Abstract
Background
There is a paucity of literature quantifying the extent to which time to adjuvant chemotherapy for stage III colon cancer patients varies between individual surgeons, medical oncologists, and hospitals.
Methods
A retrospective cohort study was conducted by merging the New York State Cancer Registry with the Statewide Planning & Research Cooperative System and Medicare claims to identify stage III colon cancer patients from 2004 to 2009 who underwent resection and received adjuvant chemotherapy. Multilevel logistic regression models characterized variation in delayed time to adjuvant chemotherapy (>8 weeks vs. ≤8 weeks). Multilevel competing-risks Cox proportional hazards models assessed the effect of delayed time to adjuvant chemotherapy on disease-specific survival.
Results
The proportion of delayed time to adjuvant chemotherapy was 36 % in 1133 patients treated by 516 surgeons and 351 medical oncologists at 163 hospitals. After controlling for case-mix, the majority of the clustering variation (72 %) in delayed time to adjuvant chemotherapy is attributed to differences between medical oncologists. Risk-adjusted surgeon-specific, medical oncologist-specific, and hospital-specific probabilities of delayed time to adjuvant chemotherapy ranged from 30 to 38, 17 to 59, and 27 to 43 %, respectively. Delayed time to adjuvant chemotherapy was associated with disease-specific survival (hazard ratio [HR] 1.24, 95 % confidence interval [CI] 1.07–1.45).
Conclusions
These findings suggest there is substantial variation in time to adjuvant chemotherapy among stage III colon cancer patients. Reasons for delays may be due to system factors that influence individual providers to make varying decisions on the time of initiation. Future research should identify what these factors may be and how to address them to promote better delivery of care.
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References
National Comprehensive Cancer Network. Colon cancer (Version 2.2015). http://www.nccn.org/professionals/physician_gls/pdf/colon.pdf. Accessed 12 Jan 2016.
Benson AB 3rd, Schrag D, Somerfield MR et al. American Society of Clinical Oncology recommendations on adjuvant chemotherapy for stage II colon cancer. J Clin Oncol. 2004;22:3408–19.
Engstrom PF, Benson AB 3rd, Saltz L. Colon cancer clinical practice guidelines in oncology. JNCCN. 2003;1:40–53.
Moertel CG, Fleming TR, Macdonald JS, et al. Levamisole and fluorouracil for adjuvant therapy of resected colon carcinoma. N Engl J Med. 1990;322:352–8.
Wolmark N, Rockette H, Fisher B, et al. The benefit of leucovorin-modulated fluorouracil as postoperative adjuvant therapy for primary colon cancer: results from National Surgical Adjuvant Breast and Bowel Project protocol C-03. J Clin Oncol. 1993;11:1879–87.
O’Connell MJ, Mailliard JA, Kahn MJ, et al. Controlled trial of fluorouracil and low-dose leucovorin given for 6 months as postoperative adjuvant therapy for colon cancer. J Clin Oncol. 1997;15:246–50.
Yothers G, O’Connell MJ, Allegra CJ, et al. Oxaliplatin as adjuvant therapy for colon cancer: updated results of NSABP C-07 trial, including survival and subset analyses. J Clin Oncol 2011;29:3768–74.
Andre T, Boni C, Mounedji–Boudiaf L, et al. on behalf of the multicenter international study of oxaliplatin/5-fluorouracil/leucovorin in the adjuvant treatment of colon cancer (mosaic) investigators oxaliplatin, fluorouracil, and leucovorin as adjuvant treatment for colon cancer. N Engl J Med. 2004;350:2343–51.
Schrag D, Cramer LD, Bach PB, Begg CB. Age and adjuvant chemotherapy use after surgery for stage III colon cancer. J Natl Cancer Inst. 2001;93(11):850–7.
Becerra AZ, Probst CP, Tejani MA, et al. Opportunity lost: adjuvant chemotherapy in patients with stage III colon cancer remains underused. Surgery. 2015;158(3):692–9.
Wasserman DW, Boulos M, Hopman WM, Booth CM, Goodwin R, Biagi JJ. Reasons for delay in time to initiation of adjuvant chemotherapy for colon cancer. J Oncol Pract. 2014.
