Hospitals Have Work to Do to Meet Standards for Colon Cancer Care

Journal of the National Cancer Institute

A study in the September online edition of the found that the percentage of US hospitals adhering to national guidelines on the postsurgical treatment of colon cancer more than doubled from 1997 to 2005. That is the good news. The bad news is that 62% of the nearly 1300 hospitals in the United States are still failing to comply with the guidelines.

Does this mean the glass is half-full or half-empty? “On the one hand it’s disturbing,” said Warren Enker, MD, vice chairman, Department of Surgery, Beth Israel Medical Center, New York. “On the other hand, it’s exciting to see that efforts to educate both the medical community and the lay public about what the standards should be in every cancer are working.”

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Inside the numbers. The national guidelines were developed and endorsed by several leading cancer organizations, including the National Comprehensive Cancer Network mend that a minimum of 12 lymph nodes be examined following surgery to determine whether the patient’s colon cancer has metastasized and to diagnose the stage of cancer accurately. Progress being made. A 1996-1997 study found that only 15% of hospitals made sure to check at least 12 nodes. This has increased to 38% of hospitals, in the most recent 2004-2005 study.

“It’s a big step in the right direction to find out where we are and how we can improve,” said Daniel Anderson, MD, staff gastroenterologist for Southern California Permanente Medical Group and clinical professor of medicine at University of California in San Diego. “And the fact that it’s going on a report card for hospitals means they will pay a lot of attention to it.”

Judy Smith, MD, medical director at Roswell Park Cancer Institute in Buffalo, New York, says that setting standards of quality metrics and having those metrics in the public eye offers a great opportunity to improve care. “This is part of the move toward consumerism,” she explained. “[It is a] move towards patients and their families having a greater role in determining where they’re going to get treatment and having a greater understanding of what their treatment will be.”

Moving the metrics forward. Increasing hospitals' adherence to national guidelines by more than 50% may be a positive step forward, but much work still needs to be done before community hospitals—which were 33.7 percent compliant in the recent study—match the level of compliance (78%) seen at National Cancer Institute-designated comprehensive cancer centers. Dr. Smith suggested that the responsibility for ensuring the adequacy of surgery does not lie with the hospital: “The surgeons need to take responsibility, hand in hand with pathologists, because there are 2 components to having an adequate number of lymph nodes. The surgeon has to remove them and the pathologist has to identify them. It’s a team, and it has to be the team that optimizes the outcome.”

Dr. Smith adds that it is important for the medical staff at hospitals to step forward and establish standards for quality outcomes. Staff at medical facilities need to demand the highest quality outcomes from their surgeons and pathologists, as well as from medical oncologists. “[T]he second part of this is making sure that medical oncology gives appropriate chemotherapy when it’s indicated, because that is also a very clear quality outcome,” said Dr. Smith.

Education and awareness. Roswell Park Cancer Institute, a charter member of NCCN, helped develop the national guidelines and believes strongly in adherence to them. “We are data driven,” Dr. Smith said. “We hire physicians, faculty and surgeons who have an interest in being data driven, guideline compliant, and using the latest technology in medical research.”

Dr. Enker said that Beth Israel, while not exclusive in its approach, has set up disease management teams for different types of cancers. He believes that taking this step can improve all aspects of cancer care dramatically. According to Dr. Enker, organizing staff into disease management teams and applying service specialties to each disease results in better recognition of a particular disease, how it progresses, and what the standards of treatment are for the condition. The disease management team also discusses appropriate screening measures and determines which patients should undergo genetic testing.

Improvements to chemotherapy regimens, explained Dr. Enker, including better effectiveness and less toxicity, sometimes mean that a group of patients previously vulnerable to spread or metastasis might survive or be cured provided the team accurately earmarks patients for a chemotherapy regimen. “What’s important is that we continue to make progress through raising the standards, raising the bar, and increasing accountability—both to ourselves and to the public at large,” he concluded.

Ed Rabinowitz is a veteran healthcare writer and reporter. He welcomes comments at edwardr@frontiernet.net.