Patients who have complications after colorectal cancer surgery are less likely to get chemotherapy, even when it is clearly recommended for their diagnosis, a study in the December issue of the journal Diseases of the Colon & Rectum.
In addition, patients with complications were more than twice as likely to have their chemotherapy delayed for more than 120 days after diagnosis or two months after surgery (the appropriate timeframe for receiving chemotherapy).
Surgical complications are independently associated with omission of chemotherapy for stage III colorectal cancer and with a delay in adjuvant chemotherapy; this suggests that complications of colorectal surgery may affect both short- and long-term cancer outcomes, researchers found.
"Surgical complications are typically thought to be short-term problems, but our study suggests there is a clear link between downstream cancer care and complications that occur during surgery. This is critical because chemotherapy in this subset of colorectal cancer patients has clear lifesaving benefit," according to lead study author Samantha Hendren, M.D., M.P.H., FACS, assistant professor of surgery, University of Michigan Health System.
The study looked at data from 17,108 patients who had surgery for stage III colorectal cancer. Chemotherapy is recommended for all stage III colorectal cancer patients and has been shown to improve survival as much as 16 percent after five years. Patients were identified for the study from the Surveillance, Epidemiology and End Results-Medicare database, a large population-based registry.
Because chemotherapy stresses the body and slows healing, medical oncologists are generally reluctant to give chemotherapy to patients who are frail or unwell because of complications from surgery. Hendren also suggests that some patients may opt out of chemotherapy after experiencing surgical complications.
Complications include pneumonia, urinary tract infections, heart attack, wound infections, need for additional surgery, or abscess drainage. Researchers believe some of these can be prevented.
Nationally, variations exist among hospitals in use of chemotherapy for stage III colorectal cancer. Surgical complications could be one factor that explains this disparity, say researchers; they urge hospitals to adopt quality measures to reduce complications.
"To date, quality guidelines for CRC care have focused on several areas: screening, surveillance, the use and timeliness of adjuvant treatments, surgical specimen quality, and pathology reporting. Results of the present study suggest that avoiding surgical complications may be of equal importance to CRC outcomes as these other quality criteria," they wrote.
The research raises the possibility of cancer quality improvement through a direct focus on surgical safety, according to the authors. "It also prompts the question of whether variations in surgical safety contribute to observed hospital variation in mortality for CRC, through the mechanism of surgical complications leading to chemotherapy omission/delay."
"If we're going to try to improve compliance with chemotherapy guidelines, we need to be aware why patients are not getting it. Surgical complications could be part of that picture," says Hendren, noting that it will be the topic of her next study.
Given that the "why" is still up in the air, the take-away for providers isn't a simple "improve compliance." They need to do that, she says, but they also need to assess more carefully the underlying reasons why some patients aren't getting chemotherapy
It's about getting chemotherapy to more patients and implementing programs to improve surgical safety (leading to fewer complications), she said in an interview.
"In Michigan we have a surgical quality improvement program across the state, where hospitals have banded together—with money from the hospitals and from the health insurance industry—to decrease complication rates from surgery by disseminating the practices of hospitals with good results," she explains. "These types of initiatives are so important, and this study shows that they might have much more far-reaching effects than simply decreasing costs or length of stay. They might have longer-term effects on cancer survival."