Quality check: concordance between two monitoring systems for postoperative organ/space-surgical site infections in rectal cancer surgery. Linkage of data from the Catalan Cancer Plan and the VINCat infection surveillance programme.

BACKGROUND: The Catalan Cancer Plan (CCP) undertakes periodic audits of cancer treatment outcomes, including organ/space surgical site infections (O/S-SSI) rates, while the Catalan Healthcare-associated Infections Surveillance Programme (VINCat) carries out standardized prospective surveillance of surgical site infections (SSI) in colorectal surgery. This cohort study aimed to assess the concordance between these two monitoring systems for O/S-SSI following primary rectal cancer surgery. METHODS: The study compared O/S-SSI incidence data from CCP clinical audits versus the VINCat Programme in patients undergoing surgery for primary rectal cancer, in 2011-12 and 2015-16, in publicly funded centres in Spain. The main outcome variable was the incidence of O/S-SSI in the first 30 days after surgery. Concordance between the two registers was analysed using Cohen's kappa. Discordant cases were reviewed by an expert, and the main reasons for discrepancies evaluated. RESULTS: Pooling data from both databases generated a sample of 2867 patients. Of these, O/S-SSI was detected in 414 patients-235 were common to both registry systems, with satisfactory concordance (κ = 0.69, 95% confidence interval 0.65-0.73). The rate of discordance from the CCP (positive cases in VINCat and negative in CCP) was 2.7%, and from VINCat (positive in CCP and negative in VINCat) was 3.6%. External review confirmed O/S-SSI in 66.2% of the cases in the CCP registry and 52.9% in VINCat. CONCLUSIONS: This type of synergy shows the potential of pooling data from two different information sources with a satisfactory level of agreement as a means to improving O/S-SSI detection. CLINICALTRIALS: gov Identifier: NCT06104579. Registered 30 November 2023.

Transanal Total Mesorectal Excision Versus Anterior Total Mesorectal Excision for Rectal Cancer: A Propensity Score Matched, Population-Based Study in Catalonia, Spain.

