Surgeon-Level Variation in Utilization of Local Staging and Neoadjuvant Therapy for Stage II-III Rectal Adenocarcinoma

  • Douglas S. SwordsEmail author
  • David E. Skarda
  • William T. Sause
  • Ute Gawlick
  • George M. Cannon
  • Mark A. Lewis
  • Courtney L. Scaife
  • Jesse A. Gygi
  • H. Tae Kim
2018 SSAT Plenary Presentation



Neoadjuvant therapy (NT) is the standard of care for clinical stage II-III rectal adenocarcinoma, but utilization remains suboptimal. We aimed to determine the underlying reasons for omission of local staging and NT.


We conducted a retrospective study of patients with clinical stage II-III or undocumented clinical stage/pathologic stage II-III rectal adenocarcinoma who were treated in 2010–2016 in one of nine Intermountain Healthcare hospitals. The outcomes of omission of local staging and NT were examined with multivariable models. Risk- and reliability-adjusted rates of local staging and NT were calculated for surgeons who treated ≥ 3 patients. Pathologic and long-term outcomes were examined after excluding patients who were not resected or who underwent local excision (N = 11).


Local staging was omitted in 43/240 (17.9%) patients and NT was omitted in 41/240 (17.1%). The strongest risk factors for local staging and NT omission were upper rectal tumors and surgeons who treated ≤ 3 cases/year. Thirty-six of 41 (87.8%) cases of omitted NT had local staging omitted. Adjusted surgeon-specific local staging rates varied 1.6-fold (56.3–92.4%) and NT rates varied 2.8-fold (34.1–97.1%). Surgeon local staging and NT rates were strongly correlated (r = 0.92). NT was associated with lower rates of positive circumferential radial margins (7.9 vs. 20.0%; P = 0.02), node positivity (33.3 vs. 55.0%; P = 0.01), and local recurrences (7.6 vs. 14.9% at 5 years; P = 0.0176).


NT omission should be understood as a consequence of surgeon failure to perform local staging in most cases. Quality improvement efforts should focus on improving utilization of local staging.


Rectal cancer Locally advanced Clinical staging Local staging Locoregional staging EUS MRI Neoadjuvant treatment Preoperative Neoadjuvant chemoradiotherapy Disparities Centers of excellence OSTRICH Consortium National Accreditation Program for Rectal Cancer 


Author Contributions

Study conception and design: Swords, Skarda, Sause, Kim

Acquisition and analysis of data: Swords, Gygi

Interpretation of data: Swords, Skarda, Sause, Gawlick, Cannon, Lewis, Scaife, Gygi, Kim

Drafting of manuscript: Swords

Critical revision of manuscript: Swords, Skarda, Sause, Gawlick, Cannon, Lewis, Scaife, Gygi, Kim

Final approval of submission: Swords, Skarda, Sause, Gawlick, Cannon, Lewis, Scaife, Gygi, Kim

Supplementary material

11605_2019_4107_MOESM1_ESM.docx (18 kb)
ESM 1 (DOCX 17 kb)


