D. S. Swords1,2, D. E. Skarda1,2, H. Kim2, W. T. Sause3, G. J. Stoddard4, C. L. Scaife1 1University Of Utah,Surgery,Salt Lake City, UT, USA 2Intermountain Healthcare,Surgical Services,Salt Lake City, UT, USA 3Intermountain Healthcare,Oncology Services,Salt Lake City, UT, USA 4University Of Utah,Division Of Epidemiology,Salt Lake City, UT, USA
Introduction: The Commission-on-Cancer (CoC) rectal cancer quality measure (QM) states that patients with clinical stage I/pathologic stage II-III rectal cancer (“upstaged”) should receive adjuvant chemoradiation. Notably, the QM does not consider upstaging to be guideline discordant care. We hypothesized that there is facility variation in delivery of adjuvant chemoradiation to such patients, and that there is also variation among facilities in rates of upstaging.
Methods: This retrospective study of the 2009-2014 National Cancer Database examined patients < 80 years with clinical stage I rectal adenocarcinoma. Exclusion criteria included: previous cancer, no surgery, local tumor destruction/excision only, neoadjuvant therapy, surgery not at the reporting facility, and unknown clinical or pathologic stage. Outcomes were (1) being upstaged and (2) receipt of adjuvant chemoradiation among upstaged patients who survived ≥ 180 days post-diagnosis. Covariates with univariate p-values < 0.2 for each outcome were entered into multivariable poisson regression models with robust variance estimates. An imputed analysis of 50 data sets obtained through multiple imputation by chained equations was used to account for missing data. Risk- and reliability-adjusted estimates for each facility were generated to examine facility rates of outcomes.
Results: Among 6,031 patients the median age was 60 years, 57.7% were male, and 83.0% were white. Upstaging occurred in 1,607 patients (26.6%). Of pathologic stage II-III patients, 712 (67.2%) received adjuvant chemoradiation. Upstaging was independently predicted by age < 50, Hispanic ethnicity, higher grade, mucinous/signet ring histology, larger size, and elevated CEA. Treatment at > 1 CoC facility was associated with upstaging, but facility type and volume were not. Receipt of adjuvant chemoradiation among upstaged patients was independently associated with age < 70, short travel distance, pathologic stage III (vs. II), and abdominoperineal resection (vs. low anterior resection). Surprisingly, treatment at academic and high volume facilities was associated with omission of adjuvant chemoradiation. Adjusted facility rates of upstaging ranged from 15.4% to 52.7%, and adjuvant chemoradiation rates ranged from 25.3% to 84.0% (Figure).
Conclusion: There is 3-fold variation in adjusted facility rates of adjuvant chemoradiation for patients with clinical stage I/pathologic stage II-III rectal adenocarcinoma, which verifies the utility of this part of the CoC rectal cancer QM. However, there is also significant facility-level variation in rates of upstaging. Providing feedback to facilities with high outlier rates of upstaging should be considered as a quality improvement strategy.
