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Weeks KS, Gao X, Kahl AR, Engelbart J, Greteman BB, Hassan I, Kapadia MR, Nash SH, Charlton ME. Perspectives on Referring for Rectal Cancer Surgery: a Survey Study of Gastroenterologist and General Surgeons in Iowa. J Gastrointest Cancer 2024; 55:681-690. [PMID: 38151606 DOI: 10.1007/s12029-023-00998-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2023] [Indexed: 12/29/2023]
Abstract
PURPOSE To understand referral practices for rectal cancer surgical care and to secondarily determine differences in referral practices by two main hypothesized drivers of referral: the rurality of the community endoscopists' practice and their affiliation with a colorectal surgeon. METHODS Community gastroenterologists and general surgeons in Iowa completed a mailed questionnaire on practice demographics, volume, and referral practices for rectal cancer patients. Rurality was operationalized with RUCA codes. RESULTS Twenty-two of 53 gastroenterologists (42%) and 120 of 188 general surgeons (64%) (total 144/241, 60%) in Iowa responded. Most performed colonoscopies, including 22 gastroenterologists (100%) and 96 general surgeons (80%). Regular referral of rectal cancer patients to colorectal surgeons was reported for 57% of urban physicians affiliated with a colorectal surgeon, 33% of urban physicians not affiliated with a colorectal surgeon, and 57% and 72% of physicians in large and small rural areas, respectively, who were not affiliated with a colorectal surgeon. High surgeon volume, high hospital volume, and colorectal surgeon specialty were important factors in the referral decisions for over half the physicians. 69% of diagnosing urban general surgeons reported performing rectal cancer surgery about half the time or more, while 85% of small rural and 60% of large rural diagnosing general surgeons reported never or rarely performing rectal cancer surgery. CONCLUSIONS Diagnosing physicians have variable rectal cancer referral practices, including consistency in referred to surgeon and prioritization of volume and specialization. Prioritizing specialized or high-volume rectal cancer surgical care would require changing existing referring patterns.
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Affiliation(s)
- Kristin S Weeks
- Department of Internal Medicine, The Ohio State University Medical Center, 410 W Tenth Ave, 43210, Columbus, OH, USA
| | - Xiang Gao
- Department of Surgery, University of Iowa Carver College of Medicine, 200 Hawkins Dr, 52242, Iowa City, IA, USA
| | - Amanda R Kahl
- State Health Registry of Iowa, University of Iowa, 2600 UCC, 52242, Iowa City, IA, USA
| | - Jacklyn Engelbart
- Department of Surgery, University of Iowa Carver College of Medicine, 200 Hawkins Dr, 52242, Iowa City, IA, USA
| | - Breanna B Greteman
- College of Public Health, Department of Epidemiology, University of Iowa, 145 N Riverside Dr, 52242, Iowa City, IA, USA
| | - Imran Hassan
- Department of Surgery, University of Iowa Carver College of Medicine, 200 Hawkins Dr, 52242, Iowa City, IA, USA
| | - Muneera R Kapadia
- Department of Surgery, University of North Carolina at Chapel Hill, 101 Manning Drive, 27599, Chapel Hill, NC, USA
| | - Sarah H Nash
- State Health Registry of Iowa, University of Iowa, 2600 UCC, 52242, Iowa City, IA, USA
- College of Public Health, Department of Epidemiology, University of Iowa, 145 N Riverside Dr, 52242, Iowa City, IA, USA
| | - Mary E Charlton
- State Health Registry of Iowa, University of Iowa, 2600 UCC, 52242, Iowa City, IA, USA.
- College of Public Health, Department of Epidemiology, University of Iowa, 145 N Riverside Dr, 52242, Iowa City, IA, USA.
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Kapadia MR, Senatore PJ, Messick C, Hull TL, Shaffer VO, Morris AM, Dietz DW, Wexner SD, Wick EC. The value of national accreditation program for rectal cancer: A survey of accredited programs and programs seeking accreditation. Surgery 2024; 175:1007-1012. [PMID: 38267342 DOI: 10.1016/j.surg.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 12/12/2023] [Accepted: 12/13/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND Significant variation in rectal cancer care has been demonstrated in the United States. The National Accreditation Program for Rectal Cancer was established in 2017 to improve the quality of rectal cancer care through standardization and emphasis on a multidisciplinary approach. The aim of this study was to understand the perceived value and barriers to achieving the National Accreditation Program for Rectal Cancer accreditation. METHODS An electronic survey was developed, piloted, and distributed to rectal cancer programs that had already achieved or were interested in pursuing the National Accreditation Program for Rectal Cancer accreditation. The survey contained 40 questions with a combination of Likert scale, multiple choice, and open-ended questions to provide comments. This was a mixed methods study; descriptive statistics were used to analyze the quantitative data, and thematic analysis was used to analyze the qualitative data. RESULTS A total of 85 rectal cancer programs were sent the survey (22 accredited, 63 interested). Responses were received from 14 accredited programs and 41 interested programs. Most respondents were program directors (31%) and program coordinators (40%). The highest-ranked responses regarding the value of the National Accreditation Program for Rectal Cancer accreditation included "improved quality and culture of rectal cancer care," "enhanced program organization and coordination," and "challenges our program to provide optimal, high-quality care." The most frequently cited barriers to the National Accreditation Program for Rectal Cancer accreditation were cost and lack of personnel. CONCLUSION Our survey found significant perceived value in the National Accreditation Program for Rectal Cancer accreditation. Adhering to standards and a multidisciplinary approach to rectal cancer care are critical components of a high-quality care rectal cancer program.
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Affiliation(s)
- Muneera R Kapadia
- Department of Surgery, University of North Carolina at Chapel Hill, NC
| | - Peter J Senatore
- Inspira Health, Rowan University School of Medicine, Vineland, NJ
| | | | - Tracy L Hull
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH
| | | | - Arden M Morris
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - David W Dietz
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL
| | - Elizabeth C Wick
- Department of Surgery, University of California, San Francisco, CA.
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Donnelly C, Or M, Toh J, Thevaraja M, Janssen A, Shaw T, Pathma-Nathan N, Harnett P, Chiew KL, Vinod S, Sundaresan P. Measurement that matters: A systematic review and modified Delphi of multidisciplinary colorectal cancer quality indicators. Asia Pac J Clin Oncol 2024; 20:259-274. [PMID: 36726222 DOI: 10.1111/ajco.13917] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 12/19/2022] [Accepted: 12/26/2022] [Indexed: 02/03/2023]
Abstract
AIM To develop a priority set of quality indicators (QIs) for use by colorectal cancer (CRC) multidisciplinary teams (MDTs). METHODS The review search strategy was executed in four databases from 2009-August 2019. Two reviewers screened abstracts/manuscripts. Candidate QIs and characteristics were extracted using a tailored abstraction tool and assessed for scientific soundness. To prioritize candidate indicators, a modified Delphi consensus process was conducted. Consensus was sought over two rounds; (1) multidisciplinary expert workshops to identify relevance to Australian CRC MDTs, and (2) an online survey to prioritize QIs by clinical importance. RESULTS A total of 93 unique QIs were extracted from 118 studies and categorized into domains of care within the CRC patient pathway. Approximately half the QIs involved more than one discipline (52.7%). One-third of QIs related to surgery of primary CRC (31.2%). QIs on supportive care (6%) and neoadjuvant therapy (6%) were limited. In the Delphi Round 1, workshop participants (n = 12) assessed 93 QIs and produced consensus on retaining 49 QIs including six new QIs. In Round 2, survey participants (n = 44) rated QIs and prioritized a final 26 QIs across all domains of care and disciplines with a concordance level > 80%. Participants represented all MDT disciplines, predominantly surgical (32%), radiation (23%) and medical (20%) oncology, and nursing (18%), across six Australian states, with an even spread of experience level. CONCLUSION This study identified a large number of existing CRC QIs and prioritized the most clinically relevant QIs for use by Australian MDTs to measure and monitor their performance.
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Affiliation(s)
- Candice Donnelly
- Faculty of Medicine and Health, University of Sydney, Camperdown, Australia
| | - Michelle Or
- Radiation Oncology Network, Western Sydney Local Health District, Westmead, Australia
| | - James Toh
- Department of Surgery, Westmead Hospital, Westmead, Australia
- Westmead Clinical School, University of Sydney, Sydney, Australia
| | | | - Anna Janssen
- Faculty of Medicine and Health, University of Sydney, Camperdown, Australia
| | - Tim Shaw
- Faculty of Medicine and Health, University of Sydney, Camperdown, Australia
| | | | - Paul Harnett
- Westmead Clinical School, University of Sydney, Sydney, Australia
- Crown Princess Mary Cancer Centre, Western Sydney Local Health District, Westmead, Australia
| | - Kim-Lin Chiew
- Ingham Institute for Applied Medical Research, Liverpool, Australia
- Liverpool Cancer Therapy Centre, South Western Sydney Local Health District, Liverpool, Australia
- South Western Clinical School, University of New South Wales, Randwick, Australia
- Princess Alexandra Hospital, Division of Cancer Services, Brisbane, Australia
| | - Shalini Vinod
- Liverpool Cancer Therapy Centre, South Western Sydney Local Health District, Liverpool, Australia
- South Western Clinical School, University of New South Wales, Randwick, Australia
| | - Puma Sundaresan
- Radiation Oncology Network, Western Sydney Local Health District, Westmead, Australia
- Westmead Clinical School, University of Sydney, Sydney, Australia
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Loria A, Ramsdale EE, Aquina CT, Cupertino P, Mohile SG, Fleming FJ. From Clinical Trials to Practice: Anticipating and Overcoming Challenges in Implementing Watch-and-Wait for Rectal Cancer. J Clin Oncol 2024; 42:876-880. [PMID: 38315943 DOI: 10.1200/jco.23.01369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 11/10/2023] [Accepted: 12/12/2023] [Indexed: 02/07/2024] Open
Affiliation(s)
- Anthony Loria
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Erika E Ramsdale
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY
| | - Christopher T Aquina
- Departments of Colorectal Surgery and Surgical Oncology, AdventHealth Orlando, Orlando, FL
| | - Paula Cupertino
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Supriya G Mohile
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY
| | - Fergal J Fleming
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY
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Nash S, Weeks K, Kahl AR, Del Vecchio NJ, Gao X, Guyton K, Charlton M. Diagnosing Provider, Referral Patterns, Facility Type, and Patient Satisfaction Among Iowa Rectal Cancer Patients. J Gastrointest Cancer 2024; 55:355-364. [PMID: 37646879 DOI: 10.1007/s12029-023-00963-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE Rectal cancer treatment at high-volume centers is associated with higher likelihood of guideline-concordant care and improved outcomes. Whether rectal cancer patients are referred for treatment at high-volume hospitals may depend on diagnosing provider specialty. We aimed to determine associations of diagnosing provider specialty with treating provider specialty and characteristics of the treating facility for rectal cancer patients in Iowa. METHODS Rectal cancer patients identified using the Iowa Cancer Registry completed a mailed survey on their treatment experience and decision-making process. Provider type was defined by provider specialty and whether the provider referred patients elsewhere for surgery. Multivariable-adjusted logistic regression models were used to examine predictors of being diagnosed by a general surgeon who also performed the subsequent surgery. RESULTS Of 417 patients contacted, 381 (76%) completed the survey; our final analytical sample size was 267. Half of respondents were diagnosed by a gastroenterologist who referred them elsewhere; 30% were diagnosed by a general surgeon who referred them elsewhere, and 20% were diagnosed by a general surgeon who performed the surgery. Respondents who were ≥ 65 years old, had less than a college education, and who made < $50,000 per year were more likely to be diagnosed by a general surgeon who performed surgery. In multivariable-adjusted models, respondents diagnosed and treated by the same general surgeon were more likely to have surgery at hospitals with low annual colorectal cancer surgery volume and less likely to be satisfied with their care. CONCLUSIONS Among rectal cancer patients in Iowa, respondents who were diagnosed and treated by the same provider were less likely to get treatment at a high-volume facility. This study informs the importance of provider referral in centralization of rectal cancer care.
