Patterns of care for adjuvant therapy in a random population-based sample of patients diagnosed with colorectal cancer

Adjuvant Chemotherapy Is Associated with Improved Survival for Stage III Colon Cancer When Initiated Beyond 8 Weeks

BACKGROUND

The National Comprehensive Cancer Network (NCCN) guidelines recommend adjuvant chemotherapy (AC) within 6-8 weeks of surgical resection for patients with stage III colon cancer. However, postoperative complications or prolonged surgical recovery may affect the receipt of AC. The aim of this study was to assess the utility of AC for patients with prolonged postoperative recovery.

METHODS

We queried the National Cancer Database (2010-2018) for patients with resected stage III colon cancer. Patients were categorized as having either normal or prolonged length of stay (PLOS: >7 days, 75th percentile). Multivariable Cox proportional hazard regression and logistic regressions were used to identify factors associated with overall survival and receipt of AC.

RESULTS

Of the 113,387 patients included, 30,196 (26.6%) experienced PLOS. Of the 88,115 (77.7%) patients who received AC, 22,707 (25.8%) initiated AC more than 8 weeks after surgery. Patients with PLOS were less likely to receive AC (71.5% vs. 80.0%, OR: 0.72, 95%CI=0.70-0.75) and displayed inferior survival (75 vs. 116 months, HR: 1.39, 95%CI=1.36-1.43). Receipt of AC was also associated with patient factors such as high socioeconomic status, private insurance, and White race (p<0.05 for all). AC within and after 8 weeks of surgery was associated with improved survival for patients with both normal LOS and PLOS (normal LOS: <8 weeks HR: 0.56, 95% CI: 0.54-0.59, >8 weeks HR: 0.68, 95% CI: 0.65-0.71; PLOS: <8 weeks HR: 0.51, 95% CI: 0.48-0.54, >8 weeks HR: 0.63, 95% CI 0.60-0.67). AC was associated with significantly improved survival if initiated up to 15 weeks postoperatively (normal LOS: HR: 0.72, 95%CI=0.61-0.85; PLOS: HR: 0.75, 95%CI=0.62-0.90), and very few patients (<3.0%) initiated AC beyond this time.

CONCLUSION

Receipt of AC for stage III colon cancer may be affected by surgical complications or otherwise prolonged recovery. Timely and even delayed AC (>8 weeks) are both associated with improved overall survival. These findings highlight the importance of delivering guideline-based systemic therapies, even after complicated surgical recovery.

The View of Turkish Oncologists Regarding MSI Status and Tumor Localization in Stage II and III Colon Cancer

INTRODUCTION

Although several clinical factors which show the benefit of adjuvant chemotherapy (AC) in early-stage colon cancer use for evaluating the risk of relapse, there is no consensus on which risk factors are more reliable. In this study, we evaluated both the utility of MSI and the daily practice of the Turkish oncologists in stage II and III colon cancer.

MATERIAL AND METHOD

We conducted an online questionnaire which was consisting of twenty questions including the treatment choices and duration about stage II-III colon cancer depending on sidedness and risk factors for relapse.

RESULTS

More than 65% of the oncologists declared the use of MSI testing in stage II colon cancer without considering any risk factors. In stage 3 colon cancer oncologists had an equal decision "to do or not to do" in MSI testing. More than 50% of the oncologists had preferred XELOX protocol in high-risk stage II (T4N0) colon cancer, while three out of four preferred observation in low-risk stage II (T3N0) patients without risk factors. Two-thirds of the oncologists had preferred 6 months of treatment in stage II colon cancer with at least one risk factor.

CONCLUSION

Turkish oncologists participating to this trial had declared conflicting results about adjuvant treatment in early-stage colorectal cancer in their daily practice compared with the updated guidelines, especially, MSI evaluation utility in stage III colon cancers, adjuvant chemotherapy (AC) duration, and oxaliplatin adding to AC in elderly and stage II patients.

Are there sex differences among colorectal cancer patients in treatment and survival? A Swiss cohort study

BACKGROUND

Colorectal cancer (CRC) is among the three most common incident cancers and causes of cancer death in Switzerland for both men and women. To promote aspects of gender medicine, we examined differences in treatment decision and survival by sex in CRC patients diagnosed 2000 and 2001 in the canton of Zurich, Switzerland.

METHODS

Characteristics assessed of 1076 CRC patients were sex, tumor subsite, age at diagnosis, tumor stage, primary treatment option and comorbidity rated by the Charlson Comorbidity Index (CCI). Missing data for stage and comorbidities were completed using multivariate imputation by chained equations. We estimated the probability of receiving surgery versus another primary treatment using multivariable binomial logistic regression models. Univariable and multivariable Cox proportional hazards regression models were used for survival analysis.

RESULTS

Females were older at diagnosis and had less comorbidities than men. There was no difference with respect to treatment decisions between men and women. The probability of receiving a primary treatment other than surgery was nearly twice as high in patients with the highest comorbidity index, CCI 2+, compared with patients without comorbidities. This effect was significantly stronger in women than in men (p-interaction = 0.010). Survival decreased with higher CCI, tumor stage and age in all CRC patients. Sex had no impact on survival.

CONCLUSION

The probability of receiving any primary treatment and survival were independent of sex. However, female CRC patients with the highest CCI appeared more likely to receive other therapy than surgery compared to their male counterparts.

Racial Comparisons in Timeliness of Colon Cancer Treatment in an Equal-Access Health System

BACKGROUND

Non-Hispanic black (NHB) adults with cancer may have longer time-to-treatment than non-Hispanic whites (NHW) in the United States. Unequal access to medical care may partially account for this racial disparity. This study aimed to investigate whether there were racial differences in time-to-treatment and in treatment delays for patients diagnosed with colon cancer in the equal-access Military Health System (MHS).

METHODS

Patients age 18-79 years diagnosed with colon adenocarcinoma between January 1, 1998, and December 31, 2014, were identified in the Department of Defense Central Cancer Registry and the MHS Data Repository-linked databases. Median time-to-treatment (surgery and chemotherapy) and 95% confidence intervals were compared between NHBs and NHWs in multivariable quantile regression models. Odds ratios and 95% confidence intervals of receiving delayed treatment defined by guidelines for NHBs relative to NHWs were estimated using multivariable logistic regression.

RESULTS

Patients (n = 3067) had a mean age at diagnosis of 58.4 (12.2) years and the racial distribution was 76.7% NHW and 23.3% NHB. Median adjusted time-to-treatment was similar for NHB compared to NHW patients. The likelihood of receiving delayed treatment was similar between NHB and NHW patients.

CONCLUSIONS

In the MHS, there was no evidence of treatment delays for NHBs compared to NHWs, suggesting the role of equal access to medical care and insurance coverage in reducing racial disparities in colon cancer treatment.

The effect of comorbidities on outcomes in colorectal cancer survivors: a population-based cohort study

PURPOSE

To examine the prevalence of comorbidities and the association of these comorbidities with demographics, tumor characteristics, treatments received, overall survival, and causes of death in a population-based cohort of colorectal cancer (CRC) patients.

METHODS

Adult patients with stage I-III CRC diagnosed between 2004 and 2015 were included. Comorbidities were captured using Charlson comorbidity index. Causes of death were categorized using International Classification of Diseases, tenth revision codes. Patients were categorized into five mutually exclusive comorbid groups (cardiovascular disease alone, diabetes alone, cardiovascular disease plus diabetes, other comorbidities, or no comorbidities). Data were analyzed using descriptive statistics, Kaplan-Meier survival analyses, and Cox proportional hazards models.

RESULTS

There were 12,265 patients. Mean follow-up was 3.8 years. Approximately one third of patients had a least one comorbidity, with cardiovascular disease and diabetes being most common. There were statistically significant differences across comorbid groups on treatments received and overall survival. Those with comorbidity had lower odds of treatment and greater risk of death than those with no comorbidity. Those with cardiovascular disease plus diabetes fared the worst for prognosis (median overall survival 3.3 [2.8-3.7] years; adjusted HR for death, 2.27, 95% CI 2.0-2.6, p < .001). Cardiovascular disease was the most common cause of non-CRC death.

CONCLUSIONS

CRC patients with comorbidity received curative intent treatment less frequently and experienced worse outcomes than patients with no comorbidity. Cardiovascular disease was the most common cause of non-cancer death.

IMPLICATIONS FOR CANCER SURVIVORS

Management of comorbidities, including healthy lifestyle coaching, at diagnosis and into survivorship is an important component of cancer care.

