Factors That Contribute to Differences in Survival of Black vs White Patients With Colorectal Cancer

Molecular, Socioeconomic, and Clinical Factors Affecting Racial and Ethnic Disparities in Colorectal Cancer Survival

Importance

Disparity in overall survival (OS) and differences in the frequency of driver gene variants by race and ethnicity have been separately observed in patients with colorectal cancer; however, how these differences contribute to survival disparity is unknown.

Objective

To quantify the association of molecular, socioeconomic, and clinical covariates with racial and ethnic disparities in overall survival among patients with colorectal cancer.

Design, Setting, and Participants

This single-center cohort study was conducted at a tertiary-level cancer center using relevant data on all patients diagnosed with colorectal cancer from January 1, 1973, to March 1, 2023. The relative contribution of variables to the disparity was determined using mediation analysis with sequential multivariate Cox regression models.

Main Outcome

OS, from diagnosis date and from start of first-line chemotherapy.

Results

The study population of 47 178 patients (median [IQR] age, 57.0 [49-66] years; 20 465 [43.4%] females and 26 713 [56.6%] males; 3.0% Asian, 8.7% Black, 8.8% Hispanic, and 79.4% White individuals) had a median (IQR) follow-up from initial diagnosis of 124 (174) months and OS of 55 (145) months. Compared with White patients, Black patients had worse OS (hazard ratio [HR], 1.16; 95% CI, 1.09-1.24; P <.001), whereas Asian and Hispanic patients had better OS (HR, 0.66; 95% CI, 0.59-0.74; P <.001; and 0.86; 95% CI, 0.81-0.92; P <.001, respectively). When restricted to patients with metastatic disease, the greatest disparity was between Black patients compared with White patients (HR, 1.2; 95% CI, 1.06-1.37; P <.001). Evaluating changes in OS disparity over 20 years showed disparity decreasing among Asian, Hispanic, and White patients, but increasing between Black patients and White patients (HRs, 1.18; 95% CI, 1.07-1.31 for 2008-2012; 1.24, 95% CI, 1.08-1.42 for 2013-2017; and 1.50; 95% CI, 1.20-1.87 for 2018-2023). Survival outcomes for first-line chemotherapy were worse for Black patients compared with White patients (median OS, 18 vs 26 months; HR, 1.30; 95% CI, 1.01-1.70). Among 7628 patients who had clinical molecular testing, APC, KRAS, and PIK3CA showed higher variant frequency in Black patients (false discovery rate [FDR], 0.01; < 0.001; and 0.01, respectively), whereas BRAF and KIT were higher among White patients (FDR, 0.001 and 0.01). Mediation analysis identified neighborhood socioeconomic status as the greatest contributor to OS disparity (29%), followed by molecular characteristics (microsatellite instability status, KRAS variation and BRAF variation, 10%), and tumor sidedness (9%).

Conclusions

This single-center cohort study identified substantial OS disparity and differing frequencies of driver gene variations by race and ethnicity. Socioeconomic status had the largest contribution but accounted for less than one-third of the disparity, with substantial contribution from tumor molecular features. Further study of the associations of genetic ancestry and the molecular pathogenesis of colorectal cancer with chemotherapy response is needed.

Investigating the Obesity Paradox in Colorectal Cancer: An Analysis of Prospectively Collected Data in a Diverse Cohort

BACKGROUND

Prior studies are inconclusive regarding the effect of obesity on mortality in persons with colorectal cancer (CRC). We sought to determine the association of pre-diagnosis body mass index (BMI) trajectories on mortality after CRC diagnosis.

METHODS

Utilizing the Multiethnic Cohort, we included adults aged 18-75 between 1 January 1993 and 1 January 2019 with a diagnosis of CRC and at least three available BMIs. The primary exposure, BMI, was subjected to group-based trajectory modeling (GBTM). We evaluated all-cause and CRC-specific mortality, using Cox proportional hazard (PH) models.

RESULTS

Of 924 persons, the median age was 60 years, and 54% were female. There was no statistically significant association between pre-cancer BMI trajectory and either all-cause or cancer-specific mortality. In competing risk analysis, the risk of CRC-specific mortality was higher for African Americans (HR = 1.56, 95% CI [1.00-2.43], p = 0.048) and smokers (HR = 1.59, 95% CI [1.10-2.32], p = 0.015). Risk of all-cause mortality was higher for Hawaiian persons (HR = 2.85, 95% CI [1.31-6.21], p = 0.009) and persons with diabetes (HR = 1.83, 95% CI [1.08-3.10], p = 0.026).

CONCLUSIONS

Pre-diagnosis BMI trajectories were not associated with mortality after CRC diagnosis, whereas race/ethnicity, diabetes, and smoking were associated with an increased risk of death. Our findings suggest the obesity paradox alone does not account for mortality after CRC diagnosis.

Predictors and outcomes of delays between diagnosis and definitive surgery for rectal cancer

BACKGROUND

The National Accreditation Program for Rectal Cancer (NAPRC) recommends definitive treatment of rectal cancer commence within 60 days from diagnosis. This study aimed to assess predictors of >60 days delay between diagnosis and definitive surgery of rectal cancer and the impact on survival and short-term outcomes.

METHODS

Retrospective cohort analysis of patients with stage I-III rectal adenocarcinoma who underwent proctectomy without preoperative neoadjuvant treatment from the National Cancer Database (2015-2019). Based on the time interval between diagnosis and definitive surgery, patients were divided into timely non-adherent (>60 days) and timely-adherent (≤60 days) groups. Multivariate analysis determined predictors of delayed definitive surgery.

RESULTS

9479 patients (57.5 % males; mean age: 63.7 years) had a 41-day median time between diagnosis and definitive surgery. Non-adherence was noted in 27.9 % of patients. Independent predictors of non-adherence were male sex (Odds ratio [OR]: 1.25; p < 0.001), Black (OR: 1.65; p < 0.001) or Asian (OR: 1.33; p = 0.014) race, Charlson score 2 (OR: 1.33; p = 0.005) or 3 (OR: 1.55; p < 0.001), urban residence (OR: 1.21; p = 0.003), abdominoperineal resection (OR: 1.69; p < 0.001), pelvic exenteration (OR: 1.7; p = 0.002), and robotic-assisted surgery (OR: 1.22; p = 0.001). Medicare (OR: 0.725; p = 0.003) and private insurance (OR: 0.711; p < 0.001) were associated with better adherence. 30-day and 90-day mortality, unplanned readmission, and overall survival were similar.

