Fragmented Care in the Treatment of Rectal Cancer and Time to Definitive Therapy

Abstract

BACKGROUND: The National Accreditation Program for Rectal Cancer (NAPRC) emphasizes a multidisciplinary approach for treating rectal cancer and has developed performance measures to ensure that patients receive standardized care. We hypothesized that rectal cancer patients receiving care at multiple centers would be less likely to receive timely and appropriate care. STUDY DESIGN: A single institution retrospective review of a prospectively maintained database was performed. All patients undergoing proctectomy and ≤1 other treatment modality (eg radiation and/or chemotherapy) for Stage II/III rectal adenocarcinoma were included. Unified care was defined as receiving all modalities of care at our institution, and fragmented care was defined as having at least 1 treatment modality at another institution. RESULTS: From 2009 to 2019, 415 patients met inclusion criteria, with 197 (47.5%) receiving fragmented care and 218 (52.5%) receiving unified care. The unified cohort patients were more likely to see a colorectal surgeon before starting treatment (89.0% vs 78.7%, p < 0.01) and start definitive treatment within 60 days of diagnosis (89.0% vs 79.7%, p = 0.01). On adjusted analysis, unified care patients were 2.78 times more likely to see a surgeon before starting treatment (95% CI 1.47–5.24) and 2.63 times more likely to start treatment within 60 days (95% CI 1.35–5.13). There was no difference in 90-day mortality or 5-year disease-free survival. CONCLUSIONS: This retrospective cohort study suggests patients with rectal cancer receiving fragmented care are at an increased risk of delays in care without any impact on disease-free survival. These findings need to be considered within the context of ongoing regionalization of rectal cancer care to ensure all patients receive optimal care, irrespective of whether care is delivered across multiple institutions.

Does fragmented cancer care affect survival? Analysis of gastric cancer patients using national insurance claim data

“…4 Division of Cancer Control and Policy, National Cancer Control Institute, National Cancer Center, Gyeonggi-do, Goyang-Si, Republic of Korea. 5 Department of Information and Statistics, RINS, Gyeongsang National University, 501 Jinju-daero, Jinju-si, Gyeongsangnam-do, South Korea.…”

“…Patients with cancer commonly receive fragmented cancer care, which is defined as undergoing treatment across multiple healthcare facilities [3][4][5]. Previous studies have demonstrated that fragmented cancer care is associated with a reduction in overall survival, high healthcare costs, unnecessary treatments, increased time to treatment, and inferior quality of care [3,[6][7][8].…”

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“…The management of individuals with rectal cancer often requires several diagnostic tests, the use of multidisciplinary teams during the delivery of multimodality treatment, and ongoing surveillance for identifying recurrent or metastatic disease. With this level of complexity, the fragmentation of care can occur [ 3 ], and inconsistent delivery of treatments may be observed [ 4 ]. In addition, due to the nature of the treatments, patients with rectal cancer often experience high rates of short- and long-term morbidity.…”

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“…This pathway can lead to poor compliance and healthcare disparities since it can be particularly burdensome for patients with lower health literacy, limited expenses for travel, or inability to take off time from work. Recent work has also shown that “fragmented” rectal cancer care across multiple institutions can lead to delays in treatment [ 1 ].…”