Treatment and Survival Disparities in the National Cancer Institute's Patterns of Care Study (1987-2017)

BACKGROUND

Cancer health services research is a primary tool for analyzing the association between various factors, cancer health care delivery, and the resultant outcomes. To address disparities strategies must be developed to target factors that are related to differences in care; however, to date, most disparities studies have been descriptive. The primary objective was to describe cancer treatment and survival disparities in community oncology practice patterns found in the National Cancer Institute's population-based Patterns of Care (POC) Study (1987-2017). Secondarily, we compared POC findings to peer-reviewed literature. In POC data, older age was consistently associated with decreased odds of treatment and increased mortality. Interestingly, in contrast to current literature, few POC studies found race/ethnicity significantly predicted disparities. Cancer health disparities are complex; they are multifactorial, differ by cancer site and may wax and wane. The complexity supports the need for deeper understanding and targeted interventions to ensure equitable cancer care and outcomes.

Better Late than Never? Adherence to Adjuvant Therapy Guidelines for Stage III Colon Cancer in an Underserved Region

INTRODUCTION

In 2008, the American College of Surgeons Commission on Cancer (CoC) issued a quality guideline for stage III colon cancer (CC) recommending adjuvant chemotherapy (AC) within 120 days of diagnosis. We examined adherence in a healthcare system serving a region with disparities in CC outcomes.

METHODS

In a retrospective analysis of patients (2005-2014) with stage III CC in a multi-hospital healthcare system, the associations between adherence, clinicopathologic, demographic, geographic, and socioeconomic data and overall survival (OS) were examined.

RESULTS

Of 1171 CC patients, 438 (37.4%) had stage III disease with 63% (n = 276) receiving AC and 37% (n = 162) not. AC conferred a 5-year OS advantage (62.4 vs. 42.5%, p < 0.0001). Younger age independently predicted AC receipt (OR = 0.95, p < 0.0001). Of 252 AC patients < 80 years, 75.8% were CoC guideline compliant (GC) whereas 24.2% were not (nGC). Although there was no OS difference between GC and nGC, both had superior survival (p < 0.0001) compared to non-AC patients. Surgical complications trended towards independent association with non-compliance (p = 0.07) CONCLUSION: Guideline compliance in our system (63%) is lower than the CoC Estimated Performance Rate (72.4%). Age influenced absolute receipt of AC while surgical complications may impact guideline compliance. Even when administered beyond 120 days, AC was associated with a survival benefit.

Patterns of Sociodemographic and Clinicopathologic Characteristics of Stages II and III Colorectal Cancer Patients by Age: Examining Potential Mechanisms of Young-Onset Disease

Background and Aims. As a first step toward understanding the increasing incidence of colorectal cancer (CRC) in younger (age < 50) populations, we examined demographic, clinicopathologic, and socioeconomic characteristics and treatment receipt in a population-based sample of patients newly diagnosed with stages II and III CRC. Methods. Patients were sampled from the National Cancer Institute's Patterns of Care studies in 1990/91, 1995, 2000, 2005, and 2010 (n = 6, 862). Tumor characteristics and treatment data were obtained through medical record review and physician verification. We compared sociodemographic and clinicopathologic characteristics and treatment patterns of younger (age < 50) and older (age 50–69, age ≥ 70) CRC patients. Results. Younger patients were more likely to be black (13%) and Hispanic (15%) than patients aged 50–69 years (11% and 10%, resp.) and ≥70 years (7% each). A larger proportion of young white (41%) and Hispanic (33%) patients had rectal tumors, whereas tumors in the right colon were the most common in young black patients (39%). The majority of younger patients received chemotherapy and radiation therapy, although receipt of microsatellite instability testing was suboptimal (27%). Conclusion. Characteristics of patients diagnosed with young-onset CRC differ considerably by race/ethnicity, with a higher proportion of black and Hispanic patients diagnosed at the age of < 50 years.

Race/ethnicity and socio-economic differences in colorectal cancer surgery outcomes: analysis of the nationwide inpatient sample

Background

The purpose of this study was to examine racial and socio-economic differences in the receipt of laparoscopic or open surgery among patients with colorectal cancer, and to determine if racial and socio-economic differences exist in post-surgical complications, in-hospital mortality and hospital length of stay among patients who received surgery.

Methods

We conducted a cross-sectional analysis of hospitalized patients with a primary diagnosis of colorectal cancer between 2007 and 2011 using data from Nationwide Inpatient Sample. ICD-9 codes were used to capture primary diagnosis, surgical procedures, and health outcomes during hospitalization. We used logistic regression analysis to determine racial and socio-economic predictors of surgery type, post-surgical complications and mortality, and linear regression analysis to assess hospital length of stay.

Results

A total of 122,631 patients were admitted with a primary diagnosis of malignant colorectal cancer between 2007 and 2011. Of these, 17,327 (14.13 %) had laparoscopic surgery, 70,328 (57.35 %) received open surgery, while 34976 (28.52 %) did not receive any surgery. Black (36 %) and Hispanic (34 %) patients were more likely to receive no surgery compared with Whites (27 %) patients. However, among patients that received any surgery, there were no racial differences in which surgery was received (laparoscopic versus open, p = 0.2122), although socio-economic differences remained, with patients from lower residential income areas significantly less likely to receive laparoscopic surgery compared with patients from higher residential income areas (OR: 0.74, 95 % CI: 0.70-0.78). Among patients who received any surgery, Black patients (OR = 1.07, 95 % CI: 1.01-1.13), and patients with Medicare (OR = 1.16, 95 % CI: 1.11-1.22) and Medicaid (OR = 1.15, 95 % CI: 1.07-1.25) insurance experienced significantly higher post-surgical complications, in-hospital mortality (Black OR = 1.18, 95 % CI: 1.00-1.39), and longer hospital stay (Black β = 1.33, 95 % CI: 1.16-1.50) compared with White patients or patients with private insurance.

Conclusion

Racial and socio-economic differences were observed in the receipt of surgery and surgical outcomes among hospitalized patients with malignant colorectal cancer in the US.

Treatment and Survival of Medicare Beneficiaries with Colorectal Cancer: A Comparative Analysis Between a Rural State Cancer Registry and National Data

The aim was to examine and compare with "national" estimates, receipt of colorectal cancer (CRC) treatment in the initial phase of care and survival following a CRC diagnosis in rural Medicare beneficiaries. A retrospective study was conducted on fee-for-service Medicare beneficiaries diagnosed with CRC in 2003-2006, identified from West Virginia Cancer Registry (WVCR)-Medicare linked database (N = 2119). A comparative cohort was identified from Surveillance, Epidemiology, and End Results (SEER)-Medicare (N = 38,168). CRC treatment received was ascertained from beneficiaries' Medicare claims in the 12 months post CRC diagnosis or until death, whichever happened first. Receipt of minimally appropriate CRC treatment (MACT) was defined using recommended CRC treatment guidelines. All-cause and CRC-specific mortality in the 36-month period post CRC diagnosis were examined. Differences in usage of CRC surgery, chemotherapy, and radiation were observed between the 2 populations, with those from WVCR-Medicare being less likely to receive any type of CRC surgery (adjusted odds ratio [AOR] = 0.82; 95% confidence interval [CI] = [0.73-0.93]). Overall, those from WVCR-Medicare had a lower likelihood of receiving MACT, (AOR = 0.85; 95% CI = [0.76-0.96]) compared to their national counterparts. Higher hazard of CRC mortality was observed in the WVCR-Medicare cohort (adjusted hazard ratio = 1.26; 95% CI = [1.20-1.32]) compared to the SEER-Medicare cohort. Although more beneficiaries from WVCR-Medicare were diagnosed in early-stage CRC compared to their SEER-Medicare counterparts, they had a lower likelihood of receiving MACT and a higher hazard of CRC mortality. This study highlights the need for an increased focus on improving access to care at every phase of the CRC care continuum, especially for those from rural settings.

Chemotherapy use and adoption of new agents is affected by age and comorbidities in patients with metastatic colorectal cancer

BACKGROUND

The treatment of metastatic colorectal cancer (mCRC) has changed substantially in the last 2 decades, but to the authors' knowledge, the effect of age and comorbidities on chemotherapy use has not been well studied to date.

METHODS

Patients with mCRC who were being treated with 5-fluorouracil (5-FU)-based chemotherapy between January 1995 to December 2009 were studied using the LifeLink Health Plan Claims Database. The cohort was divided into older (aged >70 years) and younger (aged ≤70 years) patients. The Charlson Comorbidity Index (CCI) was used to assess comorbidity burden. The Wilcoxon and chi-square tests were used in univariate and logistic regression in multivariate analyses.

