Temporal trends in colorectal procedure use after colorectal cancer resection

Characteristics Associated With Nonreceipt of Surveillance Testing and the Relationship With Survival in Stage II and III Colon Cancer

We investigated characteristics of patients with colon cancer that predicted nonreceipt of posttreatment surveillance testing and the subsequent associations between surveillance status and survival outcomes. This was a retrospective cohort study of the Surveillance, Epidemiology, and End Results database combined with Medicare claims. Patients diagnosed between 2002 and 2009 with disease stages II and III and who were between 66 and 84 years of age were eligible. A minimum of 3 years' follow-up was required, and patients were categorized as having received any surveillance testing (any testing) versus none (no testing). Poisson regression was used to obtain risk ratios with 95% confidence intervals for the relative likelihood of No Testing. Cox models were used to obtain subdistribution hazard ratios with 95% confidence intervals for 5- and 10-year cancer-specific and noncancer deaths. There were 16,009 colon cancer cases analyzed. Patient characteristics that predicted No Testing included older age, Black race, stage III disease, and chemotherapy. Patients in the No Testing group had an increased rate of 10-year cancer death that was greater for patients with stage III disease (subdistribution hazard ratio = 1.79, 95% confidence interval: 1.48, 2.17) than those with stage II disease (subdistribution hazard ratio = 1.41, 95% confidence interval: 1.19, 1.66). Greater efforts are needed to ensure all patients receive the highest quality medical care after diagnosis of colon cancer.

Cost-effectiveness of alternative colonoscopy surveillance strategies to mitigate metachronous colorectal cancer incidence

BACKGROUND

The incidence of metachronous colorectal cancer (MCRC) among colorectal cancer (CRC) survivors varies significantly, and the optimal colonoscopy surveillance practice for mitigating MCRC incidence is unknown.

METHODS

A cost-effectiveness analysis was used to compare the performances of the US Multi-Society Task Force guideline and all clinically reasonable colonoscopy surveillance strategies for 50- to 79-year-old posttreatment CRC patients with a computer simulation model.

RESULTS

The US guideline [(1,3,5)] recommends the first colonoscopy 1 year after treatment, whereas the second and third colonoscopies are to be repeated at 3- and 5-year intervals. Some promising alternative cost-effective strategies were identified. In comparison with the US guideline, under various scenarios for a 20-year period, 1) reducing the surveillance interval of the guideline after the first colonoscopy by 1 year [(1,2,5)] would save up to 78 discounted life-years (LYs) and prevent 23 MCRCs per 1000 patients (incremental cost-effectiveness ratio [ICER] ≤ $23,270/LY), 2) reducing the intervals after the first and second negative colonoscopies by 1 year [(1,2,4)] would save/prevent up to 109 discounted LYs and 36 MCRCs (ICER ≤ $52,155/LY), and 3) reducing the surveillance intervals after the first and second negative colonoscopy by 1 and 2 years [(1,2,3)] would save/prevent up to 141 discounted LYs and 50 MCRCs (ICER ≤ $63,822/LY). These strategies would require up to 1100 additional colonoscopies per 1000 patients. Although the US guideline might not be cost-effective in comparison with a less intensive oncology guideline [(3,3,5); the ICER could be as high as $140,000/LY], the promising strategies would be cost-effective in comparison with such less intensive guidelines unless the cumulative MCRC incidence were very low.

CONCLUSIONS

The US guideline might be improved by a slight increase in the surveillance intensity at the expense of moderately increased cost. More research is warranted to explore the benefits/harms of such practices. Cancer 2016;122:2560-70. © 2016 American Cancer Society.

Colorectal cancer survivors' needs and preferences for survivorship information

PURPOSE

Before developing a survivorship care plan (SCP) that colorectal cancer (CRC) survivors will value, understanding the informational needs of CRC survivors is critical.

