Failure to comply with NCCN guidelines for the management of pancreatic cancer compromises outcomes

Abstract

Introduction: There are little data available regarding compliance with the National Comprehensive Cancer Network (NCCN) guidelines. We investigated variation in the management of pancreatic cancer (PC) among large hospitals in California, USA, specifically to evaluate whether compliance with NCCN guidelines correlates with patient outcomes.

Methods: The California Cancer Registry was used to identify patients treated for PC from 2001 to 2006. Only hospitals with ≥ 400 beds were included to limit evaluation to centres possessing resources to provide multimodality care (n= 50). Risk-adjusted multivariable models evaluated predictors of adherence to stage-specific NCCN guidelines for PC and mortality.

Results: In all, 3706 patients were treated for PC in large hospitals during the study period. Compliance with NCCN guidelines was only 34.5%. Patients were less likely to get recommended therapy with advanced age and low socioeconomic status (SES). Using multilevel analysis, controlling for patient factors (including demographics and comorbidities), hospital factors (e.g. size, academic affiliation and case volume), compliance with NCCN guidelines was associated with a reduced risk of mortality [odds ratio (OR) for death 0.64 (0.53-0.77, P < 0.0001)].

Conclusions: There is relatively poor overall compliance with the NCCN PC guidelines in California's large hospitals. Higher compliance rates are correlated with improved survival. Compliance is an important potential measure of the quality of care.

Figure 1

Compliance rate (green bars) for the 50 large California hospitals, with highest compliance to the left. Blue bars indicate academic hospitals. The red bars indicate annual case volume

Figure 2

Kaplan–Meier curve comparing survival of those who received compliant care (green line) vs. non-compliant care (red line) for all stages (a) and excluding stage IV (b). (P < 0.001 for both)

Figure 3

Kaplan–Meier curves comparing survival of stages I–III patients who received compliant care (green line) vs. non-compliant care (red line) at (from left to right) low- (1–15), medium- (16–25) and high- (>25) volume centres. Improved survival is seen for compliant care in every setting. (P < 0.001 for all)