A randomized controlled trial to improve lymph node assessment in stage II colon cancer.

HYPOTHESIS: Physicians seem to learn best from their peers, yet the impact of opinion leaders on physician behavior is unclear. Because colon cancer staging has been identified as being suboptimal in Ontario, Canada, we sought to evaluate the influence of expert and local opinion leaders for colon cancer on optimizing colon cancer lymph node assessment. DESIGN, SETTING, PARTICIPANTS: A cluster-randomized trial including all hospitals in Ontario that identified a local opinion leader with intervention between January 5 and June 17, 2004. INTERVENTION: All 42 centers received a standardized lecture about colon cancer lymph node assessment delivered by an expert opinion leader in colon cancer. The 21 intervention hospitals also received academic detailing of a local opinion leader by the expert opinion leader and a toolkit. MAIN OUTCOME MEASURES: Mean number of lymph nodes assessed in patients with stage II colon cancer and the proportion of cases staged with a minimum of 12 lymph nodes before and after a standardized lecture were assessed. RESULTS: Patient demographic and tumor factors were similar in both groups before and after the standardized lecture. Lymph node assessment significantly improved after the standardized lecture at intervention and control sites (P < .001). No additional benefit of academic detailing and toolkit provision in the intervention was demonstrated. CONCLUSIONS: In-person provision of information by an expert opinion leader in colon cancer may stimulate performance regarding lymph node assessment for colon cancer. Academic detailing of a local opinion leader did not further improve lymph node assessment.

Compliance, attitudes and barriers to post-operative colorectal cancer follow-up.

RATIONALE: Meta-analyses demonstrate that surveillance following curative-intent colorectal cancer (CRC) surgery can improve survival. Our multidisciplinary team adopted a stringent CRC follow-up (FU) guideline in 2000. The purpose of this study was to assess adherence and barriers to FU for CRC. METHODS: Patients with primary CRC aged 19-75 years, treated with curative intent surgery from July 2000 to December 2002 were identified from a prospective database. Compliance with FU was assessed primarily by chart review. We also surveyed patients and providers to explore attitudes and barriers to surveillance adherence using tenets of the Health Belief Model. RESULTS: 96 patients met inclusion criteria and were appropriate for FU. Median FU was 34 months. Guideline targets were met for 70% of clinic visits; 49% of carcinoembryonic antigen (CEA) determinations; and 62% of abdominal imaging studies. Post-operative colonoscopy did not occur in 6/93 patients. Seventy per cent of health care providers and 55% of patients completed a survey. Access to testing and confusion about which provider orders investigations were identified as important barriers to FU. CONCLUSION: Patterns of CRC FU were widely variable despite implementation of a guideline. Despite patient and provider agreement with the principles of CRC FU, adoption was inhibited by confusion among multiple providers regarding investigation coordination.

Outcomes of salvage surgery for squamous cell carcinoma of the anal canal.

BACKGROUND: For patients with anal canal cancer who fail combined modality treatment (CMT), salvage surgery (SS) offers the potential for long term survival. The literature regarding SS is limited by small patient numbers and/or heterogeneous treatment protocols. We report on a large series of patients initially treated with chemoradiation at a major referral center. METHODS: We identified 60 patients with persistent or recurrent anal cancer who had undergone SS; 20 were excluded. Overall and disease-free survival (OS, DFS) curves were constructed using the Kaplan Meier method. Univariate analysis was done using the Log-Rank test, and multivariable analysis using Cox proportional hazards. RESULTS: The 40 patients (29 women, 11 men, median age 57) underwent curative intent resection. The initial procedure was multivisceral resection (n = 24), abdominoperineal resection alone (n = 14) or local excision (n = 2). Postoperative mortality was 5%. Postoperative complications were seen in 72%. Median follow-up was 18 months overall and 36 months in survivors. Median OS was 41 months; OS and disease free survival at 5 years were 39% and 30%, respectively. Recurrence was present in 21 patients at time of analysis. Failure was locoregional in 86% (18 of 21) and distant in 48% (10 of 21). Independent predictors of poor OS were male gender, Charlson Comorbidity Score and tumor size. Independent predictors of poor disease free survival were positive margins and lymphovascular invasion. CONCLUSION: SS for anal canal cancer was associated with significant morbidity. Long-term survival was achieved in 39% of patients. Comorbidities should guide patient selection, and R0 resection should be the goal.

