Outcomes in rectal cancer care in Uruguay: A study on quality indicators.
Authors: Fontes Santiago , Berry Megan , Marín-Jiménez Ana , Sánchez Juan Carlos , Reyes Graciela , Cuello Mauricio , Krygier Gabriel David 
Published: September 2021

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Background: For years, rectal cancer has been considered a model oncologic entity and significant therapeutic improvements have been made in the last two decades. However, evidence suggests there are important differences in quality of care between countries, institutions and teams. Therefore, population-based audits are of great importance to ensure quality cancer care. Quality indicators (QIs) provide information on safety and quality of cancer screening, diagnosis and treatment. Aim: To describe and analyze quality indicators for diagnosis and treatment of rectal carcinoma at a high-volume cancer center in Uruguay. Methods: A retrospective descriptive study was performed as a sub-analysis of a cohort of 971 patients. A total of 497 rectal or rectosigmoid-junction carcinoma patients treated between 2008 and 2020 at the Uruguayan National Cancer Institute were included. Previously validated target values formed the basis of the QIs used in this study. Each QI was reported as the proportion (% 95% CI) of patients fulfilling the criteria out of eligible patients. Kaplan–Meier method was used to calculate overall survival rates. Results: Mean age was 62 years, 59.5% were male, and 78% showed no evidence of disseminated disease at diagnosis. Diagnosis and staging: combined contrast-enhanced CT TAP scan was performed in 66% of the sample, 51% of cases had a total colonoscopy before elective curative intent surgery. Locoregional c-TN staging was assessed by high resolution MRI in 64% of cases. Only 30% and 63% of patients in the preoperatively irradiated and the nonirradiated groups had a minimum of 12 lymph nodes examined. Multimodal treatment: preoperative chemo-radiation was delivered for stages II and III middle/low-third rectal cancers in 81% of the cases. Adjuvant therapy was prescribed in 75% and 47% of stages III and II receiving surgery as upfront treatment, respectively. 78% of cStage IV patients received palliative chemotherapy. Surrogate indicators of outcome: 82% had distal tumor-free margins, although only 72% had a pathological circumferential radial margin ((y)pCRM) mentioned in the pathology report. Non-curative (R1,2) resections in M0 rectal carcinoma in our cohort was below the target value of <20%. 15% of our cases had a positive (y)pCRM. Treatment-outcomes: Our cumulative overall local recurrence was 12.6% and the 3-year overall survival rate was 84.8%. Conclusions: Continuous analysis of QIs in rectal cancer is necessary for internal quality management and for external quality assessment, to improve and compare treatment outcomes. Our results highlight the positive aspects of rectal cancer care at our center and reveal the weak points in diagnosis and treatment that need special attention. They will serve as a guide in the implementation of new strategies and programs that will aim to improve safety and quality of rectal cancer care for Uruguayan patients, regardless of where they live or are treated.