BACKGROUND: The clinical value of transanal total mesorectal excision is debated. OBJECTIVE: This study aimed to compare short- and medium-term effects of transanal versus anterior total mesorectal excision for rectal cancer. DESIGN: This was a multicenter retrospective cohort study. SETTING: The study included all Catalonian public hospitals. PATIENTS: All patients receiving transanal or anterior total mesorectal excision (open or laparoscopic) for nonmetastatic primary rectal cancer in 2015 to 2016 were included. MAIN OUTCOME MEASURES: Data on vital status were collected to March 2019. Between-group differences were minimized by applying propensity score matching to baseline patient characteristics. Competing risk models were used to assess systemic and local recurrence along with death at 2 years, and multivariable Cox regression was used to assess 2-year disease-free survival. Results are expressed with their 95% CIs. RESULTS: The final subsample was 537 patients receiving total mesorectal excision (transanal approach: n = 145; anterior approach: n = 392). Median follow-up was 39.2 months (interquartile range, 33.0-45.8). Accounting for death as a competing event, there was no association between transanal total mesorectal excision and local recurrence (matched subhazard ratio 1.28, 95% CI 0.55-2.96). There were no statistical differences in the comparative rate of local recurrence (transanal: 1.77 per 100 person-years, 95% CI 0.76-3.34; anterior: 1.37 per 100 person-years, 95% CI 0.8-2.15) or mortality (transanal: 3.98 per 100 person-years, 95% CI 2.36-6.16; anterior: 2.99 per 100 person-years, 95% CI 2.1-4.07). Groups presented similar 2-year cumulative incidence of local recurrence (4.83% versus 3.57%) and disease-free survival (HR, 1.33; 95% CI 0.92-1.92). LIMITATIONS: We used data only from the public system, the study is retrospective, and data on individual surgeons are not reported. CONCLUSION: These population-based results support the use of either the transanal, open, or laparoscopic approach for rectal cancer in Catalonia. See Video Abstract at http://links.lww.com/DCR/B744.ESCISIÓN MESORRECTAL TOTAL TRANSANAL VERSUS ESCISIÓN MESORRECTAL TOTAL ANTERIOR PARA EL CÁNCER DE RECTO: UN ESTUDIO POBLACIONAL CON EMPAREJAMIENTO DE PUNTAJE DE PROPENSIÓN EN CATALUÑA, ESPAÑA. ANTECEDENTES: Se debate el valor clínico de la escisión mesorrectal total transanal. OBJETIVO: Comparar los efectos a corto y mediano plazo de la escisión mesorrectal total transanal versus anterior para el cáncer de recto. DISEO: Este fue un estudio de cohorte retrospectivo multicéntrico. AJUSTE: El estudio incluyó a todos los hospitales públicos de Cataluña. PACIENTES: Todos los pacientes no metastásicos que recibieron escisión mesorrectal total anterior o transanal (abierta o laparoscópica) por cáncer de recto primario en 2015-16. PRINCIPALES MEDIDAS DE VALORACION: Los datos sobre el estado vital se recopilaron hasta marzo de 2019. Las diferencias entre los grupos se minimizaron aplicando el emparejamiento de puntajes de propensión a las características iniciales del paciente. Se utilizaron modelos de riesgo competitivo para evaluar la recurrencia sistémica y local junto con la muerte a los dos años, y la regresión de Cox multivariable para evaluar la supervivencia libre de enfermedad a dos años. Los resultados se expresan con sus intervalos de confianza del 95%. RESULTADOS: La submuestra final fue de 537 pacientes que recibieron escisión mesorrectal total (abordaje transanal: n = 145; abordaje anterior: n = 392). La mediana de seguimiento fue de 39,2 meses (rango intercuartílico 33,0-45,8). Teniendo en cuenta la muerte como un evento competitivo, no hubo asociación entre la escisión mesorrectal total transanal y la recurrencia local (cociente de subriesgo apareado 1,28, 0,55-2,96). No hubo diferencias estadísticas en la tasa comparativa de recurrencia local (transanal: 1,77 por 100 personas-año, 0,76-3,34; anterior: 1,37 por 100 personas-año, 0,8-2,15) o mortalidad (transanal: 3,98 por 100 personas-año, 2,36-6,16; anterior: 2,99 por 100 personas-año, 2,1-4,07). Los grupos presentaron una incidencia acumulada de dos años similar de recidiva local (4,83% frente a 3,57%, respectivamente) y supervivencia libre de enfermedad (índice de riesgo 1,33, 0,92-1,92). LIMITACIONES: Utilizamos datos solo del sistema público, el estudio es retrospectivo y no se informan datos sobre cirujanos individuales. CONCLUSIONES: Estos resultados poblacionales apoyan el uso del abordaje transanal, abierto o laparoscópico para el cáncer de recto en Cataluña. Consulte. Video Resumen en http://links.lww.com/DCR/B744. (Traducción- Dr. Francisco M. Abarca-Rendon).

Influence of adherence to adjuvant endocrine therapy on disease-free and overall survival: a population-based study in Catalonia, Spain.

