Rural versus urban colorectal and lung cancer patients: differences in stage at presentation

Lung cancer mortality trends and disparities: A cross-sectional analysis 1999-2020

BACKGROUND

Lung cancer remains a leading cause of morbidity and mortality in the United States. Given the importance of epidemiological insight on lung cancer outcomes as the foundation for targeted interventions, we aimed to examine lung cancer death trends in the United States in the recent 22-year period, exploring demographic disparities and yearly mortality shifts.

METHODS

Mortality information was obtained from the CDC Wide-ranging Online Data for Epidemiologic Research database from the years 1999-2020. Demographic information included age, sex, race or ethnicity, and area of residence. We performed log-linear regression models to assess temporal mortality shifts and calculated average annual percentage change (AAPC) and compared age-adjusted mortality rates (AAMR) across demographic subpopulations.

RESULTS

A total of 3,380,830 lung cancer deaths were identified. The AAMR decreased from 55.4 in 1999-31.8 in 2020 (p<0.001). Males (AAMR 57.6) and non-Hispanic (NH) (AAMR 47.5) populations were disproportionately impacted compared to females (AAMR 36.0) and Hispanic (AAMR 19.1) populations, respectively. NH Black populations had the highest AAMR (48.5) despite an overall reduction in lung cancer deaths (AAPC -3.3 %) over the study period. Although non-metropolitan regions were affected by higher mortality rates, the annual decrease in mortality among metropolitan regions (AAPC -2.8 %, p<0.001) was greater compared to non-metropolitan regions (AAPC -1.7 %, p<0.001). Individuals living in the Western US (AAPC -3.4 %, p<0.001) experienced the greatest decline in lung cancer mortality compared to other US census regions.

CONCLUSIONS

Our findings revealed lung cancer mortality inequalities in the US. By contextualizing these mortality shifts, we provide a larger framework of data-driven initiatives for societal and health policy changes for improving access to care, minimizing healthcare inequalities, and improving outcomes.

Impact of rural residence on the presentation, management and survival of patients with non-metastatic muscle-invasive bladder carcinoma

PURPOSE

To assess the impact of rural and remote residence on the receipt of guidelines-recommended treatment, quality of treatment and overall survival (OS) in patients with non-metastatic muscle-invasive bladder cancer (MIBC).

MATERIALS AND METHODS

Patients with MIBC were identified using National Cancer Database. Patients were classified into three residential areas. Logistic regression models were used to assess associations between geographic residence and receipt of radical cystectomy (RC) or chemoradiation therapy (CRT). Models were fitted to assess quality benchmarks of RC and CRT.

RESULTS

We identified 71,395 patients. Of those 58,874 (82.5%) were living in Metro areas, 8,534 (11.9%) in urban-rural adjacent (URA), and 3,987 (5.6%) in urban-rural remote to metro area (URR). URR residence was significantly associated with poor OS compared to URA and Metro residence (HR 0.87, 95% CI 0.81-0.94 and HR 0.90, 95% CI 0.87-0.93, p<0.001). There was no difference in the likelihood of receiving RC and CRT among different residential areas. Among patients who underwent RC; individuals living in URR were less likely to receive neoadjuvant chemotherapy and adequate lymph node dissection, and had a higher probability of positive surgical margin than those living in metro areas. For those who received CRT; individuals living in Metro areas were more likely to receive concomitant systemic therapy compared to URR.

CONCLUSIONS

Rural residence is associated with lower OS for MIBC patients and less likelihood of meeting quality benchmarks for RC and CRT. This data should be used to guide further health policy and allocation of resources for rural population.

The Intersection of Race and Rurality and its Effect on Colorectal Cancer Survival

INTRODUCTION

Outcomes in colorectal cancer treatment are historically worse in Black people and residents of rural areas. Purported reasons include factors such as systemic racism, poverty, lack of access to care, and social determinants of health. We sought to determine whether outcomes worsened when race and rural residence intersected.

METHODS

The National Cancer Database was queried for individuals with stage II-III colorectal cancer (2004-2018). To examine the intersectionality of race/rurality on outcomes, race (Black/White) and rurality (based on county) were combined into a single variable. Main outcome of interest was 5-year survival. Cox hazard regression analysis was performed to determine variables independently associating with survival. Control variables included age at diagnosis, sex, race, Charlson-Deyo score, insurance status, stage, and facility type.

RESULTS

Of 463 948 patients, 5717 were Black-Rural, 50 742 were Black-Urban, 72 241 were White-Rural, and 33 5271 were White-Urban. Five-year mortality rate was 31.6%. Univariate Kaplan-Meier survival analysis demonstrated race-rurality was associated with overall survival (P < .001), with White-Urban having the greatest mean survival length (47.9 months) and Black-Rural with the lowest (46.7 months). Multivariable analysis found that Black-Rural (1.26, 95% confidence interval [1.20-1.32]), Black-Urban (1.16, [1.16-1.18]), and White-Rural (HR: 1.05; (1.04-1.07) had increased mortality when compared to White-Urban individuals (P < .001).

CONCLUSION

Although White-Rural individuals fared worse than White-Urban, Black individuals fared worst of all, with the poorest outcomes observed in Black individuals in rural areas. This suggests that both Black race and rurality negatively affect survival, and act synergistically to further worsen outcomes.

Rural Disparities in Lung Cancer-directed Surgery: A Medicare Cohort Study

OBJECTIVE

The primary objective of this study was to determine the influence of rural residence on access to and outcomes of lung cancer-directed surgery for Medicare beneficiaries.

SUMMARY OF BACKGROUND DATA

Lung cancer is the leading cause of cancerrelated death in the United States and rural patients have 20% higher mortality. Drivers of rural disparities along the continuum of lung cancercare delivery are poorly understood.

METHODS

Medicare claims (2015-2018) were used to identify 126,352 older adults with an incident diagnosis of nonmetastatic lung cancer. Rural Urban Commuting Area codes were used to define metropolitan, micropolitan, small town, and rural site of residence. Multivariable logistic regression models evaluated influence of place of residence on 1) receipt of cancer-directed surgery, 2) time from diagnosis to surgery, and 3) postoperative outcomes.

RESULTS

Metropolitan beneficiaries had higher rate of cancer-directed surgery (22.1%) than micropolitan (18.7%), small town (17.5%), and isolated rural (17.8%) (P < 0.001). Compared to patients from metropolitan areas, there were longer times from diagnosis to surgery for patients living in micropolitan, small, and rural communities. Multivariable models found nonmetropolitan residence to be associated with lower odds of receiving cancer-directed surgery and MIS. Nonmetropolitan residence was associated with higher odds of having postoperative emergency department visits.

CONCLUSIONS

Residence in nonmetropolitan areas is associated with lower probability of cancer-directed surgery, increased time to surgery, decreased use of MIS, and increased postoperative ED visits. Attention to timely access to surgery and coordination of postoperative care for nonmetropolitan patients could improve care delivery.

Designing home-based physical activity programs for rural cancer survivors: A survey of technology access and preferences

Background

While technology advances have increased the popularity of remote interventions in underserved and rural cancer communities, less is understood about technology access and preferences for home-based physical activity programs in this cancer survivor population.

Purpose

To determine access, preferences, and needs, for a home-based physical activity program in rural cancer survivors.

Methods

A Qualtrics Research Panel was recruited to survey adults with cancer across the United States. Participants self-reported demographics, cancer characteristics, technology access and usage, and preferences for a home-based physical activity program. The Godin Leisure Time Exercise Questionnaire (GLTEQ) assessed current levels of physical activity. Descriptive statistics included means and standard deviations for continuous variables, and frequencies for categorical variables. Independent samples t-tests explored differences between rural and non-rural participants.

Results

Participants (N=298; mean age=55.2 ± 16.5) had a history of cancer (mean age at diagnosis=46.5), with the most commonly reported cancer type being breast (25.5%), followed by prostate (16.1%). 74.2% resided in rural hometowns. 95% of participants reported accessing the internet daily. On a scale of 0-100, computer/laptop (M=63.4) and mobile phone (M=54.6) were the most preferred delivery modes for a home-based physical activity intervention, and most participants preferred balance/flexibility (72.2%) and aerobic (53.9%) exercises. Desired intervention elements included a frequency of 2-3 times a week (53.5%) for at least 20 minutes (75.7%). While there were notable rural disparities present (e.g., older age at diagnosis, lower levels of education; ps<.001), no differences emerged for technology access or environmental barriers (ps>.08). However, bias due to electronic delivery of the survey should not be discounted.

