Assessing Compliance with National Comprehensive Cancer Network Guidelines for Elderly Patients with Stage III Colon Cancer: The Fox Chase Cancer Center Partners' Initiative

Abstract

Background Fox Chase Cancer Center Partners (FCCCP) performs an annual quality review of affiliate practices based on National Comprehensive Cancer Network (NCCN) guidelines. Given recent treatment advances, we initiated this medical record review in elderly patients with stage III colon cancer to measure compliance with these guidelines. Methods Medical records of 124 patients age ≥ 65 diagnosed with stage III colon cancer between 2003 and 2006 were reviewed. Metrics were developed and based on NCCN guidelines for workup and staging, treatment, and gerontology. Documentation was reviewed via paper (13 sites) and electronic record (2 sites). Results High compliance with staging and workup guidelines was noted with chest imaging (100%), stage (98%), computed tomography (CT) of the abdomen/pelvis (93%), pathology (91%), and carcinoembryonic antigen (CEA; 91%). Activities of daily living were documented commonly (83%) but colonoscopy less (75%). Age and life expectancy were discussed with the patient in only 49%. Nearly all patients (123 of 124 patients) received adjuvant chemotherapy, with 76 patients (61%) receiving oxaliplatin. Common regimens were FOLFOX (oxaliplatin plus infusional/bolus 5-fluorou-racil and folinic acid) 54%, 5-fluorouracil/leucovorin (5-FU/LV; 19%), and capecitabine (12%). Reasons for excluding oxaliplatin were comorbidity (68%), age (19%), and not specified (13%). Three-quarters of the patients had ≥ 12 lymph nodes sampled and 56% identified the radial margin. Nearly all patients (115 = 93%) received surveillance with history and physical and CEA. Surveillance CT was performed in 78% of the patients. Conclusions A quality review of community oncology practices can assess implementation of treatment advances. Guideline compliance for elderly patients with stage III colon cancer is generally high. Forty percent did not receive oxaliplatin and documentation of life expectancy was infrequent. Further study of oncologist decision making for elderly colon cancer patients is warranted.

The impact of comorbidity on cancer survival: a review

“…In a US national survey of surgeons and medical oncologists caring for patients with colorectal cancer, physicians agreed with guidelines recommending adjuvant chemotherapy for young, otherwise healthy patients with stage III colon cancer, but differed widely on recommendations for patients with comorbid illnesses 119. Comorbidity is the most frequent reason for nonreceipt of cancer treatment cited in the medical charts of patients with lung (68% of nontreated patients) and colorectal (47% of nontreated patients) cancer 117,118. To some extent, this finding probably reflects concern about toxicity in patients with comorbidity.…”

Comorbidity in older adults with cancer

“…(33) The presence of comorbidities is one of the most frequent reasons for non-receipt of cancer treatment cited in the medical chart. (35, 36) Although chronic conditions appear to be a strong barrier to the receipt of adjuvant chemotherapy, some studies have shown a similar survival benefit with or without many common comorbid illnesses. (37) Reduced chemotherapy treatment and decreased adjuvant referral patterns may represent thoughtful and appropriate treatment decisions on the part of both physicians and/or patients based on the presence of comorbidities and limited life expectances.…”

Comparative effectiveness of chemotherapy in elderly patients with metastatic colorectal cancer.

“…A recent review of the medical records of patients aged 65 or older diagnosed with stage III colon cancer between 2003 and 2006 revealed that 61 % received a regimen containing oxaliplatin, 54 % were treated with FOLFOX, 19 % received 5-FU/LV, and 12 % were administered with capecitabine monotherapy. Among those not treated with oxaliplatin, the primary reason was comorbid health conditions with age cited as a reason for not administering oxaliplatin for 19 % of patients [27]. Patient characteristics such as age, gender, race, and comorbidity burden appear to be important factors in prescribing chemotherapy treatment, but after adjusting for these factors, there were no significant differences in OS between the CAP-based and 5-FU/LV-based regimens.…”

“…Furthermore, there is limited knowledge about the use of recommended newer agents for the treatment of mCRC in community settings, particularly for older and demographically diverse patient populations [23]. However, there is evidence to suggest variations in the management of patients with all stages of CRC with several studies reporting lower rates of chemotherapy for older patients [23][24][25][26][27] and almost 30 % of stage III and IV patients were less likely to receive guideline-recommended therapies [27]. An analysis of patients in the National Cancer Data Base who were treated for CRC from 2003 to 2007 revealed that 25.9 % of patients with stage IV disease received no chemotherapy and older patients with preexisting comorbid conditions were at increased risk of under-treatment [23].…”

“…An analysis of patients in the National Cancer Data Base who were treated for CRC from 2003 to 2007 revealed that 25.9 % of patients with stage IV disease received no chemotherapy and older patients with preexisting comorbid conditions were at increased risk of under-treatment [23]. Comorbid health conditions and older age appear to influence physicians' choice of treatment regimen for all stages of CRC with older patients more likely to receive shorter chemotherapy regimens with less toxicity [23][24][25][26][27]. The goal of this study was to evaluate treatment patterns, OS, and frequency of complications requiring medical resource utilization in older, demographically diverse patients undergoing treatment for mCRC.…”