Concordance with clinical practice guidelines for adjuvant chemotherapy in patients with stage I-III colon cancer: Experience in 2 Canadian provinces

Newfoundland Colorectal Cancer Registry, Department of Medicine, Memorial University of Newfoundland, St. John's, NL.
Canadian journal of surgery. Journal canadien de chirurgie (Impact Factor: 1.51). 05/2009; 52(2):92-7.
Source: PubMed
ABSTRACT
Clinical practice guidelines (CPGs) for the adjuvant treatment of colorectal cancer were published by the National Institutes of Health in 1991. The American Society of Clinical Oncology and Cancer Care Ontario have recommended adjuvant chemotherapy for patients with high-risk stage II colon cancer. We evaluated differences in concordance with guidelines in the treatment of patients with stage I-III colon cancer in the Canadian provinces of Newfoundland and Labrador and Ontario.
We assessed clinical data and treatment from January 1999 to December 2000 for 130 patients from Newfoundland and Labrador and 315 patients from Ontario who had stage I-III colon cancer. The primary outcome was concordance with guidelines for adjuvant treatment. We evaluated factors affecting the use of chemotherapy in patients with stage II disease.
No patients received adjuvant therapy for stage I disease. Forty-five of 52 patients (87%) in Newfoundland and Labrador and 108 of 115 patients (94%) in Ontario received adjuvant chemotherapy for stage III colon cancer. Twenty of 55 patients (36%) in Newfoundland and Labrador and 44 of 116 patients (38%) in Ontario received adjuvant therapy for stage II disease. Eighteen of 41 patients (44%) in Newfoundland and Labrador and 30 of 53 patients (57%) in Ontario with high-risk features received adjuvant treatment, which was significantly higher than patients without high-risk features. There was a strong trend toward using chemotherapy in patients with stage II disease who were 50 years or younger, independent of high-risk status.
Concordance with CPGs for adjuvant chemotherapy in patients with stage II colon cancer was not optimal. This may reflect selection bias among referring surgeons, a paucity of level-I evidence and the belief that other factors such as age may play a role in predicting outcome.

Full-text

Available from: Elizabeth Dicks, Nov 20, 2014
92 J can chir, Vol. 52, N
o
2, avril 2009
© 2009 Association médicale canadienne
Accepted for publication
Feb. 27, 2008
Correspondence to:
Dr. W.G. Pollett
Department of Surgery
300 Prince Philip Dr.
St John’s NL A1B 3V6
fax 709 777-8128
wpollett@mun.ca
RESEARCH
RECHERCHE
Concordance with clinical practice guidelines for
adjuvant chemotherapy in patients with stage I–III
colon cancer: experience in 2 Canadian provinces
Debrah A. Wirtzfeld, MD
*
Lynn Mikula, MD
Robert Gryfe, MD
Pietro Ravani, MD
Elizabeth L. Dicks, PhD
*
Pat Parfrey, MD
*
Steve Gallinger, MD
William G. Pollett, MD
*
From the *Newfoundland Colorectal
Cancer Registry, Department of Medi-
cine, Memorial University of Newfound-
land, St. John’s, NL, the †Ontario Familial
Colorectal Cancer Registry, Cancer Care
Ontario and Department of Surgery,
Samuel Lunenfeld Research Institute,
Mount Sinai Hospital, University of
Toronto, Toronto, Ont., and the ‡Clinical
Epidemiology Unit, Faculty of Medicine,
Memorial University of Newfoundland and
Divisione di Negrologia e Dialisi, Azienda
Istituti Ospitalieri di Cremona, Italy
Background: Clinical practice guidelines (CPGs) for the adjuvant treatment of colo-
rectal cancer were published by the National Institutes of Health in 1991. The Amer-
ican Society of Clinical Oncology and Cancer Care Ontario have recommended adju-
vant chemotherapy for patients with high-risk stage II colon cancer. We evaluated
differences in concordance with guidelines in the treatment of patients with stage I–III
colon cancer in the Canadian provinces of Newfoundland and Labrador and Ontario.