Conclusion

These findings provide insights into the preferred physical activity intervention (e.g., computer delivery, balance/flexibility exercises) in rural cancer survivors, while highlighting the need for personalization. Future efforts should consider these preferences when designing and delivering home-based interventions in this population.

Risk Factors for Colorectal Adenocarcinoma in an Indigenous Population in East Africa

Introduction

The incidence of colorectal cancer (CRC) is increasing in East Africa. Changes in lifestyle and dietary changes, particularly alcohol consumption, smoking, and consumption of cooked meats with a reduction in fibre in the diet may be responsible. The objective of our study was to determine the risk factors responsible for CRC in Uganda.

Methods

We recruited 129 participants with histologically proven colorectal adenocarcinoma and 258 control participants from four specialized hospitals in central Uganda from 2019 to 2021. Controls were block matched for age (±5 years) and sex of the case participants. The risk factor variables included; area of residence, tribe, body mass index (BMI), smoking, alcohol consumption and family history of gastrointestinal cancer. We used conditional or ordinal logistic regression to obtain crude and adjusted odds ratios for risk factors associated with CRC.

Results

In bivariate analysis, case participants were more likely to be associated with urban residence (cOR:62.11; p<0.001); family history of GI cancer (cOR: 14.34; p=0.001); past smokers (cOR: 2.10; p=0.080); past alcohol drinkers (cOR: 2.35; p=0.012); current alcohol drinkers (cOR: 3.55; p<0.001); high BMI 25–29.9 kg/m² (cOR: 2.49; p<0.001); and high BMI ≥30kg/m² (cOR: 2.37; p=0.012). In the multivariate analysis, urban residence (aOR: 82.79; p<0.001), family history of GI cancer (aOR: 61.09; p<0.001) and past smoking (aOR: 4.73; p=0.036) were independently associated with a higher risk of developing CRC.

Conclusion

A family history of gastrointestinal cancer was a risk factor for CRC. While population-based CRC screening may not be feasible in low income-countries, targeted CRC screening for first-degree relatives with CRC should be considered in East Africa. Molecular genetic studies need to be carried out to determine the role of hereditary factors in our population. Prevention strategies should be adopted to avoid smoking in our population which was associated with an increased risk of CRC.

Association of Rurality, Race and Ethnicity, and Socioeconomic Status With the Surgical Management of Colon Cancer and Postoperative Outcomes Among Medicare Beneficiaries

Importance

Rural patients with colon cancer experience worse outcomes than urban patients, but the extent to which disparities are explained by social determinants is not known.

Objectives

To evaluate the association of rurality with surgical treatment and outcomes of colon cancer and to investigate the intersection of rurality with race and ethnicity and socioeconomic status.

Design, Settings, and Participants

This cohort study included fee-for-service Medicare beneficiaries 65 years or older diagnosed with incident, nonmetastatic colon cancer between April 1, 2016, and September 30, 2018, with follow-up until December 31, 2018. Data were analyzed from August 3, 2020, to April 30, 2021.

Exposures

Rurality of patient's residence, categorized as metropolitan, micropolitan, or small town or rural, using Rural-Urban Commuting Area codes.

Main Outcomes and Measures

Receipt of surgery, emergent surgery, or minimally invasive surgery (MIS); 90-day surgical complications; and 90-day mortality.

Results

Among 57 710 Medicare beneficiaries with incident, nonmetastatic colon cancer, 46.6% were men, 53.4% were women, and the mean (SD) age was 76.6 (7.2) years. In terms of race and ethnicity, 3.7% were Hispanic, 6.4% were non-Hispanic Black (hereinafter Black), 86.1% were non-Hispanic White (hereinafter White), and 3.8% were American Indian or Alaska Native, Asian or Pacific Islander, or unknown race or ethnicity. Patients residing in nonmetropolitan areas were more likely to undergo surgical resection than those residing in metropolitan areas (69.2% vs 63.9%; P < .001). Black race was independently associated with lower hazard of surgical resection (hazard ratio, 0.92 [95% CI, 0.88-0.95]). Race and ethnicity and measures of socioeconomic status did not modify the association of rurality with surgery. Beneficiaries from small town and rural areas had higher odds of undergoing emergent surgery (adjusted odds ratio [OR], 1.32 [95% CI, 1.20-1.44]) but lower odds of undergoing MIS (adjusted OR, 0.75 [95% CI, 0.70-0.80]), with similar findings for patients residing in micropolitan areas. Members of racial and ethnic minority groups who resided in small town and rural settings experienced higher odds of postoperative surgical complications (P = .001 for interaction) and mortality (P = .001 for interaction). Notably, White patients who resided in small town and rural areas experienced lower odds of postoperative mortality than their White metropolitan counterparts (adjusted OR, 0.81 [95% CI, 0.71-0.92]), but Black patients who resided in small town and rural areas had significantly higher odds of postoperative mortality (adjusted OR, 1.86 [95% CI, 1.16-2.97]) than their Black metropolitan counterparts.

Conclusions and Relevance

These findings suggest that Medicare beneficiaries from small town and rural areas were more likely to undergo surgery for nonmetastatic colon cancer than metropolitan beneficiaries but also more likely to undergo emergent surgery and less likely to have MIS. The experiences of rural patients varied by race; rurality was associated with higher postoperative mortality for Black patients but not for other racial and ethnic groups.

Rural-Urban Disparities in Cancer Outcomes: Opportunities for Future Research

Cancer care disparities among rural populations are increasingly documented and may be worsening, likely because of the impact of rurality on access to state-of-the-art cancer prevention, diagnosis, and treatment services, as well as higher rates of risk factors such as smoking and obesity. In 2018, the American Society of Clinical Oncology undertook an initiative to understand and address factors contributing to rural cancer care disparities. A key pillar of this initiative was to identify knowledge gaps and promote the research needed to understand the magnitude of difference in outcomes in rural vs nonrural settings, the drivers of those differences, and interventions to address them. The purpose of this review is to describe continued knowledge gaps and areas of priority research to address them. We conducted a comprehensive literature review by searching the PubMed (Medline), Embase, Web of Science, and Cochrane Library databases for studies published in English between 1971 and 2021 and restricted to primary reports from populations in the United States and abstracted data to synthesize current evidence and identify continued gaps in knowledge. Our review identified continuing gaps in the literature regarding the underlying causes of rural-urban disparities in cancer outcomes. Rapid advances in cancer care will worsen existing disparities in outcomes for rural patients without directed effort to understand and address barriers to high-quality care in these areas. Research should be prioritized to address ongoing knowledge gaps about the drivers of rurality-based disparities and preventative and corrective interventions.

Health-Related and Behavioral Factors Associated With Lung Cancer Stage at Diagnosis: Observations From Alberta's Tomorrow Project

Background

Lung cancer is the leading cause of cancer death in Canada, with stage at diagnosis among the top predictors of lung cancer survival. Identifying factors associated with stage at diagnosis can help reduce lung cancer morbidity and mortality. This study used data from a prospective cohort study of adults living in Alberta, Canada to examine factors associated with lung cancer stage at diagnosis.

Methods

This cohort study used data from adults aged 35–69 years enrolled in Alberta’s Tomorrow Project. Partial Proportional Odds models were used to examine associations between sociodemographic characteristics and health-related factors and subsequent lung cancer stage at diagnosis.

Results

A total of 221 participants (88 males and 133 females) developed lung cancer over the study period. Nearly half (48.0%) of lung cancers were diagnosed at a late stage (stage IV), whereas 30.8 % and 21.3% were diagnosed at stage I/II and III, respectively. History of sunburn in the past year was protective against late-stage lung cancer diagnosis (odds ratio (OR) .40, P=.005). In males, a higher number of lifetime prostate specific antigen tests was associated with reduced odds of late-stage lung cancer diagnosis (odds ratio .66, P=.02). Total recreational physical activity was associated with increased odds of late-stage lung cancer diagnosis (OR 1.08, P=.01).

Discussion

Lung cancer stage at diagnosis remains a crucial determinant of prognosis. This study identified important factors associated with lung cancer stage at diagnosis. Study findings can inform targeted cancer prevention initiatives towards improving early detection of lung cancer and lung cancer survival.

Influence of Race, Insurance, and Rurality on Equity of Breast Cancer Care

BACKGROUND

Considerable gaps in knowledge remain regarding the intersectionality between race, insurance status, rurality, and community-level socioeconomic status that contribute in concert to disparities in breast cancer care delivery.

