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Treating Colon Cancer According to Guidelines

Key findings

Overall, just over half (56%) of Stage III colon cancer patients age 65 and older were treated with guideline-recommended chemotherapy from 2010 to 2015. Rates were significantly lower in patients age 80 and older. Nonetheless, there continues to be variation among regions and age groups.

Measure:  Percentage of Stage III colon cancer patients age 65 or over treated with guideline-recommended chemotherapy

 

Desired Direction:

 

An image of an arrow pointing upwards. This indicates that desired direction for this action is upwards.

 

As of this Report:

 

An image of a yellow box. This indicates that there is no time trend and this action is below but approaching target or has notable regional variation.

What is cancer surgery?

  • Cancer surgery is the removal of cancerous tumours. It is often the first step in treating cancer.
  • Removal of cancer tumours also provides an opportunity for a complete pathology assessment, 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 body [1]. Drugs can be administered by pills (oral), injections or intravenously (IV).
  • Adjuvant chemotherapy refers to chemotherapy given to patients after surgery in which all of the tumour has been removed. 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 decreases the risk of the cancer returning (recurrence), especially when it has already spread to 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.
  • Patients are treated according to guidelines if they receive fluorouracil/leucovorin/oxaliplatin-based post-operative intravenous chemotherapy, or an oral drug (capecitabine, also known as Xeloda®) within 120 days of surgery [2].
  • 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.
  • Concordance is measured in patients age 65 and older because complete information on the use of oral chemotherapy is available.

Integrated means that all of the different people involved in my care understand what has been done and what needs to be done and add to the treatment plan not delay or decrease its effectiveness. It’s important because as a cancer patient we need to know that nothing is being missed and we are receiving the best treatment possible because everyone understands what is being done and what the timeline is.

Laurie P., Patient/Family Advisor

Figure 1. Percentage of patients age 65 and older with Stage III colon cancer (diagnosed from 2010 to 2015) who received guideline-recommended chemotherapy following surgery, by Local Health Integration Network (LHIN) of surgery facility

More information regarding the methodology is available.

Report date: January 2018

Data source: OCR, eClaims, CSI, DAD, NACRS, ALR, ODB

Prepared by: Analytics and Informatics, Cancer Care Ontario

Figure 2. Percentage of patients age 65 and older with Stage III colon cancer (diagnosed from 2010 to 2015) who received guideline-recommended chemotherapy following surgery, by age

More information regarding the methodology is available.

Report date: January 2018

Data source: OCR, eClaims, CSI, DAD, NACRS, ALR, ODB

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. p-value <.0001 by chi-square test

 

Figure 3. Percentage of patients age 65 and older with Stage III colon cancer (diagnosed from 2010 to 2015) who received any guideline-recommended chemotherapy following surgery, by chemotherapy drug and age

More information regarding the methodology is available.

Report date: January 2018

Data source: OCR, eClaims, CSI, DAD, NACRS,ALR, ODB

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. p-value <.0001 by chi-square test, age group is very significant.
  2. 10 people belonging to Activity Level Reporting (ALR) not included here.

 

Data Table 1. Percentage of patients age 65 and older with Stage III colon cancer (diagnosed from 2010 to 2015) who received guideline-recommended chemotherapy following surgery, by Local Health Integration Network (LHIN) of surgery facility

LHIN Percentage of patients who received guideline-recommended chemotherapy (%) Patients age 65+ with Ssage 3 colon cancer who received guideline recommended chemotherapy within 120 days of surgery Patients age 65+ with stage 3 colon cancer who had a cancer surgery within 120 days of diagnosis Lower confidence interval (%) Upper confidence interval (%)
Ontario 56.5 1657 2934 54.7 58.3
Erie St. Clair 50.4 71 141 41.8 59.0
South West 58.7 145 247 52.4 65.1
Waterloo Wellington 56.0 89 159 47.9 64.0
Hmltn-Ngr-Hldmnd-Brnt 58.5 220 376 53.4 63.6
Central West 65.8 73 111 56.5 75.0
Mississauga Halton 51.3 96 187 43.9 58.8
Toronto Central 52.5 116 221 45.7 59.3
Central 62.1 200 322 56.7 67.6
Central East 60.4 186 308 54.8 66.0
South East 53.7 88 164 45.7 61.6
Champlain 50.6 158 312 44.9 56.4
North Simcoe Muskoka 56.9 87 153 48.7 65.0
North East 53.7 95 177 46.0 61.3
North West 57.4 31 54 43.3 71.5

Report date: January 2018

Data source: OCR, eClaims, CSI, DAD, NACRS, ALR, ODB

Prepared by: Analytics and Informatics, Cancer Care Ontario

Data Table 2. Percentage of patients age 65 and older with Stage III colon cancer (diagnosed from 2010 to 2015) who received guideline-recommended chemotherapy following surgery, by age

Age group Percentage of patients who received guideline-recommended chemotherapy (%) Patients with stage 3 colon cancer who received guideline recommended chemotherapy within 120 days of surgery Patients with stage 3 colon cancer who had a cancer surgery within 120 days of diagnosis Lower confidence interval (%) Upper confidence interval (%)
65 to 71 81.5 659 809 78.7 84.2
71 to 80 65.1 773 1,188 62.3 67.8
80+ 24.0 225 937 21.2 26.8