Lima IS, Yasui Y, Scarfe A, Winget M. Association between receipt and timing of adjuvant chemotherapy and survival for patients with stage III colon cancer in Alberta, Canada. Cancer. 2011;117(16):3833–40.
Biagi JJ, Raphael MJ, Mackillop WJ, Kong W, King WD, Booth CM. Association between time to initiation of adjuvant chemotherapy and survival in colorectal cancer: a systematic review and meta-analysis. JAMA. 2011;305(22):2335–42.
Des guetz G, Nicolas P, Perret GY, Morere JF, Uzzan B. Does delaying adjuvant chemotherapy after curative surgery for colorectal cancer impair survival? A meta-analysis. Eur J Cancer. 2010;46(6):1049–55.
Kim IY, Kim BR, Kim YW. Factors affecting use and delay (≥ 8 weeks) of adjuvant chemotherapy after colorectal cancer surgery and the impact of chemotherapy-use and delay on oncologic outcomes. PLoS One. 2015;10(9):e0138720.
Chan A, Woods R, Kennecke H, Gill S. Factors associated with delayed time to adjuvant chemotherapy in stage iii colon cancer. Curr Oncol. 2014;21(4):181–6.
Simpson GS, Smith R, Sutton P, et al. The aetiology of delay to commencement of adjuvant chemotherapy following colorectal resection. Int J Surg Oncol. 2014;2014:670212.
Malietzis G, Mughal A, Currie AC, et al. Factors implicated for delay of adjuvant chemotherapy in colorectal cancer: a meta-analysis of observational studies. Ann Surg Oncol. 2015;22(12):3793–802.
Merlo J, Chaix B, Ohlsson H, et al. A brief conceptual tutorial of multilevel analysis in social epidemiology: using measures of clustering in multilevel logistic regression to investigate contextual phenomena. J Epidemiol Community Health. 2006;60(4):290–7.
Goldstein H. Multilevel statistical models. 2. London, Edward Arnold; 1995.
Snijders T, Bosker R. Multilevel analysis: an introduction to basic and advanced multilevel modeling. London, Sage Publications; 1999.
Korsgaard M, Pedersen L, Laurberg S. Delay of diagnosis and treatment of colorectal cancer—A population-based Danish study. Cancer Detect Prev. 2008;32(1):45–51.
Van erning FN, Janssen-heijnen ML, Creemers GJ, Pruijt HF, Maas HA, Lemmens VE. Deciding on adjuvant chemotherapy for elderly patients with stage III colon cancer: a qualitative insight into the perspectives of surgeons and medical oncologists. J Geriatr Oncol. 2015;6(3):219–24.
Keating NL, Landrum MB, Klabunde CN, et al. Adjuvant chemotherapy for stage III colon cancer: do physicians agree about the importance of patient age and comorbidity? J Clin Oncol. 2008;26(15):2532-7.
Winget M, Hossain S, Yasui Y, Scarfe A. Characteristics of patients with stage III colon adenocarcinoma who fail to receive guideline-recommended treatment. Cancer. 2010;116:4849–56.
Tawk R, Abner A, Ashford A, Brown CP. Differences in colorectal cancer outcomes by race and insurance. Int J Environ Res Public Health. 2016;13(1):ijerph13010048.
Baker SG, Bonetti M. Evaluating markers for guiding treatment. J Natl Cancer Inst. 2016;108(9).
Robbins AS, Siegel RL, Jemal A. Racial disparities in stage-specific colorectal cancer mortality rates from 1985 to 2008. J Clin Oncol. 2012;30(4):401–5.
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Becerra, A.Z., Aquina, C.T., Mohile, S.G. et al. Variation in Delayed Time to Adjuvant Chemotherapy and Disease-Specific Survival in Stage III Colon Cancer Patients. Ann Surg Oncol 24, 1610–1617 (2017). https://doi.org/10.1245/s10434-016-5622-4
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DOI: https://doi.org/10.1245/s10434-016-5622-4