Methods: We assessed clinical data and treatment from January 1999 to December
2000 for 130 patients from Newfoundland and Labrador and 315 patients from Ontario
who had stage I–III colon cancer. The primary outcome was concordance with guide-
lines for adjuvant treatment. We evaluated factors affecting the use of chemotherapy in
patients with stage II disease.
Results: No patients received adjuvant therapy for stage I disease. Forty-five of 52 pa-
tients (87%) in Newfoundland and Labrador and 108 of 115 patients (94%) in Ontario
received adjuvant chemotherapy for stage III colon cancer. Twenty of 55 patients (36%)
in Newfoundland and Labrador and 44 of 116 patients (38%) in Ontario received adju-
vant therapy for stage II disease. Eighteen of 41 patients (44%) in Newfoundland and
Labrador and 30 of 53 patients (57%) in Ontario with high-risk features received adju-
vant treatment, which was significantly higher than patients without high-risk features.
There was a strong trend toward using chemotherapy in patients with stage II disease
who were 50 years or younger, independent of high-risk status.
Conclusion: Concordance with CPGs for adjuvant chemotherapy in patients with
stage II colon cancer was not optimal. This may reflect selection bias among referring
surgeons, a paucity of level-I evidence and the belief that other factors such as age
may play a role in predicting outcome.
Contexte : Les National Institutes of Health ont publié en 1991 leurs lignes direc-
trices sur le traitement adjuvant du cancer colorectal. L’American Society of Clinical
Oncology et Action Cancer Ontario ont recommandé la chimiothérapie adjuvante aux
patients atteints d’un cancer du côlon de stade II à haut risque. Nous avons mesuré les
différences en ce qui a trait au respect des lignes directrices dans le traitement des pa-
tients atteints d’un cancer du côlon de stade I à III dans les provinces canadiennes de
Terre-Neuve-et-Labrador et de l’Ontario.
Méthodes : Nous avons analysé, pour la période allant de janvier 1999 à décembre
2000, les données cliniques et les traitements relatifs à 130 patients de Terre-Neuve-
et-Labrador et de 315 patients de l’Ontario atteints d’un cancer du côlon de stade I à
III. Le paramètre principal était la fidélité aux lignes directrices pour le traitement
adjuvant. Nous avons examiné les facteurs affectant l’utilisation de la chimiothérapie
chez les patients atteints d’un cancer de stade II.
Résultats : Aucun patient n’a reçu de traitement adjuvant pour un cancer de stade I.
Quarante-cinq patients sur 52 (87 %) de Terre-Neuve-et-Labrador et 108 patients
sur 115 (94 %) de l’Ontario ont reçu une chimiothérapie adjuvante pour un cancer du
côlon de stade III. Vingt patients sur 55 (36 %) de T-N-L et 44 patients sur 116
(38 %) de l’Ontario ont reçu un traitement adjuvant pour un cancer de stade II. Dix-
huit patients sur 41 (44 %) de T-N-L et 30 patients sur 53 (57 %) de l’Ontario
présentant des caractéristiques de risque élevé ont reçu un traitement adjuvant, soit un
nombre significativement plus élevé que chez les patients ne présentant pas ces carac-
téristiques. On a noté une forte tendance à l’utilisation de la chimiothérapie chez les
patients atteints d’un cancer de stade II âgés de 50 ans ou moins, indépendamment du
degré de risque.
This work was supported by the National
Cancer Institute, National Institutes of
Health under RFA # CA-96-011 and
through cooperative agreements with
members of the Colon Cancer Family
Registry and P.I.s. The content of this
manuscript does not necessarily reflect
the views or policies of the National
Cancer Institute or any of the collaborating
institutions or investigators in the Colon
CFR, nor does mention of trade names,
commercial products or organizations
imply endorsement by the US Government
or the Colon CFR.
