Adan Z Becerra1,2,3, Steven D Wexner4, David W Dietz5, Zhaomin Xu6, Christopher T Aquina6, Carla F Justiniano6, Alex A Swanger6, Larissa K Temple6, Katia Noyes7, John R Monson8, Fergal J Fleming6. 1. Division of Epidemiology, Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, USA. abecerra@aledade.com. 2. Surgical Health Outcomes and Research Enterprise, University of Rochester Medical Center, Rochester, NY, USA. abecerra@aledade.com. 3. Aledade, Inc, Bethesda, MD, USA. abecerra@aledade.com. 4. Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA. 5. Department of Colorectal Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA. 6. Surgical Health Outcomes and Research Enterprise, University of Rochester Medical Center, Rochester, NY, USA. 7. Department of Epidemiology and Environmental Health, University at Buffalo, Buffalo, NY, USA. 8. Center for Colon and Rectal Surgery, Florida Hospital Medical Group, Orlando, FL, USA.
Abstract
BACKGROUND: Rectal cancer patients who are understaged may not be offered the highest quality treatment modalities, which are based on an accurate assessment of preoperative staging. The objective of this study was to evaluate heterogeneity in the probability of being understaged at Commission on Cancer hospitals in the United States and to assess how this variation affects outcomes. METHODS: The 2006-2013 National Cancer Data Base was queried for clinical stage I-III rectal cancer patients who underwent resection. The initial clinical stage was compared with the "gold standard," pathological stage. A Bayesian multilevel logistic regression model was used to characterize variation in hospital-specific probabilities of being understaged (clinical stage < pathologic stage). Separate analyses assessed the impact of being understaged on positive circumferential resection margins (CRM), receipt of adjuvant chemotherapy, and 5-year overall survival. RESULTS: Among 12,684 patients who did not receive neoadjuvant chemoradiation and treated at 1176 hospitals, 3044 (24%) were understaged. After patient level risk-adjustment, a 24-fold difference in the probability of being understaged was observed between hospitals (range 3-72%, median = 15%). Understaging was independently associated with positive CRM [odds ratio (OR) 1.59, 95% confidence interval (CI) 1.39, 1.92] and receipt of adjuvant chemotherapy (OR 14.22, 95% CI 13.55, 18.88). Despite an increase in the delivery of systemic therapy after surgical resection, understaging was associated with worse survival (hazard ratio = 1.61, 95% CI 1.48, 1.95). CONCLUSIONS: Deficiencies in high-quality rectal cancer management begin with incorrect clinical staging. The risk-adjusted probability of understaging varied widely between hospitals. This institutional failure to provide optimal oncological management at the start of care was associated with worse long-term survival.
BACKGROUND:Rectal cancerpatients who are understaged may not be offered the highest quality treatment modalities, which are based on an accurate assessment of preoperative staging. The objective of this study was to evaluate heterogeneity in the probability of being understaged at Commission on Cancer hospitals in the United States and to assess how this variation affects outcomes. METHODS: The 2006-2013 National Cancer Data Base was queried for clinical stage I-III rectal cancerpatients who underwent resection. The initial clinical stage was compared with the "gold standard," pathological stage. A Bayesian multilevel logistic regression model was used to characterize variation in hospital-specific probabilities of being understaged (clinical stage < pathologic stage). Separate analyses assessed the impact of being understaged on positive circumferential resection margins (CRM), receipt of adjuvant chemotherapy, and 5-year overall survival. RESULTS: Among 12,684 patients who did not receive neoadjuvant chemoradiation and treated at 1176 hospitals, 3044 (24%) were understaged. After patient level risk-adjustment, a 24-fold difference in the probability of being understaged was observed between hospitals (range 3-72%, median = 15%). Understaging was independently associated with positive CRM [odds ratio (OR) 1.59, 95% confidence interval (CI) 1.39, 1.92] and receipt of adjuvant chemotherapy (OR 14.22, 95% CI 13.55, 18.88). Despite an increase in the delivery of systemic therapy after surgical resection, understaging was associated with worse survival (hazard ratio = 1.61, 95% CI 1.48, 1.95). CONCLUSIONS: Deficiencies in high-quality rectal cancer management begin with incorrect clinical staging. The risk-adjusted probability of understaging varied widely between hospitals. This institutional failure to provide optimal oncological management at the start of care was associated with worse long-term survival.
Authors: Alisha Lussiez; Samantha J Rivard; Kamren Hollingsworth; Sherif R Z Abdel-Misih; Philip S Bauer; Katherine A Hrebinko; Glen C Balch; Lillias H Maguire Journal: Dis Colon Rectum Date: 2021-12-27 Impact factor: 4.412