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Affiliation(s)
- Sarah Nash
- Department of Epidemiology, College of Public Health, University of Iowa, 145 N Riverside Dr., IA, 52242, Iowa City, USA
- State Health Registry of Iowa, College of Public Health, University of Iowa, 145 N Riverside Dr., IA, 52242, Iowa City, USA
| | - Kristin Weeks
- Department of Internal Medicine, The Ohio State University Medical Center, 410 W Tenth Ave, Columbus, OH, 43210, USA
| | - Amanda R Kahl
- State Health Registry of Iowa, College of Public Health, University of Iowa, 145 N Riverside Dr., IA, 52242, Iowa City, USA
| | - Natalie J Del Vecchio
- Division of Public Health Science, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Xiang Gao
- Department of Surgery, University of Iowa Carver College of Medicine, 200 Hawkins Dr., IA, 52242, Iowa City, USA
| | - Kristina Guyton
- Department of Surgery, University of Iowa Carver College of Medicine, 200 Hawkins Dr., IA, 52242, Iowa City, USA
| | - Mary Charlton
- Department of Epidemiology, College of Public Health, University of Iowa, 145 N Riverside Dr., IA, 52242, Iowa City, USA.
- State Health Registry of Iowa, College of Public Health, University of Iowa, 145 N Riverside Dr., IA, 52242, Iowa City, USA.
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Arndt KR, Dombek GE, Allar BG, Storino A, Fleishman A, Quinn J, Fabrizio A, Cataldo TE, Messaris E. Impact of National Accreditation Program for Rectal Cancer guidelines on surgical margin status. Surg Oncol 2023; 51:101921. [PMID: 36898906 DOI: 10.1016/j.suronc.2023.101921] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 01/13/2023] [Accepted: 02/21/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND The American College of Surgeons established the National Accreditation Program for Rectal Cancer (NAPRC) to standardize rectal cancer care. We sought to assess the impact of NAPRC guidelines at a tertiary care center on surgical margin status. MATERIALS AND METHODS The Institutional NSQIP database was queried for patients with rectal adenocarcinoma undergoing surgery for curative intent two years prior to and following implementation of NAPRC guidelines. Primary outcome was surgical margin status before (pre-NAPRC) versus after (post-NAPRC) implementation of NAPRC guidelines. RESULTS Surgical pathology in five (5%) pre-NAPRC and seven (8%) post-NAPRC patients had positive radial margins (p = 0.59); distal margins were positive in three (3%) post-NAPRC and six (7%) post-NAPRC patients (p = 0.37). Local recurrence was observed in seven (6%) pre-NAPRC patients, there were no recurrences to date in post-NAPRC patients (p = 0.15). Metastasis was observed in 18 (17%) pre-NAPRC patients and four (4%) post-NAPRC patients (p = 0.55). CONCLUSION NAPRC implementation was not associated with a change in surgical margin status for rectal cancer at our institution. However, the NAPRC guidelines formalize evidence-based rectal cancer care and we anticipate that improvements will be greatest in low-volume hospitals which may not utilize multidisciplinary collaboration.
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Affiliation(s)
- Kevin R Arndt
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Gabrielle E Dombek
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Benjamin G Allar
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Alessandra Storino
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Aaron Fleishman
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jeanne Quinn
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Anne Fabrizio
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Thomas E Cataldo
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Evangelos Messaris
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Boyle JM, van der Meulen J, Kuryba A, Cowling TE, Braun MS, Aggarwal A, Walker K, Fearnhead NS. What is the impact of hospital and surgeon volumes on outcomes in rectal cancer surgery? Colorectal Dis 2023; 25:1981-1993. [PMID: 37705203 PMCID: PMC10946964 DOI: 10.1111/codi.16745] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 04/24/2023] [Accepted: 05/30/2023] [Indexed: 09/15/2023]
Abstract
AIM Evidence for a positive volume-outcome relationship for rectal cancer surgery is unclear. This study aims to evaluate the volume-outcome relationship for rectal cancer surgery at hospital and surgeon level in the English National Health Service (NHS). METHOD All patients undergoing a rectal cancer resection in the English NHS between 2015 and 2019 were included. Multilevel multivariable logistic regression was used to model relationships between outcomes and mean annual hospital and surgeon volumes (using a linear plus a quadratic term for volume) with adjustment for patient characteristics. RESULTS A total of 13 858 patients treated in 166 hospitals were included. Six hospitals (3.6%) performed fewer than 10 rectal cancer resections per year, and 381 surgeons (45.0%) performed fewer than five such resections per year. Patients treated by high-volume surgeons had a reduced length of stay (p = 0.016). No statistically significant volume-outcome relationships were demonstrated for 90-day mortality, 30-day unplanned readmission, unplanned return to theatre, stoma at 18 months following anterior resection, positive circumferential resection margin and 2-year all-cause mortality at either hospital or surgeon level (p values > 0.05). CONCLUSION Almost half of colorectal surgeons in England do not meet national guidelines for rectal cancer surgeons to perform a minimum of five major resections annually. However, our results suggest that centralizing rectal cancer surgery with the main focus of increasing operative volume may have limited impact on NHS surgical outcomes. Therefore, quality improvement initiatives should address a wider range of evidence-based process measures, across the multidisciplinary care pathway, to enhance outcomes for patients with rectal cancer.
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Affiliation(s)
- Jemma M. Boyle
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- Clinical Effectiveness UnitRoyal College of Surgeons of EnglandLondonUK
| | - Jan van der Meulen
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- Clinical Effectiveness UnitRoyal College of Surgeons of EnglandLondonUK
| | - Angela Kuryba
- Clinical Effectiveness UnitRoyal College of Surgeons of EnglandLondonUK
| | - Thomas E. Cowling
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- Clinical Effectiveness UnitRoyal College of Surgeons of EnglandLondonUK
| | - Michael S. Braun
- Department of OncologyThe Christie NHS Foundation TrustManchesterUK
- School of Medical SciencesUniversity of ManchesterManchesterUK
| | - Ajay Aggarwal
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- Department of OncologyGuy's and St. Thomas' NHS Foundation TrustLondonUK
| | - Kate Walker
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- Clinical Effectiveness UnitRoyal College of Surgeons of EnglandLondonUK
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Goffredo P, Hart AA, Tran CG, Kahl AR, Gao X, Del Vecchio NJ, Charlton ME, Hassan I. Patterns of Care and Outcomes of Rectal Cancer Patients from the Iowa Cancer Registry: Role of Hospital Volume and Tumor Location. J Gastrointest Surg 2023; 27:1228-1237. [PMID: 36949239 DOI: 10.1007/s11605-023-05656-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 02/09/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Centralization of rectal cancer surgery has been associated with high-quality oncologic care. However, several patient, disease and system-related factors can impact where patients receive care. We hypothesized that patients with low rectal tumors would undergo treatment at high-volume centers and would be more likely to receive guideline-based multidisciplinary treatment. METHODS Adults who underwent proctectomy for stage II/III rectal cancer were included from the Iowa Cancer Registry and supplemented with tumor location data. Multinomial logistic regression was employed to analyze factors associated with receiving care in high-volume hospital, while logistic regression for those associated with ≥ 12 lymph node yield, pre-operative chemoradiation and sphincter-preserving surgery. RESULTS Of 414 patients, 38%, 39%, and 22% had low, mid, and high rectal cancers, respectively. Thirty-two percent were > 65 years, 38% female, and 68% had stage III tumors. Older age and rural residence, but not tumor location, were associated with surgical treatment in low-volume hospitals. Higher tumor location, high-volume, and NCI-designated hospitals had higher nodal yield (≥ 12). Hospital-volume was not associated with neoadjuvant chemoradiation rates or circumferential resection margin status. Sphincter-sparing surgery was independently associated with high tumor location, female sex, and stage III cancer, but not hospital volume. CONCLUSIONS Low tumor location was not associated with care in high-volume hospitals. High-volume and NCI-designated hospitals had higher nodal yields, but not significantly higher neoadjuvant chemoradiation, negative circumferential margin, or sphincter preservation rates. Therefore, providing educational/quality improvement support in lower volume centers may be more pragmatic than attempting to centralize rectal cancer care among high-volume centers.
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Affiliation(s)
- P Goffredo
- Division of Colon & Rectal Surgery, University of Minnesota, Minneapolis, MN, USA
| | - A A Hart
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - C G Tran
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - A R Kahl
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA
- Iowa Cancer Registry, University of Iowa College of Public Health, Iowa City, IA, USA
| | - X Gao
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - N J Del Vecchio
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - M E Charlton
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA
- Iowa Cancer Registry, University of Iowa College of Public Health, Iowa City, IA, USA
| | - I Hassan
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
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Tang D, Rivard SJ, Weng W, Ramm CA, Cleary RK, Hendren S. Lack of Complete Pretreatment Staging Is Associated With Omission of Neoadjuvant Therapy for Rectal Cancer: A Statewide Study. Dis Colon Rectum 2023; 66:662-670. [PMID: 35195556 DOI: 10.1097/dcr.0000000000002265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Standardized local staging and neoadjuvant therapy are rectal cancer management quality measures supported by the Commission on Cancer and National Accreditation Program for Rectal Cancer for the management of rectal cancer. Previous studies suggested that up to 25% of patients with stage II/III rectal cancer patients do not receive neoadjuvant therapy. We hypothesized that failure to receive neoadjuvant therapy may be caused by failure to properly stage patients before surgery. OBJECTIVE This study aimed to determine whether lack of local rectal cancer staging is associated with underutilization of neoadjuvant therapy and to determine risk factors for omission of neoadjuvant therapy. DESIGN Retrospective cohort study. Bivariate and multivariable analyses were performed on patient, tumor, and 30-day outcome factors associated with neoadjuvant therapy and staging. SETTINGS hospitals participated in the Michigan Surgical Quality Collaborative Colorectal Cancer Project from January 2014 to December 2019. PATIENTS Elective, clinical stage II/III, mid-to-low rectal cancer resections. Patients with upper rectal cancer were excluded. MAIN OUTCOME MEASURES Percentage of patients receiving neoadjuvant therapy. RESULTS The final cohort included 350 patients with clinical stage II/III mid or low rectal cancer-80.9% of patients who had received neoadjuvant therapy and 83.2% of patients who had MRI and/or endoscopic ultrasound. A significant association was found between receiving neoadjuvant therapy and MRI/endorectal ultrasound staging ( p < 0.0001). Eighty-seven percent of patients who had MRI/endorectal ultrasound received neoadjuvant chemoradiotherapy; 49% of patients who did not have MRI/endorectal ultrasound staging received neoadjuvant chemoradiotherapy. Multivariate analysis revealed that risk factors for the omission of neoadjuvant therapy were older age and incomplete staging. LIMITATIONS Observational study with the possibility of unmeasured confounding variables. CONCLUSIONS Neoadjuvant therapy is underused in patients with stage II/III rectal cancer. Omission of pretreatment staging with MRI/endorectal ultrasound is associated with omission of neoadjuvant therapy. These data suggest the need for regional and national quality improvement strategies to standardize the multidisciplinary management of rectal cancer. See Video Abstract at http://links.lww.com/DCR/B923 . LA FALTA DE ESTADIFICACIN COMPLETA PREVIA AL TRATAMIENTO SE ASOCIA CON LA OMISIN DE LA TERAPIA NEOADYUVANTE PARA EL CNCER DE RECTO UN ESTUDIO ESTATAL ANTECEDENTES: La estadificación local estandarizada y la terapia neoadyuvante son medidas de calidad de la Comisión sobre el Cáncer y el Programa Nacional de Acreditación para el Cáncer de Recto para el tratamiento del cáncer de recto. Estudios previos sugirieron que hasta el 25% de los pacientes con cáncer de recto en estadio II/III no reciben terapia neoadyuvante. Planteamos la hipótesis de que la falla en recibir la terapia neoadyuvante puede deberse a la falla en la estadificación adecuada de los pacientes antes de la cirugía.OBJETIVO: El propósito de este estudio es determinar si la falta de estadificación local del cáncer de recto está asociada con la infrautilización de la terapia neoadyuvante y determinar los factores de riesgo para la omisión de la terapia neoadyuvante.DISEÑO: Estudio de cohorte retrospectivo. Se realizaron análisis bivariados y multivariados sobre el paciente, el tumor y los factores de resultado a los 30 días asociados con la terapia neoadyuvante y la estadificación.AJUSTE: Un total de 31 hospitales que participaron en el Proyecto Quirugico Colaborativo de Cáncer Colorrectal de Calidad de Michigan desde enero de 2014 hasta diciembre de 2019.PACIENTES: Resecciones electivas, en estadio clínico II/III, de cáncer de recto medio a bajo. Se excluyeron los pacientes con cáncer de recto superior.MEDIDA DE RESULTADO PRINCIPAL: Porcentaje de pacientes que reciben terapia neoadyuvante. Porcentaje de pacientes que reciben terapia neoadyuvante.RESULTADOS: La cohorte final fue de 350 casos con cáncer de recto medio o bajo en estadio clínico II/III. El 80,9% tenía terapia neoadyuvante y el 83,2%, resonancia magnética y/o ultrasonido endoscópico. Hubo una asociación significativa entre recibir terapia neoadyuvante y la estadificación MRI/ERUS ( p < 0,0001). El 87% de los pacientes a los que se les realizaron imágenes con MRI/ERUS recibieron NT, mientras que el 49% de los pacientes a los que no se les realizó la estadificación con MRI/ERUS tuvieron NT. El análisis multivariante reveló que los factores de riesgo para la omisión de la terapia neoadyuvante fueron la edad avanzada y la estadificación incompleta.LIMITACIONES: Estudio observacional con posibilidad de confusión de variables no medidas.CONCLUSIONES: La terapia neoadyuvante está infrautilizada en pacientes con cáncer de recto en estadio II/III. La omisión de la estadificación previa al tratamiento con MRI/ERUS se asocia con la omisión de la terapia neoadyuvante. Estos datos sugieren la necesidad de estrategias regionales y nacionales de mejora de la calidad para estandarizar el manejo multidisciplinario del cáncer de recto. Consulte Video Resumen en http://links.lww.com/DCR/B923 . (Traducción-Dr Yolanda Colorado ).
