Hospital Variability in Use of Adjuvant Chemotherapy for Patients with Stage 2 and 3 Colon Cancer.
BACKGROUND
Following oncologic resection, adjuvant chemotherapy is associated with decreased recurrence and improved survival in stage 3 colon cancer. However, there is controversy regarding its use in stage 2 colon cancer with high-risk features (tumor depth T4, poorly differentiated, positive margin, and/or inadequate lymph node retrieval). Consensus guidelines recommend no adjuvant chemotherapy in the absence of these high-risk features (low-risk stage 2).


OBJECTIVE
This study aimed to examine hospital characteristics associated with poor risk-adjusted, stage-specific guideline compliance for the use of adjuvant chemotherapy in stage 3 and low-risk stage 2 colon cancer.


METHODS
This was a retrospective study. Stepwise logistic regression was used to identify patient and hospital factors associated with administration of adjuvant chemotherapy. Hierarchical regression models were used to calculate risk- and reliability-adjusted rates of chemotherapy use and observed-to-expected ratios in each hospital's stage 2 low-risk and stage 3 patients.


METHODS
Data were retrieved from the National Cancer Database.


METHODS
Patients selected were adults treated with oncologic resection for stage 2 to 3 colon cancer between 2004 and 2010.


METHODS
The primary outcome measured was receipt of adjuvant chemotherapy.


RESULTS
A total of 167,345 patients were identified at 1395 hospitals. The mean overall risk-adjusted adjuvant chemotherapy rate was 65.3% for stage 3 and 15.2% for low-risk stage 2. Analysis of low outlier hospitals for stage 3 colon cancer, where adjuvant chemotherapy was underutilized, demonstrated that 62.8% were low-volume centers and 51.4% were community centers. Of high outlier hospitals for stage 2 low-risk disease, where adjuvant chemotherapy was overutilized, 87.2% were low-volume hospitals and 67.2% were community centers.


CONCLUSIONS
Selection bias and the inability to compare specific chemotherapy regimens were limitations of this study.


CONCLUSIONS
Following oncologic resection, administration of adjuvant chemotherapy for low-risk stage 2 and stage 3 disease varies substantially among hospitals in the United States. Outlier hospitals were most likely to be low-volume community centers.
1 Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio 2 Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, Ohio.
Meghan C
MC
Daly
Dennis J
DJ
Hanseman
Daniel E
DE
Abbott
Shimul A
SA
Shah
Ian M
IM
Paquette
D000368:Aged; D017024:Chemotherapy, Adjuvant / Q000379:methods / Q000706:statistics & numerical data; D003082:Colectomy / Q000379:methods; D003110:Colonic Neoplasms / Q000453:epidemiology / Q000473:pathology / Q000628:therapy; D005260:Female; D019983:Guideline Adherence / Q000592:standards / Q000706:statistics & numerical data; D006761:Hospitals / Q000145:classification / Q000592:standards / Q000706:statistics & numerical data; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000517:prevention & control*; D009367:Neoplasm Staging; D017063:Outcome Assessment, Health Care; D018579:Patient Selection; D012189:Retrospective Studies; D020379:Risk Adjustment / Q000379:methods / Q000592:standards; D012307:Risk Factors; D014481:United States