Quality of care indicators in rectal cancer

Abstract

Quality of health care is a hot topic, especially with regard to cancer. Although rectal cancer is, in many aspects, a model oncologic entity, there seem to be substantial differences in quality of care between countries, hospitals and physicians. PROCARE, a Belgian multidisciplinary national project to improve outcome in all patients with rectum cancer, identified a set of quality of care indicators covering all aspects of the management of rectal cancer. This set should permit national and international benchmarking, i.e. comparing results from individual hospitals or teams with national and international performances with feedback to participating teams. Such comparison could indicate whether further improvement is possible and/or warranted.

Full text

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Quality of care indicators in rectal cancer
P. Demetter1, W. Ceelen2, E. Danse3, K. Haustermans4, A. Jouret-Mourin5, A. Kartheuser6, S.
Laurent7, G. Molle8, N. Nagy9, P. Scalliet10, E. Van Cutsem11, M. Van Den Eynde12, J. Van de
Stadt13, E. Van Eycken14, J.-L. Van Laethem15, K. Vindevoghel16, F. Penninckx17
1Pathology, Erasme University Hospital (ULB); 2Surgery, Ghent University Hospital (UG) ;
3Radiology, Cliniques Universitaires St.-Luc (UCL) ; 4Radiotherapy, Universitair Ziekenhuis
Gasthuisberg (KUL) ; 5Pathology, Cliniques Universitaires St.-Luc (UCL) ; 6Surgery, Cliniques
Universitaires St.-Luc (UCL); 7Gastroenterology, Ghent University Hospital (UG); 8Surgery,
Hôpital de Jolimont; 9Pathology, CHU Charleroi; 10Radiotherapy, Cliniques Universitaires St.-
Luc (UCL); 11Gastroenterology, Universitair Ziekenhuis Gasthuisberg (KUL);
12Gastroenterology, Cliniques Universitaires St.-Luc (UCL); 13Surgery, Erasme University
Hospital (ULB); 14Stichting Kankerregister, Brussels; 15Gastroenterology, Erasme University
Hospital (ULB); 16Surgery, O.L.V. van Lourdes Ziekenhuis Waregem; 17Surgery, Universitair
Ziekenhuis Gasthuisberg (KUL)
Corresponce: Pieter Demetter
Department of Pathology
Erasme University Hospital
Route de Lennik 808
B-1070 Bruxelles
Fax +32 (0)2 555 47 90
E-mail pieter.demetter@erasme.ulb.ac.be

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ABSTRACT
Quality of health care is a hot topic, especially with regard to cancer. Although rectal cancer
is, in many aspects, a model oncologic entity, there seem to be substantial differences in
quality of care between countries, hospitals and physicians. PROCARE, a Belgian
multidisciplinary national project to improve outcome in all patients with rectum cancer,
identified a set of quality of care indicators covering all aspects of the management of rectal
cancer. This set should permit national and international benchmarking, i.e. comparing
results from individual hospitals or teams with national and international performances with
feedback to participating teams. Such comparison could indicate whether further
improvement is possible and/or warranted.

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Quality of healthcare can be defined as “the degree to which health services for individuals
and populations increase the likelihood of desired health outcomes and are consistent with
current professional knowledge”(1). This is a hot topic, especially for cancer care.
Rectal carcinoma is, in many aspects, a model oncologic entity. Major milestones in rectal
cancer treatment during the past 25 years were the introduction of total mesorectal excision
(TME) (2) and the development of a multimodal neo-adjuvant therapy concept (3).
Nevertheless, there seem to be substantial differences in quality of care between countries,
hospitals and physicians (4-6). To reduce hospital variation, most initiatives aim on selective
referral, encouraging patients to seek care in high-volume hospitals, where cancer care is
concentrated to site-specialist multidisciplinary teams (7). There is, however, a growing
awareness that population-based audit of cancer services is essential to ensure high quality
cancer care: as an alternative to volume-based referral, hospitals and surgeons can also
improve their results by learning from their own outcome statistics and those from
colleagues treating a similar patient group.
Although this is widely recognised, the vast majority of reports on the relation between
quality and outcome of rectal cancer focuses on surgical outcomes mainly related to surgeon
or hospital volume (8-10), level of surgical training (11), ethnicity or socio-economic status
(12,13) of the patients. Those are in fact basically structural factors. The number of initiatives
developing indicators to measure the quality of rectal cancer care taking into account the
whole process from patient presentation to postoperative follow-up are scarce (14,15).
PROCARE (PROject on CAncer of the REctum), a Belgian multidisciplinary national project to
improve outcome in all patients with rectum cancer (4,16,17), has been launched in 2006.
Guidelines were made by a multidisciplinary group (18) and are also available on the web
(19). Decentralised implementation of guidelines was organised by the scientific and
professional organisations. Overall quality of care is assured by registration in a specific
national database starting in 2006. Through feedback all centres are able to position
themselves in comparison to national indicators. The quality of care indicators cover the
following domains: diagnosis and staging, neoadjuvant treatment, surgery, adjuvant
treatment, palliative treatment, follow-up and histopathologic examination. Some indicators
cover most if not all of these items, and can be considered general quality indicators.
General quality indicators
In this group five indicators are considered: overall survival by stage, disease-specific survival
by stage, disease-free survival, relative survival and proportion of patients with local
recurrence.

