Impact of comorbidity and healthcare utilization on colorectal cancer stage at diagnosis: literature review

Understanding mechanisms of racial disparities in breast cancer: an assessment of screening and regular care in the Carolina Breast Cancer Study

PURPOSE

Screening history influences stage at detection, but regular preventive care may also influence breast tumor diagnostic characteristics. Few studies have evaluated healthcare utilization (both screening and primary care) in racially diverse screening-eligible populations.

METHODS

This analysis included 2,058 women age 45-74 (49% Black) from the Carolina Breast Cancer Study, a population-based cohort of women diagnosed with invasive breast cancer between 2008 and 2013. Screening history (threshold 0.5 mammograms per year) and pre-diagnostic healthcare utilization (i.e. regular care, based on responses to "During the past ten years, who did you usually see when you were sick or needed advice about your health?") were assessed as binary exposures. The relationship between healthcare utilization and tumor characteristics were evaluated overall and race-stratified.

RESULTS

Among those lacking screening, Black participants had larger tumors (5 + cm) (frequency 19.6% vs 11.5%, relative frequency difference (RFD) = 8.1%, 95% CI 2.8-13.5), but race differences were attenuated among screening-adherent participants (10.2% vs 7.0%, RFD = 3.2%, 0.2-6.2). Similar trends were observed for tumor stage and mode of detection (mammogram vs lump). Among all participants, those lacking both screening and regular care had larger tumors (21% vs 8%, RR = 2.51, 1.76-3.56) and advanced (3B +) stage (19% vs 6%, RR = 3.15, 2.15-4.63) compared to the referent category (screening-adherent and regular care). Under-use of regular care and screening was more prevalent in socioeconomically disadvantaged areas of North Carolina.

CONCLUSIONS

Access to regular care is an important safeguard for earlier detection. Our data suggest that health equity interventions should prioritize both primary care and screening.

Advanced stage presentation and its determinant factors among colorectal cancer patients in Amhara regional state Referral Hospitals, Northwest Ethiopia

INTRODUCTION

Nowadays, the burden of colorectal cancer (CRC) has been increasing in the world, particularly in developing nations. This could be related to the poor prognosis of the disease due to late presentation at diagnosis and poor treatment outcomes. In Ethiopia, studies related to the stage of colorectal cancer at diagnosis and its determinants are limited. Therefore, the study was intended to assess advanced stage presentation and its associated factors among colorectal cancer patients in northwest Ethiopia.

METHODS

An institution-based retrospective study was conducted among 367 CRC patients at two oncologic centers (the University of Gondar and Felege Hiwot comprehensive specialized hospitals) from January 1, 2017, to December 31, 2020. Data were entered into EPi-data 4.2.0.0 and transferred to STATA version 14 statistical software for analysis. Binary logistic regression was used to identify factors associated with the outcome variable. All variables with P-value < 0.2 during bi-variable analysis were considered for multivariable logistic regression. The level of statistical significance was declared at P-value <0.05.

RESULTS

The magnitude of advanced stage presentation of colorectal cancer was 83.1%. Being rural dwellers (Adjusted odds ratio (AOR) = 3.6; 95% CI: 1.8,7.2), not medically insured (AOR = 3.9; 95% CI: 1.9,7.8), patients delay (AOR = 6.5; 95% CI:3.2, 13.3), recurrence of the disease (AOR = 2.3; 95% CI: 1.1,4.7), and no comorbidity illness (AOR = 4.4; 95% CI: 2.1, 9.1) were predictors of advanced stage presentation of CRC.

CONCLUSION

The current study revealed that the advanced-stage presentation of colorectal cancer patients was high. It is recommended that the community shall be aware of the signs and symptoms of the disease using different media, giving more emphasis to the rural community, expanding health insurance, and educating patients about the recurrence chance of the disease. Moreover, expansion of colorectal treatment centers and screening of colorectal cancer should be given emphasis.

Occurrence of comorbidity with colorectal cancer and variations by age and stage at diagnosis

BACKGROUND

While age and stage at diagnosis are known to affect treatment choices and survival from colorectal cancer (CRC), few studies have investigated the extent to which these effects are influenced by comorbidity. In this study, we describe the occurrence of comorbidity in CRC cases in South Australia and associations of comorbidity with age, stage and the age-stage relationship. Furthermore, we report on the association of individual comorbidities with age and stage at diagnosis.

