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The Effect of Hospital Volume and Socioeconomic Status on Colostomy Rates for Rectal Cancer

Heather Jones, MD

University of Pennsylvania Cancer
Ultima Vez Modificado: 12 de mayo del 2001

Presenter: D. C. Hodgson
Affiliation:

Background:

Loss of sphincter function due to rectal cancer is associated with significant impairment in the quality of a patient?s life. This study evaluated the impact of surgical case-volume or patient demographics on the risk of undergoing permanent colostomy for rectal cancer.

Materials and Methods:

• 7047 patients with stage I-III rectal cancer undergoing surgery from 1994-1997 and registered in the California Cancer Registry were included.
• Surgical procedures were identified from hospital discharge abstracts.
• The outcome measure was the performance of colostomy within 4 months of diagnosis and no reversal within one year.
• Adjustments were made for patient age, sex, race, comorbidity, socioeconomic status (SES), tumor stage and location using multiple logistic regression.
• SES was measured using the proportion of adults with a college degree in a patient's zip code.

Results:

• Patients undergoing surgery in hospitals with greater case-volume, or living in higher SES communities were significantly less likely to undergo permanent colostomy in unadjusted (P< 0.001, Mantel-Haenszel) and adjusted analyses.
• Other significant independent predictors were male gender, non-Asian race, advanced tumor stage, distal tumor location and greater comorbidity.

Authors' Conclusions

• Greater hospital case-volume and higher SES are associated with a lower risk of undergoing permanent colostomy.
• The practice patterns underlying these findings should be investigated so that sphincter preservation can be achieved for all eligible patients.

Clinical/Scientific Implications:

The functional and emotional distress associated with sphincter loss is significant. It is an expected finding that more advanced tumors and distal tumors are associated with higher rates of colostomy. It is not clear why low volume centers would have higher colostomy rates. It may be a case of these centers not having advanced staging equipment such as endorectal ultrasound. Thus, they underestimate tumors that are more advanced. However, it may also be that these low volume centers are not offering neoadjuvant therapy such as radiation and chemotherapy to down-stage a tumor and make it more amenable to surgical resection.