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Facility Variation in Local Staging of Rectal Adenocarcinoma and its Contribution to Underutilization of Neoadjuvant Therapy

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Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

Guidelines recommend neoadjuvant therapy (NT) for clinical stage II–III (locally advanced) rectal adenocarcinoma, but utilization remains suboptimal. The causes of NT omission remain poorly understood.

Methods

The main outcomes in this study of patients with resected clinically non-metastatic rectal adenocarcinoma in the 2010–2015 National Cancer Database were local staging utilization in patients with non-metastatic tumors (i.e., undocumented clinical stage/pathologic stage I–III) and NT utilization for locally advanced tumors. Multivariable regression was used to examine predictors of these outcomes. Facility-specific risk- and reliability-adjusted local staging and NT rates were calculated. Positive margins and overall survival (OS) were examined as secondary outcomes.

Results

Local staging was omitted in 7737/43,819 (17.7%) patients with clinically non-metastatic tumors and NT was omitted in 5199/31,632 (16.4%) patients with locally advanced tumors. NT was utilized in 24,826 (91.1%) locally advanced patients who had local staging vs. 1607 (36.6%) patients who did not; 2785 (53.6%) locally advanced patients with NT omitted also had local staging omitted. Treatment at facilities with lowest quintile local staging rates was associated with NT omission (relative risk 2.41, 95% confidence interval 2.11, 2.75). Adjusted facility local staging rates varied sixfold (16.1–98.0%), facility NT rates varied twofold (43.9–95.9%), and they were correlated (r = 0.58; P < 0.001). Local staging omission and NT omission were independently associated with positive margins and decreased OS.

Conclusions

Local staging omission is a common care process in over half of cases of omitted NT. These data emphasize the need for quality improvement efforts directed at providing facilities feedback about their local staging rates.

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Authors and Affiliations

  1. Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA

    Douglas S. Swords, Benjamin S. Brooke, David E. Skarda & Courtney L. Scaife

  2. Surgical Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA

    Douglas S. Swords, David E. Skarda & H. Tae Kim

  3. Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA

    Gregory J. Stoddard

  4. Oncology Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA

    William T. Sause

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Contributions

All authors have provided substantial contributions to the conception or design of the work or to the acquisition, analysis, or interpretation of the data for the work; drafted the work or revised it critically for important intellectual content; approved the version to be published; and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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Correspondence to Douglas S. Swords.

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NCDB Disclosure

The data used in the study are derived from a de-identified NCDB file. The American College of Surgeons and the Commission on Cancer have not verified and are not responsible for the analytic or statistical methodology employed, or the conclusions drawn from these data by the investigator.

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Swords, D.S., Brooke, B.S., Skarda, D.E. et al. Facility Variation in Local Staging of Rectal Adenocarcinoma and its Contribution to Underutilization of Neoadjuvant Therapy. J Gastrointest Surg 23, 1206–1217 (2019). https://doi.org/10.1007/s11605-018-4039-8

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