METHODS

The South Australian Cancer Registry (SACR) provided CRC data (C18-C20, ICD-10) for 2004-2013 diagnoses. CRC data were linked with comorbidity data drawn from hospital records and health insurance claims. Logistic regression was used to model associations of comorbidity with age and stage.

RESULTS

For the 8462 CRC cases in this study, diabetes, peptic ulcer disease, and previous cancers were the most commonly recorded co-existing conditions. Most comorbidities were associated with older age, although some presented more frequently in younger people. Patients at both ends of the age spectrum (<50 and 80 + years) had an increased likelihood of CRC diagnosis at an advanced stage compared with other ages (50-79 years old). Adjusting for comorbidities moderated the association of older age with advanced stage. Conditions associated with advanced stage included dementia (OR = 1.25 (1.01-1.55)), severe liver disease (OR = 1.68 (1.04-2.70)), and a previous cancer (OR = 1.18 (1.08-1.28)).

CONCLUSION

Comorbidities are prevalent with CRC, especially in older people. These comorbidities differ in their associations with age at diagnosis and stage. Dementia and chronic heart failure were associated with older age whereas inflammatory bowel disease and alcohol access were associated with younger onset of the disease. Severe liver disease and dementia were associated with more advanced stage and rheumatic disease with less advanced stage. Comorbidities also interact with age at diagnosis and appear to vary the likelihood of advanced-stage disease. CRC patient have different association of age with stage depending on their comorbidity status.

The Prognostic Value of Eight Comorbidity Indices in Older Patients with Cancer: The ELCAPA Cohort Study

Background: A prognostic assessment is crucial for making cancer treatment decisions in older patients. We assessed the prognostic performance (relative to one-year mortality) of eight comorbidity indices in a cohort of older patients with cancer. Methods: We studied patients with cancer aged ≥70 included in the Elderly Cancer Patient (ELCAPA) cohort between 2007 and 2010. We assessed seven nonspecific indices (Charlson Comorbidity Index (CCI), three modified versions of the CCI, the Elixhauser Comorbidity Index, the Gagne index, and the Cumulative Illness Rating Scale for Geriatrics (CIRS-G)) and the National Cancer Institute Comorbidity Index. Results: Overall, 510 patients were included. Among patients with nonmetastatic cancer, all the comorbidity indices were independently associated with 1-year mortality (adjusted hazard ratios (aHRs) of 1.44 to 2.51 for one standard deviation increment; p < 0.05 for all) and had very good discriminant ability (Harrell’s C > 0.8 for the eight indices), but were poorly calibrated. Among patients with metastatic cancer, only the CIRS-G was independently associated with 1-year mortality (aHR (95% confidence interval): 1.26 [1.06−1.50]). Discriminant ability was moderate (0.61 to 0.70) for the subsets of patients with metastatic cancer and colorectal cancer. Conclusion: Comorbidity indices had strong prognostic value and discriminative ability for one-year mortality in older patients with nonmetastatic cancer, although calibration was poor. In older patients with metastatic cancer, only the CIRS-G was predictive of one-year mortality.

Abstaining from annual health check-ups is a predictor of advanced cancer diagnosis: a retrospective cohort study

Background

Cancer prevention is a crucial challenge in preventive medicine. Several studies have suggested that voluntary health check-ups and recommendations from health professionals are associated with increased participation in cancer screening. In Japan, it is recommended that individuals aged 40–74 years should undergo annual health check-ups; however, the compliance to this recommendation is approximately <50%. According to the national survey, individuals who do not undergo annual health check-ups are at a higher risk for cancer. However, to the best of our knowledge, no previous study has investigated the association between the use of health check-ups and the incidence rate of cancer. We hypothesised that not undergoing periodic health check-ups and/or less use of outpatient medical services are predictors for advanced cancer.

Methods

To explore the relationship between health check-up or outpatient service utilisation and cancer incidence, this retrospective cohort study used data at two time points—baseline in 2014 and endpoint in 2017—from the National Health Insurance (NHI) claims and cancer registry. A multivariable logistic regression analysis was performed to investigate whether cancer diagnosis was associated with health check-up or outpatient service utilisation.

