title: Effect of postoperative complications on adjuvant chemotherapy use for stage III colon cancer.
abstract: OBJECTIVE
  The National Quality Forum has endorsed a quality metric concerning the use of adjuvant chemotherapy administration in stage III colon cancer, yet a substantial treatment gap exists. Our objective was to evaluate the association of postoperative complications on the use of adjuvant therapy after colectomy for cancer.
  
  
  METHODS
  Data from the American College of Surgeons National Surgical Quality Improvement Program and National Cancer Data Base were linked to augment cancer registry information with robust clinical data on comorbidities and postoperative complications (2006-2008). The association of complications on adjuvant chemotherapy use was assessed using hierarchical multivariable regression models.
  
  
  RESULTS
  From 126 hospitals, 2368 patients underwent resection for stage III colon adenocarcinoma. Overall utilization of adjuvant chemotherapy was 63.2% (1497/2368). Of the 871 patients who did not receive chemotherapy, 652 met National Quality Forum exclusion criteria: death, severe comorbidity, refusal of care, advanced age (≥80 years), or prior malignancy. Of the remaining 219 patients, 19.1% (42/219) had 1 or more serious postoperative complications (eg, pneumonia, pulmonary failure). After accounting for the aforementioned potential explanations, the utilization rate was 87.2% (1497/1716). The strongest predictors of adjuvant chemotherapy omission were prolonged postoperative ventilation, renal failure, reintubation, and pneumonia (all Ps < 0.05). Superficial surgical site infection did not decrease adjuvant therapy receipt but delayed the time to its use by 3-fold. Serious complications increased time to chemotherapy by 65%. Abscess/anastomotic leak increased time to adjuvant chemotherapy by more than 5-fold.
  
  
  CONCLUSIONS
  Serious postoperative complications explained nearly 20% of the adjuvant chemotherapy treatment gap for patients with stage III colon cancer. The use of clinical data remains important when judging provider performance.
authors.affiliation: *Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL; †Northwestern Institute for Comparative Effectiveness Research in Oncology, the Surgical Outcomes and Quality Improvement Center, and the Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL; ‡Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL; §Department of Surgery, Jesse Brown VAMC, Chicago, IL; ¶Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH; and ‖Department of Surgery, University of California, Los Angeles, and VA Greater Los Angeles Healthcare System, Los Angeles, CA.
authors.forename: Ryan P
authors.initials: RP
authors.lastname: Merkow
authors.forename: David J
authors.initials: DJ
authors.lastname: Bentrem
authors.forename: Mary F
authors.initials: MF
authors.lastname: Mulcahy
authors.forename: Jeanette W
authors.initials: JW
authors.lastname: Chung
authors.forename: Daniel E
authors.initials: DE
authors.lastname: Abbott
authors.forename: Thomas E
authors.initials: TE
authors.lastname: Kmiecik
authors.forename: Andrew K
authors.initials: AK
authors.lastname: Stewart
authors.forename: David P
authors.initials: DP
authors.lastname: Winchester
authors.forename: Clifford Y
authors.initials: CY
authors.lastname: Ko
authors.forename: Karl Y
authors.initials: KY
authors.lastname: Bilimoria
mesh_terms: D000368:Aged; D017024:Chemotherapy, Adjuvant; D003110:Colonic Neoplasms / Q000188:drug therapy* / Q000473:pathology / Q000601:surgery*; D003131:Combined Modality Therapy; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D011183:Postoperative Complications