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Affiliation(s)
- Dalun Tang
- Department of Surgery, St Joseph Mercy Hospital, Ann Arbor, Michigan
| | - Samantha J Rivard
- Division of Colon and Rectal Surgery, Department of Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan
| | - Wenjing Weng
- Michigan Surgical Quality Collaborative, University of Michigan, Michigan Medicine, Ann Arbor, Michigan
| | - Carole A Ramm
- Department of Academic Research, St Joseph Mercy Hospital, Ann Arbor, Michigan
| | - Robert K Cleary
- Department of Surgery, St Joseph Mercy Hospital, Ann Arbor, Michigan
| | - Samantha Hendren
- Division of Colon and Rectal Surgery, Department of Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan
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Brady JT, Bingmer K, Bliggenstorfer J, Xu Z, Fleming FJ, Remzi FH, Monson JRT, Wexner SD, Dietz DW. Could meeting the standards of the National Accreditation Program for Rectal Cancer in the National Cancer Database improve patient outcomes? Colorectal Dis 2023; 25:916-922. [PMID: 36727838 DOI: 10.1111/codi.16503] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 01/13/2023] [Accepted: 01/23/2023] [Indexed: 02/03/2023]
Abstract
AIM The National Accreditation Program for Rectal Cancer (NAPRC) was developed to improve rectal cancer patient outcomes in the United States. The NAPRC consists of a set of process and outcome measures that hospitals must meet in order to be accredited. We aimed to assess the potential of the NAPRC by determining whether achievement of the process measures correlates with improved survival. METHODS The National Cancer Database was used to identify patients undergoing curative proctectomy for non-metastatic rectal cancer from 2010 to 2014. NAPRC process measures identified in the National Cancer Database included clinical staging completion, treatment starting <60 days from diagnosis, carcinoembryonic antigen level measured prior to treatment, tumour regression grading and margin assessment. RESULTS There were 48 669 patients identified with a mean age of 62 ± 12.9 years and 61.3% of patients were men. The process measure completed most often was assessment of proximal and distal margins (98.4%) and the measure completed least often was the serum carcinoembryonic antigen level prior to treatment (63.8%). All six process measures were completed in 23.6% of patients. After controlling for age, gender, comorbidities, annual facility resection volume, race and pathological stage, completion of all process measures was associated with a statistically significant mortality decrease (Cox hazard ratio 0.88, 95% CI 0.81-0.94, P < 0.001). CONCLUSION Participating institutions provided complete datasets for all six process measures in less than a quarter of patients. Compliance with all process measures was associated with a significant mortality reduction. Improved adoption of NAPRC process measures could therefore result in improved survival rates for rectal cancer in the United States.
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Affiliation(s)
- Justin T Brady
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Katherine Bingmer
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | | | - Zhaomin Xu
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Fergal J Fleming
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Feza H Remzi
- Department of Surgery, New York University Langone Medical Center, New York, New York, USA
| | - John R T Monson
- AdventHealth Surgical Health Outcomes Consortium, AdventHealth, Orlando, Florida, USA
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center Cleveland Clinic Florida, Weston, Florida, USA
| | - David W Dietz
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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11
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Kennecke HF, O'Callaghan CJ, Loree JM, Moloo H, Auer R, Jonker DJ, Raval M, Musselman R, Ma G, Caycedo-Marulanda A, Simianu VV, Patel S, Pitre LD, Helewa R, Gordon VL, Neumann K, Nimeiri H, Sherry M, Tu D, Brown CJ. Neoadjuvant Chemotherapy, Excision, and Observation for Early Rectal Cancer: The Phase II NEO Trial (CCTG CO.28) Primary End Point Results. J Clin Oncol 2023; 41:233-242. [PMID: 35981270 PMCID: PMC9839227 DOI: 10.1200/jco.22.00184] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
PURPOSE Organ-sparing therapy for early-stage I/IIA rectal cancer is intended to avoid functional disturbances or a permanent ostomy associated with total mesorectal excision (TME). The objective of this phase II trial was to determine the outcomes and organ-sparing rate of patients with early-stage rectal cancer treated with neoadjuvant chemotherapy followed by transanal excision surgery (TES). METHODS This phase II trial included patients with clinical T1-T3abN0 low- or mid-rectal adenocarcinoma eligible for endoscopic resection who were treated with 3 months of chemotherapy (modified folinic acid-fluorouracil-oxaliplatin 6 or capecitabine-oxaliplatin). Those with evidence of response proceeded to transanal endoscopic surgery 2-6 weeks later. The primary end point was protocol-specified organ preservation rate, defined as the proportion of patients with tumor downstaging to ypT0/T1N0/X and who avoided radical surgery. RESULTS Of 58 patients enrolled, all commenced chemotherapy and 56 proceeded to surgery. A total of 33/58 patients had tumor downstaging to ypT0/1N0/X on the surgery specimen, resulting in an intention-to-treat protocol-specified organ preservation rate of 57% (90% CI, 45 to 68). Of 23 remaining patients recommended for TME surgery on the basis of protocol requirements, 13 declined and elected to proceed directly to observation resulting in 79% (90% CI, 69 to 88) achieving organ preservation. The remaining 10/23 patients proceeded to recommended TME of whom seven had no histopathologic residual disease. The 1-year and 2-year locoregional relapse-free survival was, respectively, 98% (95% CI, 86 to 100) and 90% (95% CI, 58 to 98), and there were no distant recurrences or deaths. Minimal change in quality of life and rectal function scores was observed. CONCLUSION Three months of induction chemotherapy may successfully downstage a significant proportion of patients with early-stage rectal cancer, allowing well-tolerated organ-preserving surgery.
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Affiliation(s)
- Hagen F. Kennecke
- Providence Cancer Institute and Earle A Chiles Research Institute, Portland, OR,Hagen F. Kennecke, MD, MHA, Providence Cancer Institute, 4805 NE Glisan St, Portland, OR 97213; Twitter: @HKENNECKE; e-mail:
| | | | | | - Hussein Moloo
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Rebecca Auer
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Manoj Raval
- Providence-St. Paul's Hospital, Vancouver, BC, Canada
| | | | - Grace Ma
- Health Sciences North, Sudbury, ON, Canada
| | | | | | - Sunil Patel
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | | | | | | | | | | | - Max Sherry
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | - Dongsheng Tu
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | - Carl J. Brown
- Providence-St. Paul's Hospital, Vancouver, BC, Canada
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12
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Naffouje SA, Ali MA, Kamarajah SK, White B, Salti GI, Dahdaleh F. Assessment of Textbook Oncologic Outcomes Following Proctectomy for Rectal Cancer. J Gastrointest Surg 2022; 26:1286-1297. [PMID: 35441331 DOI: 10.1007/s11605-021-05213-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 11/20/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Outcomes of rectal adenocarcinoma vary considerably. Composite "textbook oncologic outcome" (TOO) is a single metric that estimates optimal clinical performance for cancer surgery. METHODS Patients with stage II/III rectal adenocarcinoma who underwent single-agent neoadjuvant chemoradiation and proctectomy within 5-12 weeks were identified in the National Cancer Database (NCDB). TOO was defined as achievement of negative distal and circumferential resection margin (CRM), retrieval of ≥ 12 nodes, no 90-day mortality, and length of stay (LOS) < 75th percentile of corresponding year's range. Multivariable logistic regression was used to identify predictors of TOO. RESULTS Among 318,225 patients, 8869 met selection criteria. Median age was 62 years (IQR 54-71), and 5550 (62.6%) were males. Low anterior resection was the most common procedure (LAR, 6,037 (68.1%) and 3084 (34.8%) were treated at a high-volume center (≥ 20 rectal resections/year). TOO was achieved in 3967 patients (44.7%). Several components of TOO were achieved commonly, including negative CRM (87.4%), no 90-day mortality (98.0%), no readmission (93.0%), and no prolonged hospitalization (78.8%). Logistic regression identified increasing age, non-private insurance, low-volume centers, open approach, Black race, Charlson score ≥ 3, and abdominoperineal resection (APR) as predictors of failure to achieve TOO. Over time, TOOs were attained more commonly which correlated with increased minimally invasive surgery (MIS) adoption. TOO achievement was associated with improved survival. CONCLUSIONS Rectal adenocarcinoma patients achieve TOO uncommonly. Treatment at high-volume centers and MIS approach were among modifiable factors associated with TOO in this study.
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Affiliation(s)
- Samer A Naffouje
- Department of Surgical Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Muhammed A Ali
- Department of Surgery, Queen Elizabeth Hospital Birmingham, University Hospital Birmingham NHS Trust, Birmingham, UK
| | - Sivesh K Kamarajah
- Department of Surgery, Queen Elizabeth Hospital Birmingham, University Hospital Birmingham NHS Trust, Birmingham, UK
| | - Bradley White
- Department of General Surgery, University of Illinois Hospital and Health Sciences System, Chicago, IL, USA
| | - George I Salti
- Department of General Surgery, University of Illinois Hospital and Health Sciences System, Chicago, IL, USA.,Department of Surgical Oncology, Edward-Elmhurst Health, 120 Spalding Drive, Ste 205, Naperville, IL, 60540, USA
| | - Fadi Dahdaleh
- Department of Surgical Oncology, Edward-Elmhurst Health, 120 Spalding Drive, Ste 205, Naperville, IL, 60540, USA.
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13
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Raman S, Tsoraides SS, Sylla P, Sarin A, Farkas L, DeKoster E, Hull T, Wexner S. Analysis of Patterns of Compliance with Accreditation Standards of National Accreditation Program for Rectal Cancer. J Am Coll Surg 2022; 234:368-376. [PMID: 35213501 DOI: 10.1097/xcs.0000000000000054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We identified commonly deficient standards across rectal cancer programs that underwent accreditation review by the National Accreditation Program for Rectal Cancer to evaluate for patterns of noncompliance. STUDY DESIGN With the use of the internal database of the American College of Surgeons, programs that underwent accreditation review from 2018 to 2020 were evaluated. The occurrence and frequency of noncompliance with the standards, using the 2017 standards manual, were evaluated. Programs were further stratified based on the year of review, annual rectal cancer volume, and Commission on Cancer classification. RESULTS A total of 25 programs with annual rectal cancer volume from 14 to more than 200 cases per year underwent accreditation review. Only 2 programs achieved 100% compliance with all standards. Compliance with standards ranged from 48% to 100%. The 2 standards with the lowest level of compliance included standard 2.5 and standard 2.11 that require all patients with rectal cancer to be discussed at a multidisciplinary team meeting before the initiation of definitive treatment and within 4 weeks after definitive surgical therapy, respectively. Patterns of noncompliance persisted when programs were stratified on the basis oof the year of survey, annual rectal cancer volume, and Commission on Cancer classification. The corrective action process allowed all programs to ultimately become successfully accredited. CONCLUSION During this initial phase of the National Accreditation Program for Rectal Cancer accreditation, the majority of programs undergoing review did not achieve 100% compliance and went through a corrective action process. Although the minimal multidisciplinary team meeting attendance requirements were simplified in the 2021 revised standards, noncompliance related to presentation of all patients at the multidisciplinary team meeting before and after definitive treatment highlights the need for programs seeking accreditation to implement optimized and standardized workflows to achieve compliance.