Results

A total of 72,171 participants were included in the analysis. The results of the multivariable logistic regression showed that individuals who skipped health check-ups had a higher risk of cancer diagnosis (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.04–1.40). Moreover, not undergoing health check-ups increased the risk of advanced-stage cancer (OR, 1.78; 95% CI, 1.29–2.44). Furthermore, increased rate of outpatient service utilisation was negatively associated with advanced cancer diagnosis.

Conclusions

This is the first study reporting that not undergoing health check-ups is a predictor of cancer diagnosis and advanced cancer stage. Primary prevention strategies for NHI members who do not undergo health check-ups must be reassessed. Moreover, future research should examine secondary prevention strategies, such as health education and recommendations from health professionals to facilitate adequate utilisation of preventive health services.

Supplementary information

The online version contains supplementary material available at https://doi.org/10.1265/ehpm.21-00292.

Associations between comorbidities and advanced stage diagnosis of lung, breast, colorectal, and prostate cancer: A systematic review and meta-analysis

Comorbidities and advanced stage diagnosis (ASD) are both associated with poorer cancer outcomes, but the association between comorbidities and ASD is poorly understood. We summarized epidemiological evidence on the association between comorbidities and ASD of selected cancers in a systematic review and meta-analysis. We searched PubMed and Web of Science databases up to June 3rd, 2021 for studies assessing the association between comorbidities and ASD of lung, breast, colorectal, or prostate cancer. Summary odds ratios (ORs) and 95% confidence intervals (95%CIs) were calculated using random-effects models. Also, potential variations in the associations between comorbidities and ASD by cancer type were investigated using random-effects meta-regression. Thirty-seven studies were included in this review, including 8,069,397 lung, breast, colorectal, and prostate cancer patients overall. The Charlson comorbidity index score was positively associated with ASD (stages III-IV) of breast cancer but was inversely associated with ASD of lung cancer (p_interaction = 0.004). Regarding specific comorbidities, diabetes was positively associated with ASD (OR = 1.17, 95%CI = 1.09-1.26), whereas myocardial infarction was inversely associated with ASD (OR = 0.84, 95%CI = 0.75-0.95). The association between renal disease and ASD differed by cancer type (p_interaction < 0.001). A positive association was found with prostate cancer (OR = 2.02, 95%CI = 1.58-2.59) and an inverse association with colorectal cancer (OR = 0.84, 95%CI = 0.70-1.00). In summary, certain comorbidities (e.g., diabetes) may be positively associated with ASD of several cancer types. It needs to be clarified whether closer monitoring for early cancer signs or screening in these patients is reasonable, considering the problem of over-diagnosis particularly relevant in patients with short remaining life expectancy such as those with comorbidities. Also, evaluation of the cost-benefit relationship of cancer screening according to the type and severity of comorbidity (rather than summary scores) may be beneficial for personalized cancer screening in populations with chronic diseases.

Antibiotics Use and Subsequent Risk of Colorectal Cancer: A Swedish Nationwide Population-Based Study

Background

Antibiotics use may increase colorectal cancer (CRC) risk by altering the gut microbiota, with suggestive evidence reported. Our study aims to investigate antibiotics use in relation to subsequent CRC risk.

Methods

This is a nationwide, population-based study with a matched case-control design (first primary CRC cases and 5 matched, cancer-free controls). Complete-population data, extracted from Swedish national registers for the period 2005-2016, were used to calculate odds ratios and 95% confidence intervals.

Results

We included 40 545 CRC cases and 202 720 controls. Using the full dataset, we found a positive association between more frequent antibiotics use and CRC, excluding antibiotics prescribed within 2 years of diagnosis attenuated results toward the null. In site-specific analyses, excluding the 2-year washout, the positive association was confined to the proximal colon (adjusted odds ratio for very high use vs no use = 1.17, 95% confidence interval = 1.05 to 1.31). For rectal cancer, an inverse association, which appears to be driven by women, was observed. Quinolones and sulfonamides and/or trimethoprims were positively associated with proximal colon cancer, whereas a more general inverse association, across antibiotics classes, was observed for rectal cancer. We found no association between methenamine hippurate, a urinary tract antiseptic not affecting the gut microbiota, and CRC risk.

Conclusions

This register-based study covering the entire population of Sweden found a robust association between antibiotics use and higher risk of proximal colon cancer and an inverse association with rectal cancer in women. This study strengthens the evidence from previous investigations and adds important insight into site-specific colorectal carcinogenesis.

