R. L. Hoffman1, K. D. Simmons1, R. E. Roses1, N. N. Mahmoud1, R. R. Kelz1 1Hospital Of The University Of Pennsylvania,Philadelphia, PA, USA
Introduction:
Adherence to guideline-based care for colon cancer patients has been shown to result in decreased costs, shorter durations of inpatient stays, and improved survival. Surgeons play an integral role in the management of colon cancer. The aim of this study was to examine adherence to NCCN guidelines amongst colon resection patients by demographic and clinical characteristics.
Methods:
Patients aged 65-84 years diagnosed with AJCC stage II and III colon cancer who underwent a colon resection were identified in the SEER-Medicare database (2005-2009). High risk (HR) stage II disease was defined as those with a T4 tumor, poor differentiation and <12 lymph nodes examined. Adherence was classified as undertreatment (UT), overtreatment (OT) or concordant care (CC) using stage- and grade-specific NCCN guidelines in combination with chemotherapy and radiation codes from Medicare claims files. Comorbidities were determined using ICD-9 codes from AHRQ predefined category buckets based on diagnoses present in Medicare Outpatient claims at or before the time of colon cancer diagnosis. Descriptive statistics were computed to determine adherence patterns.
Results:
A total of 13017 stage II and III patients who underwent colectomy were identified; 3618 (27.8%) were categorized as stage IIA/B low risk (LR), 3314 (35.5%) as stage IIA/B HR, and 6085 (46.7%) as stage IIIA/B/C. There were a total of 2287 patients ages 65-69, 3,206 ages 70-74, 3,807 ages 75-79 and 3717 ages 80-84 years. Males constituted 43.2% of the cohort (5619). White patients made up 82.5% (10743) and black 9.2% (1200). A total of 8322 (63.9%) patients had one or more comorbidities, with hypertension and iron deficiency anemia being the most common. CC was noted in 6348 cases (48.8%), UT in 5837 (44.8%) and OT in 832 (6.4%). CC was the most likely treatment for stage IIA/B LR patients (87.2%, 3153), patients under the age of 80 (52.3%, 4860), white patients (49.2%, 5280), black patients (47.6%, 571), Asian patients (48.8%, 238) and patients with 1+ comorbidities (52.8%, 4393). Location of residence was not associated with the likelihood of CC. UT was most common amongst stage IIA/B HR patients (80.1%, 2671), stage III patients (54.2%; 3166), patients ages 80-84 (35.9%; 2098), Hispanics (48.9%; 112), and patients without documented comorbidity (53.1%, 2492). OT was less frequent than UT. Patients over 79 years of age (35.9%) and women (59.3%) were over-represented in the UT group; men (50.8%) and patients ages 70-74 (30.7%) were over-represented in the OT group.
Conclusion:
Stage IIA/B low-risk patients were most likely to receive concordant care. The lower rate of CC among stage IIA/B high-risk and stage III is likely attributable to multiple factors, including clinical judgment based on the strength of evidence presented in the guidelines. Understanding the nuances of treatment adherence across different groups will allow a more targeted focus of efforts to decrease disparities in care.