BACKGROUND: The objective of the current study was to examine the impact of adherence to guidelines on stage‐specific survival outcomes in patients with stage III and high‐risk stage II colon cancer. The National Comprehensive Cancer Network (NCCN) has established working, expert consensus, and evidence‐based guidelines for organ‐specific cancer care, including care of patients with colon cancer. METHODS: Patients who were diagnosed with colon adenocarcinoma between 1998 and 2002 were selected from within the National Cancer Data Base. The cohort was limited to patients who received their first course of treatment at the reporting facility. Pathologic variables, including tumor depth, lymph node status, and evidence of metastatic disease, were used to restage patients, and the patients were divided into low‐risk and high‐risk categories on the basis of criteria defined by the NCCN. Relative survival rates were calculated for the entire cohort, stratified according to adherence versus nonadherence to NCCN treatment guidelines. RESULTS: In univariate analysis of treatment adherence patterns for both patient subgroups (high‐risk stage II and stage III), several factors were associated with a higher rate of nonadherence in both groups, including older age (P < .001); Medicaid, Medicare, or uninsured status versus private insurance (P < .001); and subsequent treatment at a facility other than the facility at which the cancer was first diagnosed (P < .001). In multivariate analysis, multiple factors were associated with differences in relative survival, although analyses that included the year of diagnosis did not demonstrate significant differences over time. CONCLUSIONS: The current study documented practice patterns in a heterogeneous population of patients with colon cancer and demonstrated a survival benefit for patients with stage III and high‐risk stage II colon cancer who received treatment that adhered to NCCN guidelines. These data validate the current NCCN practice guidelines for colon cancer and support the concept of guideline‐based metrics that can be compared across institutions to assess the quality of cancer care and to compare the quality of cancer care among institutions. Cancer 2013. © 2012 American Cancer Society.

Purpose Health care access and advanced cancer stage are associated with oncologic outcomes for numerous common cancers. However, the impact of patient travel distance to health care on stage at diagnosis has not been well characterized. Methods This study used a historical cohort of patients with colon cancer in the National Cancer Data Base from 2003 through 2010. The primary outcome, stage at diagnosis, was evaluated using hierarchical regression modeling. A secondary outcome was time to receipt of initial therapy that was evaluated using Cox shared frailty modeling. Results Among 296,474 patients with colon cancer (mean age, 68 ± 13.6 years; 47.6% male; 78.5% white), 3.9% traveled ≥ 50 miles to the diagnosing facility. Fewer black patients, patients with higher income, and patients with lower education traveled longer distances (trend test P < .001 for all). Patients traveling ≥ 50 miles were more likely to present with metastatic disease compared with those traveling less than 12.5 miles (odds ratio [OR], 1.18; 95% CI, 1.12 to 1.24) or 12.5 to 49.9 miles (OR, 1.18; 95% CI, 1.12 to 1.24). In sensitivity analyses, the association was robust to alternate methods of modeling travel distance (quintile stratification or continuous). Travel distance ≥ 50 miles was also associated with a higher likelihood of earlier initiation of therapy compared with travel distance of less than 12.5 miles (hazard ratio [HR], 1.10; 95% CI, 1.08 to 1.13) or 12.5 to 49.9 miles (HR, 1.11; 95% CI, 1.08 to 1.13). Conclusion Advanced colon cancer stage at diagnosis is associated with patient travel distance to health care, which may be a barrier to early cancer screening. Health care reform efforts designed to address only insurance coverage may not mitigate disparities based on difficulties accessing cancer care.