CONCLUSIONS

Male Black or Asian patients with high Charlson scores, and undergoing abdominoperineal resection, pelvic exenteration, and robotic-assisted surgery were more likely non-adherent with NAPRC standards with >60 days delay before definitive surgery for rectal cancer. Hopefully, recognition for these reasons for delay of definitive surgery will lead to an improvement in adherence to the standards.

Hospital Accreditation Status and Treatment Differences Among Black Patients With Colon Cancer

Importance

Hospital-level factors, such as hospital type or volume, have been demonstrated to play a role in treatment disparities for Black patients with cancer. However, data evaluating the association of hospital accreditation status with differences in treatment among Black patients with cancer are lacking.

Objective

To evaluate the association of Commission on Cancer (CoC) hospital accreditation status with receipt of guideline-concordant care and mortality among non-Hispanic Black patients with colon cancer.

Design, Setting, and Participants

This population-based cohort study used the National Program of Cancer Registries, which is a multicenter database with data from all 50 states and the District of Columbia, and covers 97% of the cancer population in the US. The participants included non-Hispanic Black patients aged 18 years or older diagnosed with colon cancer between January 1, 2018, and December 31, 2020. Race and ethnicity were abstracted from medical records as recorded by health care facilities and practitioners. The data were analyzed from December 7, 2023, to January 17, 2024.

Exposure

CoC hospital accreditation.

Main Outcome and Measures

Guideline-concordant care was defined as adequate lymphadenectomy during surgery for patients with stages I to III disease or chemotherapy administration for patients with stage III disease. Multivariable logistic regression models investigated associations with receipt of guideline-concordant care and Cox proportional hazards regression models assessed associations with 3-year cancer-specific mortality.

Results

Of 17 249 non-Hispanic Black patients with colon cancer (mean [SD] age, 64.8 [12.8] years; 8724 females [50.6%]), 12 756 (74.0%; mean [SD] age, 64.7 [12.8] years) were treated at a CoC-accredited hospital and 4493 (26.0%; mean [SD] age, 65.1 [12.5] years) at a non-CoC-accredited hospital. Patients treated at CoC-accredited hospitals compared with those treated at non-CoC-accredited hospitals had higher odds of receiving guideline-concordant lymphadenectomy (adjusted odds ratio [AOR], 1.89; 95% CI, 1.69-2.11) and chemotherapy (AOR, 2.31; 95% CI, 1.97-2.72). Treatment at CoC-accredited hospitals was associated with lower cancer-specific mortality for patients with stages I to III disease who received surgery (adjusted hazard ratio [AHR], 0.87; 95% CI, 0.76-0.98) and for patients with stage III disease eligible for chemotherapy (AHR, 0.75; 95% CI, 0.59-0.96).

Conclusions and Relevance

In this cohort study of non-Hispanic Black patients with colon cancer, patients treated at CoC-accredited hospitals compared with those treated at non-CoC-accredited hospitals were more likely to receive guideline-concordant care and have lower mortality risk. These findings suggest that increasing access to high-quality guideline-concordant care at CoC-accredited hospitals may reduce variations in cancer treatment and outcomes for underserved populations.

Recent racial/ethnic disparities in cancer-specific mortality among patients diagnosed with rectal cancer

Background

African American patients frequently receive nonstandard treatment and demonstrate poorer overall survival (OS) outcomes compared to White patients. Our objective was to analysis whether racial/ethnic disparities in rectal cancer-specific mortality remain after accounting for clinical characteristics, treatment, and access-to-care-related factors.

Methods

Individuals diagnosed with rectal cancer between 2011 and 2020 were identified using the Surveillance, Epidemiology, and End Results Database. The cumulative incidence of rectal cancer-specific mortality was computed. Sub-distribution hazard ratios (sdHRs) and 95% confidence intervals (CIs) for rectal cancer-specific mortality associated with race/ethnicity were estimated using Fine and Gray model with stepwise adjustments for clinical characteristics, treatment modalities, and factors related to access-to-care.

Results

Among 54,370 patients, non-Hispanic (NH) Black individuals exhibited the highest cumulative incidence of rectal cancer-specific mortality (39%), followed by American Indian/Alaska Native (AI/AN) (35%), Hispanics (32%), NH-White (31%), and Asian/Pacific Islander (API) (30%). After adjusting for clinical characteristics, NH-Black patients had a 28% increased risk of rectal cancer mortality (sdHR, 1.28; 95% CI: 1.20-1.35) compared to NH-White patients. In contrast, mortality disparities between Hispanic-White, AI/AN-White, and API-White groups were not significant. The Black-White mortality differences persisted even after adjustments for treatment and access-to-care-related factors. In stratified analyses, among patients with a median household income below $59,999, AI/AN patients showed higher mortality than NH-Whites when adjusted for clinical characteristics (sdHR, 1.32; 95% CI: 1.03-1.70).

Conclusions

Overall, the racial/ethnic disparities in rectal cancer-specific mortality were largely attributable to differences in clinical characteristics, treatment modalities, and factors related to access-to-care. These findings emphasize the critical need for equitable healthcare to effectively address and reduce the significant racial/ethnic disparities in rectal cancer outcomes.

Trends and disparities in colorectal cancer hospitalizations and outcomes: a 10-year joinpoint trend study

Background

Colorectal cancer (CRC) poses a significant burden on healthcare systems globally. Sociodemographic factors intricately influence CRC epidemiology, yet their impact on inpatient care remains underexplored. This study aimed to assess trends in CRC hospitalization and the effect of sociodemographic factors on outcomes of CRC patients.

Methods

A retrospective longitudinal analysis was conducted using data from the Healthcare Cost and Utilization Project National Inpatient Sample. Trends in CRC admissions were assessed, stratified by sociodemographic variables. Disparities in hospital-associated outcomes were examined. Statistical methods included multivariable regression and joinpoint regression analysis.

Results

The prevalence of CRC hospitalizations uptrended from 760 per 100,000 hospitalizations in 2010 to 841 per 100,000 hospitalizations in 2019 (P trend < 0.001). The mean age decreased from 67 to 66 years (P < 0.001). Male gender and White race were predominant across the study period. Inpatient mortality decreased from 4.5% in 2010 to 4.16% in 2019 (P trend = 0.033). On sex subgroup analysis, men had a significantly higher mortality rate (P = 0.034). Racially, Blacks had the highest mortality rate (P = 0.550) and only Whites showed a significant decline in mortality over the study period (P = 0.003). Hospitalization length decreased while total hospital charges increased.

