© The Author 2006. Published by Oxford University Press.
CORRESPONDENCE |
Re: Completion of Therapy by Medicare Patients With Stage III Colon Cancer
Affiliations of authors: Department of Medical Oncology, Royal Melbourne Hospital and Western Hospital, Victoria, Australia (PG, LL); Department of Colorectal Surgery, Royal Melbourne Hospital, Victoria, Australia (IJ, IH); Department of Colorectal Surgery, Western Hospital, Victoria, Australia (SM, IS, IF); Ludwig Institute of Cancer Research, Victoria, Australia (PG, MC, JJ, LL)
Correspondence to: Peter Gibbs, MD, Oncology, Royal Melbourne Hospital, Grattan St., Parkville, Victoria 3050, Australia (e-mail: peter.gibbs{at}mh.org.au).
We read with interest the article by Dobie et al. (1). These investigators linked data from the Surveillance, Epidemiology, and End Results program to Medicare claims and attempted to address the important questions: what percentage of patients in routine clinical practice fail to complete adjuvant treatment for stage III colon cancer and what are the associated factors? However, as the authors acknowledge, their study was limited to patients who were older than 65 years, and it contained multiple assumptions, liberal definitions, and arbitrary classification—largely because they had no data (other than episodes of chemotherapy) beyond the initial patient contact.
Our prospective comprehensive colorectal cancer database contained 1347 patients who were entered during the 8-year period from January 1, 1998, through December 31, 2005, including 274 patients with stage III colon cancer (153 men and 121 women). We have complete data on the management of individual patients after diagnosis (Table 1), with patients receiving adjuvant 5-fluorouracil–based chemotherapy, according to standard protocols. To our knowledge, this correspondence is the first documentation of both physician-related factors and patient decision making in this context and their influence on the percentage of patients starting adjuvant chemotherapy and finishing all adjuvant chemotherapy treatments.
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Age at diagnosis ranged from 19 years to 92 years, with a median of 66 years. Data regarding initiation of adjuvant chemotherapy (Table 1) demonstrate that adjuvant chemotherapy was not recommended by the treating physician for 28% of the patients who were 65 years or older but was recommended for all patients younger than 65 years (P = .015). When treatment was recommended, a similar number of patients in both age groups decided not to undergo treatment (7% overall).
As shown in Table 1, of the 203 patients who started treatment, 160 (79%) completed treatment and 97 (48%) completed treatment at the starting dose. The percentage of patients in the two age groups completing chemotherapy was similar (75% [67 patients who were 
65 years] versus 82% [93 patients who were <65 years]). Reasons for discontinuing treatment were also similar in both age groups, with treatment-related toxicity being the most common explanation. Our study also documents the number of patients, 13 (6% overall), who decided not to complete treatment in the absence of clinically significant toxicity.
Our results demonstrate that both the physician and patient influence the initiation of chemotherapy, with physician's advice against adjuvant chemotherapy in the elderly population being the dominant reason why chemotherapy was not initiated. Of the 203 patients who started adjuvant therapy, compared with the 803 patients in the arm who received 5-fluorouracil alone in a recently completed clinical trial, the rates of chemotherapy completion at full dose (79% versus 87%, respectively) and at reduced dose (48% versus 56%) were not markedly different (2). Any trend for reduced completion rates in our cohort could be the result of two factors. In the community setting, some of the patients would have been excluded from a clinical trial because of factors that would decrease the likelihood of them completing treatment, such as comorbidity. Also, 13 (6%) of the 203 patients discontinued treatment in the absence of clinically significant toxicity, which we would consider less likely in the presumably more motivated and supported clinical trial population. Further in-depth studies of outcomes in routine clinical care are warranted.
NOTES
Editor's note: The authors of Dobie et al. declined to respond to this Correspondence.
REFERENCES
(1) Dobie SA, Baldwin LM, Dominitz JA, Matthews B, Billingsley K, Barlow W. Completion of therapy by Medicare patients with stage III colon cancer. J Natl Cancer Inst 2006;98:610–9.
(2) Lembersky BC, Wieand HS, Petrelli NJ, O'Connell MJ, Colangelo LH, Smith RE, et al. Oral uracil and tegafur plus leucovorin compared with intravenous fluorouracil and leucovorin in stage II and III carcinoma of the colon: results from National Surgical Adjuvant Breast and Bowel Project Protocol C-06. J Clin Oncol 2006;24:2059–64.
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