Immunotherapy Utilization Among Patients With Metastatic NSCLC: Impact of Comorbidities

In patients with metastatic non-small cell lung cancer (mNSCLC), the extent to which immunotherapy utilization rate varies by comorbidities is unclear. Using the National Cancer Database from 2015 to 2016, we assessed the association between levels of comorbidity and immunotherapy utilization among mNSCLC patients. Burden of comorbidities was ascertained based on the modified Charlson-Deyo score and categorized as an ordinal variable (0, 1, and ≥2). Immunotherapy utilization was determined based on registry data. Multivariable logistic regressions were used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) for the comorbidity score while adjusting for sociodemographic factors, histopathologic subtype, surgery, chemotherapy, radiotherapy, insurance, facility type, and other cancer history. Subgroup analyses were conducted by age and race/ethnicity. Overall, of the 89,030 patients with mNSCLC, 38.6% (N=34,382) had the comorbidity score of ≥1. Most patients were non-Hispanic white (82.3%, N=73,309) and aged 65 years and above (63.2%, N=56,300), with the mean age of 68.4 years (SD=10.6). Only 7.0% (N=6220) of patients received immunotherapy during 2015-2106. Patients with a comorbidity score of ≥2 had a significantly lower rate of immunotherapy utilization versus those without comorbidities (aOR=0.85; 95% CI, 0.78-0.93; P-trend<0.01). In subgroup analysis by age, association patterns were similar among patients younger than 65 and those aged 65-74 years. There were no significant differences in subgroup analysis by race/ethnicity, although statistical significance was only observed for white patients (comorbidity score ≥2 vs. 0: aOR=0.85; 95% CI, 0.77-0.93; P-trend<0.01). In conclusion, mNSCLC patients with a high burden of comorbidities are less likely to receive immunotherapy.

Comorbid chronic diseases and cancer diagnosis: disease-specific effects and underlying mechanisms

An earlier diagnosis is a key strategy for improving the outcomes of patients with cancer. However, achieving this goal can be challenging, particularly for the growing number of people with one or more chronic conditions (comorbidity/multimorbidity) at the time of diagnosis. Pre-existing chronic diseases might affect patient participation in cancer screening, help-seeking for new and/or changing symptoms and clinicians' decision-making on the use of diagnostic investigations. Evidence suggests, for example, that pre-existing pulmonary, cardiovascular, neurological and psychiatric conditions are all associated with a more advanced stage of cancer at diagnosis. By contrast, hypertension and certain gastrointestinal and musculoskeletal conditions might be associated with a more timely diagnosis. In this Review, we propose a comprehensive framework that encompasses the effects of disease-specific, patient-related and health-care-related factors on the diagnosis of cancer in individuals with pre-existing chronic illnesses. Several previously postulated aetiological mechanisms (including alternative explanations, competing demands and surveillance effects) are integrated with newly identified mechanisms, such as false reassurances, or patient concerns about appearing to be a hypochondriac. By considering specific effects of chronic diseases on diagnostic processes and outcomes, tailored early diagnosis initiatives can be developed to improve the outcomes of the large proportion of patients with cancer who have pre-existing chronic conditions.

Colorectal cancer in Saudi Arabia as the proof-of-principle model for implementing strategies of predictive, preventive, and personalized medicine in healthcare

Colorectal cancer (CRC) is the most commonly diagnosed cancer among Saudi males and ranks third in females with up to 73% of cases diagnosed at late stage. This review provides an analysis of CRC situation in the Kingdom of Saudi Arabia (KSA) from healthcare perspective. A PUBMED (1986-2018) search was done to identify publications focusing on CRC in KSA. Due to reports of increased CRC incidence among young age group (< 50), and given the young population of KSA, the disease may burden the national healthcare system in the next decades. Environmental factors attributed to increasing incidence rates of CRC include red meat consumption, sedentary lifestyle, and increased calorie intake. Despite substantial investment in healthcare, attention to predictive diagnostics and targeted prevention is lacking. There is a need to develop national screening guidelines based on evidence that supports a reduction in incidence and mortality of CRC when screening is implemented. Future approaches are discussed based on multi-level diagnostics, risk assessment, and population screening programs focused on the needs of young populations that among others present the contents of the advanced approach by predictive, preventive, and personalized medicine. Recommendations are provided that could help to develop policies at regional and national levels. Countries with demographics and lifestyle similar to KSA may gain insights from this review to shape their policies and procedures.