Conclusion

Our study highlights sociodemographic disparities in CRC outcomes, emphasizing the need for targeted interventions to address inequity in screening, diagnosis, and treatment. Continued research is needed to inform effective healthcare practices in mitigating these disparities and improving survival outcomes.

Association of Historical Housing Discrimination and Colon Cancer Treatment and Outcomes in the United States

PURPOSE

In the 1930s, the federally sponsored Home Owners' Loan Corporation (HOLC) used racial composition in its assessment of areas worthy of receiving loans. Neighborhoods with large proportions of Black residents were mapped in red (ie, redlining) and flagged as hazardous for mortgage financing. Redlining created a platform for systemic disinvestment in these neighborhoods, leading to barriers in access to resources that persist today. We investigated the association between residing in areas with different HOLC ratings and receipt of quality cancer care and outcomes among individuals diagnosed with colon cancer-a leading cause of cancer deaths amenable to early detection and treatment.

METHODS

Individuals who resided in zip code tabulation areas in 196 cities with HOLC rating and were diagnosed with colon cancer from 2007 to 2017 were identified from the National Cancer Database and assigned a HOLC grade (A, best; B, still desirable; C, definitely declining; and D, hazardous and mapped in red). Multivariable logistic regression models investigated association of area-level HOLC grade and late stage at diagnosis and receipt of guideline-concordant care. The product-limit method evaluated differences in time to adjuvant chemotherapy. Multivariable Cox proportional hazard models investigated differences in overall survival (OS).

RESULTS

There were 149,917 patients newly diagnosed with colon cancer with a median age of 68 years. Compared with people living in HOLC A areas, people living in HOLC D areas were more likely to be diagnosed with late-stage disease (adjusted odds ratio, 1.06 [95% CI, 1.00 to 1.12]). In addition, people living in HOLC B, C, and D areas had 8%, 16%, and 24% higher odds of not receiving guideline-concordant care, including lower receipt of surgery, evaluation of ≥12 lymph nodes, and chemotherapy. People residing in HOLC B, C, or D areas also experienced delays in initiation of adjuvant chemotherapy after surgery. People residing in HOLC C (adjusted hazard ratio [aHR], 1.09 [95% CI, 1.05 to 1.13]) and D (aHR, 1.13 [95% CI, 1.09 to 1.18]) areas had worse OS, including 13% and 20% excess risk of death for individuals diagnosed with early- and 6% and 8% for late-stage disease for HOLC C and D, respectively.

CONCLUSION

Historical housing discrimination is associated with worse contemporary access to colon cancer care and outcomes.

Hereditary Colorectal Cancer Syndromes Registry: What, How, and Why?

Caring for patients with colorectal cancer inherited cancer syndromes is complex, and it requires a well-thought integration process between a multidisciplinary team, an accessible database, and a registry coordinator. This requires an aligned vision between the administrative business team and the clinical team. Although we can manage most of the cancers that those patients develop according to oncologic guidance, the future risk of patients and their families might add emotional and psychological burdens on them in the absence of a well-qualified and trained team where balancing quality of life and cancer risk are at the essence of decision making.

Nomogram model for predicting cancer-specific mortality in patients with early-onset colorectal cancer: a competing risk analysis insight from the SEER database and an external validation cohort

Background

Early-onset colorectal cancer (EOCRC) is increasing in incidence and poses a growing threat. Urgent research is needed, especially in survival analysis, to enhance comprehension and treatment strategies. This study aimed to explore the risk factors associated with cancer-specific mortality (CSM) and other-cause mortality (OCM) in patients with EOCRC. Additionally, the study aimed to develop a nomogram predicting CSM using a competitive risk model and validate its accuracy through the use of training, using internal and external cohorts.

Methods

Data from EOCRC patients were collected from the Surveillance, Epidemiology, and End Results (SEER) database (2008-2017). EOCRC patients who were treated at a tertiary hospital in northeast China between 2014 and 2020 were also included in the study. The SEER data were divided into the training and validation sets at a 7:3 ratio. A univariate Cox regression model was employed to identify prognostic factors. Subsequently, multivariate Cox regression models were applied to ascertain the presence of independent risk factors. A nomogram was generated to visualize the results, which were evaluated using the concordance index (C-index), area under the curve (AUC), and calibration curves. The clinical utility was assessed via decision curve analysis (DCA).

Results

Multivariable Cox regression analysis demonstrated that factors such as race, tumor differentiation, levels of carcinoembryonic antigen (CEA), marital status, histological type, American Joint Committee on Cancer (AJCC) stage, and surgical status were independent risk factors for CSM in EOCRC patients. In addition, age, gender, chemotherapy details, CEA levels, marital status, and AJCC stage were established as independent risk factors for OCM in individuals diagnosed with EOCRC. A nomogram was developed using the identified independent risk factors, demonstrating excellent performance with a C-index of 0.806, 0.801, and 0.810 for the training, internal validation, and external validation cohorts, respectively. The calibration curves and AUC further confirmed the accuracy and discriminative ability of the nomogram. Furthermore, the DCA results indicated that the model had good clinical value.

Conclusions

In this study, a competing risk model for CSM was developed in EOCRC patients. The model demonstrates a high level of predictive accuracy, providing valuable insights into the treatment decision-making process.

Racial Disparities in Receipt of Guideline-Concordant Care for Early-Onset Colorectal Cancer in the United States

PURPOSE

Young individuals racialized as Black are more likely to die after a colorectal cancer (CRC) diagnosis than individuals racialized as White in the United States. This study examined racial disparities in receipt of timely and guideline-concordant care among individuals racialized as Black and White with early-onset CRC.

METHODS

Individuals age 18-49 years racialized as non-Hispanic Black and White (self-identified) and newly diagnosed with CRC during 2004-2019 were selected from the National Cancer Database. Patients who received recommended care (staging, surgery, lymph node evaluation, chemotherapy, and radiotherapy) were considered to have received guideline-concordant care. Odds ratios (ORs) were adjusted for age and sex. The decomposition method was used to estimate the relative contribution of demographic characteristics (age and sex), comorbidities, health insurance, and facility type to the racial disparity in receipt of guideline-concordant care. The product-limit method was used to evaluate differences in time to treatment between patients racialized as Black and White.

