Department of Medicine, Epidemiology, and Population Sciences, Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas.
Department of Medicine, Epidemiology, and Population Sciences, Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas.
Ann Thorac Surg. 2022 Jan;113(1):279-285. doi: 10.1016/j.athoracsur.2020.12.046. Epub 2021 Jan 20.
Treatment selection for patients with esophageal adenocarcinoma is predicated on clinical staging information, which is inaccurate in 20% to 30% of cases and could impact the delivery of guideline-concordant treatment. We aimed to evaluate the association between staging concordance at the patient and hospital levels with the delivery of guideline-concordant treatment among esophageal adenocarcinoma patients.
This was a national cohort study of resected esophageal adenocarcinoma patients in the National Cancer Data Base (2006 to 2015) treated either with upfront resection or neoadjuvant therapy followed by surgery. Patient- and hospital-level clinical and pathologic staging concordance and deviations from treatment guidelines were ascertained. For neoadjuvant therapy patients, staging concordance was predicted through Bayesian analysis. Reliability adjustment was used when evaluating hospital-level concordance.
Among 9393 esophageal adenocarcinoma patients treated at 927 hospitals, 41% had upfront surgery. Among upfront surgery patients, staging concordance was 85.1% for T1N0 and 86.9% for T3-T4N+ disease, but less than 50% for all others. Among patients treated with neoadjuvant therapy, treatment downstaging was observed in 33.9%. Deviations from treatment guidelines were identified in 38.5% of upfront surgery patients and 3.3% of neoadjuvant therapy patients. The proportion of concordantly staged patients ranged from 60.1% to 87.9%, and deviations from treatment guidelines were observed among 14.9% to 22.7% of the patients. Patient staging concordance increased, and deviations from guidelines decreased, as hospital-level concordance increased (trend test, P values less than .001 for all).
Deviations from treatment guidelines in esophageal adenocarcinoma patients appear to be a function of inaccurate clinical staging information, which should be a new focus for quality improvement efforts.
食管腺癌患者的治疗选择取决于临床分期信息，但在 20%至 30%的病例中，该信息并不准确，这可能会影响符合指南的治疗的实施。我们旨在评估患者和医院层面的分期一致性与食管腺癌患者接受符合指南的治疗之间的关系。
这是一项全国性队列研究，纳入了国家癌症数据库（2006 年至 2015 年）中接受根治性切除术或新辅助治疗后手术的食管腺癌患者。确定了患者和医院层面的临床和病理分期一致性和对治疗指南的偏离。对于新辅助治疗患者，通过贝叶斯分析预测分期一致性。在评估医院层面的一致性时使用可靠性调整。
在 927 家医院接受治疗的 9393 例食管腺癌患者中，有 41%接受了根治性手术。在接受根治性手术的患者中，T1N0 的分期一致性为 85.1%，T3-T4N+疾病的分期一致性为 86.9%，但其他所有疾病的分期一致性均低于 50%。在接受新辅助治疗的患者中，观察到治疗降期 33.9%。在接受根治性手术的患者中有 38.5%存在治疗指南偏离，在接受新辅助治疗的患者中有 3.3%存在治疗指南偏离。在接受新辅助治疗的患者中有 3.3%存在治疗指南偏离。一致性分期患者的比例为 60.1%至 87.9%，在 14.9%至 22.7%的患者中观察到治疗指南偏离。随着医院层面一致性的增加，患者分期的一致性增加，偏离治疗指南的情况减少（趋势检验，所有 P 值均小于.001）。
食管腺癌患者的治疗指南偏离似乎是临床分期信息不准确的结果，这应成为质量改进努力的新重点。