Contrasting effects of comorbidities on emergency colon cancer diagnosis: a longitudinal data-linkage study in England

BACKGROUND

One in three colon cancers are diagnosed as an emergency, which is associated with worse cancer outcomes. Chronic conditions (comorbidities) affect large proportions of adults and they might influence the risk of emergency presentations (EP).

METHODS

We aimed to evaluate the effect of specific pre-existing comorbidities on the risk of colon cancer being diagnosed following an EP rather than through non-emergency routes. The cohort study included 5745 colon cancer patients diagnosed in England 2005-2010, with individually-linked cancer registry, primary and secondary care data. In addition to multivariable analyses we also used potential-outcomes methods.

RESULTS

Colon cancer patients with comorbidities consulted their GP more frequently with cancer symptoms during the pre-diagnostic year, compared with non-comorbid cancer patients. EP occurred more frequently in patients with 'serious' or complex comorbidities (diabetes, cardiac and respiratory diseases) diagnosed/treated in hospital during the years pre-cancer diagnosis (43% EP in comorbid versus 27% in non-comorbid individuals; multivariable analysis Odds Ratio (OR), controlling for socio-demographic factors and symptoms: men OR = 2.40; 95% CI 2.0-2.9 and women OR = 1.98; 95% CI 1.6-2.4. Among women younger than 60, gynaecological (OR = 3.41; 95% CI 1.2-9.9) or recent onset gastro-intestinal conditions (OR = 2.84; 95% CI 1.1-7.7) increased the risk of EP. In contrast, primary care visits for hypertension monitoring decreased EPs for both genders.

CONCLUSIONS

Patients with comorbidities have a greater risk of being diagnosed with cancer as an emergency, although they consult more frequently with cancer symptoms during the year pre-cancer diagnosis. This suggests that comorbidities may interfere with diagnostic reasoning or investigations due to 'competing demands' or because they provide 'alternative explanations'. In contrast, the management of chronic risk factors such as hypertension may offer opportunities for earlier diagnosis. Interventions are needed to support the diagnostic process in comorbid patients. Appropriate guidelines and diagnostic services to support the evaluation of new or changing symptoms in comorbid patients may be useful.

Do comorbidities influence help-seeking for cancer alarm symptoms? A population-based survey in England

Background

We examined associations between different chronic morbidities and help-seeking for possible cancer symptoms.

Methods

Postal survey of individuals aged >50 years in England. Participants could report prior morbidities in respect of 12 pre-defined conditions. Among patients experiencing possible cancer symptoms we examined associations between specific morbidities and self-reported help-seeking (i.e. contacted versus not contacted a GP) for each alarm symptom using regression analyses.

Results

Among 2042 respondents (42% response rate), 936 (46%) recently experienced 1 of 14 possible cancer symptoms considered in our analysis. Of them, 80% reported one or more morbidities, most frequently hypertension/hypercholesterolemia (40%), osteomuscular (36%) and heart diseases (21%). After adjustment for socio-demographic characteristics, patients with hypertension/hypercholesterolemia were more likely to report help-seeking for possible cancer symptoms, such as unexplained cough (OR = 2.0; 95% confidence interval (CI) 1.1-3.5), pain (OR = 2.2; 95% CI 1.0-4.5) and abdominal bloating (OR = 2.3; 95% CI 1.1-4.8). Urinary morbidity was associated with increased help-seeking for abdominal bloating (OR = 5.4; 95% CI 1.2-23.7) or rectal bleeding (OR = 5.8; 95% CI 1.4-23.8). In contrast, heart problems reduced help-seeking for change in bowel habits (OR = 0.4; 95% CI 0.2-1.0).

Conclusions

Comorbidities are common and may facilitate help-seeking for possible cancer symptoms, but associations vary for specific symptom-comorbidity pairs. The findings can contribute to the design of future cancer symptom awareness campaigns.

Serum matrix metalloproteinase-9 level as a biomarker for colorectal cancer: a diagnostic meta-analysis

AIM

To comprehensively evaluate the diagnostic value of serum matrix metalloproteinase-9 (MMP-9) level for colorectal cancer (CRC).

METHODS

Both of the relationships between MMP-9 level and CRC and the diagnostic value were evaluated from 12 eligible papers.

