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Reports Shows Hospitals Fail Colon Cancer Quality Check

September 10, 2008

A new study on Tuesday suggests almost two-thirds of hospitals fail to check colon cancer patients well enough for signs that their tumor is spreading.

Doctors should examine at least 12 lymph nodes to figure out whether colon cancer has metastasized — spread to other parts of the body — and to accurately diagnose the stage, or severity, of the cancer, Leading medical organizations said.

Such information helps guide future treatment, including whether a patient with metastatic cancer gets the chemotherapy that can help improve survival.

But Northwestern University researchers reported that nearly 1,300 hospitals found that overall, just 38 percent fully comply with the guideline.

“We were disappointed at how low the compliance rate is still,” said Dr. Karl Bilimoria of Northwestern University’s Feinberg School of Medicine in Chicago, who led the study.

Currently the nation’s second leading cancer killer, colorectal cancer is set to claim almost 50,000 lives this year.

Colon cancer treatment involves surgery to remove the part of the colon that contains the cancer along with some healthy tissue on either side of the cancer to help ensure none remains behind. Nearby lymph nodes then are removed and tested for the presence of cancer.

Checking too few lymph nodes may give a false impression that cancer has not spread. Knowing if cancer has entered the rest of the body is an important factor in long-term survival – and thus helps doctors decide who gets chemotherapy after surgery and who can skip it.

Bilimoria said it is not uncommon to fail to find cancer if only six lymph nodes are checked — only to detect it when more lymph nodes are examined.

“Patients who could benefit from additional chemotherapy may not be getting complete treatment and have a higher chance of relapse,” said Dr. Durado Brooks of the American Cancer Society, who wasn’t involved with the study. “It is something that consumers need to begin asking. … Frankly, that is most likely to change medical practice.”

Surgeons must remove enough of the fat tissue by the colon to check enough nodes, and pathologists must painstakingly dissect that tissue to find the tiny nodes.

Bilimoria said surgeons frequently tell of getting pathology reports of four clean nodes and asking the pathologist to find more, “and lo and behold, one of those additional nodes turns out to be positive.”

Up to half of colon cancer patients have at least 12 nodes checked, according to previous studies. Bilimoria’s study is the first look at which hospitals are most likely to follow the guideline – and will report the rates directly to each institution.

His team examined a national cancer database for records showing which hospitals checked 12 or more lymph nodes in at least 75 percent of eligible patients in 2004 and 2005, the latest data available.

With 78 percent complying, National Cancer Institute-designated “Comprehensive Cancer Centers” did the best job. Just under 34 percent of community hospitals, which are far more common and care for many more patients, complied. Just over half of other academic medical centers and Veterans Administration hospitals met the standard.

Bilimoria said improvement takes work from both surgeons and pathologists, noting that Northwestern went from about 50 percent compliance a decade ago to full compliance today.

He said the National Quality Forum recently listed the standard as a sign of quality care and that at least one insurance giant has begun requiring proof of 12-node checks before listing surgeons as preferred providers.

Bilimoria advises patients to ask about the 12-node check in choosing a surgeon and to check their pathology report to be sure it was done.

“Maybe some people don’t know that they should be reaching a certain number. And certainly there may be some people who don’t believe that it’s important,” he said.

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