Physician Follow-Up and Guideline Adherence in Post- Treatment Surveillance of Colorectal Cancer

Physician Follow-Up and Guideline Adherence in Post- Treatment Surveillance of Colorectal Cancer Gabriela M. Vargas, MD Kristin M. Sheffield, PhD, Abhishek Parmar, MD, Yimei Han, MS, Kimberly M. Brown, MD, Taylor S. Riall, MD, PhD

OUTLINE Background Review current guidelines for post-treatment surveillance Previous population-based studies Colorectal cancer post-treatment surveillance in Texas

COLORECTAL CANCER Siegel, R et al. Cancer Statistics, 2013. CA Cancer J Clin. 2013 Jan;63(1):11-30.

COLORECTAL CANCER Siegel, R et al. Cancer Statistics, 2013. CA Cancer J Clin. 2013 Jan;63(1):11-30.

PROGNOSIS When detected early, cure is possible with complete resection Up to 30-40% of patients will develop local recurrences or distant metastases after curative resection In most cases, recurrences occur in the first 2-3 years post treatment Viehl, C. T., et al. (2010). Inadequate Quality of Surveillance after Curative Surgery for Colon Cancer. Ann Surg Oncol, 17(10), 2663 2669.

POST-TREATMENT SURVEILLANCE Goals of post-resection surveillance Identify recurrent cancer or metastatic disease Identify new primary neoplasms Benefits of post-resection surveillance Median five-year overall survival after resection of colorectal liver metastases is 30% (range 12%-41%) Fernandez, FG, et al. Five-year Survival After Resection of Hepatic Metastases from Colorectal Cancer in Patients Screened by Positron Emission Tomography with F-18 Fluorodeoxyglucose (FDG- PET). Ann Surg. 2004; 240:438-47

CURRENT GUIDELINES The American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN) recommend: H&P Every 3-6 months for first 3 years then every 6-12 months for next 2 years CEA testing Every 2-6 months for 2-3 years Colonoscopy One in 1-3 years CT scan chest, abdomen, and pelvis (starting in 2005) Yearly for 3-5 years

CONTROVERSIES CT chest, abdomen, and pelvis Recommended for patients at high risk for recurrence Poorly differentiated tumors Lymphovascular invasion CEA New recommendation in 2006 Recommended for patients with Stage II-III disease

NON-RECOMMENDED TESTS Liver US Chest x-ray FOBT Fecal DNA testing Barium enemas LFTs MRI PET/PET CT

Stage I-III patients 3 academic/university-affiliated institutions Surveillance was left to discretion of treating physician All treating physicians received a letter with surveillance recommendations Median follow-up 33.5 months Viehl, C. T., et al. (2010). Inadequate Quality of Surveillance after Curative Surgery for Colon Cancer. Ann Surg Oncol, 17(10), 2663 2669.

POPULATION-BASED STUDIES Viehl, C. T., et al. (2010). Inadequate Quality of Surveillance after Curative Surgery for Colon Cancer. Ann Surg Oncol, 17(10), 2663 2669.

POPULATION-BASED STUDIES Results Overall adherence: 11.6% CEA testing adherence 32.8% 43.6% in those who received chemo vs. 26.8% in those who did not receive chemo (p=0.06) Colonoscopy adherence 23.8% 40.0% in those who received chemo vs. 18.8% in those who did not receive chemo (p=ns) US/CT adherence 31.7% 52.6% in those who received chemo vs. 21.4 in those who did not receive chemo (p=0.07) Viehl, C. T., et al. (2010). Inadequate Quality of Surveillance after Curative Surgery for Colon Cancer. Ann Surg Oncol, 17(10), 2663 2669.

SEER-Medicare data 2000-2001 Stage I-III cancers All patients followed for 3 years starting 6 months after diagnosis Excluded patients not undergoing surgical resection Cooper GS, Kou TD, Reynolds HL. Receipt of guideline-recommended follow-up in older colorectal cancer survivors : a population-based analysis. Cancer 2008; 113(8):2029-37

POPULATION-BASED STUDIES Guideline met: > 2 office visits/year > 2 CEA tests/year in years 1 and > 1 colonoscopy within 3 years Excess of guidelines: Patient met guidelines and received > 1 CT scan for cancers not poorly differentiated, and/or > 1 PET scan Cooper GS, Kou TD, Reynolds HL. Receipt of guideline-recommended follow-up in older colorectal cancer survivors : a population-based analysis. Cancer 2008; 113(8):2029-37

POPULATION-BASED STUDIES Results Overall: 17.1% met composite guidelines 22.7% exceeded recommended guidelines 92.3% met surveillance guidelines for office visits 46.7% met guideline-based recommendations for CEA testing 73.6% met guideline-specified criteria for colonoscopy Cooper GS, Kou TD, Reynolds HL. Receipt of guideline-recommended follow-up in older colorectal cancer survivors : a population-based analysis. Cancer 2008; 113(8):2029-37

POPULATION-BASED STUDIES Factors associated with lack of guideline adherence Local stage Well differentiated tumors Advanced age African American race Increased co-morbidity Cooper GS, Kou TD, Reynolds HL. Receipt of guideline-recommended follow-up in older colorectal cancer survivors : a population-based analysis. Cancer 2008; 113(8):2029-37

POPULATION-BASED STUDIES 47.7% of patients underwent CT scans 6.8% of patients had > 1 PET scan Factors associated with exceeding recommendations: Younger age Regional cancers Cooper GS, Kou TD, Reynolds HL. Receipt of guideline-recommended follow-up in older colorectal cancer survivors : a population-based analysis. Cancer 2008; 113(8):2029-37

