton
- Primary Care Diagnostics, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Anne E Spencer
- Health Economics Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
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14
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Atallah C, Oduyale O, Stem M, Eltahir A, Almaazmi HH, Efron JE, Safar B. Are academic hospitals better at treating metastatic colorectal cancer? Surgery 2020; 169:248-256. [PMID: 32680747 DOI: 10.1016/j.surg.2020.05.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/03/2020] [Accepted: 05/05/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND There is a strong association between hospital volume and surgical outcomes in resectable colorectal cancer. The purpose of our study was to investigate the association between hospital facility type and survival of patients with metastatic colorectal cancer. METHODS Adults from the National Cancer Database (2010-2015) with a primary diagnosis of colorectal metastases were included and stratified by facility type: community cancer program, comprehensive community cancer program, and academic/research program. The primary outcome was 5-year overall survival, analyzed using Kaplan-Meier survival curves, log-rank test, and the Cox proportional hazards regression model. RESULTS Among the 52,958 included patients, 13.72% were treated at a community cancer program, 49.89% at a comprehensive community cancer program, and 36.29% at an academic/research program. A significant increase in the proportion of patients being treated in an academic/research program has been observed from 2010 to 2015. An academic/research program tended to use more chemotherapy with colorectal radical resection and liver or lung resection and immunotherapy with chemotherapy. In adjusted analysis, the academic/research program had decreased risk of mortality in comparison to the community cancer program and the comprehensive community cancer program (hazard ratio 0.90, 95% confidence interval 0.86-0.94; 0.87, 0.85-0.90; each P < .001; respectively). Similar results were seen after stratifying by metastatic site and treatment type. CONCLUSION The prognosis and overall survival of patients with metastatic disease is better in an academic/research program compared with a community cancer program or a comprehensive community cancer program, with this difference persisting across sites of metastatic disease and treatment types. Further studies are required to validate these results and investigate disparities in the management of metastatic colorectal cancer.
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Affiliation(s)
- Chady Atallah
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Oluseye Oduyale
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Miloslawa Stem
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ahmed Eltahir
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hamda H Almaazmi
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Jonathan E Efron
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Bashar Safar
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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15
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van Dijk D, van Dijk BAC, Weistra A, Links TP, Plukker JTM. Surgical Complications and Referral Patterns in 567 Patients with Differentiated Thyroid Cancer in the Northern Region of the Netherlands: A Population-Based Study Towards Clinical Management Implementation. Ann Surg Oncol 2020; 27:3872-3881. [PMID: 32328986 PMCID: PMC7471192 DOI: 10.1245/s10434-020-08470-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND In the Netherlands, differentiated thyroid cancer (DTC) is treated surgically in three different hospital types, including university, teaching, and non- teaching peripheral hospitals. This study evaluates postoperative complications and referral patterns in patients with DTC in the northern region of the Netherlands to gain an understanding on how to improve management implementation. METHODS Data from 567 patients diagnosed between 1989 and 2009 were obtained from the Netherlands Cancer Registry and were supplemented with information from hospital digital information systems and patient records from 15 hospitals: 1 university, 3 teaching, and 11 peripheral hospitals. Surgically treated patients with a histologically proven DTC derived from the original pathology reports were included. RESULTS Surgical treatment could be performed in a single procedure in 234 patients (41.3%), but several surgeries were needed in the remaining 333 patients (58.7%). Recurrent laryngeal nerve (RLN) palsy occurred after all types of thyroid surgical procedures, but mostly after initial (hemi)thyroidectomy and reoperations. RLN was temporary in 3.2% of the nerves at risk and persistent in 1.8%. Temporary hypocalcemia developed in 13.7% of patients, and persistent hypocalcemia occurred in 4.8%. Patients were mainly referred to the university hospital from a non-teaching (40.7%, 48/118) or teaching hospital (11.1%, 16/144); however, 80% of patients were not referred. CONCLUSIONS The complication rate and number of multiple surgeries support the efforts in optimizing clinical management in thyroid cancer. Careful considerations prior to initial surgical treatment by early discussion in telemedicine-based regional tumor boards could possibly prevent reoperations and potentially diminish complications.