  1. 1.
    Monson JR, Probst CP, Wexner SD, Remzi FH, Fleshman JW, Garcia-Aguilar J, Chang GJ, Dietz DW, Consortium for Optimizing the Treatment of Rectal C. Failure of evidence-based cancer care in the United States: the association between rectal cancer treatment, cancer center volume, and geography. Ann Surg. 2014;260(4):625–31; discussion 31-2. doi: Scholar
  2. 2.
    Sauer R, Becker H, Hohenberger W, Rodel C, Wittekind C, Fietkau R, Martus P, Tschmelitsch J, Hager E, Hess C, Karstens J, Liersch T, Schmidberger H, Raab R, GRCS Group. Preoperative versus Postoperative Chemoradiotherapy for Rectal Cancer. NEJM. 2004;351(17):1731–40.CrossRefGoogle Scholar
  3. 3.
    NCCN Clinical Practice Guidelines in Oncology: Rectal Cancer. Version 3.17. [cited May 15, 2018]. Available at:
  4. 4.
    Sineshaw HM, Jemal A, Thomas CR, Jr., Mitin T. Changes in treatment patterns for patients with locally advanced rectal cancer in the United States over the past decade: An analysis from the National Cancer Data Base. Cancer. 2016;122(13):1996–2003. doi: Scholar
  5. 5.
    Midura E, Jung, AD, Daly, MC, Hansenman, DJ, Shah, SA, Paquette, IM. Cancer Center Volume and Type Impact Stage-Specific Utilization of Neoadjuvant Therapy in Rectal Cancer. Dig Dis Sci. 2017;62(8):1906–12.CrossRefGoogle Scholar
  6. 6.
    Delitto D, George TJ, Jr., Loftus TJ, Qiu P, Chang GJ, Allegra CJ, Hall WA, Hughes SJ, Tan SA, Shaw CM, Iqbal A. Prognostic Value of Clinical vs Pathologic Stage in Rectal Cancer Patients Receiving Neoadjuvant Therapy. J Natl Cancer Inst. 2018;110(5):460–6. doi: Scholar
  7. 7.
    Wexner S, Berho ME,. The Rationale for and Reality of the New National Accreditation Program for Rectal Cancer. Dis Colon Rectum. 2017;60(6):595–602.CrossRefGoogle Scholar
  8. 8.
    Dietz DW, Consortium for Optimizing Surgical Treatment of Rectal C. Multidisciplinary management of rectal cancer: the OSTRICH. J Gastrointest Surg. 2013;17(10):1863–8. doi: Scholar
  9. 9.
    Glasgow SC, Morris AM, Baxter NN, Fleshman JW, Alavi KS, Luchtefeld MA, Monson JR, Chang GJ, Temple LK. Development of The American Society of Colon and Rectal Surgeons’ Rectal Cancer Surgery Checklist. Dis Colon Rectum. 2016;59(7):601–6. doi: Scholar
  10. 10.
    Lee L, Dietz D, Fleming F, Remzi F, Wexner S, Winchester D, Monson J. Accreditation Readiness in US Multidisciplinary Rectal Cancer Care: A Survey of OSTRICH Member Institutions. JAMA Surg. 2018;153(4):388–90.CrossRefGoogle Scholar
  11. 11.
    Orangio GR. A National Accreditation Program for Rectal Cancer: A Long and Winding Road. Dis Colon Rectum. 2018;61(2):145–6. doi: Scholar
  12. 12.
    Commision on Cancer Measures for Quality of Cancer Care. [cited October 9, 2017]. Available at
  13. 13.
    Brady JT, Xu Z, Scarberry KB, Saad A, Fleming FJ, Remzi FH, Wexner SD, Winchester DP, Monson JRT, Lee L, Dietz DW, Consortium for Optimizing the Treatment of Rectal C. Evaluating the Current Status of Rectal Cancer Care in the US: Where We Stand at the Start of the Commission on Cancer's National Accreditation Program for Rectal Cancer. J Am Coll Surg. 2018;226(5):881–90. doi: CrossRefGoogle Scholar
  14. 14.
    Schrag D, Weiser MR, Goodman KA, Gonen M, Hollywood E, Cercek A, Reidy-Lagunes DL, Gollub MJ, Shia J, Guillem JG, Temple LK, Paty PB, Saltz LB. Neoadjuvant chemotherapy without routine use of radiation therapy for patients with locally advanced rectal cancer: a pilot trial. J Clin Oncol. 2014;32(6):513–8. doi: Scholar
  15. 15.
    Weiser MR FA, Schrag D, Boughey JC, You YN. Progress in the PROSPECT trial: precision treatment for rectal cancer?. Bull Am Coll Surg. 2015;100(4):51–2.Google Scholar
  16. 16.
    Sauer R, Liersch T, Merkel S, Fietkau R, Hohenberger W, Hess C, Becker H, Raab HR, Villanueva MT, Witzigmann H, Wittekind C, Beissbarth T, Rodel C. Preoperative versus postoperative chemoradiotherapy for locally advanced rectal cancer: results of the German CAO/ARO/AIO-94 randomized phase III trial after a median follow-up of 11 years. J Clin Oncol. 2012;30(16):1926–33. doi: Scholar
  17. 17.
    Lai L, Fuller, CD, Kachnic, LA, Thomas, CR Jr,. Can pelvic radiotherapy be omitted in select patients with rectal cancer?. Semin Oncol. 2006;66(6 Suppl 11):S70–4.CrossRefGoogle Scholar
  18. 18.
    Gunderson LL, Sargent DJ, Tepper JE, Wolmark N, O’Connell MJ, Begovic M, Allmer C, Colangelo L, Smalley SR, Haller DG, Martenson JA, Mayer RJ, Rich TA, Ajani JA, MacDonald JS, Willett CG, Goldberg RM. Impact of T and N stage and treatment on survival and relapse in adjuvant rectal cancer: a pooled analysis. J Clin Oncol. 2004;22(10):1785–96. doi: Scholar
  19. 19.
    Tepper J, O'Connell, M, Niedzwiecki, D, Hollis, DR, Benson, AB 3rd, Cummings, B, Gunderson, LL, Macdonald, JS, Martenson, JA, Mayer, RJ. Adjuvant therapy in rectal cancer: analysis of stage, sex, and local control--final report of intergroup 0114. J Clin Oncol. . 2002;20(7):1744–50.CrossRefGoogle Scholar