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Affiliation(s)
- Shankar Raman
- From the MercyOne Des Moines Surgical Group, Des Moines, IA (Raman)
| | - Steven S Tsoraides
- Department of Surgery, University of Illinois College of Medicine at Peoria; Department of Surgery, Springfield Clinic, Peoria, IL (Tsoraides)
| | - Patricia Sylla
- Department of surgery, Mount Sinai Medical Center New York, NY (Sylla)
| | - Ankit Sarin
- Department of surgery, University of California, San Francisco, CA (Sarin)
| | - Linda Farkas
- Department of surgery, University of Texas Southwestern Medical Center, Dallas, TX (Farkas)
| | - Erin DeKoster
- Cancer programs, American College of Surgeons, Chicago, IL (DeKoster)
| | - Tracy Hull
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH (Hull)
| | - Steven Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL (Wexner)
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Lin M, O'Guinn M, Zipprer E, Hsieh JC, Dardon AT, Raman S, Foglia CM, Chao SY. Impact of Medicaid Expansion on the Diagnosis, Treatment, and Outcomes of Stage II and III Rectal Cancer Patients. J Am Coll Surg 2022; 234:54-63. [PMID: 35213460 DOI: 10.1097/xcs.0000000000000010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Insurance status has been associated with disparities in stage at cancer diagnosis. We examined how Medicaid expansion (ME) impacted diagnoses, surgical treatment, use of neoadjuvant therapies (NCRT), and outcomes for Stage II and III rectal cancer. STUDY DESIGN We used 2010-2017 American College of Surgeons National Cancer Database (NCDB) to identify patients ages 18-65, with Medicaid as primary form of payment, and were diagnosed with Stage II or III rectal cancer. Patients were stratified based on Census bureau division's ME adoption rates of High, Medium, Low. Overall trends were examined, and patient characteristics and outcomes were compared before and after ME date of 1/1/2014. RESULTS Over 8 years of NCDB data examined, there was an increasing trend of Stage II and III rectal cancer diagnoses, surgical resection, and use of NCRT for Medicaid patients. We observed an increase in age, proportion of White Medicaid patients in Low ME divisions, and proportion of fourth income quartile patients in High ME divisions. Univariate analysis showed decreased use of open surgery for all 3 categories after ME, but adjusted odds ratios (aOR) were not significant based on multivariate analysis. NCRT utilization increased after ME for all 3 ME adoption categories and aOR significantly increased for Low and High ME divisions. ME significantly decreased 90-day mortality. CONCLUSIONS Medicaid expansion had important impacts on increasing Stage II and III rectal cancer diagnoses, use of NCRT, and decreased 90-day mortality for patients with Medicaid. Our study supports increasing health insurance coverage to improve Medicaid patient outcomes in rectal cancer care.
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Affiliation(s)
- Mayin Lin
- From the MercyOne Des Moines Surgical Group (Lin, Raman), Des Moines, IA
- the Department of Surgery, Creighton University, Omaha, NE (Lin, Raman)
| | - Makayla O'Guinn
- the General Surgery Residency Program, MercyOne Des Moines Medical Center (O'Guinn, Zipprer), Des Moines, IA
| | - Elizabeth Zipprer
- the General Surgery Residency Program, MercyOne Des Moines Medical Center (O'Guinn, Zipprer), Des Moines, IA
| | - John C Hsieh
- the Department of Animal Science, Iowa State University, Ames, IA (Hsieh)
| | - Arturo Torices Dardon
- the General Surgery Residency Program, NewYork-Presbyterian/Queens, Flushing, NY (Dardon)
| | - Shankar Raman
- From the MercyOne Des Moines Surgical Group (Lin, Raman), Des Moines, IA
- the Department of Surgery, Creighton University, Omaha, NE (Lin, Raman)
| | - Christopher M Foglia
- the Department of Surgery, NewYork-Presbyterian/Queens, Weill Cornell Medicine, Flushing, NY (Foglia, Chao)
| | - Steven Y Chao
- the Department of Surgery, NewYork-Presbyterian/Queens, Weill Cornell Medicine, Flushing, NY (Foglia, Chao)
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15
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Becerra AZ, Aquina CT, Grunvald MW, Underhill JM, Bhama AR, Hayden DM. Variation in the volume-outcome relationship after rectal cancer surgery in the United States: Retrospective study with implications for regionalization. Surgery 2021; 172:1041-1047. [PMID: 34961602 DOI: 10.1016/j.surg.2021.11.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 11/16/2021] [Accepted: 11/29/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Previous studies have demonstrated improved outcomes for patients with rectal cancer treated at higher-volume hospitals. However, little is known whether heterogeneity in this effect exists. The objective was to test whether the effect of increased annual rectal cancer resection volume on outcomes is consistent across all hospitals treating rectal cancer. METHODS Adult stage I to III patients who underwent surgical resection for rectal adenocarcinoma from 2004 to 2016 were identified in the National Cancer Database. RESULTS We included 120,522 patients treated at 763 hospitals in this retrospective cohort study. Higher volume was linearly and incrementally related to outcomes in unadjusted analyses. In adjusted models, for an average patient at the average hospital, the effect of increasing the annual caseload of rectal cancer resections by 20 resections per year was associated with 8%, (hazard ratio = 0.92, 95% confidence interval = 0.87, 0.97), 18% (odds ratio = 0.82, 95% confidence interval = 0.70, 0.98), and 16% (odds ratio = 0.84, 95% confidence interval = 0.73, 0.95) relative reductions in 5-year overall survival, 30-, and 90-day mortality, respectively, and with a 19% (odds ratio = 1.19, 95% confidence interval = 1.04, 1.36) relative increase in the rate of neoadjuvant chemoradiation. These effects varied by individual hospitals such that 39% of hospitals do not see any benefit in 5-year overall survival associated with higher volumes. Increased volume was associated with lower positive circumferential resection margin rates at 19% of the hospitals. CONCLUSION This study confirms that higher-volume hospitals have improved outcomes after rectal cancer surgery. However, there exists significant variation in these effects induced by individual within-hospital effects. Regionalization policies may need to be flexible in identifying the hospitals that would achieve enhanced benefits from treating a larger volume of patients.
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Affiliation(s)
- Adan Z Becerra
- Department of Surgery, Rush University Medical Center, Chicago, IL.
| | - Christopher T Aquina
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Miles W Grunvald
- Department of Surgery, Rush University Medical Center, Chicago, IL
| | | | - Anuradha R Bhama
- Department of Surgery, Rush University Medical Center, Chicago, IL
| | - Dana M Hayden
- Department of Surgery, Rush University Medical Center, Chicago, IL. https://twitter.com/dmhayden21
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Type of recurrence is associated with disease-free survival after salvage surgery for locally recurrent rectal cancer. Int J Colorectal Dis 2021; 36:2603-2611. [PMID: 34296325 PMCID: PMC8923354 DOI: 10.1007/s00384-021-03998-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/14/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE To compare the characteristics and outcomes of rectal cancer patients with local recurrence at a perianastomotic site (PA), a surgical field (SF) site, or in lateral lymph nodes (LLN). METHODS A total of 114 consecutive patients who underwent surgery for recurrent, non-metastatic rectal cancer at a single comprehensive cancer center between 1997 and 2012 were grouped on the basis of radiographic assessment of type of recurrence: PA, 76 (67%) patients; SF, 25 (22%) patients; LLN, 13 (11%) patients. Demographic, clinical, and pathological features were compared between the three groups, as were disease-free survival (DFS) and overall survival (OS). RESULTS Recurrence type was associated with positive circumferential margin in the primary resection (PA, 4 [6%]; SF, 4 [19%]; LLN, 3 [25%]; P = 0.027), prior neoadjuvant therapy for the primary tumor (PA, 57 [75%]; SF, 18 [72%]; LLN, 4 [31%]; P = 0.007), and location of the primary tumor in the upper rectum (PA, 33 [45%]; SF, 5 [23%]; LLN, 1 [8%]; P < 0.001). Patients with PA had longer median DFS (PA, 5.1 years; SF, 1.5 years; LLN, 1.2 years; P = 0.036). There was a non-significant trend toward longer OS and higher rates of R0 resection for PA. CONCLUSION Type of recurrence after salvage surgery for locally recurrent rectal cancer is associated with longer DFS in patients with PA recurrence.
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What's the magic number? Impact of time to initiation of treatment for rectal cancer. Surgery 2021; 171:1185-1192. [PMID: 34565608 PMCID: PMC8940728 DOI: 10.1016/j.surg.2021.08.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 07/20/2021] [Accepted: 08/17/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND National guidelines, including the National Accreditation Program for Rectal Cancer, recommend initiation of rectal cancer treatment within 60 days of diagnosis; however, the effect of timely treatment initiation on oncologic outcomes is unclear. The purpose of this study was to evaluate the impact on oncologic outcomes of initiation of rectal cancer treatment within 60 days of diagnosis. METHODS This was a retrospective review of stage II/III rectal cancer patients performed using the United States Rectal Cancer Consortium, a collaboration of 6 academic medical centers. Patients with clinical stage II/III rectal cancer who underwent radical resection between January 1, 2010 and December 31, 2018 were included. The primary exposure was treatment initiation, defined as either resection or initiation of chemotherapy or chemoradiotherapy, within 60 days of diagnosis. The primary outcome was disease recurrence, and the secondary outcome was all-cause mortality. RESULTS A total of 1,031 patients meeting inclusion criteria were included in the analysis. Treatment was initiated within 60 days of diagnosis in 830 patients (80.5%) and after 60 days in 201 patients (20.3%). In multivariable logistic regression, older age, non-White race, and residence greater than 100 miles from the treatment center were significantly associated with delay in treatment beyond 60 days. In survival analysis, 167 patients (16.2%) experienced recurrent disease, and 127 patients (12.3%) died of any cause. In an adjusted model accounting for pathologic staging, treatment sequence, distance to care, age, comorbidities, treatment center, and receipt of adjuvant chemotherapy, neither progression-free survival nor all-cause mortality was significantly associated with timely initiation of therapy with hazard ratios of 1.09 (0.70, 1.69) and 1.03 (0.63, 1.66), respectively. CONCLUSION This study found no difference in oncologic outcomes with initiation of treatment beyond 60 days.