RESULTS

A total of 16,087 patients were identified, with 24% of the patients who were receiving chemotherapy being aged >70 years. The percentage of patients with a CCI >1 receiving chemotherapy increased over time (14% in 1996 vs 40% after 2004; P<.05). Older patients were less likely to receive treatment with >2 agents compared with younger patients (15% vs.22% and 11% vs.16%, respectively, in 2003 and 2009; P<.001). After approval by the US Food and Drug Administration in 1998, the use of irinotecan was lower in older compared with younger patients, a difference that resolved by 2002 (15% vs 38% [P<.05]; 62% in both groups [P = .9], respectively). Similarly, oxaliplatin was used more frequently in younger patients in 2003 (22% vs 15%; P<.05), with a decrease in this difference noted by 2009 (64% vs 60%; P = .95). On multivariate analysis, older age (odds ratio, 0.65; P<.001) and a CCI >1 (odds ratio, 0.84; P<.001) were found to be associated with a lower likelihood of receiving combination chemotherapy.

CONCLUSIONS

In this commercially insured population, the percentage of older patients treated for mCRC was low, and the rate of chemotherapy adoption was found to lag behind that of younger patients. However, the percentage of older patients with comorbidities receiving therapy increased over time. Cancer 2016;122:3191-8. © 2016 American Cancer Society.

The impact of comorbidity on cancer and its treatment

Answer questions and earn CME/CNE Comorbidity is common among cancer patients and, with an aging population, is becoming more so. Comorbidity potentially affects the development, stage at diagnosis, treatment, and outcomes of people with cancer. Despite the intimate relationship between comorbidity and cancer, there is limited consensus on how to record, interpret, or manage comorbidity in the context of cancer, with the result that patients who have comorbidity are less likely to receive treatment with curative intent. Evidence in this area is lacking because of the frequent exclusion of patients with comorbidity from randomized controlled trials. There is evidence that some patients with comorbidity have potentially curative treatment unnecessarily modified, compromising optimal care. Patients with comorbidity have poorer survival, poorer quality of life, and higher health care costs. Strategies to address these issues include improving the evidence base for patients with comorbidity, further development of clinical tools to assist decision making, improved integration and coordination of care, and skill development for clinicians. CA Cancer J Clin 2016;66:337-350. © 2016 American Cancer Society.

Factors Impacting Treatment Choice in the First-Line Treatment of Colorectal Cancer

INTRODUCTION

To investigate the factors that affect the choice of 5-fluorouracil (5-FU) or its oral alternative, capecitabine, as first-line treatment in patients with colorectal cancer (CRC).

METHODS

Patients treated with 5-FU or capecitabine for CRC between January 1, 2011 and December 31, 2013 in a teaching hospital in the Sydney metropolitan area, Australia were identified using the hospital's database MOSAIQ^®. The electronic medical record of each patient was manually reviewed to extract factors potentially affecting treatment choice. Logistic regression was used to assess which patient and/or treatment factors could explain the choice between 5-FU or capecitabine. Where it was available in the medical correspondence, the explicit reason for the choice made was extracted.

RESULTS

170 CRC patients were included; 119 on 5-FU, and 51 on capecitabine. The odds of receiving capecitabine as a first-line treatment were positively associated with giving patients a choice in the decision (OR = 17.51, 95% CI: 5.37-57.08). Qualitative data suggest treatment choices were motivated by convenience (oral administration) and tolerability. Time from diagnosis to treatment commencement (OR = 1.02 per month, 95% CI 1.00-1.04) was also found to be positively associated with the choice of capecitabine. The odds of being treated with capecitabine were lower for patients who lived further from the treating hospital (OR = 0.22, 95% CI 0.05-0.94).

CONCLUSION

This study suggests that patient choice, favoring oral capecitabine over i.v. 5-FU, was a key factor influencing first-line treatment for CRC in this cohort. To respect their autonomy, patients should be involved in the clinical decision making process.

Approach to the older patient with stage II/III colorectal cancer: who should get curative-intent therapy?

The majority of new colorectal cancer diagnoses occur in adults 65 and older a rapidly growing segment of the U.S. population. Older adults are a markedly heterogeneous group, and although recent clinical trials in locally advanced colorectal cancer have incorporated limited numbers of older patients, the data can not be generalized to most older patients. In particular, patients who are not "fit"-those with poor functional reserve, major comorbidities, or who otherwise meet criteria for frailty or "prefrailty"-are poorly represented in published trials. Population-based data demonstrate that older adults are much less likely to be treated in the adjuvant or neoadjuvant settings for stage II/III colorectal cancer, but it is unclear what the basis should be for withholding potentially curative therapy. Age and Eastern Cooperative Oncology Group (ECOG) performance status (PS) are frequently used to determine eligibility for treatment, but data increasingly suggest these are inadequate; the emerging definition of a spectrum of "fit" to "frail" older patients may provide additional guidance. Available data suggest that fit older patients may benefit as much from curative-intent therapy as younger patients. For frail or vulnerable (prefrail) patients, on the other hand, the benefit must be carefully weighed against the risk of toxicity and competing risks from their comorbidities. Life expectancy and patient preferences should always be elucidated. Geriatrician comanagement may be helpful in determining priorities, providing a comprehensive assessment, and modifying competing risk factors. Even many vulnerable or frail patients can successfully complete (and derive benefit from) carefully considered treatment regimens.

Race and Insurance Differences in the Receipt of Adjuvant Chemotherapy Among Patients With Stage III Colon Cancer

PURPOSE

Although the incidence and mortality of colon cancer in the United States has declined over the past two decades, blacks have worse outcomes than whites. Variations in treatment may contribute to mortality differentials.

METHODS

Patients diagnosed with stage III colon cancer were randomly sampled from the SEER program from the years 1990, 1991, 1995, 2000, 2005, and 2010. Patients were categorized as non-Hispanic white (n = 835) or black (n = 384). Treatment data were obtained from a review of the medical records, and these data were verified through contact with the original treating physicians. Log-binomial regression models were used to estimate the association between race and receipt of adjuvant chemotherapy. Effect modification by insurance was assessed with use of single referent models.

RESULTS

Receipt of adjuvant chemotherapy among both white and black patients increased from the period encompassing the years 1990 and 1991 (white, 58%; black, 45%) to the year 2005 (white, 72%; black, 71%) and then decreased in the year 2010 (white, 66%; black, 57%). There were marked racial disparities in the time period of 1990 to 1991 and again in 2010, with black patients less likely to receive adjuvant chemotherapy as compared with white patients (risk ratio [RR], .82; 95% CI, .72 to .93). For black patients, receipt of adjuvant chemotherapy did not differ across insurance categories (RR for private insurance, .80; 95% CI, .69 to .93; RR for Medicare, .84; 95% CI, .69 to 1.02; and RR for Medicaid, .84; 95% CI, .69 to 1.02), although a larger proportion had Medicaid in all years of the study as compared with white patients.

CONCLUSION

The chemotherapy differential narrowed after the time period of 1990 to 1991, but our findings suggest that the disparity reemerged in 2010. Recent decreases in chemotherapy use may be due, in part, to the economic downturn and an increase in Medicaid coverage.

Patterns of Colorectal Cancer Care in the United States: 1990-2010

BACKGROUND

Colorectal cancer (CRC) mortality has declined in the United States, in part because of advances in treatment. Few studies have evaluated the adoption of therapies and temporal changes in patterns of care.

METHODS

Patients age 20 years and older diagnosed with stages II/III CRC were randomly sampled from the population-based Surveillance, Epidemiology, and End Results (SEER) program in 1990-1991, 1995, 2000, 2005, and 2010 (n = 7057). Therapy was obtained from medical records and physician verification. We described the receipt of chemotherapy and radiation therapy. Log-binomial regression was used to examine factors associated with therapy. All statistical tests were two-sided.

RESULTS

Chemotherapy receipt among colon cancer patients increased from 1990 (stage II: 22.5%; stage III: 56.3%) to 2005 (stage II: 32.1%; stage III: 72.4%) and declined slightly in 2010 (stage II: 29.3%; stage III: 66.4%). Stage III colon cancer patients who were older (vs <55 years, 75-79 years: risk ratio [RR] 0.81, 95% confidence interval [CI] = 0.71 to 0.91; ≥80 years: RR = 0.37, 95% CI = 0.28 to 0.47) or had a comorbidity score of 2 or higher (vs 0, RR = 0.56, 95% CI = 0.35 to 0.87) received chemotherapy less often. Receipt of radiation therapy by rectal cancer patients increased across all years from 45.5% to 66.1%. Increasing age (vs <55 years, 75-79 years: RR = 0.59, 95% CI = 0.47 to 0.74; ≥80 years: RR = 0.33, 95% CI = 0.25 to 0.45) was associated with lower chemoradiation use among stage II/III rectal cancer patients.

CONCLUSION

Our findings demonstrate increased adoption of chemotherapy and radiation therapy for colon and rectal cancer patients and differences in therapy by age, comorbidity, and diagnosis year. Increased receipt of these therapies in the community may further reduce CRC mortality.