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Can J Surg, Vol. 52, No. 2, April 2009 93
C
olorectal cancer is the third most common can-
cer in Canada.
1
Although screening has been
shown to improve survival,
2–4
almost 50% of pa-
tients in North America present with either stage III or
IV disease.
5
Clinical practice guidelines (CPGs) are “systematically
developed statements to assist both practitioner and patient
decisions about appropriate heath care for specific clinical
circumstances.”
6
When based on high-quality evidence,
CPGs should assist in clinical decision-making, improve
health care delivery and decrease ineffective costs.
7,8
Al-
though CPGs represent the best available evidence, con-
cordance with guidelines is voluntary.
In 1991, the National Institutes of Health (NIH; Na-
tional Cancer Institute, United States) published the first
evidence-based guidelines for the use of adjuvant therapy
in patients with colorectal cancer.
9
The expert panel con-
cluded that patients with stage III colon cancer benefit
from adjuvant fluorouracil (5-FU)–based chemotherapy.
No adjuvant therapy was recommended for patients with
stage I or II colon cancer. Although systematic review does
not support the routine use of adjuvant chemotherapy after
curative resection in patients with stage II colon cancer,
10,11
it should be considered in patients with poor prognostic
factors.
12–14
Such factors include malignant bowel obstruc-
tion, perforation at the tumour site, the presence of lymph-
atic and/or vascular invasion and tumour aneuploidy. Al-
though molecular features such as tumour microsatellite
instability status may be important, these have not been
emphasized in currently accepted guidelines. Although the
approach to the treatment of stage II colon cancer is evolv-
ing, adjuvant treatment is currently recommended for
high-risk patients with stage II disease and all patients with
stage III disease, as per the NIH, American Society of
Clinical Oncology (ASCO) and Cancer Care Ontario
(CCO) guidelines.
9,13,14
Concordance with these guidelines
has not been systematically evaluated in Canada. Factors
that influence the decision to administer adjuvant
chemotherapy in patients with stage II colon cancer after
curative resection have not previously been addressed in
the English literature.
The Colorectal Cancer Interdisciplinary Health Re-
search Team was initiated in 2000 as a joint effort by a
multidisciplinary team of investigators in Newfoundland
and Labrador and Ontario to study incident cases of colo-
rectal cancer in the 2 Canadian provinces. Newfoundland
and Labrador has a population of about 505 000
15
and
1 regional cancer centre. Peripheral clinics are staffed by
oncologists from the regional centre. Conversely, Ontario
has a population of 12 160 000
15
and 9 cancer centres that
provide comprehensive cancer services. The purpose of
our study was to evaluate concordance with NIH, ASCO
and CCO guidelines for the administration of adjuvant
chemotherapy in patients with stage I–III colon cancer
and to explore whether differences exist between the
2 provinces.
METHODS
In Newfoundland and Labrador, we reviewed all incident
cases of colon cancer diagnosed between Jan. 1, 1999, and
Dec. 31, 2000 in patients aged 20–74 years. The New-
foundland and Labrador Familial Colorectal Cancer
Registry (NFCCR) is a true population-based registry that
collected information on patients aged 20–74 years who
received diagnoses of colorectal cancer between 1999 and
2003. The Newfoundland Cancer Treatment and Re-
search Centre (NCTRC) identified each patient with an
International Classification of Diseases (ICD-10) code to
indicate colon (153) or rectal (154) cancer. The team
pathologist retrieved and reviewed pathology reports to
ensure a diagnosis of adenocarcinoma, signet ring car-
cinoma or pseudomyxoma accompanied by adenocar-
cinoma. We forwarded a letter to the attending physicians
of all patients with a diagnosis of colon cancer (153) de-
scribing the study and providing details on who the pa-
tients should contact if they were interested in participat-
ing. If a patient was deceased, we identified the next of kin
by several methods, including through family physicians
and nursing clinics. We then contacted the next of kin in
the same manner as the patients, asking for consent to a
review of the patients’ medical records (proxy consent).