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Both survival and local recurrence rate are affected by most processes of rectal cancer care
(18). Therefore, survival, disease-free survival and local recurrence are frequently used in
clinical studies on rectal cancer (18,20-23).
Diagnosis and staging
With regard to these indicators, PROCARE considers proportion of patients (a) with a
documented distance from the anal verge, (b) in whom a CT of the abdomen and X-ray or CT
thorax was performed before any treatment, (c) in whom a CEA was performed before any
treatment, (d) in whom complete large bowel-imaging was performed before undergoing
elective surgery, (e) in whom a transrectal ultrasonograpgy (TRUS) and pelvic CT and/or
pelvic MRI were performed before any treatment and (f) with cStage II-III rectal cancer that
have a reported cCRM (clinical circumferential resection margin). Other indicators taken into
account are time between first histopathologic diagnosis and first treatment, accuracy of
cM0 staging, accuracy of cT/cN staging in case of no or short radiotherapy, use of TRUS in
cT1/cT2 stages, and use of MRI in cStage II or III.
The distance from the lower edge of the tumour to the anal verge is an important clinical
parameter, since it co-determines the indication for neoadjuvant treatment, the type of
surgery and the outcome (18,24,25). The aim of imaging techniques such as CT, MRI and PET
is to detect hepatic and extrahepatic metastatic disease (18). A combined thorax and
abdomen/pelvis spiral contrast-enhanced CT is recommended for routine use (14). Pre-
treatment CEA levels have been related to cancer stage and survival independent of pTN
stage in nonmetastatic colorectal cancer (18). Therefore, the serum CEA level should be
determined in all patients before the start of any treatment (25). It is recommended that
patients with rectal cancer undergo a total colonoscopy with resection of concomitant
polyps if possible (18). However, if colonoscopy is judged to be too risky or if colonoscopy is
refused, a high-quality double contrast barium enema or virtual colonoscopy should be
performed (14,24-26). Patients with rectal cancer should have locoregional cTN staging.
TRUS and high-resolution MRI (or CT) play an important role in the staging of rectal cancer
(18). An important outcome of the preoperative staging is the CRM, which is a predictor of
local and distant recurrence as well as survival (27-32). The CRM can be reliably predicted by
preoperative high-resolution MRI (18). According to the guidelines of the Association of
Coloproctology of Great Britain and Ireland (ACPGBI), the interval between making a
diagnosis of cancer and the start of treatment should be less than 4 weeks (18,33).
Neoadjuvant treatment
In this category seven indicators are considered: proportion of cStage I patients that
received neoadjuvant radio(chemo)therapy, proportion of cStage II-III patients (a) that
received a neoadjuvant pelvic radiotherapy (RT), (b) treated with neoadjuvant 5-FU based
chemoradiation that received a continuous infusion of 5-FU, (c) treated with a long course of