METHODS

We surveyed survivors treated for nonmetastatic CRC at two hospitals in New York about their needs and preferences for survivorship information. Participants completed treatment 6 to 24 months before the interview and had not received an SCP. We evaluated whether survivors knew their treatment history (10 topics), whether they understood ongoing risks (four topics), and their preferences for receiving 16 topics of survivorship information.

RESULTS

One hundred seventy-five survivors completed the survey. Most survivors remembered information about past treatment (98% to 99% for each treatment). Fewer survivors knew their risks of local recurrence, distant recurrence, or developing a new CRC (69%, 77%, and 40%, respectively). Most participants reported receiving information about their cancer history and ongoing oncology visits (77% to 86% across topics). Across all topics, 93% to 99% of those who reported receiving information found the information useful. A minority of survivors reported they received information about symptoms to report to doctors, returning to work, or financial or legal issues (5% to 48% across topics), but those who did found the information useful (89% to 100% across topics).

CONCLUSIONS

In the absence of an SCP, CRC survivors still generally understood their cancer history. However, many lacked knowledge of ongoing risks and prevention. Most survivors stated that they found the survivorship information they received useful. SCPs for CRC survivors should focus less on past care and more on helping survivors understand their risks and plan for the future.

Predictors of colonoscopy use one year after colonoscopy: prospective study of surveillance behavior for colorectal cancer

We hypothesized that perceived risk of colorectal cancer (CRC) and CRC worry would be the main predictors of surveillance behavior in patients undergoing colonoscopy. We therefore assessed factors predicting colonoscopy use for re-examination one year after colonoscopy. Patients who had undergone colonoscopy and were scheduled for re-examination one year later were recruited. Patients were administered questionnaires after baseline colonoscopy assessing demographic factors, perceived risk, CRC worry, cancer preventability, knowledge of CRC and results of colonoscopy. We confirmed whether participants underwent colonoscopy re-examinations one year later (follow-up). Finally, 56 participants completed the research and were used in the final analysis (response rate = 65.1%). We found that 37.5% of the participants who underwent baseline colonoscopy underwent follow-up colonoscopy one year later. Follow-up colonoscopy was not significantly associated with any psychological variables, but was significantly associated with educational status (postsecondary) (odds ratio [OR] = 7.10, 95% confidence interval [CI] = 1.83-27.56) and the results of baseline colonoscopy in patients who did not undergo polypectomy but had remaining polyps (OR = 4.26, 95% CI = 1.02-17.84). Additionally, significant differences in cancer threat-related variables were observed among groups of patients who, during baseline colonoscopy, underwent polypectomy but had no remaining polyps, had polyps removed with some polyps remaining, or did not undergo polypectomy but had remaining polyps (p < .05), with the latter group having a significant relationship with repeat colonoscopy. Cancer threat-related variables were not predictive of repeat colonoscopy after one year. In contrast, patient educational status and the colonoscopy results were predictors. We also found a non-linear relationship between high CRC threat and inhibition of the screening behavior in that the CRC threat functions as motivation for the surveillance behavior of colonoscopy.

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

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

Receipt of recommended surveillance among colorectal cancer survivors: a systematic review

PURPOSE

Regular surveillance decreases the risk of recurrent cancer in colorectal cancer (CRC) survivors. However, studies suggest that receipt of follow-up tests is not consistent with guidelines. This systematic review aimed to: (1) examine receipt of recommended post-treatment surveillance tests and procedures among CRC survivors, including adherence to established guidelines, and (2) identify correlates of CRC surveillance.

METHODS

Systematic searches of Medline, PubMed, PsycINFO, CINAHL Plus, and Scopus databases were conducted using terms adapted for each database's keywords and subject headings. Studies were screened for inclusion using a three-step process: (1) lead author reviewed abstracts of all eligible studies; (2) coauthors reviewed random 5 % samples of abstracts; and (3) two sets of coauthors reviewed all "maybe" abstracts. Discrepancies were adjudicated through discussion.

