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Murshed I, Dinger TL, de Gaay Fortman DPE, Traeger L, Bedrikovetski S, Hunter A, Kroon HM, Sammour T. Outcomes of rectal cancer treatment in rural Australia and New Zealand: analysis of the bowel cancer outcomes registry. ANZ J Surg 2024. [PMID: 39205431 DOI: 10.1111/ans.19194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 06/26/2024] [Accepted: 07/28/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND The demographics and geography of Australia and New Zealand (ANZ), with few metropolitan centres and vast, sparsely populated rural areas, represent a challenge to providing equal care to all patients. This study aimed to compare rectal cancer care at rural and urban hospitals in ANZ. METHODS From the Bowel Cancer Outcomes Registry (BCOR, formerly known as the Bi-National Colorectal Cancer Audit; BCCA), rectal cancer patients treated between 2007 and 2020 were compared based on hospital location (urban versus rural). Propensity-score matching was performed to correct for differences in baseline characteristics between groups. RESULTS A total of 9385 rectal cancer patients were identified from the BCOR: 1329 (14.2%) were treated at rural hospitals and 8056 (85.8%) at urban hospitals. Propensity-score matching resulted in 889 patients in each group, matched for age, ASA score, hospital type (public/private), tumour height from the anal verge, and pre-treatment cT- and cAJCC-stage. Rural patients had fewer pre-treatment MRIs (67.9% versus 74.7%; P = 0.002), and underwent less neoadjuvant therapy (44.7% versus 50.9%; P = 0.01). Rural patients underwent fewer ULARs (39.4% versus 45.6%; P = 0.03), and fewer anastomoses were formed (67.9% versus 74.4%; P = 0.05). CRM rates and postoperative AJCC stages (P = 0.19) were similar between groups (P = 0.87). Fewer rural patients received adjuvant chemotherapy (37.8% versus 43.3%; P = 0.02). CONCLUSION There are significant differences in pre-treatment MRI rates, (neo)adjuvant treatment rates and surgical procedures performed between rectal cancer patients treated at rural and urban hospitals in ANZ, while CRM rates and postoperative AJCC stages are similar.
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Affiliation(s)
- Ishmam Murshed
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Tessa L Dinger
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Department of Surgery, St. Antonius Hospital, Utrecht, The Netherlands
| | - Duveke P E de Gaay Fortman
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Department of Internal Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Luke Traeger
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Sergei Bedrikovetski
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Andrew Hunter
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Hidde M Kroon
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Tarik Sammour
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
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Harbaugh CM, Kunnath NJ, Suwanabol PA, Dimick JB, Hendren SK, Ibrahim AM. Association of National Accreditation Program for Rectal Cancer Accreditation with Outcomes after Rectal Cancer Surgery. J Am Coll Surg 2024; 239:98-105. [PMID: 38546122 DOI: 10.1097/xcs.0000000000001064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Abstract
BACKGROUND The National Accreditation Program for Rectal Cancer (NAPRC) defined a set of standards in 2017 centered on multidisciplinary program structure, evidence-based care processes, and internal audit to address widely variable rectal cancer practices and outcomes across US hospitals. There have been no studies to-date testing the association between NAPRC accreditation and rectal cancer outcomes. STUDY DESIGN This was a retrospective, observational study of Medicare beneficiaries aged 65 to 99 years with rectal cancer who underwent proctectomy from 2017 to 2020. The primary exposure was NAPRC accreditation and the primary outcomes included mortality (in-hospital, 30 day, and 1 year) and 30-day complications, readmissions, and reoperations. Associations between NAPRC accreditation and each outcome were tested using multivariable logistic regression with risk-adjustment for patient and hospital characteristics. RESULTS Among 1,985 hospitals, 65 were NAPRC-accredited (3.3%). Accredited hospitals were more likely to be nonprofit and teaching with 250 or more beds. Among 20,202 patients, 2,078 patients (10%) underwent proctectomy at an accredited hospital. Patients at accredited hospitals were more likely to have an elective procedure with a minimally invasive approach and sphincter preservation. Risk-adjusted in-hospital mortality (1.1% vs 1.3%; p = 0.002), 30-day mortality (2.1% vs 2.9%; p < 0.001), 30-day complication (18.3% vs 19.4%; p = 0.01), and 1-year mortality rates (11% vs 12.1%; p < 0.001) were significantly lower at accredited compared with nonaccredited hospitals. CONCLUSIONS NAPRC-accredited hospitals have lower risk-adjusted morbidity and mortality for major rectal cancer surgery. Although NAPRC standards address variability in practice, without directly addressing surgical safety, our findings suggest that NAPRC-accredited hospitals may provide higher quality surgical care.
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Affiliation(s)
- Calista M Harbaugh
- From the Department of Surgery, University of Michigan, Ann Arbor, MI (Harbaugh, Suwanabol, Dimick, Hendren, Ibrahim)
- Center for Healthcare Outcomes and Policy, Institute for Healthcare Innovation and Policy, University of Michigan, Ann Arbor, MI (Harbaugh, Kunnath, Suwanabol, Dimick, Hendren, Ibrahim)
| | - Nicholas J Kunnath
- Center for Healthcare Outcomes and Policy, Institute for Healthcare Innovation and Policy, University of Michigan, Ann Arbor, MI (Harbaugh, Kunnath, Suwanabol, Dimick, Hendren, Ibrahim)
| | - Pasithorn A Suwanabol
- From the Department of Surgery, University of Michigan, Ann Arbor, MI (Harbaugh, Suwanabol, Dimick, Hendren, Ibrahim)
- Center for Healthcare Outcomes and Policy, Institute for Healthcare Innovation and Policy, University of Michigan, Ann Arbor, MI (Harbaugh, Kunnath, Suwanabol, Dimick, Hendren, Ibrahim)
| | - Justin B Dimick
- From the Department of Surgery, University of Michigan, Ann Arbor, MI (Harbaugh, Suwanabol, Dimick, Hendren, Ibrahim)
- Center for Healthcare Outcomes and Policy, Institute for Healthcare Innovation and Policy, University of Michigan, Ann Arbor, MI (Harbaugh, Kunnath, Suwanabol, Dimick, Hendren, Ibrahim)
| | - Samantha K Hendren
- From the Department of Surgery, University of Michigan, Ann Arbor, MI (Harbaugh, Suwanabol, Dimick, Hendren, Ibrahim)
- Center for Healthcare Outcomes and Policy, Institute for Healthcare Innovation and Policy, University of Michigan, Ann Arbor, MI (Harbaugh, Kunnath, Suwanabol, Dimick, Hendren, Ibrahim)
| | - Andrew M Ibrahim
- From the Department of Surgery, University of Michigan, Ann Arbor, MI (Harbaugh, Suwanabol, Dimick, Hendren, Ibrahim)
- Center for Healthcare Outcomes and Policy, Institute for Healthcare Innovation and Policy, University of Michigan, Ann Arbor, MI (Harbaugh, Kunnath, Suwanabol, Dimick, Hendren, Ibrahim)
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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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Kapadia MR, Senatore PJ, Messick C, Hull TL, Shaffer VO, Morris AM, Dietz DW, Wexner SD, Wick EC. The value of national accreditation program for rectal cancer: A survey of accredited programs and programs seeking accreditation. Surgery 2024; 175:1007-1012. [PMID: 38267342 DOI: 10.1016/j.surg.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 12/12/2023] [Accepted: 12/13/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND Significant variation in rectal cancer care has been demonstrated in the United States. The National Accreditation Program for Rectal Cancer was established in 2017 to improve the quality of rectal cancer care through standardization and emphasis on a multidisciplinary approach. The aim of this study was to understand the perceived value and barriers to achieving the National Accreditation Program for Rectal Cancer accreditation. METHODS An electronic survey was developed, piloted, and distributed to rectal cancer programs that had already achieved or were interested in pursuing the National Accreditation Program for Rectal Cancer accreditation. The survey contained 40 questions with a combination of Likert scale, multiple choice, and open-ended questions to provide comments. This was a mixed methods study; descriptive statistics were used to analyze the quantitative data, and thematic analysis was used to analyze the qualitative data. RESULTS A total of 85 rectal cancer programs were sent the survey (22 accredited, 63 interested). Responses were received from 14 accredited programs and 41 interested programs. Most respondents were program directors (31%) and program coordinators (40%). The highest-ranked responses regarding the value of the National Accreditation Program for Rectal Cancer accreditation included "improved quality and culture of rectal cancer care," "enhanced program organization and coordination," and "challenges our program to provide optimal, high-quality care." The most frequently cited barriers to the National Accreditation Program for Rectal Cancer accreditation were cost and lack of personnel. CONCLUSION Our survey found significant perceived value in the National Accreditation Program for Rectal Cancer accreditation. Adhering to standards and a multidisciplinary approach to rectal cancer care are critical components of a high-quality care rectal cancer program.
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Affiliation(s)
- Muneera R Kapadia
- Department of Surgery, University of North Carolina at Chapel Hill, NC
| | - Peter J Senatore
- Inspira Health, Rowan University School of Medicine, Vineland, NJ
| | | | - Tracy L Hull
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH
| | | | - Arden M Morris
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - David W Dietz
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL
| | - Elizabeth C Wick
- Department of Surgery, University of California, San Francisco, CA.
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Nash S, Weeks K, Kahl AR, Del Vecchio NJ, Gao X, Guyton K, Charlton M. Diagnosing Provider, Referral Patterns, Facility Type, and Patient Satisfaction Among Iowa Rectal Cancer Patients. J Gastrointest Cancer 2024; 55:355-364. [PMID: 37646879 DOI: 10.1007/s12029-023-00963-y] [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: 08/09/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE Rectal cancer treatment at high-volume centers is associated with higher likelihood of guideline-concordant care and improved outcomes. Whether rectal cancer patients are referred for treatment at high-volume hospitals may depend on diagnosing provider specialty. We aimed to determine associations of diagnosing provider specialty with treating provider specialty and characteristics of the treating facility for rectal cancer patients in Iowa. METHODS Rectal cancer patients identified using the Iowa Cancer Registry completed a mailed survey on their treatment experience and decision-making process. Provider type was defined by provider specialty and whether the provider referred patients elsewhere for surgery. Multivariable-adjusted logistic regression models were used to examine predictors of being diagnosed by a general surgeon who also performed the subsequent surgery. RESULTS Of 417 patients contacted, 381 (76%) completed the survey; our final analytical sample size was 267. Half of respondents were diagnosed by a gastroenterologist who referred them elsewhere; 30% were diagnosed by a general surgeon who referred them elsewhere, and 20% were diagnosed by a general surgeon who performed the surgery. Respondents who were ≥ 65 years old, had less than a college education, and who made < $50,000 per year were more likely to be diagnosed by a general surgeon who performed surgery. In multivariable-adjusted models, respondents diagnosed and treated by the same general surgeon were more likely to have surgery at hospitals with low annual colorectal cancer surgery volume and less likely to be satisfied with their care. CONCLUSIONS Among rectal cancer patients in Iowa, respondents who were diagnosed and treated by the same provider were less likely to get treatment at a high-volume facility. This study informs the importance of provider referral in centralization of rectal cancer care.
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Affiliation(s)
- Sarah Nash
- Department of Epidemiology, College of Public Health, University of Iowa, 145 N Riverside Dr., IA, 52242, Iowa City, USA
- State Health Registry of Iowa, College of Public Health, University of Iowa, 145 N Riverside Dr., IA, 52242, Iowa City, USA
| | - Kristin Weeks
- Department of Internal Medicine, The Ohio State University Medical Center, 410 W Tenth Ave, Columbus, OH, 43210, USA
| | - Amanda R Kahl
- State Health Registry of Iowa, College of Public Health, University of Iowa, 145 N Riverside Dr., IA, 52242, Iowa City, USA
| | - Natalie J Del Vecchio
- Division of Public Health Science, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Xiang Gao
- Department of Surgery, University of Iowa Carver College of Medicine, 200 Hawkins Dr., IA, 52242, Iowa City, USA
| | - Kristina Guyton
- Department of Surgery, University of Iowa Carver College of Medicine, 200 Hawkins Dr., IA, 52242, Iowa City, USA
| | - Mary Charlton
- Department of Epidemiology, College of Public Health, University of Iowa, 145 N Riverside Dr., IA, 52242, Iowa City, USA.
- State Health Registry of Iowa, College of Public Health, University of Iowa, 145 N Riverside Dr., IA, 52242, Iowa City, USA.
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Cheraghlou S, Pahalyants V, Jairath NK, Doudican NA, Carucci JA. High-volume facilities are significantly more likely to use guideline-adherent systemic immunotherapy for metastatic Merkel cell carcinoma: implications for cancer care regionalization. Arch Dermatol Res 2024; 316:86. [PMID: 38349538 DOI: 10.1007/s00403-024-02817-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 12/17/2023] [Accepted: 01/11/2024] [Indexed: 02/15/2024]
Abstract
Merkel cell carcinoma (MCC) is a neuroendocrine skin cancer with a high rate of mortality. While still relatively rare, the incidence of MCC has been rapidly rising in the US and around the world. Since 2017, two immunotherapeutic drugs, avelumab and pembrolizumab, have been FDA-approved for the treatment of metastatic MCC and have revolutionized outcomes for MCC. However, real-world outcomes can differ from clinical trial data, and the adoption of novel therapeutics can be gradual. We aimed to characterize the treatment practices and outcomes of patients with metastatic MCC across the US. A retrospective cohort study of adult cases of MCC in the National Cancer Database diagnosed from 2004 to 2019 was performed. Multivariable logistic regressions to determine the association of a variety of patient, tumor, and system factors with likelihood of receipt of systemic therapies were performed. Univariate Kaplan-Meier and multivariable Cox survival regressions were performed. We identified 1017 cases of metastatic MCC. From 2017 to 2019, 54.2% of patients received immunotherapy. This increased from 45.1% in 2017 to 63.0% in 2019. High-volume centers were significantly more likely to use immunotherapy (odds ratio 3.235, p = 0.002). On univariate analysis, patients receiving systemic immunotherapy had significantly improved overall survival (p < 0.001). One-, 3-, and 5-year survival was 47.2% (standard error [SE] 1.8%), 21.8% (SE 1.5%), and 16.5% (SE 1.4%), respectively, for patients who did not receive immunotherapy versus 62.7% (SE 3.5%), 34.4% (SE 3.9%), and 23.6% (SE 4.4%), respectively, for those who did (Fig. 1). In our multivariable survival regression, receipt of immunotherapy was associated with an approximately 35% reduction in hazard of death (hazard ratio 0.665, p < 0.001; 95% CI 0.548-0.808). Our results demonstrate that the real-world survival advantage of immunotherapy for metastatic MCC is similar to clinical trial data. However, many patients with metastatic disease did not receive this guideline-recommended therapy in our most recent study year, and use of immunotherapy is higher at high-volume centers. This suggests that regionalization of care to high-volume centers or dissemination of their practices, may ultimately improve patient survival.