Surgery as a bridge to palliative chemotherapy in patients with malignant bowel obstruction from colorectal cancer.

BACKGROUND: Malignant bowel obstruction (MBO) is a feature of the clinical course of 10-28% of colorectal cancer (CRC) patients and is associated with a poor prognosis. Recent advancements in palliative chemotherapy regimens have prolonged survival in patients with stage IV CRC. Few reports exist that describe outcomes in patients who have had surgery for MBO and subsequent chemotherapy as part of their treatment. The objective of this study was to review surgical outcomes in patients with MBO for CRC and to evaluate the extent to which surgery can serve as a bridge to palliative chemotherapy. METHODS: Patients who presented with MBO and had surgical treatment were identified from a prospectively kept database at a single tertiary care center between 09/99 and 08/04. Charts were retrospectively reviewed and clinical and outcomes data were abstracted. RESULTS: Forty-seven patients were identified who had surgery as part of the treatment for MBO from CRC. Operations included resections, bypasses and stoma creation. Overall, 80% of patients were able to tolerate solid food post-operatively and return home. The median survival for the entire cohort was 3.5 months. Seven patients died within 30 days of surgery. Of the remainder, 24 patients were palliated with surgery alone and 16 patients ultimately received palliative chemotherapy. Survival in the final cohort was significantly prolonged (P < 0.001). CONCLUSION: Surgery can adequately palliate a substantial proportion of patients with MBO from CRC with acceptable morbidity and mortality. In addition, in a subset of patients it can facilitate palliative chemotherapy that is associated with improved overall survival.

Results of an aggressive approach to resection of locally recurrent rectal cancer.

BACKGROUND: The value of resection for locally recurrent rectal cancer (LRRC) remains controversial. We analyzed outcomes of an aggressive approach to resection of LRRC. METHODS: We conducted a retrospective chart review of 52 consecutive patients who underwent resection of LRRC from September 1997 through August 2005. Overall and disease-free survival (OS, DFS) curves were constructed by the Kaplan-Meier method, and compared by log-rank analysis. Median follow-up time was 29 months (range 3-72). RESULTS: Thirty-one patients (60%) were male. Median age was 60 years (range 36-88). Forty-six of the 52 patients were resected with curative intent, while 6 had known distant metastases at the time of resection. All 52 patients underwent grossly complete resection of local disease, and 41 (79%) had microscopically clear resection margins. An en bloc sacrectomy was performed in 28 (54%) patients. Postoperative mortality was nil; significant complications developed in 42% of patients. The complication rate was higher in patients with sacrectomy than without (50 vs. 33%, P = 0.017, Chi square). For the entire cohort of 52 patients, median OS and DFS were 40 and 24 months, respectively. Survival was equivalent in patients with and without sacrectomy. In the 46 patients who had resection with curative intent, 4-year OS was 48%. Median OS in the six patients with distant metastases at the time of resection was 21 months. OS was predicted by the presence of metastases (P = 0.01), and margin status (P < 0.0001). DFS was predicted by margin status (P = 0.0001). CONCLUSIONS: In this series of patients who underwent resection of LRRC, microscopic margin status was the most significant predictor of OS and DFS. Requirement for en bloc sacrectomy was not associated with inferior survival. Carefully selected patients with distant metastases may benefit from resection of LRRC.

A blended knowledge translation initiative to improve colorectal cancer staging [ISRCTN56824239].

BACKGROUND: A significant gap has been documented between best practice and the actual practice of surgery. Our group identified that colorectal cancer staging in Ontario was suboptimal and subsequently developed a knowledge translation strategy using the principles of social marketing and the influence of expert and local opinion leaders for colorectal cancer. METHODS/DESIGN: Opinion leaders were identified using the Hiss methodology. Hospitals in Ontario were cluster-randomized to one of two intervention arms. Both groups were exposed to a formal continuing medical education session given by the expert opinion leader for colorectal cancer. In the treatment group the local Opinion Leader for colorectal cancer was detailed by the expert opinion leader for colorectal cancer and received a toolkit. Forty-two centres agreed to have the expert opinion leader for colorectal cancer come and give a formal continuing medical education session that lasted between 50 minutes and 4 hours. No centres refused the intervention. These sessions were generally well attended by most surgeons, pathologists and other health care professionals at each centre. In addition all but one of the local opinion leaders for colorectal cancer met with the expert opinion leader for colorectal cancer for the academic detailing session that lasted between 15 and 30 minutes. DISCUSSION: We have enacted a unique study that has attempted to induce practice change among surgeons and pathologists using an adapted social marketing model that utilized the influence of both expert and local opinion leaders for colorectal cancer in a large geographic area with diverse practice settings.