RESULTS

Thirty-four studies are included in the review. Overall adherence ranged from 12 to 87 %. Within the initial 12 to 18 months post-treatment, adherence to recommended office visits was 93 %. Adherence ranged from 78 to 98 % for physical exams, 18-61 % for colonoscopy, and 17-71 % for carcinoembryonic antigen (CEA) testing. By 2 to 3 years post-treatment, cumulative adherence ranged from 70 to 88 % for office visits, 89-93 % for physical exams, 49-94 % for colonoscopy, and 7-79 % for CEA testing. Between 18 and 28 % of CRC survivors received greater than recommended overall surveillance; overuse of physical exams (42 %), colonoscopy (24-76 %), and metastatic disease testing (1-29 %) was also prevalent. Studies of correlates of CRC surveillance focused on sociodemographic and disease/treatment characteristics, and patterns of association were inconsistent across studies.

CONCLUSIONS

Deviation from surveillance recommendations includes both under- and overuse. Examination of modifiable determinants is needed to inform interventions targeting appropriate and timely receipt of recommended surveillance.

IMPLICATIONS FOR CANCER SURVIVORS

Among CRC survivors, it remains unclear what modifiable psychosocial factors are associated with the observed under- and overuse of surveillance. Understanding and intervening with these psychosocial factors is critical to improving adherence to guideline-recommended surveillance and thereby reducing mortality among this group of survivors.

A checklist for ascertaining study cohorts in oncology health services research using secondary data: report of the ISPOR oncology good outcomes research practices working group

OBJECTIVES

The ISPOR Oncology Special Interest Group formed a working group at the end of 2010 to develop standards for conducting oncology health services research using secondary data. The first mission of the group was to develop a checklist focused on issues specific to selection of a sample of oncology patients using a secondary data source.

METHODS

A systematic review of the published literature from 2006 to 2010 was conducted to characterize the use of secondary data sources in oncology and inform the leadership of the working group prior to the construction of the checklist. A draft checklist was subsequently presented to the ISPOR membership in 2011 with subsequent feedback from the larger Oncology Special Interest Group also incorporated into the final checklist.

RESULTS

The checklist includes six elements: identification of the cancer to be studied, selection of an appropriate data source, evaluation of the applicability of published algorithms, development of custom algorithms (if needed), validation of the custom algorithm, and reporting and discussions of the ascertainment criteria. The checklist was intended to be applicable to various types of secondary data sources, including cancer registries, claims databases, electronic medical records, and others.

CONCLUSIONS

This checklist makes two important contributions to oncology health services research. First, it can assist decision makers and reviewers in evaluating the quality of studies using secondary data. Second, it highlights methodological issues to be considered when researchers are constructing a study cohort from a secondary data source.

Many patients who undergo surgery for colorectal cancer receive surveillance colonoscopies earlier than recommended by guidelines

BACKGROUND & AIMS

Patients treated with surgery for colorectal cancer (CRC) should undergo colonoscopy examinations 1, 4, and 9 years later, to check for cancer recurrence. We investigated the use patterns of surveillance colonoscopies among Medicare patients.

METHODS

We used the Surveillance, Epidemiology and End Results (SEER)-Medicare linked database to identify patients who underwent curative surgery for colorectal cancer from 1992 to 2005 and analyzed the timing of the first 3 colonoscopies after surgery. Early surveillance colonoscopy was defined as a colonoscopy, for no reason other than surveillance, within 3 months to 2 years after a colonoscopy examination with normal results.

RESULTS

Approximately 32.1% and 27.3% of patients with normal results from their first and second colonoscopies, respectively, underwent subsequent surveillance colonoscopies within 2 years (earlier than recommended). Of patients who were older than 80 years at their first colonoscopy, 23.6% underwent a repeat procedure within 2 years for no clear indication. In multivariable analysis, early surveillance colonoscopy was not associated with sex, race, or patients' level of education. There was significant regional variation in early surveillance colonoscopies among the Surveillance, Epidemiology, and End Results regions. There was a significant trend toward reduced occurrence of second early surveillance colonoscopies.

