Surgeon-Level Variation in Utilization of Local Staging and Neoadjuvant Therapy for Stage II-III Rectal Adenocarcinoma
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Neoadjuvant therapy (NT) is the standard of care for clinical stage II-III rectal adenocarcinoma, but utilization remains suboptimal. We aimed to determine the underlying reasons for omission of local staging and NT.
We conducted a retrospective study of patients with clinical stage II-III or undocumented clinical stage/pathologic stage II-III rectal adenocarcinoma who were treated in 2010–2016 in one of nine Intermountain Healthcare hospitals. The outcomes of omission of local staging and NT were examined with multivariable models. Risk- and reliability-adjusted rates of local staging and NT were calculated for surgeons who treated ≥ 3 patients. Pathologic and long-term outcomes were examined after excluding patients who were not resected or who underwent local excision (N = 11).
Local staging was omitted in 43/240 (17.9%) patients and NT was omitted in 41/240 (17.1%). The strongest risk factors for local staging and NT omission were upper rectal tumors and surgeons who treated ≤ 3 cases/year. Thirty-six of 41 (87.8%) cases of omitted NT had local staging omitted. Adjusted surgeon-specific local staging rates varied 1.6-fold (56.3–92.4%) and NT rates varied 2.8-fold (34.1–97.1%). Surgeon local staging and NT rates were strongly correlated (r = 0.92). NT was associated with lower rates of positive circumferential radial margins (7.9 vs. 20.0%; P = 0.02), node positivity (33.3 vs. 55.0%; P = 0.01), and local recurrences (7.6 vs. 14.9% at 5 years; P = 0.0176).
NT omission should be understood as a consequence of surgeon failure to perform local staging in most cases. Quality improvement efforts should focus on improving utilization of local staging.
KeywordsRectal cancer Locally advanced Clinical staging Local staging Locoregional staging EUS MRI Neoadjuvant treatment Preoperative Neoadjuvant chemoradiotherapy Disparities Centers of excellence OSTRICH Consortium National Accreditation Program for Rectal Cancer
Study conception and design: Swords, Skarda, Sause, Kim
Acquisition and analysis of data: Swords, Gygi
Interpretation of data: Swords, Skarda, Sause, Gawlick, Cannon, Lewis, Scaife, Gygi, Kim
Drafting of manuscript: Swords
Critical revision of manuscript: Swords, Skarda, Sause, Gawlick, Cannon, Lewis, Scaife, Gygi, Kim
Final approval of submission: Swords, Skarda, Sause, Gawlick, Cannon, Lewis, Scaife, Gygi, Kim
- 1.Monson JR, Probst CP, Wexner SD, Remzi FH, Fleshman JW, Garcia-Aguilar J, Chang GJ, Dietz DW, Consortium for Optimizing the Treatment of Rectal C. Failure of evidence-based cancer care in the United States: the association between rectal cancer treatment, cancer center volume, and geography. Ann Surg. 2014;260(4):625–31; discussion 31-2. doi: https://doi.org/10.1097/SLA.0000000000000928.CrossRefGoogle Scholar
- 3.NCCN Clinical Practice Guidelines in Oncology: Rectal Cancer. Version 3.17. [cited May 15, 2018]. Available at: https://www.nccn.org/professionals/physician_gls/pdf/rectal.pdf.
- 4.Sineshaw HM, Jemal A, Thomas CR, Jr., Mitin T. Changes in treatment patterns for patients with locally advanced rectal cancer in the United States over the past decade: An analysis from the National Cancer Data Base. Cancer. 2016;122(13):1996–2003. doi: https://doi.org/10.1002/cncr.29993.CrossRefGoogle Scholar
- 6.Delitto D, George TJ, Jr., Loftus TJ, Qiu P, Chang GJ, Allegra CJ, Hall WA, Hughes SJ, Tan SA, Shaw CM, Iqbal A. Prognostic Value of Clinical vs Pathologic Stage in Rectal Cancer Patients Receiving Neoadjuvant Therapy. J Natl Cancer Inst. 2018;110(5):460–6. doi: https://doi.org/10.1093/jnci/djx228.CrossRefGoogle Scholar
- 9.Glasgow SC, Morris AM, Baxter NN, Fleshman JW, Alavi KS, Luchtefeld MA, Monson JR, Chang GJ, Temple LK. Development of The American Society of Colon and Rectal Surgeons’ Rectal Cancer Surgery Checklist. Dis Colon Rectum. 2016;59(7):601–6. doi: https://doi.org/10.1097/DCR.0000000000000606.CrossRefGoogle Scholar
- 12.Commision on Cancer Measures for Quality of Cancer Care. [cited October 9, 2017]. Available at https://www.facs.org/quality-programs/cancer/ncdb/qualitymeasures.
