A Novel Risk-Adjusted Nomogram for Rectal Cancer Surgery Outcomes

IMPORTANCE The circumferential resection margin is the primary determinant of local recurrence and a major factor in survival in rectal cancer. Neither chemotherapy nor chemoradiation compensates for a margin positive for cancer. OBJECTIVE To identify treatment-related factors associated with hospital margin-positive resection and to develop a tool that could be used by individual hospitals to assess their outcomes based on their unique mix of patient and tumor characteristics. DESIGN Retrospective review of the National Cancer Data Base, 1998-2007. SETTINGS Community and academic/research hospitals. PARTICIPANTS Individuals with histologically confirmed localized rectal/rectosigmoid adenocarcinoma. EXPOSURE All individuals underwent radical resection for rectal cancer with or without neoadjuvant therapy. MAIN OUTCOMES AND MEASURES Rate of margin positivity determined and adjusted for patient-and tumor-related factors to calculate expected margin positivity per hospital. An observed to expected ratio was calculated based on patient-and tumor-related factors to identify treatment-associated variation. RESULTS The overall margin-positive resection rate was 5.2%. Patients with margins positive for cancer were more likely to be older, male, and African American; not have private insurance; and have their cancer diagnosed later in the study period. Associated tumor-related factors include rectal location, higher American Joint Committee on Cancer stage, signet/mucinous histology, and poor/undifferentiated grade. Among hospitals that were significantly low outliers, 47% were comprehensive community hospitals, and 43.9% were academic/research hospitals; of those that were significantly high outliers, 52.3% were comprehensive community hospitals, and 17.8% were academic/research hospitals. High-volume centers made up 80% of significantly low outlier hospitals and 17% of significantly high outlier hospitals. The rates of chemotherapy and radiation were similar, but low outlier hospitals gave more neoadjuvant radiation 26.3% vs 17%). CONCLUSIONS AND RELEVANCE After adjustment for patient-and tumor-related factors, we identified both low and high outlier hospitals for margin positivity at resection, as well as potentially modifiable risk factors. The nomogram created in this model allows for the evaluation of observed and expected event rates for individual hospitals, providing a hospital self-assessment tool for identifying targets for improvement.