Factors Contributing to Delay in Specialist Care After Colorectal Cancer Diagnosis in Kentucky

Risk factors affecting patients survival with colorectal cancer in Morocco: survival analysis using an interpretable machine learning approach

The aim of our study was to assess the overall survival rates for colorectal cancer at 3 years and to identify associated strong prognostic factors among patients in Morocco through an interpretable machine learning approach. This approach is based on a fully non-parametric survival random forest (RSF), incorporating variable importance and partial dependence effects. The data was povided from a retrospective study of 343 patients diagnosed and followed at Hassan II University Hospital. Covariate selection was performed using the variable importance based on permutation and partial dependence plots were displayed to explore in depth the relationship between the estimated partial effect of a given predictor and survival rates. The predictive performance was measured by two metrics, the Concordance Index (C-index) and the Brier Score (BS). Overall survival rates at 1, 2 and 3 years were, respectively, 87% (SE = 0.02; CI-95% 0.84-0.91), 77% (SE = 0.02; CI-95% 0.73-0.82) and 60% (SE = 0.03; CI-95% 0.54-0.66). In the Cox model after adjustment for all covariates, sex, tumor differentiation had no significant effect on prognosis, but rather tumor site had a significant effect. The variable importance obtained from RSF strengthens that surgery, stage, insurance, residency, and age were the most important prognostic factors. The discriminative capacity of the Cox PH and RSF was, respectively, 0.771 and 0.798 for the C-index while the accuracy of the Cox PH and RSF was, respectively, 0.257 and 0.207 for the BS. This shows that RSF had both better discriminative capacity and predictive accuracy. Our results show that patients who are older than 70, living in rural areas, without health insurance, at a distant stage and who have not had surgery constitute a subgroup of patients with poor prognosis.

Timeliness of diagnostic evaluation for postmenopausal bleeding: A retrospective cohort study using claims data

BACKGROUND

Postmenopausal bleeding (PMB) is a common gynecologic condition. Although it can be a sign of uterine cancer, most patients have benign etiology. However, research on quality of diagnostic evaluation for PMB has been limited to cancer patients. To extend this research, we examined the timeliness of diagnostic evaluation for PMB among patients with benign conditions.

METHODS

Using the 2008-2019 MarketScan Research Databases, we identified 499176 patients (456741 with commercial insurance and 42435 with Medicaid insurance) who presented with PMB but did not have gynecologic cancer. For each patient, we measured the time from their PMB reporting to the date of their first diagnostic procedure. The association between patient characteristics and time to first diagnostic procedure was examined using Cox proportional hazards models (for the overall sample and then stratified by insurance type).

RESULTS

Overall, 54.3% of patients received a diagnostic procedure on the same day when they reported PMB and 86.6% received a diagnostic procedure within 12 months after reporting PMB. These percentages were 39.4% and 77.1%, respectively, for Medicaid patients, compared to 55.7% and 87.4%, respectively, for commercially insured patients (p<0.001 for both). Medicaid patients had an 18% lower rate of receiving a diagnostic procedure at any given time point than commercially insured patients (adjusted hazard ratio = 0.82, 95% CI: 0.81-0.83). Meanwhile, older age and non-gynecologic comorbidities were associated with a lower rate whereas concomitant gynecologic conditions and recent use of preventive care were associated with a higher rate of receiving diagnostic procedures. Analysis stratified by insurance type identified additional risk factors for delayed diagnostic procedures (e.g., non-metropolitan versus metropolitan location for commercially insured patients and Black versus White race for Medicaid patients).

CONCLUSION

A sizable proportion of patients did not receive prompt diagnostic evaluation for PMB. Both clinical and non-clinical factors could affect timeliness of evaluation.

Risk factors affecting patients survival with colorectal cancer in Morocco : Survival Analysis using an Interpretable Machine Learning Approach

The aim of our study was to assess the overall survival rates for colorectal patients in Morocco and to identify strong prognostic factors using a novel approach combining survival random forest and the Cox model. Covariate selection was performed using the variable importance based on permutation and partial dependence plots were displayed to explore in depth the relationship between the estimated partial effect of a given predictor and survival rates. The predictive performance was measured by two metrics, the Concordance Index (C-index) and the Brier Score (BS). Overall survival rates at 1, 2 and 3 years were, respectively, 87% (SE = 0.02; CI-95% = 0.84-0.91), 77% (SE = 0.02; CI-95% = 0.73-0.82) and 60% (SE = 0.03; CI-95% = 0.54-0.66). In the Cox model after adjustment for all covariates, sex, tumor differentiation had no significant effect on prognosis, but rather tumor site had a significant effect. The variable importance obtained from RSF strengthens that surgery, stage, insurance, residency, and age were the most important prognostic factors. The discriminative capacity of the Cox PH and RSF was, respectively, 0.771 and 0.798 for the C-index, while the accuracy of the Cox PH and RSF was, respectively, 0.257 and 0.207 for the Brier Score. This shows that RSF had both better discriminative capacity and predictive accuracy. Our results show that patients who are older than 70, living in rural areas, without health insurance, at a distant stage and who have not had surgery constitute a subgroup of patients with poor prognosis.

