Greater Guideline Adherence, Better Survival, Absence of Racial Survival Disparity Among Colorectal Cancer Patients in Integrated Health-Care System


Key Points

  • The integrated health-care system had a higher rate of adherence to NCCN guidelines and better overall survival.
  • No racial survival disparities were found in the integrated health-care system.

In a retrospective analysis reported in the Journal of Clinical Oncology, Rhoads et al found that treatment of colorectal cancer patients in an integrated health-care system was associated with greater compliance with National Comprehensive Cancer Network (NCCN) guidelines, better survival, and no survival disparity between black or other minority patients vs white patients.

Study Details

This secondary data analysis used the California Cancer Registry linked to state discharge abstracts of 33,593 patients treated for stage I to III colon cancer at 348 hospitals between 2001 and 2006. The integrated health-care system accounted for 44 facilities (13%) and 6,357 patients (19%). The integrated health system had a higher proportion of patients aged 55 to 74 years (47% vs 40%), a lower proportion aged ≥ 85 years (10% vs 15%), and a lower proportion of white patients (66% vs 71%).

Guideline Adherence

Adherence to NCCN guidelines was higher in the integrated health system for surgery overall (95.1% vs92.3%, P < .001), including higher rates (all P < .05) for black (93.3% vs 87.3%), Hispanic (94% vs 90.4%), and Asian-Pacific Islander patients (95% vs 91.8%) and for chemotherapy overall (75.8% vs54.0%, P < .001), including higher rates (P < .05) for Hispanic (81.3% vs 58.5%) and Asian-Pacific Islander patients (84.4% vs 58.5%). There were no significant differences in quality of lymph node examination between the integrated health system and other settings.


Propensity score-matched analysis showed improved 5-year overall survival in the integrated system across all disease stages (hazard ratio [HR] = 0.87, P < .001), including in stage I or II (HR = 0.85, P < .001) and stage III (HR = 0.92, P < .001).

In a model adjusting for age, sex, Charlson comorbidity score, stage of disease, insurance, and socioeconomic status, compared with white patients, there was no difference in mortality risk for black (HR = 0.86, P = .12), Hispanic (HR = 0.92, P = .37), or Asian-Pacific Islander patients (HR = 0.83, P = .11) in the integrated health system. In other settings, compared with white patients, there was increased risk for black patients (HR = 1.15, P = .007) and decreased risk for Hispanic (HR = 0.90, P = .009) and Asian-Pacific Islander patients (HR = 0.74, P < .001).

The investigators concluded: “The [integrated health-care system] delivered higher rates of evidence-based care and was associated with lower 5-year mortality. Racial/ethnic disparities in survival were absent in the [integrated health-care system]. Integrated systems may serve as the cornerstone for developing accountable care organizations poised to improve cancer outcomes and eliminate disparities under health-care reform.”

Kim F. Rhoads, MD, MPH, of Stanford Cancer Institute, is the corresponding author for the Journal of Clinical Oncology article.

The study was supported by the National Cancer Institute and Robert Wood Johnson Foundation.

Dr. Rhoads reported stock or other ownership with Medivation.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.