OBJECTIVE: To assess adherence to endocrine therapy and its relation to recurrence and mortality in women with early breast cancer. METHODS: This is a retrospective cohort study in population-based cancer registries in two Catalonian provinces of Spain. We included all cases of invasive stage I-III breast cancer diagnosed from 2007 to 2011 and with follow-up to 2017. Adherence to endocrine therapy was measured by means of prescription refills. Patients were considered non-adherent if they filled less than 80% of their prescriptions. After collecting data from patients' medical records, we analysed clinical variables and their relation with adherence by means of logistic and Cox regression models. RESULTS: The study included 2413 women. Five-year adherence was 84.5%; the greatest risk for non-adherence was in women under 50 years of age, diagnosed with stage III cancer, treated with neoadjuvant therapy, or receiving tamoxifen or sequential treatment. Adverse effects were associated with greater adherence. Non-adherence was significantly and independently associated with recurrence (hazard ratio [HR] 1.71, 95% confidence interval [CI] 1.16-2.51) and all-cause mortality (HR 2.11, 95% CI 1.62-2.74), after adjusting for age and tumour stage. CONCLUSIONS: Although non-adherence was relatively infrequent in this population-based study, its impact on the risk of recurrence and mortality was considerable. Clinicians should make efforts to ensure therapeutic adherence during clinical follow-up of women with breast cancer.

Improving clinical outcomes through centralization of rectal cancer surgery and clinical audit: a mixed-methods assessment.

BACKGROUND: The aim of centralizing rectal cancer surgery in Catalonia (Spain) was to improve the quality of patient care. We evaluated the impact of this policy by assessing patterns of care, comparing the clinical audits carried out and analysing the implications of the healthcare reform from an organizational perspective. METHODS: A mixed methods approach based on a convergent parallel design was used. Quality of rectal cancer care was assessed by means of a clinical audit for all patients receiving radical surgery for rectal cancer in two time periods (2005-2007 and 2011-2012). The qualitative study consisted of 18 semi-structured interviews in September-December 2014, with healthcare professionals, managers and experts. RESULTS: From 2005-2007 to 2011-2012, hospitals performing rectal cancer surgery decreased from 51 to 32. The proportion of patients undergoing surgery in high volume centres increased from 37.5% to 52.8%. Improved report of total mesorectal excision (36.2 vs. 85.7), less emergency surgery (5.6% vs. 3.6%) and more lymph node examinations (median: 14.1 vs. 16) were observed (P < 0.001). However, centralizing highly complex cancers using different critical masses and healthcare frameworks prompted the need for rearticulating partnerships at a hospital, rather than disease, level. CONCLUSION: The centralization of rectal cancer surgery has been associated with better quality of care and conformity with clinical guidelines. However, a more integrated model of care delivery is needed to strengthen the centralization strategy.

Management, Survival, and Costs of Pancreatic Cancer: Population-Based Observational Study in Catalonia.

AIM: Few published studies comprehensively describe the characteristics of patients with pancreatic cancer and their treatment in clinical practice. This study aimed to describe the current clinical practice for treating pancreatic cancer in Catalonia, along with the associated survival and treatment costs. METHODS: A retrospective observational cohort study in patients diagnosed with pancreatic cancer from 2014 to 2018, using data from the healthcare records of the Public Health System of Catalonia, was conducted. Treatment patterns and costs were described by age groups from 2014 to 2018, with survival reported until December 2021. RESULTS: The proportion of patients receiving surgery with curative intent was low, especially in older patients (23% of patients <60 years and 9% of patients ≥80 years). The percentage of patients treated with drugs for unresectable disease also decreased with age (45% of patients <60 years and 8% of patients ≥80 years). Although age was associated with significant differences in survival after curative surgery, no differences attributable to age were observed in patients who received pharmacological treatment for unresectable disease. In patients under 60 years of age, the mean cost of the first year of treatment was EUR 17,730 (standard deviation [SD] 5754) in those receiving surgery and EUR 5398 (SD 9581) in those on pharmacological treatment for unresectable disease. In patients over 80, the mean costs were EUR 15,339 (SD 2634) and EUR 1845 (SD 3413), respectively. CONCLUSIONS: Half of the patients diagnosed with pancreatic cancer did not receive specific treatment. Surgery with curative intent was associated with longer survival, but only 18% of (mostly younger) patients received this treatment. Chemotherapy was also used less frequently in patients of advanced age, though survival in treated patients was comparable across all age groups, so careful oncogeriatric assessment is advisable to ensure the most appropriate indication for eligibility in older patients. In general, earlier diagnosis and more effective pharmacological treatments are necessary to treat frail patients with high comorbidity, a common profile in older patients.

