New data reveal that after curative resection for colorectal cancer, many patients do not adhere to screening guidelines. Although the majority of patients adhered to surveillance guidelines for follow-up office visits, less than half met the guideline-based recommendations for carcinoembryonic antigen (CEA) testing. About three quarters of patients met the guideline-specified criteria for colonoscopy, although in some regions compliance was as low as 67%.
According to the analysis, which was published online September 8 in Cancer, only 17.1% underwent testing at the recommended frequency; 60.2% underwent testing below recommended levels and 22.7% underwent testing above guideline recommendations. In addition, the researchers noted that a significant number of patients underwent procedures that are not recommended by clinical practice guidelines, suggesting the potential overuse of surveillance tests. “Poor compliance is probably multifactorial,” said lead author Gregory S. Cooper, MD, a professor of medicine at the Case Western Reserve University’s School of Medicine, in Cleveland, Ohio. “Some of it may be patients refusing further testing, some may be physicians — especially nonspecialists — not being aware of guidelines or having competing demands.” Dr. Cooper pointed out that in some cases, such as for when longevity is limited, poor compliance might be appropriate. Guidelines from professional societies typically recommend routine postoperative surveillance for patients who have undergone a potentially curative resection, and usually recommend a combination of regularly scheduled physician office visits, CEA testing, and colonoscopy. But in addition to not adhering to established guidelines, the authors write, a subset of patients might receive imaging procedures, such as computerized tomography (CT) and positron emission tomography (PET). These procedures are generally not part of standard follow-up guidelines and, as a result, some patients receive care in excess of guidelines while the care of others does not meet guideline-based standards. Assessing Compliance Among Colorectal Cancer Survivors Actual compliance with follow-up guidelines has not been well studied, and this is what the authors set out to do. Using the population-based linked Surveillance, Epidemiology, and End Results (SEER)–Medicare database, the authors identified 9426 eligible patients, aged 66 years or older, who were diagnosed with adenocarcinoma of the colon or rectum in 2000 or 2001. Patients were observed up to 3 years after their initial diagnosis and, in addition to measuring overall adherence to guidelines, the researchers looked at differences across patient subgroups. The researchers used the following criteria to evaluate compliance with guidelines: Guidelines were met if there were 2 or more office visits per year, 2 or more CEA tests per year in years 1 and 2, at least 1 colonoscopy in 3 years. Guidelines were exceeded if patients met guidelines and received at least 1 CT scan for cancers not poorly differentiated and/or at least 1 PET scan. All others were considered to have failed to meet the guidelines. The highest degree of compliance was for follow-up office visits; 92.3% of the cohort fulfilled surveillance guidelines, with at least 2 visits in each year of follow-up. However, only 46.7% of patients met the guideline-based recommendations for CEA testing, and lower rates of compliance were seen in black patients, patients who were 80 years of age and older, and patients with higher comorbidity scores. Almost three quarters of patients (73.4%) met the guideline-specified criteria for colonoscopy, and several subgroups, including advanced age and increased comorbidities, were associated with lower adherence. In addition, variations were observed in SEER sites, from a low of 67.6% in New Mexico to a high of 78.8% in Hawaii. “Geographic differences may reflect local practice patterns,” Dr. Cooper told Medscape Oncology. “Racial differences could be either physician or patient driven, but could account in part for the known higher stage-specific mortality in African Americans.” Using a multivariate logistic regression model, researchers were able to identify several factors associated with the meeting or exceeding of guideline-recommended surveillance care. The most significant variables associated with improved compliance were being young and having a regional-stage cancer. Patients with lower comorbidity scores, poorly differentiated cancers, and those from nonblack racial groups were more likely to undergo testing. Multivariate analysis was also used to predict potential overuse of testing. Although not routinely recommended, abdominal/pelvic CT scans and PET scans were documented in 47.7% and 6.8% of patients, respectively. Patients who were younger and who had regional-stage cancer were more likely to exceed guidelines, whereas black patients were less likely to exceed guidelines. “The take-home message for physicians is that routine surveillance has been shown to improve survival after a potentially curative treatment for colorectal cancer,” said Dr. Cooper. “Assuming that the patient will benefit from early detection of recurrence, the use of these procedures should be encouraged. As some of these patients may be receiving their care from primary-care physicians alone, primary providers should also be aware of guidelines.” Tracking Colorectal Cancer Screening A computerized reminder system might help to increase screening rates, not only among cancer survivors but also in the general population. According to a study published in the September issue of Medical Care, a computerized tracking system, called ClinfoTracker, was used by community-based primary-care physicians, and screening rates for colorectal cancer increased by an average of 9%. Even though the system was tested in primary-care practices, lead author Donald Nease, MD, an associate professor of family medicine at the University of Michigan Medical School, in Ann Arbor, and cocreator of ClinfoTracker, emphasized that it can be used in any specialty, including oncology. The study was conducted from 2003 to 2005 in 12 community practices in the Great Lakes Research into Practice Network, a statewide practice-based research network located in Michigan. The primary-outcome measures were pre- and poststudy practice-level colorectal screening rates among patients who were seen during the 9-month study period, and the ability to maintain screening was measured by days of reminder printing. All of the participating primary-care practices except 1 increased their rates of colorectal cancer screening. The exception “had to do with the practice’s cohesion,” Dr. Nease told Medscape Oncology. “The practice never really came together. One individual provider did [a] really outstanding [job], but the practice as a whole did not.” The rates of improvement ranged from 3.3% to 16.8%, and the greatest impact on screening rates occurred in practices that were more technologically savvy and where there was more cohesion and adaptability among employees. Overall, baseline screening rates in the 12 practices averaged 41.7% and, at 9 months, this increased to an average of 66.5%. When the researchers analyzed the impact of technology and organizational cohesion factors, they found that high-technology practices printed on 74% of days, compared with 45% of days for low-technology practices. However, practices that are less technologically savvy should not shy away from using a system like this, explained Dr. Nease. “We actually had practices that were not tech savvy that showed great improvements, so it’s not a definite barrier, especially using our current model of implementation.” The commercial version of ClinfoTracker is called Cielo Clinic. It is being used at all 5 University of Michigan Health Systems family-medicine clinics and at several other community practices and hospitals in Michigan. Dr. Cooper’s study was supported by a Research Project Grant from the American Cancer Society. Dr. Nease’s study was supported by a joint grant from the National Cancer Institute/Agency for Healthcare Research and Quality. Dr. Nease and 1 of his coauthors, Michael S. Klinkman, MD, MS, from the University of Michigan, serve on the Medical Advisory Board of Cielo MedSolutions LLC, and receive royalties from the University of Michigan.
Cancer. Published online before print September 8, 2008. Med Care. 2008;46(suppl 1):S68-S73.
Abstract Reviewed by Ramaz Mitaishvili, MD
