Poor Compliance Of Quality Measures Following Colon Cancer Surgery

Main Category: Colorectal Cancer
Article Date: 11 Sep 2008 - 2:00 PDT

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School has barely begun, but many U.S. hospitals have already received their report card in colon cancer. They flunked.

A new study from Northwestern University's Feinberg School of Medicine and the American College of Surgeons finds the majority of hospitals don't check enough lymph nodes after a patient's colon cancer surgery to determine if the disease has spread.

Checking more lymph nodes is linked to improved survival of colon cancer because it allows doctors to accurately diagnose the stage of disease and prescribe the most effective treatment.

Over the past decade, a number of oncology organizations have recommended a minimum of 12 lymph nodes be examined to determine whether colon cancer has metastasized and to accurately diagnose the stage of cancer. That critical information affects whether a patient receives chemotherapy, which is highly effective in improving survival after colon cancer has spread.

Yet, more than 60 percent of nearly 1,300 institutions in the U.S. failed to comply with the recommendation to examine 12 nodes, the Northwestern study found. The study will be published in the Sept. 9 online issue of the Journal of the National Cancer Institute.

"It's disappointing that despite so much emphasis on this particular issue, so many hospitals still aren't checking enough lymph nodes to ensure they diagnose the accurate stage of cancer," said Karl Bilimoria, M.D., lead author and a surgery resident at the Feinberg School. "Knowing the accurate stage of your disease affects your survival and treatment. That's critical."

Colon cancer is the second leading cause of cancer death in the United States.

"Every surgeon has a story about a colon cancer patient where the pathology report showed only a few lymph nodes and no cancer was found," said Bilimoria, who also is a research fellow at the American College of Surgeons. "Then the surgeon asks the pathologist to check six or eight more nodes, and one of those turns out to be positive for cancer. That completely changes the treatment plan."

In the study, Bilimoria found National Cancer Institute-designated Comprehensive Cancer centers had higher compliance with the 12- node measure than other academic hospitals, Veterans Administration hospitals and community hospitals (78 percent versus 52.4 percent, 53 percent, 33.7 percent respectively in 2004-2005.)

Hospitals have improved over the past decade, but not enough. In 1996-1997, 15 percent of hospitals were checking at least 12 nodes compared to 38 percent in 2004-2005. The hospitals that did not comply treat about 65 percent of colon cancer diagnosed in the U.S.

Patients can protect themselves by asking the surgeon ahead of time if she thinks this issue is important, and if she routinely has 12 or more nodes checked after surgery, Bilimoria advised. Then the patient can read the post-operative pathology report and see how many lymph nodes were actually examined. If the number is lower than 12, the patient should ask his surgeon about it, Bilimoria said. More lymph nodes can be checked in the tissue that has been previously removed with the cancerous colon.

Bilimoria said hospitals need better education and cooperative efforts between pathologists and surgeons. He also recommended hospitals have a cancer committee that follows compliance with these types of quality measures.

"When there is poor adherence, they should act on it and identify why they are not meeting that standard," he said.

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Source: Marla Paul
Northwestern University

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