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Affiliation(s)
- Shayan Cheraghlou
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Vartan Pahalyants
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Neil K Jairath
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Nicole A Doudican
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, NY, USA
| | - John A Carucci
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, NY, USA.
- NYU Dermatologic Surgical Associates, 222 East 41st Street, New York, NY, 10017, USA.
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Lee-Miller C, Montgomery KE, Evered J, Phelps K, Norslien K, Parkes A, Kwekkeboom K. A Midwest Stakeholder Evaluation of an Adolescent and Young Adult Cancer Survivor Needs Assessment Survey. J Adolesc Young Adult Oncol 2024; 13:123-131. [PMID: 37581596 DOI: 10.1089/jayao.2023.0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023] Open
Abstract
Purpose: Over 87,000 adolescents and young adults (AYAs) are diagnosed with cancer in the United States each year. Improvement in outcomes in the AYA population has lagged that of both younger and older patients. This decrement may be attributable to several factors, including insufficient supportive care services. Our team modified the Needs Assessment & Service Bridge (NA-SB) tool, utilizing an iterative approach with patient and clinician stakeholders to meet the needs of the AYA population at a large Midwestern Cancer Center. Methods: We recruited a 10-member AYA Advisory Board (AB) from our Cancer Center patients, and met five times over 9 months to discuss supportive care and the NA-SB. We recruited a multidisciplinary group of oncology clinicians to assess content validity and conducted interviews with nine clinician stakeholders to discuss implementation. Results: The AB generated a 59-item-modified NA-SB, retaining most of the original NA-SB items and adding several more. Five items with concerns for relevance and/or clarity were revised to create the final 58-item-modified NA-SB. Priorities for implementation were identified by AB and clinician stakeholders. Conclusions: The modified NA-SB thoroughly reflects supportive care needs of our Midwestern AYA cancer survivors. When implemented, the tool may facilitate patient-care team communication and provide data to prioritize development of new supportive care resources. AYA cancer survivors have unique supportive care needs that are insufficiently addressed by current care models; using the modified NA-SB may help address those needs, leading to improved AYA outcomes.
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Affiliation(s)
- Cathy Lee-Miller
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | | | - Jane Evered
- Department of Family Medicine and Community Health, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Kat Phelps
- University of Wisconsin-Madison School of Nursing, Madison, Wisconsin, USA
| | | | - Amanda Parkes
- Division of Hematology, Medical Oncology, and Palliative Care, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
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Lo A, Le B, Colin-Escobar J, Ruiz A, Creps J, Kampalath R, Lee S. Disparities in Diagnostic Imaging for Initial Local Staging for Rectal Cancer. J Am Coll Radiol 2024; 21:154-164. [PMID: 37634795 DOI: 10.1016/j.jacr.2023.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 06/30/2023] [Accepted: 07/08/2023] [Indexed: 08/29/2023]
Abstract
OBJECTIVE To assess the presence, quality, and timeliness of initial staging imaging for rectal cancer patients, and to evaluate demographic factors associated with disparities. METHODS We conducted a chart review of consecutive rectal adenocarcinoma cancer registry cases from a single institution for the period from 2015 to 2020. We recorded whether initial staging MRI or endoscopic ultrasound (EUS) was performed, and whether it was performed in or outside the institution. MRI quality was assessed based on compliance to the Society of Abdominal Radiology rectal cancer disease-focused panel protocol recommendations. The times between diagnosis and imaging were calculated. Patients' age, race, ethnicity, sex, body mass index, address, and primary payer were acquired from the electronic medical record. Descriptive analysis, odds ratios, and Student's t tests were used for analysis. RESULTS Of 346 patients, 39% were female, and the average age was 59 years. A total of 93 patients (26.8%) had no initial staging MRI or endoscopic ultrasound. Of the 142 MRIs evaluated for image quality, 100 patient exams (72.4%) met the criteria for adequate quality. The mean time interval from diagnosis to imaging was 30.9 days. A lower likelihood of receiving initial local staging was associated with being of Hispanic ethnicity (P < .01), having Medicaid or no insurance (P < .01), and residing in a low-income census block (P < .01). Higher quality of imaging was associated with residence in a census block with high median income (P < 0.01), more recent diagnosis (P < .01), and MRI performed at the institution presented (P < .01). CONCLUSIONS Although radiologic workup variability was found across all demographics, sociodemographic factors have an effect on local initial imaging of rectal cancer, emphasizing the need to improve image acquisition for underserved patients and improve quality standardization at low-volume centers.
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Affiliation(s)
- Angelina Lo
- Department of Radiology, University of California, Irvine, School of Medicine, Orange, California
| | - Brittany Le
- Department of Radiology, University of California, Irvine, School of Medicine, Orange, California
| | - Jessica Colin-Escobar
- Department of Radiology, University of California, Irvine, School of Medicine, Orange, California
| | - Andres Ruiz
- Department of Radiology, University of California, Irvine, School of Medicine, Orange, California
| | - James Creps
- Department of Radiology, University of California, Irvine, School of Medicine, Orange, California
| | - Rony Kampalath
- Society of Abdominal Radiology Colorectal and Anal Cancer Disease Focused-Panel, Educational Subcommittee Lead, Department of Radiology, University of California, Irvine, School of Medicine, Orange, California
| | - Sonia Lee
- Radiology Lead of the Inflammatory Bowel Disease Multidisciplinary Conference, and a Member of the Society of Abdominal Radiology Treated Hepatocellular Carcinoma Disease Focused Panel, Department of Radiology, University of California, Irvine, School of Medicine, Orange, California.
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Unuvar M, Blansfield J, Wang S, Hoffman RL. Trends in adoption of total neoadjuvant therapy for locally advanced rectal cancer. Am J Surg 2024; 227:229-236. [PMID: 37923661 DOI: 10.1016/j.amjsurg.2023.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 10/05/2023] [Accepted: 10/06/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Total neoadjuvant chemoradiation (TNT), an accepted strategy for the treatment of locally advanced rectal cancer (LARC), was first included in guidelines in 2018. We aimed to describe trends in, and factors associated with TNT receipt. METHODS A retrospective cohort study of adult patients with LARC was performed using the national cancer database (2012-2020). TNT status was determined, and temporal trends analyzed. Factors associated with TNT receipt were identified by stage. RESULTS A total of 51,407 patients were identified; 57.3 % received TNT. Increasing age and comorbidities were associated with higher rates of TNT receipt. Patients with stage III disease were more likely to receive TNT (stage II OR 0.92, 95%CI 0.88-0.96). Patients were 38 % more likely to get TNT after guideline inclusion (OR1.38, 95%CI 1.31-1.46). CONCLUSION Rates of TNT were consistently above 50 % and rose after inclusion in the NCCN guidelines. This study establishes baseline patterns in rates of TNT for future benchmarking.
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Affiliation(s)
- Maria Unuvar
- Geisinger Medical Center, Department of General Surgery, 100 N. Academy Ave, Danville, PA, 17822, USA.
| | - Joseph Blansfield
- Geisinger Medical Center, Department of General Surgery, Division of Surgical Oncology, 100 N. Academy Ave, Danville, PA, 17822, USA
| | - Shengxuan Wang
- Geisinger Department of Biostatistics, 100 N. Academy Ave, Danville, PA, 17822, USA
| | - Rebecca L Hoffman
- Geisinger Medical Center, Department of General Surgery, Division of Colon & Rectal Surgery, 100 N. Academy Ave, Danville, PA, 17822, USA
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Chen SY, Radomski SN, Stem M, Papanikolaou A, Gabre-Kidan A, Gearhart SL, Efron JE, Atallah C. Factors associated with not undergoing surgery for locally advanced rectal cancers: An NCDB propensity-matched analysis. Surgery 2023; 174:1323-1333. [PMID: 37852832 DOI: 10.1016/j.surg.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/01/2023] [Accepted: 09/05/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND The traditional treatment paradigm for patients with locally advanced rectal cancers has been neoadjuvant chemoradiation followed by curative intent surgery and adjuvant chemotherapy. This study aimed to assess surgery trends for locally advanced rectal cancers, factors associated with forgoing surgery, and overall survival outcomes. METHODS Adults with locally advanced rectal cancers were retrospectively analyzed using the National Cancer Database (2004-2019). Propensity score matching was performed. Factors associated with not undergoing surgery were identified using multivariable logistic regression. Kaplan-Meier and log-rank tests were used for 5-year overall survival analysis, stratified by stage and treatment type. RESULTS A total of 72,653 patients were identified, with 64,396 (88.64%) patients undergoing neoadjuvant + surgery ± adjuvant therapy, 579 (0.80%) chemotherapy only, 916 (1.26%) radiation only, and 6,762 (9.31%) chemoradiation only. The proportion of patients who underwent surgery declined over the study period (95.61% in 2006 to 92.29% in 2019, P trend < .001), whereas the proportion of patients who refused surgery increased (1.45%-4.48%, P trend < .001). Factors associated with not undergoing surgery for locally advanced rectal cancers included older age, Black race (odds ratio 1.47, 95% CI 1.35-1.60, P < .001), higher Charlson-Deyo score (score ≥3: 1.79, 1.58-2.04, P < .001), stage II cancer (1.22, 1.17-1.28, P < .001), lower median household income, and non-private insurance. Neoadjuvant + surgery ± adjuvant therapy was associated with the best 5-year overall survival, regardless of stage, in unmatched and matched cohorts. CONCLUSION Despite surgery remaining an integral component in the management of locally advanced rectal cancers, there is a concerning decline in guideline-concordant surgical care for rectal cancer in the United States, with evidence of persistent socioeconomic disparities. Providers should seek to understand patient perspectives/barriers and guide them toward surgery if appropriate candidates. Continued standardization, implementation, and evaluation of rectal cancer care through national accreditation programs are necessary to ensure that all patients receive optimal treatment.
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Affiliation(s)
- Sophia Y Chen
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shannon N Radomski
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Miloslawa Stem
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Angelos Papanikolaou
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Surgery, NYU Langone Health, NYC, NY
| | - Alodia Gabre-Kidan
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Susan L Gearhart
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jonathan E Efron
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Chady Atallah
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Surgery, NYU Langone Health, NYC, NY.
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11
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Canavan M, Wang X, Ascha M, Miksad R, Showalter TN, Calip G, Gross CP, Adelson K. End-of-Life Systemic Oncologic Treatment in the Immunotherapy Era: The Role of Race, Insurance, and Practice Setting. J Clin Oncol 2023; 41:4729-4738. [PMID: 37339389 PMCID: PMC10602547 DOI: 10.1200/jco.22.02180] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 02/15/2023] [Accepted: 04/25/2023] [Indexed: 06/22/2023] Open
Abstract
PURPOSE Receipt of antineoplastic systemic treatment near end of life (EOL) has been shown to harm patient and caregiver experience, increase hospitalizations, intensive care unit and emergency department use, and drive-up costs; yet, these rates have not declined. To understand factors contributing to use of antineoplastic EOL systemic treatment, we explored its association with practice- and patient-level factors. METHODS We included patients from a real-world electronic health record-derived deidentified database who received systemic therapy for advanced or metastatic cancer diagnosed starting in 2011 and died within 4 years between 2015 and 2019. We assessed use of EOL systemic treatment at 30 and 14 days before death. We divided treatments into three subcategories: chemotherapy alone, chemotherapy and immunotherapy in combination, and immunotherapy (with/without targeted therapy), and estimated conditional odds ratios (ORs) and 95% CIs for patient and practice factors using multivariable mixed-level logistic regression. RESULTS Among 57,791 patients from 150 practices, 19,837 received systemic treatment within 30 days of death. We observed 36.6% of White patients, 32.7% of Black patients, 43.3% of commercially insured patients, and 37.0% of Medicaid patients received EOL systemic treatment. White patients and those with commercial insurance were more likely to receive EOL systemic treatment than Black patients or those with Medicaid. Treatment at community practices was associated with higher odds of receiving 30-day systemic EOL treatment than treatment at academic centers (adjusted OR, 1.51). We observed large variations in EOL systemic treatment rates across practices. CONCLUSION In a large real-world population, EOL systemic treatment rates were related to patient race, insurance type, and practice setting. Future work should examine factors that contribute to this usage pattern and its impact on downstream care. [Media: see text].
