Quality of timely adjuvant chemotherapy for veterans with colorectal cancer.

Abstract

78 Background: National Comprehensive Cancer Network (NCCN) recommends adjuvant chemotherapy for patients with high risk stage II or stage III colorectal cancer (CRC). Treatment within 8 weeks of surgery improves disease free survival and decreases recurrence. National Veterans Health Administration (VHA) CRC data demonstrated adherence to this standard; however, there was regional variation. We sought to describe time to treatment at a Southeast Regional VHA facility to determine local targets for quality improvement initiatives. Methods: We retrospectively reviewed 705 electronic medical records of patients who underwent colorectal surgery from January 1, 2000 to December 31, 2015 at VHA Tennessee Valley Healthcare System. Two trained clinician abstractors reviewed standard elements (k = 0.79 – 0.92). The population included patients with pathological stage high risk II or III CRC and excluded those with metastatic disease or documented NCCN defined exclusion from chemotherapy. We analyzed 2 populations; chemotherapy received and a sensitivity analysis population of patients who were eligible for, but did not receive, chemotherapy (no documentation of NCCN ineligibility or declined). The primary outcome was chemotherapy within 8 weeks of surgery, evaluated during three time periods due to changes in NCCN guidelines. Results: Of 705 colorectal surgeries, we excluded 262 for non-cancers, 220 for stage I or low-risk stage II cancers, and 46 for NCCN defined exclusion, yielding 177 cases: 120 colon and 57 rectal cancers. Patients were 98% male, 85% white, and median age 64 years [Interquartile Range 60, 70]. Among those receiving chemotherapy (123/177 [69.5%]), median time to treatment was 50.5 days [40,64]; with 63% receiving chemotherapy within 8 weeks. Results varied over time. Between 2000-2004 75% received within 8 weeks; 2005-2009, 62%; 2010-2015, 41%. Including all eligible patients, the proportion receiving timely treatment declined; overall 44%; 2000-2004, 57%; 2005-2009, 45%; 2010-2015, 25%. Conclusions: Improving care processes for patients with CRC can improve timely treatment. Exploring barriers such as prolonged hospitalization, wound healing, and port placement may reveal areas for quality improvement.