Patients or the next of kin consented to the completion of
a family history and dietary questionnaire and to the ex-
traction of information pertaining to the diagnosis and
treatment of their diseases from their medical records.
In Ontario, we asked patients enrolled in the Ontario
Familial Colorectal Cancer Registry (OFCCR), a National
Cancer Institute–funded consortium for the study of the
genetic epidemiology of colorectal cancer, to participate in
our study. The OFCCR is 1 of 6 international sites partici-
pating in the Cooperative Familial Registry for Colorectal
Studies established by the NCI. We used the population-
based Ontario Cancer Registry (OCR) to identify all cases
of invasive colon cancer diagnosed between Jan. 1, 1999,
and Jun. 30, 2000, among residents of Ontario aged 18–
74 years. Patients were recruited into the OFCCR by
mechanisms previously outlined in detail.
16
Briefly, all
Conclusion : La fidélité aux lignes directrices en matière de chimiothérapie adju-
vante dans le cancer du côlon de stade II n’a pas été jugée optimale. Ce phénomène
pourrait résulter d’un biais de sélection de la part des chirurgiens référents, d’un
manque de preuves de niveau 1 et de la perception que d’autres facteurs, comme l’âge,
peuvent jouer un rôle dans le pronostic.
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94 J can chir, Vol. 52, N
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high- or intermediate-risk patients and a 25% random
sample of low-risk patients were recruited into the
OFCCR. Patients enrolled in our study consented to the
completion of a family history and dietary questionnaire
and to the extraction of information pertaining to the diag-
nosis and treatment of their diseases from their medical
records. We did not seek proxy consent in Ontario.
After obtaining informed consent, trained health record
technicians or research nurses retrospectively reviewed
medical records and extracted the relevant data, including
information on patient demographics, diagnosis (symp-
toms, location of diagnosis, site of cancer and date of diag-
nosis), surgical intervention (date, type of surgery, opera-
tive findings, hospital/surgeon), pathology (stage, number
of lymph nodes, tumour differentiation/cell type, margins,
perineural/lymphovascular invasion), adjuvant treatment
(start date, type of chemotherapy), follow-up (metachro-
nous primary, first documented locoregional and/or distant
recurrence and treatment), time to last follow-up and/or
death and cause of death.
To verify the accuracy of the data, 2 of us (D.W. and
L.M.) randomly reviewed about one-half of the charts. We
reviewed all records for participants with stage III disease
who did not receive adjuvant chemotherapy (n = 14). We
assessed the charts of patients with stage II disease to
determine the presence or absence of high-risk features
(i.e., clinical obstruction or tumour perforation at presenta-
tion, T4 lesion, poor differentiation, lymphatic invasion,
perineural invasion, vascular invasion or mucin production)
and whether these features were used to guide chemother-
apy recommendations. We excluded patients with stage IV
disease from this analysis. The local institutional review
boards and the advisory committee of the NIH Coopera-
tive Family Registries for Colorectal Cancer Studies ap-
proved all study procedures.
We used descriptive statistics where appropriate. We
performed multivariate analysis to determine factors asso-
ciated with the administration of chemotherapy in patients
with stage II disease.
RESULTS
Study population
In Newfoundland and Labrador, there were 274 incident
cases of colon cancer diagnosed between Jan. 1, 1999, and
Dec. 31, 2000; 191 patients (70%) or their appropriate
proxies consented to participate. Of these, we included
130 patients (68%) with stage I–III disease in our study.
There were 2464 patients with colon cancer diagnosed
between Jan. 1, 1999, and Jun. 30, 2000, in the OCR. Of
these, 1031 (42%) completed a family history question-
naire and were recruited into the OFCCR. We deemed all
patients who reported a high-risk family history (28) or an
intermediate-risk family history (331) to be eligible for
inclusion in our study. In addition, we also deemed a 25%
random sample of patients who reported a low-risk family
history (155/508) to be eligible for inclusion in this study
(514/2464, 21%). In total, 364 of 514 patients (71%) con-
sented to participate. Of these, we included 315 patients
(87%) with stage I–III disease in our study.
