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Adjuvant Chemotherapy for Stage III Colon Cancer: Do Physicians Agree About the Importance of Patient Age and Comorbidity?

Nancy L. Keating, Mary Beth Landrum, Carrie N. Klabunde, Robert H. Fletcher, Selwyn O. Rogers, William R. Doucette, Diana Tisnado, Steven Clauser, Katherine L. Kahn

From the Division of General Internal Medicine and the Department of Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital; the Departments of Health Care Policy and Ambulatory Care and Prevention, Harvard Medical School, Boston, MA; Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD; the Division of Clinical and Administrative Pharmacy, University of Iowa, Iowa City, IA; RAND, Santa Monica; and the Division of General Internal Medicine, University of California, Los Angeles, Los Angeles, CA

Corresponding author: Nancy L. Keating, MD, MPH, Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115; e-mail: keating{at}hcp.med.harvard.edu

Purpose: We surveyed cancer physicians to understand how patients' age and comorbidity influence adjuvant chemotherapy recommendations and whether physician or practice characteristics also affect these recommendations.

Methods: National survey of surgeons and medical oncologists caring for patients with colorectal cancer regarding whether they would recommend adjuvant chemotherapy for hypothetical patients with stage III colon cancer who varied by age (55 v 80 years) and comorbid illness (none, moderate, severe congestive heart failure [CHF]). Repeated measures logistic regression was used to assess the influence of patient, physician, and practice characteristics on chemotherapy recommendations.

Results: Of 1,096 physicians, nearly all recommended chemotherapy for patients who were 55 years old with no comorbidity (99.0%), 55-years old with moderate CHF (88.6%), or 80 years old with no comorbidity (92.6%); many fewer recommended chemotherapy for 55-year-old patients with severe CHF (24.9%) or 80-year-old patients with moderate (47.2%) or severe (9.0%) CHF (P < .001). Younger physicians (P < .001) were more likely than others to recommend adjuvant chemotherapy overall, although physician factors explained little of the variability in recommendations.

Conclusion: Physicians agree with guidelines recommending adjuvant chemotherapy for young, healthy patients with stage III colon cancer but differ widely on recommendations for patients who are older and sicker. Few physician or practice characteristics were associated with recommendations. For older and sicker patients, the individual physicians seen may have a substantial impact on the likelihood of receiving chemotherapy. Understanding better the sources of variation not explained by patients' clinical characteristics may allow improved tailoring of therapy to patients most likely to benefit.

This work of the Cancer Care Outcomes Research and Surveillance (CanCORS) Consortium was supported by grants from the National Cancer Institute (NCI) to the Statistical Coordinating Center (U01 CA093344) and the NCI-supported Primary Data Collection and Research Centers (Dana Farber Cancer Institute/Cancer Research Network U01 CA093332, Harvard Medical School/Northern California Cancer Center U01 CA093324, RAND/UCLA U01 CA093348, University of Alabama at Birmingham U01 CA093329, University of Iowa U01 CA01013, University of North Carolina U01 CA093326) and by a Department of Veteran's Affairs grant to the Durham VA Medical Center U01 CDA093344 (MOU) and HARQ 03-438MO-03).

Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.