Report date: January 2018

Data source: OCR, eClaims, CSI, DAD, NACRS, ALR, ODB

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. p-value <.0001 by chi-square test

 

Data Table 3. Percentage of patients age 65 and older with Stage III colon cancer (diagnosed from 2010 to 2015) who received any guideline-recommended chemotherapy following surgery, by chemotherapy drug and age

Age group Percentage of patients who received no treatment Patients with stage 3 colon cancer who received no treatment within 120 days of surgery Patients with stage 3 colon cancer who had a cancer surgery within 120 days of diagnosis No treatment lower confidence interval (%) No treatment upper confidence interval (%) Percentage of patients who were treated with Capecitabine Patients with stage 3 colon cancer who were treated with capecitabine within 120 days of surgery Patients with stage 3 colon cancer who had a cancer surgery within 120 days of diagnosis Colon-oral lower confidence interval (%) Colon-oral upper confidence interval (%) Percentage of patients who received oxaliplatin-based treatment Patients with stage 3 colon cancer who received oxaliplatin-based treatment within 120 days of surgery Patients with stage 3 colon cancer who had a cancer surgery within 120 days of diagnosis Colon-IV lower confidence interval (%) Colon-IV upper confidence interval (%)
65 to 70 18.6 150 805 15.9 21.4 14.2 114 805 11.7 16.6 67.2 541 805 63.9 70.5
71 to 80 35.1 415 1,182 32.4 37.9 38.7 457 1,182 35.8 41.5 26.2 310 1,182 23.7 28.8
80+ 76.0 712 937 73.2 78.8 21.8 204 937 19.1 24.5 2.2 21 937 1.2 3.2

Report date: January 2018

Data source: OCR, eClaims, CSI, DAD, NACRS,ALR, ODB

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. p-value <.0001 by chi-square test, age group is very significant.
  2. 10 people belonging to Activity Level Reporting (ALR) not included here.

 

What do the results show?

Moderate variation in the use of guideline-recommended chemotherapy for Stage III colon cancer is present across regions (Figure 1).

  • Overall, 56% of Stage III colon cancer patients age 65 or older received any guideline-recommended chemotherapy in 2015. That is similar to previous years.
  • Regions vary from just over 50% of their patients being treated according to guidelines to 66%. This suggests an opportunity for improvement.
  • Although other provinces report greater percentages of patients receiving chemotherapy following cancer surgery, their data are not directly comparable because they include all patients, including those younger than age 65.
  • The jurisdiction with the largest percentage of patients treated according to guidelines for all ages is Saskatchewan, where 65% of Stage III colon cancer patients received guideline-recommended chemotherapy in 2012 [3].

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 the age groups of 65 to 70 and 71 to 80, the use of guideline-recommended chemotherapy was 81% and 65%, respectively. After age 80, the rate fell to 24% (Figure 2).
  • The decrease in use of any guideline-recommended chemotherapy with increasing patient age has previously been reported [4].
  • This may be because trials of adjuvant chemotherapy often do not include older patients, so relying on evidence to make assumptions about the benefits of adjuvant chemotherapy in much older patients may be problematic [5].
  • 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 age 80 and older [4].
  • According to the 2015 Cancer System Performance Report by the Canadian Partnership Against Cancer, the decrease in adjuvant chemotherapy among older patients may be due to these patients being more likely to have other health conditions or to be taking medications that may interact negatively with chemotherapy [6].
  • Older patients also have lower referral rates to a medical oncologist from their surgeons, which may be a reason fewer older patients receive guideline-recommended chemotherapy [7].
  • Oral chemotherapy is used more frequently (39%) for those age 71 to 80, while intravenous chemotherapy is more common (67%) for those age 65 to 70. This may be because intravenous chemotherapy (oxaliplatin) has been shown to be less effective in populations over the age of 70 [8].

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 [2].
  • We are best able to determine concordance with guidelines for patients age 65 and older and for those who have a valid stage report because of the lack of data about the use of oral chemotherapy for those younger than 65 and because treatment guidelines vary by stage.

Find out more

For more information on the Systemic Treatment Program, visit Cancer Care Ontario’s website.

Notes

  1. 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.
  2. Jonker D, Spithoff K, Maroun J; 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 here.
  3. Canadian Partnership Against Cancer. Post-operative chemotherapy for Stage III colon cancer patients [Internet].Toronto: Canadian Partnership Against Cancer; 2018 [cited 2018 Jan 30]. Available from here.
  4. 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.
  5. Hubbard J, Jatoi A. Adjuvant chemotherapy in colon cancer: ageism or appropriate care? J Clin Oncol. 2011;29(24):3209–10.
  6. Canadian Partnership Against Cancer. The 2015 cancer system performance report [Internet]. Toronto: Canadian Partnership Against Cancer; 2015 [cited 2018 Mar 6]. Available from here.
  7. 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.
  8. Cancer Facts & Figures [Internet]. Atlanta: American Cancer Society; c. 2018 [cited 2015 Mar 11]. Available from here.