Adherence to NCCN treatment guidelines for rectal cancer: Analysis of national practice patterns.

Abstract

3554 Background: The purpose of this study was to determine current practice trends and factors influencing adherence to the National Comprehensive Cancer Network (NCCN) guidelines for rectal adenocarcinoma. Methods: Retrospective cohort study of patients with rectal cancer identified from the National Cancer Database (2003-2007). Adherence to stage-specific NCCN guidelines was evaluated after individually determining AJCC/TNM stage for each patient (clinical (c) stage for patients receiving neoadjuvant therapy or pathologic (p) stage for those who received surgical resection as a first course of treatment). Stage-specific multivariate analyses were performed to determine factors associated with adherence to NCCN guidelines. Results: 45,876 patients with rectal cancer who met study criteria were analyzed. Overall, adherence to treatment guidelines was observed in 63% of patients; stage I (66%), stage II (57%), stage III (61%) and stage IV (73%). Nonadherence for stage I was largely due to overtreatment (20%) with neoadjuvant therapy. Stage I patients were least likely to be undertreated (14%) compared with stages II (43%), III (39%) and IV (27%), respectively (p<0.001). A primary reason for nonadherence was undertreatment of stage pII (44%) and pIII (40%) patients through lack of adjuvant therapy. Factors associated with adherence across all stages included age, race, comorbidity index, insurance status and type of facility. Conclusions: Young, healthy, clinical stage I rectal cancer patients with insurance are more likely to be overtreated. Conversely, pathologic stage II and III patients who are older, have greater comorbid disease, are underinsured or treated at community hospitals were likely to be undertreated. The impact of these departures from national practice guidelines on patient outcomes remain to be elucidated. Odds ratio for adherence. Stage I Stage II Stage III Stage IV Age <50 - - - - 50-64 1.22 0.84 0.86 0.56 65-74 1.25 0.60 0.70 0.42 >75 1.15 0.24 0.26 0.13 Charlson-Deyo ≥1 vs. 0 1.42 0.77 0.75 0.64 Insurance status Private - - - - Medicare 0.91 0.89 0.84 0.68 Medicaid 0.61 0.79 0.72 0.62 Uninsured 0.51 0.57 0.70 0.42 Facility Teaching - - - - Cancer center 1.01 0.93 1.07 0.92 Community 0.86 0.80 0.90 0.74