Objective: The National Quality Forum has endorsed a quality metric concerning the use of adjuvant chemotherapy administration in stage III colon cancer, yet a substantial treatment gap exists. Our objective was to evaluate the association of postoperative complications on the use of adjuvant therapy after colectomy for cancer.
Patients and Methods: Data from the American College of Surgeons National Surgical Quality Improvement Program and National Cancer Data Base were linked to augment cancer registry information with robust clinical data on comorbidities and postoperative complications (2006–2008). The association of complications on adjuvant chemotherapy use was assessed using hierarchical multivariable regression models.
Results: From 126 hospitals, 2368 patients underwent resection for stage III colon adenocarcinoma. Overall utilization of adjuvant chemotherapy was 63.2% (1497/2368). Of the 871 patients who did not receive chemotherapy, 652 met National Quality Forum exclusion criteria: death, severe comorbidity, refusal of care, advanced age (≥80 years), or prior malignancy. Of the remaining 219 patients, 19.1% (42/219) had 1 or more serious postoperative complications (eg, pneumonia, pulmonary failure). After accounting for the aforementioned potential explanations, the utilization rate was 87.2% (1497/1716). The strongest predictors of adjuvant chemotherapy omission were prolonged postoperative ventilation, renal failure, reintubation, and pneumonia (all Ps < 0.05). Superficial surgical site infection did not decrease adjuvant therapy receipt but delayed the time to its use by 3-fold. Serious complications increased time to chemotherapy by 65%. Abscess/anastomotic leak increased time to adjuvant chemotherapy by more than 5-fold.
Conclusions: Serious postoperative complications explained nearly 20% of the adjuvant chemotherapy treatment gap for patients with stage III colon cancer. The use of clinical data remains important when judging provider performance.
Adjuvant chemotherapy in stage III colon cancer prolongs survival and is a National Quality Forum–endorsed quality metric that will be used to publicly evaluate hospitals. Evidence indicates that a large proportion of eligible patients never receive treatment, but no study has comprehensively investigated the contribution of postoperative complications. We found that complications were strongly associated with adjuvant therapy omission or treatment delays and explained nearly 20% of the adjuvant chemotherapy treatment gap for patients with stage III colon cancer.
*Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL;
†Northwestern Institute for Comparative Effectiveness Research in Oncology, the Surgical Outcomes and Quality Improvement Center, and the Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL;
‡Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL;
§Department of Surgery, Jesse Brown VAMC, Chicago, IL;
¶Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH; and
‖Department of Surgery, University of California, Los Angeles, and VA Greater Los Angeles Healthcare System, Los Angeles, CA.
Reprints: Ryan P. Merkow, MD, MS, Division of Research and Optimal Patient Care, American College of Surgeons, 633 N. St. Clair St, 22nd Floor, Chicago, IL 60611. E-mail: RMerkow@facs.org.
This article was presented at the Gastrointestinal Cancer Symposium of the American Society of Clinical Oncology, January 20, 2012, San Francisco, CA.
Disclosure: Supported in part by the American Cancer Society (#280521) to R.P.M. and K.Y.B. and the Northwestern Institute for Comparative Effectiveness Research in Oncology to R.P.M., K.Y.B., and D.J.B. The authors declare no conflicts of interest.