CONCLUSIONS

Many Medicare enrollees who have undergone curative resection for colorectal cancer undergo surveillance colonoscopy more frequently than recommended by the guidelines. Reducing overuse could free limited resources for appropriate colonoscopy examinations of inadequately screened populations.

Are cancer registries a viable tool for cancer survivor outreach? A feasibility study

PURPOSE

Little is known about cancer survivors' receptivity to being contacted through cancer registries for research and health promotion efforts. We sought to (1) determine breast and colorectal cancer (CRC) survivors' responsiveness to a mailed survey using an academic medical center's cancer registry, (2) assess whether responsiveness varied according to sociodemographic characteristics and medical history, and (3) examine the prevalence and correlates of respondents' awareness and willingness to be contacted through the state cancer registry for future research studies.

METHODS

Stage 0-III breast and CRC survivors diagnosed between January 2004 and December 2009 were identified from an academic medical center cancer registry. Survivors were mailed an invitation letter with an opt-out option, along with a survey assessing sociodemographic characteristics, medical history, and follow-up cancer care access and utilization.

RESULTS

A total of 452 (31.4 %) breast and 53 (22.2 %) CRC survivors responded. Willingness to be contacted through the state cancer registry was high among both breast (74 %) and CRC (64 %) respondents even though few were aware of the registry and even fewer knew that their information was in the registry. In multivariable analyses, tumor stage I and not having a family history of cancer were associated with willingness among breast and CRC survivors, respectively.

CONCLUSIONS

Our findings support the use of state cancer registries to contact survivors for participation in research studies.

IMPLICATIONS FOR CANCER SURVIVORS

Survivors would benefit from partnerships between researchers and cancer registries that are focused on health promotion interventions.

Ethnic disparities in colonoscopy use among colorectal cancer survivors: a systematic review

PURPOSE

After curative treatment for colorectal cancer (CRC), routine colonoscopies are recommended. We aimed to identify all studies of ethnic disparities in CRC surveillance and examine any association between race/ethnicity and colonoscopy use.

METHODS

We conducted a systematic literature review to address the association between race/ethnicity and colonoscopy use among CRC survivors. We searched Medline for relevant articles. Two authors reviewed titles, abstracts, and articles based on pre-determined inclusion/exclusion criteria.

RESULTS

Of the 1,544 titles reviewed, eight studies published since 2001 investigated racial/ethnic disparities in colonoscopy use. Four articles showed a small significant ethnic disparity in the receipt of timely colonoscopy, and the remaining four articles showed a nonsignificant trend in the same direction. The effect did not vary by time of diagnosis or proportion of minorities in each study, though studies with larger samples showed somewhat greater racial/ethnic disparities in colonoscopy use.

CONCLUSIONS

We found at least a small disparity in the use of colonoscopy among CRC survivors, suggesting that ethnic disparities continue beyond prevention, detection, and treatment of CRC. It is important to identify areas of unequal care in CRC survivorship and to promote timely surveillance among CRC survivors who belong to racial/ethnic minorities to decrease disparities in mortality.

IMPLICATIONS FOR CANCER SURVIVORS

CRC survivors who belong to racial/ethnic minorities may be less likely to receive follow-up colonoscopies on time, which could contribue to higher rates of death from CRC among minorities.

Surveillance after resection for colorectal cancer

BACKGROUND

Professional societies recommend posttreatment surveillance for colorectal cancer (CRC) survivors. This study describes the use of surveillance over time, with a particular focus on racial/ethnic disparities, and also examines the role of area characteristics, such as capacity for CRC screening, on surveillance.

