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Cirocco WC. INVITED COMMENTARY: Adherence to standards over centralization of care: the practical approach to accommodate the high risk, underinsured rural colorectal cancer patient and the role of the 'Fundamentals of Rectal Cancer Surgery'. J Gastrointest Surg 2024:S1091-255X(24)00633-4. [PMID: 39313146 DOI: 10.1016/j.gassur.2024.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2024] [Accepted: 09/18/2024] [Indexed: 09/25/2024]
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Weeks KS, Gao X, Kahl AR, Engelbart J, Greteman BB, Hassan I, Kapadia MR, Nash SH, Charlton ME. Perspectives on Referring for Rectal Cancer Surgery: a Survey Study of Gastroenterologist and General Surgeons in Iowa. J Gastrointest Cancer 2024; 55:681-690. [PMID: 38151606 DOI: 10.1007/s12029-023-00998-1] [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] [Accepted: 12/06/2023] [Indexed: 12/29/2023]
Abstract
PURPOSE To understand referral practices for rectal cancer surgical care and to secondarily determine differences in referral practices by two main hypothesized drivers of referral: the rurality of the community endoscopists' practice and their affiliation with a colorectal surgeon. METHODS Community gastroenterologists and general surgeons in Iowa completed a mailed questionnaire on practice demographics, volume, and referral practices for rectal cancer patients. Rurality was operationalized with RUCA codes. RESULTS Twenty-two of 53 gastroenterologists (42%) and 120 of 188 general surgeons (64%) (total 144/241, 60%) in Iowa responded. Most performed colonoscopies, including 22 gastroenterologists (100%) and 96 general surgeons (80%). Regular referral of rectal cancer patients to colorectal surgeons was reported for 57% of urban physicians affiliated with a colorectal surgeon, 33% of urban physicians not affiliated with a colorectal surgeon, and 57% and 72% of physicians in large and small rural areas, respectively, who were not affiliated with a colorectal surgeon. High surgeon volume, high hospital volume, and colorectal surgeon specialty were important factors in the referral decisions for over half the physicians. 69% of diagnosing urban general surgeons reported performing rectal cancer surgery about half the time or more, while 85% of small rural and 60% of large rural diagnosing general surgeons reported never or rarely performing rectal cancer surgery. CONCLUSIONS Diagnosing physicians have variable rectal cancer referral practices, including consistency in referred to surgeon and prioritization of volume and specialization. Prioritizing specialized or high-volume rectal cancer surgical care would require changing existing referring patterns.
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Affiliation(s)
- Kristin S Weeks
- Department of Internal Medicine, The Ohio State University Medical Center, 410 W Tenth Ave, 43210, Columbus, OH, USA
| | - Xiang Gao
- Department of Surgery, University of Iowa Carver College of Medicine, 200 Hawkins Dr, 52242, Iowa City, IA, USA
| | - Amanda R Kahl
- State Health Registry of Iowa, University of Iowa, 2600 UCC, 52242, Iowa City, IA, USA
| | - Jacklyn Engelbart
- Department of Surgery, University of Iowa Carver College of Medicine, 200 Hawkins Dr, 52242, Iowa City, IA, USA
| | - Breanna B Greteman
- College of Public Health, Department of Epidemiology, University of Iowa, 145 N Riverside Dr, 52242, Iowa City, IA, USA
| | - Imran Hassan
- Department of Surgery, University of Iowa Carver College of Medicine, 200 Hawkins Dr, 52242, Iowa City, IA, USA
| | - Muneera R Kapadia
- Department of Surgery, University of North Carolina at Chapel Hill, 101 Manning Drive, 27599, Chapel Hill, NC, USA
| | - Sarah H Nash
- State Health Registry of Iowa, University of Iowa, 2600 UCC, 52242, Iowa City, IA, USA
- College of Public Health, Department of Epidemiology, University of Iowa, 145 N Riverside Dr, 52242, Iowa City, IA, USA
| | - Mary E Charlton
- State Health Registry of Iowa, University of Iowa, 2600 UCC, 52242, Iowa City, IA, USA.
- College of Public Health, Department of Epidemiology, University of Iowa, 145 N Riverside Dr, 52242, Iowa City, IA, USA.