Consideration of comorbidity in treatment decision making in multidisciplinary cancer team meetings: a systematic review

BACKGROUND

Comorbidity is very common among patients with cancer. Multidisciplinary team meetings (MDTs) are increasingly the context within which cancer treatment decisions are made internationally. Little is known about how comorbidity is considered, or impacts decisions, in MDTs.

METHODS

A systematic literature review was conducted to evaluate previous evidence on consideration, and impact, of comorbidity in cancer MDT treatment decision making. Twenty-one original studies were included.

RESULTS

Lack of information on comorbidity in MDTs impedes the ability of MDT members to make treatment recommendations, and for those recommendations to be implemented among patients with comorbidity. Where treatment is different from that recommended due to comorbidity, it is more conservative, despite evidence that such treatment may be tolerated and effective. MDT members are likely to be unaware of the extent to which issues such as comorbidity are ignored.

CONCLUSIONS

MDTs should systematically consider treatment of patients with comorbidity. Further research is needed to assist clinicians to undertake MDT decision making that appropriately addresses comorbidity. If this were to occur, it would likely contribute to improved outcomes for cancer patients with comorbidities.

Physicians' beliefs about the benefits and risks of adjuvant therapies for stage II and stage III colorectal cancer

BACKGROUND

Adjuvant therapy plays a major role in treating colorectal cancer, and physicians' views of its effectiveness influence treatment decisions. We assessed physicians' views of the relative benefits and risks of adjuvant chemotherapy and radiotherapy for stages II and III colon and rectal cancers.

METHODS

The Cancer Care Outcomes Research and Surveillance Consortium surveyed a geographically dispersed population of medical oncologists, radiation oncologists, and surgeons in the United States about the benefits and risks of adjuvant therapies for colorectal cancer. We used logistic regression to assess the association of physician and practice characteristics with beliefs about adjuvant therapies.

RESULTS

Among 1,296 respondents, > 90% believed the benefits of adjuvant therapies for stage III colorectal cancer outweigh the risks. Only 21.9%, 50%, and 50.4% believed in the net benefit of chemotherapy for stage II colon cancer, chemotherapy for stage II rectal cancer, and radiation for stage II rectal cancer, respectively. Younger physicians were less likely than others to perceive adjuvant therapy for stage II colorectal cancer as beneficial. Medical oncologists were more likely than surgeons and radiation oncologists to endorse the benefits of adjuvant chemotherapy and radiation for stage II rectal cancer, but less likely for stage II colon cancer.

CONCLUSIONS

Physicians largely agreed that the benefits of adjuvant chemotherapy for stage III colon cancer, as well as chemotherapy, and radiation for stage III rectal cancer, outweigh the risks, consistent with strong evidence, but were divided over the net benefit of adjuvant therapies for stage II colorectal cancer, where evidence is inconsistent.

Treatment patterns among colorectal cancer patients in South Australia: a demonstration of the utility of population-based data linkage

RATIONALE, AIMS AND OBJECTIVES

Population level data on colorectal cancer (CRC) management in Australia are lacking. This study assessed broad level patterns of care and concordance with guidelines for CRC management at the population level using linked administrative data from both the private and public health sectors across South Australia. Disparities in CRC treatment were also explored.

METHOD

Linking information from the South Australian Cancer Registry, hospital separations, radiotherapy services and hospital-based cancer registry systems provided data on the socio-demographic, clinical and treatment characteristics for 4641 CRC patients, aged 50-79 years, diagnosed from 2003 to 2008. Factors associated with receiving site/stage-specific treatments (surgery, chemotherapy and radiotherapy) and overall concordance with treatment guidelines were identified using Poisson regression analysis.

RESULTS

About 83% of colon and 56% of rectal cancer patients received recommended treatment. Provision of neo-adjuvant/adjuvant therapies may be less than optimal. Radiotherapy was less likely among older patients (prevalence ratio 0.7, 95% confidence interval 0.5-0.8). Chemotherapy was less likely among older patients (0.7, 0.6-0.8), those with severe or multiple co-morbidities (0.8, 0.7-0.9), and those from rural areas (0.9, 0.8-1.0). Overall discordance with treatment guidelines was more likely among rectal cancer patients (3.0, 2.7-3.3), older patients (1.6, 1.4-1.8), those with multiple co-morbid conditions (1.3, 1.1-1.4), and those living in rural areas (1.2, 1.0-1.3).

CONCLUSIONS

Greater emphasis should be given to ensure CRC patients who may benefit from neo-adjuvant/adjuvant therapies have access to these treatments.

First-line bevacizumab and capecitabine-oxaliplatin in elderly patients with mCRC: GEMCAD phase II BECOX study

Background:

Subgroup analyses of clinical studies suggest that bevacizumab plus XELOX is effective and tolerable in elderly patients with metastatic colorectal cancer (mCRC). The prospective BECOX study examined the efficacy and safety of bevacizumab plus XELOX, followed by bevacizumab plus capecitabine in elderly patients with mCRC.

Methods:

Patients aged ⩾70 years with Eastern Cooperative Oncology Group performance status 0 out of 1 and confirmed mCRC were included. Patients received bevacizumab 7.5 mg kg⁻¹ and oxaliplatin 130 mg m⁻² on day 1, plus capecitabine 1000 mg m⁻² bid orally on days 1–14 every 21 days; oxaliplatin was discontinued after 6 cycles. The primary end point was time to progression (TTP).

Results:

The intent-to-treat population comprised 68 patients (65% male, median age 76 years). Median TTP was 11.1 months; median overall survival was 20.4 months; overall response rate was 46%. Grade 3 or 4 adverse events included diarrhoea (18%) and asthenia (16%). Grade 3 or 4 adverse events of special interest for bevacizumab included deep-vein thrombosis (6%) and pulmonary embolism (4%).

Conclusions:

Bevacizumab plus XELOX was effective and well tolerated in elderly patients in the BECOX study. The adverse-event profile was similar to previous reports; no new safety concerns were identified. Fit elderly patients with mCRC should be considered for treatment with bevacizumab plus XELOX.

Increasing late stage colorectal cancer and rectal cancer mortality demonstrates the need for screening: a population based study in Ireland, 1994-2010

BACKGROUND

This paper describes trends in colorectal cancer incidence, survival and mortality from 1994 to 2010 in Ireland prior to the introduction of population-based screening.

METHODS

We examined incidence (National Cancer Registry Ireland (NCRI) and mortality (Central Statistics Office) from 1994 to 2010. Age standardised rates (ASR) for incidence and mortality have been calculated, weighted by the European standard population. Annual percentage change was calculated in addition to testing for linear trends in treatment and case fraction of early and late stage disease. Relative survival was calculated considering deaths from all causes.

RESULTS

The colorectal cancer ASR was 63.7 per 100,000 in males and 38.7 per 100,000 in females in 2010. There was little change in the ASR over time in either sex, or when colon and rectal cancers were considered separately; however the number of incident cancers increased significantly during 1994-2010 (1752 to 2298). The case fractions of late stage (III/IV) colon and rectal cancers rose significantly over time. One and 5 year relative survival improved for both sexes between the periods 1994-2008. Colorectal cancer mortality ASRs decreased annually from 1994-2009 by 1.8% (95% CI -2.2, -1.4). Rectal cancer mortality ASRs rose annually by 2.4% (95% CI 1.1, 3.6) and 2.8% (95% CI 1.2, 4.4) in males and females respectively.

CONCLUSIONS

Increases in late-stage disease and rectal cancer mortality demonstrate an urgent need for colorectal cancer screening. However, the narrow age range at which screening is initially being rolled-out in Ireland means that the full potential for reductions in late-stage cancers and incidence and mortality are unlikely to be achieved. While it is possible that the observed increase in rectal cancer mortality may be partly an artefact of cause of death misclassification, it could also be explained by variations in treatment and adherence to best practice guidelines; further investigation is warranted.

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

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

Association between the availability of medical oncologists and initiation of chemotherapy for patients with stage III colon cancer

PURPOSE

Although the number of medical oncologists (MOs) has steadily increased over time, and adjuvant chemotherapy provides significant survival benefit for patients with stage III colon cancer, many patients still do not receive chemotherapy. Uneven geographic distribution of MOs may contribute to decreasing access to cancer care. This study explored the association of MO availability by hospital service area (HSA) of patient residence and access to chemotherapy treatment.

METHODS

Using the linked SEER-Medicare database, the study identified 9,262 patients who were age ≥66 years and underwent colectomy for stage III colon cancer diagnosed from 2000 to 2005. MOs were identified by physician specialty codes. HSAs are geographic areas that are relatively self-contained with respect to routine hospital care. Multivariate logistic regression was used to investigate the association between MO availability by HSA of patient residence and initiation of chemotherapy.