RESULTS

The high MMP-9 level increased CRC risk. The estimated sensitivity and specificity were 69 and 68%, respectively, which signified that the diagnostic value was medium. Diagnostic odds ratio and the area under the receiver operating characteristic curve suggested MMP-9 level has a moderate diagnostic value in CRC. Additionally, the likelihood matrix indicated MMP-9 levels could be considered as a biomarker for the diagnosis of CRC.

CONCLUSION

Patients with CRC have elevated MMP-9 levels, which is a potential biomarker for CRC diagnosis.

Cancer, ageing, multimorbidity and primary care

Cancer care is complex, and made more so by multimorbidity and ageing. Multimorbidity affects all stages of cancer care from prevention and early detection through to end of life care. The effectiveness of cancer treatments in multimorbid patients may not be understood, as many conditions common in older people may be exclusion criteria in oncology clinical trials. The interaction between pre-existing physical capacity, multiple medical conditions and ageing can delay diagnosis, impact on treatments, complicate survivor care, and impact on decisions about starting and ceasing treatments. General Practitioners (GPs) manages multimorbidity routinely, yet the GP role in comprehensive cancer care is limited. Integration of GP management of multimorbidity in conjunction with oncology services should improve patient outcomes. Integration of care for these patients can educate patients on the minimisation of multimorbidity, develop personalised screening plans and contribute to the wholistic management of people in the surveillance period. GPs should have a major role in end of life care. Integration of general practice and oncology should benefit patient care.

Reproducibility, reliability and validity of population-based administrative health data for the assessment of cancer non-related comorbidities

BACKGROUND

Patients with comorbidities do not receive optimal treatment for their cancer, leading to lower cancer survival. Information on individual comorbidities is not straightforward to derive from population-based administrative health datasets. We described the development of a reproducible algorithm to extract the individual Charlson index comorbidities from such data. We illustrated the algorithm with 1,789 laryngeal cancer patients diagnosed in England in 2013. We aimed to clearly set out and advocate the time-related assumptions specified in the algorithm by providing empirical evidence for them.

METHODS

Comorbidities were assessed from hospital records in the ten years preceding cancer diagnosis and internal reliability of the hospital records was checked. Data were right-truncated 6 or 12 months prior to cancer diagnosis to avoid inclusion of potentially cancer-related comorbidities. We tested for collider bias using Cox regression.

RESULTS

Our administrative data showed weak to moderate internal reliability to identify comorbidities (ICC ranging between 0.1 and 0.6) but a notably high external validity (86.3%). We showed a reverse protective effect of non-cancer related Chronic Obstructive Pulmonary Disease (COPD) when the effect is split into cancer and non-cancer related COPD (Age-adjusted HR: 0.95, 95% CI:0.7-1.28 for non-cancer related comorbidities). Furthermore, we showed that a window of 6 years before diagnosis is an optimal period for the assessment of comorbidities.

CONCLUSION

To formulate a robust approach for assessing common comorbidities, it is important that assumptions made are explicitly stated and empirically proven. We provide a transparent and consistent approach useful to researchers looking to assess comorbidities for cancer patients using administrative health data.

Factors associated with late stage at diagnosis among Puerto Rico's government health plan colorectal cancer patients: a cross-sectional study

Background

Late stage at diagnosis of cancer is considered a key predictor factor for a lower survival rate. Knowing and understanding the barriers to an early diagnosis of colorectal cancer is critical in the fight to reduce the social and economic burden caused by cancer in Puerto Rico. This study evaluates factors associated to colorectal cancer stage at diagnosis among Puerto Rico’s Government Health Plan (GHP) patients.

Methods

We conducted a cross-sectional study based on a secondary data analysis using information from the Puerto Rico Central Cancer Registry (PRCCR) and the Puerto Rico Health Insurance Administration (PRHIA). Logistic regression models were used to estimate the unadjusted odds ratio (ORs) and adjusted odds ratio (AORs), and their 95 % confidence intervals (CIs). Colorectal cancer cases diagnosed between January 1, 2012 and December 31, 2012, among persons 50 to 64 years of age, participants of the GHP and with a cancer diagnosis reported to the PRCCR were included in the study.

