Is timing to delivery of treatment a reliable measure of quality of care for patients with colorectal adenocarcinoma?

doi:10.1016/j.surg.2013.04.049

Surgery

Volume 154, Issue 3, September 2013, Pages 421-428

https://doi.org/10.1016/j.surg.2013.04.049 Get rights and content

Background

Among patients with colorectal adenocarcinoma, patient race has been associated with differences in colorectal cancer survival. Survival disparities between ethnic groups may be related to treatment delays, treating hospital, or other patient factors. We hypothesized that prolonged interval to delivery of cancer therapy negatively impacts survival.

Study Design

We designed a retrospective cohort study using tumor registry and clinical database information from two academically affiliated hospitals. We examined factors associated with interval to treatment and associations between interval and overall survival.

Results

Among 592 patients treated by a cohort of physicians, we found no differences in cancer stage related to race or treating hospital. Interval to treatment differed between different hospitals (29 vs 16 days; P < .0001); yet, there were no differences in overall survival related to treatment interval, treating hospital, race, or insurance status. Tumor grade and tumor stage were associated with decreased overall survival.

Conclusion

Differences exist related to the timing of definitive care for patients in this series; however, these differences do not translate directly into differences in overall survival. We must deliver quality health care in an efficient and timely manner; however, the metric of interval to treatment may not measure reliably the quality of care received.

Section snippets

Rationale and specific aims

Our overall aim was to demonstrate whether interval to treatment delivery was associated with differences in survival in a cohort of patients with colorectal adenocarcinoma. We hypothesized that differences in interval to treatment delivery may be influenced by patient factors, physician factors, and health care system factors. We hypothesized that the most powerful factor impacting interval to treatment would be the health care system delivering treatment. To isolate the impact of interval to

Methods

We conducted a retrospective review of all patients diagnosed with colon and rectal carcinoma at the main campus of UT Southwestern Medical Center in Dallas, Texas. Patients were treated at either Parkland Health and Hospital Systems (county) or University Hospital-St. Paul (university) from January 1, 2000, to October 31, 2008. Patients identified in tumor registry databases at each institution as having primary colorectal carcinoma were included in the study population. Patients diagnosed

Aim 1: To identify a single cohort of patients from two affiliated hospitals diagnosed and non-emergently treated within the hospital system

At the county and university hospitals, 1,181 patients were treated for colorectal cancer during the 8-year study period. Figure 1, A illustrates the process of inclusion and exclusion from the study. The most common reason for exclusion (69% of excluded cases) was the patient being diagnosed outside the health system. Emergency cases comprised 29% (n = 60) of excluded patients in the county hospital population and 21% (n = 79) in the university hospital population. Our final study population

Discussion

Previous studies have documented disparate outcomes for patients with colorectal cancer¹³; however, factors that contribute to these observed differences have yet to be determined. Studies looking at differences in screening and tumor biology/histology have failed to demonstrate substantial differences to account for these differences in outcomes.7, 8, 14 In the present study, we compare patients treated at two affiliated hospitals in which patients were cared for by overlapping physician