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Affiliation(s)
| | | | | | - Rebecca Miksad
- Flatiron Health, Inc, New York, NY
- Department of Hematology and Oncology, Boston Medical Center, Boston, MA
| | | | - Gregory Calip
- Flatiron Health, Inc, New York, NY
- Program on Medicines and Public Health, Titus Family Department of Clinical Pharmacy, University of Southern California School of Pharmacy, Los Angeles, CA
| | | | - Kerin Adelson
- Yale School of Medicine, New Haven, CT
- MD Anderson Cancer Center, University of Texas, Houston, TX
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12
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Eom SS, Park SH, Eom BW, Man Yoon H, Kim YW, Ryu KW. Real-World Compliance of Surgical Treatment According to the Korean Gastric Cancer Guideline 2018: Evaluation From the Nationwide Survey Data 2019 in Korea. J Gastric Cancer 2023; 23:535-548. [PMID: 37932221 PMCID: PMC10630559 DOI: 10.5230/jgc.2023.23.e32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 08/08/2023] [Accepted: 08/17/2023] [Indexed: 11/08/2023] Open
Abstract
PURPOSE This study evaluated real-world compliance with surgical treatment according to Korea's gastric cancer treatment guidelines. MATERIALS AND METHODS The 2018 Korean Gastric Cancer Treatment Guidelines were evaluated using the 2019 national survey data for surgically treated gastric cancer based on postoperative pathological results in Korea. In addition, the changes in surgical treatments in 2019 were compared with those in the 2014 national survey data implemented before the publication of the guidelines in 2018. The compliance rate was evaluated according to the algorithm recommended in the 2018 Korean guidelines. RESULTS The overall compliance rates in 2019 were 83% for gastric resection extent, 87% for lymph node dissection, 100% for surgical approach, and 83% for adjuvant chemotherapy, similar to 2014. Among patients with pathologic stages IB, II, and III disease who underwent total gastrectomy, the incidence of splenectomy was 8.08%, a practice not recommended by the guidelines. The survey findings revealed that 48.66% of the patients who underwent gastrectomy had pathological stage IV disease, which was not recommended by the 2019 guidelines. Compared to that in 2014, the rate of gastrectomy in stage IV patients was 54.53% in 2014. Compliance rates were similar across all regions of Korea, except for gastrectomy in patients with stage IV disease. CONCLUSIONS Real-world compliance with gastric cancer treatment guidelines was relatively high in Korea.
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Affiliation(s)
- Sang Soo Eom
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
- Department of Surgery, Inje University College of Medicine, Ilsan Paik Hospital, Goyang, Korea
| | - Sin Hye Park
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Bang Wool Eom
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Hong Man Yoon
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Young-Woo Kim
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Keun Won Ryu
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea.
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13
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Del Rosario M, Chang J, Ziogas A, Clair K, Bristow RE, Tanjasiri SP, Zell JA. Differential Effects of Race, Socioeconomic Status, and Insurance on Disease-Specific Survival in Rectal Cancer. Dis Colon Rectum 2023; 66:1263-1272. [PMID: 35849491 PMCID: PMC10548716 DOI: 10.1097/dcr.0000000000002341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND National Comprehensive Cancer Network guideline adherence improves cancer outcomes. In rectal cancer, guideline adherence is distributed differently by race/ethnicity, socioeconomic status, and insurance. OBJECTIVE This study aimed to determine the independent effects of race/ethnicity, socioeconomic status, and insurance status on rectal cancer survival after accounting for differences in guideline adherence. DESIGN This was a retrospective study. SETTINGS The study was conducted using the California Cancer Registry. PATIENTS This study included patients aged 18 to 79 years diagnosed with rectal adenocarcinoma between January 1, 2004, and December 31, 2017, with follow-up through November 30, 2018. Investigators determined whether patients received guideline-adherent care. MAIN OUTCOME MEASURES ORs and 95% CIs were used for logistic regression to analyze patients receiving guideline-adherent care. Disease-specific survival analysis was calculated using Cox regression models. RESULTS A total of 30,118 patients were examined. Factors associated with higher odds of guideline adherence included Asian and Hispanic race/ethnicity, managed care insurance, and high socioeconomic status. Asians (HR, 0.80; 95% CI, 0.72-0.88; p < 0.001) and Hispanics (HR, 0.91; 95% CI, 0.83-0.99; p = 0.0279) had better disease-specific survival in the nonadherent group. Race/ethnicity were not factors associated with disease-specific survival in the guideline adherent group. Medicaid disease-specific survival was worse in both the nonadherent group (HR, 1.56; 95% CI, 1.40-1.73; p < 0.0001) and the guideline-adherent group (HR, 1.18; 95% CI, 1.08-1.30; p = 0.0005). Disease-specific survival of the lowest socioeconomic status was worse in both the nonadherent group (HR, 1.42; 95% CI, 1.27-1.59) and the guideline-adherent group (HR, 1.20; 95% CI, 1.08-1.34). LIMITATIONS Limitations included unmeasured confounders and the retrospective nature of the review. CONCLUSIONS Race, socioeconomic status, and insurance are associated with guideline adherence in rectal cancer. Race/ethnicity was not associated with differences in disease-specific survival in the guideline-adherent group. Medicaid and lowest socioeconomic status had worse disease-specific survival in both the guideline nonadherent group and the guideline-adherent group. See Video Abstract at http://links.lww.com/DCR/B954 . EFECTOS DIFERENCIALES DE LA RAZA, EL NIVEL SOCIOECONMICO COBERTURA SOBRE LA SUPERVIVENCIA ESPECFICA DE LA ENFERMEDAD EN EL CNCER DE RECTO ANTECEDENTES: El cumplimiento de las guías de la National Comprehensive Cancer Network mejora los resultados del cáncer. En el cáncer de recto, el cumplimiento de las guías se distribuye de manera diferente según la raza/origen étnico, nivel socioeconómico y el cobertura médica.OBJETIVO: Determinar los efectos independientes de la raza/origen étnico, el nivel socioeconómico y el estado de cobertura médica en la supervivencia del cáncer de recto después de tener en cuenta las diferencias en el cumplimiento de las guías.DISEÑO: Este fue un estudio retrospectivo.ENTORNO CLINICO: El estudio se realizó utilizando el Registro de Cáncer de California.PACIENTES: Pacientes de 18 a 79 años diagnosticados con adenocarcinoma rectal entre el 1 de enero de 2004 y el 31 de diciembre de 2017 con seguimiento hasta el 30 de noviembre de 2018. Los investigadores determinaron si los pacientes recibieron atención siguiendo las guías.PRINCIPALES MEDIDAS DE RESULTADO: Se utilizaron razones de probabilidad e intervalos de confianza del 95 % para la regresión logística para analizar a los pacientes que recibían atención con adherencia a las guías. El análisis de supervivencia específico de la enfermedad se calculó utilizando modelos de regresión de Cox.RESULTADOS: Se analizaron un total de 30.118 pacientes. Los factores asociados con mayores probabilidades de cumplimiento de las guías incluyeron raza/etnicidad asiática e hispana, seguro de atención administrada y nivel socioeconómico alto. Los asiáticos e hispanos tuvieron una mejor supervivencia específica de la enfermedad en el grupo no adherente HR 0,80 (95 % CI 0,72 - 0,88, p < 0,001) y HR 0,91 (95 % CI 0,83 - 0,99, p = 0,0279). La raza o el origen étnico no fueron factores asociados con la supervivencia específica de la enfermedad en el grupo que cumplió con las guías. La supervivencia específica de la enfermedad de Medicaid fue peor tanto en el grupo no adherente HR 1,56 (IC del 95 % 1,40 - 1,73, p < 0,0001) como en el grupo adherente a las guías HR 1,18 (IC del 95 % 1,08 - 1,30, p = 0,0005). La supervivencia específica de la enfermedad del nivel socioeconómico más bajo fue peor tanto en el grupo no adherente HR 1,42 (IC del 95 %: 1,27 a 1,59) como en el grupo adherente a las guías HR 1,20 (IC del 95 %: 1,08 a 1,34).LIMITACIONES: Las limitaciones incluyeron factores de confusión no medidos y la naturaleza retrospectiva de la revisión.CONCLUSIONES: La raza, el nivel socioeconómico y cobertura médica están asociados con la adherencia a las guías en el cáncer de recto. La raza/etnicidad no se asoció con diferencias en la supervivencia específica de la enfermedad en el grupo que cumplió con las guías. Medicaid y el nivel socioeconómico más bajo tuvieron peor supervivencia específica de la enfermedad tanto en el grupo que no cumplió con las guías como en los grupos que cumplieron. Consulte Video Resumen en http://links.lww.com/DCR/B954 . (Traducción- Dr. Francisco M. Abarca-Rendon).
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Affiliation(s)
- Michael Del Rosario
- Division of Hematology/Oncology, Department of Medicine, University of California, Irvine, Irvine, California
| | - Jenny Chang
- Department of Medicine, University of California, Irvine, Irvine, California
| | - Argyrios Ziogas
- Department of Medicine, University of California, Irvine, Irvine, California
| | - Kiran Clair
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, Irvine, Irvine, California
| | - Robert E. Bristow
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, Irvine, Irvine, California
| | - Sora P. Tanjasiri
- Department of Medicine, University of California, Irvine, Irvine, California
- Chao Family Comprehensive Cancer Center, University of California, Irvine, Irvine, California
| | - Jason A. Zell
- Division of Hematology/Oncology, Department of Medicine, University of California, Irvine, Irvine, California
- Department of Medicine, University of California, Irvine, Irvine, California
- Chao Family Comprehensive Cancer Center, University of California, Irvine, Irvine, California
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14
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Korngold EK, Gollub MJ, Kim DH, Moreno CC, de Prisco G, Harisinghani M, Khatri G. Update on The National Accreditation Program for Rectal Cancer (NAPRC): the radiologist's role. Abdom Radiol (NY) 2023; 48:2814-2824. [PMID: 37160474 DOI: 10.1007/s00261-023-03919-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 04/08/2023] [Accepted: 04/11/2023] [Indexed: 05/11/2023]
Abstract
The National Accreditation Program for Rectal Cancer (NAPRC) was established by the American College of Surgeons with the goal of standardizing care of rectal cancer patients in order to improve outcomes. NAPRC accreditation requires compliance with an established set of standards, many of which are directly related to radiology participation in multidisciplinary conference, rectal MR image acquisition, interpretation and reporting, and radiologist education. This paper outlines the pertinent standards/requirements for radiologists as part of the Rectal Cancer Multidisciplinary Team in the NAPRC guidelines, with proposed methods and tips for implementation of these standards from the perspective of the radiologist.
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Affiliation(s)
| | - Marc J Gollub
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David H Kim
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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15
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Azevedo JM, Panteleimonitis S, Mišković D, Herrando I, Al-Dhaheri M, Ahmad M, Qureshi T, Fernandez LM, Harper M, Parvaiz A. Textbook Oncological Outcomes for Robotic Colorectal Cancer Resections: An Observational Study of Five Robotic Colorectal Units. Cancers (Basel) 2023; 15:3760. [PMID: 37568576 PMCID: PMC10417291 DOI: 10.3390/cancers15153760] [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: 04/23/2023] [Revised: 06/27/2023] [Accepted: 07/06/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND The quality of care of patients receiving colorectal resections has conventionally relied on individual metrics. When discussing with patients what these outcomes mean, they often find them confusing or overwhelming. Textbook oncological outcome (TOO) is a composite measure that summarises all the 'desirable' or 'ideal' postoperative clinical and oncological outcomes from both a patient's and doctor's point of view. This study aims to evaluate the incidence of TOO in patients receiving robotic colorectal cancer surgery in five robotic colorectal units and understand the risk factors associated with failure to achieve a TOO in these patients. METHODS We present a retrospective, multicentric study with data from a prospectively collected database. All consecutive patients receiving robotic colorectal cancer resections from five centres between 2013 and 2022 were included. Patient characteristics and short-term clinical and oncological data were collected. A TOO was achieved when all components were realized-no conversion to open, no complication with a Clavien-Dindo (CD) ≥ 3, length of hospital stay ≤ 14, no 30-day readmission, no 30-day mortality, and R0 resection. The main outcome measure was a composite measure of "ideal" practice called textbook oncological outcomes. RESULTS A total of 501 patients submitted to robotic colorectal cancer resection were included. Of the 501 patients included, 388 (77.4%) achieved a TOO. Four patients were converted to open (0.8%); 55 (11%) had LOS > 14 days; 46 (9.2%) had a CD ≥ 3 complication; 30-day readmission rate was 6% (30); 30-day mortality was 0.2% (1); and 480 (95.8%) had an R0 resection. Abdominoperineal resection was a risk factor for not achieving a TOO. CONCLUSIONS Robotic colorectal cancer surgery in robotic centres achieves a high TOO rate. Abdominoperineal resection is a risk factor for failure to achieve a TOO. This measure may be used in future audits and to inform patients clearly on success of treatment.
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Affiliation(s)
- José Moreira Azevedo
- Champalimaud Foundation, Av. Brasilia, 1400-038 Lisbon, Portugal (L.M.F.); (A.P.)
- Faculty of Medicine, University of Lisbon, Av. Prof. Egas Moniz MB, 1649-028 Lisbon, Portugal
| | - Sofoklis Panteleimonitis
- Champalimaud Foundation, Av. Brasilia, 1400-038 Lisbon, Portugal (L.M.F.); (A.P.)
- School of Health and Care Professions, University of Portsmouth, St. Andrews Court, St. Michael’s Road, Portsmouth PO1 2PR, UK;
- St. Mark’s Hospital, London NW10 7NS, UK;
| | | | - Ignacio Herrando
- Champalimaud Foundation, Av. Brasilia, 1400-038 Lisbon, Portugal (L.M.F.); (A.P.)
| | | | - Mukhtar Ahmad
- Poole Hospital NHS Trust, Longfleet Road, Poole BH15 2JB, UK; (M.A.); (T.Q.)
| | - Tahseen Qureshi
- Poole Hospital NHS Trust, Longfleet Road, Poole BH15 2JB, UK; (M.A.); (T.Q.)
| | | | - Mick Harper
- School of Health and Care Professions, University of Portsmouth, St. Andrews Court, St. Michael’s Road, Portsmouth PO1 2PR, UK;
| | - Amjad Parvaiz
- Champalimaud Foundation, Av. Brasilia, 1400-038 Lisbon, Portugal (L.M.F.); (A.P.)