Results

There were 68 (35.79 %) colorectal cancer patients diagnosed at early stage while 122 (64.21 %) where diagnosed at late stage. In the multivariate analysis having a diagnostic delay of more than 59 days (AOR 2.94, 95 % CI: 1.32 to 6.52) and having the first visit through the emergency room (AOR 3.48, 95 % CI: 1.60 to 7.60) were strong predictors of being diagnosed with colorectal cancer at a late stage.

Conclusions

These results are relevant to understand the factors that influence the outcomes of colorectal cancer patients in the GHP. Therefore, it is important to continue developing studies to understand the Government Health Plan patient’s pathways to a cancer diagnosis, in order to promote assertive decisions to improve patient outcomes.

The impact of comorbidity on cancer and its treatment

Answer questions and earn CME/CNE Comorbidity is common among cancer patients and, with an aging population, is becoming more so. Comorbidity potentially affects the development, stage at diagnosis, treatment, and outcomes of people with cancer. Despite the intimate relationship between comorbidity and cancer, there is limited consensus on how to record, interpret, or manage comorbidity in the context of cancer, with the result that patients who have comorbidity are less likely to receive treatment with curative intent. Evidence in this area is lacking because of the frequent exclusion of patients with comorbidity from randomized controlled trials. There is evidence that some patients with comorbidity have potentially curative treatment unnecessarily modified, compromising optimal care. Patients with comorbidity have poorer survival, poorer quality of life, and higher health care costs. Strategies to address these issues include improving the evidence base for patients with comorbidity, further development of clinical tools to assist decision making, improved integration and coordination of care, and skill development for clinicians. CA Cancer J Clin 2016;66:337-350. © 2016 American Cancer Society.

The impact of patient comorbidity on cancer stage at diagnosis

Background:

It is known that cancer stage is affected by comorbidity, but the evidence regarding the magnitude and even direction of this effect is highly inconsistent and poorly understood. The aims of this study were to establish the impact of comorbidity on cancer stage at diagnosis, using both specific individual comorbid conditions and a global measure of comorbidity; and to assess whether this impact varied by cancer site, level of comorbidity burden and individual comorbidity type.

Methods:

We examined comorbidity among 14 096 patients with breast, colon, rectal, liver, stomach, ovarian, uterine, bladder or kidney cancer. Patients were identified from cancer registry data, and then linked to hospitalisation data to determine the presence of comorbidity in the 5 years preceding cancer diagnosis. Individual comorbid conditions were identified using ICD-10 codes, and overall burden of comorbidity attributed using a cancer-specific measure of comorbidity (C3 Index).

Results:

We observed that the presence of patient comorbidity (a) increases the odds of being diagnosed with distant metastases, (b) does not lead to earlier diagnosis and (c) increases the likelihood of a patient receiving no stage of disease at diagnosis.

Conclusions:

Patient comorbidity has a substantial impact on cancer stage at diagnosis; however, this impact varies considerably by cancer type, individual comorbid condition and overall comorbidity burden.

Patterns of health care utilization preceding a colorectal cancer diagnosis are strong predictors of dying quickly following diagnosis

Background

Understanding the predictors of a quick death following diagnosis may improve timely access to palliative care. The objective of this study was to explore whether factors in the 24 months prior to a colorectal cancer (CRC) diagnosis predict a quick death post-diagnosis.

Methods

Data were from a longitudinal study of all adult persons diagnosed with CRC in Nova Scotia, Canada, from 01Jan2001-31Dec2005. This study included all persons who died of any cause by 31Dec2010, except those who died within 30 days of CRC surgery (n = 1885 decedents). Classification and regression tree models were used to explore predictors of time from diagnosis to death for the following time intervals: 2, 4, 6, 8, 12, and 26 weeks from diagnosis to death. All models were performed with and without stage at diagnosis as a predictor variable. Clinico-demographic and health service utilization data in the 24 months pre-diagnosis were provided via linked administrative databases.

Results

The strongest, most consistent predictors of dying within 2, 4, 6, and 8 weeks of CRC diagnosis were related to health services utilization in the 24 months prior to diagnosis: i.e., number of specialist visits, number of days spent in hospital, and number of family physician visits. Stage at diagnosis was the strongest predictor of dying within 12 and 26 weeks of diagnosis.

Conclusions

Identifying potential predictors of a short timeframe between cancer diagnosis and death may aid in the development of strategies to facilitate timely and appropriate referral to palliative care upon a cancer diagnosis.