Treatment at stage I
No adjuvant chemotherapy recommended in CPGs
Of the 21 patients in Newfoundland and Labrador with
stage I disease and the 60 patients in Ontario with stage 1
disease, none received adjuvant chemotherapy (Table 1).
Treatment at stage II
Chemotherapy as a function of risk status,
Newfoundland and Labrador
Of 55 patients with stage II colon cancer in Newfound-
land and Labrador (Fig. 1A), 41 (75%) had at least 1 high-
risk feature. Twenty-nine of the 41 patients (71%) consid-
ered to be high-risk were referred to medical oncology.
Of these, 18 patients (62%) received adjuvant chemother-
apy (44% of the high-risk cohort). Of the 11 high-risk
patients who were referred to medical oncology but did
not receive chemotherapy, 1 was felt to be medically unfit,
1 did not have the issue revisited after work-up for a be-
nign liver lesion, 4 were noted to have high-risk features
for which adjuvant chemotherapy showed no definitive
benefit and 5 were felt to have no high-risk features,
although at least 1 was noted in the standardized tumour
pathology summary.
Fourteen of 55 patients (25%) in Newfoundland and
Labrador with stage II disease were classified as low-risk.
Of these, 11 (73%) were assessed by medical oncology.
Three of 11 patients (27%) who were assessed received
adjuvant therapy (21% of the low-risk cohort). This was
based solely on the presence of tumour ulceration. We did
not consider tumour ulceration to be a high-risk feature
for the purposes of our study because it is not identified in
the CCO and ASCO guidelines.
Chemotherapy as a function of risk status, Ontario
Adequate information was available for 116 of 132 pa-
tients (88%) with stage II disease in Ontario to classify
these patients as either high- (53) or low-risk (63)
Table 1. Adjuvant chemotherapy by stage
Province; no. (%) of patients
Stage at diagnosis
Newfoundland
and Labrador Ontario Total
Stage I 0/21 0/60 0/81
Stage II 20/55 (36) 44/116 (38) 64/171 (37)
Stage III 45/52 (87) 108/115 (94) 153/167 (92)
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Can J Surg, Vol. 52, No. 2, April 2009 95
(Fig. 1B). The absence of standardized pathology report-
ing for the remaining 16 patients (12%) made this deter-
mination impossible.
Fifty-three of 116 patients (46%) were considered to be
high-risk; of these, 36 (68%) were referred to medical
oncology and 17 (32%) were not. Thirty of 36 patients
(83%) referred received adjuvant chemotherapy. We were
unable to determine from an assessment of the initial med-
ical oncology consultations why the other 6 patients were
not offered adjuvant chemotherapy.
Sixty-three of 116 patients (54%) in Ontario with stage
II disease were classified as low-risk. Of these, 22 patients
(35%) were assessed by medical oncology. Fourteen of the
22 patients (64%) who were assessed received adjuvant
chemotherapy (22% of the low-risk cohort). The reasons
for this were not stated. The receipt of adjuvant chemo-
therapy differed significantly as a function of risk status
(χ
2
1
= 14.0, p < 0.001).
As the proportion of low- and high-risk patients who
received adjuvant chemotherapy (low-risk = 21% in New-
foundland and Labrador and 22% in Ontario; high-risk =
44% in Newfoundland and Labrador and 57% in Ontario)
did not differ significantly as a function of province, we
combined data from the 2 provinces for further analysis.
We performed multivariate logistic regression to iden-
tify independent predictors of those who received
chemotherapy. Variables included in the model were high-
risk status (odds ratio [OR] 3.82, 95% confidence interval
[CI] 1.87–7.81), province (not significant) and age 50 years
or less at diagnosis (OR 0.38, 95% CI 0.14–1.03). The
proportion of those who received chemotherapy was
68% in those aged 50 years or less and 36% in those older
than 50 years. There was a strong trend toward using
chemotherapy in the younger group, independent of high-
risk status.
