Abstract
Analysis of routine population-based data has previously shown that patterns of surgical treatment for colorectal cancer can vary widely, but there is limited evidence available to determine if such variation is also seen in the use of chemotherapy. This study quantified variation in adjuvant chemotherapy across both England using cancer registry data and in more detail across the representative Yorkshire and Humber regions. Individuals with Stages II and III colorectal cancer who underwent major resection from 2014 to 2015 were identified. Rates of chemotherapy were calculated from the Systemic Anticancer Treatment database using multilevel logistic regression. Additionally, questionnaires addressing different clinical scenarios were sent to regional oncologists to investigate the treatment preferences of clinicians. The national adjusted chemotherapy treatment rate ranged from 2% to 46% (Stage II cancers), 19% to 81% (Stage III cancers), 24% to 75% (patients aged <70 years) and 5% to 46% (patients aged ≥70 years). Regionally, the rates of treatment and the proportions of treated patients receiving combination chemotherapy varied by stage (Stage II 4%-26% and 0%-55%, Stage III 48%-71% and 40%-84%) and by age (<70 years 35%-68% and 49%-91%; ≥70 years 15%-39% and 6%-75%). Questionnaire responses showed significant variations in opinions for high-risk Stage II patients with both deficient and proficient mismatch repair tumours and Stage IIIB patients aged ≥70 years. Following a review of the evidence, open discussion in our region has enabled a consensus agreement on an algorithm for colorectal cancer that is intended to reduce variation in practice.
Highlights
The Food and Drug Administration approved the use of adjuvant fluorouracil (5FU) chemotherapy for Stage III colon cancer in 1990; the initial recommended duration of 1 year was revised down to 6 months by the end of the decade.[1,2] Since 2000, the uses of capecitabine and oxaliplatin have been established, the former being shown to be at least equivalent to 5FU and the latter further improving survival.[3,4,5,6] In 2011, the National Institute for Health and Care Excellence (NICE) released permissive guidance for the use of adjuvant chemotherapy for high-risk Stage II disease
More recently the duration of treatment has been further shortened to 3 months; the evidence strongest when using oxaliplatin and capecitabine (CAPOX) but the shorter course can still be considered for single agent capecitabine or oxaliplatin and 5FU (FOLFOX).[10,11]
We provided guidance on patients with rectal cancer who had received neoadjuvant chemoradiotherapy, which was more conservative than NICE, European Society for Medical Oncology (ESMO), National Comprehensive Cancer Network (NCCN) and American Society of Clinical Oncology (ASCO) guidance and more akin to Dutch guidance
Summary
The Food and Drug Administration approved the use of adjuvant fluorouracil (5FU) chemotherapy for Stage III colon cancer in 1990; the initial recommended duration of 1 year was revised down to 6 months by the end of the decade.[1,2] Since 2000, the uses of capecitabine and oxaliplatin have been established, the former being shown to be at least equivalent to 5FU and the latter further improving survival.[3,4,5,6] In 2011, the National Institute for Health and Care Excellence (NICE) released permissive guidance for the use of adjuvant chemotherapy for high-risk Stage II disease. More recently NICE have recommended 3 months for all patients when using CAPOX.[12]
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