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Simon HL, de Paula TR, Profeta da Luz MM, Kiran RP, Keller DS. Predictors of Positive Circumferential Resection Margin in Rectal Cancer: A Current Audit of the National Cancer Database. Dis Colon Rectum 2021; 64:1096-1105. [PMID: 33951688 DOI: 10.1097/dcr.0000000000002115] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Positive circumferential resection margin is a predictor of local recurrence and worse survival in rectal cancer. National programs aimed to improve rectal cancer outcomes were first created in 2011 and continue to evolve. The impact on circumferential resection margin during this time frame has not been fully evaluated in the United States. OBJECTIVE The purpose of this study was to determine the incidence and predictors of positive circumferential resection margin after rectal cancer resection, across patient, provider, and tumor characteristics. DESIGN This was a retrospective cohort study. SETTINGS The study was conducted using the National Cancer Database, 2011-2016. PATIENTS Adults who underwent proctectomy for pathologic stage I to III rectal adenocarcinoma were included. MAIN OUTCOME MEASURES Rate and predictors of positive circumferential resection margin, defined as resection margin ≤1 mm, were measured. RESULTS Of 52,620 cases, circumferential resection margin status was reported in 90% (n = 47,331) and positive in 18.4% (n = 8719). Unadjusted analysis showed that patients with positive circumferential resection margin were more often men, had public insurance and shorter travel, underwent total proctectomy via open and robotic approaches, and were treated in Southern and Western regions at integrated cancer networks (all p < 0.001). Multivariate analysis noted that positive proximal and/or distal margin on resected specimen had the strongest association with positive circumferential resection margin (OR = 15.6 (95% CI, 13.6-18.1); p < 0.001). Perineural invasion, total proctectomy, robotic approach, neoadjuvant chemoradiation, integrated cancer network, advanced tumor size and grade, and Black race had increased risk of positive circumferential resection margin (all p < 0.050). Laparoscopic approach, surgery in North, South, and Midwest regions, greater hospital volume and travel distance, lower T-stage, and higher income were associated with decreased risk (all p < 0.028). LIMITATIONS This was a retrospective cohort study with limited variables available for analysis. CONCLUSIONS Despite creation of national initiatives, positive circumferential resection margin rate remains an alarming 18.4%. The persistently high rate with predictors of positive circumferential resection margin identified calls for additional education, targeted quality improvement assessments, and publicized auditing to improve rectal cancer care in the United States. See Video Abstract at http://links.lww.com/DCR/B584. PREDICTORES PARA UN MARGEN POSITIVO DE RESECCIN CIRCUNFERENCIAL EN EL CNCER DE RECTO UNA AUDITORA VIGENTE DE LA BASE DE DATOS NACIONAL DE CANCER ANTECEDENTES:El margen positivo de resección circunferencial es un predictor de recurrencia local y peor sobrevida en el cáncer de recto. Los programas nacionales destinados a mejorar los resultados del cáncer de recto se crearon por primera vez en 2011 y continúan evolucionando. La repercusión del margen de resección circunferencial durante este período de tiempo no se ha evaluado completamente en los Estados Unidos.OBJETIVO:Determinar la incidencia y los predictores para un margen positivo de resección circunferencial posterior a la resección del cáncer de recto, según las características del paciente, el proveedor y el tumor.DISEÑO:Estudio de cohorte retrospectivo.AMBITO:Base de datos nacional de cáncer, 2011-2016.PACIENTES:Adultos que se sometieron a proctectomía por adenocarcinoma de recto con un estadío por patología I-III.PRINCIPALES VARIABLES EVALUADAS:Tasa y predictores para un margen positivo de resección circunferencial, definido como margen de resección ≤ 1 mm.RESULTADOS:De 52,620 casos, la condición del margen de resección circunferencial se informó en el 90% (n = 47,331) y positivo en el 18.4% (n = 8,719). El análisis no ajustado mostró que los pacientes con margen positivo de resección circunferencial se presentó con mayor frecuencia en hombres, tenían un seguro social y viajes más cortos, se operaron de proctectomía total abierta y robótica, y fueron tratados en las regiones del sur y el oeste en redes integradas de cáncer (todos p <0,001). El análisis multivariado destacó que el margen proximal y / o distal positivo de la pieza resecada tenía la asociación más fuerte con el margen postivo de resección circunferencial (OR 15,6; IC del 95%: 13,6-18,1, p <0,001). La invasión perineural, la proctectomía total, el abordaje robótico, la quimioradioterapia neoadyuvante, la red de cáncer integrada, el tamaño y grado del tumor avanzado y la raza afroamericana tenían un mayor riesgo de un margen de una resección positiva circunferencial (todos p <0,050). El abordaje laparoscópico, la cirugía en las regiones Norte, Sur y Medio Oeste, un mayor volumen hospitalario y distancia de viaje, estadio T más bajo y mayores ingresos se asociaron con una disminución del riesgo (todos p <0,028).LIMITACIONES:Estudio de cohorte retrospectivo con variables limitadas disponibles para análisis.CONCLUSIONES:A pesar del establecimiento de iniciativas nacionales, la tasa de margen positivo de resección circunferencial continúa siendo alarmante, 18,4%. El índice continuamente elevado junto a los predictores de un margen positivo de resección circunferencial hace un llamado para una mayor educación, evaluaciones específicas de mejora de la calidad y difusión de las auditorías para mejorar la atención del cáncer de recto en los Estados Unidos. Vea el resumen de video en http://links.lww.com/DCR/B584. Consulte Video Resumen en http://links.lww.com/DCR/B584.
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Affiliation(s)
- Hillary L Simon
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Thais Reif de Paula
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Magda M Profeta da Luz
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Ravi P Kiran
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, New York
| | - Deborah S Keller
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, New York
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Racial Disparities in Treatment for Rectal Cancer at Minority-Serving Hospitals. J Gastrointest Surg 2021; 25:1847-1856. [PMID: 32725520 DOI: 10.1007/s11605-020-04744-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 07/14/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Racial disparities exist in patients with rectal cancer with respect to both treatment and survival. Minority-serving hospitals (MSHs) provide healthcare to a disproportionately large percent of minority patients in the USA. We examined the effects of rectal cancer treatment at MSH to understand drivers of these disparities. METHODS The NCDB was queried (2004-2015), and patients diagnosed with stage II or III rectal adenocarcinoma were identified. Racial case mix distribution was calculated at the institutional level, and MSHs were defined as those within the top decile of Black and Hispanic patients. Logistic regression was used to identify predictors of receipt of standard of care treatment. Survival was assessed using the Kaplan-Meier method, and Cox proportional hazards models were used to evaluate adjusted risk of death. Analyses were clustered by facility. RESULTS A total of 68,842 patients met the inclusion criteria. Of these patients, 63,242 (91.9%) were treated at non-MSH, and 5600 (8.1%) were treated at MSH. In multivariable analysis, treatment at MSH (OR 0.70 95%CI 0.61-0.80 p < 0.001) and Black race (OR 0.75 95%CI 0.70-0.81 p < 0.001) were associated with significantly lower odds of receiving standard of care. In adjusted analysis, Black patients had a significantly higher risk of mortality (HR 1.20 95%CI 1.14-1.26 p < 0.001). CONCLUSIONS Treatment at MSH institutions and Black race were associated with significantly decreased odds of receipt of recommended standard therapy for locally advanced rectal adenocarcinoma. Survival was worse for Black patients compared to White patients despite adjustment for receipt of standard of care.
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20
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Abelson JS, Barron J, Bauer PS, Chapman WC, Schad C, Ohman K, Glasgow S, Hunt S, Mutch M, Smith RK, Wise PE, Silviera M. Travel Time to a High Volume Center Negatively Impacts Timing of Care in Rectal Cancer. J Surg Res 2021; 266:96-103. [PMID: 33989893 DOI: 10.1016/j.jss.2021.02.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 01/16/2021] [Accepted: 02/27/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Regionalization of rectal cancer surgery may lead to worse disease free survival owing to longer travel time to reach a high volume center yet no study has evaluated this relationship at a single high volume center volume center. MATERIALS AND METHODS This was a retrospective review of rectal cancer patients undergoing surgery from 2009 to 2019 at a single high volume center. Patients were divided into two groups based on travel time. The primary outcome was disease-free survival (DFS). Additional outcomes included treatment within 60 d of diagnosis, completeness of preoperative staging, and evaluation by a colorectal surgeon prior to initiation of treatment. RESULTS A lower proportion of patients with long travel time began definitive treatment within 60 d of diagnosis (74.0% versus 84.0%, P= 0.01) or were seen by the treating colorectal surgeon before beginning definitive treatment (74.8% versus 85.4%, P < 0.01). On multivariable logistic regression analysis, patients with long travel time were significantly less likely to begin definitive treatment within 60 d of diagnosis (OR = 0.54; 95% CI = 0.31-0.93) or to be evaluated by a colorectal surgeon prior to initiating treatment (OR = 0.45; 95% CI = 0.25-0.80). There were no significant differences in DFS based on travel time. CONCLUSIONS Although patients with long travel times may be vulnerable to delayed, lower quality rectal cancer care, there is no difference in DFS when definitive surgery is performed at a high volume canter. Ongoing research is needed to identify explanations for delays in treatment to ensure all patients receive the highest quality care.
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Affiliation(s)
- Jonathan S Abelson
- Division of Colon and Rectal Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts.
| | - John Barron
- Saint Louis University School of Medicine, Saint Louis, Missouri
| | - Philip S Bauer
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - William C Chapman
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Christine Schad
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Kerri Ohman
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Sean Glasgow
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Steven Hunt
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Matthew Mutch
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Radhika K Smith
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Paul E Wise
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Matthew Silviera
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, Missouri
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21
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van Huizen LS, Dijkstra PU, Hemmer PH, van Etten B, Buis CI, Olsder L, van Vilsteren FG, Ahaus K(CB, Roodenburg JL. Reorganizing the Multidisciplinary Team Meetings in a Tertiary Centre for Gastro-Intestinal Oncology Adds Value to the Internal and Regional Care Pathways. A Mixed Method Evaluation. Int J Integr Care 2021; 21:8. [PMID: 33664641 PMCID: PMC7908930 DOI: 10.5334/ijic.5526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 01/19/2021] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION The reorganisation of the structure of a Gastro-Intestinal Oncology Multidisciplinary Team Meeting (GIO-MDTM) in a tertiary centre with three care pathways is evaluated on added value. METHODS In a mixed method investigation, process indicators such as throughput times were analysed and stakeholders were interviewed regarding benefits and drawbacks of the reorganisation and current MDTM functioning. RESULTS For the hepatobiliary care pathway, the time to treatment plan increased, but the time to start treatment reduced significantly. The percentage of patients treated within the Dutch standard of 63 days increased for the three care pathways. From the interviews, three themes emerged: added value of MDTMs, focus on planning integrated care and awareness of possible improvements. DISCUSSION The importance of evaluating interventions in oncology care pathways is shown, including detecting unexpected drawbacks. The evaluation provides insight into complex dynamics of the care pathways and contributes with recommendations on functioning of an MDTM. CONCLUSIONS Throughput times are only partly determined by oncology care pathway management, but have influence on the functioning of MDTMs. Process indicator information can help to reflect on integration of care in the region, resulting in an increase of patients treated within the Dutch standard.
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Affiliation(s)
- Lidia S. van Huizen
- University of Groningen, University Medical Center Groningen, Department of Oral and Maxillofacial Surgery, Groningen, The Netherlands
- University of Groningen, University Medical Center Groningen, Department of Quality and Patient Safety, Groningen, The Netherlands
- Kerteza, a Worldwide Consultancy and Training Institute for Healthcare Organizations, Kasterlee, Belgium
| | - Pieter U. Dijkstra
- University of Groningen, University Medical Center Groningen, Department of Oral and Maxillofacial Surgery, Groningen, The Netherlands
- University of Groningen, University Medical Center Groningen, Center for Rehabilitation, Groningen, The Netherlands
| | - Patrick H.J. Hemmer
- University of Groningen, University Medical Center Groningen, Department of Surgery, Groningen, The Netherlands
| | - Boudewijn van Etten
- University of Groningen, University Medical Center Groningen, Department of Surgery, Groningen, The Netherlands
| | - Carlijn I. Buis
- University of Groningen, University Medical Center Groningen, Department of Surgery, Groningen, The Netherlands
| | - Linde Olsder
- University of Groningen, University Medical Center Groningen, Department of Surgery, Groningen, The Netherlands
| | - Frederike G.I. van Vilsteren
- University of Groningen, University Medical Center Groningen, Department of Gastroenterology and Hepatology, Groningen, The Netherlands
| | - Kees (C.)T. B. Ahaus
- University of Groningen, University Medical Center Groningen, Department of Quality and Patient Safety, Groningen, The Netherlands
- Erasmus University Rotterdam, Erasmus School of Health Policy & Management, Rotterdam, The Netherlands
| | - Jan L.N. Roodenburg
- University of Groningen, University Medical Center Groningen, Department of Oral and Maxillofacial Surgery, Groningen, The Netherlands
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22
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Biju K, Zhang GQ, Stem M, Sahyoun R, Safar B, Atallah C, Efron JE, Rajput A. Impact of Treatment Coordination on Overall Survival in Rectal Cancer. Clin Colorectal Cancer 2021; 20:187-196. [PMID: 33618972 DOI: 10.1016/j.clcc.2021.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 01/15/2021] [Accepted: 01/17/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Rectal cancer treatment is often multimodal, comprising of surgery, chemotherapy, and radiotherapy. However, the impact of coordination between these modalities is currently unknown. We aimed to assess whether delivery of nonsurgical therapy within same facility as surgery impacts survival in patients with rectal cancer. METHODS A patient cohort with rectal cancer stages II to IV who received multimodal treatment between 2004 and 2016 from National Cancer Database was retrospectively analyzed. Patients were categorized into three groups: (A) surgery + chemotherapy + radiotherapy at same facility (surgery + 2); (B) surgery + chemotherapy or radiotherapy at same facility (surgery + 1); or (C) only surgery at reporting facility (chemotherapy + radiotherapy elsewhere; surgery + 0). The primary outcome was 5-year overall survival (OS), analyzed using Kaplan-Meier curves, log-rank tests, and Cox proportional-hazards models. RESULTS A total of 44,716 patients (16,985 [37.98%] surgery + 2, 12,317 [27.54%] surgery + 1, and 15,414 [34.47%] surgery + 0) were included. In univariate analysis, we observed that surgery+2 patients had significantly greater 5-year OS compared to surgery + 1 or surgery + 0 patients (5-year OS: 63.46% vs 62.50% vs 61.41%, respectively; P= .002). We observed similar results in multivariable Cox proportional-hazards analysis, with surgery + 0 group demonstrating increased hazard of mortality when compared to surgery + 2 group (HR: 1.09; P< .001). These results held true after stratification by stage for stage II (HR 1.10; P= .022) and stage III (HR 1.12; P< .001) but not for stage IV (P= .474). CONCLUSION Greater degree of care coordination within the same facility is associated with greater OS in patients with stage II to III rectal cancer. This finding illustrates the importance of interdisciplinary collaboration in multimodal rectal cancer therapy.
