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Etiology of Delays in the Initiation of Adjuvant Chemotherapy and Their Impact on Outcomes for Stage II and III Rectal Cancer

Cheung, Winson Y. M.D.1; Neville, Bridget A. M.P.H.2; Earle, Craig C. M.D., M.Sc.3

Diseases of the Colon & Rectum: June 2009 - Volume 52 - Issue 6 - p 1054-1064
doi: 10.1007/DCR.0b013e3181a51173
Original Contributions

PURPOSE: This study was designed to evaluate the role of access to care and postsurgical recovery on delays in adjuvant chemotherapy for rectal cancer.

METHODS: Using data from the linked Surveillance, Epidemiology, and End Results-Medicare database, we analyzed patients with Stage II or III rectal cancer who received adjuvant chemotherapy after curative rectal cancer surgery between 1991 and 2002. Logistic and Cox regressions were performed to assess determinants of adjuvant chemotherapy delays and outcomes in two cohorts: patients with access to medical oncology care because of prior neoadjuvant chemotherapy (Group A) and patients without such access (Group B). Length of postoperative hospital stay served as the main proxy for postsurgical recovery.

RESULTS: A total of 442 and 5,617 patients were included in Groups A and B, respectively. The median interval between surgery and adjuvant chemotherapy was 46 days in Group A and 42 days in Group B. Although 17 percent and 11 percent of patients in Groups A and B, respectively, waited three or more months for adjuvant chemotherapy, median overall survival was worse in this subset than in those who waited less than 3 months (54 vs. 76 months, P < 0.01). Postoperative hospital stay independently predicted for adjuvant chemotherapy delay in both groups. Disparities in delays were seen only in Group B, such that patients who were older or black had greater odds of an adjuvant chemotherapy delay (for both, P < 0.05).

CONCLUSION: Advanced age and black race contribute to adjuvant chemotherapy delays and inferior outcomes, but postoperative recovery is the more important driver.

1 Department of Medical Oncology, University of Toronto, Toronto, Ontario, Canada

2 Center for Outcomes and Policy Research, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts

3 Institute of Clinical Evaluative Sciences, Toronto, Ontario, Canada

Read at the meeting of The American Society of Clinical Oncology Gastrointestinal Cancers Symposium, Orlando, Florida, January 25 to 27, 2008.

Address of correspondence: Craig C. Earle, M.D., M.Sc., Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Room G-106, Toronto, Ontario, M4N 3M5, Canada. E-mail:

© The ASCRS 2009