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Standard neoadjuvant chemoradiotherapy underused for advanced rectal cancer
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Although the use of standard-of-care neoadjuvant chemoradiotherapy has increased among patients with advanced rectal cancers, only half of eligible patients receive this treatment, according to an analysis of data from the National Cancer Data Base.
Socioeconomic factors may play a role in those rates, the researchers wrote in the study.
“The results of the current study indicate that facilities with low or medium case volumes are less likely to offer patients the standard treatment, and that socioeconomic factors, such as not being non-Hispanic white race/ethnicity, a lack of private insurance, and residence in a neighborhood with a lower education background are independent factors associated with a lower probability of receiving the standard national guidelines-supported therapies,” Helmneh M. Sineshaw, MD, MPH, director of treatment patterns and outcomes research at the American Cancer Society, and colleagues wrote.
Neoadjuvant chemoradiotherapy followed by total mesorectal excision has been considered standard of care since 2004 based on improvements in local control, decreased toxicity and sphincter preservation compared with total mesorectal excision followed by adjuvant chemoradiotherapy.
Sineshaw and colleagues sought to examine treatment patterns regarding the receipt of neoadjuvant chemotherapy in the United States over the past decade.
The analysis included data from 66,197 patients in the National Cancer Data Base who were diagnosed with and treated for American Joint Committee on Cancer stage II to III rectal adenocarcinoma between 2004 and 2012.
Researchers looked at treatment trends for patients treated from 2004 to 2006 (n = 21,302), 2007 to 2009 (n = 21,808), and 2010 to 2012 (n = 23,087). They also calculated 5-year OS probabilities for patients treated between 2004 and 2007 (n = 28,550).
Neoadjuvant chemotherapy use increased across all three time periods examined (2004-2006, 42.9%; 2007-2009, 50%; 2010-2012, 55%; P < .0001 for all).
Although use of neoadjuvant chemotherapy increased, adjuvant chemoradiotherapy use decreased throughout the study (2004-2006, 16%; 2007-2009, 10.5%; 2010-2012, 6.7%; P < .0001 for all).
Receipt of surgery alone also decreased from 13.1% between 2004 and 2006 to 8.7% between 2010 and 2012 (P < .0001).
Socioeconomic factors predicted receipt of neoadjuvant chemotherapy. Use of neoadjuvant chemotherapy was less common among those who were older (OR for age of 80 years or older at time of diagnosis = 0.26, 95% CI, 0.83-0.93), who were not of non-Hispanic white race/ethnicity (OR for non-Hispanic black patients = 0.85, 95% CI, 0.8-0.91; OR for Hispanic patients = 0.86, 95% CI, 0.80-0.93) and who lacked private insurance (OR for uninsured patients = 0.92, 95% CI, 0.86-1.01; OR for Medicaid = 0.9; 95% CI, 0.83-0.97; OR for Medicare = 0.9; 95% CI, 0.81-0.9).
Further, use of neoadjuvant chemotherapy was less common at facilities that did not have a high case volume (OR for low case volume = 0.71, 95% CI, 0.66-0.76; OR for medium case volume = 0.83 95% CI, 0.79-0.87).
OS for patients treated between 2004 and 2007 varied depending on treatment. Five-year OS rates were highest for patients who received neoadjuvant chemoradiotherapy (72.4%) and surgery plus adjuvant chemoradiotherapy (70.9%) and lowest for patients who underwent surgery alone (44.9%) and definitive chemoradiotherapy (48.8%).
Compared with patients who received neoadjuvant chemoradiotherapy, patients who received definitive chemoradiotherapy (HR = 1.48, 95% CI, 1.37-1.59) and surgery alone (HR = 1.66, 95% CI, 1.56-1.77) had an increased risk for 5-year mortality.
“Over the past decade, since the publication of the randomized trial by the German Rectal Cancer Study group, we have observed an increase in the rate of neoadjuvant chemoradiotherapy in the management of patients with locally advanced rectal cancer in the United States, with the parallel decrease in the use of adjuvant chemoradiotherapy,” Sineshaw and colleagues wrote. “Unfortunately, with only 55% of U.S. patients with locally advanced rectal cancer receiving the standard of treatment in the recent years, one must address the gap between the guidelines and the variable penetrance into routine clinical practice.” – by Nick Andrews
Disclosure : One researcher reports honoraria from Novocure and royalties from UpToDate. The other researchers report no relevant financial disclosures.
Perspective
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Joshua Shaeffer Hill, MD, MS
This report by Sineshaw and colleagues has again demonstrated that cancer care within the United States is associated with significant disparities. In this study, which used the National Cancer Data Base (NCDB) as a data source, the researchers analyzed nearly 60,000 records of patients with stage II and III rectal adenocarcinoma and assessed compliance with national guidelines for neoadjuvant radiation.
This report shows that the use of neoadjuvant chemoradiation has increased from 42.9% of all patients diagnosed between 2004 to 2006, to 55% of patients diagnosed between 2010 to 2012.
Although the rate of adoption of neoadjuvant chemotherapy after the publication of a German Rectal Cancer Study Group trial in 2004 is a laudable finding a 30% increase in patients treated with neoadjuvant chemoradiation approximately 45% of patients are still not receiving what is considered to be the standard of care. Moreover, the factors that are associated with nonstandardized care are the same factors that have been seen before in other health care-related disparities: income, ethnicity and hospital volume.
Treatment of rectal cancer is rapidly changing. Newer treatment algorithms may decrease the use of radiation in selected patients who have less bulky stage II tumors. There also is significant debate about what to do with patients who develop a clinical complete response after neoadjuvant chemoradiation.
However, we should not let these newer debates cloud our vision when expanding access to excellent care. Neoadjuvant chemoradiation remains the standard of care for patients with stage II and III rectal adenocarcinoma, and our national policies should err on overtreatment to help eliminate disparities. Only in specialized centers where there is sufficient expertise to pursue individual multidisciplinary treatment plans should neoadjuvant chemoradiation be withheld.
How to expand access is a difficult challenge. The American College of Surgeons is seeking to establish rectal cancer centers of excellence. Also, a consortium of health care institutions (OSTRiCh) has been established to maximize the care of rectal cancers. It is hoped that these efforts will lead to standardized care among all individuals.
Reference:
Sauer R, et al. N Engl J Med. 2004;351:1731-1740.
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