title: Failure of evidence-based cancer care in the United States: the association between rectal cancer treatment, cancer center volume, and geography.
abstract: OBJECTIVE
  This study examines recent adherence to recommended neoadjuvant chemoradiotherapy guidelines for patients with rectal cancer across geographic regions and institution volume and assesses trends over time.
  
  
  BACKGROUND
  A recent report by the Institute of Medicine described US cancer care as chaotic. Cited deficiencies included wide variation in adherence to evidence-based guidelines even where clear consensus exists.
  
  
  METHODS
  Patients operated on for clinical stage II and III rectal cancer were selected from the 2006-2011 National Cancer Data Base. Multivariable logistic regressions were used to assess variation in chemotherapy and radiation use by cancer center type, geographical location, and hospital volume. The analysis controlled for patient age at diagnosis, sex, race/ethnicity, primary payer, average household income, average education, urban/rural classification of patient residence, comorbidity, and oncologic stage.
  
  
  RESULTS
  There were 30,994 patients who met the inclusion criteria. Use of neoadjuvant radiation therapy and chemotherapy varied significantly by type of cancer center. The highest rates of adherence were observed in high-volume centers compared with low-volume centers (78% vs 69%; adjusted odds ratio = 1.46; P < 0.001). This variation is mirrored by hospital geographic location. Primary payer and year of diagnosis were not predictive of rates of neoadjuvant chemoradiotherapy.
  
  
  CONCLUSIONS
  Adherence to evidence-based treatment guidelines in rectal cancer is suboptimal in the United States, with significant differences based on hospital volume and geographic regions. Little improvement has occurred in the last 5 years. These results support the implementation of standardized care pathways and a Centers of Excellence program for US patients with rectal cancer.
authors.affiliation: *Surgical Health Outcomes & Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY †Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Weston, FL ‡Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH §Department of Surgery, Baylor University Medical Center, Dallas, TX ¶Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY; and ‖Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: John R T
authors.initials: JR
authors.lastname: Monson
authors.forename: Christian P
authors.initials: CP
authors.lastname: Probst
authors.forename: Steven D
authors.initials: SD
authors.lastname: Wexner
authors.forename: Feza H
authors.initials: FH
authors.lastname: Remzi
authors.forename: James W
authors.initials: JW
authors.lastname: Fleshman
authors.forename: Julio
authors.initials: J
authors.lastname: Garcia-Aguilar
authors.forename: George J
authors.initials: GJ
authors.lastname: Chang
authors.forename: David W
authors.initials: DW
authors.lastname: Dietz
mesh_terms: D000368:Aged; D002173:Cancer Care Facilities / Q000706:statistics & numerical data; D059186:Chemoradiotherapy, Adjuvant / Q000706:statistics & numerical data*; D019317:Evidence-Based Medicine; D005260:Female; D005843:Geography; D019983:Guideline Adherence; D061847:Hospitals, High-Volume / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D020360:Neoadjuvant Therapy / Q000706:statistics & numerical data*; D017410:Practice Guidelines as Topic; D012004:Rectal Neoplasms / Q000601:surgery / Q000628:therapy*; D012189:Retrospective Studies; D014481:United States