RESULTS

Within 3 months after colectomy, 5,622 patients (60.7%) initiated chemotherapy. Adjusting for clinical and patient characteristics, patients residing in an HSA with ≥ one MO had an increased likelihood of initiating chemotherapy within 3 months after colectomy compared with those living in areas with no MOs (one to two MOs: OR, 1.451 [P < .01]; three to eight MOs: OR, 1.497 [P < .01]; ≥ nine MOs: OR, 1.322 [P < .01]).

CONCLUSION

Results suggest that the availability of ≥ one MO within the HSA in which a patient resides was associated with greater access to chemotherapy after surgery.

Patterns of Pelvic Radiotherapy in Patients with Stage II/III Rectal Cancer

High-level evidence supports adjuvant radiotherapy for rectal cancer. We examined the influence of sociodemographic factors on patterns of adjuvant radiotherapy for resected Stage II/III rectal cancer. Methods. Patients undergoing surgical resection for stage II/III rectal cancer were identified in SEER registry. Results. A total of 21,683 patients were identified. Majority of patients were male (58.8%), white (83%), and with stage III (54.9%) and received radiotherapy (66%). On univariate analysis, male gender, stage III, younger age, year of diagnosis, and higher socioeconomic status (SES) were associated with radiotherapy. Radiotherapy was delivered in 84.4% of patients <50; however, only 32.8% of those are >80 years. Logistic regression demonstrated a significant increase in the use of radiotherapy in younger patients who are <50 (OR, 10.3), with stage III (OR, 1.21), males (OR, 1.18), and with higher SES. Conclusions. There is a failure to conform to standard adjuvant radiotherapy in one-third of patients, and this is associated with older age, stage II, area-level of socioeconomic deprivation, and female sex.

Differences between referred and nonreferred patients in cancer research

BACKGROUND

In Canada, provincial cancer registries have been established to provide rigorous population-based data for patients with colorectal cancer. Databases maintained by regional cancer agencies contain a broader scope of information and have been used as a surrogate source of information for colorectal cancer research. It is unclear whether these data can be reliably extrapolated to all patients affected by colorectal cancer. We sought to determine whether patients included in a referral-based database are systematically different from patients who are not included.

METHODS

We conducted a retrospective cohort study to compare patients referred to the British Columbia Cancer Agency with those who were not referred. Comparison was based on age, sex and geographic location. We used univariate and logistic regression analysis to identify significant differences between the cohorts.

RESULTS

Univariate analysis demonstrated that the referral and nonreferral cohorts differed in sex, age and geographic location. For patients with rectal cancer, the referral and nonreferral cohorts varied in age and geographic location. Multivariate analysis demonstrated significant differences in age and geographic location but not sex for patients with colon and rectal cancer.

CONCLUSION

Patients included in the referral database differed in age and geographic location from those included only in the provincial database. Studies using large data sets from referral centres must be interpreted with caution and may not be representative of the entire patient population.

Impact of obesity on cancer survivorship and the potential relevance of race and ethnicity

Evidence that obesity is associated with cancer incidence and mortality is compelling. By contrast, the role of obesity in cancer survival is less well understood. There is inconsistent support for the role of obesity in breast cancer survival, and evidence for other tumor sites is scant. The variability in findings may be due in part to comorbidities associated with obesity itself rather than with cancer, but it is also possible that obesity creates a physiological setting that meaningfully alters cancer treatment efficacy. In addition, the effects of obesity at diagnosis may be distinct from the effects of weight change after diagnosis. Obesity and related comorbid conditions may also increase risk for common adverse treatment effects, including breast cancer-related lymphedema, fatigue, poor health-related quality of life, and worse functional health. Racial and ethnic groups with worse cancer survival outcomes are also the groups for whom obesity and related comorbidities are more prevalent, but findings from the few studies that have addressed these complexities are inconsistent. We outline a broad theoretical framework for future research to clarify the specifics of the biological-social-environmental feedback loop for the combined and independent contributions of race, comorbid conditions, and obesity on cancer survival and adverse treatment effects. If upstream issues related to comorbidities, race, and ethnicity partly explain the purported link between obesity and cancer survival outcomes, these factors should be among those on which interventions are focused to reduce the burden of cancer.

Analytic morphometric assessment of patients undergoing colectomy for colon cancer

BACKGROUND

Analytic morphometrics provides objective data that may better stratify risk. We investigated morphometrics and outcome among colon cancer patients.

METHODS

An IRB-approved review identified 302 patients undergoing colectomy who had CT scans. These were processed to measure psoas area (PA), density (PD), subcutaneous fat (SFD), visceral fat (VF), and total body fat (TBF). Correlation with complications, recurrence, and survival were obtained by t-tests and linear regression models after adjusting for age and Charlson index.

RESULTS

The best predictor of surgical complications was PD. PMH, Charlson, BMI, and age were not significant when PD was considered. SF area was the single best predictor of a wound infection. While all measures of obesity correlated with outcome, TBF was most predictive. Final multivariate Cox models for survival included age, Charlson score, nodal positivity, and TBF.

CONCLUSIONS

Analytic morphometric analysis provided objective data that stratified complications and outcome better than age, BMI, or co-morbidities.

Adherence to clinical practice guidelines for adjuvant chemotherapy for colorectal cancer in a Canadian province: a population-based analysis

PURPOSE

Clinical practice guidelines (CPGs) recommend adjuvant chemotherapy after curative-intent surgery for colorectal cancer (CRC). Studies have shown variable rates of adherence to adjuvant therapy CPGs. This study sought to determine the proportion of patients in Nova Scotia receiving CPG-concordant adjuvant chemotherapy within 12 weeks of surgery for CRC in 2001 to 2005, and to identify factors associated with chemotherapy receipt beyond 12 weeks from surgery or chemotherapy nonreceipt.

METHODS

Patients with stages IIB or III colon or stages II or III rectal cancer who underwent curative-intent surgery in Nova Scotia were identified through the provincial cancer registry and anonymously linked to 14 administrative health databases. Chart review was conducted to obtain chemotherapy data and reasons for chemotherapy nonreceipt. Logistic regression was used to identify factors independently associated with receipt of chemotherapy and meeting the 12-week benchmark (P < .05).

RESULTS

A total of 1,151 patients were identified, of whom 59% received chemotherapy. Factors predicting chemotherapy receipt were male sex, age < 75 years, no hospital readmission within 30 days of surgery, stage III disease, no prior cancer diagnosis, and rectal cancer. Of the 679 patients who received chemotherapy, 479 (72%) met the 12-week benchmark, with male sex, urban residence, less social deprivation, colon cancer and increased length of hospital stay as significant factors. Of the 472 patients who did not receive chemotherapy, the most common reason for nonreceipt was no consultation with a medical oncologist (53%).

CONCLUSION

A number of factors influence adherence to adjuvant chemotherapy CPGs for CRC and should be incorporated in future work as novel regimens enter clinical practice.

Postoperative adjuvant chemotherapy use in patients with stage II/III rectal cancer treated with neoadjuvant therapy: a national comprehensive cancer network analysis

PURPOSE

Practice guidelines recommend that patients who receive neoadjuvant chemotherapy and radiation for locally advanced rectal cancer complete postoperative adjuvant systemic chemotherapy, irrespective of tumor downstaging.

PATIENTS AND METHODS

The National Comprehensive Cancer Network (NCCN) Colorectal Cancer Database tracks longitudinal care for patients treated at eight specialty cancer centers across the United States and was used to evaluate how frequently patients with rectal cancer who were treated with neoadjuvant chemotherapy also received postoperative systemic chemotherapy. Patient and tumor characteristics were examined in a multivariable logistic regression model.

RESULTS

Between September 2005 and December 2010, 2,073 patients with stage II/III rectal cancer were enrolled in the database. Of these, 1,193 patients receiving neoadjuvant chemoradiotherapy were in the analysis, including 203 patients not receiving any adjuvant chemotherapy. For those seen by a medical oncologist, the most frequent reason chemotherapy was not recommended was comorbid illness (25 of 50, 50%); the most frequent reason chemotherapy was not received even though it was recommended or discussed was patient refusal (54 of 74, 73%). After controlling for NCCN Cancer Center and clinical TNM stage in a multivariable logistic model, factors significantly associated with not receiving adjuvant chemotherapy were age, Eastern Cooperative Oncology Group performance status ≥ 1, on Medicaid or indigent compared with private insurance, complete pathologic response, presence of re-operation/wound infection, and no closure of ileostomy/colostomy.

CONCLUSION

Even at specialty cancer centers, a sizeable minority of patients with rectal cancer treated with curative-intent neoadjuvant chemoradiotherapy do not complete postoperative chemotherapy. Strategies to facilitate the ability to complete this third and final component of curative intent treatment are necessary.

Chemotherapy use and patient treatment preferences in advanced colorectal cancer: a prospective cohort study

BACKGROUND

The objective of this study was to determine how patient preferences guide the course of palliative chemotherapy for advanced colorectal cancer.

