|Measure ||Desired Direction ||As of this Report |
|Percentage of stage III colon cancer patients ages 65 or over treated with guideline-recommended chemotherapy || || |
|Percentage of patients diagnosed with stage III colon cancer whose wait between cancer surgery and adjuvant chemotherapy was ≤ 60 days || || |
| See Methodology and Approach to find out how the ratings are calculated. |
Overall, just over half (57%) of stage III colon cancer patients ages 65 and older were treated with guideline-recommended chemotherapy from 2010 to 2013. Rates were significantly lower in patients ages 80 and over. There has been a steady increase in the percentage of stage III colon cancer patients receiving adjuvant chemotherapy within 60 days following surgery across the province, improving from 62% in 2010 to 72% in 2013. Nonetheless, there continues to be significant variation among regions and age groups.
What is cancer surgery?
- Cancer surgery is the removal of cancerous tumours. It often is the first step in treating cancer.
- Removal of the cancer also provides an opportunity for a complete pathology assessment of the tumour, including determining the exact type and stage of the cancer.
- For the purposes of this indicator, surgery is defined as the first surgical procedure after a cancer diagnosis.
What is adjuvant chemotherapy?
- Chemotherapy often slows or stops cancer cells from growing, multiplying or spreading to other parts of the body1. Systemic prescriptions can be pills, injections, or intravenously (IV).
- Adjuvant chemotherapy means the chemotherapy is given after cancer surgery to completely remove the primary tumour. This has been shown to increase the chances of killing any remaining, non-visible cancer cells, to prevent recurrence (return) of cancer, to prolong life and to improve the chances of a cure in this group of patients.
What are the colon cancer guidelines?
- Stage III colon cancers are typically first treated by surgical removal of the tumour (resection).
- Adding adjuvant chemotherapy will decrease the risk of it returning (recurrence), especially in those where the cancer has already spread to local lymph nodes (stage III colon cancer).
- Cancer Care Ontario has developed evidence-based treatment guidelines for the administration of post-operative adjuvant chemotherapy for patients with stage III colon cancer. Both the Full Report and the Summary are available on the Cancer Care Ontario website.
- Patients are treated according to guidelines if they receive 5-FU (5-fluorouracil)/leucovorin/oxaliplatin-based post-operative intravenous chemotherapy, or an oral drug (capecitabine, also known as Xeloda®) within 120 days of surgery2.
- This indicator measures, by region and age, how well these guidelines were followed.
- A valid stage report is needed because treatment guidelines vary by stage.
- We are best able to measure concordance for those patients ages 65 and older where we have complete information on the use of oral chemotherapy.
What do the results show?
There is moderate variation in the use of guideline-recommended chemotherapy for stage III colon cancer across regions (Figure 1).
- Overall, 57% of stage III colon cancer patients ages 65 or older received any guideline-recommended chemotherapy in 2013. That is similar to previous years.
- Regions vary from just over 44% of their patients being treated according to guidelines to almost 68%. This suggests an opportunity for improvement.
- Although other provinces report greater percentages of patients receiving chemotherapy following surgical resection, the data is not directly comparable because it includes all patients, including those younger than 65 years.
- The jurisdiction with the largest percentage of patients treated according to guidelines for all ages is Saskatchewan, where 82% of stage III colon cancer patients received guideline-recommended chemotherapy in 20093.
The use of guideline-recommended chemotherapy for stage III colon cancer—and the use of specific chemotherapy drugs—varies significantly by age (Figures 2 and 3).
- For those age 65 to 70 and 71 to 80, the use of guideline-recommended chemotherapy is 83% and 65%, respectively. After age 80, the rate falls to 25% (Figure 2).
- The decrease in use of any guideline-recommended chemotherapy with increasing patient age has been reported previously4.
- This may be because trials of adjuvant chemotherapy often do not include the very elderly, so relying on evidence to make assumptions about much older patients may be problematic5.
- Older patients may experience greater difficulty tolerating chemotherapy and more adverse events; this also may be a factor in the decreasing prescription of guideline-recommended chemotherapy in those ages 80 and older4.
- According to the 2014 Cancer System Performance Report by the Canadian Partnership Against Cancer, the decrease in adjuvant chemotherapy among older patients may be because they are more likely to have other health conditions or be taking medications that may interact negatively with chemotherapy6.
- Older patients have lower referral rates to a medical oncologist from their surgeons, which may be the reason fewer older patients receive guideline-recommended chemotherapy7.
- Capecitabine is used more frequently (38%) for those ages 71 to 80, while oxaliplatin-based treatment is more common (68%) for those ages 65 to 70. This may be due to the fact that oxaliplatin has been shown to be less effective in populations over the age of 708.
- Another reason may be the patient’s choice whether to pursue treatment altogether or treatment with a particular chemotherapy drug.
Overall, wait time between surgery and chemotherapy for stage III colon cancer patients has decreased over time, but there is substantial regional variation (Figure 4).
- Of the patients with stage III colon cancer who received adjuvant chemotherapy across the province, 72% started within 60 days of surgery in 2013, compared to 62% in 2010.