Barriers to optimal assessment of lymph nodes in colorectal cancer specimens.

Lymph node (LN) retrieval and assessment is critically important for accurate staging and treatment planning in colorectal cancer (CRC). Practicing pathologists in Ontario were identified and surveyed by phone to identify barriers to optimal retrieval and assessment. Of the pathologists surveyed, 57.9% were aware of guidelines for LN retrieval in CRC, but only 25.0% identified that a minimum of 12 LNs are necessary for accurate designation of node negativity. An important role exists for an education strategy aimed at bridging the knowledge gap among practicing pathologists and surgeons regarding optimal LN assessment in CRC specimens.

Identifying educationally influential specialists: issues arising from the use of "classic" criteria.

INTRODUCTION: Educationally influential physicians (EIPs) are identified by their colleagues as people who (1) encourage learning and enjoy sharing their knowledge, (2) are clinical experts and always seem up to date, and (3) treat others as equals. We aimed to identify surgical and pathologist EIPs for colorectal cancer (CRC) in Ontario as part of a blended knowledge transfer program. METHODS: A population-based cohort of surgeons (n = 794) and pathologists (n = 449) were sent surveys modeled on the Hiss method for identifying EIPs. Four formal mailings (including incentives) and telephone calls and faxes were completed. This labor-intensive process identified "general" EIPs and surgery or pathology EIPs for CRC. The characteristics of EIPs in these groups were studied. RESULTS: The response rate was 41% for surgeons and 42% for pathologists. One hundred eighteen general EIPs were identified and substantially more surgical EIPs for CRC (n = 63) than pathology EIPs for CRC (n = 6) were recognized. Forty-two of 81 medical centers in Ontario identified an EIP We also identified a cohort of "domain experts, " physicians whose opinion was valued for CRC but who did not meet the Hiss EIP criteria. This cohort of "domain experts" was larger than the cohort of ElPs for CRC for both surgeons (63 vs. 154) and pathologists (6 vs. 154). DISCUSSION: In this population study, we identified EIPs for CRC using the Hiss method, although significantly more surgical than pathology EIPs for CRC were recognized. The educational influence of domain experts who do not fulfill the Hiss characteristics compared with EIPs for CRC remains to be determined.

Interest and participation in support group programs among patients with colorectal cancer.

Previous studies have demonstrated that support intervention improved quality of life and survival for patients with breast, melanoma, prostate, and gastrointestinal cancer. A standardized approach to encourage participation in support group programs among patients with colorectal cancer (CRC) had been initiated at this study site. The purpose of this study was to examine the characteristics of patients with CRC interested in this type of intervention and to identify barriers to attendance at an established patient support program. Consecutive patients with CRC were informed and encouraged to attend Wellspring, a nonprofit patient support program that offers a wide range of services. A patient survey was conducted and correlated with data on the clinical, social, and demographic characteristics of patients. Factors predictive of interest in the Wellspring support program and barriers to attendance were examined.Fifty-eight patients were eligible for this study. A total of 44 (76%) surveys were completed. Predictors of interest in patient support were age less than 65 years, encouragement from medical staff to attend, level of education, comfort in spiritual beliefs, religious affiliation, and complementary/alternative medicine use. Disease stage, gender, ethnicity, and level of social supports were not significant in this population. Although patients were routinely informed about the program in a standardized fashion, a significant proportion (36.4%) of patients did not recall receiving encouragement. Multiple logistic regression showed that level of education and recollection of encouragement from medical staff were independent predictors of interest. Although 14 patients were interested in attending (32%), only 4 ultimately attended Wellspring programs (9.1%). The most frequently cited barrier to attendance was a perception of adequate support at home, followed by living too far away, no perceived need of supports, and not feeling well.A significant proportion of patients with CRC are interested in structured support programs, but only a minority of patients ultimately participate in such programs. Further participation may be achieved by recognizing common barriers to participation and optimizing strategies to enhance attendance. Optimizing use of support services such as Wellspring has the potential to improve the effectiveness of the multidisciplinary cancer care of patients with CRC.