METHODS

Eligible patients with metastatic colorectal cancer (mCRC) were enrolled nationwide in a prospective, population-based cohort study. Data were obtained through medical record abstraction and patient surveys. Logistic regression analysis was used to evaluate patient characteristics associated with visiting medical oncology and receiving chemotherapy and patient characteristics, beliefs, and preferences associated with receiving >1 line of chemotherapy and receiving combination chemotherapy.

RESULTS

Among 702 patients with mCRC, 91% consulted a medical oncologist; and among those, 82% received chemotherapy. Patients ages 65 to 75 years and aged ≥75 years were less likely to visit an oncologist, as were patients who were too sick to complete their own survey. In adjusted analyses, patients aged ≥75 years who had moderate or severe comorbidity were less likely to receive chemotherapy, as were patients who were too sick to complete their own survey. Patients received chemotherapy even if they believed that chemotherapy would not extend their life (90%) or that chemotherapy would not likely help with cancer-related problems (89%), or patients preferred treatment focusing on comfort even if it meant not living as long (90%). Older patients were less likely to receive combination first-line therapy. Patient preferences and beliefs were not associated with receipt of >1 line of chemotherapy or combination chemotherapy.

CONCLUSIONS

The majority of patients received chemotherapy even if they expressed negative or marginal preferences or beliefs regarding chemotherapy. Patient preferences and beliefs were not associated with the intensity or number of chemotherapy regimens.

The role of comorbidities on the uptake of systemic treatment and 3-year survival in older cancer patients

BACKGROUND

Older patients are notably absent from clinical trials. Thus, observational studies are the primary avenue for understanding the role of comorbidity in cancer care and survival. We examined the impact of comorbidity on systemic treatment initiation and 3-year survival in a cohort of older cancer patients.

PATIENTS AND METHODS

Our cohort comprised 2753 Australian veterans aged ≥65 years with full health coverage and a cancer registry notification for colorectal (CRC), breast, prostate or non-small-cell lung cancer (NSCLC). We established comorbidities based on drugs prescribed in the 6 months prior to cancer diagnosis.

RESULTS

Patients with higher comorbidity burden were more likely to receive systemic treatment for prostate cancer [adjusted odds ratio 1.21, 95% confidence interval (CI) 1.05-1.39] but less likely for NSCLC (0.63, 95% CI 0.45-0.86). After adjusting for receipt of treatment, increased comorbidity resulted in shorter survival for CRC [adjusted hazard ratio (aHR) 1.16, 95% CI 1.07-1.26] and breast cancer (aHR 1.23, 95% CI 1.02-1.48). However, we did not demonstrate significant improvements in 3-year survival for patients receiving systemic treatment.

CONCLUSION

Comorbidity influences systemic treatment uptake and adversely affects survival, with impact dependent upon comorbidity and cancer type. Clinical trials should be undertaken in older patients to better understand the risks and benefits of cancer treatments.

Biomarkers, bundled payments, and colorectal cancer care

Changes in the management of cancers such as colorectal cancer (CRC) are urgently needed, as such cancers continue to be one of the most commonly diagnosed cancers; CRC accounts for 21% of all cancers and is responsible for mortalities second only to lung cancer in the United States. A comprehensive science-driven approach towards markedly improved early detection/screening to efficacious targeted therapeutics with clear diagnostic and prognostic markers is essential. In addition, further changes addressing rising costs, stemming from recent health care reform measures, will be brought about in part by changes in how care is reimbursed. For oncology, the advances in genomics and biomarkers have the potential to define subsets of patients who have a prognosis or response to a particular type of therapy that differs from the mean. Better definition of a cancer's behavior will facilitate developing care plans tailored to the patient. One method under study is episode-based payment or bundling, where one payment is made to a provider organization to cover all expenses associated with a discrete illness episode. Payments will be based on the average cost of care, with providers taking on a risk for overutilization and outliers. For providers to thrive in this environment, they will need to know what care a patient will require and the costs of that care. A science-driven "personalized approach" to cancer care has the potential to produce better outcomes with reductions in the use of ineffectual therapies and costs. This promising scenario is still in the future, but progress is being made, and the shape of things to come for cancer care in the age of genomics is becoming clearer.

Quality indicators for colorectal cancer surgery and care according to patient-, tumor-, and hospital-related factors

Background

Colorectal cancer (CRC) care has improved considerably, particularly since the implementation of a quality of care program centered on national evidence-based guidelines. Formal quality assessment is however still needed. The aim of this research was to identify factors associated with practice variation in CRC patient care.

Methods

CRC patients identified from all cancer centers in South-West France were included. We investigated variations in practices (from diagnosis to surgery), and compliance with recommended guidelines for colon and rectal cancer. We identified factors associated with three colon cancer practice variations potentially linked to better survival: examination of ≥12 lymph nodes (LN), non-use and use of adjuvant chemotherapy for stage II and stage III patients, respectively.

Results

We included 1,206 patients, 825 (68%) with colon and 381 (32%) with rectal cancer, from 53 hospitals. Compliance was high for resection, pathology report, LN examination, and chemotherapy use for stage III patients. In colon cancer, 26% of stage II patients received adjuvant chemotherapy and 71% of stage III patients. 84% of stage US T3T4 rectal cancer patients received pre-operative radiotherapy. In colon cancer, factors associated with examination of ≥12 LNs were: lower ECOG score, advanced stage and larger hospital volume; factors negatively associated were: left sided tumor location and one hospital district. Use of chemotherapy in stage II patients was associated with younger age, advanced stage, emergency setting and care structure (private and location); whereas under-use in stage III patients was associated with advanced age, presence of comorbidities and private hospitals.

Conclusions

Although some changes in practices may have occurred since this observational study, these findings represent the most recent report on practices in CRC in this region, and offer a useful methodological approach for assessing quality of care. Guideline compliance was high, although some organizational factors such as hospital size or location influence practice variation. These factors should be the focus of any future guideline implementation.

Racial and ethnic disparities in outcomes with radiation therapy for rectal adenocarcinoma

BACKGROUND

Race/ethnicity may modify cancer outcomes and manifest as survival disparities for patients with rectal cancer. Our objective was to determine whether disparate rectal cancer outcomes result from variable efficacy of radiation therapy for major racial/ethnic groups.

METHODS

The Los Angeles County Cancer Surveillance Program (CSP) identified patients with rectal adenocarcinoma between the years 1988 and 2006. Patients who underwent curative-intent surgery were grouped by race/ethnicity and by receipt (yes vs. no) and timing (neoadjuvant vs. adjuvant) of radiation therapy. The impact of receipt and timing of radiation therapy on overall survival was then assessed.

RESULTS

Of 4,961 patients in CSP, 2,229 (45%) received radiation therapy. Overall, there was no difference in survival among patients according to receipt of radiation therapy. We then examined the radiation cohort, wherein 919 (41%) and 1,310 (59%) patients received neoadjuvant or adjuvant radiation, respectively. Overall, patients who received neoadjuvant compared to adjuvant radiation had improved survival (median survival (MS), 9.4 vs. 6.8 years, respectively; p < 0.001). Among those patients who received neoadjuvant radiation, whites, Hispanics, and Asians had significantly longer survival than blacks (MS, 10.4, 10.4, and 10.4 vs. 4.4 years, respectively; p = 0.003). On multivariate analysis, race/ethnicity was an independent predictor of survival (p = 0.001).

CONCLUSIONS

To our knowledge, this is the first study examining the efficacy of radiation therapy for racial/ethnic groups with rectal cancer. Disparate outcomes were observed for the administration of radiation therapy for select racial/ethnic groups. The reasons for these disparities in outcomes should be investigated to better optimize radiation therapy for patients with rectal cancer.

Pharmacogenetics of oxaliplatin as adjuvant treatment in colon carcinoma: are single nucleotide polymorphisms in GSTP1, ERCC1, and ERCC2 good predictive markers?

PURPOSE

Adjuvant chemotherapy improves survival in stage III colon cancer patients. However, a subgroup of patients still develops recurrent disease at some point in time, partly because of the ineffectiveness of the chemotherapy. Predictive markers of response are therefore crucial. Our aim was to study the predictive value of functional polymorphisms in genes involved in the metabolism of oxaliplatin and in DNA repair in stage III colon cancer patients.

MATERIALS AND METHODS

Normal DNA was isolated from 98 patients diagnosed with stage III colon carcinoma. Single nucleotide polymorphisms (SNPs) in three genes (the excision repair cross-complementing genes ERCC1 [19007T>C] and ERCC2 [2251A>C], and the glutathione S-transferase pi 1 gene [GSTP1 313A>G]) were tested by PCR followed by digestion with restriction enzymes or by direct sequencing. These genes and SNPs were selected on the basis of their reported associations with oxaliplatin response in colorectal cancer.