Centralisation of surgery for complex cancer diseases: A scoping review of the evidence base on pancreatic cancer.

BACKGROUND: Centralisation of cancer surgery is a commonly applied healthcare strategy worldwide. This study aimed to detail the design of centralisation policies, to shed light on the implications of such policies in real practice and to describe the different perspectives taken to deal with difficulties that emerged, taking pancreatic cancer as an example of a complex cancer disease requiring surgery. METHODOLOGY: A scoping review was conducted using the MEDLINE database. We systematically searched for eligible studies published between January 2000 and December 2018. RESULTS: In the 33 included studies, centralisation of pancreatic cancer surgery was implemented through three different models: designated hospitals, definition of minimum volumes per provider, and/or recommendations included in protocols and national guidelines. The presence of highly advanced technology and infrastructures, the availability of extensive service coverage and advanced care processes based on expert multidisciplinary teams, and higher caseloads were identified as key components of centralisation policy. CONCLUSIONS: Centralisation models for pancreatic cancer surgery showed that having expert centres where the care process is comprehensively guided is a foundational policy approach. External quality assessment and the accreditation of centres and professionals performing complex surgical procedures are levers that may positively impact the effectiveness of the measure. POLICY SUMMARY: while we found different experiences and three models of centralisation, all of them were guided by the will to positively impact on pancreatic cancer patients' access to expert care. Clinical research might be able to make progress in the coming years and perhaps contribute to reversing a critical situation of high mortality and growing incidence. However, policymakers must optimise health system responses considering current resources, as suggested by the recommendations proposed in the framework of the EU initiative Bratislava Statement for pancreatic cancer care.

Prehospital care for ovarian cancer in Catalonia: could we do better in primary care? Retrospective cohort study.

OBJECTIVE: To assess the impact of prehospital factors (diagnostic pathways, first presentation to healthcare services, intervals, participation in primary care) on 1-year and 5-year survival in people with epithelial ovarian cancer (EOC). DESIGN: Retrospective quasi-population-based cohort study. SETTING: Catalan Integrated Public Healthcare System. PARTICIPANTS: People with EOC who underwent surgery with a curative intent in public Catalan hospitals between 1 January 2013 and 31 December 2014. OUTCOME MEASURES: Data from primary and secondary care clinical histories and care processes in the 18 months leading up to confirmation (signs and symptoms at presentation, diagnosis pathways, referrals, diagnosis interval) of the EOC diagnosis (stage, histology type, treatment). Diagnostic process intervals were based on the Aarhus statement. 1-year and 5-year survival analysis was undertaken. RESULTS: Of the 513 patients included in the cohort, 67.2% initially consulted their family physician, while 36.4% were diagnosed through emergency services. In the Cox models, survival was influenced by advanced stage at 1 year (HR 3.84, 95% CI 1.23 to 12.02) and 5 years (HR 5.36, 95% CI 3.07 to 9.36), as was the type of treatment received, although this association was attenuated over follow-up. Age became significant at 5 years of follow-up. After adjusting for age, adjusted morbidity groups, stage at diagnosis and treatment, 5-year survival was better in patients presenting with gynaecological bleeding (HR 0.35, 95% CI 0.16 to 0.79). Survival was not associated with a starting point involving primary care (HR 1.39, 95% CI 0.93 to 2.09), diagnostic pathways involving referral to elective gynaecological care from non-general practitioners (HR 0.80, 95% CI 0.51 to 1.26), or self-presentation to emergency services (HR 0.82, 95% CI 0.52 to 1.31). CONCLUSIONS: Survival in EOC is not associated with diagnostic pathways or prehospital healthcare, but it is influenced by stage at diagnosis, administration of primary cytoreduction plus chemotherapy and patient age.

