Douglas S Swords1,2, David E Skarda3,4, William T Sause5, Ute Gawlick3, George M Cannon5, Mark A Lewis5, Courtney L Scaife4, Jesse A Gygi5, H Tae Kim3. 1. Surgical Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA. douglas.swords@hsc.utah.edu. 2. Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA. douglas.swords@hsc.utah.edu. 3. Surgical Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA. 4. Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA. 5. Oncology Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA.
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.
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.
Entities:
Keywords:
Centers of excellence; Clinical staging; Disparities; EUS; Local staging; Locally advanced; Locoregional staging; MRI; National Accreditation Program for Rectal Cancer; Neoadjuvant chemoradiotherapy; Neoadjuvant treatment; OSTRICH Consortium; Preoperative; Rectal cancer
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Authors: J E Tepper; M O'Connell; D Niedzwiecki; D R Hollis; A B Benson; B Cummings; L L Gunderson; J S Macdonald; J A Martenson; R J Mayer Journal: J Clin Oncol Date: 2002-04-01 Impact factor: 44.544
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Authors: Douglas S Swords; Benjamin S Brooke; David E Skarda; Gregory J Stoddard; H Tae Kim; William T Sause; Courtney L Scaife Journal: J Gastrointest Surg Date: 2018-11-12 Impact factor: 3.452