METHODS

Surveillance, Epidemiology, and End Results (SEER)-Medicare data were used to identify individuals aged 66 to 85 years who were diagnosed with CRC from 1993 to 2005 and treated with surgery. The study examined factors associated with subsequent receipt of a colonoscopy, carcinoembryonic antigen (CEA) testing, primary care (PC) visits, and a composite measure of overall surveillance.

RESULTS

Of eligible subjects, 61.0% had a colonoscopy, 68.0% had CEA testing, 77.1% had PC visits, and 43.0% received overall surveillance. After adjustment, blacks were less likely than whites to undergo colonoscopy (odds ratio [OR] 0.76, 95% confidence interval [CI] = 0.69-0.83) and to receive CEA testing and overall surveillance, whereas white/Hispanic rates did not differ. Rates for all outcomes increased from 1993 to 2005, but black/white disparities remained. Individuals in areas with greatest capacity for CRC screening were more likely (OR = 1.09, 95% CI = 1.02-1.18) to receive colonoscopy, and those in areas with the greatest percentage of blacks were less likely (OR = 0.89, 95% CI = 0.83-0.95) to receive colonoscopy. Those living in areas with shortage of PC were less likely to receive PC visits (OR = 0.55, 95% CI = 0.48-0.64) and overall surveillance (OR = 0.83, 95% CI = 0.71-0.98).

CONCLUSIONS

Many CRC survivors do not get recommended surveillance, and black/white disparities in rates of surveillance have not improved. Characteristics of the area where an individual lives contribute to the use of surveillance.

An international review of the patterns and determinants of health service utilisation by adult cancer survivors

Background

There is a need to review factors related to health service utilisation by the increasing number of cancer survivors in order to inform care planning and the organisation and delivery of services.

Methods

Studies were identified via systematic searches of Medline, PsycINFO, CINAHL, Social Science Citation Index and the SEER-MEDICARE library. Methodological quality was assessed using STROBE; and the Andersen Behavioural Model was used as a framework to structure, organise and analyse the results of the review.

Results

Younger, white cancer survivors were most likely to receive follow-up screening, preventive care, visit their physician, utilise professional mental health services and least likely to be hospitalised. Utilisation rates of other health professionals such as physiotherapists were low. Only studies of health service use conducted in the USA investigated the role of type of health insurance and ethnicity. There appeared to be disparate service use among US samples in terms of ethnicity and socio-demographic status, regardless of type of health insurance provision s- this may be explained by underlying differences in health-seeking behaviours. Overall, use of follow-up care appeared to be lower than expected and barriers existed for particular groups of cancer survivors.

Conclusions

Studies focussed on the use of a specific type of service rather than adopting a whole-system approach and future health services research should address this shortcoming. Overall, there is a need to improve access to care for all cancer survivors. Studies were predominantly US-based focussing mainly on breast or colorectal cancer. Thus, the generalisability of findings to other health-care systems and cancer sites is unclear. The Andersen Behavioural Model provided an appropriate framework for studying and understanding health service use among cancer survivors. The active involvement of physicians and use of personalised care plans are required in order to ensure that post-treatment needs and recommendations for care are met.

Patient-clinician information engagement improves adherence to colorectal cancer surveillance after curative treatment: results from a longitudinal study

