Lankenau Institute for Medical Research, Lankenau Medical Center, Wynnewood, PA, USA.
Department of Surgery, Lankenau Medical Center, Marks Colorectal Surgical Associates, Wynnewood, PA, USA.
J Natl Cancer Inst. 2023 Dec 6;115(12):1616-1625. doi: 10.1093/jnci/djad164.
T stage is a prognostic biomarker for overall survival in colon cancer and pathologic T4 disease is a high-risk characteristic. Adjuvant chemotherapy is recommended to improve overall survival in pT4N0M0, but compliance with guidelines is unknown. We aimed to evaluate adjuvant chemotherapy use and impact on overall survival in pT4N0M0 colon cancer.
The National Cancer Database was reviewed for pT4N0M0 colon adenocarcinomas undergoing curative surgical resection (2010-2017). Cases were stratified into no adjuvant chemotherapy and adjuvant chemotherapy cohorts. Moderated multiple regression assessed factors associated with no AC. Kaplan-Meier and Cox regression assessed overall survival in propensity-score matched cohorts. The main outcome measures were adjuvant chemotherapy use, factors associated with adjuvant chemotherapy, and impact on overall survival.
Of 11 847 cases, 62.4% (n = 7391) received no adjuvant chemotherapy. With private insurance, comorbidities or income do not affect adjuvant chemotherapy use. Medicare cases with a Charlson-Deyo comorbidity index of 0 (odds ratio [OR] = 0.861, 95% confidence interval [CI] = 0.760 to 0.975; P = .019) and Medicare payors with high income (OR = 0.813, 95% CI = 0.690 to 0.959; P = .014) were associated with adjuvant chemotherapy. Medicaid Charlson-Deyo comorbidity index 0 (OR = 1.374, 95% CI = 1.125 to 1.679; P = .002) and uninsured Charlson-Deyo comorbidity index 0 (OR = 1.351, 95% CI = 1.120 to 1.629; P = .002) were associated with no adjuvant chemotherapy. Adjuvant chemotherapy was associated with improved 5-year overall survival (71.7% vs 56.4%; P < .001; adjusted hazard ratio = 0.543, 95% CI = 0.499 to 0.590; P < .001).
Although adjuvant chemotherapy is associated with improved overall survival, compliance is low. There is a complex relationship between payor, income, comorbidity, and adjuvant chemotherapy receipt. Medicare patients with no comorbidities or higher income have better adjuvant chemotherapy use. With private insurance, adjuvant chemotherapy compliance is not affected by comorbidities or income, whereas Medicaid and uninsured patients with no comorbidities have poor compliance. Future work could target these disparities for equitable care.
T 期是结直肠癌总生存的预后生物标志物，病理 T4 期疾病是高危特征。建议在 pT4N0M0 中使用辅助化疗以提高总生存率，但对指南的遵循情况尚不清楚。我们旨在评估 pT4N0M0 结肠癌中辅助化疗的使用情况及其对总生存率的影响。
对 2010-2017 年接受根治性手术切除的 pT4N0M0 结肠腺癌的国家癌症数据库进行了回顾。病例分为无辅助化疗和辅助化疗两组。调节性多变量回归评估与无 AC 相关的因素。Kaplan-Meier 和 Cox 回归评估倾向评分匹配队列的总生存率。主要观察指标为辅助化疗的使用、与辅助化疗相关的因素以及对总生存率的影响。
在 11847 例病例中，62.4%（n=7391）未接受辅助化疗。有私人保险、合并症或收入不影响辅助化疗的使用。医疗保险病例的 Charlson-Deyo 合并症指数为 0（比值比[OR] = 0.861，95%置信区间[CI] = 0.760 至 0.975；P=0.019），收入较高的医疗保险支付者（OR = 0.813，95%CI = 0.690 至 0.959；P=0.014）与辅助化疗相关。医疗补助的 Charlson-Deyo 合并症指数为 0（OR = 1.374，95%CI = 1.125 至 1.679；P=0.002）和无保险的 Charlson-Deyo 合并症指数为 0（OR = 1.351，95%CI = 1.120 至 1.629；P=0.002）与无辅助化疗相关。辅助化疗与 5 年总生存率提高相关（71.7% vs 56.4%；P<0.001；调整后的危险比=0.543，95%CI = 0.499 至 0.590；P<0.001）。
尽管辅助化疗与总生存率的提高相关，但遵循情况不佳。支付者、收入、合并症和辅助化疗之间存在复杂的关系。无合并症或收入较高的医疗保险患者的辅助化疗使用率较高。有私人保险的患者，合并症或收入并不影响辅助化疗的使用，而没有合并症的医疗补助和无保险患者的辅助化疗使用率较低。未来的工作可以针对这些差异进行公平护理。