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preoperative pelvic RT or chemoradiation that completed this neoadjuvant treatment within
the planned timing and (d) treated with a long course of preoperative pelvic RT or
chemoradiation that was operated 4 to 12 weeks after completion of the (chemo)radiation,
the proportion of patients with cCRM < or = 2mm on MRI/CT that received long course
neoadjuvant radio(chemo)therapy, and the rate of acute grade 4 radio(chemo)therapy-
related complications.
Preoperative (chemo)radiation therapy has become a common practice for stage II and III
rectal cancers (34). It has been well documented that neoadjuvant chemoradiation induces
tumour regression and downstaging, and therefore increases tumour resectability and the
rate of sphincter preservation (35-37). Furthermore, as shown by a large, prospective,
randomised trial conducted by the German Rectal Cancer Study Group (3), this treatment
modality results in a significantly reduced rate of local recurrence and treatment toxicity
when compared with postoperative chemoradiation, while preoperative chemoradiation
does not seem to offer survival advantage. Although many quality indicators on
chemotherapy and radiotherapy are identified in the literature (24-26), none of these
specifically address neoadjuvant treatment. Therefore, the PROCARE recommendations on
neoadjuvant treatment were used as a basis to formulate additional indicators (18).
Surgery
The list of surgery-related quality of care indicators includes 10 items: (a) proportion of R0
resections, (b) (y)p distal margin involved (positive) after SSO or Hartmann’s procedure for
low rectal cancer (< or = 5cm), (c) mesorectal (y)pCRM positivity after radical surgical
resection, (d) proportion of abdominoperineal anorectal excision (APR), Hartmann’s
procedure or proctocolectomy with definitive ileostomy, (e) proportion of patients with
stoma 1 year after sphincter-sparing surgery, (f) major leakage after partial mesorectal
excision (PME) + SSO + reconstruction, (g) major leakage after TME + SSO + reconstruction
(global, i.e. with or without primary derivative stoma), (h) inpatient or 30-day mortality, (i)
rate of intra-operative rectal perforation and (j) postoperative major surgical morbidity
requiring reintervention under narcosis after radical surgical resection.
Curative resection rate is used very often as a quality indicator (14,25,26). Indeed, the main
emphasis of surgery is to obtain clear surgical margins yielding a curative R0 resection (no
residual tumour) (15). TME has been considered the optimal surgical modality for the
treatment of rectal cancer since Heald et al. reported TME in 1982 (2); therefore, the
proportion of APR and Hartmann’s procedure is considered a very important quality
indicator (being an outcome of importance to patients) (26). Surgeons should aim, wherever
possible and desirable, to preserve the anal sphincter (18). A temporary defunctioning stoma
should be considered each time the anastomosis is at risk for leakage after sphincter-sparing
surgery (18). In general, a temporary stoma is closed within 1 year after surgery, i.e. after the
end of adjuvant chemotherapy. Inpatient or 30-day mortality is an outcome that is affected

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by many factors (14,18,26), such as stage, age, comorbidity, mode of surgery i.e.
elective/scheduled vs. urgent/emergency. These factors need to be taken into account at
risk-adjustment for appropriate interpretation of this indicator (26). Intra-operative
perforation increases local recurrence and decreases survival; it occurs more frequently
during APR as compared with anterior resection (18).
Adjuvant treatment
F or this item the PROCARE Workgroup selected five quality indicators: (a) proportion of
(y)pStage III patients with R0 resection that received adjuvant chemotherapy within 3
months after surgery, (b) proportion of pStage II-III patients with R0 resection that received
adjuvant radiotherapy or chemoradiotherapy within 3 months after surgery, (c) proportion
of (y)pStage II-III patients with R0 resection that started adjuvant chemotherapy within 12
weeks after surgical resection, (d) proportion of (y)pStage II-III patients with R0 resection
treated with adjuvant chemo(radio)therapy, that received 5-FU based chemotherapy and (e)
rate of acute grade 4 chemotherapy-related complications.
The rationale for early adjuvant therapy is that it is able to treat micrometastatic disease at a
time when tumour burden is at a minimum. 5-FU given by intravenous injection for 5 days
every 4 weeks for 6 cycles is the regimen for which the most evidence is available and that is
clearly effective in prolonging survival in patients with stage III (18). Treatment with
chemotherapy is associated with an acceptable complication rate. However, the occurrence
of complication is dose-dependent and can be kept low artificially by lowering the dose.
Palliative treatment
The proportion of cStage IV patients receiving chemotherapy is the only quality indicator
that was retained in this setting. The aim of palliative systemic therapy is to improve survival
and quality of live in patients with metastatic disease (18).
Follow-up
In this domain, the rate of curatively treated patients that received a colonoscopy within 1
year after resection, and late grade 4 complications of radiotherapy or chemoradiation were
selected.
For curatively treated patients it is recommended to perform a colonoscopy within 1 year
after resection; the aim is to detect local recurrence at an early potentially (surgically)
curable stage, and to detect new primary tumours (18,26).
Histopathologic examination
The list of quality indicators in the domain of histopathologic examination includes (a) the
use of a specific pathology report sheet, (b) the quality of TME according to Quirke (38,39)