- School of Health and Care Professions, University of Portsmouth, St. Andrews Court, St. Michael’s Road, Portsmouth PO1 2PR, UK;
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16
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Russell TA, Ko C. History and Role of Quality Accreditation. Clin Colon Rectal Surg 2023; 36:279-284. [PMID: 37223226 PMCID: PMC10202542 DOI: 10.1055/s-0043-1761592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Accreditation has played a major role in the evolution of health care quality as well as the structure and organization of American medicine. In its earliest iterations, accreditation aimed to set a minimum standard of care, and now more prominently sets standards for high quality, optimal patient care. There are several institutions that provide accreditations that are relevant to colorectal surgery including the American College of Surgeons (ACS) Commission on Cancer, National Cancer Institute Cancer Center Designation, National Accreditation Program for Rectal Cancer, and the ACS Geriatrics Verification Program. While each program has unique criteria, the aim of accreditation is to assure high-quality evidenced-based care. In addition to these benchmarks, these programs provide avenues for collaboration and research between centers and programs.
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Affiliation(s)
- Tara A. Russell
- Division of Colorectal Surgery, Department of Surgery, University of California Los Angeles, Los Angeles, California
| | - Clifford Ko
- Division of Colorectal Surgery, Department of Surgery, University of California Los Angeles, Los Angeles, California
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17
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Goffredo P, Hart AA, Tran CG, Kahl AR, Gao X, Del Vecchio NJ, Charlton ME, Hassan I. Patterns of Care and Outcomes of Rectal Cancer Patients from the Iowa Cancer Registry: Role of Hospital Volume and Tumor Location. J Gastrointest Surg 2023; 27:1228-1237. [PMID: 36949239 PMCID: PMC11283177 DOI: 10.1007/s11605-023-05656-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 02/09/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Centralization of rectal cancer surgery has been associated with high-quality oncologic care. However, several patient, disease and system-related factors can impact where patients receive care. We hypothesized that patients with low rectal tumors would undergo treatment at high-volume centers and would be more likely to receive guideline-based multidisciplinary treatment. METHODS Adults who underwent proctectomy for stage II/III rectal cancer were included from the Iowa Cancer Registry and supplemented with tumor location data. Multinomial logistic regression was employed to analyze factors associated with receiving care in high-volume hospital, while logistic regression for those associated with ≥ 12 lymph node yield, pre-operative chemoradiation and sphincter-preserving surgery. RESULTS Of 414 patients, 38%, 39%, and 22% had low, mid, and high rectal cancers, respectively. Thirty-two percent were > 65 years, 38% female, and 68% had stage III tumors. Older age and rural residence, but not tumor location, were associated with surgical treatment in low-volume hospitals. Higher tumor location, high-volume, and NCI-designated hospitals had higher nodal yield (≥ 12). Hospital-volume was not associated with neoadjuvant chemoradiation rates or circumferential resection margin status. Sphincter-sparing surgery was independently associated with high tumor location, female sex, and stage III cancer, but not hospital volume. CONCLUSIONS Low tumor location was not associated with care in high-volume hospitals. High-volume and NCI-designated hospitals had higher nodal yields, but not significantly higher neoadjuvant chemoradiation, negative circumferential margin, or sphincter preservation rates. Therefore, providing educational/quality improvement support in lower volume centers may be more pragmatic than attempting to centralize rectal cancer care among high-volume centers.
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Affiliation(s)
- P Goffredo
- Division of Colon & Rectal Surgery, University of Minnesota, Minneapolis, MN, USA
| | - A A Hart
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - C G Tran
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - A R Kahl
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA
- Iowa Cancer Registry, University of Iowa College of Public Health, Iowa City, IA, USA
| | - X Gao
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - N J Del Vecchio
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - M E Charlton
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA
- Iowa Cancer Registry, University of Iowa College of Public Health, Iowa City, IA, USA
| | - I Hassan
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
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18
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Tang D, Rivard SJ, Weng W, Ramm CA, Cleary RK, Hendren S. Lack of Complete Pretreatment Staging Is Associated With Omission of Neoadjuvant Therapy for Rectal Cancer: A Statewide Study. Dis Colon Rectum 2023; 66:662-670. [PMID: 35195556 DOI: 10.1097/dcr.0000000000002265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Standardized local staging and neoadjuvant therapy are rectal cancer management quality measures supported by the Commission on Cancer and National Accreditation Program for Rectal Cancer for the management of rectal cancer. Previous studies suggested that up to 25% of patients with stage II/III rectal cancer patients do not receive neoadjuvant therapy. We hypothesized that failure to receive neoadjuvant therapy may be caused by failure to properly stage patients before surgery. OBJECTIVE This study aimed to determine whether lack of local rectal cancer staging is associated with underutilization of neoadjuvant therapy and to determine risk factors for omission of neoadjuvant therapy. DESIGN Retrospective cohort study. Bivariate and multivariable analyses were performed on patient, tumor, and 30-day outcome factors associated with neoadjuvant therapy and staging. SETTINGS hospitals participated in the Michigan Surgical Quality Collaborative Colorectal Cancer Project from January 2014 to December 2019. PATIENTS Elective, clinical stage II/III, mid-to-low rectal cancer resections. Patients with upper rectal cancer were excluded. MAIN OUTCOME MEASURES Percentage of patients receiving neoadjuvant therapy. RESULTS The final cohort included 350 patients with clinical stage II/III mid or low rectal cancer-80.9% of patients who had received neoadjuvant therapy and 83.2% of patients who had MRI and/or endoscopic ultrasound. A significant association was found between receiving neoadjuvant therapy and MRI/endorectal ultrasound staging ( p < 0.0001). Eighty-seven percent of patients who had MRI/endorectal ultrasound received neoadjuvant chemoradiotherapy; 49% of patients who did not have MRI/endorectal ultrasound staging received neoadjuvant chemoradiotherapy. Multivariate analysis revealed that risk factors for the omission of neoadjuvant therapy were older age and incomplete staging. LIMITATIONS Observational study with the possibility of unmeasured confounding variables. CONCLUSIONS Neoadjuvant therapy is underused in patients with stage II/III rectal cancer. Omission of pretreatment staging with MRI/endorectal ultrasound is associated with omission of neoadjuvant therapy. These data suggest the need for regional and national quality improvement strategies to standardize the multidisciplinary management of rectal cancer. See Video Abstract at http://links.lww.com/DCR/B923 . LA FALTA DE ESTADIFICACIN COMPLETA PREVIA AL TRATAMIENTO SE ASOCIA CON LA OMISIN DE LA TERAPIA NEOADYUVANTE PARA EL CNCER DE RECTO UN ESTUDIO ESTATAL ANTECEDENTES: La estadificación local estandarizada y la terapia neoadyuvante son medidas de calidad de la Comisión sobre el Cáncer y el Programa Nacional de Acreditación para el Cáncer de Recto para el tratamiento del cáncer de recto. Estudios previos sugirieron que hasta el 25% de los pacientes con cáncer de recto en estadio II/III no reciben terapia neoadyuvante. Planteamos la hipótesis de que la falla en recibir la terapia neoadyuvante puede deberse a la falla en la estadificación adecuada de los pacientes antes de la cirugía.OBJETIVO: El propósito de este estudio es determinar si la falta de estadificación local del cáncer de recto está asociada con la infrautilización de la terapia neoadyuvante y determinar los factores de riesgo para la omisión de la terapia neoadyuvante.DISEÑO: Estudio de cohorte retrospectivo. Se realizaron análisis bivariados y multivariados sobre el paciente, el tumor y los factores de resultado a los 30 días asociados con la terapia neoadyuvante y la estadificación.AJUSTE: Un total de 31 hospitales que participaron en el Proyecto Quirugico Colaborativo de Cáncer Colorrectal de Calidad de Michigan desde enero de 2014 hasta diciembre de 2019.PACIENTES: Resecciones electivas, en estadio clínico II/III, de cáncer de recto medio a bajo. Se excluyeron los pacientes con cáncer de recto superior.MEDIDA DE RESULTADO PRINCIPAL: Porcentaje de pacientes que reciben terapia neoadyuvante. Porcentaje de pacientes que reciben terapia neoadyuvante.RESULTADOS: La cohorte final fue de 350 casos con cáncer de recto medio o bajo en estadio clínico II/III. El 80,9% tenía terapia neoadyuvante y el 83,2%, resonancia magnética y/o ultrasonido endoscópico. Hubo una asociación significativa entre recibir terapia neoadyuvante y la estadificación MRI/ERUS ( p < 0,0001). El 87% de los pacientes a los que se les realizaron imágenes con MRI/ERUS recibieron NT, mientras que el 49% de los pacientes a los que no se les realizó la estadificación con MRI/ERUS tuvieron NT. El análisis multivariante reveló que los factores de riesgo para la omisión de la terapia neoadyuvante fueron la edad avanzada y la estadificación incompleta.LIMITACIONES: Estudio observacional con posibilidad de confusión de variables no medidas.CONCLUSIONES: La terapia neoadyuvante está infrautilizada en pacientes con cáncer de recto en estadio II/III. La omisión de la estadificación previa al tratamiento con MRI/ERUS se asocia con la omisión de la terapia neoadyuvante. Estos datos sugieren la necesidad de estrategias regionales y nacionales de mejora de la calidad para estandarizar el manejo multidisciplinario del cáncer de recto. Consulte Video Resumen en http://links.lww.com/DCR/B923 . (Traducción-Dr Yolanda Colorado ).
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Affiliation(s)
- Dalun Tang
- Department of Surgery, St Joseph Mercy Hospital, Ann Arbor, Michigan
| | - Samantha J Rivard
- Division of Colon and Rectal Surgery, Department of Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan
| | - Wenjing Weng
- Michigan Surgical Quality Collaborative, University of Michigan, Michigan Medicine, Ann Arbor, Michigan
| | - Carole A Ramm
- Department of Academic Research, St Joseph Mercy Hospital, Ann Arbor, Michigan
| | - Robert K Cleary
- Department of Surgery, St Joseph Mercy Hospital, Ann Arbor, Michigan
| | - Samantha Hendren
- Division of Colon and Rectal Surgery, Department of Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan
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Ryles HT, Hong CX, Andy UU, Farrow MR. Changing Practices in the Surgical Management of Adnexal Torsion: An Analysis of the National Surgical Quality Improvement Program Database. Obstet Gynecol 2023; 141:888-896. [PMID: 37023448 PMCID: PMC10147583 DOI: 10.1097/aog.0000000000005142] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 01/12/2023] [Indexed: 04/08/2023]
Abstract
OBJECTIVE To evaluate trends in the surgical management of adnexal torsion and to evaluate these trends with respect to the updated American College of Obstetricians and Gynecologists (ACOG) guidelines. METHODS We performed a retrospective cohort study using the National Surgical Quality Improvement Program database. Women who underwent surgery for adnexal torsion between 2008 and 2020 were identified on the basis of International Classification of Diseases codes. Surgeries were grouped as either ovarian conservation or oophorectomy with the use of Current Procedural Terminology codes. Patients were also grouped into year cohorts with respect to the publication of the updated ACOG guidelines (2008-2016 compared with 2017-2020). Multivariable logistic regression, weighted by cases per year, was used to assess differences between groups. RESULTS Of the 1,791 surgeries performed for adnexal torsion, 542 (30.3%) involved ovarian conservation and 1,249 (69.7%) involved oophorectomy. Older age, higher body mass index, higher American Society of Anesthesiologists classification, anemia, and diagnosis of hypertension were significantly associated with oophorectomy. There was no significant difference in the proportion of oophorectomies performed before 2017 compared with after 2017 (71.9% vs 69.1%, odds ratio [OR] 0.89, 95% CI 0.69-1.16; adjusted OR 0.94, 95% CI 0.71-1.25). A significant decrease in proportion of oophorectomies performed each year was identified over the entire study period (-1.6%/y, P=.02, 95% CI -3.0% to -0.22%); however, the rates did not differ before and after 2017 (interaction P=.16). CONCLUSION There was a modest decrease in the proportion of oophorectomies for adnexal torsion performed per year over the study period. However, oophorectomy is still commonly performed for adnexal torsion, despite updated guidelines from ACOG recommending ovarian conservation.
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Affiliation(s)
- Hannah T Ryles
- Department of Obstetrics and Gynecology and the Division of Urogynecology, Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia; and the Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
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Ginzberg SP, Soegaard Ballester JM, Wirtalla CJ, Morales KH, Pryma DA, Mandel SJ, Kelz RR, Wachtel H. Racial and Ethnic Disparities in Appropriate Thyroid Cancer Treatment, Before and After the Release of the 2015 American Thyroid Association Guidelines. Ann Surg Oncol 2023; 30:2928-2937. [PMID: 36749501 DOI: 10.1245/s10434-023-13158-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/12/2023] [Indexed: 02/08/2023]
Abstract
BACKGROUND The 2015 American Thyroid Association (ATA) guidelines reduced the recommended extent of therapy for low-risk thyroid cancers. Little is known about the impact of these changes on overall treatment patterns and on previously described racial/ethnic disparities in guideline-concordant care. This study aimed to assess trends in thyroid cancer care before and after release of the 2015 guidelines, with particular attention to racial/ethnic disparities. METHODS Patients with well-differentiated thyroid cancer were identified from the National Cancer Database (2010-2018). An interrupted time series design was used to assess trends in treatment before and after the 2015 guidelines. Appropriateness of surgical and radioactive iodine (RAI) treatment was determined based on the ATA guidelines, and the likelihood of receiving guideline-concordant treatment was compared between racial/ethnic groups. RESULTS The study identified 309,367 patients (White 74%, Black 8%, Hispanic 9%, Asian 6%). Between 2010 and 2015, the adjusted probability of appropriate surgery was lower for Black (- 2.1%; p < 0.001), Hispanic (- 1.0%; p < 0.001), and Asian (- 2.1%; p < 0.001) patients than for White patients. After 2015, only Hispanic patients had a lower probability of undergoing appropriate surgical therapy (- 2.6%; p = 0.040). Similarly, between 2010 and 2015, the adjusted probability of receiving appropriate RAI therapy was lower for the Hispanic (- 3.6%; p < 0.001) and Asian (- 2.4%; p < 0.001) patients than for White patients. After 2015, the probability of appropriate RAI therapy did not differ between groups. CONCLUSIONS Between 2010 and 2015, patients from racial/ethnic minority backgrounds were less likely than White patients to receive appropriate surgical and RAI therapy for thyroid cancer. After the 2015 guidelines, racial/ethnic disparities in treatment improved.
