Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, MO.
Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, MO.
J Am Coll Surg. 2021 Jan;232(1):27-33. doi: 10.1016/j.jamcollsurg.2020.10.017. Epub 2020 Oct 24.
The National Accreditation Program for Rectal Cancer (NAPRC) emphasizes a multidisciplinary approach for treating rectal cancer and has developed performance measures to ensure that patients receive standardized care. We hypothesized that rectal cancer patients receiving care at multiple centers would be less likely to receive timely and appropriate care.
A single institution retrospective review of a prospectively maintained database was performed. All patients undergoing proctectomy and ≤1 other treatment modality (eg radiation and/or chemotherapy) for Stage II/III rectal adenocarcinoma were included. Unified care was defined as receiving all modalities of care at our institution, and fragmented care was defined as having at least 1 treatment modality at another institution.
From 2009 to 2019, 415 patients met inclusion criteria, with 197 (47.5%) receiving fragmented care and 218 (52.5%) receiving unified care. The unified cohort patients were more likely to see a colorectal surgeon before starting treatment (89.0% vs 78.7%, p < 0.01) and start definitive treatment within 60 days of diagnosis (89.0% vs 79.7%, p = 0.01). On adjusted analysis, unified care patients were 2.78 times more likely to see a surgeon before starting treatment (95% CI 1.47-5.24) and 2.63 times more likely to start treatment within 60 days (95% CI 1.35-5.13). There was no difference in 90-day mortality or 5-year disease-free survival.
This retrospective cohort study suggests patients with rectal cancer receiving fragmented care are at an increased risk of delays in care without any impact on disease-free survival. These findings need to be considered within the context of ongoing regionalization of rectal cancer care to ensure all patients receive optimal care, irrespective of whether care is delivered across multiple institutions.
国家直肠癌认证计划（NAPRC）强调多学科方法治疗直肠癌，并制定了绩效指标以确保患者接受标准化治疗。我们假设在多个中心接受治疗的直肠癌患者不太可能获得及时和适当的治疗。
对前瞻性维护的数据库进行了单机构回顾性研究。所有接受 II/III 期直肠腺癌直肠切除术和≤1 种其他治疗方式（如放疗和/或化疗）的患者均纳入研究。统一治疗是指在本机构接受所有治疗方式，而分散治疗是指在其他机构接受至少 1 种治疗方式。
2009 年至 2019 年，共有 415 名患者符合纳入标准，其中 197 名（47.5%）接受分散治疗，218 名（52.5%）接受统一治疗。统一治疗组的患者在开始治疗前更有可能见到结直肠外科医生（89.0%比 78.7%，p<0.01），并在诊断后 60 天内开始确定性治疗（89.0%比 79.7%，p=0.01）。在调整分析中，统一治疗组患者在开始治疗前见到外科医生的可能性是前者的 2.78 倍（95%CI 1.47-5.24），在 60 天内开始治疗的可能性是前者的 2.63 倍（95%CI 1.35-5.13）。90 天死亡率和 5 年无病生存率无差异。
本回顾性队列研究表明，接受分散治疗的直肠癌患者在治疗延迟方面风险增加，但对无病生存率没有影响。在直肠癌治疗区域化的背景下，需要考虑这些发现，以确保所有患者无论治疗机构数量如何，都能获得最佳治疗。