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Surgical Cancer Care in Safety-Net Hospitals: a Systematic Review
2023, Journal of Gastrointestinal Surgery
Tertiary medical centers in the USA provide specialized, high-volume surgical cancer care, contributing standards for quality and outcomes. For the most vulnerable populations, safety-net hospitals (SNHs) remain the predominant provider of both complex and routine healthcare needs. The objective of this study was to evaluate access to and quality of surgical oncology care within SNHs.
A comprehensive and systematic review of the literature was conducted using PubMed, EMBASE, and Cochrane Library databases to identify all studies (January 2000–October 2021) reporting the delivery of surgical cancer care at SNHs in the USA (PROSPERO #CRD42021290092). These studies describe the process and/or outcomes of surgical care for gastrointestinal, hepatopancreatobiliary, or breast cancer patients seeking treatment at SNHs.
Of 3753 records, 37 studies met the inclusion criteria. Surgical care for breast cancer (43%) was the most represented, followed by colorectal (30%) and hepatopancreatobiliary (16%) cancers. Financial constraints, cultural and language barriers, and limitations to insurance coverage were cited as common reasons for disparities in care within SNHs. Advanced disease at presentation was common among cancer patients seeking care at SNHs (range, 24–61% of patients). Though reports comparing cancer survival between SNHs and non-SNHs were few, results were mixed, underscoring the variability in care seen across SNHs.
These findings highlight barriers in care facing many cancer patients. Continued efforts should address improving both access and quality of care for SNH patients. Future models include a transition away from a two-tiered system of resourced and under-resourced hospitals toward an integrated cancer system.
A systematic review of methodological considerations in time to diagnosis and treatment in colorectal cancer research
2023, Cancer Epidemiology
Research focusing on timely diagnosis and treatment of colorectal cancer is necessary to improve outcomes for people with cancer. Previous attempts to consolidate research on time to diagnosis and treatment have noted varied methodological approaches and quality, limiting the comparability of findings. This systematic review was conducted to comprehensively assess the scope of methodological issues in this field and provide recommendations for future research. Eligible articles had to assess the role of any interval up to treatment, on any outcome in colorectal cancer, in English, with no limits on publication time. Four databases were searched (Ovid Medline, EMBASE, EMCARE and PsycInfo). Papers were screened by two independent reviewers using a two-stage process of title and abstract followed by full text review. In total, 130 papers were included and had data extracted on specific methodological and statistical features. Several methodological problems were identified across the evidence base. Common issues included arbitrary categorisation of intervals (n = 107, 83%), no adjustment for potential confounders (n = 65, 50%), and lack of justification for included covariates where there was adjustment (n = 40 of 65 papers that performed an adjusted analysis, 62%). Many articles introduced epidemiological biases such as immortal time bias (n = 37 of 80 papers that used survival as an outcome, 46%) and confounding by indication (n = 73, 56%), as well as other biases arising from inclusion of factors outside of their temporal sequence. However, determination of the full extent of these problems was hampered by insufficient reporting. Recommendations include avoiding artificial categorisation of intervals, ensuring bias has not been introduced due to out-of-sequence use of key events and increased use of theoretical frameworks to detect and reduce bias. The development of reporting guidelines and domain-specific risk of bias tools may aid in ensuring future research can reliably contribute to recommendations regarding optimal timing and strengthen the evidence base.
Impact of delay to surgery on survival in stage I-III colon cancer
2020, European Journal of Surgical Oncology
Citation Excerpt :
Studies looking at the impact of delays to surgery are limited and conflicting. Several recent studies have not revealed a significant association between a prolonged interval to CC resection and long-term survival [12–15]. However, other large-scale population-based studies showed ambiguous results [16,17].
To assess the impact of delay from diagnosis to curative surgery on survival in patients with non-metastatic colon cancer.
National Cancer database (NCDB) analysis (2004–2013) including all consecutive patients diagnosed with stage I-III colon cancer and treated with primary elective curative surgery. Short and long delays were defined as lower and upper quartiles of time from diagnosis to treatment, respectively. Age-, sex-, race-, tumor stage and location-, adjuvant treatment-, comorbidity- and socioeconomic factors-adjusted overall survival (OS) was compared between the two groups (short vs. long delay). A multivariable Cox regression model was used to identify the independent impact of each factor on OS.
Time to treatment was <16 days in the short delay group (31,171 patients) and ≥37 days in the long delay group (29,617 patients). OS was 75.4 vs. 71.9% at 5 years and 56.6 vs. 49.7% at 10 years in short and long delay groups, respectively (both p < 0.0001). Besides demographic (comorbidities, advanced age) and pathological factors (transverse and right-vs. left-sided location, advanced tumor stage, poor differentiation, positive microscopic margins), treatment delay had a significant impact on OS (HR 1.06, 95% CI 1.05–1.07 per 14 day-delay) upon multivariable analysis. The adjusted hazard ratio for death increased continuously with delay times of longer than 30 days, to become significant after a delay of 40 days.
This analysis using a national cancer database revealed a significant impact on OS when surgeries for resectable colon cancer were delayed beyond 40 days from time of diagnosis.
Impact of therapeutic delay in colorectal cancer on overall survival and cancer recurrence – is there a safe timeframe for prehabilitation?
2019, European Journal of Surgical Oncology
Citation Excerpt :
Multiple studies regarding this therapeutic delay show different results. A number of studies demonstrated that delayed treatment is not significantly associated with survival or oncologic outcome [2–4]. Others showed a negative association between time to treatment and survival in case of rectal cancer but not for colonic cancer [5–7].
Interest in adoption of a prehabilitation programme in management of colorectal cancer is increasing, but current waiting time targets leave no opening for intervention. Prompt treatment following diagnosis is demanded but defending evidence is lacking. We aimed to investigate the impact of prolonged therapeutic delay on overall and cancer-free survival in patients with primary colorectal cancer.