Socioeconomic Status and Distance to Reference Centers for Complex Cancer Diseases: A Source of Health Inequalities? A Population Cohort Study Based on Catalonia (Spain).

The centralization of complex surgical procedures for cancer in Catalonia may have led to geographical and socioeconomic inequities. In this population-based cohort study, we assessed the impacts of these two factors on 5-year survival and quality of care in patients undergoing surgery for rectal cancer (2011-12) and pancreatic cancer (2012-15) in public centers, adjusting for age, comorbidity, and tumor stage. We used data on the geographical distance between the patients' homes and their reference centers, clinical patient and treatment data, income category, and data from the patients' district hospitals. A composite 'textbook outcome' was created from five subindicators of hospitalization. We included 646 cases of pancreatic cancer (12 centers) and 1416 of rectal cancer (26 centers). Distance had no impact on survival for pancreatic cancer patients and was not related to worse survival in rectal cancer. Compared to patients with medium-high income, the risk of death was higher in low-income patients with pancreatic cancer (hazard ratio (HR) 1.46, 95% confidence interval (CI) 1.15-1.86) and very-low-income patients with rectal cancer (HR 5.14, 95% CI 3.51-7.52). Centralization was not associated with worse health outcomes in geographically dispersed patients, including for survival. However, income level remained a significant determinant of survival.

Effects of partner smoking status and gender on long term abstinence rates of patients receiving smoking cessation treatment.

AIMS: To assess the effect of partner smoking status on the success of a cessation program. DESIGN: Prospective cohort. SETTING: Smoking Cessation Unit in Hospital of Bellvitge (Hospitalet de Llobregat, Barcelona). PARTICIPANTS: A total of 1516 smokers of 10 or more cigarettes who started a smoking cessation program between January 1995 and December 2001 were included. MEASUREMENTS: All patients gave information about smoking history and smoking partner status. Abstinence was determined by carbon monoxide exhaled. FINDINGS: Significant differences were found in the abstinence rates at 12 months by smoking partner status: abstinence was achieved by 28.3% of patients with smoking partner, and by 46.5% of patients without smoking partner (p<0.001). Subjects whose partner was smoking at the beginning of the program appear to be more likely to relapse than subjects without smoking partners (p<0.001) and this is more pronounced in women than in men. However no significant gender differences were found in any group of smoking partner status. CONCLUSIONS: Having a smoking partner is a determinant of relapse 1 year after the beginning of the cessation program. Interacting not just with the smoker, but also with his or her partner, could neutralize interpersonal influences making smokers more accessible to behavioural and pharmacological techniques.

Assessing the effectiveness of a guideline recommendation for pre-operative radiochemotherapy in rectal cancer.

AIM: To ascertain the degree of adherence to the guideline recommendation on pre-operative RT/ChT for stage-II and -III patients in Catalonian public hospitals, and its impact on local recurrence among rectal cancer patients. METHODS: Data were derived from a multicentre retrospective cohort study of patients who underwent curative-intent surgery for primary rectal cancer at Catalonian public hospitals in 2005 and 2007. RESULTS: The study covered 1229 patients with TNM stage-II or -III primary rectal cancer. Of these patients, 54.5% underwent pre-operative RT/ChT; 14.9% underwent post-operative RT (± chemotherapy); and 30.6% did not undergo any RT. The crude local recurrence rate at 2years was 4.1% and the crude distant recurrence rate at 2years was 6.5%. The results of the univariate analyses showed a local-recurrence hazard ratio of 1.84 for the group of patients that received no RT versus the group that received pre-operative RT/ChT (p<0.01). CONCLUSIONS: This is the first population-based study in Catalonia to support the use of pre-operative RT/ChT in rectal cancer patients because, in line with the results of population-based studies reported from other countries, its application, compared to non-application of RT, was found to lead to a clear reduction in the probability of local recurrence.