The Canadian Partnership Against Cancer Rectal Cancer Project: Protocol for a Pan-Canadian, Multidisciplinary Quality Improvement Initiative to Optimize the Quality of Rectal Cancer Care

Knowledge Translation Interventions to Address Gaps in Rectal Cancer Care

Importance

Over the last 2 decades, increasing use of multimodal strategies has led to significant improvements in oncologic outcomes for patients with rectal cancer. However, uptake of these strategies varies among centers, suggesting that best evidence is not always implemented into practice.

Objectives

To identify gaps in care and initiate knowledge translation interventions to close existing gaps.

Design, Setting, and Participants

This 3-year multifaceted, prospective quality improvement study was conducted at 8 high-volume rectal cancer centers across Canada. From April 2016 to December 2018, patients with stage I to III rectal cancer undergoing total mesorectal excision were enrolled. Data were analyzed from January 2022 through December 2023.

Interventions

Process measures for multimodal strategies to optimize rectal cancer care were selected and prospectively collected for patients with stage I to III rectal cancer undergoing total mesorectal excision. Knowledge translation interventions were implemented to increase uptake of these strategies.

Main Outcome and Measure

Change in uptake of process measures over the study period, with measures taken every 3 months, from time 1 (baseline) to time 7 (18 months).

Results

Among 645 patients with stage I to III rectal cancer (389 male [60.3%]; mean [SD] age, 68.1 [8.2] years), iterative results showed that uptake of 6 of 12 process measures (eg, presentation at multidisciplinary cancer conference: 22 of 77 patients [28.6%] at time 1 to 64 of 91 patients [70.3%] at time 7; P < .001) and 1 pathology measure (inadequate lymph node retrieval: 15 of 77 patients at time 1 [19.5%] to 6 of 91 patients at time 7 [6.6%]; P = .002) improved over time. Positive circumferential resection margin, positive distal margin, and inadequate lymph node retrieval rates at 2 years were 44 patients (6.8%), 10 patients (1.6%), and 79 patients (12.2%), respectively.

Conclusions and Relevance

In this study, there was an improvement in 6 process measures and 1 pathology measure for patients with stage I to III rectal cancer. Furthermore, this study led to standardized processes of care for rectal cancer that may facilitate continuous quality improvement and multicenter trials across Canada.

Quality indicator selection for the Canadian Partnership against Cancer rectal cancer project: A modified Delphi study

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.