- The variation between Local Health Integration Networks (LHINs) from 2010 to 2013 ranges from 38% in South West to 86% in Erie St. Clair.
- There is evidence that delays experienced by patients who are not treated within the recommended time period are process-related delays, such as delays in referral, consultation and chemotherapy booking9,10.
Age is a factor that contributes to wait times (Figure 5).
- Seventy-three percent (73) of patients ages 30 to 49 years received adjuvant chemotherapy within 60 days of surgery. This is compared with 46% of patients ages 80 and older. There is a trend that fewer patients receive adjuvant chemotherapy as age increases.
Why is this important for patient care?
- Understanding variations in treatment practices and why they occur can contribute to efforts to improve quality of care and associated outcomes.
- Evidence-based treatment guidelines are intended to help clinicians and patients choose the treatments that have the most favourable outcomes.
- Stage III colon cancer patients who receive guideline-recommended chemotherapy are more likely to have better outcomes than those who do not receive it2.
- We are best able to determine concordance with guidelines for patients ages 65 and older (because of data availability about the use of oral chemotherapy for those younger than 65), and for those who have a valid stage report (because treatment guidelines vary by stage)
Wait times for adjuvant chemotherapy affect survival in certain situations.
- Having a clinically relevant and person-centred measure allows a deeper understanding of barriers to timely access to adjuvant chemotherapy, and helps identify opportunities for improvement.
Measuring wait times increases person-centred care.
- Cancer Care Ontario reports wait times between surgery and adjuvant chemotherapy because these wait times are more relevant to patients than other wait times.
- Having relevant integrated measures such as these address the importance of continuity of care for patients in the cancer system (see Patient Experience).
- Many things need to happen after surgery before a patient is ready for chemotherapy. These may include time for wound healing, awaiting pathology results, consulting with the medical oncologist and planning treatment.
It serves as a barometer of the health of the cancer system.
- Wait times serve as an important barometer for how well the cancer system is working.
- Measuring wait times is important for identifying aspects of treatment or processes that add to wait times and affect access to care.11
Find out more
More information on the Systemic Treatment Program is available on the Cancer Care Ontario website.
- Zanke B, Evans WK. Systemic therapy: building on a strong base. In: Sullivan T, Evans W, Angus H, Hudson A, editors. Strengthening the quality of cancer services in Ontario. Ottawa: CHA Press; 2003.
- Jonker D, Spithoff K, Maroun J, and the Gastrointestinal Cancer Disease Site Group. Adjuvant systemic chemotherapy for stage II and III colon cancer following complete resection: guideline recommendations [Internet]. Toronto: Cancer Care Ontario; 2013 [cited 2015 Mar 11] Available from: https://cancercare.on.ca/common/pages/UserFile.aspx?fileId=13998.
- Canadian Partnership Against Cancer The 2012 cancer system performance report [Internet]. Toronto: Canadian Partnership Against Cancer; 2012 [cited 2016 Feb23]. Available from: http://www.cancerview.ca/idc/groups/public/documents/webcontent/2012_system_performance_rep.pdf.
- Abrams TA, Brightly R, Mao J, Kirkner G, Meyerhardt JA, Schrag D, et al. Patterns of adjuvant chemotherapy use in a population-based cohort of patients with resected stage II or III colon cancer. J Clin Oncol. 2011; 29(24):3255–62.
- Hubbard J, Jatoi A. Adjuvant chemotherapy in colon cancer: ageism or appropriate care? J Clin Oncol. 2011; 29(24): 3209–10.
- Canadian Partnership Against Cancer. The 2014 cancer system performance report [Internet]. Toronto: Canadian Partnership Against Cancer; 2014. Available from: http://www.cancerview.ca/idc/groups/public/documents/webcontent/sp_report_2014.pdf.
- Maddison AR, Asada Y, Urquhart R, Johnston G, Burge F, Porter G. Inequity in access to guideline-recommended colorectal cancer treatment in Nova Scotia, Canada. Healthcare Policy. 2012; 8(2):71.
- 7 American Cancer Society. Cancer facts & figures, 2014 [Internet]. Atlanta: American Cancer Society; 2014 [cited 2015 Mar 11]. Available from: http://www.cancer.org/acs/groups/content/@research/documents/webcontent/acspc-042151.pdf.
- Chan A, Woods R, Kennecke H, Gill S. Factors associated with delayed time to adjuvant chemotherapy in stage III colon cancer. Curr Oncol. 2014; 21(4):181–186.
- Wasserman DW, Boulos M, Hopman WM, Booth CM, Goodwin R, Biagi JJ. Reasons for delay in time to initiation of adjuvant chemotherapy for colon cancer. J Oncol Pract. 2014 Aug 19. doi: 10.1200/JOP.2014.001531
- Saint-Jacques N, Rayson D, Al-Fayea T, Virik K, Morzychi W, Younis T. Waiting times in early-stage non-small cell lung cancer. J Thorac Oncol. 2008; 3(8) 865–870.