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Affiliation(s)
- Deborah van Dijk
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
| | - Boukje A C van Dijk
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands.,Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Annemieke Weistra
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Thera P Links
- Department of Endocrinology, Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - John Th M Plukker
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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16
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Strous MT, Janssen-Heijnen ML, Vogelaar F. Impact of therapeutic delay in colorectal cancer on overall survival and cancer recurrence – is there a safe timeframe for prehabilitation? EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2019; 45:2295-2301. [DOI: 10.1016/j.ejso.2019.07.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 05/19/2019] [Accepted: 07/03/2019] [Indexed: 11/17/2022]
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17
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Association Between Hospital and Surgeon Volume and Rectal Cancer Surgery Outcomes in Patients With Rectal Cancer Treated Since 2000: Systematic Literature Review and Meta-analysis. Dis Colon Rectum 2018; 61:1320-1332. [PMID: 30286023 PMCID: PMC7000208 DOI: 10.1097/dcr.0000000000001198] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Previous reviews and meta-analyses, which predominantly focused on patients treated before 2000, have reported conflicting evidence about the association between hospital/surgeon volume and rectal cancer outcomes. Given advances in rectal cancer resection, such as total mesorectal excision, it is essential to determine whether volume plays a role in rectal cancer outcomes among patients treated since 2000. OBJECTIVE The purpose of this study was to determine whether there is an association between hospital/surgeon volume and rectal cancer surgery outcomes among patients treated since 2000. DATA SOURCES We searched PubMed and EMBASE for articles published between January 2000 and December 29, 2017. STUDY SELECTION Articles that analyzed the association between hospital/surgeon volume and rectal cancer outcomes were selected. INTERVENTION Rectal cancer resection was the study intervention. MAIN OUTCOME MEASURES The outcome measures of this study were surgical morbidity, postoperative mortality, surgical margin positivity, permanent colostomy rates, recurrence, and overall survival. RESULTS Although 2845 articles were retrieved and assessed by the search strategy, 21 met the inclusion and exclusion criteria. There was a significant protective association between higher hospital volume and surgical morbidity (OR = 0.80 (95% CI, 0.70-0.93); I = 35%), permanent colostomy (OR = 0.51 (95% CI, 0.29-0.92); I = 34%), and postoperative mortality (OR = 0.62 (95% CI, 0.43-0.88); I = 34%), and overall survival (OR = 0.99 (95% CI, 0.98-1.00); I = 3%). Stratified analysis showed that the magnitude of association between hospital volume and rectal cancer surgery outcomes was stronger in the United States compared with other countries. Surgeon volume was not significantly associated with overall survival. The articles included in this analysis were high quality according to the Newcastle-Ottawa scale. Funnel plots suggested that the potential for publication bias was low. LIMITATIONS Some articles included rectosigmoid cancers. CONCLUSIONS Among patients diagnosed since 2000, higher hospital volume has had a significant protective effect on rectal cancer surgery outcomes.
