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Failure of Evidence-Based Cancer Care in the US - Rectal Cancer Treatment, Geography and Hospital Type
John R.T. Monson1, Christian P Probst*1, Steven D Wexner2, Feza H Remzi*3, James Fleshman*4, Julio Garcia-Aguilar5, George J Chang*6, David W Dietz, On behalf of The OSTRiCh Consortium*3
1University of Rochester Medical Center, Rochester, NY;2Cleveland Clinic, Weston, FL;3Cleveland Clinic, Cleveland, OH;4Baylor University Medical Center, Houston, TX;5Memorial Sloan-Kettering Cancer Center, New York, NY;6University of Texas MD Anderson Cancer Center, Houston, TX
OBJECTIVE(S):
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 with formally published guidelines. This study examines adherence to recommended neoadjuvant chemoradiation for patients with rectal cancer across geographic regions, institution types and over time.
METHODS:
Patients who underwent operation for clinical stage 2 and 3 rectal cancer were selected from the 2006-2011 National Cancer Data Base (NCDB)(n=32,171), 4-9 years after guideline release. Multivariable logistic regressions were used to assess variation in chemoradiation use by center type and geographical location, controlling for differences in patient age, sex, race, primary payor, comorbidity, and year of diagnosis.
RESULTS:
Use of neoadjuvant chemoradiation varied significantly between center types. The highest rates were observed in academic centers (radiation 79%, chemotherapy 78%) and the lowest rates were provided in community programs (radiation 71% and chemotherapy 70%, p<0.001). This variation is mirrored by geographic location. Primary payor and year of diagnosis were not predictive of rates of treatment.
CONCLUSIONS:
Adherence to evidence-based treatment guidelines in rectal cancer is suboptimal in the US, with differences across facility types 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 rectal cancer patients. 
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