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Does Fragmentation of Care in Locally Advanced Rectal Cancer Increase Patient Mortality?



To evaluate health care fragmentation in patients with stage II and III rectal cancers.


Fragmentation of care among multiple hospitals may worsen outcomes for cancer patients.


National Cancer Database was queried for adult patients who underwent radiation and surgery for locally advanced (stage II–III) rectal adenocarcinoma from 2006 to 2015. Fragmented care was defined as receiving radiation at a different hospital from surgery. Descriptive statistics characterized patients, and survival probability was plotted using the Kaplan-Meier method and a Cox proportional hazards model.


A total of 37,081 patients underwent surgery and radiation for stage II–III rectal cancer from 2006 to 2015 (24,102 integrated care vs. 12,979 fragmented care). Patients who received fragmented care (hazard ratio [HR] 1.105; 95% CI 1.045–1.169) had a higher risk of mortality. Patients who received at least surgery (HR 0.84; 95% CI 0.77–0.92) at academic hospitals had a lower risk of mortality. Academic hospitals had a higher proportion of patients with fragmented care (38.0 vs. comprehensive community 32.8% vs. community 33.8%, p < 0.001). Within academic hospitals, fragmented care portended worse survival (integrated academic 80.0% vs. fragmented academic 76.7%, p = 0.0002). Fragmented care at academic hospitals had increased survival over integrated care at community hospitals (fragmented academic 76.7 vs. integrated community 72.2%, p = 0.00039).


In patients with stage II–III rectal cancer, patients who have integrated care at academic hospitals or at least surgery at academic centers had better survival. All efforts should be made to reduce care fragmentation and surgery at academic centers should be prioritized.

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Correspondence to Kyle Freischlag.

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Freischlag, K., Olivere, L., Turner, M. et al. Does Fragmentation of Care in Locally Advanced Rectal Cancer Increase Patient Mortality?. J Gastrointest Surg 25, 1287–1296 (2021).

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  • Fragmentation
  • Rectal cancer
  • Malignancy
  • Outcomes