title: Predictors of Nonadherence to NCCN Guideline Recommendations for the Management of Stage I Anal Canal Cancer.
abstract: Background:Definitive chemoradiotherapy (CRT) is recommended by the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Anal Carcinoma for all patients with stage I anal canal cancer. Because these patients were not well represented in clinical trials establishing CRT as standard therapy, it is unclear whether NCCN recommendations are being closely followed for stage I disease. This study identified factors that predict for NCCN Guideline-concordant versus NCCN Guideline-discordant care.Methods:Using the National Cancer Data Base, we identified patients diagnosed with anal canal carcinoma from 2004 to 2012 who received concurrent CRT (radiotherapy [RT] 45.0-59.4 Gy with multiagent chemotherapy), RT alone (45.0-59.4 Gy), or surgical procedure alone (local tumor destruction, tumor excision, or abdominoperineal resection). Demographic and clinicopathologic factors were analyzed using the chi-square test and logistic regression modeling.Results:A total of 1,082 patients with histologically confirmed stage I anal cancer were identified, among whom 665 (61.5%) received CRT, 52 (4.8%) received RT alone, and 365 (33.7%) received only a surgical procedure. Primary analyses were restricted to patients receiving CRT or excision alone, as these were most common. Multivariable analysis identified factors independently associated with reduced odds of CRT receipt: low versus intermediate/high tumor grade (adjusted odds ratio [AOR], 0.21; 95% CI, 0.14-0.29;P<.001), tumor size <1 cm vs 1 to 2 cm (AOR, 0.24; 95% CI, 0.17-0.35;P<.001), age ≥70 versus 50 to 69 years (AOR, 0.36; 95% CI, 0.24-0.54;P<.001), male sex (AOR, 0.63; 95% CI, 0.45-0.90;P=.009), and treatment at an academic versus a non-academic facility (AOR, 0.58; 95% CI, 0.41-0.81;P=.002).Conclusions:Despite the NCCN recommendation of CRT for stage I anal cancer, at least one-third of patients appear to be receiving guideline-discordant management. Excision alone is more common for patients who are elderly, are male, have small or low-grade tumors, or were evaluated at academic facilities.
authors.affiliation: Department of Therapeutic Radiology, Surgical Oncology Section, Yale School of Medicine, New Haven, Connecticut
authors.forename: Adam J
authors.initials: AJ
authors.lastname: Kole
authors.affiliation: Department of Therapeutic Radiology, Surgical Oncology Section, Yale School of Medicine, New Haven, Connecticut
authors.forename: John M
authors.initials: JM
authors.lastname: Stahl
authors.affiliation: Department of Therapeutic Radiology, Surgical Oncology Section, Yale School of Medicine, New Haven, Connecticut
authors.forename: Henry S
authors.initials: HS
authors.lastname: Park
authors.affiliation: Department of Surgery, Surgical Oncology Section, Yale School of Medicine, New Haven, Connecticut
authors.forename: Sajid A
authors.initials: SA
authors.lastname: Khan
authors.affiliation: Department of Therapeutic Radiology, Surgical Oncology Section, Yale School of Medicine, New Haven, Connecticut
authors.forename: Kimberly L
authors.initials: KL
authors.lastname: Johung
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D001005:Anus Neoplasms / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy*; D003131:Combined Modality Therapy; D016208:Databases, Factual; D019468:Disease Management; D005260:Female; D006801:Humans; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D060787:Neoplasm Grading; D009367:Neoplasm Staging; D016017:Odds Ratio; D017410:Practice Guidelines as Topic; D011379:Prognosis; D016016:Proportional Hazards Models; D012307:Risk Factors; D016896:Treatment Outcome