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18
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Curtis NJ, West MA, Salib E, Ockrim J, Allison AS, Dalton R, Francis NK. Time from colorectal cancer diagnosis to laparoscopic curative surgery-is there a safe window for prehabilitation? Int J Colorectal Dis 2018; 33:979-983. [PMID: 29574506 DOI: 10.1007/s00384-018-3016-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/04/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND There is a growing interest in the adoption of formal prehabilitation programmes prior to elective surgery but regulatory targets mandate prompt treatment following cancer diagnosis. We aimed to investigate if time from diagnosis to surgery is linked to short- and long-term outcomes. METHODS An exploratory analysis was performed utilising a dedicated, prospectively populated database. Inclusion criteria were biopsy-proven colorectal adenocarcinoma undergoing elective laparoscopic surgery with curative intent. Demographics, date of diagnosis and surgery was captured with patients dichotomised using 4-, 8- and 12-week time points. All patients were followed in a standardised pathway for 5 years. Overall survival was assessed with the Kaplan-Meier log-rank method. RESULTS Six hundred sixty-eight consecutive patients met inclusion criteria. Mean time from diagnosis to surgery was 53 days (95% CI 48.3-57.8). Identified risk factors for longer time to surgery were males (OR 1.92 [1.2-3.1], p = 0.008), age ≤ 65 (OR 1.9 [1.2-3], p = 0.01), higher ASA scores (p = 0.01) stoma formation (OR 6.9 [4.1-11], p < 0.001) and neoadjuvant treatment (OR 5.06 [3.1-8.3], p < 0.001). There was no association between time to surgery and BMI (p = 0.36), conversion (16.3%, p = 0.5), length of stay (p = 0.33) and readmission or reoperation (p = 0.3). No differences in five-year survival were seen in those operated within 4, 8 and 12 weeks (p = 0.397, p = 0.962 and p = 0.611, respectively). Multivariate analysis showed time from diagnosis to surgery was not associated with five-year overall survival (HR 0.99, p = 0.52). CONCLUSION Time from colorectal cancer diagnosis to curative laparoscopic surgery did not impact on overall survival. This finding may allow preoperative pathway alteration without compromising safety.
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Affiliation(s)
- N J Curtis
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, BA21 4AT, UK.,Department of Surgery and Cancer, Imperial College London, Level 10, St Mary's Hospital, Praed Street, London, W2 1NY, UK
| | - M A West
- Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Tremona Road, Southampton, SO16 6YD, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - E Salib
- Faculty of Health and Life Sciences, Brownlow Hill, University of Liverpool, Liverpool, L69 7ZX, UK
| | - J Ockrim
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, BA21 4AT, UK
| | - A S Allison
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, BA21 4AT, UK
| | - R Dalton
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, BA21 4AT, UK
| | - Nader K Francis
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, BA21 4AT, UK. .,Faculty of Science, University of Bath, Wessex House 3.22, Bath, BA2 7AY, UK.
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19
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Leong KJ, Chapman MAS. Current data about the benefit of prehabilitation for colorectal cancer patients undergoing surgery are not sufficient to alter the NHS cancer waiting targets. Colorectal Dis 2017; 19:522-524. [PMID: 28498541 DOI: 10.1111/codi.13723] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 03/24/2017] [Indexed: 02/08/2023]
Affiliation(s)
- K J Leong
- Good Hope Hospital, Sutton Coldfield, UK
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20
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Abstract
PURPOSE Hospital factors along with various patient and surgeon factors are considered to affect the prognosis of colorectal cancer. Hospital volume is well known, but little is known regarding other hospital factors. METHODS We reviewed data on 853 patients with stage IV colorectal cancer who underwent elective palliative primary tumor resection between January 2006 and December 2007. To detect the hospital factors that could influence the prognosis of incurable colorectal cancer, the relationships between patient/hospital factors and overall survival were analyzed. Among hospital factors, hospital type (Group A: university hospital or cancer center; Group B: community hospital), hospital volume, and number of colorectal surgeons were examined. RESULTS In univariate analysis, Group A hospitals showed significantly better prognosis than Group B hospitals (p = 0.034), while hospital volume and number of colorectal surgeons were not associated with overall survival. After adjustment for patient factors in multivariate analysis, hospital type was significantly associated with overall survival (hazard ratio: 1.31; 95 % confidence interval: 1.05-1.63; p = 0.016). However, there was no significant difference in short-term outcomes between hospital types. CONCLUSIONS Hospital type was identified as a hospital factor that possibly affects the prognosis of stage IV colorectal cancer patients.
