Quality Oncology Practice Initiative Finds Low Rates of Pre-Treatment Staging Imaging Among Patients With Rectal Cancer

A study on whether National Comprehensive Cancer Network (NCCN) guidelines on the use of imaging to stage nonmetastatic rectal cancer were being followed in clinical practice revealed that one-third to one-half of these patients did not receive appropriate imaging (JCO Oncol Pract. 2022; OP2100455. doi:10.1200/OP.21.00455.).

To develop an optimal treatment plan, oncologists need appropriate staging assessments. Guidelines issued by the NCCN recommend using pelvic magnetic resonance imaging or endorectal ultrasonography to determine disease stage before initiating treatment of nonmetastatic rectal cancer. This imaging helps clinicians to determine the cancer’s size and extent (T) and whether regional lymph nodes (N) are affected. T and N staging is crucial for determining the best initial treatment. Whereas patients with stage T1-2 N0 disease should start treatment with surgical resection, those with stage T3-4 or N1-2 disease should start treatment with multimodality therapy such as radiation therapy with concurrent chemotherapy.

To evaluate the concordance between the NCCN guidelines and what was done in clinical practice, researchers at the American Society of Clinical Oncology (ASCO) and 4 U.S. academic medical institutions used a quality measure that addressed the staging workup for patients with rectal cancer. This measure was an element of ASCO’s Quality Oncology Practice Initiative (QOPI).

“To our best knowledge, the current study is the only to examine this question in contemporary patients,” wrote Ronald Chen, MD, MPH, University of Kansas Medical Center, Kansas City, KS, and colleagues.

During the study period from Fall 2016 through Fall 2019, 103 practices participating in the QOPI reported their performance on QOPI measure Colorectal 78, which examined the appropriate use of imaging in the initial staging of patients with rectal cancer. The practices that participated in the study were self-selected to submit data on this measure during 7 rounds of data collection. At each time point, 20 to 33 practices reported data for a total of 1,158 unique patients.

The researchers calculated the percentage of patients who received guideline-concordant imaging at the 7 assessment time points that resulted from these data collection rounds. They then measured the difference between rates of concordance at the initial time point and at the 6 subsequent time points by using logistic regression with random-effects models. 

From these measurements, the researchers concluded that adherence to guidelines increased over time; whereas 38% of patients received guideline-recommended staging imaging in Fall 2016, 56% received it in Fall 2019. 

“This study is also unique in demonstrating that implementing a metric specifically related to rectal cancer staging may be associated with improved performance,” Dr. Chen and team commented.

After noting the high rate of nonconcordance in Fall 2016, the researchers surveyed the 69 practices that submitted data in 2016 and 2017 to determine what accounted for this high rate. Their survey revealed that nonconcordance mainly resulted from lack of care coordination between the oncologists and surgeons (in 16 practices, or 57%) and from lack of awareness of appropriate staging scans (in 8 practices, or 29%).

“The results from our study indicate that there is confusion regarding which provider is responsible for ordering scans, which highlights the need for improved communication among providers to optimize care coordination,” the researchers concluded.