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Affiliation(s)
- Kevin Biju
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - George Q Zhang
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Miloslawa Stem
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rebecca Sahyoun
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Bashar Safar
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Chady Atallah
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jonathan E Efron
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ashwani Rajput
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
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23
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Gilshtein H, Wexner SD. National Accreditation Program for Rectal Cancer. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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24
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Abelson JS, Bauer PS, Barron J, Bommireddy A, Chapman WC, Schad C, Ohman K, Hunt S, Mutch M, Silviera M. Fragmented Care in the Treatment of Rectal Cancer and Time to Definitive Therapy. J Am Coll Surg 2020; 232:27-33. [PMID: 33190785 DOI: 10.1016/j.jamcollsurg.2020.10.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/15/2020] [Accepted: 10/15/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The National Accreditation Program for Rectal Cancer (NAPRC) emphasizes a multidisciplinary approach for treating rectal cancer and has developed performance measures to ensure that patients receive standardized care. We hypothesized that rectal cancer patients receiving care at multiple centers would be less likely to receive timely and appropriate care. STUDY DESIGN A single institution retrospective review of a prospectively maintained database was performed. All patients undergoing proctectomy and ≤1 other treatment modality (eg radiation and/or chemotherapy) for Stage II/III rectal adenocarcinoma were included. Unified care was defined as receiving all modalities of care at our institution, and fragmented care was defined as having at least 1 treatment modality at another institution. RESULTS From 2009 to 2019, 415 patients met inclusion criteria, with 197 (47.5%) receiving fragmented care and 218 (52.5%) receiving unified care. The unified cohort patients were more likely to see a colorectal surgeon before starting treatment (89.0% vs 78.7%, p < 0.01) and start definitive treatment within 60 days of diagnosis (89.0% vs 79.7%, p = 0.01). On adjusted analysis, unified care patients were 2.78 times more likely to see a surgeon before starting treatment (95% CI 1.47-5.24) and 2.63 times more likely to start treatment within 60 days (95% CI 1.35-5.13). There was no difference in 90-day mortality or 5-year disease-free survival. CONCLUSIONS This retrospective cohort study suggests patients with rectal cancer receiving fragmented care are at an increased risk of delays in care without any impact on disease-free survival. These findings need to be considered within the context of ongoing regionalization of rectal cancer care to ensure all patients receive optimal care, irrespective of whether care is delivered across multiple institutions.
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Affiliation(s)
- Jonathan S Abelson
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, MO.
| | - Philip S Bauer
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, MO
| | - John Barron
- Saint Louis University School of Medicine, Saint Louis, MO
| | - Ani Bommireddy
- Saint Louis University School of Medicine, Saint Louis, MO
| | - William C Chapman
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Christine Schad
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Kerri Ohman
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Steven Hunt
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Matthew Mutch
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Matthew Silviera
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, MO
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25
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Gao X, Weeks KS, Gribovskaja-Rupp I, Hassan I, Ward MM, Charlton ME. Provider Viewpoints in the Management and Referral of Rectal Cancer. J Surg Res 2020; 258:370-380. [PMID: 33051062 DOI: 10.1016/j.jss.2020.08.073] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 07/22/2020] [Accepted: 08/25/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Patients with rectal cancer treated at specialized or high-volume hospitals have better outcomes, but a minority of these patients are treated there. Physician recommendations are important considerations for patients with rectal cancer when making treatment decisions, yet little is known about the factors that affect these physician referral patterns. METHODS Semistructured telephone interviews were conducted in 2018-2019 with Iowa gastroenterologists (GIs) and general surgeons (GSs) who performed colonoscopies in a community setting. A thematic approach was used to analyze and code qualitative data. RESULTS We interviewed 10 GIs and 6 GSs with self-reported averages of 15.5 y in practice, 1100 endoscopic procedures annually, and 6 rectal cancer diagnoses annually. Physicians believed surgeon experience and colorectal specialization were directly related to positive outcomes in rectal cancer resections. Most GSs performed resections on patients they diagnosed and typically only referred patients to colorectal surgeons (CRS) in complex cases. Conversely, GIs generally referred to CRS in all cases. Adhering to existing referral patterns due to the pressure of health care networks was a salient theme for both GIs and GSs. CONCLUSIONS While respondents believe that high volume/specialization is related to improved surgical outcomes, referral recommendations are heavily influenced by existing referral networks. Referral practices also differ by diagnosing specialty and suggest rural patients may be less likely to be referred to a CRS because more GSs perform colonoscopies in rural areas and tend to keep patients for resection. System-level interventions that target referral networks may improve rectal cancer outcomes at the population level.
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Affiliation(s)
- Xiang Gao
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa.
| | - Kristin S Weeks
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa
| | | | - Imran Hassan
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Marcia M Ward
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, Iowa
| | - Mary E Charlton
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa.
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26
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Wexner SD, White CM. Improving Rectal Cancer Outcomes with the National Accreditation Program for Rectal Cancer. Clin Colon Rectal Surg 2020; 33:318-324. [PMID: 32968367 DOI: 10.1055/s-0040-1713749] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Background The treatment of rectal cancer has undergone dramatic changes over the past 50 years. It has evolved from a rather morbid disease usually requiring a permanent stoma, almost exclusively managed by surgeons, to one that involves experts across numerous disciplines to provide the best care for the patient. With significant improvements in surgical techniques, the use of chemotherapy and radiotherapy, advanced imaging, and standardization of pathological assessment, the perioperative morbidity and permanent colostomy rates have significantly decreased. We have seen improvements in the quality of the specimen and rates of recurrence as well as disease-free survival. Rectal cancer, as demonstrated in European trials, has now been recognized as a disease best managed by a multidisciplinary team. Objective The aim of this article is to evaluate the main body of literature leading to the advances made possible by the new American College of Surgeons Commission on Cancer National Accreditation Program for Rectal Cancer. Results Following the launch of the American College of Surgeons Commission on Cancer National Accreditation Program for Rectal Cancer, we expect dramatic increases in membership and accreditation, with associated improvement in center performance and, ultimately, in patient outcomes. Limitations The National Accreditation Program for Rectal Cancer began in 2017. To date, the only data that have been analyzed are from the preintervention phase. Conclusions Based on the results of studies within the United States and on the successes demonstrated in Europe, it remains our hope and expectation that the management of rectal cancer in the United States will rapidly improve.
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Affiliation(s)
- Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida
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27
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Lu PW, McCarty JC, Fields AC, Azzeh M, Goldberg JE, Irani J, Bleday R, Melnitchouk N. The Distribution of Colorectal Surgeons in the United States. J Surg Res 2020; 251:71-77. [DOI: 10.1016/j.jss.2020.01.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 01/14/2020] [Accepted: 01/25/2020] [Indexed: 11/30/2022]
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28
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Xu Z, Fleming FJ. Quality Assurance, Metrics, and Improving Standards in Rectal Cancer Surgery in the United States. Front Oncol 2020; 10:655. [PMID: 32411608 PMCID: PMC7202129 DOI: 10.3389/fonc.2020.00655] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 04/08/2020] [Indexed: 12/20/2022] Open
Abstract
Rectal cancer surgery has seen significant improvement in recent years. This has been possible in part due to focus on surgeon education and training, specific surgical quality metrics, and longitudinal tracking of data through the use of registries. In countries that have implemented such efforts, data has shown significant improvement in outcomes. However, there continues to be significant variation in rectal cancer outcomes and practices worldwide. Just within the United States, county level mortality rates from rectal cancer range from 8-15 per 100,000 to 38-59 per 100,000. In order to continue to improve rectal cancer patient outcomes, there needs to be evidence based guidelines and standards centered around the framework of structure, process, and outcomes. In addition, there must be a feedback system by which programs can continually assess their performance. Obtaining evidence for specific standards and measures can be challenging and requires analyzing available data and literature, some of which may be conflicting. This article evaluates the evolution of metrics and standards used for quality improvement in rectal cancer and ongoing efforts to further improve patient outcomes.
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Affiliation(s)
- Zhaomin Xu
- Surgical Health Outcomes and Research Enterprise (SHORE), Division of Colorectal Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Fergal J Fleming
- Surgical Health Outcomes and Research Enterprise (SHORE), Division of Colorectal Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY, United States
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29
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Fields AC, Lu PW, Yoo J, Irani J, Goldberg JE, Bleday R, Melnitchouk N. Treatment of stage I-III rectal cancer: Who is refusing surgery? J Surg Oncol 2020; 121:990-1000. [PMID: 32090341 DOI: 10.1002/jso.25873] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 02/10/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Surgical resection is a cornerstone in the management of patients with rectal cancer. Patients may refuse surgical treatment for several reasons although the rate of refusal is currently unknown. METHODS The National Cancer Database was utilized to identify patients with stage I-III rectal cancer. Patients who refused surgical resection were compared to patients who underwent curative resection. RESULTS A total of 509 (2.6%) patients with stage I and 2082 (3.5%) patients with stage II/III rectal cancer refused surgery. In multivariable analysis for stage I disease, older age, Black race, and Medicaid/no insurance were independent predictors of surgery refusal. Patients were less likely to refuse surgery if they had a higher income or lived further distances from the treatment facility. In multivariable analysis for stage II/III disease, older age, Black race, insurance other than private, and rural county were independent predictors of surgery refusal. Patients were less likely to refuse surgery if they had higher Charlson comorbidity scores, lived further distances from the treatment facility, or underwent chemoradiation. There was a significant decrease in survival for patients refusing surgery compared to patients undergoing recommended surgery. CONCLUSIONS A small proportion of patients refuse surgery for rectal cancer, and this treatment decision significantly affects survival.
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Affiliation(s)
- Adam C Fields
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Pamela W Lu
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - James Yoo
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Jennifer Irani
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Joel E Goldberg
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Ronald Bleday
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Nelya Melnitchouk
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Surgery, Harvard Medical School, Boston, Massachusetts
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30
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Antunez AG, Kanters AE, Regenbogen SE. Evaluation of Access to Hospitals Most Ready to Achieve National Accreditation for Rectal Cancer Treatment. JAMA Surg 2020; 154:516-523. [PMID: 30785616 DOI: 10.1001/jamasurg.2018.5521] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The American College of Surgeons National Accreditation Program for Rectal Cancer (NAPRC) promotes multidisciplinary care to improve oncologic outcomes in rectal cancer. However, accreditation requirements may be difficult to achieve for the lowest-performing institutions. Thus, it is unknown whether the NAPRC will motivate care improvement in these settings or widen disparities. Objectives To characterize hospitals' readiness for accreditation and identify differences in the patients cared for in hospitals most and least prepared for accreditation. Design, Setting, and Participants A total of 1315 American College of Surgeons Commission on Cancer-accredited hospitals in the National Cancer Database from January 1, 2011, to December 31, 2015, were sorted into 4 cohorts, organized by high vs low volume and adherence to process standards, and patient and hospital characteristics and oncologic outcomes were compared. The patients included those who underwent surgical resection with curative intent for rectal adenocarcinoma, mucinous adenocarcinoma, or signet ring cell carcinoma. Data analysis was performed from November 2017 to January 2018. Exposures Hospitals' readiness for accreditation, as determined by their annual resection volume and adherence to 5 available NAPRC process standards. Main Outcomes and Measures Hospital characteristics, patient sociodemographic characteristics, and 5-year survival by hospital. Results Among the 1315 included hospitals, 38 (2.9%) met proposed thresholds for all 5 NAPRC process standards and 220 (16.7%) met the threshold on 4 standards. High-volume hospitals (≥20 resections per year) tended to be academic institutions (67 of 104 [64.4%] vs 159 of 1211 [13.1%]; P = .001), whereas low-volume hospitals (<20 resections per year) tended to be comprehensive community cancer programs (530 of 1211 [43.8%] vs 28 of 104 [26.9%]; P = .001). Patients in low-volume hospitals were more likely to be older (11 429 of 28 076 [40.7%] vs 4339 of 12 148 [35.7%]; P < .001) and have public insurance (13 054 of 28 076 [46.5%] vs 4905 of 12 148 [40.4%]; P < .001). Low-adherence hospitals were more likely to care for black and Hispanic patients (1980 of 19 577 [17.2%] vs 3554 of 20 647 [10.1%]; P < .001). On multivariable Cox proportional hazards model regression, high-volume hospitals had better 5-year survival outcomes than low-volume hospitals (hazard ratio, 0.99; 95% CI, 0.99-1.00; P < .001), but there was no significant survival difference by hospital process standard adherence. Conclusions and Relevance Hospitals least likely to receive NAPRC accreditation tended to be community institutions with worse survival outcomes, serving patients at a lower socioeconomic position. To possibly avoid exacerbating disparities in access to high-quality rectal cancer care, the NAPRC study findings suggest enabling access for patients with socioeconomic disadvantage or engaging in quality improvement for hospitals not yet achieving accreditation benchmarks.
