A. Adhia1, J. Feinglass1, K. Engelhardt1, M. DeCamp1, D. Odell1 1Northwestern University,Chicago, IL, USA
Introduction: Esophageal cancer is the leading cause of death among GI malignancies and the incidence of the disease is rising faster than any other solid organ tumor. Patients frequently present with locally advanced disease (stage III), contributing to challenges in treatment decision making. Our objective was to assess adherence to four novel quality measures in patients with stage III esophageal cancer.
Methods: 18,555 patients diagnosed with stage III esophageal cancer were identified from the National Cancer Database (NCDB) between 2004 and 2014. Four quality measures were defined from NCCN guidelines: administration of induction therapy, >15 lymph nodes sampled at resection, surgery within 120 days of neoadjuvant treatment, and R0 resection. The association of patient demographic and treatment variables (age, sex, location of lesion, histology, income, education, race and ethnicity and year of diagnosis) with measure adherence was assessed using logistic regression. Risk of all-cause mortality was assessed comparing adherent and non-adherent cases using Cox modeling. Kaplan-Meier survival estimates of groups that adhered to none, one of four, two of four etc. quality measures were performed.
Results: Adherence was high for three of the quality measures: neoadjuvant treatment (92.7%), timing of surgery (82.5%) and completeness of resection (91.5%). However, nodal evaluation was adequate in only a minority of patients (20.0%). Advanced age, Medicaid insurance status, lower level of education and Black or Hispanic ethnicity were all associated with statistically significant increased odds of non-adherence for all measures. Adherence improved in the more recent time period, with cases after 2008 having improved adherence in administration of induction therapy (OR = 2.58 in 2012-2014 period) and adequate nodal staging (OR = 2.49 in 2012-2014). Achieving adherence was associated with a statistically significant decrease in all-cause mortality for administration of induction therapy (HR = 0.70 [0.62, 0.78]), nodal staging (HR = 0.67 [0.63, 0.70]), and R0 resection (HR = 0.48 [0.43, 0.53]), but not for timing of surgery (HR = 0.93 [0.85, 1.02]). Survival improved as the number of quality measures an individual patient adhered to increased (Figure).
Conclusion: Adherence to quality measures in the care of patients with stage III esophageal cancer is associated with improved survival. Understanding variability in measure adherence may identify potential targets for cancer quality improvement initiatives.