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21
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Neal RD, Tharmanathan P, France B, Din NU, Cotton S, Fallon-Ferguson J, Hamilton W, Hendry A, Hendry M, Lewis R, Macleod U, Mitchell ED, Pickett M, Rai T, Shaw K, Stuart N, Tørring ML, Wilkinson C, Williams B, Williams N, Emery J. Is increased time to diagnosis and treatment in symptomatic cancer associated with poorer outcomes? Systematic review. Br J Cancer 2015; 112 Suppl 1:S92-107. [PMID: 25734382 PMCID: PMC4385982 DOI: 10.1038/bjc.2015.48] [Citation(s) in RCA: 638] [Impact Index Per Article: 70.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND It is unclear whether more timely cancer diagnosis brings favourable outcomes, with much of the previous evidence, in some cancers, being equivocal. We set out to determine whether there is an association between time to diagnosis, treatment and clinical outcomes, across all cancers for symptomatic presentations. METHODS Systematic review of the literature and narrative synthesis. RESULTS We included 177 articles reporting 209 studies. These studies varied in study design, the time intervals assessed and the outcomes reported. Study quality was variable, with a small number of higher-quality studies. Heterogeneity precluded definitive findings. The cancers with more reports of an association between shorter times to diagnosis and more favourable outcomes were breast, colorectal, head and neck, testicular and melanoma. CONCLUSIONS This is the first review encompassing many cancer types, and we have demonstrated those cancers in which more evidence of an association between shorter times to diagnosis and more favourable outcomes exists, and where it is lacking. We believe that it is reasonable to assume that efforts to expedite the diagnosis of symptomatic cancer are likely to have benefits for patients in terms of improved survival, earlier-stage diagnosis and improved quality of life, although these benefits vary between cancers.
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Affiliation(s)
- R D Neal
- North Wales Centre for Primary Care Research, Bangor University, Bangor LL13 7YP, UK
| | - P Tharmanathan
- Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - B France
- North Wales Centre for Primary Care Research, Bangor University, Bangor LL13 7YP, UK
| | - N U Din
- North Wales Centre for Primary Care Research, Bangor University, Bangor LL13 7YP, UK
| | - S Cotton
- Betsi Cadwaladr University Health Board, Wrexham Maelor Hospital, Wrexham LL13 7TD, UK
| | - J Fallon-Ferguson
- Primary Care Collaborative Cancer Clinical Trials Group, School of Primary, Aboriginal, and Rural Healthcare, University of Western Australia, M706, 35 Stirling Highway, Crawley, Western Australia 6009, Australia
| | - W Hamilton
- University of Exeter Medical School, Exeter EX1 2LU, UK
| | - A Hendry
- North Wales Centre for Primary Care Research, Bangor University, Bangor LL13 7YP, UK
| | - M Hendry
- North Wales Centre for Primary Care Research, Bangor University, Bangor LL13 7YP, UK
| | - R Lewis
- Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - U Macleod
- Centre for Health and Population studies, Hull York Medical School, University of Hull, Hull HU6 7RX, UK
| | - E D Mitchell
- Leeds Institute of Health Sciences, University of Leeds, Leeds LS2 9LJ, UK
| | - M Pickett
- Betsi Cadwaladr University Health Board, Wrexham Maelor Hospital, Wrexham LL13 7TD, UK
| | - T Rai
- North Wales Organisation for Randomised Trials in Health, Bangor University, Bangor LL57 2PZ, UK
| | - K Shaw
