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Adequacy of the National Quality Forum's Colon Cancer Adjuvant Chemotherapy Quality Metric

Is 4 Months Soon Enough?

Massarweh, Nader N. MD, MPH*; Haynes, Alex B. MD, MPH; Chiang, Yi-Ju MSPH*; Chang, George J. MD, MS*; You, Y. Nancy MD, MHSc*; Feig, Barry W. MD*; Cormier, Janice N. MD, MPH*

doi: 10.1097/SLA.0000000000000859
Original Articles

Objective: To ascertain whether the National Quality Forum-endorsed time interval for adjuvant chemotherapy (AC) initiation optimizes patient outcome.

Background: Delayed AC initiation for stage III colon cancer is associated with worse survival and the focus of a National Quality Forum quality metric (<4 months among patients aged <80 years).

Methods: Observational cohort study of patients with stage III colon cancer younger than 80 years within the National Cancer Data Base (2003–2010). The primary outcome was 5-year overall survival evaluated using multivariate Cox proportional hazards regression. Aggregate survival estimates for historical surgery-only controls from pooled National Surgical Adjuvant Breast and Bowel Project trial data were also used.

Results: Among 51,331 patients (60.8 ± 11.6 years, 50.2% males, and 77.3% white), 76.3% received standard AC (≤2 months) and 21.6% delayed (>2 and <4 months) AC. Earlier AC was associated with better 5-year overall survival [standard AC, 69.8%; delayed AC, 62.0%; late AC (4–6 months), 51.4%; log-rank, P < 0.001]. The survival rate after late AC was similar to surgery alone (51.1%; Wilcoxon rank sum, P = 0.10). Compared with late AC, standard AC (hazard ratio, 0.62; 95% confidence interval, 0.54–0.72) and delayed AC (hazard ratio, 0.77; 95% confidence interval, 0.66–0.89) significantly decreased risk of death. Risk of death was also lower for standard AC compared to delayed AC (hazard ratio, 0.81; 95% confidence interval, 0.77–0.86).

Conclusions: One in 5 patients with stage III colon cancer initiates AC within the National Quality Forum-endorsed interval, but does not derive the full benefit. These data support strengthening current quality improvement initiatives and colon cancer treatment guidelines to encourage AC initiation within 2 months of resection when possible, but not beyond 4 months.

Delayed adjuvant chemotherapy (AC) for patients with stage III colon cancer adversely impacts outcomes and is the focus of a National Quality Forum (NQF) quality metric. One in 5 patients initiates AC within the NQF-endorsed interval but does not derive the full benefit.

*Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX

Department of Surgery, Massachusetts General Hospital, Boston, MA.

Reprints: Janice N. Cormier, MD, MPH, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Unit 1484, Box 301402, Houston, TX 77230. E-mail:

Disclosure: None of the authors has any conflict of interest to report.

The American College of Surgeons and the Commission on Cancer have not verified and are neither responsible for the analytic or statistical methodology employed nor the conclusions drawn from these data.

Supported by National Institutes of Health/National Cancer Institute grant CA16672 (The University of Texas MD Anderson Cancer Center Support Grant).

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