Treatment at stage III
Adjuvant chemotherapy recommended by CPGs
Most patients with stage III colon cancer received adju-
vant chemotherapy (Table 1). In Newfoundland and
Labrador, 45 of 52 (87%) patients with stage III colon
cancer received adjuvant chemotherapy. Of the 7 who did
not, 3 patients died postoperatively, 1 had a delayed post-
operative course following an anastomotic leak, 1 was
treated for a synchronous retroperitoneal lymphoma and
3 were not referred (no reason given). In Ontario, 108 of
115 (94%) received adjuvant chemotherapy. There was no
information available for 4 patients, 1 patient refused ther-
apy, 1 had metastatic breast cancer and there was no rea-
son given for 1 patient.
DISCUSSION
In 1991, the NIH published the first evidence-based
guidelines for the use of adjuvant therapy in patients with
colon cancer.
9
Although systematic review does not
support the routine use of adjuvant chemotherapy in
patients with stage II disease, it should be considered in
patients with high-risk features,
12–14
including malignant
bowel obstruction or perforation at the time of presenta-
tion, T4 disease, perineural/lymphovascular invasion or
aneuploidy.
The results of our study show that patients with stage I
and III colon cancer were managed according to current
recommendations in both provinces. Clearly, guidelines
supported by adequate level-I evidence have been acknowl-
edged by the appropriate target audience, including sur-
geons and medical oncologists, resulting in successful
implementation.
Although patients with high-risk stage II disease were
18 (62%) offered
chemotherapy
3 (27%) offered
chemotherapy
41 (75%)
high-risk
14 (25%)
low-risk
29 (71%) referred to
medical oncology
11 (73%) referred to
medical oncology
55 patients with
stage II disease
30 (83%) offered
chemotherapy
14 (64%) offered
chemotherapy
53 (46%)
high-risk
63 (54%)
low-risk
36 (68%) referred to
medical oncology
22 (35%) referred to
medical oncology
116 patients with
stage II disease
A B
Fig. 1. Receipt of adjuvant chemotherapy (stage II) as a function of risk status in (A) Newfoundland and Labrador and (B) Ontario.
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96 J can chir, Vol. 52, N
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significantly more likely to receive chemotherapy than
patients with low-risk stage II disease, our data suggest that
other information was used in the decision to administer
adjuvant chemotherapy in patients with stage II disease.
This may reflect a paucity of level-I evidence. It appears
that patient age influenced the decision to offer adjuvant
chemotherapy in that there was a strong trend in favour of
chemotherapy in patients aged 50 years or younger who
had stage II disease, independent of high-risk status. This
requires further study as younger age tends to be cor-
related with high-frequency microsatellite instability
tumours.
17,18
There is evidence that patients with this type
of tumour may not derive the same benefit from 5-FU–
based chemotherapy.
19
Thus the use of age alone as an ad-
verse prognostic factor in the decision to administer 5-FU–
based adjuvant chemotherapy may not be sound.
Only 71% of patients with high-risk stage II disease in
Newfoundland and Labrador and 68% of these patients in
Ontario were referred to medical oncology. It has previ-
ously been shown that patients with stage II colon cancer
were less likely to be referred for consideration of adjuvant
chemotherapy (76% for stage II colon cancer, 92% for
stage III colon cancer).
20
We cannot comment on whether
this reflects a lack of knowledge on the part of surgeons as
to the potential benefit for high-risk patients, whether
surgeons do not feel that the evidence is strong enough
to warrant referral for patients with stage II disease, or
whether other factors such as resource allocation are at
play. It has been shown that concordance with guidelines
develops along a continuum from awareness to acceptance
to ability to enforce to successful implementation.
