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In Reply:

Division of General Internal Medicine, Brigham and Women's Hospital, the Department of Health Care Policy, Harvard Medical School, Boston, MA

Katherine L. Kahn

The Rand Corporation, Santa Monica, and Division of General Internal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA

We appreciate the findings reported by Ananda et al¹ about the association of patient age and comorbidity in recommendations for adjuvant chemotherapy for stage III colon cancer among a cohort of patients in Australia. We agree that these patient-level data are consistent and complementary to our physician-reported findings, with both data sources providing evidence that chemotherapy is recommended less frequently for patients with more comorbid illness, particularly when they are older.² The consistency of these findings across two distinct data sources spanning two different continents increases the validity of the findings. This is particularly noteworthy because these two settings differ somewhat in their approaches to delivering and financing health care. Although the Australian data characterize care delivered by five medical oncologists practicing at four hospitals in one city, our physician survey data describe reports of care for 1,096 medical oncologists and surgeons across multiple care settings.

The consistent findings across the two reports underscore the importance of knowing why physicians make recommended randomized trial–based interventions less often for patients with comorbidity and advanced age. The patient-level finding from Ananda et al that older patients were more reluctant to accept recommended chemotherapy suggests that patients’ preferences might influence physicians’ treatment recommendations. From the provider perspective, it is well known that care varies widely across areas,³ yet the large variations we observed in our survey of physicians were not explained by physician characteristics or practice location and suggest a lack of consensus regarding best practice. Further examination of patient-level, provider-level, and linked data sets are needed to understand the lower rates of recommended cancer therapies among older and sicker patients and provide the basis for informed interventions. These studies might suggest additional trials are needed targeting older adult and comorbid patients or that interventions are needed to target patient, provider, or systems-level issues. Ultimately, combining data from multiple sources, including patients, physicians, medical records, and health plans, is important to fully understand differences in care delivered. We anticipate that future studies from the Cancer Care Outcomes Research and Surveillance Consortium⁴ will further expand our understanding of reasons for variations in delivery of care to patients with cancer.

AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The author(s) indicated no potential conflicts of interest.

ACKNOWLEDGMENTS

This work of the Cancer Care Outcomes Research and Surveillance Consortium was supported by grants from the National Cancer Institute and the Department of Veterans’ Affairs.

REFERENCES

1. Reference deleted

2. Keating NL, Landrum MB, Klabunde CN, et al: Adjuvant chemotherapy for stage III colon cancer: Do physicians agree about the importance of patient age and comorbidity? J Clin Oncol 26:2532-2537, 2008[Abstract/Free Full Text]

3. Wennberg JE, Cooper MM: The Dartmouth Atlas of Health Care, 1998. Hanover, NH, Center for Evaluative Clinical Sciences, Dartmouth Medical School, 1998

4. Ayanian JZ, Chrischilles EA, Fletcher RH, et al: Understanding cancer treatment and outcomes: The Cancer Care Outcomes Research and Surveillance Consortium. J Clin Oncol 22:2992-2996, 2004[Free Full Text]

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Related Correspondence

• Patient Age and Comorbidity Are Major Determinants of Adjuvant Chemotherapy Use for Stage III Colon Cancer in Routine Clinical Practice
  Sumitra Ananda, Kathryn M. Field, Suzanne Kosmider, Daniel Compston, Jayesh Desai, Lionel C. Lim, Frances S. Barnett, Ian T. Jones, Iain Skinner, and Peter Gibbs
  JCO 2008 26: 4516-4517 [Full Text]

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