  20. 20.
    Schisterman EF, Cole SR, Platt RW. Over adjustment bias and unnecessary adjustment in epidemiologic studies. Epidemiology. 2009;20(4 ):488–95.CrossRefGoogle Scholar
  21. 21.
    Deyo RA CD, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. Clin Epidemiol. 1992;45:613–9.CrossRefGoogle Scholar
  22. 22.
    Rickles AS, Dietz DW, Chang GJ, Wexner SD, Berho ME, Remzi FH, Greene FL, Fleshman JW, Abbas MA, Peters W, Noyes K, Monson JR, Fleming FJ, Consortium for Optimizing the Treatment of Rectal C. High Rate of Positive Circumferential Resection Margins Following Rectal Cancer Surgery: A Call to Action. Ann Surg. 2015;262(6):891–8. doi: CrossRefGoogle Scholar
  23. 23.
    Zhang J, Yu KF. What’s the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes. JAMA. 1998;280:1690–1.CrossRefGoogle Scholar
  24. 24.
    Knol MJ, LeCessie S, Algra A, Vandenbroucke JP, Groenwold RH. Overestimation of risk ratios by odds ratios in trials and cohort studies: alternatives to logistic regression. CMAJ. 2012;184(8):895–6.CrossRefGoogle Scholar
  25. 25.
    Muller CJ, MacLehose RF. Estimating predicted probabilities from logistic regression: different methods correspond to different target populations. Int J Epidemiol. 2014;43(3):962–70.CrossRefGoogle Scholar
  26. 26.
    Norton EC, Miller MM, Kleinman LC. Computing adjusted risk ratios and risk differences in Stata. Stata J. 2013;13(3):492–509.CrossRefGoogle Scholar
  27. 27.
    Dimick JB WH, Birkmeyer JD. Surgical mortality as an indicator of hospital quality: the problem with small sample size. JAMA. 2004;292(7):847–51.CrossRefGoogle Scholar
  28. 28.
    Dimick J, Staiger, DO, Birkmeyer, JD.,. Ranking hospitals on surgical mortality: the importance of reliability adjustment. Health Serv Res. 2010;45(6):1614–29.CrossRefGoogle Scholar
  29. 29.
    Dimick JB, Ghaferi AA, Osborne NH, Ko CY, Hall BL. Reliability adjustment for reporting hospital outcomes with surgery. Ann Surg. 2012;255(4):703–7. doi: Scholar
  30. 30.
    Bland J M, Altman D G. Correlation, regression, and repeated data. BMJ 1994;308(896).Google Scholar
  31. 31.
    Bland J M, Altman D G. Calculating correlation coefficients with repeated observations: Part 2—Correlation between subjects. BMJ. 1995;310(633).Google Scholar
  32. 32.
    Charlton ME, Lin C, Jiang D, Stitzenberg KB, Halfdanarson TR, Pendergast JF, Chrischilles EA, Wallace RB. Factors associated with use of preoperative chemoradiation therapy for rectal cancer in the Cancer Care Outcomes Research and Surveillance Consortium. Am J Clin Oncol. 2013;36(6):572–9. doi: Scholar
  33. 33.
    Charlton M, Hrabe, JE, Wright, KB, Schlichting, JA, McDowell, BD, Halfdanarson, TR, Lin, C, Stitzenberg, KB, Cromwell, JW. Hospital Characteristics Associated with Stage II/III Rectal Cancer Guideline Concordant Care: Analysis of Surveillance, Epidemiology and End Results-Medicare Data. J Gastrointest Surg. 2016;20(5):1002–11.CrossRefGoogle Scholar
  34. 34.
    Charlton ME, Mattingly-Wells LR, Marcet JE, McMahon Waldschmidt BC, Cromwell JW. Association between surgeon characteristics and their preferences for guideline-concordant staging and treatment for rectal cancer. Am J Surg. 2014;208(5):817–23. doi: Scholar
  35. 35.
    Chang JS, Lee Y, Lim JS, Kim NK, Baik SH, Min BS, Huh H, Koom WS. The magnetic resonance imaging-based approach for identification of high-risk patients with upper rectal cancer. Ann Surg. 2014;260(2):293–8. doi: Scholar
  36. 36.
    Marinello F, Frasson, M, Baguena, G, Flor-Lorente, B, Cervantes, A, Roselló, S, Espí, A, García-Granero, E,. Selective approach for upper rectal cancer treatment: total mesorectal excision and preoperative chemoradiation are seldom necessary. Dis Colon Rectum. 2015;58(6):556–65.CrossRefGoogle Scholar
  37. 37.
    Battersby NJ, How P, Moran B, Stelzner S, West NP, Branagan G, Strassburg J, Quirke P, Tekkis P, Pedersen BG, Gudgeon M, Heald B, Brown G, Group MIS. Prospective Validation of a Low Rectal Cancer Magnetic Resonance Imaging Staging System and Development of a Local Recurrence Risk Stratification Model: The MERCURY II Study. Ann Surg. 2016;263(4):751–60. doi: CrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2019

Authors and Affiliations

  • Douglas S. Swords
    • 1
    • 2
    Email author
  • David E. Skarda
    • 1
    • 2
  • William T. Sause
    • 3
  • Ute Gawlick
    • 1
  • George M. Cannon
    • 3
  • Mark A. Lewis
    • 3
  • Courtney L. Scaife
    • 2
  • Jesse A. Gygi
    • 3
  • H. Tae Kim
    • 1
  1. 1.Surgical Services Clinical ProgramIntermountain HealthcareSalt Lake CityUSA
  2. 2.Department of SurgeryUniversity of UtahSalt Lake CityUSA
  3. 3.Oncology Services Clinical ProgramIntermountain HealthcareSalt Lake CityUSA

Personalised recommendations