RESULTS

Of the 84,882 patients with colon cancer and 62,573 patients with rectal cancer, 20.8% and 14.5% were racialized as Black, respectively. Individuals racialized as Black were more likely to not receive guideline-concordant care for colon (adjusted OR [aOR], 1.18 [95% CI, 1.14 to 1.22]) and rectal (aOR, 1.27 [95% CI, 1.21 to 1.33]) cancers. Health insurance explained 28.2% and 21.6% of the disparity among patients with colon and rectal cancer, respectively. Individuals racialized as Black had increased time to adjuvant chemotherapy for colon cancer (hazard ratio [HR], 1.28 [95% CI, 1.24 to 1.32]) and neoadjuvant chemoradiation for rectal cancer (HR, 1.42 [95% CI, 1.37 to 1.47]) compared with individuals racialized as White.

CONCLUSION

Patients with early-onset CRC racialized as Black receive worse and less timely care than individuals racialized as White. Health insurance, a modifiable factor, was the largest contributor to racial disparities in receipt of guideline-concordant care in this study.

Impact of Repeated Reimbursement Penalties on Hospital Total Quality Scores

OBJECTIVES

The incidence of hospital-acquired conditions (HACs) is a serious public health issue with implications ranging from patient morbidity and mortality to negative financial impacts on patients and health care systems. Despite substantial efforts to address and reduce HACs, research into the effect of quality improvement programs is inconclusive. This study seeks to better understand the relationship between repeated reimbursement penalties and improvement in HAC quality scores.

METHODS

A quantitative comparative analysis of U.S. health care data was conducted. Data on quality outcomes and hospital characteristics were sourced from the Hospital-Acquired Condition Reduction Program from fiscal years 2018 and 2019 and the Centers for Medicare & Medicaid Services Inpatient Prospective Payment System impact files, respectively.

RESULTS

In total, 3123 U.S. hospitals were analyzed to compare differences between total HAC scores of hospitals with and without penalties in consecutive years. Hospitals with repeated penalties had significantly greater improvement in scores ( t497.262 = -13.00, P < 0.001), and the impact was greatest in small hospitals (<100 beds). Repeated penalties had a smaller impact on disproportionate share hospitals (Cohen d = 0.73). Among all hospitals, the effect of repeated penalties was large (Cohen d = 0.75).

CONCLUSIONS

This study suggests that repeated penalties can improve quality scores in U.S. hospitals. However, the effect may be exaggerated for smaller hospitals and those that serve patient populations with a relatively higher socioeconomic status. The reason disproportionate share hospitals did not show as much improvement as nondisproportionate hospitals may be because hospitals serving vulnerable populations often have fewer resources.

National analysis of racial disparities in emergent surgery for colorectal cancer

Background

Racial disparities in access to preoperative evaluation for colorectal cancer remain unclear. Emergent admission may indicate lack of access to timely care. The present work aimed to evaluate the association of admission type with race among patients undergoing colorectal cancer surgery.

Methods

All adults undergoing resection for colorectal cancer in 2011-2020 National Inpatient Sample were identified. Multivariable regression models were developed to examine the association of admission type with race. Primary outcome was major adverse events (MAE), including mortality and complications. Secondary outcomes included costs and length of stay (LOS). Interaction terms between year, admission type, and race were used to analyze trends.

Results

Of 722,736 patients, 67.6 % had Elective and 32.4 % Emergent admission. Black (AOR 1.38 [95 % CI 1.33-1.44]), Hispanic (1.45 [1.38-1.53]), and Asian/Pacific Islander or Native American (1.25 [1.18-1.32]) race were associated with significantly increased odds of Emergent operation relative to White. Over the study period, non-White patients consistently comprised over 5 % greater proportion of the Emergent cohort compared to Elective. Furthermore, Emergent admission was associated with 3-fold increase in mortality and complications, 5-day increment in LOS, and $10,100 increase in costs. MAE rates among Emergent patients remained greater than Elective with a widening gap over time. Non-White patients experienced significantly increased MAE regardless of admission type.

Conclusion

Non-White race was associated with increased odds of emergent colorectal cancer resection. Given the persistent disparity over the past decade, systematic approaches to alleviate racial inequities in colorectal cancer screening and improve access to timely surgical treatment are warranted.

American Cancer Society's report on the status of cancer disparities in the United States, 2023

In 2021, the American Cancer Society published its first biennial report on the status of cancer disparities in the United States. In this second report, the authors provide updated data on racial, ethnic, socioeconomic (educational attainment as a marker), and geographic (metropolitan status) disparities in cancer occurrence and outcomes and contributing factors to these disparities in the country. The authors also review programs that have reduced cancer disparities and provide policy recommendations to further mitigate these inequalities. There are substantial variations in risk factors, stage at diagnosis, receipt of care, survival, and mortality for many cancers by race/ethnicity, educational attainment, and metropolitan status. During 2016 through 2020, Black and American Indian/Alaska Native people continued to bear a disproportionately higher burden of cancer deaths, both overall and from major cancers. By educational attainment, overall cancer mortality rates were about 1.6-2.8 times higher in individuals with ≤12 years of education than in those with ≥16 years of education among Black and White men and women. These disparities by educational attainment within each race were considerably larger than the Black-White disparities in overall cancer mortality within each educational attainment, ranging from 1.03 to 1.5 times higher among Black people, suggesting a major role for socioeconomic status disparities in racial disparities in cancer mortality given the disproportionally larger representation of Black people in lower socioeconomic status groups. Of note, the largest Black-White disparities in overall cancer mortality were among those who had ≥16 years of education. By area of residence, mortality from all cancer and from leading causes of cancer death were substantially higher in nonmetropolitan areas than in large metropolitan areas. For colorectal cancer, for example, mortality rates in nonmetropolitan areas versus large metropolitan areas were 23% higher among males and 21% higher among females. By age group, the racial and geographic disparities in cancer mortality were greater among individuals younger than 65 years than among those aged 65 years and older. Many of the observed racial, socioeconomic, and geographic disparities in cancer mortality align with disparities in exposure to risk factors and access to cancer prevention, early detection, and treatment, which are largely rooted in fundamental inequities in social determinants of health. Equitable policies at all levels of government, broad interdisciplinary engagement to address these inequities, and equitable implementation of evidence-based interventions, such as increasing health insurance coverage, are needed to reduce cancer disparities.

