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

  • 2018 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Introduction

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.

Methods

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).

Results

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).

Conclusions

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.

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Authors and Affiliations

  1. Surgical Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA

    Douglas S. Swords, David E. Skarda, Ute Gawlick & H. Tae Kim

  2. Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA

    Douglas S. Swords, David E. Skarda & Courtney L. Scaife

  3. Oncology Services Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA

    William T. Sause, George M. Cannon, Mark A. Lewis & Jesse A. Gygi

Authors
  1. Douglas S. Swords
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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

Corresponding author

Correspondence to Douglas S. Swords.

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Swords, D.S., Skarda, D.E., Sause, W.T. et al. Surgeon-Level Variation in Utilization of Local Staging and Neoadjuvant Therapy for Stage II-III Rectal Adenocarcinoma. J Gastrointest Surg 23, 659–669 (2019). https://doi.org/10.1007/s11605-019-04107-1

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