SAN FRANCISCO – In locally advanced rectal cancer, fragmentation of radiotherapy and surgery comes at a cost, even at academic medical centers, according to a new analysis of data from the National Cancer Center Database. Researchers found that survival was higher when care was integrated – that is, both the surgery and the radiotherapy were performed at the same location.
The study paints a complex picture. Academic settings had a higher frequency of fragmented care than comprehensive community and community hospitals, but treatment in them was associated with better overall survival. However, patients who received fragmented care at academic hospitals had no survival advantage over the other institutions, according to Kyle Freischlag, MD, an intern at the University of Iowa, Iowa City, who presented the study at the annual clinical congress of the American College of Surgeons. The study was conducted at Duke University, Durham, N.C., during Dr. Freischlag’s time there.
Cancer care is becoming more centralized, with the expectation that patients will travel to specialty centers for treatment. But this isn’t possible for all patients, so some may get surgery at one locale, and radiation therapy at a closer, more convenient center.
The push for centralization of cancer care is embodied by the National Accreditation Program for Rectal Cancer, which accredits hospitals to be centers of excellence for rectal cancer surgery. “It’s a great program, it’s very comprehensive. But it is resource intensive to become accredited, so realistically, I think it will be mostly larger-volume hospitals that will apply for accreditation,” said Elise Lawson, MD, in an interview. Dr. Lawson is assistant professor of surgery at University of Wisconsin–Madison, and moderated the session where the research was presented.
“It is a great first step to improving the quality of rectal cancer care, but this study highlights that accreditation of large-volume centers may not be enough, and that we have to be careful that we aren’t going to exacerbate existing disparities in access and quality of care for patients who live in rural settings,” Dr. Lawson added.
In an analysis of 28,227 patients between 2006 and 2015, 17,663 of whom had integrated care, the researchers found that integrated care patients had a lower likelihood of 30-day unplanned readmissions (6.2% vs. 7.0%; P =.01), and those with fragmented care experienced higher mortality (hazard ratio, 1.07; 95% confidence interval, 1.01-1.12). Treatment in an academic center was associated with lower mortality overall than treatment in community centers (HR, 0.881; P =.005).
Fragmented care was more common in academic centers (40% vs. 36% in comprehensive community centers vs. 37% in community centers, P less than .001). Within academic centers, 5-year overall survival was worse with fragmented versus integrated care (70% vs. 74%; P =.00016).
The researchers found that performance of surgery at an academic center was itself a predictor of better survival (odd ratio, 0.88; 95% CI, 0.81-0.96). Integrated care at an academic center was associated with lower 30-day mortality (0.5% vs. 0.6% in integrated comprehensive community centers vs. 1.1% in integrated community centers; P = .038) and better 5-year overall survival (73% vs. 71% vs. 66%; HR, 0.85; 95% CI, 0.75-0.98; P less than .0001). “However, that survival benefit seen in academic hospitals disappeared when they had fragmented care,” Dr. Freischlag noted.
The study is limited by its retrospective nature, though the researchers did adjust for clinical and demographic characteristics, and selection bias for fragmented care should be generalizable across hospital types.
Dr. Freischlag believes that centralization has created additional financial and emotional burdens on patients, reduced the chances of patients receiving adjuvant therapy and completing radiation therapy, and led to increased stage at diagnosis, all factors that might explain the survival difference. He called for efforts to reduce fragmentation, and to conduct surgery at academic centers whenever possible, since that is associated with a survival advantage.
Dr. Lawson agreed, and called for a greater focus on improving care across centers. “It’s a problem if we’re only improving the large volume centers and not thinking about the burden that travel places on patients that live far away from these centers. This study is further showing that it matters not just where you get surgery, but also chemotherapy and radiation – so we need to think about how to coordinate comprehensive care for patients with rectal cancer better.”
The study received no external funding. Dr. Freischlag and Dr. Lawson reported no relevant conflicts of interest.
SOURCE: Freischlag K et al. J Am Coll Surg. 2019 Oct;229(4):Suppl 1, S52.