- Primary Care Collaborative Cancer Clinical Trials Group, School of Primary, Aboriginal, and Rural Healthcare, University of Western Australia, M706, 35 Stirling Highway, Crawley, Western Australia 6009, Australia
| | - N Stuart
- School of Medical Sciences, Bangor University, Bangor, LL57 2AS UK
| | - M L Tørring
- Research Unit for General Practice, Aarhus University, Bartholins Alle 2, Aarhus DK-8000, Denmark
| | - C Wilkinson
- North Wales Centre for Primary Care Research, Bangor University, Bangor LL13 7YP, UK
| | - B Williams
- Primary Care Collaborative Cancer Clinical Trials Group, School of Primary, Aboriginal, and Rural Healthcare, University of Western Australia, M706, 35 Stirling Highway, Crawley, Western Australia 6009, Australia
| | - N Williams
- North Wales Centre for Primary Care Research, Bangor University, Bangor LL13 7YP, UK
- North Wales Organisation for Randomised Trials in Health, Bangor University, Bangor LL57 2PZ, UK
| | - J Emery
- Primary Care Collaborative Cancer Clinical Trials Group, School of Primary, Aboriginal, and Rural Healthcare, University of Western Australia, M706, 35 Stirling Highway, Crawley, Western Australia 6009, Australia
- General Practice & Primary Care Academic Centre, University of Melbourne, 200 Berkeley Street, Melbourne, Victoria 3053, Australia
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22
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Whistance RN, Forsythe RO, McNair AGK, Brookes ST, Avery KNL, Pullyblank AM, Sylvester PA, Jayne DG, Jones JE, Brown J, Coleman MG, Dutton SJ, Hackett R, Huxtable R, Kennedy RH, Morton D, Oliver A, Russell A, Thomas MG, Blazeby JM. A systematic review of outcome reporting in colorectal cancer surgery. Colorectal Dis 2014; 15:e548-60. [PMID: 23926896 DOI: 10.1111/codi.12378] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 05/01/2013] [Indexed: 02/08/2023]
Abstract
AIM Evaluation of surgery for colorectal cancer (CRC) is necessary to inform clinical decision-making and healthcare policy. The standards of outcome reporting after CRC surgery have not previously been considered. METHOD Systematic literature searches identified randomized and nonrandomized prospective studies reporting clinical outcomes of CRC surgery. Outcomes were listed verbatim, categorized into broad groups (outcome domains) and examined for a definition (an appropriate textual explanation or a supporting citation). Outcome reporting was considered inconsistent if results of the outcome specified in the methods were not reported. Outcome reporting was compared between randomized and nonrandomized studies. RESULTS Of 5644 abstracts, 194 articles (34 randomized and 160 nonrandomized studies) were included reporting 766 different clinical outcomes, categorized into seven domains. A mean of 14 ± 8 individual outcomes were reported per study. 'Anastomotic leak', 'overall survival' and 'wound infection' were the three most frequently reported outcomes in 72, 60 and 44 (37.1%, 30.9% and 22.7%) studies, respectively, and no single outcome was reported in every publication. Outcome definitions were significantly more often provided in randomized studies than in nonrandomized studies (19.0% vs 14.9%, P = 0.015). One-hundred and twenty-seven (65.5%) papers reported results of all outcomes specified in the methods (randomized studies, n = 21, 61.5%; nonrandomized studies, n = 106, 66.2%; P = 0.617). CONCLUSION Outcome reporting in CRC surgery lacks consistency and method. Improved standards of outcome measurement are recommended to permit data synthesis and transparent cross-study comparisons.