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Affiliation(s)
- Alexis G Antunez
- University of Michigan Medical School, Ann Arbor.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Arielle E Kanters
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor.,Department of Surgery, University of Michigan, Ann Arbor
| | - Scott E Regenbogen
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor.,Department of Surgery, University of Michigan, Ann Arbor
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31
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Sharp SP, Malizia R, Skancke M, Arsoniadis EG, Ata A, Stain SC, Valerian BT, Lee EC, Wexner SD. A NSQIP analysis of trends in surgical outcomes for rectal cancer: What can we improve upon? Am J Surg 2020; 220:401-407. [PMID: 31964524 DOI: 10.1016/j.amjsurg.2020.01.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 12/01/2019] [Accepted: 01/04/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is significant variation in rectal cancer outcomes in the USA, and reported outcomes have been inferior to those in other countries. In recognition of this fact, the American College of Surgeons (ACS) recently launched the Commission on Cancer (CoC) National Accreditation Program for Rectal Cancer (NAPRC) in an effort to further optimize rectal cancer care. Large surgical databases will play an important role in tracking surgical and oncologic outcomes. Our study sought to explore the trends in surgical outcomes over the decade prior to the NAPRC using a large national database. METHODS The ACS National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2017 was used to select colorectal cancer cases which were divided into abdominal-colonic (AC) and pelvic-rectal (PR) cohorts based upon the operation performed. Outcomes of interest were occurrence of any major surgical complication, mortality within 30 days of procedure, and postoperative length of stay (LOS). Chi-square and two sample t-tests were used to evaluate association between various risk factors and outcomes. Modified Poisson regression was used to compare and estimate the unadjusted and adjusted effect of procedure type on the outcomes. STATA 15.1 was used for analysis and statistical significance was set at 0.05. RESULTS A total of 34,159 patients were analyzed. AC cases constituted 50.7% of the overall cohort. The two groups were relatively similar in demographic distribution, but the PR patients had higher rates of hypoalbuminemia and were sicker (ASA class 3 or greater). Rates of non-sphincter preserving operations ranged from 30 to 34%. Higher complication rates in the PR cohort were mainly infectious and surgical site complications, while rates of deep vein thrombosis and pulmonary embolism were similar between the two cohorts. On bivariate analysis, rates of mortality were similar between the two groups (AC: 1.02% vs PR: 0.91%, p = 0.395), while PR patients were found to be 1.36 times (95% CI: 1.32-1.41) more likely to have major complications and 1.40 times (95% CI: 1.35-1.44) more likely to have an extended LOS as compared to the AC patients. After multivariable analysis, PR patients continued to have a higher likelihood of major complications (IRR: 1.31, 95% CI 1.25-1.36) and extended LOS (IRR: 1.38, 95% CI: 1.33-1.43). 10-year trends showed a significant reduction in the percentage of patients with prolonged lengths of hospitalization as well as a reduction of nearly 20% in the mean LOS, but without improvement in morbidity or mortality. CONCLUSIONS Patients undergoing PR operations were more likely to have had major complications than were patients who underwent AC procedures; unfortunately no improvement in the rate of these complications or in mortality occurred. Perhaps the significant reduction in LOS is due in part to an increased prevalence of minimally invasive surgery and/or enhanced recovery protocols. Data were found to be lacking within NSQIP for several important variables including key oncologic data, stratification by surgical volume, and patient geographic location. We anticipate that the NAPRC should help improve PR surgical and oncologic outcomes including decreasing morbidity and mortality rates during the next decade.
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Affiliation(s)
- Stephen P Sharp
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA; Division of Colon and Rectal Surgery, Albany Medical Center, Albany, NY, USA
| | - Robert Malizia
- Division of Colon and Rectal Surgery, Albany Medical Center, Albany, NY, USA
| | - Matthew Skancke
- Department of General Surgery and Colorectal Surgery at the George Washington University Hospital, Washington, DC, USA
| | | | - Ashar Ata
- Division of Colon and Rectal Surgery, Albany Medical Center, Albany, NY, USA
| | - Steven C Stain
- Division of Colon and Rectal Surgery, Albany Medical Center, Albany, NY, USA
| | - Brian T Valerian
- Division of Colon and Rectal Surgery, Albany Medical Center, Albany, NY, USA
| | - Edward C Lee
- Division of Colon and Rectal Surgery, Albany Medical Center, Albany, NY, USA
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA.
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Compliance With Preoperative Elements of the American Society of Colon and Rectal Surgeons Rectal Cancer Surgery Checklist Improves Pathologic and Postoperative Outcomes. Dis Colon Rectum 2020; 63:30-38. [PMID: 31804269 DOI: 10.1097/dcr.0000000000001511] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND In 2016, the American Society of Colon and Rectal Surgeons published a rectal cancer surgery checklist composed of the essential elements of preoperative, intraoperative, and postoperative care for patients undergoing rectal cancer surgery. OBJECTIVE The purpose of this study was to assess whether compliance with preoperative checklist elements was associated with improved pathologic and 30-day postoperative outcomes after rectal cancer surgery. DESIGN This was a retrospective cohort study. SETTINGS The study involved North American hospitals contributing to the American College of Surgeons National Surgical Quality Improvement Program. PATIENTS Adult patients who underwent elective rectal cancer surgery from 2016 to 2017 were included. INTERVENTION The study encompassed checklist compliance with 6 preoperative elements from the checklist. MAIN OUTCOME MEASURES Pathologic outcomes (circumferential resection margin status, distal resection margin status, and adequate lymph node harvest ≥12), 30-day surgical morbidity, and length of stay were measured. RESULTS In total, 2217 patients were included in the analysis. Individual compliance with the 6 available preoperative checklist items was variable, including 91.3% for pretreatment documentation of tumor location within the rectum, 86.8% for complete colonoscopy, 84.0% for appropriate preoperative stoma marking, 79.8% for appropriate use of neoadjuvant radiotherapy, 76.6% for locoregional staging, and 70.8% for distant staging. Only 836 patients (37.7%) had all 6 checklist elements complete, whereas 1381 (62.3%) did not. Compared with patients without checklist compliance, patients with checklist compliance were younger (60.0 vs 63.0 y; p < 0.001) but otherwise had similar demographic characteristics. On multivariate regression, checklist compliance was associated with lower odds of circumferential resection margin positivity (OR = 0.47 (95% CI, 0.31-0.71); p < 0.001), higher odds of an adequate lymph node harvest ≥12 (OR = 1.60 (95% CI, 1.29-2.00); p < 0.001), reduced surgical morbidity (OR = 0.78 (95% CI, 0.65-0.95); p = 0.01), and shorter length of stay (β = -0.87 (95% CI, -1.51 to -0.24); p = 0.007). The association between checklist compliance and reduced odds of circumferential resection margin positivity remained on sensitivity analysis (OR = 0.61 (95% CI, 0.42-0.88); p = 0.009) when adjusting for neoadjuvant radiation. LIMITATIONS This study was limited by its absence of long-term oncologic data and missing variables. CONCLUSIONS Compliance with 6 preoperative elements of the American Society of Colon and Rectal Surgeons rectal cancer surgery checklist was associated with significantly improved pathologic outcomes and reduced postoperative morbidity. See Video Abstract at http://links.lww.com/DCR/B80. EL CUMPLIMIENTO CON LOS ELEMENTOS PREOPERATORIOS DE LA LISTA DE VERIFICACIÓN DE CIRUGÍA PARA CÁNCER RECTAL DE LA SOCIEDAD AMERICANA DE CIRUJANOS DE COLON Y RECTO MEJORA LOS RESULTADOS HISTOPATOLÓGICOS Y POSTOPERATORIOS: En 2016, la Sociedad Americana de Cirujanos de Colon y Recto publicó una lista de verificación de cirugía de cáncer de recto que comprende los elementos esenciales de la atención pre, intra y postoperatoria para pacientes sometidos a cirugía de cáncer de recto.Evaluar si el cumplimiento con los elementos preoperatorios de la lista de verificación se asoció con mejores resultados histopatológicos y postoperatorios a 30 días después de la cirugía de cáncer rectal.Estudio de cohorte retrospectiva.Hospitales norteamericanos que contribuyen al Programa Nacional de Mejora de la Calidad Quirúrgica del Colegio Americano de Cirujanos.Pacientes adultos que se sometieron a cirugía electiva de cáncer rectal entre 2016 y 2017.Cumplimiento de la lista de verificación con seis elementos preoperatorios de la lista de verificación.Resultados histopatológicos (estado del margen de resección circunferencial, estado del margen de resección distal, cosecha adecuada de ganglios linfáticos ≥12), morbilidad quirúrgica a 30 días y duración de la estadía.En total, 2,217 pacientes fueron incluidos en el análisis. El cumplimiento individual de los seis ítems disponibles de la lista de verificación preoperatoria fue variable: 91.3% para la documentación previa al tratamiento de la localización del tumor dentro del recto, 86.8% para colonoscopía completa, 84.0% para el marcado preoperatorio apropiado del sitio de estoma, 79.8% para el uso apropiado de radioterapia neoadyuvante, 76.6 % para estadificación locorregional y 70.8% para estadificación distante. Solo 836 (37.7%) pacientes tenían los seis elementos de la lista de verificación completos, mientras que 1,381 (62.3%) no. En comparación con los pacientes sin cumplimiento de la lista de verificación, los pacientes con cumplimiento de la lista de verificación eran más jóvenes (60.0 vs. 63.0 años, p <0.001), pero por lo demás tenían características demográficas similares. En la regresión multivariada, el cumplimiento de la lista de verificación se asoció con menores probabilidades de positividad en el margen de resección circunferencial (OR = 0.47; IC del 95%: 0.31-0.71, p <0.001), mayores probabilidades de una cosecha adecuada de ganglios linfáticos ≥12 (OR = 1.60, IC 95% 1.29-2.00, p <0.001), menor morbilidad quirúrgica (OR = 0.78, IC 95% 0.65-0.95, p = 0.01) y menor duración de estadía (β = -0.87, IC 95% -1.51 - - 0.24, p = 0.007). La asociación entre el cumplimiento de la lista de verificación y las probabilidades reducidas de positividad del margen de resección circunferencial se mantuvo en el análisis de sensibilidad (OR = 0.61; IC del 95%: 0.42-0.88, p = 0.009) al ser ajustado con radiación neoadyuvante.Ausencia de datos oncológicos a largo plazo y variables faltantes.El cumplimiento de seis elementos preoperatorios de la lista de verificación de cirugía de cáncer rectal de la Sociedad Americana de Cirujanos de Colon y Recto se asoció con resultados histopatológicos significativamente mejores y una menor morbilidad postoperatoria. Vea el resumen en video en http://links.lww.com/DCR/B80.