METHODS

Women age 18-64 y old with either private, Medicaid, or no insurance coverage and a diagnosis of breast cancer from the North Carolina Central Cancer Registry (2010-2015) were identified and reviewed. Logistic regression models examined the impact of race, insurance status, rurality, and the Social Deprivation Index (SDI) on advanced stage disease at diagnosis (III, IV) and receipt of cancer directed surgery (CDS). Models tested two-way interactions between race, insurance status, rurality, and SDI.

RESULTS

Of the study population (n = 23,529), 14.6% were diagnosed with advanced stage disease (III, IV), and 97.1% of women with non-metastatic breast cancer (n = 22,438) received cancer directed surgery (CDS). Twenty percent of women were non-Hispanic Black (NHB), 3.0% Hispanic, 10.9% Medicaid insured, 5.9% uninsured, 20.0% of women resided in rural areas, and 20.0% resided in communities of the highest quartile SDI. NHB race, Medicaid or uninsured status, and residence in rural or socially deprived areas were associated with advanced stage breast cancer at diagnosis. NHB and Medicaid or uninsured women were significantly less likely to receive CDS. There were no statistically significant interactions found influencing stage at diagnosis or receipt of cancer directed surgery.

CONCLUSIONS

In a heterogeneous population across the state of North Carolina, non-Hispanic Black race, Medicaid or uninsured status, and residence in rural or high social deprivation communities are independently associated with advanced stage breast cancer at diagnosis, while non-Hispanic Black race and Medicaid or uninsured status are associated with lower odds to receive cancer directed surgery.

Rural vs urban inequalities in stage at diagnosis for lung cancer

OBJECTIVES

Early diagnosis of lung cancer increases the chance of survival. The aim of this study was to measure the relationship between geographic residence in Saskatchewan and stage of lung cancer at the time of diagnosis.

MATERIALS AND METHODS

Retrospective cohort analysis of 2,972 patients with a primary diagnosis of either non-small cell cancer (NSCLC) or small cell lung cancer (SCLC) between 2007 and 2012 was performed. Incidence proportion of early and advanced stage cancer, and relative risk of being diagnosed with advanced-stage lung cancer relative to early-stage was calculated.

RESULTS

Compared to urban Saskatchewan, rural Saskatchewan lung cancer patients had a higher relative risk of advanced stage NSCLC (relative risk [RR] = 1.11, 95% confidence interval [CI]: 1.01-1.22). Rural Saskatchewan was further subdivided into north and south. The relative risk of advanced stage NSCLC in rural north Saskatchewan compared to urban Saskatchewan was even greater (RR = 1.17, 95% CI: 1.03-1.31). Although not statistically significant, there was a trend for a higher incidence of advanced stage SCLC in rural and rural north vs urban Saskatchewan (RR = 1.16, 95% CI: 0.95-1.43 and RR = 1.22; 95% CI: 0.94-1.58, respectively). There was a higher incidence proportion of advanced stage NSCLC in rural areas relative to urban (31.6-34.4 vs 29.5 per 10,000 people).

CONCLUSION

Patients living in rural Saskatchewan have higher incidence proportion of and were more likely to present with advanced stage NSCLC in comparison to urban Saskatchewan patients at time of diagnosis. This inequality was even greater in rural north Saskatchewan.

The need to study rural cancer outcome disparities at the local level: a retrospective cohort study in Kansas and Missouri

Background

Rural residence is commonly thought to be a risk factor for poor cancer outcomes. However, a number of studies have reported seemingly conflicting information regarding cancer outcome disparities with respect to rural residence, with some suggesting that the disparity is not present and others providing inconsistent evidence that either urban or rural residence is associated with poorer outcomes. We suggest a simple explanation for these seeming contradictions: namely that rural cancer outcome disparities are related to factors that occur differentially at a local level, such as environmental exposures, lack of access to care or screening, and socioeconomic factors, which differ by type of cancer.

Methods

We conducted a retrospective cohort study examining ten cancers treated at the University of Kansas Medical Center from 2011 to 2018, with individuals from either rural or urban residences. We defined urban residences as those in a county with a U.S. Department of Agriculture Urban Influence Code (UIC) of 1 or 2, with all other residences defines a rural. Inverse probability of treatment weighting was used to create a pseudo-sample balanced for covariates deemed likely to affect the outcomes modeled with cumulative link and weighted Cox-proportional hazards models.

Results

We found that rural residence is not a simple risk factor but rather appears to play a complex role in cancer outcome disparities. Specifically, rural residence is associated with higher stage at diagnosis and increased survival hazards for colon cancer but decreased risk for lung cancer compared to urban residence.

Conclusion

Many cancers are affected by unique social and environmental factors that may vary between rural and urban residents, such as access to care, diet, and lifestyle. Our results show that rurality can increase or decrease risk, depending on cancer site, which suggests the need to consider the factors connected to rurality that influence this complex pattern. Thus, we argue that such disparities must be studied at the local level to identify and design appropriate interventions to improve cancer outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12190-w.

Urbanization Levels and Its Association with Prevalence of Risk Factors and Colorectal Cancer Incidence

BACKGROUND

Colorectal cancer is one of the most common cancers in the world. This study aimed to determine the relationship between risk factors and the incidence of colorectal cancer in Urbanization levels in Iran.

METHODS

This was a population-based study. Urbanization levels were determined using the census data of the Statistical Center in 2012. Data on risk factors for colorectal cancer were obtained from the information provided by the Iranian Non-Communicable Disease Control Center and the incidence of colorectal cancer from the data from the National Cancer Registry System. Negative binomial regression analysis was used to determine the relationship between colorectal cancer risk factors and urbanization levels with colorectal cancer incidence. For statistical analysis, SPSS and Stata software were used. A significant level of P≤0.05 was considered.

RESULTS

The relationship between urbanization levels and risk factors with the incidence of colorectal cancer, nutrition Status, tobacco use, and body mass index were not significant. There was a significant relationship between physical activity and incidence at different levels and between levels of urbanization and incidence rate, indicating a lower incidence rate of colorectal cancer at lower levels of urbanization.

CONCLUSION

Colorectal cancer incidence is higher at higher levels of urbanization than lower levels. The difference between regions in terms of urbanization can have in flounce on access to facilities, health service, and counseling opportunities to modify the risk factors and access to proper screening and follow-up care.

Colorectal Cancer Surgery Quality in Manitoba: A Population-Based Descriptive Analysis

Unwarranted clinical variation in healthcare impacts access, productivity, performance, and outcomes. A strategy proposed for reducing unwarranted clinical variation is to ensure that population-based data describing the current state of health care services are available to clinicians and healthcare decision-makers. The objective of this study was to measure variation in colorectal cancer surgical treatment patterns and surgical quality in Manitoba and identify areas for improvement. This descriptive study included individuals aged 20 years or older who were diagnosed with invasive cancer (adenocarcinoma) of the colon or rectum between 1 January 2010 and 31 December 2014. Laparoscopic surgery was higher in colon cancer (24.1%) compared to rectal cancer (13.6%). For colon cancer, the percentage of laparoscopic surgery ranged from 12.9% to 29.2%, with significant differences by regional health authority (RHA) of surgery. In 86.1% of colon cancers, ≥12 lymph nodes were removed. In Manitoba, the negative circumferential resection margin for rectal cancers was 96.9%, and ranged from 96.0% to 100.0% between RHAs. The median time between first colonoscopy and resection was 40 days for individuals with colon cancer. This study showed that high-quality colorectal cancer surgery is being conducted in Manitoba along with some variation and gaps in quality. As a result of this work, a formal structure for ongoing measuring and reporting surgical quality has been established in Manitoba. Quality improvement initiatives have been implemented based on these findings and periodic assessments of colorectal cancer surgery quality will continue.

A cross-sectional study to assess knowledge of women about cervical cancer: an urban and rural comparison

INTRODUCTION

Cervical cancer and its etiopathogenesis, the age of women in whom it is diagnosed, average life expectancy, and prognosis are information widely covered in scientific reports. However, there is no coherent information regarding which regions-urban or rural-it may occur more often. This is important because the literature on the subject reports that people living in rural areas have a worse prognosis when it comes to detection, treatment, and life expectancy than city dwellers.

