title: Adequacy of the National Quality Forum's Colon Cancer Adjuvant Chemotherapy Quality Metric: Is 4 Months Soon Enough?
abstract: OBJECTIVE
  To ascertain whether the National Quality Forum-endorsed time interval for adjuvant chemotherapy (AC) initiation optimizes patient outcome.
  
  
  BACKGROUND
  Delayed AC initiation for stage III colon cancer is associated with worse survival and the focus of a National Quality Forum quality metric (<4 months among patients aged <80 years).
  
  
  METHODS
  Observational cohort study of patients with stage III colon cancer younger than 80 years within the National Cancer Data Base (2003-2010). The primary outcome was 5-year overall survival evaluated using multivariate Cox proportional hazards regression. Aggregate survival estimates for historical surgery-only controls from pooled National Surgical Adjuvant Breast and Bowel Project trial data were also used.
  
  
  RESULTS
  Among 51,331 patients (60.8 ± 11.6 years, 50.2% males, and 77.3% white), 76.3% received standard AC (≤ 2 months) and 21.6% delayed (>2 and <4 months) AC. Earlier AC was associated with better 5-year overall survival [standard AC, 69.8%; delayed AC, 62.0%; late AC (4-6 months), 51.4%; log-rank, P < 0.001]. The survival rate after late AC was similar to surgery alone (51.1%; Wilcoxon rank sum, P = 0.10). Compared with late AC, standard AC (hazard ratio, 0.62; 95% confidence interval, 0.54-0.72) and delayed AC (hazard ratio, 0.77; 95% confidence interval, 0.66-0.89) significantly decreased risk of death. Risk of death was also lower for standard AC compared to delayed AC (hazard ratio, 0.81; 95% confidence interval, 0.77-0.86).
  
  
  CONCLUSIONS
  One in 5 patients with stage III colon cancer initiates AC within the National Quality Forum-endorsed interval, but does not derive the full benefit. These data support strengthening current quality improvement initiatives and colon cancer treatment guidelines to encourage AC initiation within 2 months of resection when possible, but not beyond 4 months.
authors.affiliation: *Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX †Department of Surgery, Massachusetts General Hospital, Boston, MA.
authors.forename: Nader N
authors.initials: NN
authors.lastname: Massarweh
authors.forename: Alex B
authors.initials: AB
authors.lastname: Haynes
authors.forename: Yi-Ju
authors.initials: YJ
authors.lastname: Chiang
authors.forename: George J
authors.initials: GJ
authors.lastname: Chang
authors.forename: Y Nancy
authors.initials: YN
authors.lastname: You
authors.forename: Barry W
authors.initials: BW
authors.lastname: Feig
authors.forename: Janice N
authors.initials: JN
authors.lastname: Cormier
mesh_terms: D000368:Aged; D000970:Antineoplastic Agents / Q000008:administration & dosage*; D017024:Chemotherapy, Adjuvant; D002985:Clinical Protocols; D015331:Cohort Studies; D003082:Colectomy; D003110:Colonic Neoplasms / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D004334:Drug Administration Schedule; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D018579:Patient Selection; D016016:Proportional Hazards Models; D019984:Quality Indicators, Health Care; D015996:Survival Rate; D016896:Treatment Outcome
chemical_list: D000970:Antineoplastic Agents