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CRS 02-164 – HSR Study

 
CRS 02-164
Colorectal Cancer Care Outcomes Research and Quality Surveillance Data System
Dawn Provenzale, MD MS
Durham VA Medical Center, Durham, NC
Durham, NC
Funding Period: July 2003 - September 2009
BACKGROUND/RATIONALE:
The Colorectal Cancer Care Outcomes Research and Surveillance (CanCORS) Consortium has evaluated the care of newly diagnosed patients in multiple regions and health care delivery systems. This collaboration of 7 national sites, including the VA, represents a new model for studying cancer care: a large, distributed multidisciplinary team of investigators collecting shared data from patients, caregivers, physicians and medical records with a common set of rigorous protocols. This approach has enabled the Consortium to address a broader array of important clinical and policy questions than would typically be feasible at a single site. The study was presented to the public as "Share Thoughts on Care."

The 7 Primary Data Collection and Research sites (PDCRs) and their associated regions are:

1. University of Alabama at Birmingham: entire state of Alabama
2. Harvard Medical School/Northern California Cancer Center: 8 counties in northern California
3. University of Iowa: entire state of Iowa
4. University of California, Los Angeles/RAND: Los Angeles county
5. University of North Carolina at Chapel Hill: 22 counties in eastern and central North Carolina
6. Dana Farber Cancer Institute/Cancer Research Network: 5 HMOs in Seattle, Boston, Detroit, Portland (OR), and Honolulu
7. Department of Veterans Affairs: Coordinating site at Durham VA Medical Center; recruitment and enrollment sites at NY Harbor (Manhattan and Brooklyn), Baltimore, Durham, Nashville, Minneapolis, Indianapolis, Seattle, Chicago (Lakeside and Hines), Tucson, Biloxi, Temple, Atlanta, and Houston.

OBJECTIVE(S):
The two principal aims of this study were to: (a) determine how the characteristics and beliefs of cancer patients and providers and the characteristics of systems of organizations delivering cancer care influence treatment and outcomes across the continuum of care from diagnosis to recovery or death; (b) evaluate the effects of specific therapies on patients' survival, quality of life, and satisfaction with care (supplementing rather than substituting for data from randomized clinical trials).

METHODS:
The study used an observational study design. Share Thoughts on Care employed cancer registry rapid case ascertainment (RCA) in all 7 participating PDCR sites. The target population in five PDCRs consisted of all patients with newly diagnosed colorectal or lung cancer during the enrollment period for the study and who lived in the geographical area in which the site is located, without regard to the care setting. The target population in the remaining two PDCRs, the VA and DFCI/CRN, consisted of all patients diagnosed with colorectal or lung cancer during the enrollment period for the study who received their care from one of the 15 participating VA sites or from the 5 HMOs comprising the CRN. Data were collected on the care of newly diagnosed colorectal and lung cancer patients from 3 months prior to diagnosis through 15 months post-diagnosis. Primary data sources were patient (or proxy) baseline and follow-up surveys, medical records abstraction, provider surveys, and a caregivers survey. These data were pooled with cancer registry data, administrative data, and publicly available datasets. The main methods of analysis were: (a) standard methods for estimating the probability of a binary outcomes or a population mean to estimate population parameters with confidence intervals; (b) regression models for estimating the association of one or more patient-level, physician-level, or health care system feature with an outcome of interest.

FINDINGS/RESULTS:
Between September 2003 and December 2005, the CanCORS Share Thoughts on Care study enrolled 5,150 participants with lung cancer and 4,911 with colorectal cancer, and surveyed 7,874 of their providers and 1,630 of their caregivers. Median age of participants was 67 years, 57% were male, 68% were white; and 75% were educated at a high school level and above. Significant findings include:

1. Of stage III colon cancer patients who underwent curative surgery, older patients were somewhat more likely to die within 60 days of surgery (7% vs. 1%) and somewhat less likely to be referred to an oncologist (92% vs. 97%). Yet even among patients who survived and consulted with an oncologist, adjuvant chemotherapy was used much less often for patients 75 and older than for younger patients (56% vs. 87-94%).

2. Since 2004 three new targeted therapies have been approved for use in patients with metastatic colorectal cancer. VA investigators focused on bevacizumab (Avastin). During the first two years after bevacizumab was approved by the FDA, 29% of patients received it, including 21% who received it as 1st-line therapy. Female gender, younger age, and patients with increased comorbidity were significantly more likely to receive this drug as 1st-line therapy.

3. An analysis of the outcomes of chemotherapy for 1,200 patients with stage IIIB or IV lung cancer found that patients age 75 and older were much less likely than younger patients to receive chemotherapy. Elderly patients who received chemotherapy were in much better health before treatment than those who did not, reflecting selection of the fittest older patients for treatment.

4. Overall, patients reported that 39% of their treatment decisions were patient controlled, 18% were physician controlled, and 44% were shared by patients and physicians. Decisions about radiotherapy were more likely to be physician controlled than decisions about surgery or chemotherapy, whereas decisions about chemotherapy were more likely to be patient controlled. Decisions with strong supporting evidence (e.g. chemotherapy for stage III colon cancer) were most likely to shared, while decisions with uncertain benefits (e.g. chemotherapy for stage II colon cancer) were most likely to be patient controlled and those with no evidence of benefit were most likely to be physician controlled.

(5) Only 5.5% of nearly 10,000 patients had enrolled in a clinical trial. In adjusted analyses, clinical trial enrollment was significantly less common among older patients, women, racial and ethnic minorities, and those with early-stage disease.

IMPACT:
This study will promote the translation of research discoveries and innovations into patient care and systems improvements in order to reduce the incidence, late detection, suffering and mortality from colon, rectal and lung cancers among veterans. For the VA in particular, the work done within CanCORS is improving our ability to target areas for quality improvement and understanding factors that contribute to gaps in quality. Moreover, CanCORS data will enable us to better focus interventions that will improve the outcomes of the cancer care that we deliver to our veterans.


External Links for this Project

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PUBLICATIONS:

None at this time.


DRA: Aging, Older Veterans' Health and Care, Health Systems
DRE: Technology Development and Assessment
Keywords: Cancer, Practice patterns, Translation
MeSH Terms: none

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