MATERIAL AND METHODS

The subjects of the study were women and their knowledge about cervical cancer. The research was carried out using a survey directly distributed among respondents and via the Internet, portals, and discussion groups for women from Poland. Three hundred twenty-nine women took part in the study, including 164 from rural and 165 from urban areas. The collected data enabled the following: (1) an analysis of the studied groups, (2) assessment of the respondents' knowledge about cervical cancer, and (3) comparison of women's knowledge depending on where they live.

RESULTS

The average assessment of all respondents' knowledge was 3.59, with women living in rural areas scoring 3.18 and respondents from the city-4.01. Statistical significance (p < 0.001) between the level of knowledge and place of residence was determined. The results indicate that an increase in the level of education in the subjects significantly increases the chance of getting the correct answer. In the case of age analysis, the coefficients indicate a decrease in the chance of obtaining the correct answer in older subjects despite the fact that a statistically significant level was reached in individual questions.

CONCLUSIONS

Women living in rural areas have less knowledge of cervical cancer than female respondents from the city. There is a need for more awareness campaigns to provide comprehensive information about cervical cancer to women in rural areas. A holistic approach to the presented issue can solve existing difficulties and barriers to maintaining health regardless of the place of life and residence.

IMPLICATION FOR CANCER SURVIVORS

They need intensive care for women's groups most burdened with risk factors.

Sociodemographic disparities in the management of advanced lung cancer: a narrative review

Treatment of advanced non-small cell lung cancer (NSCLC) has markedly changed in the past decade with the integration of biomarker testing, targeted therapies, immunotherapy, and palliative care. These advancements have led to significant improvements in quality of life and overall survival. Despite these improvements, racial and socioeconomic disparities in lung cancer mortality persist. This narrative review aims to assess and synthesize the literature on sociodemographic disparities in the management of advanced NSCLC. A narrative overview of the literature was conducted using PubMed and Scopus and was narrowed to articles published from January 1, 2010, until July 22, 2020. Articles relevant to sociodemographic variation in (I) chemoradiation for stage III NSCLC, (II) molecular biomarker testing, (III) systemic treatment, including chemotherapy, targeted therapy, and immunotherapy, and (IV) palliative and end of life care were included in this review. Twenty-two studies were included. Sociodemographic disparities in the management of advanced NSCLC varied, but recurring findings emerged. Across most treatment domains, Black patients, the uninsured, and patients with Medicaid were less likely to receive recommended lung cancer care. However, some of the literature was limited due to incomplete data to adequately assess appropriateness of care, and several studies were out of date with current practice guidelines. Sociodemographic disparities in the management of advanced lung cancer are evident. Given the rapidly evolving treatment paradigm for advanced NSCLC, updated research is needed. Research on interventions to address disparities in advanced NSCLC is also needed.

The rise of proximal colorectal cancer: a trend analysis of subsite specific primary colorectal cancer in the SEER database

Background

Colorectal cancer (CRC) is the third most common cancer worldwide and the second leading cause of cancer-related deaths. Given the significant prevalence of CRC, regular preventative screening is required. CRCs in different locations of the colon have variable molecular pathogenesis, gross appearance, and general disease outcomes. While the overall incidence of CRC has been decreasing, the decrease in proximally located CRC significantly lags behind the other forms of CRC. The objective of this study was to establish independent risk factors for proximal CRC for better identification of populations at risk for closer CRC monitoring and observation.

Methods

A time-trend analysis was conducted using data from the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) database from 1973-2007, comparing patient characteristics (age, sex, race/ethnicity, year of diagnosis, age of diagnosis, tumor grade, tumor stage, and urban-rural setting) between CRCs originating in different locations.

Results

Analysis demonstrated that black race, female sex, age over 60, and being diagnosed in the 21st century (rather than 20th) were associated with an increased risk of proximal CRC compared to CRCs originating in other locations.

Conclusions

Our study showed that black race, female sex, and age over 60 independently increased the likelihood of proximal CRC diagnosis. Furthermore, CRC trends identify an increasing proportion of all CRCs being of proximal origin. It is imperative that patients undergo regularly scheduled complete colonoscopies by trained endoscopists, especially if they belong to the high-risk groups previously identified.

Lung Cancer Staging at Diagnosis in the Veterans Health Administration: Is Rurality an Influencing Factor? A Cross-Sectional Study

Purpose

To evaluate the association between rurality and lung cancer stage at diagnosis.

Methods:

We conducted a cross-sectional study using Veterans Health Administration (VHA) data to identify veterans newly diagnosed with lung cancer between October 1, 2011 and September 30, 2015. We defined rurality, based on place of residence, using Rural-Urban Commuting Area (RUCA) codes with the subcategories of urban, large rural, small rural, and isolated. We used multivariable logistic regression models to determine associations between rurality and stage at diagnosis, adjusting for sociodemographic and clinical characteristics. We also analyzed data using the RUCA code for patients’ assigned primary care sites and driving distances to primary care clinics and medical centers.

Findings:

We identified 4,220 veterans with small cell lung cancer (SCLC) and 25,978 with non-small cell lung cancer (NSCLC). Large rural residence (compared to urban) was associated with early-stage diagnosis of NSCLC (OR = 1.12; 95% CI: 1.00–1.24) and SCLC (OR = 1.73; 95% CI: 1.18–1.55). However, the finding was significant only in the southern and western regions of the country. White race, female sex, chronic lung disease, higher comorbidity, receiving primary care, being a former tobacco user, and more recent year of diagnosis were also associated with diagnosing early-stage NSCLC. Driving distance to medical centers was inversely associated with late-stage NSCLC diagnoses, particularly for large rural areas.

Conclusions:

We did not find clear associations between rurality and lung cancer stage at diagnosis. These findings highlight the complex relationship between rurality and lung cancer within VHA, suggesting access to care cannot be fully captured by current rurality codes.

Socio-Demographic Disparities in Gastric Adenocarcinoma: A Population-Based Study

Background: Gastric cancer is one of the leading causes of cancer-related mortality worldwide, accounting for 8.2% of cancer-related deaths. The purpose of this study was to investigate the geographic and sociodemographic disparities in gastric adenocarcinoma patients.

METHODS

We conducted a retrospective study in gastric adenocarcinoma patients between 2004 and 2013. Data were obtained from the National Cancer Data Base (NCDB). Univariate and multivariable analyses were performed to evaluate overall survival (OS). Socio-demographic factors, including the location of residence [metro area (MA) or rural area (RA)], gender, race, insurance status, and marital status, were analyzed.

RESULTS

A total of 88,246 [RA, N = 12,365; MA, N = 75,881] patients were included. Univariate and multivariable analysis showed that RA had worse OS (univariate HR = 1.08, p < 0.01; multivariate HR = 1.04; p < 0.01) compared to MA. When comparing different racial backgrounds, Native American and African American populations had poorer OS when compared to the white population; however, Asian patients had a better OS (multivariable HR = 0.68, p < 0.01). From a quality of care standpoint, MA patients had fewer median days to surgery (28 vs. 33; p < 0.01) with fewer positive margins (6.3% vs. 6.9%; p < 0.01) when compared to RA patients. When comparing the extent of lymph node dissection, 19.6% of MA patients underwent an extensive dissection (more than or equal to 15 lymph nodes) in comparison to 18.7% patients in RA (p = 0.03).

DISCUSSION

This study identifies socio-demographic disparities in gastric adenocarcinoma. Future health policy initiatives should focus on equitable allocation of resources to improve the outcomes.

Geographic and demographic features of neuroendocrine tumors in the United States of America: A population-based study

BACKGROUND

The incidence of neuroendocrine tumors (NETs) is rapidly rising. There are very few studies investigating the role of sociodemographic factors in NETs. This study was aimed at examining how geographic and sociodemographic characteristics shape outcomes in the NET population.

METHODS

A retrospective analysis using the Surveillance, Epidemiology, and End Results database was performed, and the NET patient population from 1973 to 2015 was studied. Univariate and multivariable analyses were performed to evaluate patients' disease-specific survival (DSS) and overall survival (OS). Geographic and sociodemographic factors, including the location of residence (urban area [UA] vs rural area [RA]), sex, race, insurance status, and marital status, were included in the analysis.

RESULTS

A total of 53,034 patients (5517 in RAs and 47,517 in UAs) were included in the analysis. The incidence of NETs was found to be rising in both RAs and UAs but more rapidly in RAs (with the highest incidence in 2006-2015: 5.93 per 100,000 in RAs vs 4.10 per 100,000 in UAs). Patients from RAs presented at advanced stages in comparison with patients from UAs (regional, 18% vs 16%; distant, 15% vs 13%; P < .01). In the multivariable model, RA patients had a trend toward poorer OS (hazard ratio, 1.05; P = .053) in comparison with UA patients. The multivariable analysis showed significantly worse DSS and OS for uninsured, single, and male patients in comparison with insured, married, and female patients, respectively.