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Steele SR. The Quality Dilemma. Clin Colon Rectal Surg 2023; 36:285-286. [PMID: 37223234 PMCID: PMC10202535 DOI: 10.1055/s-0043-57232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- Scott R. Steele
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
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Which Direction to Turn to Resolve the Debate on How to Improve Rectal Cancer Care: Centralize Versus Standardize? North! Dis Colon Rectum 2022; 65:865-867. [PMID: 35001053 DOI: 10.1097/dcr.0000000000002408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Chioreso C, Gao X, Gribovskaja-Rupp I, Lin C, Ward MM, Schroeder MC, Lynch CF, Chrischilles EA, Charlton ME. Hospital and Surgeon Selection for Medicare Beneficiaries With Stage II/III Rectal Cancer: The Role of Rurality, Distance to Care, and Colonoscopy Provider. Ann Surg 2021; 274:e336-e344. [PMID: 31714306 PMCID: PMC7176526 DOI: 10.1097/sla.0000000000003673] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To determine factors associated with rectal cancer surgery performed at high-volume hospitals (HVHs) and by high-volume surgeons (HVSs), including the roles of rurality and diagnostic colonoscopy provider characteristics. SUMMARY OF BACKGROUND DATA Although higher-volume hospitals/surgeons often achieve superior surgical outcomes, many rectal cancer resections are performed by lower-volume hospitals/surgeons, especially among rural populations. METHODS Patients age 66+ diagnosed from 2007 to 2011 with stage II/III primary rectal adenocarcinoma were selected from surveillance, epidemiology, and end results-medicare data. Patient ZIP codes were used to classify rural status. Hierarchical logistic regression was used to determine factors associated with surgery by HVH and HVS. RESULTS Of 1601 patients, 22% were rural and 78% were urban. Fewer rural patients received surgery at a HVH compared to urban patients (44% vs 65%; P < 0.0001). Compared to urban patients, rural patients more often had colonoscopies performed by general surgeons (and less often from gastroenterologists or colorectal surgeons), and lived substantially further from HVHs; these factors were both associated with lower odds of surgery at a HVH or by a HVS. In addition, whereas over half of both rural and urban patients received their colonoscopy and surgery at the same hospital, rural patients who stayed at the same hospital were significantly less likely to receive surgery at a HVH or by a HVS compared to urban patients. CONCLUSIONS Rural rectal cancer patients are less likely to receive surgery from a HVH/HVS. The role of the colonoscopy provider has important implications for referral patterns and initiatives seeking to increase centralization.
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Affiliation(s)
- Catherine Chioreso
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA
| | - Xiang Gao
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
| | | | - Chi Lin
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE
| | - Marcia M. Ward
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA
| | - Mary C. Schroeder
- Department of Pharmacy Practice and Science, University of Iowa College of Pharmacy, Iowa City, IA
| | - Charles F. Lynch
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA
- Iowa Cancer Registry, University of Iowa College of Public Health, Iowa City, IA
| | | | - Mary E. Charlton
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA
- Iowa Cancer Registry, University of Iowa College of Public Health, Iowa City, IA
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Patterns and characteristics of patients' selection of cancer surgeons. Am J Surg 2020; 221:1033-1041. [PMID: 33969822 DOI: 10.1016/j.amjsurg.2020.09.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/10/2020] [Accepted: 09/30/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Despite evidence of volume-outcome relationships for cancer surgery, treatment at low-volume hospitals remains common. Our objective was to evaluate whether individuals actively involved in selecting their cancer surgeon were more likely to go to hospitals recognized for quality cancer care. METHODS Individuals diagnosed with breast, prostate and colorectal cancer in 2015 completed online surveys in 2017-2018. Participants were categorized as "directed" to a surgeon (relied on referral) or "active" (sought additional information), and hospitals were categorized by NCI-designation, CoC accreditation, and academic affiliation. RESULTS Of 299 participants, 42% were active. Individuals with breast cancer were more active (aOR = 2.46,95%CI:1.32-4.59). Active participants had nonsignificantly higher odds of surgery at NCI-designated facilities (aOR = 2.04,95%CI:0.95-4.38), or academic centers (aOR = 1.51,95%CI:0.86-2.64). CONCLUSIONS While most participants were directed to their cancer surgeon, active participants tended to select NCI-designated/academic hospitals. Although centralization of cancer care would require altering referral patterns, decision-support resources may help patients make informed choices.