Introduction. Follow-up surveillance after curative treatment for colorectal cancer (CRC) patients is recommended to detect early cancer recurrences and improve survival outcomes. However, a substantial proportion of CRC patients do not undergo cancer surveillance. Several demographic and disease-related factors have been associated with cancer surveillance adherence. Thus far, patient-centered communication has not been studied as a determinant for undergoing cancer surveillance. The purpose of this study is to determine whether patient-clinician information engagement (PCIE) influences patients' self-reported adherence to recommended CRC surveillance procedures. Methods. The study was a longitudinal survey among Pennsylvanian patients diagnosed with CRC in 2005. CRC patients who were eligible for surveillance and participated in both the baseline and 1-year follow-up surveys were included in this analysis (n = 305). The main outcome measure was self-reported adherence to physical examination, carcinoembryonic antigen testing, and colonoscopy according to recommended guidelines. Results. Controlling for potential confounders, higher PCIE at baseline predicted a higher odds for CRC patients reporting adherence to recommended surveillance 1 year later by 2.8 times. Other significant predictors of adhering to recommended surveillance were a higher education level and having received systemic therapy. Discussion. In this longitudinal study among CRC patients who received curative treatment, greater patient engagement with clinicians about cancer-related information was found to improve patients' subsequent adherence to recommended surveillance. This finding provides support for encouraging greater patient-physician communication among CRC patients.

Variation in use of surveillance colonoscopy among colorectal cancer survivors in the United States

BACKGROUND

Clinical practice guidelines recommend colonoscopies at regular intervals for colorectal cancer (CRC) survivors. Using data from a large, multi-regional, population-based cohort, we describe the rate of surveillance colonoscopy and its association with geographic, sociodemographic, clinical, and health services characteristics.

METHODS

We studied CRC survivors enrolled in the Cancer Care Outcomes Research and Surveillance (CanCORS) study. Eligible survivors were diagnosed between 2003 and 2005, had curative surgery for CRC, and were alive without recurrences 14 months after surgery with curative intent. Data came from patient interviews and medical record abstraction. We used a multivariate logit model to identify predictors of colonoscopy use.

RESULTS

Despite guidelines recommending surveillance, only 49% of the 1423 eligible survivors received a colonoscopy within 14 months after surgery. We observed large regional differences (38% to 57%) across regions. Survivors who received screening colonoscopy were more likely to: have colon cancer than rectal cancer (OR = 1.41, 95% CI: 1.05-1.90); have visited a primary care physician (OR = 1.44, 95% CI: 1.14-1.82); and received adjuvant chemotherapy (OR = 1.75, 95% CI: 1.27-2.41). Compared to survivors with no comorbidities, survivors with moderate or severe comorbidities were less likely to receive surveillance colonoscopy (OR = 0.69, 95% CI: 0.49-0.98 and OR = 0.44, 95% CI: 0.29-0.66, respectively).

CONCLUSIONS

Despite guidelines, more than half of CRC survivors did not receive surveillance colonoscopy within 14 months of surgery, with substantial variation by site of care. The association of primary care visits and adjuvant chemotherapy use suggests that access to care following surgery affects cancer surveillance.

Association of health beliefs and colonoscopy use among survivors of colorectal cancer

OBJECTIVES

Clinical practice guidelines recommend ongoing testing (surveillance) for colorectal cancer survivors because they remain at risk for both local recurrences and second primary tumors. However, survivors often do not receive colorectal cancer surveillance. We used the Health Belief Model (HBM) to identify health beliefs that predict intentions to obtain routine colonoscopies among colorectal cancer survivors.

METHODS

We completed telephone interviews with 277 colorectal cancer survivors who were diagnosed 4 years earlier, between 2003 and 2005, in North Carolina. The interview measured health beliefs, past preventive behaviors, and intentions to have a routine colonoscopy in the next 5 years.

RESULTS

In bivariate analyses, most HBM constructs were associated with intentions. In multivariable analyses, greater perceived likelihood of colorectal cancer (OR = 2.00, 95% CI = 1.16-3.44) was associated with greater intention to have a colonoscopy. Survivors who already had a colonoscopy since diagnosis also had greater intentions of having a colonoscopy in the future (OR = 9.47, 95% CI = 2.08-43.16).

CONCLUSIONS

Perceived likelihood of colorectal cancer is an important target for further study and intervention to increase colorectal cancer surveillance among survivors. Other health beliefs were unrelated to intentions, suggesting that the health beliefs of colorectal cancer survivors and asymptomatic adults may differ due to the experience of cancer.