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Affiliation(s)
- R N Whistance
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol, UK; Division of Surgery Head and Neck, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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Hospital center effect for laparoscopic colectomy among elderly stage I-III colon cancer patients. Ann Surg 2014; 259:924-9. [PMID: 23817508 DOI: 10.1097/sla.0b013e31829d0468] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate hospital-level variation in short-term laparoscopic colectomy outcomes among stage I-III elderly colon cancer patients. BACKGROUND Surgical outcomes are associated with patient and surgeon characteristics. If outcomes are also impacted by the hospital where the surgery occurs, there is a hospital center effect (HCE). METHODS Surveillance, Epidemiology, and End Results (SEER)-Medicare data was used to identify stage I-III colon cancer patients treated with laparoscopic colectomies. Multilevel regressions were utilized to study potential HCE for length of stay (LOS), 30-day rehospitalization, and in-hospital mortality, adjusting for patient, surgeon, and hospital-level characteristics. To quantify HCE, we calculated the median instantaneous rate ratio (MIRR) for LOS and median odds ratio (MOR) for in-hospital mortality and 30-day rehospitalization. Sensitivity analyses were conducted for high volume/medical school affiliated hospitals and colorectal surgeons. RESULTS The multilevel analyses based on 4617 patients from 465 hospitals documented statistically significant HCEs for LOS (MIRR = 1.35; P < 0.001) and in-hospital mortality (MOR = 1.69; P = 0.032), but no HCE for 30-day rehospitalization. Sensitivity analyses confirmed our findings. HCE was significant for LOS in all sensitivity analyses and was significant for in-hospital mortality for high volume/medical school affiliated hospitals. CONCLUSIONS HCE exists for LOS and in-hospital mortality of laparoscopic colectomy, which suggests that the choice of hospital affects outcomes independently of other confounding variables. Reducing the variation in outcomes associated with HCE may improve the quality of cancer care.
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Archampong D, Borowski D, Wille-Jørgensen P, Iversen LH. Workload and surgeon's specialty for outcome after colorectal cancer surgery. Cochrane Database Syst Rev 2012:CD005391. [PMID: 22419309 DOI: 10.1002/14651858.cd005391.pub3] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND A large body of research has focused on investigating the effects of healthcare provider volume and specialization on patient outcomes including outcomes of colorectal cancer surgery. However there is conflicting evidence about the role of such healthcare provider characteristics in the management of colorectal cancer. OBJECTIVES To examine the available literature for the effects of hospital volume, surgeon caseload and specialization on the outcomes of colorectal, colon and rectal cancer surgery. SEARCH METHODS We searched Cochrane Central Register of Controlled Trials (CENTRAL), and LILACS using free text search words (as well as MESH-terms). We also searched Medline (January 1990-September 2011), Embase (January 1990-September 2011) and registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field. SELECTION CRITERIA Non-randomised and observational studies that compared outcomes for colorectal cancer, colon cancer and rectal cancer surgery (overall 5-year survival, five year disease specific survival, operative mortality, 5-year local recurrence rate, anastomotic leak rate, permanent stoma rate and abdominoperineal excision of the rectum rate) between high volume/specialist hospitals and surgeons and low volume/specialist hospitals and surgeons. DATA COLLECTION AND ANALYSIS Two review authors independently abstracted data and assessed risk of bias in included studies. Results were pooled using the random effects model in unadjusted and case-mix adjusted meta-analyses. MAIN RESULTS Overall five year survival was significantly improved for patients with colorectal cancer treated in high-volume hospitals (HR=0.90, 95% CI 0.85 to 0.96), by high-volume surgeons (HR=0.88, 95% CI 0.83 to 0.93) and colorectal specialists (HR=0.81, 95% CI 0.71 to 0.94). Operative mortality was significantly better for high-volume surgeons (OR=0.77, 95% CI 0.66 to 0.91) and specialists (OR=0.74, 95% CI 0.60 to 0.91), but there was no significant association with higher hospital caseload (OR=0.93, 95% CI 0.84 to 1.04) when only case-mix adjusted studies were included. There were differences in the effects of caseload depending on the level of case-mix adjustment and also whether the studies originated in the US or in other countries. For rectal cancer, there was a significant