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Lawson EH, Melvin JC, Geltzeiler CB, Heise CP, Foley EF, King RS, Harms BA, Carchman EH. Advances in the management of rectal cancer. Curr Probl Surg 2019; 56:100648. [PMID: 31779779 DOI: 10.1016/j.cpsurg.2019.100648] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 07/01/2019] [Indexed: 01/05/2023]
Affiliation(s)
| | | | - Cristina B Geltzeiler
- University of Wisconsin-Madison, Madison, WI; University of Wisconsin-Madison, William S. Middleton Memorial Veterans Hospital, Madison, WI
| | | | | | - Ray S King
- University of Wisconsin-Madison, Madison, WI
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Cirocco WC. Rectal resection following neoadjuvant therapy in a Midwest community hospital setting: The case for standardization over centralization as the means to optimize rectal cancer outcomes in the United States. Am J Surg 2018; 217:430-434. [PMID: 30236488 DOI: 10.1016/j.amjsurg.2018.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 08/31/2018] [Accepted: 09/03/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Incomplete and flawed national databases reveal strikingly inferior outcomes for rectal cancer patients resected at "low" versus "high " volume hospitals, therefore, a study of outcomes of a "high" volume surgeon in a "low" volume Midwest community hospital setting examined this perception in comparison to contemporary studies. METHODS Review of 109 consecutive patients who underwent open resection of rectal cancer following neoadjuvant therapy, 1999-2010. RESULTS Despite the majority of tumors in the low rectum (54%), the rate of abdominoperineal resection was only 39% with R0 resection achieved in 94% and primary anastomosis in 61/109 patients (56%). Disease-free survival (DFS) 73%: stage 0 (complete response)- 100%, stage I- 88%, stage II- 68%, stage III- 50%, stage IV- 0% with recurrence rate of 11% (local recurrence (LR) - 3%, distant - 8%). CONCLUSION Outcomes of rectal cancer resection by a "high" volume surgeon in a "low" volume Midwest community hospital setting were comparable to contemporary studies from tertiary care institutions. Geographic location and hospital capacity matter less than access to multispecialty expertise providing neoadjuvant therapy and following standard principles of oncologic resection, in efforts to optimize rectal cancer outcomes.
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Affiliation(s)
- William C Cirocco
- N711 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210-1228, USA.
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The impact of age on complications, survival, and cause of death following colon cancer surgery. Br J Cancer 2017; 116:389-397. [PMID: 28056465 PMCID: PMC5294480 DOI: 10.1038/bjc.2016.421] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Revised: 11/04/2016] [Accepted: 11/13/2016] [Indexed: 01/29/2023] Open
Abstract
Background: Given scarce data regarding the relationship among age, complications, and survival beyond the 30-day postoperative period for oncology patients in the United States, this study identified age-related differences in complications and the rate and cause of 1-year mortality following colon cancer surgery. Methods: The NY State Cancer Registry and Statewide Planning and Research Cooperative System identified stage I–III colon cancer resections (2004–2011). Multivariable logistic regression and survival analyses assessed the relationship among age (<65, 65–74, ⩾75), complications, 1-year survival, and cause of death. Results: Among 24 426 patients surviving >30 days, 1-year mortality was 8.5%. Older age groups had higher complication rates, and older age and complications were independently associated with 1-year mortality (P<0.0001). Increasing age was associated with a decrease in the proportion of deaths from colon cancer with a concomitant increase in the proportion of deaths from cardiovascular disease. Older age and sepsis were independently associated with higher risk of colon cancer-specific death (65–74: HR=1.59, 95% CI=1.26–2.00; ⩾75: HR=2.57, 95% CI=2.09–3.16; sepsis: HR=2.58, 95% CI=2.13–3.11) and cardiovascular disease-specific death (65–74: HR=3.72, 95% CI=2.29–6.05; ⩾75: HR=7.02, 95% CI=4.44–11.10; sepsis: HR=2.33, 95% CI=1.81–2.99). Conclusions: Older age and sepsis are associated with higher 1-year overall, cancer-specific, and cardiovascular-specific mortality, highlighting the importance of geriatric assessment, multidisciplinary care, and cardiovascular optimisation for older patients and those with infectious complications.
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Aquina CT, Probst CP, Becerra AZ, Iannuzzi JC, Kelly KN, Hensley BJ, Rickles AS, Noyes K, Fleming FJ, Monson JR. High volume improves outcomes: The argument for centralization of rectal cancer surgery. Surgery 2016; 159:736-48. [DOI: 10.1016/j.surg.2015.09.021] [Citation(s) in RCA: 138] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 08/04/2015] [Accepted: 09/23/2015] [Indexed: 11/28/2022]
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