Factors Associated With Racial and Ethnic Disparities in Locally Advanced Rectal Cancer Outcomes

Importance

Hispanic and non-Hispanic Black patients receiving neoadjuvant therapy and surgery for locally advanced rectal cancer (LARC) achieve less favorable clinical outcomes than non-Hispanic White patients, but the source of this disparity is incompletely understood.

Objective

To assess whether racial and ethnic disparities in treatment outcomes among patients with LARC could be accounted for by social determinants of health and demographic, clinical, and pathologic factors known to be associated with treatment response.

Design, Setting, and Participants

The National Cancer Database was interrogated to identify patients with T3 to T4 or N1 to N2 LARC treated with neoadjuvant therapy and surgery. Patients were diagnosed between January 1, 2004, and December 31, 2017. Data were culled from the National Cancer Database from July 1, 2022, through December 31, 2023.

Exposure

Neoadjuvant therapy for rectal cancer followed by surgical resection.

Main Outcomes and Measures

The primary outcome was the rate of pathologic complete response (pCR) following neoadjuvant therapy. Secondary outcomes were rate of tumor downstaging and achievement of pN0 status.

Results

A total of 34 500 patient records were reviewed; 21 679 of the patients (62.8%) were men and 12 821 (37.2%) were women. The mean (SD) age at diagnosis was 59.7 (12.0) years. In terms of race and ethnicity, 2217 patients (6.4%) were Hispanic, 2843 (8.2%) were non-Hispanic Black, and 29 440 (85.3%) were non-Hispanic White. Hispanic patients achieved tumor downstaging (48.9% vs 51.8%; P = .01) and pN0 status (66.8% vs 68.8%; P = .02) less often than non-Hispanic White patients. Non-Hispanic Black race, but not Hispanic ethnicity, was associated with less tumor downstaging (odds ratio [OR], 0.86 [95% CI, 0.78-0.94]), less frequent pN0 status (OR, 0.91 [95% CI, 0.83-0.99]), and less frequent pCR (OR, 0.81 [95% CI, 0.72-0.92]). Other factors associated with reduced rate of pCR included rural location (OR, 0.80 [95% CI, 0.69-0.93]), lack of or inadequate insurance (OR for Medicaid, 0.86 [95% CI, 0.76-0.98]; OR for no insurance, 0.65 [95% CI, 0.54-0.78]), and treatment in a low-volume center (OR for first quartile, 0.73 [95% CI, 0.62-0.87]; OR for second quartile, 0.79 [95% CI, 0.70-0.90]; OR for third quartile, 0.86 [95% CI, 0.78-0.94]). Clinical and pathologic variables associated with a decreased pCR included higher tumor grade (OR, 0.58 [95% CI, 0.49-0.70]), advanced tumor stage (OR for T3, 0.56 [95% CI, 0.42-0.76]; OR for T4, 0.30 [95% CI, 0.22-0.42]), and lymph node-positive disease (OR for N1, 0.83 [95% CI, 0.77-0.89]; OR for N2, 0.73 [95% CI, 0.65-0.82]).

Conclusions and Relevance

The findings of this cohort study suggest that disparate treatment outcomes for Hispanic and non-Hispanic Black patients are likely multifactorial in origin. Future investigation into additional social determinants of health and biological variables is warranted.

Racial disparities in colorectal cancer clinicopathological and molecular tumor characteristics: a systematic review

PURPOSE

African Americans have the highest colorectal cancer (CRC) mortality of all racial groups in the USA, which may relate to differences in healthcare access or advanced stage at diagnosis. Recent evidence indicates that differences in tumor characteristics may also underlie disparities in mortality. To highlight recent findings and areas for investigation, we completed the first systematic review of racial disparities in CRC tumor prognostic markers, including clinicopathological markers, microsatellite instability (MSI), oncogene mutations, and novel markers, including cancer stem cells and immune markers.

METHODS

Relevant studies were identified via PubMed, limited to original research published within the last 10 years. Ninety-six articles were identified that compared the prevalence of mortality-related CRC tumor characteristics in African Americans (or other African ancestry populations) to White cases.

RESULTS

Tumors from African ancestry cases are approximately 10% more likely to contain mutations in KRAS, which confer elevated mortality and resistance to epidermal growth factor receptor inhibition. Conversely, African Americans have approximately 50% lower odds for BRAF-mutant tumors, which occur less frequently but have similar effects on mortality and therapeutic resistance. There is less consistent evidence supporting disparities in mutations for other oncogenes, including PIK3CA, TP53, APC, NRAS, HER2, and PTEN, although higher rates of PIK3CA mutations and lower prevalence of MSI status for African ancestry cases are supported by recent evidence. Although emerging evidence suggests that immune markers reflecting anti-tumor immunity in the tumor microenvironment may be lower for African American cases, there is insufficient evidence to evaluate disparities in other novel markers, cancer stem cells, microRNAs, and the consensus molecular subtypes.

CONCLUSION

Higher rates of KRAS-mutant tumors in in African Americans may contribute to disparities in CRC mortality. Additional work is required to understand whether emerging markers, including immune cells, underlie the elevated CRC mortality observed for African Americans.

A Systems Biology Approach to Understand the Racial Disparities in Colorectal Cancer

Racial disparities between Black/African Americans (AA) and White patients in colorectal cancer are an ever-growing area of concern. Black/AA show the highest incidence and have the highest mortality among major U.S. racial groups. There is no definite cause other than possible sociodemographic, socioeconomic, education, nutrition, delivery of healthcare, screening, and cultural factors. A primary limitation in this field is the lack of and small sample size of Black/AA studies. Thus, this study aimed to investigate whether differences in gene expression contribute to this ongoing unanswered racial disparity issue. In this study, we examined transcriptomic data of Black/AA and White patient cohorts using a bioinformatic and systems biology approach. We performed a Kaplan-Meier overall survival analysis between both patient cohorts across critical colorectal cancer signal transduction networks (STN), to determine the differences in significant genes across each cohort. Other bioinformatic analyses performed included PROGENy (pathway responsive genes for activity inference), RNA sequencing differential expression using DESeq2, multivariable-adjusted regression, and other associated Kaplan-Meier analyses. These analyses identified novel prognostic genes independent from each cohort, 176 differentially expressed genes, and specific patient cohort STN survival associations. Despite the overarching limitation, the results revealed several novel differences in gene expression between the colorectal cancer Black/AA and White patient cohorts, which allows one to dive deeper into and understand the behavior on a systems level of what could be driving this racial difference across colorectal cancer. Concretely, this information can guide precision medicine approaches tailored specifically for colorectal cancer racial disparities.