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Affiliation(s)
- Sara P Ginzberg
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA.
| | | | | | - Knashawn H Morales
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel A Pryma
- Division of Nuclear Medicine, Department of Radiology, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Susan J Mandel
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Rachel R Kelz
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Heather Wachtel
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
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Brady JT, Bingmer K, Bliggenstorfer J, Xu Z, Fleming FJ, Remzi FH, Monson JRT, Wexner SD, Dietz DW. Could meeting the standards of the National Accreditation Program for Rectal Cancer in the National Cancer Database improve patient outcomes? Colorectal Dis 2023; 25:916-922. [PMID: 36727838 DOI: 10.1111/codi.16503] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 01/13/2023] [Accepted: 01/23/2023] [Indexed: 02/03/2023]
Abstract
AIM The National Accreditation Program for Rectal Cancer (NAPRC) was developed to improve rectal cancer patient outcomes in the United States. The NAPRC consists of a set of process and outcome measures that hospitals must meet in order to be accredited. We aimed to assess the potential of the NAPRC by determining whether achievement of the process measures correlates with improved survival. METHODS The National Cancer Database was used to identify patients undergoing curative proctectomy for non-metastatic rectal cancer from 2010 to 2014. NAPRC process measures identified in the National Cancer Database included clinical staging completion, treatment starting <60 days from diagnosis, carcinoembryonic antigen level measured prior to treatment, tumour regression grading and margin assessment. RESULTS There were 48 669 patients identified with a mean age of 62 ± 12.9 years and 61.3% of patients were men. The process measure completed most often was assessment of proximal and distal margins (98.4%) and the measure completed least often was the serum carcinoembryonic antigen level prior to treatment (63.8%). All six process measures were completed in 23.6% of patients. After controlling for age, gender, comorbidities, annual facility resection volume, race and pathological stage, completion of all process measures was associated with a statistically significant mortality decrease (Cox hazard ratio 0.88, 95% CI 0.81-0.94, P < 0.001). CONCLUSION Participating institutions provided complete datasets for all six process measures in less than a quarter of patients. Compliance with all process measures was associated with a significant mortality reduction. Improved adoption of NAPRC process measures could therefore result in improved survival rates for rectal cancer in the United States.
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Affiliation(s)
- Justin T Brady
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Katherine Bingmer
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | | | - Zhaomin Xu
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Fergal J Fleming
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Feza H Remzi
- Department of Surgery, New York University Langone Medical Center, New York, New York, USA
| | - John R T Monson
- AdventHealth Surgical Health Outcomes Consortium, AdventHealth, Orlando, Florida, USA
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center Cleveland Clinic Florida, Weston, Florida, USA
| | - David W Dietz
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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Weng J, Zhang Y, Liang W, Xie Y, Wang K, Xu Q, Ding Y, Li Y. Downregulation of CEMIP enhances radiosensitivity by promoting DNA damage and apoptosis in colorectal cancer. MEDICAL ONCOLOGY (NORTHWOOD, LONDON, ENGLAND) 2023; 40:73. [PMID: 36607478 DOI: 10.1007/s12032-022-01940-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 12/20/2022] [Indexed: 01/07/2023]
Abstract
Colorectal cancer (CRC) is the third leading malignancy worldwide in both new cases and deaths. Neoadjuvant radiotherapy is the standard preoperative regimens for locally advanced patients. However, approximately 50% of patients develop recurrence and metastasis after radiotherapy, which is largely due to the radiation resistance properties of the tumor, and the internal mechanism has not been elucidated. Here we found that CEMIP expression is up-regulated in a variety of tumor types, particularly in CRC. Public databases and clinical samples revealed that CEMIP expression is significantly higher in tumor tissues than in adjacent normal tissues in patients with locally advanced CRC who received neoadjuvant chemoradiotherapy, and it is closely related to the poor prognosis. Functional characterization uncovered that downregulation of CEMIP expression can enhance the radiosensitivity of CRC cells, which is confirmed to be achieved by promoting DNA damage and apoptosis. In vivo studies further verified that CEMIP knockdown can significantly improve the radiosensitivity of subcutaneously implanted colorectal tumors in mice, suggesting that CEMIP may be a radiation-resistant gene in CRC. Mechanistically, EGFR/PI3K/Akt signaling pathway is hypothesized to play a key role in CEMIP mediating radiation resistance. These results provide a potential new strategy targeting CEMIP gene for the comprehensive treatment of locally advanced CRC patients.
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Affiliation(s)
- Jiawen Weng
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.,The First School of Clinical Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Yuqin Zhang
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Weijie Liang
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Yuwen Xie
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Kai Wang
- Division of Hepatobiliopancreatic Surgery, Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Qian Xu
- The First School of Clinical Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Yi Ding
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
| | - Yiyi Li
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
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Kaslow SR, Correa-Gallego C. ASO Author Reflections: Location, Location, Location? Drivers of Variation in Guideline Adherence in the Treatment of Gastric Cancer. Ann Surg Oncol 2023; 30:309-310. [PMID: 36167939 DOI: 10.1245/s10434-022-12614-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Sarah R Kaslow
- Department of Surgery, New York University Grossman School of Medicine, New York, NY, USA.
| | - Camilo Correa-Gallego
- Department of Surgery, New York University Grossman School of Medicine, New York, NY, USA.,Department of Surgery, Mount Sinai School of Medicine, New York, NY, USA
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Kaslow SR, Hani L, Sacks GD, Lee AY, Berman RS, Correa-Gallego C. Regional Patterns of Hospital-Level Guideline Adherence in Gastric Cancer: An Analysis of the National Cancer Database. Ann Surg Oncol 2023; 30:300-308. [PMID: 36123415 DOI: 10.1245/s10434-022-12549-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 08/17/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Adherence to evidence-based guidelines for gastric cancer is low, particularly at the hospital level, despite a strong association with improved overall survival (OS). We aimed to evaluate patterns of hospital and regional adherence to National Comprehensive Cancer Network guidelines for gastric cancer. METHODS Using the National Cancer Database (2004-2015), we identified patients with stage I-III gastric cancer. Hospital-level guideline adherence was calculated by dividing the patients who received guideline adherent care by the total patients treated at that hospital. OS was estimated for each hospital. Associations between adherence, region, and survival were compared using mixed-effects, hierarchical regression. RESULTS Among 576 hospitals, the median hospital guideline adherence rate was 25% (range 0-76%) and varied significantly by region (p = 0.001). Adherence was highest in the Middle Atlantic (29%) and lowest in the East South Central region (19%); hospitals in the New England, Middle Atlantic, and East North Central regions were more likely to be guideline adherent than those in the East South Central region (all p < 0.05), after adjusting for patient and hospital mix. Most (35%) of the adherence variation was attributable to the hospital. Median 2-year OS varied significantly by region. After adjusting for hospital and patient mix, hazard of mortality was 17% lower in the Middle Atlantic (hazard ratio 0.82, 95% confidence interval 0.74-0.90) relative to the East South Central region, with most of the variation (54%) attributable to patient-level factors. CONCLUSIONS Hospital-level guideline adherence for gastric cancer demonstrated significant regional variation and was associated with longer OS, suggesting that efforts to improve guideline adherence should be directed toward lower-performing hospitals.
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Affiliation(s)
- Sarah R Kaslow
- Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA.
| | - Leena Hani
- Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Greg D Sacks
- Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Ann Y Lee
- Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Russell S Berman
- Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA
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Predictors and Outcomes of Upstaging in Rectal Cancer Patients Who Did Not Receive Preoperative Therapy. Dis Colon Rectum 2023; 66:59-66. [PMID: 35905174 DOI: 10.1097/dcr.0000000000002485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Preoperative chemoradiation is indicated for clinical stage II and III rectal cancers; however, the accuracy of clinical staging with preoperative imaging is imperfect. OBJECTIVE The study aimed to better characterize the incidence and management of clinical and pathologic stage discordances in patients who did not receive preoperative chemoradiation. DESIGN This was a retrospective cohort analysis. SETTINGS The source of data was the National Cancer Database from 2006 to 2015. PATIENTS We identified patients who underwent resection with curative intent for clinical stage I rectal adenocarcinoma without preoperative chemotherapy or radiation. MAIN OUTCOME MEASURES We evaluated the characteristics of "upstaged" patients-those with T3/T4 tumors found on pathology (pathologic stage II) and/or with positive regional nodes in the resection specimen (pathologic stage III) compared with those patients who were not upstaged (pathologic stage I). We then used a mixed-effects multivariable survival model to compare overall survival between these groups. RESULTS Among 7818 clinical stage I rectal cancer patients who did not receive preoperative therapy, tumor upstaging occurred in 819 (10.6%) and nodal upstaging occurred in 1612 (20.8%). Upstaged patients were more likely than those not upstaged to have higher grade tumors and positive margins. Survival was worse in upstaged patients (hazard ratio [HR], 1.64; 95% CI, 1.4-1.9) but improved among those upstaged patients who received either chemotherapy (HR, 0.71; 95% CI, 0.6-0.9) or chemoradiation (HR, 0.62; 95% CI, 0.5-0.7). LIMITATIONS In addition to the inherent limitations of a retrospective cohort study, the National Cancer Database does not record functional outcomes, local recurrence, or disease-specific survival, so we are restricted to the evaluation of overall survival as an oncologic outcome. CONCLUSIONS Inaccurate preoperative staging remains a common clinical challenge in the management of rectal cancer. Survival among upstaged patients is improved among those who receive recommended postoperative chemotherapy and/or chemoradiation, yet many patients do not receive guideline-concordant care. See Video Abstract at https://links.lww.com/DCR/B999 . PREDICTORES Y RESULTADOS DE SOBRE ESTADIFICACIN EN PACIENTES CON CNCER DE RECTO QUE NO RECIBIERON TERAPIA PREOPERATORIA ANTECEDENTES:La quimio radiación preoperatoria está indicada para los estadios clínicos II y III del cáncer rectal; sin embargo, la precisión de la estadificación clínica con imágenes preoperatorias es imperfecta.OBJETIVO:El objetivo fue mejorar la caracterización de la incidencia y el manejo de la discordancia del estadio clínico y patológico en pacientes que no recibieron quimio radiación preoperatoria.DISEÑO:Este fue un análisis de cohorte retrospectivo.CONFIGURACIÓN:La fuente de datos fue de la Base de datos Nacional del Cáncer entre los años 2006-2015.PACIENTES:Identificamos pacientes que fueron sometidos a resección con intención curativa por adenocarcinoma rectal en estadio clínico I, sin quimioterapia o radiación preoperatoria.PRINCIPALES MEDIDAS DE RESULTADO:Evaluamos las características de los pacientes "sobre estadificados": aquellos con tumores T3/T4 encontrados en patología (estadio patológico II) y/o con ganglios regionales positivos en la muestra de resección (estadio patológico III), en comparación con aquellos pacientes que no fueron sobre estadificados (estadio patológico I). Luego usamos un modelo de supervivencia multivariable de efectos mixtos para comparar la supervivencia general entre estos grupos.RESULTADOS:De entre 7818 pacientes con cáncer de recto, en estadio clínico I, y que no recibieron tratamiento preoperatorio, se produjo una sobre estadificación tumoral en 819 (10,6%) y una sobre estadificación ganglionar en 1612 (20,8%). Los pacientes sobre estadificados tenían más probabilidades que los no sobre estadificados de tener tumores de mayor grado y márgenes positivos. La supervivencia fue peor en los pacientes sobre estadificados (HR 1,64, IC del 95% [1,4, 1,9]), pero mejoró entre los pacientes sobre estadificados que recibieron quimioterapia (HR 0,71, IC del 95% [0,6, 0,9]) o quimio radiación (HR 0,62, 95% IC [0,5, 0,7]).LIMITACIONES:Además de las limitaciones inherente a un estudio de cohorte de tipo retrospectivo, la Base de datos Nacional del Cáncer no registra resultados funcionales, la recurrencia local o la supervivencia específica de la enfermedad, por lo que estamos restringidos a la evaluación de la supervivencia general como un resultado oncológico.CONCLUSIONES:La estadificación preoperatoria inexacta sigue siendo un desafío clínico común en el tratamiento del cáncer de recto. La supervivencia entre los pacientes con sobre estadificación mejora en aquellos que reciben la quimioterapia y/o quimio radioterapia postoperatoria recomendada, aunque muchos pacientes no reciben atención acorde con las guías. Consulte Video Resumen en http://links.lww.com/DCR/B999 . (Traducción-Dr. Osvaldo Gauto ).
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Lee KC, Zhao B, Pianka K, Liu S, Eisenstein S, Ramamoorthy S, Lopez NE. Current trends in nonoperative management for rectal adenocarcinoma: An unequal playing field? J Surg Oncol 2022; 126:1504-1511. [PMID: 36056914 DOI: 10.1002/jso.27082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 07/28/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES Increasing evidence suggests patient-oriented benefits of nonoperative management (NOM) for rectal cancer. However, vigilant surveillance requires excellent access to care. We sought to examine patient, socioeconomic, and facility-level factors associated with NOM over time. METHODS Using the National Cancer Database (2006-2017), we examined patients with Stage II-III rectal adenocarcinoma, who received neoadjuvant chemoradiation and received NOM versus surgery. Factors associated with NOM were assessed using multivariable logistic regression with backward stepwise selection. RESULTS There were 59,196 surgical and 8520 NOM patients identified. NOM use increased from 12.9% to 15.9% between 2006 and 2017. Patients who were Black (adjusted odds ratio [aOR]: 1.36, 95% confidence interval [CI]: 1.26-1.47), treated at community cancer centers (aOR: 1.22, 95% CI: 1.12-1.30), without insurance (aOR: 1.87, 95% CI: 1.68-2.09), and with less education (aOR: 1.53, 95% CI: 1.42-1.65) exhibited higher odds of NOM. Patients treated at high-volume centers (aOR: 0.79, 95% CI: 0.74-0.84) and those who traveled >25.6 miles for care (aOR: 0.59, 95% CI: 0.55-0.64) had lower odds of NOM. CONCLUSIONS Vulnerable groups who traditionally have difficulty accessing comprehensive cancer care were more likely to receive NOM, suggesting that healthcare disparities may be driving utilization. More research is needed to understand NOM decision-making in rectal cancer treatment.