CONCLUSIONS

This study has identified sociodemographic disparities in NET outcomes. Access to health care could be a potential contributing factor, although differences in environmental exposure, health behavior, and tumor biology could also be responsible.

Investigating the Impact of Geographic Location on Colorectal Cancer Stage at Diagnosis: A National Study of the SEER Cancer Registry

BACKGROUND

Early detection of colorectal cancer (CRC) is associated with decreased mortality and potential avoidance of chemotherapy. CRC screening rates are lower in rural communities and patient outcomes are poorer. This study examines the extent to which United States' rural residents present at a more advanced stage of CRC compared to nonrural residents.

METHODS

Using the 2010-2014 Surveillance, Epidemiology and End Results Incidence data, 132,277 patients with CRC were stratified using their county of residence and urban influence codes into 5 categories (metro, adjacent micropolitan, nonadjacent micropolitan, small rural, and remote small rural). Logistic regression was used to investigate the relationship between late stage at diagnosis and county-level characteristics including level of rurality, persistent poverty, low education and low employment, and patient characteristics.

RESULTS

In the adjusted analysis the rate of stage 4 CRC at diagnosis differed across geographic classification, with patients living in remote small rural counties having the highest rate of stage 4 disease (range: 19.2% in nonadjacent micropolitan counties to 22.7% in remote small rural counties). Other factors, such as patient characteristics, insurance status, and regional practice variation were also significantly associated with late-stage CRC diagnosis.

CONCLUSIONS

Geographic residence is associated with the rate of stage 4 disease at presentation. Additional patient factors are associated with stage 4 CRC disease at diagnosis. Cancer outcomes are worse for rural patients, and late stage at diagnosis may partially account for this disparity. These differences have persisted over time and suggest areas for further research, patient engagement, and education.

Providing Higher Resolution Indicators of Rurality in the Surveillance, Epidemiology, and End Results (SEER) Database: Implications for Patient Privacy and Research

BACKGROUND

The burden of cancer is higher in rural areas than urban areas. The NCI's Surveillance, Epidemiology, and End Results (SEER) database currently provides county-level information on rurality for cancer patients in its catchment area, but more nuanced measures of rurality would improve etiologic and surveillance studies.

METHODS

We analyzed disclosure risk and conducted a sample utility analysis of census tract-level measures of rurality, using (1) U.S. Department of Agriculture's Rural Urban Commuting Area (RUCA) codes and (2) U.S. Census data on percentage of the population living in nonurban areas. We evaluated the risk of disclosure by calculating the percentage of census tracts and cancer cases that would be uniquely identified by a combination of these two rurality measures with a census tract-level socioeconomic status (SES) variable. The utility analyses examined SES disparities across levels of rurality for lung and breast cancer incidence and relative survival.

RESULTS

Risk of disclosure was quite low: <0.03% of census tracts and <0.03% of cancer cases were uniquely identified. Utility analyses demonstrated an SES gradient in lung and breast cancer incidence and survival, with relatively similar patterns across rurality variables.

CONCLUSIONS

The RUCA and Census rurality measures have been added to a specialized SEER 18 database. Interested researchers can request access to this database to perform analyses of urban/rural differences in cancer incidence and survival.

IMPACT

Such studies can provide important research support for future interventions to improve cancer prevention and control.

Rural-urban residence and cancer survival in high-income countries: A systematic review

There is some evidence that place of residence is associated with cancer survival, but the findings are inconsistent, and the underlying mechanisms by which residential location might affect survival are not well understood. We conducted a systematic review of observational studies investigating the association of rural versus urban residence with cancer survival in high-income countries. We searched the Ovid Medline, EMBASE, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases up to May 31, 2016. Forty-five studies published between 1984 and 2016 were included. We extracted unadjusted and adjusted relative risk estimates with the corresponding 95% confidence intervals. Most studies reported worse survival for cancer patients living in rural areas than those in urban regions. The most consistent evidence, observed across several studies, was for colorectal, lung, and prostate cancer. Of the included studies, 18 did not account for socio-economic position. Lower survival for more disadvantaged patients is well documented; therefore, it could be beneficial for future research to take socio-economic factors into consideration when assessing rural/urban differences in cancer survival. Some studies cited differential stage at diagnosis and treatment modalities as major contributing factors to regional inequalities in cancer survival. Further research is needed to disentangle the mediating effects of these factors, which may help to establish effective interventions to improve survival for patients living outside major cities.

Continuous Rural-Urban Coding for Cancer Disparity Studies: Is It Appropriate for Statistical Analysis?

Background: The dichotomization or categorization of rural-urban codes, as nominal variables, is a prevailing paradigm in cancer disparity studies. The paradigm represents continuous rural-urban transition as discrete groups, which results in a loss of ordering information and landscape continuum, and thus may contribute to mixed findings in the literature. Few studies have examined the validity of using rural-urban codes as continuous variables in the same analysis. Methods: We geocoded cancer cases in north central Florida between 2005 and 2010 collected by Florida Cancer Data System. Using a linear hierarchical model, we regressed the occurrence of late stage cancer (including breast, colorectal, hematological, lung, and prostate cancer) on the rural-urban codes as continuous variables. To validate, the results were compared to those from using a truly continuous rurality data of the same study region. Results: In term of associations with late-stage cancer risk, the regression analysis showed that the use of rural-urban codes as continuous variables produces consistent outcomes with those from the truly continuous rurality for all types of cancer. Particularly, the rural-urban codes at the census tract level yield the closest estimation and are recommended to use when the continuous rurality data is not available. Conclusions: Methodologically, it is valid to treat rural-urban codes directly as continuous variables in cancer studies, in addition to converting them into categories. This proposed continuous-variable method offers researchers more flexibility in their choice of analytic methods and preserves the information in the ordering. It can better inform how cancer risk varies, degree by degree, over a finer spectrum of rural-urban landscape.

Trends in the incidence, treatment, and survival of patients with lung cancer in the last four decades

Purpose

This study used the Surveillance, Epidemiology, and End Results (SEER) data to investigate the changes in incidence, treatment, and survival of lung cancer from 1973 to 2015.

Patients and methods

The clinical and epidemiological data of patients with lung cancer were obtained from the SEER database. Joinpoint regression models were used to estimate the rate changes in lung cancer related to incidence, treatment, and survival.

Results

From 1973 to 2015, the average incidence of lung cancer was 59.0/100,000 person-years. The incidence increased initially, reached a peak in 1992, and then gradually decreased. A higher incidence rate was observed in males than in females and in black patients than in other racial groups. Since 1985, adenocarcinoma became the most prevalent histopathological type. The surgical rate for lung cancer was about 25%, and treatment with chemotherapy showed an increasing trend, while the radiotherapy rate was in downward trend. The surgical rate for non-small-cell lung cancer (NSCLC) was higher than that for small cell lung cancer (SCLC), while chemotherapy for SCLC far exceeded that for NSCLC. Treatment with chemotherapy and radiotherapy for advanced stage had higher rate than early stage. The 5-year relative survival rate of lung cancer increased with time, but <21%.

Conclusion

In the past four decades, the lung cancer incidence increased initially and then gradually decreased. Surgical rate experienced a fluctuant reduction, while the chemotherapy rate was in upward trend. The 5-year relative survival rate increased with years, but was still low.

Surveillance, Epidemiology, and End Results (SEER) and SEER-Medicare Databases: Use in Clinical Research for Improving Colorectal Cancer Outcomes

The Surveillance, Epidemiology, and End Results (SEER) program is a clinical database, funded by the National Cancer Institute (NCI), which was created to collect cancer incidence, prevalence, and survival data from U.S. cancer registries. By capturing approximately 30% of the U.S. population, it serves as a powerful resource for researchers focused on understanding the natural history of colorectal cancer and improvement in patient care. The linked SEER-Medicare database is a robust database allowing investigators to perform studies focusing on health disparities, quality of care, and cost of treatment in oncologic disease. Since its infancy in the early 1970s, the database has been utilized for thousands of studies resulting in novel publications that have shaped our management of colorectal cancer among other malignancies.