- 13.Brady JT, Xu Z, Scarberry KB, Saad A, Fleming FJ, Remzi FH, Wexner SD, Winchester DP, Monson JRT, Lee L, Dietz DW, Consortium for Optimizing the Treatment of Rectal C. Evaluating the Current Status of Rectal Cancer Care in the US: Where We Stand at the Start of the Commission on Cancer's National Accreditation Program for Rectal Cancer. J Am Coll Surg. 2018;226(5):881–90. doi: https://doi.org/10.1016/j.jamcollsurg.2018.01.057. CrossRefGoogle Scholar
- 14.Schrag D, Weiser MR, Goodman KA, Gonen M, Hollywood E, Cercek A, Reidy-Lagunes DL, Gollub MJ, Shia J, Guillem JG, Temple LK, Paty PB, Saltz LB. Neoadjuvant chemotherapy without routine use of radiation therapy for patients with locally advanced rectal cancer: a pilot trial. J Clin Oncol. 2014;32(6):513–8. doi: https://doi.org/10.1200/JCO.2013.51.7904.CrossRefGoogle Scholar
- 15.Weiser MR FA, Schrag D, Boughey JC, You YN. Progress in the PROSPECT trial: precision treatment for rectal cancer?. Bull Am Coll Surg. 2015;100(4):51–2.Google Scholar
- 16.Sauer R, Liersch T, Merkel S, Fietkau R, Hohenberger W, Hess C, Becker H, Raab HR, Villanueva MT, Witzigmann H, Wittekind C, Beissbarth T, Rodel C. Preoperative versus postoperative chemoradiotherapy for locally advanced rectal cancer: results of the German CAO/ARO/AIO-94 randomized phase III trial after a median follow-up of 11 years. J Clin Oncol. 2012;30(16):1926–33. doi: https://doi.org/10.1200/JCO.2011.40.1836.CrossRefGoogle Scholar
- 18.Gunderson LL, Sargent DJ, Tepper JE, Wolmark N, O’Connell MJ, Begovic M, Allmer C, Colangelo L, Smalley SR, Haller DG, Martenson JA, Mayer RJ, Rich TA, Ajani JA, MacDonald JS, Willett CG, Goldberg RM. Impact of T and N stage and treatment on survival and relapse in adjuvant rectal cancer: a pooled analysis. J Clin Oncol. 2004;22(10):1785–96. doi: https://doi.org/10.1200/JCO.2004.08.173.CrossRefGoogle Scholar
- 19.Tepper J, O'Connell, M, Niedzwiecki, D, Hollis, DR, Benson, AB 3rd, Cummings, B, Gunderson, LL, Macdonald, JS, Martenson, JA, Mayer, RJ. Adjuvant therapy in rectal cancer: analysis of stage, sex, and local control--final report of intergroup 0114. J Clin Oncol. . 2002;20(7):1744–50.CrossRefGoogle Scholar
- 22.Rickles AS, Dietz DW, Chang GJ, Wexner SD, Berho ME, Remzi FH, Greene FL, Fleshman JW, Abbas MA, Peters W, Noyes K, Monson JR, Fleming FJ, Consortium for Optimizing the Treatment of Rectal C. High Rate of Positive Circumferential Resection Margins Following Rectal Cancer Surgery: A Call to Action. Ann Surg. 2015;262(6):891–8. doi: https://doi.org/10.1097/SLA.0000000000001391. CrossRefGoogle Scholar
- 30.Bland J M, Altman D G. Correlation, regression, and repeated data. BMJ 1994;308(896).Google Scholar
- 31.Bland J M, Altman D G. Calculating correlation coefficients with repeated observations: Part 2—Correlation between subjects. BMJ. 1995;310(633).Google Scholar
- 32.Charlton ME, Lin C, Jiang D, Stitzenberg KB, Halfdanarson TR, Pendergast JF, Chrischilles EA, Wallace RB. Factors associated with use of preoperative chemoradiation therapy for rectal cancer in the Cancer Care Outcomes Research and Surveillance Consortium. Am J Clin Oncol. 2013;36(6):572–9. doi: https://doi.org/10.1097/COC.0b013e318261082b.CrossRefGoogle Scholar
- 33.Charlton M, Hrabe, JE, Wright, KB, Schlichting, JA, McDowell, BD, Halfdanarson, TR, Lin, C, Stitzenberg, KB, Cromwell, JW. Hospital Characteristics Associated with Stage II/III Rectal Cancer Guideline Concordant Care: Analysis of Surveillance, Epidemiology and End Results-Medicare Data. J Gastrointest Surg. 2016;20(5):1002–11.CrossRefGoogle Scholar
- 34.Charlton ME, Mattingly-Wells LR, Marcet JE, McMahon Waldschmidt BC, Cromwell JW. Association between surgeon characteristics and their preferences for guideline-concordant staging and treatment for rectal cancer. Am J Surg. 2014;208(5):817–23. doi: https://doi.org/10.1016/j.amjsurg.2014.03.010.CrossRefGoogle Scholar
- 36.Marinello F, Frasson, M, Baguena, G, Flor-Lorente, B, Cervantes, A, Roselló, S, Espí, A, García-Granero, E,. Selective approach for upper rectal cancer treatment: total mesorectal excision and preoperative chemoradiation are seldom necessary. Dis Colon Rectum. 2015;58(6):556–65.CrossRefGoogle Scholar
- 37.Battersby NJ, How P, Moran B, Stelzner S, West NP, Branagan G, Strassburg J, Quirke P, Tekkis P, Pedersen BG, Gudgeon M, Heald B, Brown G, Group MIS. Prospective Validation of a Low Rectal Cancer Magnetic Resonance Imaging Staging System and Development of a Local Recurrence Risk Stratification Model: The MERCURY II Study. Ann Surg. 2016;263(4):751–60. doi: https://doi.org/10.1097/SLA.0000000000001193. CrossRefGoogle Scholar