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Affiliation(s)
- Katherine C Lee
- Department of Surgery, University of California, San Diego, La Jolla, California, USA
| | - Beiqun Zhao
- Department of Surgery, University of California, San Diego, La Jolla, California, USA
| | - Kurt Pianka
- Department of Surgery, University of California, San Diego, La Jolla, California, USA
| | - Shanglei Liu
- Department of Surgery, University of California, San Diego, La Jolla, California, USA
| | - Samuel Eisenstein
- Department of Surgery, University of California, San Diego, La Jolla, California, USA
| | - Sonia Ramamoorthy
- Department of Surgery, University of California, San Diego, La Jolla, California, USA
| | - Nicole E Lopez
- Department of Surgery, University of California, San Diego, La Jolla, California, USA
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Fujiwara T, Ogura K, Alaqeel M, Healey JH. Geographic Access to High-Volume Care Providers and Survival in Patients with Bone Sarcomas: Nationwide Patterns in the United States. J Bone Joint Surg Am 2022; 104:1426-1437. [PMID: 35730765 PMCID: PMC10855024 DOI: 10.2106/jbjs.21.01140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Clinical practice guidelines recommend centralized care for patients with bone sarcoma. However, the relationship between the distance that patients travel to obtain care, institutional treatment volume, and survival is unknown. METHODS We used the National Cancer Database to examine associations between travel distance and survival among 8,432 patients with bone sarcoma diagnosed from 2004 to 2015. Associations were identified using multivariable Cox regression analyses that controlled for sociodemographic, clinical, and hospital-level factors; subgroup analyses stratified patients by histological diagnosis, tumor stage, and pediatric or adult status. RESULTS Mortality risk was lower among patients who traveled ≥50 miles (≥80.5 km) than among patients who traveled ≤10 miles (≤16.1 km) (hazard ratio [HR], 0.69 [95% confidence interval (CI), 0.63 to 0.76]). Among hospital-level factors, facility volume independently affected survival: mortality risk was lower among patients at high-volume facilities (≥20 cases per year) than at low-volume facilities (≤5 cases per year), with an HR of 0.72 (95% CI, 0.66 to 0.80). The proportion of patients who received care at high-volume facilities varied by distance traveled (p < 0.001); it was highest among patients who traveled ≥50 miles (53%) and lower among those who traveled 11 to 49 miles (17.7 to 78.9 km) (32%) or ≤10 miles (18%). Patients who traveled ≥50 miles to a high-volume facility had a lower risk of mortality (HR, 0.65 [95% CI, 0.56 to 0.77]) than those who traveled ≤10 miles to a low-volume facility. In subgroup analyses, this association was evident among patients with all 3 major histological subtypes; those with stage-I, II, and IV tumors; and adults. CONCLUSIONS This national study showed that greater travel burden was associated with higher survival rates in adults, a finding attributable to patients traveling to receive care at high-volume facilities. Despite the burdens associated with travel, modification of referral pathways to specialized centers may improve survival for patients with bone sarcoma. LEVEL OF EVIDENCE Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Tomohiro Fujiwara
- Orthopaedic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Koichi Ogura
- Orthopaedic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Motaz Alaqeel
- Orthopaedic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - John H Healey
- Orthopaedic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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Impact of Care Coordination on the Content of Communication Between Surgeons and Patients With Rectal Cancer. ANNALS OF SURGERY OPEN 2022; 3:e177. [PMID: 36199484 PMCID: PMC9508969 DOI: 10.1097/as9.0000000000000177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 06/04/2022] [Indexed: 11/25/2022] Open
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Naffouje SA, Ali MA, Kamarajah SK, White B, Salti GI, Dahdaleh F. Assessment of Textbook Oncologic Outcomes Following Proctectomy for Rectal Cancer. J Gastrointest Surg 2022; 26:1286-1297. [PMID: 35441331 DOI: 10.1007/s11605-021-05213-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 11/20/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Outcomes of rectal adenocarcinoma vary considerably. Composite "textbook oncologic outcome" (TOO) is a single metric that estimates optimal clinical performance for cancer surgery. METHODS Patients with stage II/III rectal adenocarcinoma who underwent single-agent neoadjuvant chemoradiation and proctectomy within 5-12 weeks were identified in the National Cancer Database (NCDB). TOO was defined as achievement of negative distal and circumferential resection margin (CRM), retrieval of ≥ 12 nodes, no 90-day mortality, and length of stay (LOS) < 75th percentile of corresponding year's range. Multivariable logistic regression was used to identify predictors of TOO. RESULTS Among 318,225 patients, 8869 met selection criteria. Median age was 62 years (IQR 54-71), and 5550 (62.6%) were males. Low anterior resection was the most common procedure (LAR, 6,037 (68.1%) and 3084 (34.8%) were treated at a high-volume center (≥ 20 rectal resections/year). TOO was achieved in 3967 patients (44.7%). Several components of TOO were achieved commonly, including negative CRM (87.4%), no 90-day mortality (98.0%), no readmission (93.0%), and no prolonged hospitalization (78.8%). Logistic regression identified increasing age, non-private insurance, low-volume centers, open approach, Black race, Charlson score ≥ 3, and abdominoperineal resection (APR) as predictors of failure to achieve TOO. Over time, TOOs were attained more commonly which correlated with increased minimally invasive surgery (MIS) adoption. TOO achievement was associated with improved survival. CONCLUSIONS Rectal adenocarcinoma patients achieve TOO uncommonly. Treatment at high-volume centers and MIS approach were among modifiable factors associated with TOO in this study.
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Affiliation(s)
- Samer A Naffouje
- Department of Surgical Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Muhammed A Ali
- Department of Surgery, Queen Elizabeth Hospital Birmingham, University Hospital Birmingham NHS Trust, Birmingham, UK
| | - Sivesh K Kamarajah
- Department of Surgery, Queen Elizabeth Hospital Birmingham, University Hospital Birmingham NHS Trust, Birmingham, UK
| | - Bradley White
- Department of General Surgery, University of Illinois Hospital and Health Sciences System, Chicago, IL, USA
| | - George I Salti
- Department of General Surgery, University of Illinois Hospital and Health Sciences System, Chicago, IL, USA.,Department of Surgical Oncology, Edward-Elmhurst Health, 120 Spalding Drive, Ste 205, Naperville, IL, 60540, USA
| | - Fadi Dahdaleh
- Department of Surgical Oncology, Edward-Elmhurst Health, 120 Spalding Drive, Ste 205, Naperville, IL, 60540, USA.
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Wolford D, Westcott L, Fleshman J. Specialization improves outcomes in rectal cancer surgery. Surg Oncol 2022; 43:101740. [DOI: 10.1016/j.suronc.2022.101740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 02/20/2022] [Indexed: 11/26/2022]
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Peng T, Hamann HA, David EA. Stigma May Exacerbate Disproportionately Low Guideline-Concordant Treatment Rates for Patients with Advanced Stage Lung Cancer in the United States. JTO Clin Res Rep 2022; 3:100302. [PMID: 35400082 PMCID: PMC8983342 DOI: 10.1016/j.jtocrr.2022.100302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 02/21/2022] [Accepted: 02/22/2022] [Indexed: 11/28/2022] Open
Affiliation(s)
- Terrance Peng
- Division of Thoracic Surgery, Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Heidi A. Hamann
- Department of Psychology, University of Arizona, Tucson, Arizona
- Department of Family & Community Medicine, University of Arizona, Tucson, Arizona
| | - Elizabeth A. David
- Division of Thoracic Surgery, Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California
- Corresponding author. Address for correspondence: Elizabeth A. David, MD, MAS, Division of Thoracic Surgery, Department of Surgery, University of Southern California, 1510 San Pablo Street, HCC1 Suite 514, Los Angeles, CA 90033-4612.
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Improving Outcomes of and Access to Evidence-Based Rectal Cancer Care. J Am Coll Surg 2022; 234:63-64. [PMID: 35213461 DOI: 10.1097/xcs.0000000000000038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hendren S, Kanters AE, Morris AM, Abdelsattar ZM, Berry RR, Resnicow K, Birkmeyer NJ. Barriers to high-quality rectal cancer care: A qualitative study. Am J Surg 2022; 224:483-488. [DOI: 10.1016/j.amjsurg.2022.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/27/2021] [Accepted: 01/19/2022] [Indexed: 11/25/2022]
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Disparities in rectal cancer care: A call to action for all. Am J Surg 2021; 223:846-847. [PMID: 34801226 DOI: 10.1016/j.amjsurg.2021.11.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 11/14/2021] [Indexed: 11/20/2022]
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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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Simon HL, de Paula TR, Profeta da Luz MM, Kiran RP, Keller DS. Predictors of Positive Circumferential Resection Margin in Rectal Cancer: A Current Audit of the National Cancer Database. Dis Colon Rectum 2021; 64:1096-1105. [PMID: 33951688 DOI: 10.1097/dcr.0000000000002115] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Positive circumferential resection margin is a predictor of local recurrence and worse survival in rectal cancer. National programs aimed to improve rectal cancer outcomes were first created in 2011 and continue to evolve. The impact on circumferential resection margin during this time frame has not been fully evaluated in the United States. OBJECTIVE The purpose of this study was to determine the incidence and predictors of positive circumferential resection margin after rectal cancer resection, across patient, provider, and tumor characteristics. DESIGN This was a retrospective cohort study. SETTINGS The study was conducted using the National Cancer Database, 2011-2016. PATIENTS Adults who underwent proctectomy for pathologic stage I to III rectal adenocarcinoma were included. MAIN OUTCOME MEASURES Rate and predictors of positive circumferential resection margin, defined as resection margin ≤1 mm, were measured. RESULTS Of 52,620 cases, circumferential resection margin status was reported in 90% (n = 47,331) and positive in 18.4% (n = 8719). Unadjusted analysis showed that patients with positive circumferential resection margin were more often men, had public insurance and shorter travel, underwent total proctectomy via open and robotic approaches, and were treated in Southern and Western regions at integrated cancer networks (all p < 0.001). Multivariate analysis noted that positive proximal and/or distal margin on resected specimen had the strongest association with positive circumferential resection margin (OR = 15.6 (95% CI, 13.6-18.1); p < 0.001). Perineural invasion, total proctectomy, robotic approach, neoadjuvant chemoradiation, integrated cancer network, advanced tumor size and grade, and Black race had increased risk of positive circumferential resection margin (all p < 0.050). Laparoscopic approach, surgery in North, South, and Midwest regions, greater hospital volume and travel distance, lower T-stage, and higher income were associated with decreased risk (all p < 0.028). LIMITATIONS This was a retrospective cohort study with limited variables available for analysis. CONCLUSIONS Despite creation of national initiatives, positive circumferential resection margin rate remains an alarming 18.4%. The persistently high rate with predictors of positive circumferential resection margin identified calls for additional education, targeted quality improvement assessments, and publicized auditing to improve rectal cancer care in the United States. See Video Abstract at http://links.lww.com/DCR/B584. PREDICTORES PARA UN MARGEN POSITIVO DE RESECCIN CIRCUNFERENCIAL EN EL CNCER DE RECTO UNA AUDITORA VIGENTE DE LA BASE DE DATOS NACIONAL DE CANCER ANTECEDENTES:El margen positivo de resección circunferencial es un predictor de recurrencia local y peor sobrevida en el cáncer de recto. Los programas nacionales destinados a mejorar los resultados del cáncer de recto se crearon por primera vez en 2011 y continúan evolucionando. La repercusión del margen de resección circunferencial durante este período de tiempo no se ha evaluado completamente en los Estados Unidos.OBJETIVO:Determinar la incidencia y los predictores para un margen positivo de resección circunferencial posterior a la resección del cáncer de recto, según las características del paciente, el proveedor y el tumor.DISEÑO:Estudio de cohorte retrospectivo.AMBITO:Base de datos nacional de cáncer, 2011-2016.PACIENTES:Adultos que se sometieron a proctectomía por adenocarcinoma de recto con un estadío por patología I-III.PRINCIPALES VARIABLES EVALUADAS:Tasa y predictores para un margen positivo de resección circunferencial, definido como margen de resección ≤ 1 mm.RESULTADOS:De 52,620 casos, la condición del margen de resección circunferencial se informó en el 90% (n = 47,331) y positivo en el 18.4% (n = 8,719). El análisis no ajustado mostró que los pacientes con margen positivo de resección circunferencial se presentó con mayor frecuencia en hombres, tenían un seguro social y viajes más cortos, se operaron de proctectomía total abierta y robótica, y fueron tratados en las regiones del sur y el oeste en redes integradas de cáncer (todos p <0,001). El análisis multivariado destacó que el margen proximal y / o distal positivo de la pieza resecada tenía la asociación más fuerte con el margen postivo de resección circunferencial (OR 15,6; IC del 95%: 13,6-18,1, p <0,001). La invasión perineural, la proctectomía total, el abordaje robótico, la quimioradioterapia neoadyuvante, la red de cáncer integrada, el tamaño y grado del tumor avanzado y la raza afroamericana tenían un mayor riesgo de un margen de una resección positiva circunferencial (todos p <0,050). El abordaje laparoscópico, la cirugía en las regiones Norte, Sur y Medio Oeste, un mayor volumen hospitalario y distancia de viaje, estadio T más bajo y mayores ingresos se asociaron con una disminución del riesgo (todos p <0,028).LIMITACIONES:Estudio de cohorte retrospectivo con variables limitadas disponibles para análisis.CONCLUSIONES:A pesar del establecimiento de iniciativas nacionales, la tasa de margen positivo de resección circunferencial continúa siendo alarmante, 18,4%. El índice continuamente elevado junto a los predictores de un margen positivo de resección circunferencial hace un llamado para una mayor educación, evaluaciones específicas de mejora de la calidad y difusión de las auditorías para mejorar la atención del cáncer de recto en los Estados Unidos. Vea el resumen de video en http://links.lww.com/DCR/B584. Consulte Video Resumen en http://links.lww.com/DCR/B584.
