Adherence to national clinical practice guidelines is an especially salient benchmark for rectal cancer, given the high degree of consensus among various guideline-generating agencies,” said Ryaz Chagpar, MD, of University of Texas M.D. Anderson Cancer Center, Houston. “But a nationwide hospital-based assessment of current practices with respect to stage-specific treatment of rectal cancer is lacking.”
Dr Chagpar and colleagues as sessed; current practice trends and adherence to the National Comprehensive Cancer Network (NCCN) guidelines for >47,000 persons diagnosed with rectal cancer between 2003 and 2007.
This population included 10,084 patients with stage I disease; 13,117 with stage II disease; 15,864 with stage III disease; and 8334 with stage IV disease. The demographics were fairly comparable across the disease stages.
“Overall, the majority of patients (64%) were treated in accordance with NCCN guidelines,” Dr Chagpar noted, but this leaves one third that were not. Patients with stage IV disease were most likely to receive guideline-adherent treatment (73%). Nonadherence in stage I rectal cancer was largely associated with overtreatment (20%), primarily with neoadjuvant therapy (83%). The undertreatment rate for stage I disease was 14%, evident when no surgical resection was performed or when transanal excision was used inappropriately for larger tumors.
Across all stages, most cases of undertreatment were related to a failure to use adjuvant therapy for stage II (44%) or stage III (40%) disease.
For stage I rectal cancer, age >50 years and a Charlson-Deyo comorbidity index ≥1 were independently associated with guideline adherence; the opposite trend was found for stage II to stage IV disease. “This is the result of younger, healthier clinical stage I patients being overtreated with neoadjuvant chemotherapy,” Dr Chagpar said.
Across all stages, patients with private or Medicare insurance, and those who received treatment at a comprehensive cancer center/teaching hospital or at a community cancer center were most likely to receive treatment according to NCCN guidelines.
The investigators concluded that young patients with stage I rectal cancer who were insured were likely to be overtreated, whereas patients with stage II and III cancer who were older, had comorbid conditions, were underinsured, or received treatment at community hospitals were likely to be undertreated.