Colon Cancer's Spread Often Unchecked

More Than 60% of U.S. Hospitals Fail Guidelines for Checking the Spread of Colon Cancer

From the WebMD Archives

Sept. 9, 2008 -- More than 60% of U.S. hospitals flunk minimum guidelines for checking to see if colon cancer has spread to the lymph nodes, a national "report card" shows.

If you have surgery to remove colon cancer, successful treatment depends on doctors knowing whether the cancer has spread beyond the original tumor. The best way to do this is to examine nearby lymph nodes.

Guidelines call for doctors to examine at least 12 lymph nodes close to the tumor, at least 75% of the time.

But 62% of U.S. hospitals don't meet this guideline, say Northwestern University researcher Karl Y. Bilimoria, MD, and colleagues.

"The vast majority of hospitals are not adhering to this benchmark," Bilimoria tells WebMD. "There is a lot of room for improvement."

Bilimoria's team looked at how hospitals did over time. In 1996-1997, soon after the guidelines came out, only 15% of hospitals complied with the guideline. By 2004-2005, compliance increased -- but only to 38% of hospitals.

Some types of hospitals did a lot better than others:

  • 78% of Comprehensive Cancer Centers met the guideline.
  • 52% of other university-affiliated hospitals met the guideline.
  • 53% of Veterans Administration hospitals met the guideline.
  • 34% of community hospitals met the guideline.

Bilimoria says it's crucial for doctors to examine lymph nodes to know whether a patient needs systemic chemotherapy after surgery. When lymph-node examination is inadequate, patients risk missing out on lifesaving treatment -- or risk having to undergo unnecessary chemotherapy.

"Everybody who takes care of a lot of colon cancer patients tells stories about getting a pathology report that said five lymph nodes were examined, none with metastatic disease," Bilimoria says. "Then the surgeon asked the pathologist to go back to look for more nodes, and -- lo and behold -- one is positive, completely altering the care the patient would have received."

Medical oncologist Jay Brooks, MD, chief of hematology and oncology at Ochsner Medical Center in Baton Rouge, La., says it's not the fault of any individual surgeon or pathologist.

Brooks, who was not involved in the Bilimoria study, notes that in many smaller hospitals, surgeons never meet the pathologists who examine the lymph node tissues from their patients at outside reference laboratories.


"Having the pathologist in direct conversation with the surgeon is an important thing. And the diligence with which the pathologist examines the specimen is a real critical component," Brooks tells WebMD. "We have made an extra effort to have a very integral conversation between a patient's medical oncologist, the surgeon, and the pathologist."

It works. Bilimoria says that 10 years ago, his hospital met the guideline no more than half the time. Now they meet it every year -- and are looking for the same kind of improvement in other types of cancer.

Care Bad for 60% of Colon Cancer Patients

Problems don't end even when colon cancer is properly diagnosed and treated.

More than 60% of colon cancer patients don't get proper follow-up care, find Gregory S. Cooper, MD, and colleagues at Cleveland's Case Western Reserve University.

That care is crucial, Cooper says, because 30% of patients have their cancer come back within five years of surgery. Quick detection of that second cancer results in a much better outcome.

In a study of nearly 10,000 elderly colon cancer patients covered by Medicare, the researchers found that 92% of patients regularly returned to their doctors for check-ups.

But more than one in four patients didn't get a follow-up colonoscopy within three years. (Current recommendations are to get one a year after surgery, and, if negative, every three years after that.)

Worse still, more than half of patients -- 53% -- didn't get even minimal blood tests (the CEA test) to see whether cancer might be spreading in their bodies.

"I would put most of the blame on the clinicians treating these patients," Cooper tells WebMD. "Colon cancer survivors must ask their doctors: Should I be having a blood test for cancer spread? When should I have my next colonoscopy?"

Ochsner's Brooks says it's crucial for patients who have had cancer to continue to get top-notch care from their doctors.

"Cancer isn't like appendicitis, where you get an operation and then go on with your life," Brooks says. "There are complications from treatment, complications from the disease -- and people do get second cancers. It is crucial they get follow-up care. I have worked here for 22 years, and have patients with second, third, and fourth cancers. And they're still coming in to see me."

The Bilimoria study appears in the Sept. 17 issue of the Journal of the National Cancer Institute. The Cooper study appears in the Oct. 15 issue of the journal Cancer.

WebMD Health News Reviewed by Louise Chang, MD on September 09, 2008



Bilimoria, K.Y. Journal of the National Cancer Institute, Sept. 17, 2008; vol 100: pp 1-8.

Cooper, G.S. Cancer, Oct. 15, 2008; vol 113, published online ahead of print.

Gregory S. Cooper, MD, professor of medicine, Case School of Medicine, and co-program leader for cancer prevention and control, Ireland Cancer Center of University Hospitals of Cleveland and the Case Comprehensive Cancer Center.

Karl Bilimoria, MD, American College of Surgeons research fellow at Feinberg School of Medicine, Northwestern University, Chicago.

Jay Brooks, MD, chief of medicine and chief of hematology/oncology, Ochsner Medical Center, Baton Rouge, La.

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