3126 — Colorectal Cancer Patient Refusal of Adjuvant Chemotherapy by Stage of Disease

Zullig LL (Durham VA Medical Center-Center for Health Services Research in Primary Care), Jackson GL (Durham VA Medical Center-Center for Health Services Research in Primary Care), Paynter BK (Durham VA Medical Center-Center for Health Services Research in Primary Care), Khwaja R (Durham VA Medical Center-Center for Health Services Research in Primary Care), Powell AA (Minneapolis VA Medical Center-Center for Chronic Disease Outcomes Research), Ordin DL (VA Central Office-Office of Quality and Performance), Gellad ZF (Durham VA Medical Center-Center for Health Services Research in Primary Care), Zafar SY (Durham VA Medical Center-Center for Health Services Research in Primary Care), Hamilton NS (Durham VA Medical Center-Center for Health Services Research in Primary Care), Newlin CB (Durham VA Medical Center-Center for Health Services Research in Primary Care)

Objectives:
To evaluate the rate of colorectal cancer patient refusal of adjuvant chemotherapy by disease stage among patients at 27 VA medical centers participating in the Colorectal Cancer Care Treatment Improvement Collaborative (C4).

Methods:
C4 utilized a HSRandD developed (funding: HSRandD grant CRT-05-338) electronic data abstraction tool called Colorectal Cancer Quality Measurement System (CCQMS) to collect information from the Computerized Patient Record System (CPRS). Patients included in this analysis were incident cases of stage II or III colon or rectal adenocarcinoma diagnosed between 2005 and 2008. Data were collected regarding patient refusal of adjuvant chemotherapy. Patients for whom chemotherapy was not indicated or for whom chemotherapy was medically contraindicated were excluded from analysis.

Results:
1,375 eligible patients had data entered into CCQMS. Of 747 stage II or III colon/rectal cancer patients, total of 533 patients had an indication for chemotherapy as a possible first-line treatment in conjunction with surgery (had surgery and no documented medical reason for not receiving chemotherapy). Of these 533 patients, 14.4%, refused chemotherapy, including 18.5% of stage II (n = 211) and 11.8% of stage III patients (n = 322). Specific proportions of patient refusal by stage category include: IIA (17.9%, n = 173); IIB (21.1%, n = 38); IIIA (5.9%, n = 51); IIIB (11.5%, n = 182); IIIC (15.7%, n = 89).

Implications:
The highest occurrence of refusal was in stage II patients, for whom National Comprehensive Cancer Network (NCCN) treatment guidelines indicate chemotherapy may be an option based on multiple clinical considerations. This refusal rate may be due to patients being presented with alternative treatment modalities that are not centered on chemotherapy. Strikingly however, a third of patients with stage III (lymph node-positive) cancer refused adjuvant chemotherapy. In this setting, adjuvant chemotherapy is the standard of care unless otherwise contraindicated.

Impacts:
Patients may refuse chemotherapy for a variety of reasons. Healthcare delivery systems must be equipped to provide chemotherapy based on nationally accepted standards; however, a portion of the patient population still declines standard therapy. Future studies will investigate why patients with either an absolute or relative chemotherapy indication declined treatment. These results identify the need for shared-decision support tools for patients with cancer.