Mapping rural-urban disparities in late-stage cancer with high-resolution rurality index and GWR

Effects of urban/rural residence on late-stage cancer have long been explored, but remained controversial. Spatial granularity of rural definition, temporal change of rurality, and local variability of such effects may contribute to inconsistent findings, but they have not been fully addressed. We proposed a spatially resolved and temporally comparable rurality index and a geographically weighted regression approach to re-examine this question. Taking Florida as an example, our analyses show that rural effects on late-stage cancer vary dramatically over locations (600-m cells). The odds ratios range from 0.9 to 1.10, and imply that one degree of rurality can increase/decrease local risk of late-stage cancer by up to 10%. Our study is an early attempt to explore local effects of rurality on cancer at a fine spatial scale, and reveals interesting patterns hidden by global multi-level analysis. The new framework and findings can better inform precision interventions to mitigate cancer disparities.

Ambient Asbestos Fiber Concentrations and Long-Term Trends in Pleural Mesothelioma Incidence between Urban and Rural Areas in the United States (1973-2012)

Over the past 40 years, measured ambient asbestos concentrations in the United States have been higher in urban versus rural areas. The purpose of this study was to determine whether variations in ambient asbestos concentrations have influenced pleural mesothelioma risk in females (who generally lacked historic occupational asbestos exposure relative to males). Male pleural mesothelioma incidence trends were analyzed to provide perspective for female trends. Annual age-adjusted incidence rates from 1973 to 2012 were obtained from the SEER 9, 13, and 18 databases for urban and rural locations, and standardized rate ratios were calculated. Female rural rates exceeded urban rates in almost half of the years analyzed, although the increases were not statistically significant, which is in line with expectations if there was no observable increased risk for urban locations. In contrast, male urban rates were elevated over rural rates for nearly all years examined and were statistically significantly elevated for 22 of the 40 years. Trend analyses demonstrated that trends for females remained relatively constant over time, whereas male urban and rural incidence increased into the 1980s and 1990s, followed by a decrease/leveling off. Annual female urban and rural incidence rates remained approximately five- to six-fold lower than male urban and rural incidence rates on average, consistent with the comparatively increased historical occupational asbestos exposure for males. The results suggest that differences in ambient asbestos concentrations, which have been reported to be 10-fold or greater across regions in the United States, have not influenced the risk of pleural mesothelioma.

A statewide investigation of geographic lung cancer incidence patterns and radon exposure in a low-smoking population

BACKGROUND

Lung cancer is the leading cause of cancer-related mortality in Utah despite having the nation's lowest smoking rate. Radon exposure and differences in lung cancer incidence between nonmetropolitan and metropolitan areas may explain this phenomenon. We compared smoking-adjusted lung cancer incidence rates between nonmetropolitan and metropolitan counties by predicted indoor radon level, sex, and cancer stage. We also compared lung cancer incidence by county classification between Utah and all SEER sites.

METHODS

SEER*Stat provided annual age-adjusted rates per 100,000 from 1991 to 2010 for each Utah county and all other SEER sites. County classification, stage, and sex were obtained from SEER*Stat. Smoking was obtained from Environmental Public Health Tracking estimates by Ortega et al. EPA provided low (< 2 pCi/L), moderate (2-4 pCi/L), and high (> 4 pCi/L) indoor radon levels for each county. Poisson models calculated overall, cancer stage, and sex-specific rates and p-values for smoking-adjusted and unadjusted models. LOESS smoothed trend lines compared incidence rates between Utah and all SEER sites by county classification.

RESULTS

All metropolitan counties had moderate radon levels; 12 (63%) of the 19 nonmetropolitan counties had moderate predicted radon levels and 7 (37%) had high predicted radon levels. Lung cancer incidence rates were higher in nonmetropolitan counties than metropolitan counties (34.8 vs 29.7 per 100,000, respectively). Incidence of distant stage cancers was significantly higher in nonmetropolitan counties after controlling for smoking (16.7 vs 15.4, p = 0.02*). Incidence rates in metropolitan, moderate radon and nonmetropolitan, moderate radon counties were similar. Nonmetropolitan, high radon counties had a significantly higher incidence of lung cancer compared to nonmetropolitan, moderate radon counties after adjustment for smoking (41.7 vs 29.2, p < 0.0001*). Lung cancer incidence patterns in Utah were opposite of metropolitan/nonmetropolitan trends in other SEER sites.

CONCLUSION

Lung cancer incidence and distant stage incidence rates were consistently higher in nonmetropolitan Utah counties than metropolitan counties, suggesting that limited access to preventative screenings may play a role in this disparity. Smoking-adjusted incidence rates in nonmetropolitan, high radon counties were significantly higher than moderate radon counties, suggesting that radon was also major contributor to lung cancer in these regions. National studies should account for geographic and environmental factors when examining nonmetropolitan/metropolitan differences in lung cancer.

Urban/Rural Differences in Breast and Cervical Cancer Incidence: The Mediating Roles of Socioeconomic Status and Provider Density

BACKGROUND

Breast and cervical cancer incidence vary by urbanicity, and several ecological factors could contribute to these patterns. In particular, cancer screening or other sociodemographic and health care system variables could explain geographic disparities in cancer incidence.

METHODS

Governmental and research sources provided data on 612 counties in the Surveillance, Epidemiology, and End Results program for rural-urban continuum code, socioeconomic status (SES) quintile, percent non-Hispanic White residents, density of primary care physicians, cancer screening, and breast and cervical cancer incidence rates (2009-2013). Ecological mediation analyses used weighted least squares regression to examine whether candidate mediators explained the relationship between urbanicity and cancer incidence.

RESULTS

As urbanicity increased, so did breast cancer incidence (βˆ = 0.23; p < .001). SES quintile and density of primary care physicians mediated this relationship, whereas percent non-Hispanic White suppressed it (all p < .05); county-level mammography levels did not contribute to the relationship. After controlling for these variables, urbanicity and breast cancer incidence were no longer associated (βˆ = 0.11; p > .05). In contrast, as urbanicity increased, cervical cancer incidence decreased (βˆ = -0.33; p < .001). SES quintile and density of primary care physicians mediated this relationship (both p < .05); percent non-Hispanic White and Pap screening levels did not contribute to the relationship. After controlling for these variables, the relationship between urbanicity and cervical cancer incidence remained significant (βˆ = -0.13; p < .05).

CONCLUSIONS

County-level SES and density of primary care physicians explained the relationships between urbanicity and breast and cervical cancer incidence. Improving these factors in more rural counties could ameliorate geographic disparities in breast and cervical cancer incidence.

Socially Responsible Surgery: Building Recognition and Coalition

IMPORTANCE

Socially responsible surgery (SRS) integrates surgery and public health, providing a framework for research, advocacy, education, and clinical practice to address the social barriers of health that decrease surgical access and worsen surgical outcomes in underserved patient populations. These patients face disparities in both health and in health care, which can be effectively addressed by surgeons in collaboration with allied health professionals.

OBJECTIVE

We reviewed the current state of surgical access and outcomes of underserved populations in American rural communities, American urban communities, and in low- and middle-income countries.

EVIDENCE REVIEW

We searched PubMed using standardized search terms and reviewed the reference lists of highly relevant articles. We reviewed the reports of two recent global surgery commissions.

CONCLUSION

There is an opportunity for scholarship in rural surgery, urban surgery, and global surgery to be unified under the concept of SRS. The burden of surgical disease and the challenges to management demonstrate that achieving optimal health outcomes requires more than excellent perioperative care. Surgeons can and should regularly address the social determinants of health experienced by their patients. Formalized research and training opportunities are needed to meet the growing enthusiasm among surgeons and trainees to develop their practice as socially responsible surgeons.

Influence of hospital and patient location on early postoperative outcomes after appendectomy and pyloromyotomy

BACKGROUND

The effects of hospital location and designation on postoperative pediatric outcomes remain unclear. We hypothesized that urban hospital outcomes would be superior to rural hospitals, and that outcomes at urban centers would differ for children from rural versus urban counties.

METHODS

Retrospective cohort study of children undergoing appendectomy (n=129,507) and pyloromyotomy (n=13,452) using the 2006/2009 KID databases. Hospitals were characterized by specialty designation and classified as urban/rural. County of residence was classified as urban/rural. Outcomes included complications and length of stay. Multivariate regression models were used to adjust for confounding.