TCR-Medicare data OBJECTIVES Evaluate adherence to composite guidelines H&P > 2 per year for 3 years CEA tests > 2 per year for 2 years Colonoscopy > 1 in 3 years Evaluate the trends in use of non-recommended cross-sectional imaging studies Describe the impact of oncologic follow up on: Adherence to guidelines Use of non-recommended tests

METHODS Used Texas Cancer Registry-Medicare linked data (2000-2009) Surveillance period began 90 days after surgery All patients followed 3 years Guideline adherence and use of non-recommended tests evaluated in patients who survived to the end of the surveillance period Kaplan Meier curves used to evaluate the time to first (and time from first to second) colonoscopy in the overall cohort

COHORT SELECTION First primary colon or rectal cancer diagnosed in 2001-2006 excluding CIS and stage IV N=34,431 Surgical resection N=12,381 Age 66 and older N=25,612 Exclude ESRD and non-tx residents N=17,520 Patients who survived 3 yrs post treatment N=8,080 Part A/B without HMO 1 yr before and 3 yrs after diagnosis N=13,721

PATIENT CHARACTERISTICS 3-year survivors N=8,080 Age (y), mean ± SD 75.7 + 6.5 Female gender 4337 (53.7%) Race (N=12,365) White 6985 (86.5%) Black 614 (7.6%) Hispanic 339 (4.2%) Charlson Comorbidity Score 0 5197 (64.3%) 1 1786 (22.1%) 2 661 (8.2%) 3 436 (5.4%)

TUMOR AND TREATMENT CHARACTERISTICS 3-year survivors N=8,080 Tumor Characteristics Colon cancer 6427 (79.5%) Rectal cancer 1653 (20.5%) Local 4422 (54.7%) Regional 3658 (45.3%) Poorly differentiated 1161 (14.4%) Treatment Adjuvant chemotherapy (yes) 2656 (32.9%) Adjuvant radiation (rectal cancer only) 200 (20.9%)

ADHERENCE TO GUIDELINES p = NS P = 0.018 p = 0.018

ADHERENCE TO GUIDELINES 3 year survivors Patients with regular PCP follow-up Patients with regular medical oncology follow-up Composite measure Office visits CEA testing Colonoscopy 25.1% 85.4% 29.5% 75.3% 27.7% 100% 31.8% 79.4% 61.5% 100% 70.5% 86.7% Regular follow up = 2 visit per year for three years

CEA TESTING 62.1% of patients had at least one CEA measurement 80.0% received a second test within one year of the first 34.6% had one CEA measurement per year for the 3 years 25.5% of patients with local disease 45.6% of patients with regional disease Median time between first and second measurement was 3.7 months

TIME TO COLONOSCOPY

LOGISTIC REGRESSION ANALYSIS Factor (REF) * Age (> 85 yrs) Guideline adherence OR (95% CI) 66-69 yrs 2.80 (2.09-3.74) 70-74 yrs 2.55 (1.92-3.39) 75-79 yrs 2.47 (1.85-3.28) 80-84 yrs 1.84 (1.36-2.50) Stage (Local) 1.48 (1.30-1.68) PCP visit 2x/3yrs (No) 1.51 (1.33-1.72) Medical oncologist visit (No) 14.22 (12.49-16.18) * Model also adjusted for sex, race, cancer type, tumor differentiation, Charlson comorbidity score, year of diagnosis, and education

USE OF CT AND PET/PET CT CT recommended p < 0.0001 p < 0.0001

LOGISTIC REGRESSION ANALYSIS Factor (REF) * Age (> 85 yrs) CT use OR (95% CI) PET/PET CT use OR (95% CI) 66-69 yrs 1.85 (1.54-2.21) 2.54 (1.89-3.42) 70-74 yrs 1.71 (1.44-2.03) 2.46 (1.84-3.29) 75-79 yrs 1.59 (1.34-1.88) 2.27 (1.69-3.04) 80-84 yrs 1.28 (1.07-1.53) 1.72 (1.26-2.35) Cancer (Rectum) 0.60 (0.51-0.69) 0.61 (0.52-0.71) Poorly differentiated (No) 1.17 (1.01-1.35) 1.25 (1.06-1.47) Regional stage (Local) 1.69 (1.53-1.87) 1.69 (1.49-1.91) Medical oncologist visit (No) 3.75 (3.31-4.25) 4.30 (3.79-4.88) PCP visit 2x/3yrs (No) 1.27 (1.15-1.40) 1.07 (0.94-1.21) * Model also adjusted for sex, race, cancer type, tumor differentiation, Charlson comorbidity score, year of diagnosis, and education

SUMMARY Compliance with current minimum guidelines for posttreatment surveillance of colorectal cancer is low The use of CT, PET, and PET/CT has increased over time Adherence to guidelines and use of non-recommended tests is increased in patients followed regularly by a medical oncologist

LIMITATIONS Did not look at indications for procedures Surveillance/overuse may be overestimated Use of CEA Some tumors do not have elevated CEA Use in stage I tumors not recommended Patient factors Refusal Not candidate for re-treatment due to co- morbidities

FUTURE RESEARCH IDEAS Identify barriers to guideline adherence The comparative effectiveness of ultrasound, CT, and PET/PET CT Dissemination of post treatment surveillance guidelines to patients and physicians