Addressing the variation in adjuvant chemotherapy treatment for colorectal cancer (CRC): can a regional intervention promote national change?


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Daniel Swinson1,John C. Taylor2,Jenny F. Seligmann3,Rebecca Birch4,Alice Dewdney5,Hannah Rossington4,Victoria A. Brown6,Jo Dent7,Philip Quirke8,Eva J. A. Morris4
1St James's University Hospital, Leeds, UK,2Leeds Institute of Data Analytics, University of Leeds, Leeds, UK,3St James's University Hospital, Leeds, UK, Leeds Teaching Hospitals Trust, Leeds, Leeds, UK,4Cancer Epidemiology Group, Leeds, UK, Section of Epidemiology and Biostatistics, Leeds, UK, Leeds Institute of Cancer & Pathology, Leeds, UK, Leeds Institute for Data Analytics, University of Leeds, Leeds, UK,5Department of Radiotherapy, Weston Park Hospital, Sheffield, UK, Sheffield Teaching Hospitals, Sheffield, UK,6Queen’s Centre for Oncology and Haematology, Hull, UK, Hull University Hospitals NHS Trust, Hull, UK,7Department of Oncology, Huddersfield Royal Infirmary, Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, UK,8Section of Pathology and Tumour Biology, Leeds, UK, Leeds Institute of Cancer & Pathology, Leeds, UK, University of Leeds, Leeds, UK

Abstract

Background

Analysis of routine population-based data has previously shown that surgery for patients with rectal cancer can vary widely. Through access to the Systemic Anti-Cancer Treatment (SACT) database we have quantified variation in adjuvant chemotherapy across England and in detail across a large representative region (Yorkshire and Humber).

Method

National Cancer Registry and Analysis Service (NCRAS) provided data on individuals aged ≥18 years with stage II and III CRC who underwent major resection from 01/01/14 – 31/03/16. Chemotherapy data was obtained from the SACT dataset. Rates of chemotherapy were calculated from multilevel mixed logistic regression and adjusted for age, sex, socioeconomic status, Charlson comorbidity index score and stratified by tumour stage and site. A questionnaire addressing different clinical scenarios was sent to oncologists across the region.

Results

The national adjusted chemotherapy treatment rate ranged from 2% to 43% & from 19% to 80% for patients with stage II and stage III cancers. Larger variation was seen for rectal than colon cancer, 10% to 70% vs 14% to 60%. Similar variation was seen in region and across subgroups.

 

Percentage received chemotherapy

Percentage of treated received combination-chemotherapy

Stage

Stage II

Stage III

5% – 28%

41% – 73%

0% – 63%

45% – 79%

Site

Colon

Rectal

27% – 47%

17% – 59%

31% – 72%

30% – 87%

Age

Age<70

Age≥70

33% – 68%

12% – 38%

48% – 91%

9% – 63%

Prior radiotherapy

No

Yes

20% – 58%

14% – 80%

29% – 100%

0% – 85%

A regional questionnaire obtained responses from 15 of 16 MDTs. Widest variation in opinions were observed for high risk stage II patients both with deficient and proficient mismatch repair tumours and stage IIIB patients over the age of 70.

Conclusion

Variation is seen across England in the use of adjuvant chemotherapy. Open discussion in our region has enabled consensus agreement on an algorithm for colon cancer, with one pending for rectal cancer.