RESULTS

Among appendectomy patients, treatment at urban hospitals was associated with reduced odds of any postoperative complication (OR=0.77, 95% C.I. 0.70-0.85) and anesthesia-related complications (OR=0.72, 95% C.I. 0.57-0.91). This association was strongest in the youngest children (<5 years) and at children's hospitals. For pyloromyotomy patients, urban hospitals were associated with reduced odds of any complication (OR=0.43, 95% C.I. 0.24-0.75), anesthesia-related complications (OR=0.14, 95% C.I. 0.05-0.37), and duodenal perforation (OR=0.46, 95% C.I. 0.19-1.07). These associations were most significant at children's hospitals.

CONCLUSIONS

Postoperative outcomes appear to be improved at urban specialty hospitals relative to rural hospitals for certain common pediatric procedures. Identification of the factors driving this association may help inform resource optimization efforts in pediatric surgery.

Disparities in the Utilization of Laparoscopic Surgery for Colon Cancer in Rural Nebraska: A Call for Placement and Training of Rural General Surgeons

BACKGROUND

Advances in medical technology are changing surgical standards for colon cancer treatment. The laparoscopic colectomy is equivalent to the standard open colectomy while providing additional benefits. It is currently unknown what factors influence utilization of laparoscopic surgery in rural areas and if treatment disparities exist. The objectives of this study were to examine demographic and clinical characteristics associated with receiving laparoscopic colectomy and to examine the differences between rural and urban patients who received either procedure.

METHODS

This study utilized a linked data set of Nebraska Cancer Registry and hospital discharge data on colon cancer patients diagnosed and treated in the entire state of Nebraska from 2008 to 2011 (N = 1,062). Multiple logistic regression analysis was performed to identify predictors of receiving the laparoscopic treatment.

RESULTS

Rural colon cancer patients were 40% less likely to receive laparoscopic colectomy compared to urban patients. Independent predictors of receiving laparoscopic colectomy were younger age (<60), urban residence, ≥3 comorbidities, elective admission, smaller tumor size, and early stage at diagnosis. Additionally, rural patients varied demographically compared to urban patients.

CONCLUSIONS

Laparoscopic surgery is becoming the new standard of treatment for colon cancer and important disparities exist for rural cancer patients in accessing the specialized treatment. As cancer treatment becomes more specialized, the importance of training and placement of general surgeons in rural communities must be a priority for health care planning and professional training institutions.

Does patient rurality predict quality colon cancer care?: A population-based study

BACKGROUND

More than 50 million people reside in rural America. However, the impact of patient rurality on colon cancer care has been incompletely characterized, despite its known impact on screening.

OBJECTIVE

Our study sought to examine the impact of patient rurality on quality and comprehensive colon cancer care.

DESIGN

We constructed a retrospective cohort of 123,129 patients with stage 0 to IV colon cancer. Rural residence was established based on the patient medical service study area designated by the registry.

SETTINGS

The study was conducted using the 1996-2008 California Cancer Registry.

PATIENTS

All of the patients diagnosed between 1996 and 2008 with tumors located in the colon were eligible for inclusion in this study.

MAIN OUTCOME MEASURES

Baseline characteristics were compared by rurality status. Multivariate regression models then were used to examine the impact of rurality on stage in the entire cohort, adequate lymphadenectomy in stage I to III disease, and receipt of chemotherapy for stage III disease. Proportional-hazards regression was used to examine the impact of rurality on cancer-specific survival.

RESULTS

Of all of the patients diagnosed with colon cancer, 18,735 (15%) resided in rural areas. Our multivariate models demonstrate that rurality was associated with later stage of diagnosis, inadequate lymphadenectomy in stage I to III disease, and lower likelihood of receiving chemotherapy for stage III disease. In addition, rurality was associated with worse cancer-specific survival.

LIMITATIONS

We could not account for socioeconomic status directly, although we used insurance status as a surrogate. Furthermore, we did not have access to treatment location or distance traveled. We also could not account for provider or hospital case volume, patient comorbidities, or complications.

CONCLUSIONS

A significant portion of patients treated for colon cancer live in rural areas. Yet, rural residence is associated with modest differences in stage, adherence to quality measures, and survival. Future endeavors should help improve care to this vulnerable population (see video, Supplemental Digital Content 1, http://links.lww.com/DCR/A143).

Rural residence and cancer outcomes in the United States: issues and challenges

"Neighborhoods and health" research has shown that area social factors are associated with the health outcomes that patients with cancer experience across the cancer control continuum. To date, most of this research has been focused on the attributes of urban areas that are associated with residents' poor cancer outcomes with less focused on attributes of rural areas that may be associated with the same. Perhaps because there is not yet a consensus in the United States regarding how to define "rural," there is not yet an accepted analytic convention for studying issues of how patients' cancer outcomes may vary according to "rural" as a contextual attribute. The research that exists reports disparate findings and generally treats rural residence as a patient attribute rather than a contextual factor, making it difficult to understand what factors (e.g., unmeasured individual poverty, area social deprivation, area health care scarcity) may be mediating the poor outcomes associated with rural (or non-rural) residence. Here, we review literature regarding the potential importance of rural residence on cancer patients' outcomes in the United States with an eye towards identifying research conventions (i.e., spatial and analytic) that may be useful for future research in this important area.

Urban sprawl, obesity, and cancer mortality in the United States: cross-sectional analysis and methodological challenges

BACKGROUND

Urban sprawl has the potential to influence cancer mortality via direct and indirect effects on obesity, access to health services, physical activity, transportation choices and other correlates of sprawl and urbanization.

METHODS

This paper presents a cross-sectional analysis of associations between urban sprawl and cancer mortality in urban and suburban counties of the United States. This ecological analysis was designed to examine whether urban sprawl is associated with total and obesity-related cancer mortality and to what extent these associations differed in different regions of the US. A major focus of our analyses was to adequately account for spatial heterogeneity in mortality. Therefore, we fit a series of regression models, stratified by gender, successively testing for the presence of spatial heterogeneity. Our resulting models included county level variables related to race, smoking, obesity, access to health services, insurance status, socioeconomic position, and broad geographic region as well as a measure of urban sprawl and several interactions. Our most complex models also included random effects to account for any county-level spatial autocorrelation that remained unexplained by these variables.

RESULTS

Total cancer mortality rates were higher in less sprawling areas and contrary to our initial hypothesis; this was also true of obesity related cancers in six of seven U.S. regions (census divisions) where there were statistically significant associations between the sprawl index and mortality. We also found significant interactions (p < 0.05) between region and urban sprawl for total and obesity related cancer mortality in both sexes. Thus, the association between urban sprawl and cancer mortality differs in different regions of the US.

CONCLUSIONS

Despite higher levels of obesity in more sprawling counties in the US, mortality from obesity related cancer was not greater in such counties. Identification of disparities in cancer mortality within and between geographic regions is an ongoing public health challenge and an opportunity for further analytical work identifying potential causes of these disparities. Future analyses of urban sprawl and health outcomes should consider exploring regional and international variation in associations between sprawl and health.

Prostate cancer in Scotland: does geography matter? An analysis of incidence, disease characteristics and survival between urban and rural areas

Objective:

The objective of this article is to identify whether there is a difference in survival from prostate cancer in urban and rural areas of Scotland and to identify potential inequalities in incidence, disease characteristics and the treatment of prostate cancer between these areas.

Subjects/patients and methods:

A retrospective cohort study was undertaken. Retrospective analysis of data from Information Services Division and regional cancer databases from 2005 to 2010 was performed. A comparison of NHS Highland & Western Isles as the rural group with NHS Lothian as the urban group was made. Data were collected on patient and disease characteristics, first treatment and mortality. Non-parametric continuous data were analysed using the Mann-Whitney U test. Categorical data were assessed using a two-tailed Z test. The p value for statistical significance was set at < 0.05.

Results:

The incidence of prostate cancer was higher in rural areas. Rural patients were older at diagnosis ( p < 0.0001), presented with higher risk disease ( p < 0.0001) and underwent less curative treatment ( p < 0.0001). There was potentially poorer survival in rural areas.

Conclusions:

Men living in rural areas of Scotland present with more aggressive prostate cancer and may have poorer survival. This could be due to high levels of PSA testing in urban areas, therefore further studies are needed to identify patterns of PSA testing in Scotland. These inequalities will be highlighted to the Scottish Government to inform the ‘Detect Cancer Early’ campaign for its second phase in 2015.

Rural-urban differences in health behaviors and implications for health status among US cancer survivors

PURPOSE

Rural US adults have increased risk of poor outcomes after cancer, including increased cancer mortality. Rural-urban differences in health behaviors have been identified in the general population and may contribute to cancer health disparities, but have not yet been examined among US survivors. We examined rural-urban differences in health behaviors among cancer survivors and associations with self-reported health and health-related unemployment.