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mentioned in the pathology report, (c) the distal tumour-free margin mentioned in the
pathology report, (d) the number of lymph nodes examined, (e) the (y)pCRM mentioned in
mm in the pathology report, and (f) the tumour regression grade (40) mentioned in the
pathology report (after neoadjuvant treatment).
The quality of TME according to Quirke, the harvested lymph nodes and the status of the
circumferential resection margin illustrate the quality of TME and affect the patient’s
oncological outcome (38,41-44). The pathologist should find as many lymph nodes as
possible. The median number found is an indication of the quality of the pathological
examination. According to the current TNM guidelines at least 12 lymph nodes need to be
examined in rectal cancer specimens (45), but higher numbers are desirable and achievable
in most cases, even after preoperative radiotherapy (46). Examining greater number of
nodes increases the likelihood of proper staging (47). Yields will vary in relation to many
factors; they can, however, be maximised through high-quality surgery and diligent
pathological examination (48). Examination of 6 or fewer lymph nodes is related to poor
prognosis (49). Best practice demands the reporting of CRM by radiologists and pathologists
alike (28,29,38). Grading of tumour regression is important since outcome is better in case of
complete regression than in case of residual microscopic disease which, in turn, is associated
with better prognosis than cases without or with only minor regression (40,50-52).
CONCLUSIONS AND PROSPECTS
Patients deserve consistent standards regardless of where they live or are treated. The
pursuit of excellence requires the definition of standards and the search is on to find what
parameters best guarantee equal patient outcome and care.
Based on literature search and expert opinions, the PROCARE Workgroup has identified a set
of quality of care indicators (summarised in the table) covering all aspects of the
management of rectal cancer. Ideally population-based audit should be risk-adjusted; such
approach requires intensive collaboration between clinicians and statisticians. In order to
provide teams with simple, userfriendly but relevant feedback information, it might be
useful to construct one quality index for the outcome (aggregating e.g. overall survival,
proportion of R0 resections and postoperative major surgical morbidity with reintervention
under narcosis after radical surgical resection) and one quality index for the process of
treating rectal cancer (with e.g. time between first histopathological diagnosis and first
treatment, proportion of APR and Hartmann’s procedure or total excision of colon and
rectum with definitive ileostomy, and number of lymph nodes examined).
In addition to national benchmarking, i.e. comparing results from individual hospitals or
teams with national performances with feedback to participating teams, we should also aim
for international benchmarking. This comparison could indicate whether further
improvement is possible and/or warranted.

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GENERAL QUALITY INDICATORS
Overall survival by stage
Disease-specific survival by stage
Disease-free survival
Relative survival
Proportion of patients with local recurrence
DIAGNOSIS AND STAGING
Proportion of patients with a documented distance from the anal verge
Proportion of patients with abdominal CT and thoracal X-ray or CT before any treatment
Proportion of patients in whom a CEA was performed before any treatment
Proportion of patients with complete large bowel-imaging before elective surgery
Proportion of patients with TRUS and pelvic CT and/or pelvic MRI before any treatment
Proportion of patients with cStage II-III rectal cancer that have a reported cCRM
Time between first histopathologic diagnosis and first treatment
Accuracy of cM0 staging
Accuracy of cT/cN staging in case of no or short radiotherapy
Use of TRUS in cT1/cT2 stages
Use of MRI in cStage II or III
NEOADJUVANT TREATMENT
Proportion of cStage I patients that received neoadjuvant radio(chemo)therapy
Proportion of cStage II-III patients that received a neoadjuvant pelvic radiotherapy
Proportion of cStage II-III patients with neoadjuvant chemoradiation that received a continuous 5-FU infusion
Proportion of patients completing long course neoadjuvant pelvic RT or chemoradiation within planned timing
Proportion of patients operated 4 to 12 weeks after completion of long course pelvic RT or chemoradiation
Proportion of patients with cCRM < or = 2mm that received long course neoadjuvant radio(chemo)therapy
Rate of acute grade 4 radio(chemo)therapy-related complications
SURGERY
Proportion of R0 resections
(y)p distal margin involved (positive) after SSO or Hartmann’s procedure for low rectal cancer (< or = 5cm)
Mesorectal (y)pCRM positivity after radical surgical resection
Poportion of APR, Hartmann’s procedure or proctocolectomy with definitive ileostomy
Proportion of patients with stoma 1 year after sphincter-sparing surgery
Major leakage after partial mesorectal excision + SSO + reconstruction
Major leakage after TME + SSO + reconstruction (global, i.e. with our without primary derivative stoma)
Inpatient or 30-day mortality
Rate of intra-operative rectal perforation
Postoperative major surgical morbidity requiring reintervention under narcosis after radical surgical resection
ADJUVANT TREATMENT
Proportion of (y)pStage III patients with R0 resection receiving adjuvant chemotherapy within 3 months
Proportion of pStage II-III patients with R0 resection receiving adjuvant (chemo)radiotherapy within 3 months
Proportion of (y)pStage II-III patients with R0 resection that started adjuvant chemotherapy within 12 weeks
Proportion of (y)pStage II-III patients with R0 resection treated with adjuvant chemotherapy receiving 5-FU
Rate of acute grade 4 chemotherapy-related complications
PALLIATIVE TREATMENT
Proportion of cStage IV patients receiving chemotherapy
FOLLOW-UP
Rate of curatively treated patients that received a colonoscopy within 1 year after resection
Late grade 4 complications of radiotherapy or chemoradiation
HISTOPATHOLOGIC EXAMINATION
Use of a specific pathology report sheet
Quality of TME according to Quirke mentioned in the pathology report
Distal tumour-free margin mentioned in the pathology report
Number of lymph nodes examined
(y)pCRM mentioned in mm in the pathology report
Tumour regression grade mentioned in the pathology report

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