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Fragmentation in specialist care and stage III colon cancer.

ABSTRACT: Patients with cancer frequently transition between different types of specialists and across care settings. This study explored how frequently the surgical and medical oncology care of stage III colon cancer patients occurred across more than 1 hospital and whether this was associated with mortality and costs.This was a retrospective Surveillance, Epidemiology, and End Results-Medicare cohort study of 9075 stage III colon cancer patients diagnosed between 2000 and 2009 who had received both surgical and medical oncology care within 1 year of their diagnosis. Patients were assigned to the hospital at which they had undergone their cancer surgery and to their oncologist's primary hospital, and then they were characterized according to whether these hospitals were the same or different. Outcomes included all-cause mortality, subhazards for colon cancer-specific mortality, and costs of care at 12 months.Thirty-seven percent of the patients received their surgical and medical oncology care from different hospitals. Rural patients were less likely than urban patients to receive medical oncology care from the same hospital (odds ratio, 0.62; 95% confidence interval, 0.43-0.90). Care from the same hospital was not associated with reduced all-cause or colon cancer-specific mortality but resulted in lower costs (8% of the median cost) at 12 months (dollars saved, $5493; 95% confidence interval, $1799-$9525).The delivery of surgical and medical oncology care at the same hospital was associated with lower costs; however, reforms seeking to improve outcomes and lower costs through the integration of complex care will need to address the significant proportion of patients receiving care at more than 1 hospital.

SUBMITTER: Hussain T

PROVIDER: S-EPMC4560997 | biostudies-literature | 2015 Sep

REPOSITORIES: biostudies-literature

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Fragmentation in specialist care and stage III colon cancer.

Hussain Tanvir T Chang Hsien-Yen HY Veenstra Christine M CM Pollack Craig Evan CE

Cancer 20150604 18

<h4>Background</h4>Patients with cancer frequently transition between different types of specialists and across care settings. This study explored how frequently the surgical and medical oncology care of stage III colon cancer patients occurred across more than 1 hospital and whether this was associated with mortality and costs.<h4>Methods</h4>This was a retrospective Surveillance, Epidemiology, and End Results-Medicare cohort study of 9075 stage III colon cancer patients diagnosed between 2000 ...[more]

PMID: 26043368

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Project description:BackgroundSince 2004, a regimen of 6 months of treatment with oxaliplatin plus a fluoropyrimidine has been standard adjuvant therapy in patients with stage III colon cancer. However, since oxaliplatin is associated with cumulative neurotoxicity, a shorter duration of therapy could spare toxic effects and health expenditures.MethodsWe performed a prospective, preplanned, pooled analysis of six randomized, phase 3 trials that were conducted concurrently to evaluate the noninferiority of adjuvant therapy with either FOLFOX (fluorouracil, leucovorin, and oxaliplatin) or CAPOX (capecitabine and oxaliplatin) administered for 3 months, as compared with 6 months. The primary end point was the rate of disease-free survival at 3 years. Noninferiority of 3 months versus 6 months of therapy could be claimed if the upper limit of the two-sided 95% confidence interval of the hazard ratio did not exceed 1.12.ResultsAfter 3263 events of disease recurrence or death had been reported in 12,834 patients, the noninferiority of 3 months of treatment versus 6 months was not confirmed in the overall study population (hazard ratio, 1.07; 95% confidence interval [CI], 1.00 to 1.15). Noninferiority of the shorter regimen was seen for CAPOX (hazard ratio, 0.95; 95% CI, 0.85 to 1.06) but not for FOLFOX (hazard ratio, 1.16; 95% CI, 1.06 to 1.26). In an exploratory analysis of the combined regimens, among the patients with T1, T2, or T3 and N1 cancers, 3 months of therapy was noninferior to 6 months, with a 3-year rate of disease-free survival of 83.1% and 83.3%, respectively (hazard ratio, 1.01; 95% CI, 0.90 to 1.12). Among patients with cancers that were classified as T4, N2, or both, the disease-free survival rate for a 6-month duration of therapy was superior to that for a 3-month duration (64.4% vs. 62.7%) for the combined treatments (hazard ratio, 1.12; 95% CI, 1.03 to 1.23; P=0.01 for superiority).ConclusionsAmong patients with stage III colon cancer receiving adjuvant therapy with FOLFOX or CAPOX, noninferiority of 3 months of therapy, as compared with 6 months, was not confirmed in the overall population. However, in patients treated with CAPOX, 3 months of therapy was as effective as 6 months, particularly in the lower-risk subgroup. (Funded by the National Cancer Institute and others.).

Project description:Background The identification of high-risk stage II colon cancers is key to the selection of patients who require adjuvant treatment after surgery. Microarray-based multigene-expression signatures derived from stem cells and progenitor cells hold promise, but they are difficult to use in clinical practice. Methods We used a new bioinformatics approach to search for biomarkers of colon epithelial differentiation across gene-expression arrays and then ranked candidate genes according to the availability of clinical-grade diagnostic assays. With the use of subgroup analysis involving independent and retrospective cohorts of patients with stage II or stage III colon cancer, the top candidate gene was tested for its association with disease-free survival and a benefit from adjuvant chemotherapy. Results The transcription factor CDX2 ranked first in our screening test. A group of 87 of 2115 tumor samples (4.1%) lacked CDX2 expression. In the discovery data set, which included 466 patients, the rate of 5-year disease-free survival was lower among the 32 patients (6.9%) with CDX2-negative colon cancers than among the 434 (93.1%) with CDX2-positive colon cancers (hazard ratio for disease recurrence, 3.44; 95% confidence interval [CI], 1.60 to 7.38; P=0.002). In the validation data set, which included 314 patients, the rate of 5-year disease-free survival was lower among the 38 patients (12.1%) with CDX2 protein-negative colon cancers than among the 276 (87.9%) with CDX2 protein-positive colon cancers (hazard ratio, 2.42; 95% CI, 1.36 to 4.29; P=0.003). In both these groups, these findings were independent of the patient's age, sex, and tumor stage and grade. Among patients with stage II cancer, the difference in 5-year disease-free survival was significant both in the discovery data set (49% among 15 patients with CDX2-negative tumors vs. 87% among 191 patients with CDX2-positive tumors, P=0.003) and in the validation data set (51% among 15 patients with CDX2-negative tumors vs. 80% among 106 patients with CDX2-positive tumors, P=0.004). In a pooled database of all patient cohorts, the rate of 5-year disease-free survival was higher among 23 patients with stage II CDX2-negative tumors who were treated with adjuvant chemotherapy than among 25 who were not treated with adjuvant chemotherapy (91% vs. 56%, P=0.006). Conclusions Lack of CDX2 expression identified a subgroup of patients with high-risk stage II colon cancer who appeared to benefit from adjuvant chemotherapy. (Funded by the National Comprehensive Cancer Network, the National Institutes of Health, and others.).

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Fragmentation in specialist care and stage III colon cancer.

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Fragmentation in specialist care and stage III colon cancer.

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