Disparities in access to care among patients with appendiceal or colorectal cancer and peritoneal metastases: A medicare insurance-based study in the United States

BACKGROUND

Prior studies attempting to identify disparities in the care of patients with appendiceal (AC) or colorectal cancer (CRC) with peritoneal metastasis (PM) are limited to single-institution, highly selected patient populations. This observational cohort study sought to identify factors associated with specialty care for Medicare beneficiaries with AC/CRC-PM.

MATERIALS AND METHODS

Patients >65 years old in the United States diagnosed with AC/CRC and isolated PM were identified within the Medicare Standard Analytic File (2013-2017). Mixed-effects analyses assessed patient factors associated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) and outpatient consultation with a peritoneal surface malignancy (PSM) surgeon, and Cox proportional-hazards analysis compared 3-year overall survival (OS) between patients receiving CRS/HIPEC versus systemic therapy alone.

RESULTS

Among 7,653 patients, only 250 (3.3%) underwent CRS/HIPEC. Among those individuals who did not undergo CRS/HIPEC (N=7,403), only 475 (6.4%) had outpatient consultation with a PSM surgeon. Patient factors independently associated with lower odds of CRS/HIPEC and PSM surgery consultation included older age, greater comorbidity burden, higher social vulnerability index, and further distance from a PSM center (p<0.05). CRS/HIPEC was independently associated with better 3-year OS compared with systemic therapy alone (HR=0.29, 95%CI=0.21-0.38).

CONCLUSION

An exceedingly small proportion of Medicare beneficiaries with AC/CRC-PM undergo CRS/HIPEC or even have an outpatient consultation with a PSM surgeon. Significant disparities in treatment and access to care exist for patients with higher levels of social vulnerability and those that live further away from a PSM center. Future research and interventions should focus on improving access to care for these at-risk patient populations.

Applying Latent Class Analysis on Cancer Registry Data to Identify and Compare Health Disparity Profiles in Colorectal Cancer Surgical Treatment Delay

CONTEXT

Colorectal cancer (CRC) surgical treatment delay (TD) has been associated with mortality and morbidity; however, disparities by TD profiles are unknown.

OBJECTIVES

This study aimed to identify CRC patient profiles of surgical TD while accounting for differences in sociodemographic, health insurance, and geographic characteristics.

DESIGN

We used latent class analysis (LCA) on 2005-2015 Tennessee Cancer Registry data of CRC patients and observed indicators that included sex/gender, age at diagnosis, marital status (single/married/divorced/widowed), race (White/Black/other), health insurance type, and geographic residence (non-Appalachian/Appalachian).

SETTING

The state of Tennessee in the United States that included both Appalachian and non-Appalachian counties.

PARTICIPANTS

Adult (18 years or older) CRC patients (N = 35 412) who were diagnosed and surgically treated for in situ (n = 1286) and malignant CRC (n = 34 126).

MAIN OUTCOME MEASURE

The distal outcome of TD was categorized as 30 days or less and more than 30 days from diagnosis to surgical treatment.

RESULTS

Our LCA identified a 4-class solution and a 3-class solution for in situ and malignant profiles, respectively. The highest in situ CRC patient risk profile was female, White, aged 75 to 84 years, widowed, and used public health insurance when compared with respective profiles. The highest malignant CRC patient risk profile was male, Black, both single/never married and divorced/separated, resided in non-Appalachian county, and used public health insurance when compared with respective profiles. The highest risk profiles of in situ and malignant patients had a TD likelihood of 19.3% and 29.4%, respectively.

CONCLUSIONS

While our findings are not meant for diagnostic purposes, we found that Blacks had lower TD with in situ CRC. The opposite was found in the malignant profiles where Blacks had the highest TD. Although TD is not a definitive marker of survival, we observed that non-Appalachian underserved/underrepresented groups were overrepresented in the highest TD profiles. The observed disparities could be indicative of intervenable risk.