METHODS

We identified rural (n = 1,642) and urban (n = 6,162) survivors from the cross-sectional National Health Interview Survey (2006-2010) and calculated the prevalence of smoking, physical activity, overweight/obesity, and alcohol consumption. Multivariable models were used to examine the associations of fair/poor health and health-related unemployment with health behaviors and rural-urban residence.

RESULTS

The prevalence of fair/poor health (rural 36.7 %, urban 26.6 %), health-related unemployment (rural 18.5 %, urban 10.6 %), smoking (rural 25.3 %, urban 15.8 %), and physical inactivity (rural 50.7 %, urban 38.7 %) was significantly higher in rural survivors (all p < .05); alcohol consumption was lower (rural 46.3 %, urban 58.6 %), and there were no significant differences in overweight/obesity (rural 65.4 %, urban 62.6 %). All health behaviors were significantly associated with fair/poor health and health-related unemployment in both univariate and multivariable models. After adjustment for behaviors, rural survivors remained more likely than urban survivors to report fair/poor health (OR = 1.21, 95 % CI 1.03-1.43) and health-related unemployment (OR = 1.49, 95 % CI 1.18-1.88).

CONCLUSIONS

Rural survivors may need tailored, accessible health promotion interventions to address health-compromising behaviors and improve outcomes after cancer.

Socioeconomic status, p53 abnormalities, and colorectal cancer

BACKGROUND

Low socioeconomic status (SES) has been associated with abnormal expression of p53 in breast cancer, but this relationship has not been evaluated for colorectal cancer (CRC). A cohort of CRC patients was evaluated to determine if SES is associated with abnormal p53 expression.

METHODS

The study population consisted of 249 patients who underwent curative or palliative resections for CRCs at the University of Alabama at Birmingham Hospital. Measures of SES and potential confounders were abstracted from medical records. Abnormal nuclear accumulation of p53 (p53(nac)) was measured in CRCs by immunohistochemistry. Logistic regression was used to assess the relationship between low SES and p53(nac).

RESULTS

Over half (56.2%) of the patients exhibited p53(nac) in their CRCs. After adjustment, the odds ratio for p53(nac) was 1.28 (95% CI =0.55, 2.99) for Medicaid patients relative to those without Medicaid coverage. There was no association between the prevalence of p53(nac) and unemployment, private insurance coverage, or having Medicare due to disability.

CONCLUSIONS

The odds of having p53(nac) were 1.28 times higher for patients with Medicaid coverage, although these findings were not statistically significant. The results of this pilot study, however, provide evidence of a molecular basis for the decreased survival of low SES patients with CRC.

Does patients' place of residence affect the type of physician performing primary excision of cutaneous melanoma in northern Scotland?

BACKGROUND

Rural residence may adversely affect cancer outcomes, perhaps because rural cancer patients are managed differently. Current UK guidelines recommend all patients with suspected melanoma be referred urgently for specialist excision biopsy; however, up to 20% of patients receive their biopsy in primary care. This project explored if rural dwellers with melanoma were more likely to have their primary biopsy in primary care.

METHODS

A clinical database of all primary cutaneous melanomas diagnosed in Northern Scotland between January 1991 and July 2007 was analyzed for patient demographics, clinical variables, and intermediate outcomes. Significant findings on univariate analysis were then included in a binary logistic regression model to adjust for confounders.

RESULTS

On univariate analysis patients living in rural areas were significantly more likely to have their melanomas excised in primary care compared with those living in the city (26.3% compared with 17.7%, P < .001). There were no significant differences between rural and urban dwellers in Breslow thickness or completeness of excision. Following adjustment for key confounders, those living in suburban areas and remote small towns were significantly more likely to be treated contrary to current UK melanoma guidelines compared to those in cities.

CONCLUSIONS

In Northern Scotland patients living in suburban areas and remote small towns are significantly more likely to have an initial melanoma excision in primary care, contrary to current UK guidelines. This geographical contrast signposts the way to further in-depth research into the interplay between place of residence and how the cancer journey is experienced.

The combined effect of individual and neighborhood socioeconomic status on cancer survival rates

Background

This population-based study investigated the relationship between individual and neighborhood socioeconomic status (SES) and mortality rates for major cancers in Taiwan.

Methods

A population-based follow-up study was conducted with 20,488 cancer patients diagnosed in 2002. Each patient was traced to death or for 5 years. The individual income-related insurance payment amount was used as a proxy measure of individual SES for patients. Neighborhood SES was defined by income, and neighborhoods were grouped as living in advantaged or disadvantaged areas. The Cox proportional hazards model was used to compare the death-free survival rates between the different SES groups after adjusting for possible confounding and risk factors.

Results

After adjusting for patient characteristics (age, gender, Charlson Comorbidity Index Score, urbanization, and area of residence), tumor extent, treatment modalities (operation and adjuvant therapy), and hospital characteristics (ownership and teaching level), colorectal cancer, and head and neck cancer patients under 65 years old with low individual SES in disadvantaged neighborhoods conferred a 1.5 to 2-fold higher risk of mortality, compared with patients with high individual SES in advantaged neighborhoods. A cross-level interaction effect was found in lung cancer and breast cancer. Lung cancer and breast cancer patients less than 65 years old with low SES in advantaged neighborhoods carried the highest risk of mortality. Prostate cancer patients aged 65 and above with low SES in disadvantaged neighborhoods incurred the highest risk of mortality. There was no association between SES and mortality for cervical cancer and pancreatic cancer.

Conclusions

Our findings indicate that cancer patients with low individual SES have the highest risk of mortality even under a universal health-care system. Public health strategies and welfare policies must continue to focus on this vulnerable group.

Racial and regional disparities in lung cancer incidence

BACKGROUND

Lung cancer is the second most commonly diagnosed cancer and the leading cause of cancer-related death in the United States (US). We examined data from 2004 to 2006 for lung cancer incidence rates by demographics, including race and geographic region, to identify potential health disparities.

METHODS

Data from cancer registries affiliated with the Centers for Disease Control and Prevention's (CDC) National Program of Cancer Registries (NPCR), and the National Cancer Institute's (NCI) Surveillance, Epidemiology, and End Results Program (SEER) were used for this study; representing 100% of the US population. Age-adjusted incidence rates and 95% confidence intervals for demographic (age, sex, race, ethnicity, and US Census region), and tumor (stage, grade, and histology) characteristics were calculated.

RESULTS

During 2004 to 2006, 623,388 people (overall rate of 68.9 per 100,000) were diagnosed with lung cancer in the US. Lung cancer incidence rates were highest among men (86.2), Blacks (73.0), persons aged 70 to 79 years (431.1), and those living in the South (74.7). Among Whites, the highest lung cancer incidence rate was in the South (75.6); the highest rates among Blacks (88.9) and American Indians/Alaska Natives (65.4) in the Midwest, Asians/Pacific Islanders in the West (40.0), and Hispanics in the Northeast (40.3).

CONCLUSIONS

Our findings of racial, ethnic, and regional disparities in lung cancer incidence suggest a need for the development and implementation of more effective culturally specific preventive and treatment strategies that will ultimately reduce the disproportionate burden of lung cancer in the US.

Rural-urban inequalities in detection rates of colorectal tumours in the population

BACKGROUND

Because few data are available on this topic, we investigated the influence of geographical determinants on colorectal adenoma detection and cancer incidence rates.

METHODS

Between 1990 and 1999, 6220 Côte d'Or inhabitants (France) were first-diagnosed with a colorectal adenoma, and 2389 with an invasive adenocarcinoma. The impact of the rural-urban place of residence and of a physician location in municipalities on adenoma and cancer detection rates was studied using Poisson regression.

RESULTS

World-standardized adenoma detection rate was significantly higher in urban areas (102 [95% CI: 97-107]) than in rural areas (78 [95% CI: 72-84]). The impact of the absence of physicians in municipalities was only found in rural areas. The detection rate ratio associated with the absence of a primary care physician was 0.70 [95% CI: 0.61-0.81], and the detection rate ratio associated with the absence of a gastroenterologist was 0.75 [95% CI: 0.64-0.89]. Colorectal cancer incidence rates were similar in urban and rural areas with only marginal variations related to physician location.

CONCLUSIONS

These results suggested a differential impact of geographical variables on the detection rates of colorectal adenomas and cancers in the population. Further studies are needed to examine socio-economic factors likely to be involved in these disparities.