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Hill SS, Chung SK, Meyer DC, Crawford AS, Sturrock PR, Harnsberger CR, Davids JS, Maykel JA, Alavi K. Impact of Preoperative Care for Rectal Adenocarcinoma on Pathologic Specimen Quality and Postoperative Morbidity: A NSQIP Analysis. J Am Coll Surg 2019; 230:17-25. [PMID: 31672638 DOI: 10.1016/j.jamcollsurg.2019.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/18/2019] [Accepted: 09/16/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Comprehensive and multidisciplinary care are critical in rectal cancer treatment. We sought to determine if completeness of preoperative care was associated with pathologic specimen quality and postoperative morbidity. STUDY DESIGN Clinical stage I-III rectal adenocarcinoma patients who underwent elective low anterior resection or abdominoperineal resection were identified from the 2016-2017 American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) database. The 3 preoperative NSQIP variables (colonoscopy, stoma marking, and neoadjuvant chemoradiation) were used to divide patients into 2 cohorts: complete vs incomplete preoperative care. The primary outcome was a composite higher pathologic specimen quality score (>12 lymph nodes, negative circumferential, and negative distal margins). The secondary outcome was 30-day morbidity. Preoperative characteristics were compared with ANOVAs and chi-square tests. Outcomes measures were evaluated with logistic regression. RESULTS We identified 1,125 patients: 591 (52.5%) complete and 534 (47.5%) incomplete. The complete group was younger, had more women, lower-third rectal tumors, clinical stage III disease, and neoadjuvant treatment. The complete group had higher odds of better pathologic specimen quality after adjusting for age, sex, tumor location, stage, and neoadjuvant therapy (adjusted odds ratio [aOR] 1.75, p = 0.001). The complete group had decreased rates of transfusions (odds ratio [OR] 0.47, p < 0.001), postoperative ileus (OR 0.67, p = 0.01), sepsis (OR 0.32, p = 0.01), and readmissions (OR 0.60, p = 0.003). Other complications did not statistically differ between groups. CONCLUSIONS Complete preoperative care in rectal adenocarcinoma is associated with higher pathologic specimen quality and reduced postoperative morbidity. This highlights the importance of adherence to guideline-directed care.
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Affiliation(s)
- Susanna S Hill
- Division of Colon and Rectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
| | - Sebastian K Chung
- Division of General Surgery, University of Massachusetts Medical School, Worcester, MA
| | - David C Meyer
- Division of Colon and Rectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
| | - Allison S Crawford
- Division of General Surgery, University of Massachusetts Medical School, Worcester, MA
| | - Paul R Sturrock
- Division of Colon and Rectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
| | - Cristina R Harnsberger
- Division of Colon and Rectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
| | - Jennifer S Davids
- Division of Colon and Rectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
| | - Justin A Maykel
- Division of Colon and Rectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
| | - Karim Alavi
- Division of Colon and Rectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA.
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Kanters AE, Vu JV, Schuman AD, Van Wieren I, Duby A, Hardiman KM, Hendren SK. Completeness of operative reports for rectal cancer surgery. Am J Surg 2019; 220:165-169. [PMID: 31630821 DOI: 10.1016/j.amjsurg.2019.09.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 09/20/2019] [Accepted: 09/26/2019] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Synoptic operative reporting has been shown to improve completeness and consistency in surgical documentation. We sought to determine whether operative reports contain the key elements recommended by the National Accreditation Program for Rectal Cancer. METHODS Rectal cancer operative reports from June-December 2018 were submitted from ten hospitals in Michigan. These reports were analyzed to identify key elements in the synoptic operative template and assessed for completeness. RESULTS In total, 110 operative reports were reviewed. Thirty-one (28%) reports contained all 24 elements; all of these reports used a synoptic template. Overall, 62 (56%) reports used a synoptic template and 48 (44%) did not. Using a synoptic template significantly improved documentation, as these reports contained 92% of required elements, compared to 39% for narrative reports (p < 0.001). CONCLUSIONS/DISCUSSION Narrative operative reports inconsistently document rectal cancer resection. This study provides evidence that synoptic reporting will improve quality of documentation for rectal cancer surgery.
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Affiliation(s)
- Arielle E Kanters
- Department of Surgery, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, USA; Center for Health Outcomes and Policy, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI, USA.
| | - Joceline V Vu
- Department of Surgery, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, USA; Center for Health Outcomes and Policy, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI, USA
| | - Ari D Schuman
- Center for Health Outcomes and Policy, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI, USA
| | - Inga Van Wieren
- Center for Health Outcomes and Policy, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI, USA
| | - Ashley Duby
- Center for Health Outcomes and Policy, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI, USA
| | - Karin M Hardiman
- Department of Surgery, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, USA
| | - Samantha K Hendren
- Department of Surgery, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, USA; Center for Health Outcomes and Policy, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI, USA
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Sheetz KH, Dimick JB, Nathan H. Centralization of High-Risk Cancer Surgery Within Existing Hospital Systems. J Clin Oncol 2019; 37:3234-3242. [PMID: 31251691 DOI: 10.1200/jco.18.02035] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
PURPOSE Centralization is often proposed as a strategy to improve the quality of certain high-risk health care services. We evaluated the extent to which existing hospital systems centralize high-risk cancer surgery and whether centralization is associated with short-term clinical outcomes. PATIENTS AND METHODS We merged data from the American Hospital Association's annual survey on hospital system affiliation with Medicare claims to identify patients undergoing surgery for pancreatic, esophageal, colon, lung, or rectal cancer between 2005 and 2014. We calculated the degree to which systems centralized each procedure by calculating the annual proportion of surgeries performed at the highest-volume hospital within each system. We then estimated the independent effect of centralization on the incidence of postoperative complications, death, and readmissions after accounting for patient, hospital, and system characteristics. RESULTS The average degree of centralization varied from 25.2% (range, 6.6% to 100%) for colectomy to 71.2% (range, 8.3% to 100%) for pancreatectomy. Greater centralization was associated with lower rates of postoperative complications and death for lung resection, esophagectomy, and pancreatectomy. For example, there was a 1.1% (95% CI, 0.8% to 1.4%) absolute reduction in 30-day mortality after pancreatectomy for each 20% increase in the degree of centralization within systems. Independent of volume and hospital quality, postoperative mortality for pancreatectomy was two times higher in the least centralized systems than in the most centralized systems (8.9% v 3.7%, P < .01). Centralization was not associated with better outcomes for colectomy or proctectomy. CONCLUSION Greater centralization of complex cancer surgery within existing hospital systems was associated with better outcomes. As hospitals affiliate in response to broader financial and organization pressures, these systems may also present unique opportunities to improve the quality of high-risk cancer care.
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Affiliation(s)
- Kyle H Sheetz
- Department of Surgery, University of Michigan, Ann Arbor, MI.,Center for Healthcare Outcomes and Policy, Ann Arbor, MI
| | - Justin B Dimick
- Department of Surgery, University of Michigan, Ann Arbor, MI.,Center for Healthcare Outcomes and Policy, Ann Arbor, MI
| | - Hari Nathan
- Department of Surgery, University of Michigan, Ann Arbor, MI.,Center for Healthcare Outcomes and Policy, Ann Arbor, MI
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Swords DS, Skarda DE, Sause WT, Gawlick U, Cannon GM, Lewis MA, Scaife CL, Gygi JA, Tae Kim H. Surgeon-Level Variation in Utilization of Local Staging and Neoadjuvant Therapy for Stage II-III Rectal Adenocarcinoma. J Gastrointest Surg 2019; 23:659-669. [PMID: 30706375 DOI: 10.1007/s11605-019-04107-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 01/04/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION 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. METHODS 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). RESULTS 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). CONCLUSIONS 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.
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MESH Headings
- Adenocarcinoma/mortality
- Adenocarcinoma/pathology
- Adenocarcinoma/therapy
- Adult
- Aged
- Aged, 80 and over
- Chemoradiotherapy, Adjuvant/standards
- Chemoradiotherapy, Adjuvant/statistics & numerical data
- Female
- Follow-Up Studies
- Healthcare Disparities/statistics & numerical data
- Humans
- Male
- Margins of Excision
- Middle Aged
- Neoadjuvant Therapy/standards
- Neoadjuvant Therapy/statistics & numerical data
- Neoplasm Recurrence, Local/epidemiology
- Neoplasm Recurrence, Local/etiology
- Neoplasm Recurrence, Local/prevention & control
- Neoplasm Staging
- Practice Patterns, Physicians'/standards
- Practice Patterns, Physicians'/statistics & numerical data
- Procedures and Techniques Utilization/standards
- Procedures and Techniques Utilization/statistics & numerical data
- Proctectomy
- Quality Assurance, Health Care
- Quality Indicators, Health Care/statistics & numerical data
- Rectal Neoplasms/mortality
- Rectal Neoplasms/pathology
- Rectal Neoplasms/therapy
- Reproducibility of Results
- Retrospective Studies
- Surgeons/standards
- Surgeons/statistics & numerical data
- Treatment Outcome
- United States/epidemiology
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Affiliation(s)
- Douglas S Swords
- Surgical Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA.
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA.
| | - David E Skarda
- Surgical Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA
| | - William T Sause
- Oncology Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Ute Gawlick
- Surgical Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | - George M Cannon
- Oncology Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Mark A Lewis
- Oncology Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Courtney L Scaife
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA
| | - Jesse A Gygi
- Oncology Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | - H Tae Kim
- Surgical Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
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Justiniano CF, Aquina CT, Fleming FJ, Xu Z, Boscoe FP, Schymura MJ, Temple LK, Becerra AZ. Hospital and surgeon variation in positive circumferential resection margin among rectal cancer patients. Am J Surg 2019; 218:881-886. [PMID: 30853095 DOI: 10.1016/j.amjsurg.2019.02.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 02/15/2019] [Accepted: 02/26/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND The objective of this study was to evaluate variation in positive CRM at the surgeon and hospital levels and assess impact on disease-specific survival. METHODS Patients with stage I-III rectal cancer were identified in New York State. Bayesian hierarchical regressions estimated observed-to-expected (O/E) ratios for each surgeon/hospital. Competing-risks analyses estimated disease-specific survival among patients who were treated by surgeons/hospitals with O/E > 1 compared to those with O/E ratio ≤ 1. RESULTS Among 1,251 patients, 208 (17%) had a positive CRM. Of the 345 surgeons and 118 hospitals in the study, 99 (29%) and 48 (40%) treated a higher number of patients with CRM than expected, respectively. Patients treated by surgeons with O/E > 1 (HR = 1.38, 95% CI = 1.16, 1.67) and those treated at hospitals with O/E > 1 (HR = 1.44, 95% CI = 1.11, 1.85) had worse disease-specific survival. DISCUSSION Surgeon and hospital performance in positive CRM is associated with worse prognosis suggesting opportunities to enhance referral patterns and standardize care.
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Affiliation(s)
- Carla F Justiniano
- Surgical Health Outcomes and Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Christopher T Aquina
- Surgical Health Outcomes and Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Fergal J Fleming
- Surgical Health Outcomes and Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Zhaomin Xu
- Surgical Health Outcomes and Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Francis P Boscoe
- New York State Cancer Registry, New York State Department of Health, Albany, NY, USA
| | - Maria J Schymura
- New York State Cancer Registry, New York State Department of Health, Albany, NY, USA
| | - Larissa K Temple
- Surgical Health Outcomes and Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Adan Z Becerra
- Surgical Health Outcomes and Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA; Department of Public Health Sciences, Division of Epidemiology, University of Rochester Medical Center, Rochester, NY, USA.
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Arsoniadis EG, Kwaan MR. ASO Author Reflections: African Americans and Rectal Cancer Surgery. Ann Surg Oncol 2018; 25:856-857. [PMID: 30426263 DOI: 10.1245/s10434-018-7054-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Elliot G Arsoniadis
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA. .,Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA.
| | - Mary R Kwaan
- Section of Colorectal Surgery, Division of General Surgery, University of California, Los Angeles, CA, USA
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Wale A, Wexner SD, Saur NM, Massarotti H, Laurberg S, Kennedy E, Rockall A, Sebag-Montefiore D, Brown G. Session 1: The evolution and development of the multidisciplinary team approach: USA, European and UK experiences - what can we do better? Colorectal Dis 2018; 20 Suppl 1:17-27. [PMID: 29878684 DOI: 10.1111/codi.14073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The process of determining the best treatments that should be offered to patients with newly diagnosed colon and rectal cancer remains highly variable around the world. The aim of this expert review was to agree the key elements of good quality preoperative treatment decision making.
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Affiliation(s)
- A Wale
- Royal Marsden NHS Foundation Trust, London, UK
| | - S D Wexner
- Digestive Disease Center, Cleveland Clinic, Weston, Florida, USA.,Department of Colorectal Surgery, Cleveland Clinic, Weston, Florida, USA
| | - N M Saur
- Division of Colon and Rectal Surgery, Pennsylvania Hospital, Philadelphia, Pennsylvania, USA
| | - H Massarotti
- Department of Colorectal Surgery, Cleveland Clinic, Weston, Florida, USA
| | - S Laurberg
- Aarhus University Hospital, Aarhus, Denmark
| | - E Kennedy
- General Surgery and Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - A Rockall
- Royal Marsden NHS Foundation Trust, London, UK
| | | | - G Brown
- Royal Marsden NHS Foundation Trust, London, UK.,Imperial College London, London, UK
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