21–23
The
target audience may be unaware of the existence of the
information. Surgeons may be aware of the original guide-
line that recommended no chemotherapy for patients with
stage I and II colon cancer after curative resection. Further
refinements, based on less compelling data, may not have
been as widely disseminated. Furthermore, even once the
recommendation is known, surgeons may not accept the
validity of the guideline. Even if surgeons and medical
oncologists support the guidelines, local factors such as
resource allocation and access to treatment may influence
the ability to enforce guidelines. Medical oncology re-
sources may be such that treatment is only readily available
where there is good level-I evidence.
This complex process of guideline implementation
demands a multidisciplinary focus.
24
It has been shown that
concordance with guidelines is enhanced when members of
the target audience are actively recruited to participate in
guideline development and dissemination.
21–24
To this end,
it would be important to ensure that surgeons become
involved in the creation of guidelines. This would apply
not only to surgeons in academic centres, but also to com-
munity surgeons and other health care workers who are
seen to be local opinion leaders.
24
These individuals could
determine what guidelines are necessary, the best means to
make surgeons within their communities aware of and
accepting of the guidelines and, most importantly, the re-
source limitations that might impede the implementation
of important guidelines. It has been well documented that
CPGs without coordinated dissemination strategies rarely
result in consistent changes in physician performance
and/or behaviour.
25–27
It will become increasingly important to establish suc-
cessful multifaceted approaches that provide sound ration-
ale for the delivery of adjuvant therapy in the treatment of
colorectal and other cancers as the use of molecular mark-
ers and microarray analyses
28
come to the forefront. The
rise of increasingly expensive therapies such as cetuximab
29
and bevacizumab
30
in the adjuvant setting will require
sophisticated targeting strategies to ensure their effica-
cious, efficient and cost-effective use.
In our study, selection bias may have been introduced as
a result of the differing sampling techniques in the
2 provinces and the need to obtain consent. We used med-
ical record audit, rather than patient recall or the use of
administrative data, as an objective measure of compliance
with CPGs. This method has been shown to result in
higher levels of concordance in a recently reported study
that evaluated the receipt of recommended adjuvant ther-
apy among patients with stage II and III colon and rectal
cancer in the Veterans Affairs setting; 87% of patients with
stage II and 71% of patients with stage III colon cancer
received the recommended therapy.
20
However, we have
no reason to suspect that the main outcome measure
(receipt of recommended adjuvant chemotherapy) was cor-
related with participation in the study. Owing to the retro-
spective nature of our study, we are unable to comment on
whether the decision to refer patients to medical oncology
or offer adjuvant chemotherapy was influenced by socio-
economic status or proximity to a treatment centre. High
concordance with guidelines for stage III disease in both
provinces would suggest that guidelines that are developed
with strong input from the target audience and on the basis
of good level-I evidence will lead to more equitable and
standardized treatment protocols, at least in Canada.
In conclusion, it appears that among doctors treating
colong cancer there is not universal agreement with and
belief in an improved outcome following implementation
of the ASCO and CCO recommendations for the adjuvant
treatment of stage II colon cancer. Concordance could be
improved by multi-faceted approaches that incorporate
surgeons, who are members of the target audience and the
first point of patient contact, in all aspects of the develop-
ment and implementation of important CPGs.
Acknowledgements: Supported by a Canadian Institutes of Health Re-
search Grant. The authors wish to thank Susan Ryan, Carol Negrijn and
Janie Freud for data extraction and Andrea Kavanagh and Kevin Boyd
for data retrieval.
Competing interests: None declared.
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Can J Surg, Vol. 52, No. 2, April 2009 97
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Contributors: Drs. Wirtzfeld and Gryfe designed the study and
acquired the data. Dr. Parfrey also designed the study. Drs. Mikula,
Gallinger and Pollett also acquired the data, which Drs. Wirtzfeld,
Mikula, Ravani, Dicks and Parfrey analyzed. Drs. Wirtzfeld, Ravani and
Parfrey wrote the article, which Drs. Wirtzfeld, Mikula, Gryfe, Ravani,
Dicks, Gallinger and Pollett reviewed. All authors approved the final
version for publication.