association between high-volume hospitals and improved 5-year survival (HR=0.85, 95% CI 0.77 to 0.93), but not with operative mortality (OR=0.97, 95% CI 0.70 to 1.33); surgeon caseload had no significant association with either 5-year survival (HR=0.99, 95% CI 0.86 to 1.14) or operative mortality (OR=0.86, 95% CI 0.62 to 1.19) when case-mix adjusted studies were reviewed. Higher hospital volume was associated with significantly lower rates of permanent stomas (OR=0.64, 95% CI 0.45 to 0.90) and APER (OR=0.55, 95% CI 0.42 to 0.72). High-volume surgeons and specialists also achieved lower rates of permanent stoma formation (0.75, 95% CI 0.64 to 0.88) and (0.70, 95% CI 0.53 to 0.94, respectively). AUTHORS' CONCLUSIONS The results confirm clearly the presence of a volume-outcome relationship in colorectal cancer surgery, based on hospital and surgeon caseload, and specialisation. The volume-outcome relationship appears somewhat stronger for the individual surgeon than for the hospital; particularly for overall 5-year survival and operative mortality, there were differences between US and non-US data, suggesting provider variability at hospital level between different countries, making it imperative that every country or healthcare system must establish audit systems to guide changes in the service provision based on local data, and facilitate centralisation of services as required. Overall quality of the evidence was low as all included studies were observational by design. In addition there were discrepancies in the definitions of caseload and colorectal specialist. However ethical challenges associated with the conception of randomised controlled trials addressing the volume outcome relationship makes this the best available evidence.
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Affiliation(s)
- David Archampong
- Department of Surgery, University Hospital Wales, Cardiff, Wales, UK.
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Møller H, Sandin F, Robinson D, Bray F, Klint Å, Linklater KM, Lambert PC, Påhlman L, Holmberg L, Morris E. Colorectal cancer survival in socioeconomic groups in England: Variation is mainly in the short term after diagnosis. Eur J Cancer 2012; 48:46-53. [DOI: 10.1016/j.ejca.2011.05.018] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2011] [Revised: 05/09/2011] [Accepted: 05/12/2011] [Indexed: 11/30/2022]
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Manchon-Walsh P, Borras JM, Espinas JA, Aliste L. Variability in the quality of rectal cancer care in public hospitals in Catalonia (Spain): clinical audit as a basis for action. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2011; 37:325-33. [PMID: 21296543 DOI: 10.1016/j.ejso.2011.01.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2010] [Revised: 12/23/2010] [Accepted: 01/10/2011] [Indexed: 11/18/2022]
Abstract
AIM Clinical practice guidelines in cancer are a relevant component of Catalonian Cancer Strategy aimed at promoting equity of access to therapy and quality of cancer care. The colorectal cancer (CRC) guideline was first published in 2003 and subsequently updated in 2008. This study examined the quality of therapy administered to patients with rectal cancer in public hospitals in Catalonia (Spain) in 2005 and 2007, according to CRC guideline recommendations. METHODS We conducted a multicentre retrospective cohort study of patients who underwent curative-intent surgery for primary rectal cancer at Catalonian public hospitals in 2005 and 2007. Data were drawn from clinical records. RESULTS The study covered 1831 patients with rectal cancer. Performance of total mesorectal excision (TME) was poorly reported by surgeons (46.4%) and pathologists (36.2%). Pre-operative radiotherapy was performed on 52% of stage-II and -III patients. Compared to high-caseload hospitals, those with a low caseload (≤11 cases/year) registered more Hartman's procedures, worse TME quality, a higher rate of post-operative complications and lower adherence to recommended pre-operative radio-chemotherapy. CONCLUSIONS Reporting quality of care is essential for ascertaining current performance status and opportunities for improvement. In our case, there is a need for the quality of the information included in clinical records to be improved, and variability in adherence to guideline recommendations to be reduced. In view of the fact that heterogeneity in the quality of the health care process was linked to hospital caseload, the health authorities have decided to reorganise the provision of rectal cancer care.
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Affiliation(s)
- P Manchon-Walsh
- Catalonian Cancer Strategy Unit, Regional Health Authority, Av. Gran Via s/n, Km 2,7, 08907 L'Hospitalet de Llobregat, Barcelona, Spain.
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