Retrospective analysis was performed in a detailed dataset of patients with primary colorectal cancer who underwent curative surgical treatment between January 2010 and December 2016. Groups were made according to therapeutic delay ≤35 days or >35 days. Endpoints were overall and cancer-free survival, assessed with Kaplan-Meier survival curves, log-rank tests and Cox proportional hazard analyses.
A total of 790 patients were included of whom 559 had a colonic tumour and 231 a rectal tumour. Median therapeutic delay was 32 days (IQR 26-43 days). Multivariate analysis showed therapeutic delay >35 days was not associated with poorer overall survival (HR = 1.202, p = 0.249) or earlier cancer recurrence (HR = 1.256, p = 0.212). Similar results were found when stratifying analyses for colonic and rectal cancer, and when defining prolonged delay as >49 days.
Prolonged treatment delay does not lead to poorer overall or cancer-free survival in patients with primary colorectal cancer who underwent curative surgical treatment. This allows professionals to push current national waiting time targets in order to adopt a prehabilitation programme without jeopardizing outcomes.
Association between the time to surgery and survival among patients with colon cancer: A population-based study
2017, European Journal of Surgical Oncology
Citation Excerpt :
After adjusting for relevant confounders, there was no association between a delay to surgery and the outcomes of death or metastatic recurrence. Finally, a case series including 592 cases of colorectal cancer from 2000 to 2008 in two academic hospitals also found no difference in survival with a longer TTS.12 Our data also supports this previous work as well and greatly adds to the growing literature as we evaluated treatment delay at the population level in a well characterized contemporary cohort.
Factors associated with time-to-surgery (TTS) and survival in colon cancer has not been well studied. Cancer Care Ontario recommends surgery within 42 days of diagnosis and that 90% of patients meet this benchmark. We describe factors associated with TTS and survival in routine clinical practice.
Retrospective population-based cohort study of patients receiving elective colonic resection after diagnosis of colon cancer in Ontario, Canada from 2002 to 2008 followed until 2012. Factors associated with TTS were identified using multivariate log-binomial and Quantile regression at 42 days and 90th percentiles. The association between TTS and cancer-specific (CSS) and overall survival (OS) were examined using multivariate Cox regression.
4326 patients; median age 71 years and 52% male. Median TTS was 24 days (IQR 14–37); at the 90th percentile 56 days. Factors associated with TTS ≥ 42 days and >90th percentile included older age, co-morbid illness, surgeon volume, and stage I disease (P < 0.05 for all). In patients whose TTS was either at 42 days or 90th percentile, those ≥80 years old waited two weeks longer than those <60 years, individuals with co-morbid illness waited 10 days longer than without co-morbidity, and patients with stage I disease waited 10 days longer than those with stage IV disease (P < 0.05 for all). Delay in TTS > 42 days or >90th percentile was not associated with OS or CSS.
Age, co-morbidity, and stage of cancer are associated with TTS. There was no association between TTS and CSS or OS.
Treatment delays of colon cancer in a safety-net hospital system
2015, Journal of Surgical Research
Citation Excerpt :
There are limited data on whether short delays, on the order of days to weeks, impact colon cancer-associated outcomes and when the time between diagnosis and treatment becomes excessive. Roland et al.[7] compared patients with CRC treated at two academically affiliated hospitals, one a county hospital (Parkland Health and Hospital System) and the other a private University Hospital (University Hospital-St. Paul). Although the authors were able to identify an increased time to treatment of nonemergent CRC in the county hospital (16 versus 29 d), there were no differences in observed overall survival; the median survival in patients treated within 16 d was 4.5 y compared with 5.1 y in patients treated beyond this interval.
Disparities in colon cancer survival have been reported to result from advanced stage at diagnosis and delayed therapy. We hypothesized that delays in treatment among medically underserved patients occur as a result of system-level barriers in a safety-net hospital system.
Retrospective review and analysis of colon cancer patients treated in a large safety-net hospital system between May 2008 and May 2012. Data were collected on demographics, stage at diagnosis, time to surgery, time to adjuvant chemotherapy, and vital status. Regression analyses were performed to determine predictors of delays and failure to receive therapy.
Of 248 patients treated for colon cancer, 56% (n = 140) had advanced disease at the time of presentation; furthermore, 29.1% of all colectomies for colon cancer were performed on an urgent or emergent basis. Thirty-six patients with stage III and IV disease did not receive chemotherapy (26%). Race, age, gender, and hospice care did not predict receipt of chemotherapy or delays to treatment. Patients with stage I colon cancer had a significantly longer interval between diagnosis and elective surgery when compared with patients with stage II, III, and IV colon cancer, with only 10% (n = 3) undergoing resection sooner than 6 wk after diagnosis.
One in three patients diagnosed with colon cancer in a large safety-net hospital system require urgent or emergent surgery, and one in two present with advanced disease. Reducing disparities should focus on earlier diagnosis of colon cancer and improving access to surgical specialists.

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Surgical Outcome ResearchIs timing to delivery of treatment a reliable measure of quality of care for patients with colorectal adenocarcinoma?

Background

Study Design

Results

Conclusion

Section snippets

Rationale and specific aims

Methods

Aim 1: To identify a single cohort of patients from two affiliated hospitals diagnosed and non-emergently treated within the hospital system

Discussion

Cancer facts and figures 2009

Colorectal cancer and race: understanding the differences in outcomes between African Americans and whites

Med Clin N Am

Racial differences in tumor stage and survival for colorectal cancer in an insured population

Cancer

African-American and Caucasian disparities in colorectal cancer mortality and survival by data source: an epidemiologic review

Cancer Biomark

Differences in colorectal carcinoma stage and survival by race and ethnicity

Cancer

Disparities in oncologic surgery

World J Surg

Persistent racial and ethnic disparities in up-to-date colorectal cancer testing in medicare enrollees

J Am Geriatr Soc

Do adverse histopathologic findings in colorectal cancer patients explain disparate outcomes?

J Natl Med Assoc

Surgical Outcome Research
Is timing to delivery of treatment a reliable measure of quality of care for patients with colorectal adenocarcinoma?