SIGNIFICANCE

The purpose of this work is to investigate the racial disparities in colorectal cancer between Black/AA and White patient cohorts using a systems biology and bioinformatic approach. Our study investigates the underlying biology of each patient cohort. Concretely, the findings of this study include disparity-associated genes and pathways, which provide a tangible starting point to guide precision medicine approaches tailored specifically for colorectal cancer racial disparities.

A predictive model for early death in elderly colorectal cancer patients: a population-based study

Purpose

The purpose of this study is to determine what variables contribute to the early death of elderly colorectal cancer patients (ECRC) and to generate predictive nomograms for this population.

Methods

This retrospective cohort analysis included elderly individuals (≥75 years old) diagnosed with colorectal cancer (CRC) from 2010-2015 in the Surveillance, Epidemiology, and End Result databases (SEER) databases. The external validation was conducted using a sample of the Chinese population obtained from the China-Japan Union Hospital of Jilin University. Logistic regression analyses were used to ascertain variables associated with early death and to develop nomograms. The nomograms were internally and externally validated with the help of the receiver operating characteristic curve (ROC), calibration curve, and decision curve analysis (DCA).

Results

The SEER cohort consisted of 28,111 individuals, while the Chinese cohort contained 315 cases. Logistic regression analyses shown that race, marital status, tumor size, Grade, T stage, N stage, M stage, brain metastasis, liver metastasis, bone metastasis, surgery, chemotherapy, and radiotherapy were independent prognostic factors for all-cause and cancer-specific early death in ECRC patients; The variable of sex was only related to an increased risk of all-cause early death, whereas the factor of insurance status was solely associated with an increased risk of cancer-specific early death. Subsequently, two nomograms were devised to estimate the likelihood of all-cause and cancer-specific early death among individuals with ECRC. The nomograms exhibited robust predictive accuracy for predicting early death of ECRC patients, as evidenced by both internal and external validation.

Conclusion

We developed two easy-to-use nomograms to predicting the likelihood of early death in ECRC patients, which would contribute significantly to the improvement of clinical decision-making and the formulation of personalized treatment approaches for this particular population.

Social Determinants of Cancer Disparities

Cancer is a major public health issue that is associated with significant morbidity and mortality across the globe. At its root, cancer represents a genetic aberration, but socioeconomic, environmental, and geographic factors contribute to different cancer outcomes for selected population subsets. The disparities in the delivery of healthcare affect all aspects of cancer management from early prevention to end-of-life care. In an effort to address the inequality in the delivery of healthcare among socioeconomically disadvantaged populations, the World Health Organization defined social determinants of health (SDOH) as conditions in which people are born, live, work, and age. These factors play a significant role in the disproportionate cancer burden among different population groups. SDOH are associated with disparities in risk factor burden, screening modalities, diagnostic testing, treatment options, and quality of life of patients with cancer. The purpose of this article is to describe a more holistic and integrated approach to patients with cancer and address the disparities that are derived from their socioeconomic background.

Overall Survival Differences in Young Black Colorectal Cancer Patients: a Report from the National Cancer Database

Objectives: Black patients have the highest overall incidence rate of early onset colorectal cancer, with many of these patients presenting with more aggressive disease at diagnosis, ultimately leading to decreased overall survival. We aimed to (1) evaluate how race and age affected overall survival in colorectal cancer patients, and (2) determine the different demographic and clinical covariables that may influence survival in younger individuals. Methods: The 2017 National Cancer Database (NCDB) was used to identify all patients that had colorectal cancer between 2004-2017. These patients were then divided into groups according to age (<45 and ≥45 years old) and race (white and black). Overall survival (OS) between white and black groups according to age was compared. Initial testing of survivor functions between groups revealed violations of the proportional hazards assumption. Accordingly, we used parametric maximum likelihood analyses fitting the survivor functions to Weibull distributions. Logistic regression analysis was used to determine univariate and multivariate relationships between the covariates and race for younger subjects. Propensity score matching analysis was also used to control for differences in the demographic or clinical variables between the young black versus white subgroups. Results: Out of 1.4 million potential cases initially identified, 207,823 unique cases were deemed eligible for evaluation based on study criteria. Black patients in the study population were more likely to be female, have medical comorbidities, and come from areas with lower average income and baseline education. OS was lower in older patients of both race categories when compared to the younger cohorts. Among patients older than 45 years, there were no significant differences in proportional hazard of death between black and white patients. However, among those younger than 45 years, younger black patients had significantly increased hazard of death. Regarding disease burden at diagnosis, pathologic characteristics and overall risk of death, there were no significant differences between black and white patients. Conclusions: Overall survival in young black patients with colorectal cancer is significantly reduced when compared to young white patients, even when controlling for demographic and pathologic factors. This suggests that the outcome disparities between black and white patients are complex, and the underlying factors are not well understood.

Construction and validation of a nomogram of risk factors and cancer-specific survival prognosis for combined lymphatic metastases in patients with early-onset colorectal cancer

PURPOSE

This study aimed to investigate the risk and prognostic factors of lymph node metastasis (LNM) in early-onset colorectal cancer (EO-CRC) and to develop nomograms for quantitatively predicting LNM and the cancer-specific survival (CSS).

METHODS

A total of 22,405 EO-CRC patients were included in this study using the SEER database from 2010 to 2017. Logistic and Cox regression were used to identify risk and the potential prognostic factors, respectively, for EO-CRC with LNM. Subsequently, nomograms regarding the risk of LNM in EO-CRC patients and its corresponding CSS were constructed based on these factors. The discriminative ability, calibration and clinical usefulness of the nomograms were assessed by the area under the receiver operating characteristic (ROC) curves (AUC), calibration curves, and decision curve analysis (DCA).

RESULTS

T-stage and pathological grade were the most represented factors in the predicted LNM nomogram, while histological type and combined distant metastases were the most represented in the nomogram for CSS in EO-CRC patients with LNM (all P < 0.05). The nomogram constructed based on the prognostic factors screened by Cox regression had good performance with C-index of 0.807 and 0.802 for the training and validation cohorts, respectively. The calibration curve showed that the nomograms' predictions were in line with actual observations. Additionally, the ROC curves indicated good discrimination, and the DCA curves implied significant clinical utility of the nomograms.

CONCLUSION

The nomograms we constructed have significant performance in predicting the incidence and prognosis of LNM in EO-CRC patients, which may help clinicians to make better treatment decision making.

