Failure of Evidence-Based Cancer Care in the United States The Association Between Rectal Cancer Treatment, Cancer Center Volume, and Geography
Failure of Evidence-Based Cancer Care in the United States The Association Between Rectal Cancer Treatment, Cancer Center Volume, and Geography
复制标题
DOI：
10.1097/sla.0000000000000928
复制
发表时间：
2014-10-01
影响因子：
9
通讯作者：
Dietz, David W.
中科院分区：
文献类型：
--
作者：
Monson, John R. T.;Probst, Christian P.;Dietz, David W.
目的：本研究探讨了最近坚持推荐的新辅助放化疗指南的直肠癌患者在不同地理区域和机构的体积和评估的趋势随着时间的推移。背景：最近的一份报告，由医学研究所描述美国癌症护理混乱。引用的不足之处包括广泛的变化，在遵守循证指南，即使在明确的共识existing.Methods：患者手术的临床II期和III期直肠癌从2006-2011年国家癌症数据库。多变量逻辑回归分析用于评估癌症中心类型、地理位置和医院容量在化疗和放疗使用方面的差异。该分析控制了患者诊断时的年龄、性别、种族/民族、主要支付者、平均家庭收入、平均教育程度、患者居住地的城市/农村分类、合并症和肿瘤分期。新辅助放疗和化疗的使用因癌症中心的类型而异。与低容量中心相比，高容量中心的依从率最高（78% vs 69%;校正比值比= 1.46; P < 0.001）。这种差异反映在医院的地理位置上。主要付款人和年的诊断率的新辅助放化疗。结论：坚持循证治疗指南在直肠癌是次优的，在美国，根据医院容量和地理区域的显着差异。在过去的五年里，情况几乎没有改善。这些结果支持美国直肠癌患者实施标准化护理途径和卓越中心计划。
Objective: This study examines recent adherence to recommended neoadjuvant chemoradiotherapy guidelines for patients with rectal cancer across geographic regions and institution volume and assesses trends over time.Background: A recent report by the Institute of Medicine described US cancer care as chaotic. Cited deficiencies included wide variation in adherence to evidence-based guidelines even where clear consensus exists.Methods: Patients operated on for clinical stage II and III rectal cancer were selected from the 2006-2011 National Cancer Data Base. Multivariable logistic regressions were used to assess variation in chemotherapy and radiation use by cancer center type, geographical location, and hospital volume. The analysis controlled for patient age at diagnosis, sex, race/ethnicity, primary payer, average household income, average education, urban/rural classification of patient residence, comorbidity, and oncologic stage.Results: There were 30,994 patients who met the inclusion criteria. Use of neoadjuvant radiation therapy and chemotherapy varied significantly by type of cancer center. The highest rates of adherence were observed in high-volume centers compared with low-volume centers (78% vs 69%; adjusted odds ratio = 1.46; P < 0.001). This variation is mirrored by hospital geographic location. Primary payer and year of diagnosis were not predictive of rates of neoadjuvant chemoradiotherapy.Conclusions: Adherence to evidence-based treatment guidelines in rectal cancer is suboptimal in the United States, with significant differences based on hospital volume and geographic regions. Little improvement has occurred in the last 5 years. These results support the implementation of standardized care pathways and a Centers of Excellence program for US patients with rectal cancer.