RESULTS

The genotype frequencies were in Hardy-Weinberg equilibrium. GSTP1 and ERCC2 polymorphisms were significantly associated with sex. The AA genotype of GSTP1 313A>G was more frequent in men than in women (59% vs 30%, p = 0.02), and the CC genotype of ERCC2 2251A>C was significantly more frequent in women than in men (24% vs 6%, p = 0.02). In univariate and multivariate survival analysis, none of the tested polymorphisms seemed to influence disease-free survival. The GSTP1 AA genotype had different effects on survival between men and women; homozygous A men had significantly worse cancer-specific survival and overall survival than women with the same genotype (log rank p = 0.029 and p = 0.015, respectively).

CONCLUSION

None of the tested polymorphisms is likely to be a reliable marker of response to oxaliplatin therapy. The GSTP1 313A>G homozygous A genotype may have a prognostic value in male patients.

Pharmacogenetics of oxaliplatin as adjuvant treatment in colon carcinoma: are single nucleotide polymorphisms in GSTP1, ERCC1, and ERCC2 good predictive markers?

PURPOSE

Adjuvant chemotherapy improves survival in stage III colon cancer patients. However, a subgroup of patients still develops recurrent disease at some point in time, partly because of the ineffectiveness of the chemotherapy. Predictive markers of response are therefore crucial. Our aim was to study the predictive value of functional polymorphisms in genes involved in the metabolism of oxaliplatin and in DNA repair in stage III colon cancer patients.

MATERIALS AND METHODS

Normal DNA was isolated from 98 patients diagnosed with stage III colon carcinoma. Single nucleotide polymorphisms (SNPs) in three genes (the excision repair cross-complementing genes ERCC1 [19007T>C] and ERCC2 [2251A>C], and the glutathione S-transferase pi 1 gene [GSTP1 313A>G]) were tested by PCR followed by digestion with restriction enzymes or by direct sequencing. These genes and SNPs were selected on the basis of their reported associations with oxaliplatin response in colorectal cancer.

RESULTS

The genotype frequencies were in Hardy-Weinberg equilibrium. GSTP1 and ERCC2 polymorphisms were significantly associated with sex. The AA genotype of GSTP1 313A>G was more frequent in men than in women (59% vs 30%, p = 0.02), and the CC genotype of ERCC2 2251A>C was significantly more frequent in women than in men (24% vs 6%, p = 0.02). In univariate and multivariate survival analysis, none of the tested polymorphisms seemed to influence disease-free survival. The GSTP1 AA genotype had different effects on survival between men and women; homozygous A men had significantly worse cancer-specific survival and overall survival than women with the same genotype (log rank p = 0.029 and p = 0.015, respectively).

CONCLUSION

None of the tested polymorphisms is likely to be a reliable marker of response to oxaliplatin therapy. The GSTP1 313A>G homozygous A genotype may have a prognostic value in male patients.

Exploring racial differences in outcome and treatment for metastatic colorectal cancer: results from a large prospective observational cohort study (BRiTE)

BACKGROUND

African Americans are more likely to be diagnosed with metastatic colorectal cancer than whites and have shorter survival once they are diagnosed. In this analysis, the authors examined racial differences in clinical outcomes among patients with metastatic colorectal cancer (mCRC) who received bevacizumab.

METHODS

The study cohort consisted of 1589 white patients (81.4%) and 227 African American patients (11.6%) with mCRC who received front-line bevacizumab therapy and who were enrolled in a large, predominantly community-based, prospective, observational cohort study. Differences in time-to-event endpoints and response rates were examined by race. Differences in the incidence of baseline and treatment-related toxicities associated with bevacizumab also were examined. Finally, differences in patterns of care by race were explored.

RESULTS

The median overall survival was 22.6 months for African Americans and 22.9 months for whites, and the median progression-free survival was 9.5 months for African Americans and 9.8 months for whites. Response rates (complete responses plus partial responses) were 37.5% for African Americans and 46.3% for whites (adjusted odds ratio, 0.67; 95% confidence interval, 0.50-0.90). African Americans had higher rates of baseline diabetes (18.9% vs 11%; P = .002), higher rates of hypertension (52.9% vs 41.4%; P = .001), and worsening hypertension while on therapy (13.7% vs 8.9%; P = .02), but no differences in on-treatment arterial thromboembolic events were observed.

CONCLUSIONS

This large observational cohort study of patients with mCRC demonstrated that, when treated in a similar fashion with modern chemotherapy, African Americans and whites had equivalent cancer outcomes. No significant differences in bevacizumab-related toxicity or patterns of care were observed between African Americans and whites. The lower response rate among African Americans deserves further study.

Racial disparities in length of stay in hospice care by tumor stage in a large elderly cohort with non-small cell lung cancer

This study examined whether there are racial disparities for length of stay in hospice for patients with non-small cell lung cancer (NSCLC).We studied 53,626 deceased patients aged ≥66 years diagnosed with American Joint Committee on Cancer stages I-IV NSCLC identified from the Surveillance, Epidemiology, and End Results-Medicare linked data who used hospice services in the last six months before death, and died between 1 January 1991 and 31 December 2005. Median time (days) and percent length of stay in hospice, and multivariate incidence rate ratios (IRRs) with 95% confidence intervals (CIs) using zero-truncated negative binomial regression described relationships. In 2000-2005, most patients (64.1%) had <30 days, including those (30.2%) with <7 days length of stay in hospice care. After adjusting for confounders, the IRR for length of stay in hospice compared to whites was 38% increased for blacks (IRR = 1.38; 95% CI: 1.01-1.89), and almost three-fold increased for Hispanics (IRR = 2.91;95% CI: 1.15-7.37) at stages I-II. However, blacks at stages III-IV had slightly decreased use of hospice services (IRR = 0.91; 95% CI: 0.85-0.97). Length of stay decreased slightly among blacks diagnosed with late stage (III-IV) NSCLC in 2000-2005.The gap in disparity for length of stay in hospice has narrowed for ethnic minorities compared to whites, while some ethnic minorities had greater length of stay at early disease stage.

Patterns of adjuvant chemotherapy use in a population-based cohort of patients with resected stage II or III colon cancer

PURPOSE

Previous studies have examined predictors for initiation of adjuvant chemotherapy in stages II and III colon cancer. However, little is known regarding the use of specific chemotherapy regimens or treatment duration.

PATIENTS AND METHODS

We studied treatment records for 2,560 patients with stage II or III colon cancer who received adjuvant chemotherapy between January 2004 and April 2010 at US cancer care facilities participating in a nationwide, commercially available chemotherapy order entry system that captures patient demographics, stage, and details of chemotherapy treatment. Multivariate analyses of prospectively recorded patient and provider characteristics identified predictors of specific therapeutic approaches.

RESULTS

The addition of oxaliplatin to fluoropyrimidine-based adjuvant therapy increased during the study period (P trend < .001), and this combination represented 78% and 90% of adjuvant chemotherapy in stage II or III disease, respectively, by 2007. Older patients, those with diminished performance status, and those treated in a private practice setting were significantly less likely to receive oxaliplatin. Thirty percent of patients discontinued adjuvant therapy after less than 3 months. Older age, treatment without oxaliplatin, and receipt of treatment from a physician with a low volume of patients were each independently associated with premature discontinuation [corrected]. Six percent of patients received bevacizumab as part of their adjuvant regimen.

CONCLUSION

After 2004, oxaliplatin and fluoropyrimidine-based therapy rapidly became the predominant adjuvant treatment for both stage II and stage III colon cancer in this large US cohort. Both increasing patient age and lower volume of an oncologist's practice were associated with early termination of adjuvant therapy.

Diagnostic imaging and biopsy use among elderly medicare beneficiaries with hepatocellular carcinoma

PURPOSE

Diagnostic imaging is effective for evaluating patients suspected of having hepatocellular carcinoma (HCC). Although the diagnosis can be established with imaging alone, diagnostic biopsy may be useful for patients with tumors measuring 1 to 2 cm. To date, biopsy and imaging use among patients with HCC has not been evaluated in the general community.

PATIENTS AND METHODS

This cohort study used Surveillance, Epidemiology, and End Results (SEER) -Medicare data (2002-2005) evaluating biopsy, imaging modalities (ultrasound, computed tomography [CT] scan, and/or magnetic resonance imaging [MRI]), and HCC risk factors.

RESULTS

Of 3,696 patients, 1,197 (32.4%) underwent one or more biopsies, with no change in yearly biopsy rate (trend test, P = .64). Patients with tumors > 5 cm were most likely to receive biopsies (35.3%), with increasing rates of biopsy for larger tumors (P = .001). Patients who received biopsies underwent more imaging than those who did not (P < .001) and were more likely to have an HCC risk factor. Tumor size > 5 cm in the setting of a concurrent HCC risk factor increased the odds of biopsy. In 47.8% of patients, the diagnostic sequence was not consistent with contemporary evidence-based guidelines.