Factors Associated With Survival Disparities Between Non-Hispanic Black and White Patients With Uterine Cancer

Importance

Disparities in survival exist between non-Hispanic Black (hereafter, Black) and non-Hispanic White (hereafter, White) patients with uterine cancer.

Objective

To investigate factors associated with racial disparities in survival between Black and White patients with uterine cancer.

Design, Setting, and Patients

This cohort study used data from the National Cancer Database on 274 838 Black and White patients who received a diagnosis of uterine cancer from January 1, 2004, to December 31, 2017, with follow-up through December 2020. Statistical analysis was performed in July 2022.

Main Outcomes and Measures

Overall survival by self-reported race and evaluation of explanatory study factors associated with hazard ratio (HR) reduction for Black vs White patients. A propensity scoring approach was applied sequentially to balance racial differences in demographic characteristics, comorbidity score, neighborhood income, insurance status, histologic subtype, disease stage, and treatment.

Results

The study included 32 230 Black female patients (mean [SD] age at diagnosis, 63.8 [10.0] years) and 242 608 White female patients (mean [SD] age at diagnosis, 63.5 [10.5] years) and had a median follow-up of 74.0 months (range, 43.5-113.8 months). Black patients were more likely than White patients to have low income (44.1% vs 14.0%), be uninsured (5.7% vs 2.6%), present with nonendometrioid histologic characteristics (46.1% vs 21.6%), have an advanced disease stage (34.1% vs 19.8%), receive first-line chemotherapy (33.8% vs 18.2%), and have worse 5-year survival (58.6% vs 78.5%). Among patients who received a diagnosis at younger than 65 years of age, the HR for death for Black vs White patients was 2.43 (95% CI, 2.34-2.52) in a baseline demographic-adjusted model and 1.29 (95% CI, 1.23-1.35) after balancing other factors. Comorbidity score, neighborhood income, insurance status, histologic subtype, disease stage, treatment, and unexplained factors accounted for 0.8%, 7.2%, 11.5%, 53.1%, 5.8%, 1.2%, and 20.4%, respectively, of the excess relative risk (ERR) among the younger Black vs White patients. Among patients 65 years or older, the HR for death for Black vs White patients was 1.87 (95% CI, 1.81-1.93) in the baseline model and 1.14 (95% CI, 1.09-1.19) after balancing other factors. Comorbidity score, neighborhood income, insurance status, histologic subtype, disease stage, treatment, and unexplained factors accounted for 3.0%, 7.5%, 0.0%, 56.2%, 10.6%, 6.9%, and 15.8%, respectively, of the ERR among Black vs White patients aged 65 years or older.

Conclusions and Relevance

This study suggests that histologic subtype was the dominant factor associated with racial survival disparity among patients with uterine cancer, while insurance status represented the main modifiable factor for women younger than 65 years. Additional studies of interactions between biology and social determinants of health are merited.

Colorectal cancer statistics, 2023

Colorectal cancer (CRC) is the second most common cause of cancer death in the United States. Every 3 years, the American Cancer Society provides an update of CRC statistics based on incidence from population-based cancer registries and mortality from the National Center for Health Statistics. In 2023, approximately 153,020 individuals will be diagnosed with CRC and 52,550 will die from the disease, including 19,550 cases and 3750 deaths in individuals younger than 50 years. The decline in CRC incidence slowed from 3%-4% annually during the 2000s to 1% annually during 2011-2019, driven partly by an increase in individuals younger than 55 years of 1%-2% annually since the mid-1990s. Consequently, the proportion of cases among those younger than 55 years increased from 11% in 1995 to 20% in 2019. Incidence since circa 2010 increased in those younger than 65 years for regional-stage disease by about 2%-3% annually and for distant-stage disease by 0.5%-3% annually, reversing the overall shift to earlier stage diagnosis that occurred during 1995 through 2005. For example, 60% of all new cases were advanced in 2019 versus 52% in the mid-2000s and 57% in 1995, before widespread screening. There is also a shift to left-sided tumors, with the proportion of rectal cancer increasing from 27% in 1995 to 31% in 2019. CRC mortality declined by 2% annually from 2011-2020 overall but increased by 0.5%-3% annually in individuals younger than 50 years and in Native Americans younger than 65 years. In summary, despite continued overall declines, CRC is rapidly shifting to diagnosis at a younger age, at a more advanced stage, and in the left colon/rectum. Progress against CRC could be accelerated by uncovering the etiology of rising incidence in generations born since 1950 and increasing access to high-quality screening and treatment among all populations, especially Native Americans.

Association of Variation in US County-Level Rates of Liver Surgical Resection for Colorectal Liver Metastasis With Poverty Rates in 2010

IMPORTANCE

Among patients with colorectal liver metastasis (CRLM) who are eligible for curative-intent liver surgical resection, only half undergo liver metastasectomy. It is currently unclear how rates of liver metastasectomy vary geographically in the US. Geographic differences in county-level socioeconomic characteristics may, in part, explain variability in the receipt of liver metastasectomy for CRLM.

OBJECTIVE

To describe county-level variation in the receipt of liver metastasectomy for CRLM in the US and its association with poverty rates.

DESIGN, SETTING, AND PARTICIPANTS

This ecological, cross-sectional, and county-level analysis was conducted using data from the Surveillance, Epidemiology, and End Results Research Plus database. The study included the county-level proportion of patients who had colorectal adenocarcinoma diagnosed between January 1, 2010, and December 31, 2018, underwent primary surgical resection, and had liver metastasis without extrahepatic metastasis. The county-level proportion of patients with stage I colorectal cancer (CRC) was used as a comparator. Data analysis was performed on March 2, 2022.

EXPOSURES

County-level poverty in 2010 obtained from the US Census (proportion of county population below the federal poverty level).

MAIN OUTCOMES AND MEASURES

The primary outcome was county-level odds of liver metastasectomy for CRLM. The comparator outcome was county-level odds of surgical resection for stage I CRC. Multivariable binomial logistic regression accounting for clustering of outcomes within a county via an overdispersion parameter was used to estimate the county-level odds of receiving a liver metastasectomy for CRLM associated with a 10% increase in poverty rate.