Page 6
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    • "This better adherence to recommendations at entry than during follow-up might be partly explained by the lower level of CD4 at entry, and/ or by less opportunity for interactions with the patient when criteria for ART initiation are met at the first visit. In other medical fields (cardiology, oncology, etc.), significant gaps have also been found between clinical practice and guidelines [25,26,27,28,29,30]. Overall, our results are similar to those reported for the application of guidelines among patients with other chronic diseases [26,27,31,32,33]. "
    [Show abstract] [Hide abstract] ABSTRACT: The soluble CD14 (sCD14) level was found associated with mortality during the chronic phase of HIV-infection. Here we assessed its prognostic value in 138 patients with primary HIV-infection. Higher sCD14 levels were associated with death, from myocardial infarction, but this was based on 3 deaths only. Among 68 untreated patients, those with higher sCD14 levels had more rapid spontaneous CD4 cell decline during the first 18 months following primary-infection. This association persisted after adjustment for age, the CD4 cell count and HIV viral load at diagnosis. © The Author 2015. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.
    Full-text · Article · Mar 2015 · The Journal of Infectious Diseases
  • Source
    • "First, clinical studies of equal-access health care systems within the US have consistently observed similar chemotherapy and survival rates among AAs and NHWAs with colon cancer11121314. Second, colon cancer chemotherapy rates seem to be much higher in Canada than in the US [15,16]. Third, recent population-based studies of colon cancer care in California and Ontario suggested that people of color, including black people of various ethnic backgrounds, with colon cancer are much better served in California161718. "
    [Show abstract] [Hide abstract] ABSTRACT: Despite evidence of chemotherapy's ability to cure or comfort those with colon cancer, nearly half of such Americans do not receive it. African Americans (AA) seem particularly disadvantaged. An ethnicity by poverty by health insurance interaction was hypothesized such that the multiplicative disadvantage of being extremely poor and inadequately insured is worse for AAs than for non-Hispanic white Americans (NHWA). California registry data were analyzed for 459 AAs and 3,001 NHWAs diagnosed with stage II to IV colon cancer between 1996 and 2000 and followed until 2011. Socioeconomic data from the 2000 census categorized neighborhoods: extremely poor (>= 30% of households poor), middle (5-29% poor) and low poverty (< 5% poor). Participants were randomly selected from these poverty strata. Primary health insurers were Medicaid, Medicare, private or none. Chemotherapy rates were age and stage-adjusted and comparisons used standardized rate ratios (RR). Logistic and Cox regressions, respectively, modeled chemotherapy receipt and long term survival. A significant 3-way ethnicity by poverty by health insurance interaction effect on chemotherapy receipt was observed. Among those who did not live in extremely poor neighborhoods and were adequately insured privately or by Medicare, chemotherapy rates did not differ significantly between AAs (37.7%) and NHWAs (39.5%). Among those who lived in extremely poor neighborhoods and were inadequately insured by Medicaid or uninsured, AAs (14.6%) were nearly 60% less likely to receive chemotherapy than were NHWAs (25.5%, RR = 0.41). When the 3-way interaction effect as well as the main effects of poverty, health insurance and chemotherapy was accounted for, survival rates of AAs and NHWAs were the same. The multiplicative barrier to colon cancer care that results from being extremely poor and inadequately insured is worse for AAs than it is for NHWAs. AAs are more prevalently poor, inadequately insured, and have fewer assets so they are probably less able to absorb the indirect and direct, but uncovered, costs of colon cancer care. Policy makers ought to be cognizant of these factors as they implement the Affordable Care Act and consider future health care reforms.
    Full-text · Article · Mar 2014 · BMC Health Services Research
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    • "In other medical fields (cardiology, oncology, etc.), significant gaps have also been found between clinical practice and guidelines [17][22]. Overall, our results are slightly higher than those reported for the application of guidelines among patients with other chronic diseases [18] [19] [23]. "
    Full-text · Article · Jan 2014 · Open Journal of Preventive Medicine
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