CONCLUSIONS

Despite widespread availability and use of CT scan and MRI, one third of HCC patients undergo biopsy, suggesting a problem with the performance and/or quality of diagnostic imaging or that providers do not believe imaging alone is sufficient to establish the diagnosis. Understanding factors that drive biopsy use may help improve the care of patients with HCC.

Surgical complications are associated with omission of chemotherapy for stage III colorectal cancer

PURPOSE

Appropriate use of adjuvant chemotherapy is a widely recognized quality measure of colorectal cancer care. The objective of this study was to test the hypothesis that surgical complications are associated with omission of chemotherapy for colorectal cancer.

METHODS

We used the 1998 to 2005 Surveillance, Epidemiology and End Results-Medicare database to study adjuvant chemotherapy use among patients with stage III colorectal cancer who underwent surgical resection. Chemotherapy use was compared between patients with and without complications. Univariate analyses and multiple logistic regression were used to test the association between complications and chemotherapy omission, while adjusting for demographics, comorbidity, and other factors. Associations between complications and time to chemotherapy were also studied.

RESULTS

We identified 17,108 eligible patients with stage III colorectal cancer (median age, 75 y; 24% rectal/rectosigmoid). Using a parsimonious list of complication codes, 18% of patients had ≥ 1 complication. Thirteen percent of patients had medical complications and 3.8% of patients had complications requiring reoperation or another procedure. Adjuvant chemotherapy was omitted among 46% of patients with complications, compared with 31% of patients with no complications (P < .0001). Having a complication was independently associated with omission of chemotherapy in multivariable analysis (adjusted OR, 1.76; 95% CI 1.59-1.95). Other factors significantly associated with chemotherapy omission were age, race, marital status, urgent/emergent admission, and type of operation. Risk ratios increase with multiple complications (P < .0001). Complications were also associated with an increased risk of chemotherapy delay (P < .0001).

CONCLUSIONS

Surgical complications are independently associated with omission of chemotherapy for stage III colorectal cancer and with a delay in adjuvant chemotherapy. These data suggest that complications of colorectal surgery may affect both short- and long-term cancer outcomes. Thus, the implementation of quality improvement measures that effectively reduce perioperative complications may also provide a long-term cancer survival benefit.

Insurance status and survival disparities among nonelderly rectal cancer patients in the National Cancer Data Base

BACKGROUND

Among patients with colorectal cancer, insurance status is associated with disparities in survival as well as differences in stage and treatment. The role of stage and treatment differences in these survival disparities is not clear because insurance status is also strongly correlated with race/ethnicity, socioeconomic status, and other factors.

METHODS

The authors used data from the National Cancer Data Base, a national hospital-based cancer registry, to examine insurance status and other factors related to survival among 19,154 rectal cancer patients aged 18 to 64 years. The authors examined the impact of 10 factors on 5-year survival: age, sex, race/ethnicity, histologic grade, histologic subtype, neighborhood education and income levels, facility type, stage, and treatment.

RESULTS

Adjusted only for age, the hazard ratio (HR) for death at 5 years was 1.00 (referent) among privately insured patients, 2.05 (95% confidence interval [CI], 1.89-2.23) among Medicaid-insured patients, and 2.01 (95% CI, 1.84-2.19) among uninsured patients. After adjustment for all factors other than stage and treatment, the HRs were 1.88 (95% CI, 1.722.04) for Medicaid-insured patients and 1.84 (95% CI, 1.69-2.01) for uninsured patients. After further adjustment for stage and treatment, the HRs were 1.34 (95% CI, 1.22-1.46) for Medicaid-insured patients and 1.29 (95% CI, 1.18-1.42) for uninsured patients.

CONCLUSIONS

After adjustment for age, further adjustment for 9 other factors reduced the excess mortality among rectal cancer patients without private insurance by approximately 70%. Disparities in stage and treatment accounted for approximately 53% of the excess mortality, whereas factors other than stage and treatment accounted for approximately 17%.

How does older age influence oncologists' cancer management?

BACKGROUND

Over half of new cancer cases occur in patients aged > or = 65 years. Many older patients can benefit from intensive cancer therapies, yet evidence suggests that this population is undertreated.

METHODS

To assess preferences and influential factors in geriatric cancer management, practicing U.S. medical oncologists completed a survey containing four detailed vignettes exploring colon, breast, lung, and prostate cancer treatment. Participants were randomly assigned one of two surveys with vignettes that were identical except for patient age (<65 years or >70 years).

RESULTS

Physicians in each survey group (n = 200) were demographically similar. Intensive therapy was significantly less likely to be recommended for an older than for a younger, but otherwise identical, patient in two of the scenarios. For a woman with metastatic colon cancer (Eastern Cooperative Oncology Group [ECOG] score, 1) for whom chemotherapy was recommended, nearly all oncologists chose an intensive regimen if the patient's age was 63; but if her age was 85, one fourth of the oncologists chose a less intensive treatment. Likewise, for stage IIA breast cancer (ECOG score, 0), 93% recommended intensive adjuvant treatment for a previously healthy patient aged 63; but only 66% said they would do so if the patient's age was 75. Oncologists commonly identified patient age as an influence on treatment choice, but were even more likely to cite performance status as a determining factor.

CONCLUSIONS

Advanced age can deter oncologists from choosing intensive cancer therapy, even if patients are highly functional and lack comorbidities. Education on tailoring cancer treatment and a greater use of comprehensive geriatric assessment may reduce cancer undertreatment in the geriatric population.

Timely access and quality of care in colorectal cancer: are they related?

OBJECTIVE

Colorectal cancer patients want both timely access and high-quality care. The objective of this study was to explore relationships between quality indicators and access time intervals specific to colorectal cancer patients.

DESIGN

Prospective consecutive cohort study.

SETTING

Single health district.

PARTICIPANTS

Between February 2002 and February 2004, all patients undergoing non-emergent surgery for primary colorectal cancer were enrolled.

INTERVENTION

A standardized method was used to collect clinicodemographic, diagnostic and treatment event data.

MAIN OUTCOME MEASURES

Associations between accepted colorectal cancer-specific quality indicators and benchmarked access time intervals for diagnosis, surgery and adjuvant therapy were examined using multivariate logistic regression, controlling for clinicodemographic factors.

RESULTS

Among the 392 patients in the study cohort, 9.9% were diagnosed on screening examination, 53.1% underwent preoperative staging imaging and 74.5% underwent full preoperative colonic examination. On multivariate logistic regression, patients presenting via screening were more likely to move from presentation to diagnosis within the 4-week benchmark for this access time interval, compared with symptomatic patients (RR 8.1, P < 0.001). The absence of preoperative staging imaging was associated with achievement of the 4-week benchmark for the access time interval from diagnosis to surgery (RR 2.5, P < 0.001). Similarly, an absence of complete preoperative colonic examination was associated with achievement of the 8-week benchmark for the access time interval from surgery to adjuvant therapy (RR 6.6, P = 0.008).

CONCLUSIONS

Although several associations between quality indicators and benchmarked access time intervals for colorectal cancer patients were identified, the relationship between quality and access is complex and far from universal. It is therefore clear that quality care and timely access are not synonymous, and that both must be studied to improve colorectal cancer care.

A black-white comparison of the quality of stage-specific colon cancer treatment

BACKGROUND

Several studies have attributed racial disparities in cancer incidence and mortality to variances in socioeconomic status and health insurance coverage. However, an Institute of Medicine report found that blacks received lower quality care than whites after controlling for health insurance, income, and disease severity.

METHODS

To examine the effects of race on colorectal cancer outcomes within a single setting, the authors performed a retrospective cohort study that analyzed the cancer registry, billing, and medical records of 365 university hospital patients (175 blacks and 190 whites) diagnosed with stage II-IV colon cancer between 2000 and 2005. Racial differences in the quality (effectiveness and timeliness) of stage-specific colon cancer treatment (colectomy and chemotherapy) were examined after adjusting for socioeconomic status, health insurance coverage, sex, age, and marital status.

RESULTS

Blacks and whites had similar sociodemographic characteristics, tumor stage and site, quality of care, and health outcomes. Age and diagnostic stage were predictors of quality of care and mortality. Although few patients (5.8%) were uninsured, they were more likely to present at advanced stages (61.9% at stage IV) and die (76.2%) than privately insured and publicly insured patients (p = .002).

CONCLUSIONS

In a population without racial differences in socioeconomic status or insurance coverage, patients receive the same quality of care, regardless of racial distinction, and have similar health outcomes. Age, diagnostic stage, and health insurance coverage remained independently associated with mortality. Future studies of disparities in colon cancer treatment should examine sociocultural barriers to accessing appropriate care in various healthcare settings.