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Affiliation(s)
- Hillary L Simon
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Thais Reif de Paula
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Magda M Profeta da Luz
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Ravi P Kiran
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, New York
| | - Deborah S Keller
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, New York
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Ridgeway JL, Boardman LA, Griffin JM, Beebe TJ. Tracing the potential of networks to improve community cancer care: an in-depth single case study. Implement Sci Commun 2021; 2:92. [PMID: 34433489 PMCID: PMC8390226 DOI: 10.1186/s43058-021-00190-1] [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: 11/02/2020] [Accepted: 07/25/2021] [Indexed: 11/11/2022] Open
Abstract
Background Despite overall declines in cancer mortality in the USA over the past three decades, many patients in community settings fail to receive evidence-based cancer care. Networks that link academic medical centers (AMCs) and community providers may reduce disparities by creating access to specialized expertise and care, but research on network effectiveness is mixed. The objective of this study was to identify factors related to whether and how an exemplar AMC network served to provide advice and referral access in community settings. Methods An embedded in–depth single case study design was employed to study a network in the Midwest USA that connects a leading cancer specialty AMC with community practices. The embedded case units were a subset of 20 patients with young-onset colorectal cancer or risk-related conditions and the providers involved in their care. The electronic health record (EHR) was reviewed from January 1, 1990, to February 28, 2018. Social network analysis identified care, advice, and referral relationships. Within-case process tracing provided detailed accounts of whether and how the network provided access to expert, evidence-based care or advice in order to identify factors related to network effectiveness. Results The network created access to evidence-based advice or care in some but not all case units, and there was variability in whether and how community providers engaged the network, including the path for referrals to the AMC and the way in which advice about an evidence-based approach to care was communicated from AMC specialists to community providers. Factors related to instances when the network functioned as intended included opportunities for both rich and lean communication between community providers and specialists, coordinated referrals, and efficient and adequately utilized documentation systems. Conclusions Network existence alone is insufficient to open up access to evidence-based expertise or care for patients in community settings. In-depth understanding of how this network operated provides insight into factors that support or inhibit the potential of networks to minimize disparities in access to evidence-based community cancer care, including both personal and organizational factors.
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Affiliation(s)
- Jennifer L Ridgeway
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, 55905, USA.
| | - Lisa A Boardman
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Joan M Griffin
- Division of Health Care Delivery Research and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, 55905, USA
| | - Timothy J Beebe
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, 55455, USA
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Racial Disparities in Treatment for Rectal Cancer at Minority-Serving Hospitals. J Gastrointest Surg 2021; 25:1847-1856. [PMID: 32725520 DOI: 10.1007/s11605-020-04744-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 07/14/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Racial disparities exist in patients with rectal cancer with respect to both treatment and survival. Minority-serving hospitals (MSHs) provide healthcare to a disproportionately large percent of minority patients in the USA. We examined the effects of rectal cancer treatment at MSH to understand drivers of these disparities. METHODS The NCDB was queried (2004-2015), and patients diagnosed with stage II or III rectal adenocarcinoma were identified. Racial case mix distribution was calculated at the institutional level, and MSHs were defined as those within the top decile of Black and Hispanic patients. Logistic regression was used to identify predictors of receipt of standard of care treatment. Survival was assessed using the Kaplan-Meier method, and Cox proportional hazards models were used to evaluate adjusted risk of death. Analyses were clustered by facility. RESULTS A total of 68,842 patients met the inclusion criteria. Of these patients, 63,242 (91.9%) were treated at non-MSH, and 5600 (8.1%) were treated at MSH. In multivariable analysis, treatment at MSH (OR 0.70 95%CI 0.61-0.80 p < 0.001) and Black race (OR 0.75 95%CI 0.70-0.81 p < 0.001) were associated with significantly lower odds of receiving standard of care. In adjusted analysis, Black patients had a significantly higher risk of mortality (HR 1.20 95%CI 1.14-1.26 p < 0.001). CONCLUSIONS Treatment at MSH institutions and Black race were associated with significantly decreased odds of receipt of recommended standard therapy for locally advanced rectal adenocarcinoma. Survival was worse for Black patients compared to White patients despite adjustment for receipt of standard of care.
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Lau LW, Kethman WC, Bingmer KE, Ofshteyn A, Steinhagen E, Charles R, Dietz D, Stein SL. Evaluating disparities in delivery of neoadjuvant guideline-based chemoradiation for rectal cancer: A multicenter, propensity score-weighted cohort study. J Surg Oncol 2021; 124:810-817. [PMID: 34159619 DOI: 10.1002/jso.26572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 05/26/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Despite guideline recommendations, some patients still receive care inappropriate for their clinical stage of disease. Identification of factors that contribute to variation in guideline base care may help eradicate disparities in the treatment of early and locally advanced rectal cancer. METHODS The American College of Surgeons National Cancer Database from 2010 to 2015 was analyzed with propensity score weighting to identify factors associated with delivery and omission of neoadjuvant guideline-based chemoradiation (GBC) for those with early and locally advanced rectal cancer. RESULTS Only 74% of patients with rectal cancer received stage-appropriate neoadjuvant chemoradiation; 4544 (88%) of those with early stage disease and 8675 (68%) in locally advanced disease. Chemotherapy and radiotherapy were not planned in 27% and 34% respectively, of those who did not receive GBC. Factors associated with receipt of non-guideline-based neoadjuvant chemoradiation were age >65 years, Medicare insurance, treatment at a community facility, West-South-Central geography, having locally advanced disease, and Charlson-Deyo score >3. Receipt of ideal guideline-based neoadjuvant chemoradiation conferred a survival benefit at 5 years. CONCLUSION Patient and non-patient factors contribute to disparities in guideline-based delivery of neoadjuvant chemoradiation in the treatment of rectal cancer. Identification of these risk factors are important to help standardize care and improve survival outcomes.
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Affiliation(s)
- Lung W Lau
- UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - William C Kethman
- UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Katherine E Bingmer
- UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Asya Ofshteyn
- UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Emily Steinhagen
- UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Ronald Charles
- UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - David Dietz
- UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Sharon L Stein
- UH RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Division of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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Fujiwara T, Ogura K, Healey J. Greater travel distance to specialized facilities is associated with higher survival for patients with soft-tissue sarcoma: US nationwide patterns. PLoS One 2021; 16:e0252381. [PMID: 34086725 PMCID: PMC8177553 DOI: 10.1371/journal.pone.0252381] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 05/15/2021] [Indexed: 12/03/2022] Open
Abstract
Purpose The survival impact of geographic access to specialized care remains unknown in patients with soft-tissue sarcomas (STS). This study aimed to clarify the association between the patient travel distance and survival outcome and investigate the factors lying behind it. Methods A total of 34 528 patients with STS registered in the National Cancer Data Base, diagnosed from 2004–2016, were investigated. Results Tumor stage correlated with travel distance: patients with metastatic disease stayed closer to home. However, the type of facility showed greatest variation: 37.0%, 51.0%, 73.5%, and 75.9% of patients with ≤10 miles, 10.1–50 miles, 50.1–100 miles, and >100 miles, respectively (P<0.001), had a sarcoma care at academic/research centers. On a multivariable analysis, reduced mortality risk was associated with longer (versus short) travel distance (>100 miles: HR = 0.877; P = 0.001) and management at academic/research (versus non-academic/research) centers (HR = 0.857; P<0.001). The greatest divergence was seen in patients traveling very long distance (>100 miles) to an academic/research center, with a 26.9% survival benefit (HR = 0.731; P<0.001), compared with those traveling short distance (≤10 miles; 95.4% living in metropolitan area) to a non-academic/research center. There was no significant correlation between travel distance and survival in patients who had care at academic/research centers, whereas a survival benefit of management at academic/research centers was observed in every group of travel distance, regardless of tumor stage. Conclusions This national study demonstrated that increased travel distance was associated with superior survival, attributable to a higher proportion of patients receiving sarcoma care at distant academic/research centers. These data support centralized care for STS. Overcoming referral and travel barriers may enable more patients to be treated at specialized centers and may further improve survival rates for patients with STS, even when it imposes an increased travel burden.
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Affiliation(s)
- Tomohiro Fujiwara
- Department of Surgery, Orthopaedic Service, Memorial Sloan Kettering Cancer Center, New York, New York, United States of America
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Koichi Ogura
- Department of Surgery, Orthopaedic Service, Memorial Sloan Kettering Cancer Center, New York, New York, United States of America
| | - John Healey
- Department of Surgery, Orthopaedic Service, Memorial Sloan Kettering Cancer Center, New York, New York, United States of America
- * E-mail:
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Pooni A, Schmocker S, Brown C, MacLean A, Hochman D, Williams L, Baxter N, Simunovic M, Liberman S, Drolet S, Neumann K, Jhaveri K, Kirsch R, Kennedy ED. Quality indicator selection for the Canadian Partnership against Cancer rectal cancer project: A modified Delphi study. Colorectal Dis 2021; 23:1393-1403. [PMID: 33626193 DOI: 10.1111/codi.15599] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 12/17/2022]
Abstract
AIM It is well established that (i) magnetic resonance imaging, (ii) multidisciplinary cancer conference (MCCs), (iii) preoperative radiotherapy, (iv) total mesorectal excision surgery and (v) pathological assessment as described by Quirke are key processes necessary for high quality, rectal cancer care. The objective was to select a set of multidisciplinary quality indicators to measure the uptake of these clinical processes in clinical practice. METHOD A multidisciplinary panel was convened and a modified two-phase Delphi method was used to select a set of quality indicators. Phase 1 included a literature review with written feedback from the panel. Phase 2 included an in-person workshop with anonymous voting. The selection criteria for the indicators were strength of evidence, ease of capture and usability. Indicators for which ≥90% of the panel members voted 'to keep' were selected as the final set of indicators. RESULTS During phase 1, 68 potential indicators were generated from the literature and an additional four indicators were recommended by the panel. During phase 2, these 72 indicators were discussed; 48 indicators met the 90% inclusion threshold and included eight pathology, five radiology, 11 surgical, six radiation oncology and 18 MCC indicators. CONCLUSION A modified Delphi method was used to select 48 multidisciplinary quality indicators to specifically measure the uptake of key processes necessary for high quality care of patients with rectal cancer. These quality indicators will be used in future work to identify and address gaps in care in the uptake of these clinical processes.
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Affiliation(s)
- Amandeep Pooni
- Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada.,Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, ON, Canada
| | - Selina Schmocker
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, ON, Canada
| | - Carl Brown
- Department of Colorectal Surgery, St Paul's Hospital, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Anthony MacLean
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - David Hochman
- Department of Surgery, University of Manitoba, Winnipeg, MB, Canada
| | - Lara Williams
- Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Nancy Baxter
- University of Toronto, Toronto, ON, Canada.,Department of Surgery, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Marko Simunovic
- Department of Surgery, St Joseph's Healthcare, McMaster University, Hamilton, ON, Canada
| | - Sender Liberman
- Department of Surgery, McGill University, Montreal, QC, Canada
| | - Sébastien Drolet
- Department of Surgery, Université Laval, Quebec City, QC, Canada
| | - Katerina Neumann
- Department of Surgery, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | - Kartik Jhaveri
- University of Toronto, Toronto, ON, Canada.,Joint Department of Medical Imaging, Mount Sinai Hospital and Women's College Hospital, University Health Network, Toronto, ON, Canada
| | - Richard Kirsch
- University of Toronto, Toronto, ON, Canada.,Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Toronto, ON, Canada
| | - Erin D Kennedy
- Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada.,Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, ON, Canada
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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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43
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Abelson JS, Barron J, Bauer PS, Chapman WC, Schad C, Ohman K, Glasgow S, Hunt S, Mutch M, Smith RK, Wise PE, Silviera M. Travel Time to a High Volume Center Negatively Impacts Timing of Care in Rectal Cancer. J Surg Res 2021; 266:96-103. [PMID: 33989893 DOI: 10.1016/j.jss.2021.02.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 01/16/2021] [Accepted: 02/27/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Regionalization of rectal cancer surgery may lead to worse disease free survival owing to longer travel time to reach a high volume center yet no study has evaluated this relationship at a single high volume center volume center. MATERIALS AND METHODS This was a retrospective review of rectal cancer patients undergoing surgery from 2009 to 2019 at a single high volume center. Patients were divided into two groups based on travel time. The primary outcome was disease-free survival (DFS). Additional outcomes included treatment within 60 d of diagnosis, completeness of preoperative staging, and evaluation by a colorectal surgeon prior to initiation of treatment. RESULTS A lower proportion of patients with long travel time began definitive treatment within 60 d of diagnosis (74.0% versus 84.0%, P= 0.01) or were seen by the treating colorectal surgeon before beginning definitive treatment (74.8% versus 85.4%, P < 0.01). On multivariable logistic regression analysis, patients with long travel time were significantly less likely to begin definitive treatment within 60 d of diagnosis (OR = 0.54; 95% CI = 0.31-0.93) or to be evaluated by a colorectal surgeon prior to initiating treatment (OR = 0.45; 95% CI = 0.25-0.80). There were no significant differences in DFS based on travel time. CONCLUSIONS Although patients with long travel times may be vulnerable to delayed, lower quality rectal cancer care, there is no difference in DFS when definitive surgery is performed at a high volume canter. Ongoing research is needed to identify explanations for delays in treatment to ensure all patients receive the highest quality care.