Purpose Adherence to evidence-based treatment guidelines has been proposed as a measure of cancer care quality. We sought to determine rates of and factors associated with adherence to the National Comprehensive Cancer Network (NCCN) treatment guidelines for colon cancer. Patients and Methods Patients within the National Cancer Data Base treated for colon adenocarcinoma (2003 to 2007) were identified. Adherence to stage-specific NCCN guidelines was determined based on disease stage. Hierarchical regression analyses were performed to identify factors predictive of adherence, overtreatment, and undertreatment. Results A total of 173,243 patients were included in the final cohort, 123,953 (71%) of whom were treated according to NCCN guidelines. Patients with stage I disease were more likely to receive guideline-based treatment (96%) than patients with stage II (low risk, 66%; high risk, 36%), III (71%), or IV (73%) disease (P < .001). Adherence to consensus-based guidelines increased over time. Factors associated with adherence across all stages included age, Charlson-Deyo comorbidity index score, later year of diagnosis, and insurance status. Among patients with high-risk stage II or stage III disease, older patients with pre-existing comorbidities and patients with lower socioeconomic status were less likely to be offered adjuvant chemotherapy. Among patients with stage I and II disease, young, healthy patients were more likely to be recommended chemotherapy, in discordance with NCCN guidelines. Conclusion Significant variation exists in the treatment of colon cancer, particularly in treatment of high-risk stage II and stage III disease. The impact of nonadherence to guidelines on patient outcomes needs to be further elucidated.

BackgroundMany surgeons experience work-related pain and musculoskeletal symptoms; however, comprehensive reporting of surgeon ailments is lacking in the literature. We sought to evaluate surgeons' work-related symptoms, possible causes of these symptoms, and to report outcomes associated with those symptoms.Materials and methodsFive major medical indices were queried for articles published between 1980 and 2014. Included articles evaluated musculoskeletal symptoms and ergonomic outcomes in surgeons. A meta-analysis using a fixed-effect model was used to report pooled results.ResultsForty articles with 5152 surveyed surgeons were included. Sixty-eight percent of surgeons surveyed reported generalized pain. Site-specific pain included pain in the back (50%), neck (48%), and arm or shoulder (43%). Fatigue was reported by 71% of surgeons, numbness by 37%, and stiffness by 45%. Compared with surgeons performing open surgery, surgeons performing minimally invasive surgery (MIS) were significantly more likely to experience pain in the neck (OR 2.77 [95% CI 1.30–5.93]), arm or shoulder (OR 4.59 [2.19–9.61]), hands (OR 2.99 [1.33–6.71], and legs (OR 12.34 [5.43–28.06]) and experience higher odds of fatigue (8.09 [5.60–11.70]) and numbness (6.82 [1.75–26.65]). Operating exacerbated pain in 61% of surgeons, but only 29% sought treatment for their symptoms. We found no direct association between muscles strained and symptoms.ConclusionsMost surgeons report work-related symptoms but are unlikely to seek medical attention. MIS surgeons are significantly more likely to experience musculoskeletal symptoms than surgeons performing open surgery. Symptoms experienced do not necessarily correlate with strain.

Background Retroperitoneal sarcomas (RPS) are rare tumors for which complete surgical resection remains the mainstay of treatment. We sought to determine the impact of hospital case volume on RPS outcomes. Methods We identified 6950 patients with primary RPS who underwent surgical resection from the National Cancer Data Base (1998–2011). Treating hospitals were classified by annual case volume; low volume hospitals (LVHs) and high volume hospitals (HVHs) were defined as ≤10 and >10 cases/year, respectively. Overall survival (OS) was compared using Kaplan-Meier curves. Cox proportional hazard models were created to compare risks. Results Of 1131 reporting hospitals, most (n=1127, 99.6%) were LVHs treating the majority of patients (n=6270; 90.2%). Patients treated at LVHs were more likely to have lower grade and smaller tumors, receive radiation therapy, and undergo incomplete gross (R2) resection. Patients treated at HVHs had lower 30-day readmission rates (1.8% vs 3.4%, p<0.001), 30-day (1.9% vs 3.1%, p=0.004) and 90-day mortality (3.2% vs 5.7%, p=0.007); longer median OS (76.2 vs 64.2 months, p<0.001) and higher 5-year OS (58% vs 52%, p<0.001). After controlling for age, gender, insurance status, tumor size, tumor grade, resection margin status, and radiation administration, treatment at a HVH was independently associated with a reduced risk of death (HR 0.77, 95% CI 0.65–0.91, p=0.003). Conclusion Primary RPS are rare tumors for which few surgeons and institutions have significant experience and expertise in their multidisciplinary management and surgical resection. Although additional studies are needed, patient outcomes may be impacted by treating facility case volume and experience.