Colorectal cancer (CRC) is diagnosed in almost 150,000 patients in the United States each year and is the second leading cause of cancer-related death, accounting for more than 50,000 mortalities annually. The use of adjuvant chemotherapy has been a key quality measure for stage III CRC care because it is associated with a significant survival benefit. Chemotherapy for these patients has been shown to improve survival by as much as 16% after 5 years. However, national data indicate that guideline-recommended care is not provided to many patients. Studies have shown that the rates of adjuvant chemotherapy use for stage III CRC range from only 39% to 71%.
Few studies have shed light on the reasons for the underuse of adjuvant chemotherapy in stage III CRC. Some sociodemographic variables (eg, older age, minority ethnicity, and lower socioeconomic status) have been linked to the omission of chemotherapy. However, it’s likely that other clinical predictors— including comorbid diseases, patients opting out of chemotherapy, and the high prevalence of perioperative complications in colorectal surgery—play a role in the receipt of chemotherapy. There may also be physician reluctance to give chemotherapy to patients who are frail or too sick from their surgical recovery.
Complications in Colorectal Cancer Surgery
In the December 2010 issue of Diseases of the Colon & Rectum, my colleagues and I published a study that examined the extent to which surgical complications are associated with the omission of recommended chemotherapy for CRC patients. We looked at data from 17,108 patients who had surgery for stage III CRC using patients from the Surveillance, Epidemiology, and End Results-Medicare database. Our results showed that at least 18% of patients had one or more complication from surgery, 13% of whom had medical complications, and 3.8% had complications requiring reoperation or another procedure. Complications included pneumonia, urinary tract infections, heart attack, wound infections, need for additional surgery, and abscess drainage.
“It’s imperative that clinicians become aware of the reasons why patients are not getting chemotherapy.”
Patients in our analysis who had complications after CRC surgery were significantly less likely to get chemotherapy, even when it’s clearly recommended for their diagnosis. Adjuvant chemotherapy was omitted in 46% of patients with complications from surgery as compared with 31% of patients who did not have complications. A multivariable analysis to control for patient risk factors (eg, age and comorbidities) showed that complications are still significantly associated with omission of chemotherapy after adjusting for these factors. Other factors associated with chemotherapy omission included age, race, marital status, urgent or emergent admission, and type of operation. In addition, patients with surgical complications were more than twice as likely to have their chemotherapy delayed for more than 120 days after their diagnosis or 2 months after surgery, which is considered the appropriate timeframe for receiving chemotherapy.
Future Colorectal Cancer Management
Surgical complications are typically thought of as short-term problems for stage III CRC patients. But our investigation suggests a link between downstream cancer care and complications arising from surgery. Chemotherapy in these patients has been shown to offer lifesaving benefits, and clinicians need to be vigilant about adhering to national guideline recommendations. In order to improve compliance with guidelines, it’s imperative that clinicians become aware of the reasons why patients are not getting chemotherapy. Our data suggest that surgical complications appear to play a role.
Some of the complications experienced by patients are preventable. As such, physicians and hospitals should strive to implement quality improvement measures that effectively reduce perioperative complications. Promising strategies for decreasing complications include participation in the American College of Surgeons’ National Surgical Quality Improvement Program, and/or participating in regional, collaborative quality improvement initiatives, such as the Michigan Surgical Quality Collaborative. Focusing on surgical safety through these mechanisms may help hospitals achieve long-term cancer survival benefits.
Readings & Resources (click to view)
Hendren S, Birkmeyer JD, Yin H, Banerjee M, Sonnenday C, Morris AM. Surgical complications are associated with omission of chemotherapy for stage III colorectal cancer. Dis Colon Rectum. 2010;53:1587-1593. Available at:http://journals.lww.com/dcrjournal/Abstract/2010/12000/Surgical_Complications_Are_Associated_With.1.aspx
Wolpin BM, Meyerhardt JA, Mamon HJ, Mayer RJ. Adjuvant treatment of colorectal cancer. CA Cancer J Clin. 2007;57:168-185.
Andre´ T, Boni C, Navarro M, et al. Improved overall survival with oxaliplatin, fluorouracil, and leucovorin as adjuvant treatment in stage II or III colon cancer in the MOSAIC trial. J Clin Oncol. 2009;27:3109-3116.
McGory ML, Zingmond DS, Sekeris E, Bastani R, Ko CY. A patient’s race/ethnicity does not explain the underuse of appropriate adjuvant therapy in colorectal cancer. Dis Colon Rectum. 2006;49:319-329.