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Affiliation(s)
- Jonathan S Abelson
- Division of Colon and Rectal Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts.
| | - John Barron
- Saint Louis University School of Medicine, Saint Louis, Missouri
| | - Philip S Bauer
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - William C Chapman
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Christine Schad
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Kerri Ohman
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Sean Glasgow
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Steven Hunt
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Matthew Mutch
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Radhika K Smith
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Paul E Wise
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Matthew Silviera
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, Missouri
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Cheraghlou S, Christensen SR, Leffell DJ, Girardi M. Association of Treatment Facility Characteristics With Overall Survival After Mohs Micrographic Surgery for T1a-T2a Invasive Melanoma. JAMA Dermatol 2021; 157:531-539. [PMID: 33787836 PMCID: PMC8014201 DOI: 10.1001/jamadermatol.2021.0023] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 01/14/2021] [Indexed: 12/15/2022]
Abstract
Importance Early-stage melanoma, among the most common cancers in the US, is typically treated with wide local excision. However, recent advances in immunohistochemistry have led to an increasing number of these cases being excised via Mohs micrographic surgery (MMS). Although studies of resections for other cancers have reported that facility-level factors are associated with patient outcomes, it is not yet established how these factors may affect outcomes for patients treated with Mohs micrographic surgery. Objective To evaluate the association of treatment center academic affiliation and case volume with long-term patient survival after MMS for T1a-T2a invasive melanoma. Design, Setting, and Participants In a retrospective cohort study, 4062 adults with nonmetastatic, T1a-T2a melanoma diagnosed from 2004 to 2014 and treated with MMS in the National Cancer Database (NCDB) were identified. The NCDB includes all reportable cases from Commission on Cancer-accredited facilities and is estimated to capture approximately 50% of all incident melanomas in the US. Multivariable survival analyses were conducted using Cox proportional hazards models. Data analysis was conducted from February 27 to August 18, 2020. Exposures Treatment facility characteristics. Main Outcomes and Measures Overall survival. Results The study population included 4062 patients (2213 [54.5%] men; median [SD] age, 60 [16.3] years) treated at 462 centers. Sixty-two centers were top decile-volume facilities (TDVFs), which treated 1757 patients (61.9%). Most TDVFs were academic institutions (37 of 62 [59.7%]). On multivariable analysis, treatment at an academic center was associated with a nearly 30% reduction in hazard of death (hazard ratio, 0.730; 95% CI, 0.596-0.895). In a separate analysis, treatment at TDVFs was also associated with improved survival (hazard ratio, 0.795; 95% CI, 0.648-0.977). Conclusions and Relevance In this cohort study, treatment of patients with T1a-T2a invasive melanoma excised with MMS at academic and top decile-volume (≥8 cases per year) facilities was associated with improved long-term survival compared with those excised by MMS at nonacademic and low-volume facilities. Identification and protocolization of the practices of these facilities may help to reduce survival differences between centers.
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Affiliation(s)
- Shayan Cheraghlou
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | | | - David J. Leffell
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Michael Girardi
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
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45
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Stringfield SB, Fleshman JW. Specialization improves outcomes in rectal cancer surgery. Surg Oncol 2021; 37:101568. [PMID: 33848763 DOI: 10.1016/j.suronc.2021.101568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/24/2021] [Accepted: 03/28/2021] [Indexed: 01/23/2023]
Affiliation(s)
- Sarah B Stringfield
- Baylor University Medical Center, Department of Surgery, 3500 Gaston Ave, Dallas, TX, 75246, USA.
| | - James W Fleshman
- Baylor University Medical Center, Department of Surgery, 3500 Gaston Ave, Dallas, TX, 75246, USA
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46
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Curtis NJ, Foster JD, Miskovic D, Brown CSB, Hewett PJ, Abbott S, Hanna GB, Stevenson ARL, Francis NK. Association of Surgical Skill Assessment With Clinical Outcomes in Cancer Surgery. JAMA Surg 2021; 155:590-598. [PMID: 32374371 DOI: 10.1001/jamasurg.2020.1004] [Citation(s) in RCA: 92] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Importance Complex surgical interventions are inherently prone to variation yet they are not objectively measured. The reasons for outcome differences following cancer surgery are unclear. Objective To quantify surgical skill within advanced laparoscopic procedures and its association with histopathological and clinical outcomes. Design, Setting, and Participants This analysis of data and video from the Australasian Laparoscopic Cancer of Rectum (ALaCaRT) and 2-dimensional/3-dimensional (2D3D) multicenter randomized laparoscopic total mesorectal excision trials, which were conducted at 28 centers in Australia, the United Kingdom, and New Zealand, was performed from 2018 to 2019 and included 176 patients with clinical T1 to T3 rectal adenocarcinoma 15 cm or less from the anal verge. Case videos underwent blinded objective analysis using a bespoke performance assessment tool developed with a 62-international expert Delphi exercise and workshop, interview, and pilot phases. Interventions Laparoscopic total mesorectal excision undertaken with curative intent by 34 credentialed surgeons. Main Outcomes and Measures Histopathological (plane of mesorectal dissection, ALaCaRT composite end point success [mesorectal fascial plane, circumferential margin, ≥1 mm; distal margin, ≥1 mm]) and 30-day morbidity. End points were analyzed using surgeon quartiles defined by tool scores. Results The laparoscopic total mesorectal excision performance tool was produced and shown to be reliable and valid for the specialist level (intraclass correlation coefficient, 0.889; 95% CI, 0.832-0.926; P < .001). A substantial variation in tool scores was recorded (range, 25-48). Scores were associated with the number of intraoperative errors, plane of mesorectal dissection, and short-term patient morbidity, including the number and severity of complications. Upper quartile-scoring surgeons obtained excellent results compared with the lower quartile (mesorectal fascial plane: 93% vs 59%; number needed to treat [NNT], 2.9, P = .002; ALaCaRT end point success, 83% vs 58%; NNT, 4; P = .03; 30-day morbidity, 23% vs 50%; NNT, 3.7; P = .03). Conclusions and Relevance Intraoperative surgical skill can be objectively and reliably measured in complex cancer interventions. Substantial variation in technical performance among credentialed surgeons is seen and significantly associated with clinical and pathological outcomes.
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Affiliation(s)
- Nathan J Curtis
- Department of Surgery and Cancer, Imperial College London, London, England.,Department of General Surgery, Yeovil District Hospital National Health Service Foundation Trust, Yeovil, England
| | - Jake D Foster
- Department of Surgery and Cancer, Imperial College London, London, England.,Department of General Surgery, Yeovil District Hospital National Health Service Foundation Trust, Yeovil, England
| | | | - Chris S B Brown
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Peter J Hewett
- Department of Surgery, University of Adelaide, Adelaide, Australia
| | - Sarah Abbott
- Canterbury District Health Board, Christchurch, New Zealand
| | - George B Hanna
- Department of Surgery and Cancer, Imperial College London, London, England
| | - Andrew R L Stevenson
- Faculty of Medical and Biomedical Sciences, University of Queensland, Brisbane, Australia.,Royal Brisbane and Women's Hospital, Queensland, Australia
| | - Nader K Francis
- Department of General Surgery, Yeovil District Hospital National Health Service Foundation Trust, Yeovil, England.,University College London, London, England
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Morris MC, Winer LK, Lee TC, Shah SA, Rafferty JF, Paquette IM. Omission of Adjuvant Chemotherapy in Rectal Cancer Patients with Pathologic Complete Response: a National Analysis. J Gastrointest Surg 2021; 25:1857-1865. [PMID: 32728821 PMCID: PMC7388436 DOI: 10.1007/s11605-020-04749-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/16/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND An increasing number of patients achieve a pathologic complete response (pCR) after neoadjuvant chemoradiation for locally advanced rectal cancer. Consensus guidelines continue to recommend oncologic resection followed by adjuvant chemotherapy in these patients. We hypothesize that there is significant variability in compliance with this recommendation. METHODS The National Cancer Database was queried from 2006 to 2015 for patients with locally advanced rectal cancer who underwent neoadjuvant chemoradiation followed by oncologic resection with a pCR (ypT0N0). Hierarchical logistic regression models were used to generate risk and reliability-adjusted rates of adjuvant chemotherapy utilization in patients with pCR at each hospital. RESULTS In total, 2421 pCR patients were identified. Five-year overall survival was improved in pCR patients who received adjuvant chemotherapy compared with those who did not (92 vs. 85%, p < 0.01). Multivariate analysis indicated that improvement in overall survival remained associated with adjuvant chemotherapy (HR 0.60, 95% CI 0.44-0.82, p < 0.01). The mean adjuvant chemotherapy utilization rate among hospitals was 32%. There was an upward trend in use over the past decade, but two-thirds still do not receive the recommended therapy. High chemotherapy utilizer hospitals were more likely to be academic centers (54.9 vs. 45.9%, p < 0.01) when compared with low chemotherapy utilizers. CONCLUSION Adjuvant chemotherapy is associated with improved survival in rectal cancer patients with pCR following neoadjuvant chemoradiation and oncologic resection. However, utilization among centers in the USA was only 32% with significant variability across centers. National efforts are needed to standardize treatment patterns according to national guidelines.
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Affiliation(s)
- Mackenzie C. Morris
- grid.24827.3b0000 0001 2179 9593Department of Surgery, College of Medicine, University of Cincinnati, 2123 Auburn Ave #524, Cincinnati, OH 45219 USA
| | - Leah K. Winer
- grid.24827.3b0000 0001 2179 9593Department of Surgery, College of Medicine, University of Cincinnati, 2123 Auburn Ave #524, Cincinnati, OH 45219 USA
| | - Tiffany C. Lee
- grid.24827.3b0000 0001 2179 9593Department of Surgery, College of Medicine, University of Cincinnati, 2123 Auburn Ave #524, Cincinnati, OH 45219 USA
| | - Shimul A. Shah
- grid.24827.3b0000 0001 2179 9593Department of Surgery, College of Medicine, University of Cincinnati, 2123 Auburn Ave #524, Cincinnati, OH 45219 USA
| | - Janice F. Rafferty
- grid.24827.3b0000 0001 2179 9593Department of Surgery, College of Medicine, University of Cincinnati, 2123 Auburn Ave #524, Cincinnati, OH 45219 USA
| | - Ian M. Paquette
- grid.24827.3b0000 0001 2179 9593Department of Surgery, College of Medicine, University of Cincinnati, 2123 Auburn Ave #524, Cincinnati, OH 45219 USA
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48
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Xu Z, Fleming FJ. The treatment-travel tradeoff of colorectal cancer care. Surgery 2020; 169:989-990. [PMID: 33220976 DOI: 10.1016/j.surg.2020.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 10/08/2020] [Accepted: 10/11/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Zhaomin Xu
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, Division of Colorectal Surgery, University of Rochester Medical Center, NY; Department of Colorectal Surgery, Cleveland Clinic, OH.
| | - Fergal J Fleming
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, Division of Colorectal Surgery, University of Rochester Medical Center, NY
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49
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Gilshtein H, Wexner SD. National Accreditation Program for Rectal Cancer. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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50
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Vergara-Fernández O, Rangel-Ríos H, Trejo-Avila M, Ramos ESG, Velazquez-Fernandez D. Assessment of quality-of-care indicators for colorectal cancer surgery at a single centre in a developing country. Can J Surg 2020. [PMID: 33107816 DOI: 10.1503/cjs.013619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The implementation of quality-of-care indicators aiming to improve colorectal cancer (CRC) outcomes has been previously described by Cancer Care Ontario. The aim of this study was to assess the quality-of-care indicators in CRC at a referral centre in a developing country and to determine whether improvement occurred over time. METHODS We performed a retrospective study of our prospectively collected database of patients after CRC surgery from 2001 to 2016. We excluded patients who underwent local transanal excision, pelvic exenteration or palliative procedures. We evaluated trends over time using the Cochran-Armitage test for trend. RESULTS A total of 343 patients underwent surgical resection of CRC over the study period. There was improvement of the following indicators over time: the proportion of patients detected by screening (p = 0.03), the proportion of patients with preoperative liver imaging (p = 0.001), the proportion of patients with stage II or III rectal cancer who received neoadjuvant chemotherapy (p = 0.03), the proportion of patients with pathology reports that indicated the number of lymph nodes examined and the number of positive nodes (p = 0.001), and the proportion of patients with pathology reports describing the details on margin status (p = 0.001). CONCLUSION This study showed the feasibility of applying the Cancer Care Ontario indicators for evaluating outcomes in CRC treatment at a single centre in a developing country. Although there was an improvement of some of the quality-of-care indicators over time, policies and interventions must be implemented to improve the fulfillment of all indicators.
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Affiliation(s)
- Omar Vergara-Fernández
- From the Departments of Colorectal Surgery (Vergara-Fernández, Rangel-Ríos, Trejo-Avila, Ramos) and Surgery (Velazquez-Fernandez), Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Hugo Rangel-Ríos
- From the Departments of Colorectal Surgery (Vergara-Fernández, Rangel-Ríos, Trejo-Avila, Ramos) and Surgery (Velazquez-Fernandez), Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Mario Trejo-Avila
- From the Departments of Colorectal Surgery (Vergara-Fernández, Rangel-Ríos, Trejo-Avila, Ramos) and Surgery (Velazquez-Fernandez), Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Emilio Sanchez-Garcia Ramos
- From the Departments of Colorectal Surgery (Vergara-Fernández, Rangel-Ríos, Trejo-Avila, Ramos) and Surgery (Velazquez-Fernandez), Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - David Velazquez-Fernandez
- From the Departments of Colorectal Surgery (Vergara-Fernández, Rangel-Ríos, Trejo-Avila, Ramos) and Surgery (Velazquez-Fernandez), Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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