RESULTS

In the 194 US counties included in this study, there were 11 348 patients. At the county level, the majority of the population was male (mean [SD], 56.9% [10.2%]), White (71.9% [20.0%]), and aged between 50 and 64 (38.1% [11.0%]) or 65 and 79 (33.6% [11.4%]) years. The adjusted odds of undergoing a liver metastasectomy was lower in counties with higher poverty in 2010 (per 10% increase; odds ratio, 0.82 [95% CI, 0.69-0.96]; P = .02). County-level poverty was not associated with receipt of surgery for stage I CRC. Despite the difference in rates of surgery (mean county-level rates were 0.24 for liver metastasectomy for CRLM and 0.75 for surgery for stage I CRC), the variance at the county-level for these 2 surgical procedures was similar (F370, 193 = 0.81; P = .08).

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that higher poverty was associated with lower receipt of liver metastasectomy among US patients with CRLM. Surgery for a more common and less complex cancer comparator (ie, stage I CRC) was not observed to be associated with county-level poverty rates. However, county-level variation in surgical rates was similar for CRLM and stage I CRC. These findings further suggest that access to surgical care for complex gastrointestinal cancers such as CRLM may be partially influenced by where patients live.

The effect of medicare and screening guidelines on colorectal cancer outcomes

BACKGROUND

Colorectal cancer screening has been shown effective at reducing stage at presentation, but there is differential uptake of screening based on insurance status. We sought to determine the population-level effect of Medicare and screening guidelines on colorectal screening by race and region.

METHODS

Data on Black and white patients with colorectal cancer were obtained from the SEER database. Regression discontinuity was used to assess the causal effect of near-universal health insurance (represented by age 65) and United States Preventive Services Task Force guidelines (age 50) on the proportion of people presenting at advanced stage. This was stratified by race and region.

RESULTS

In the Southern United States, Black patients saw a significant decrease in advanced stage at presentation at age 65 (coefficient -0.12, p = 0.003), while white patients did not (coefficient -0.03, p = 0.09). At age 50, neither Black (coefficient 0.09, p = 0.10) nor white patients (coefficient -0.04, p = 0.1) saw a significant decrease in advanced stage. In the Western U.S., neither Black (coefficient 0.02, p = 0.72) or white patients (coefficient -0.02, p = 0.09) saw a significant decrease in advanced stage at age 65; however, both Black (coefficient -0.20, p = 0.008) and white patients (coefficient -0.05, p = 0.03) saw a significant decrease at age 50.

CONCLUSIONS

Our data highlight the significant impact that near-universal insurance has on reducing colorectal cancer stage at presentation in areas with poor baseline insurance coverage, particularly for Black patients. To reduce disparities in advanced stage at presentation for colorectal cancer, state-level insurance coverage should be addressed.

Racial disparities and standard treatment in locally advanced rectal cancer: a National Cancer Database study

Background

Mortality rates in colorectal cancer (CRC) continue to be higher in Black compared to White patients. While standard treatment modalities for locally advanced rectal cancer have been shown to improve outcomes, there are limited studies assessing the receipt of standard treatment in rectal cancer based on race. Therefore, we sought to evaluate the use of standard treatment across racial groups in locally advanced rectal cancer and its effect on survival.

Methods

The National Cancer Database (NCDB) was queried for patients ≥18 years old with clinical and pathologic stage II-III rectal adenocarcinoma who received treatment from 2004 to 2014. Standard treatment was defined as complete surgical excision with either neoadjuvant or adjuvant concurrent chemoradiation. Multivariable logistic regressions were used to identify racial differences in receiving standard treatment. Cox proportional hazards were used to estimate the effects of standard vs. nonstandard treatment on survival differences based on race.

Results

A total of 70,677 patients with stage II (n=35,079) or stage III (n=35,598) rectal adenocarcinoma met the inclusion criteria. On multivariate analysis, Black [odds ratio (OR): 0.75; 95% confidence interval (CI): 0.71-0.79; P<0.001] and Hispanic White (OR: 0.86; 95% CI: 0.80-0.92; P>0.001) patients were less likely to receive standard treatment compared to non-Hispanic White patients. On multivariable Cox regression, nonstandard treatment was significantly associated with worse survival [hazard ratio (HR): 1.69; 95% CI: 1.65-1.73; P<0.001] compared to standard treatment. Even after adjusting for patient, demographic, and facility characteristics, Black patients had higher mortality rates compared to White patients in the whole population (HR: 1.15; 95% CI: 1.09-1.20; P<0.0001). This survival difference between Black and non-Hispanic White patients persisted in both the standard (HR: 1.10; 95% CI: 1.03-1.19; P=0.008) and nonstandard (HR: 1.17; 95% CI: 1.10-1.25; P<0.0001) treatment subgroups. Decreased survival outcomes in Black patients were more pronounced for those who underwent nonstandard treatment, particularly when treating stage III disease (HR: 1.30; 95% CI: 1.19-1.42; P<0.0001).

Conclusions

Nonstandard treatment in stage II and III rectal cancer is associated with worse survival compared to standard treatment regimens. Black patients are more likely to receive nonstandard treatment and have worse survival outcomes compared to White patients.

Mortality of central nervous system tumors in pediatric patients of Brazil from 1979 to 2019

PURPOSE

Cancer is the second leading cause of death in children from 2001 to 2005 in Brazil. This study aimed to describe the pattern of mortality from central nervous system (CNS) tumors in children in Brazil from 1979 to 2019.

METHODS

A descriptive study was carried out using data from the Mortality Information System (SIM) of the Ministry of Health, according to the International Classification of Diseases (ICD-9 and ICD-10), between 1979 and 2019. The frequencies of the distribution of available variables were calculated: age (0 - 19 years), s skin color, tumor behavior, year and place of death (by region), ICD-10, and all of these, excluding skin color (by ICD-9). Mortality rates in general, mortality from neoplasms, and specific rates of CNS tumors were calculated considering the variables described above.

RESULTS

In 40 years (1979 - 2019), there were 21,940 deaths due to brain tumors in children. A different pattern of the mortality rate of brain tumors was shown in children per age (increasing until age 5 - 9 years (28.9%) and then decreasing until age 15 - 19 years (20.2%)). The Southeast (44.3%), Northeast (23.4%), and South (17.5%) regions of Brazil had the highest rates; 94.7% of tumors were malignant, and 91.1% of deaths were observed in hospitals.

CONCLUSION

To our knowledge, this is the first description of the mortality rate epidemiology of brain/CNS tumors in children in Brazil over 40 years. Furthermore, tumor malignancy, hospitals, and the Southeast and Northeast region of Brazil are factors associated with a higher mortality rate.

Disparities in localized malignant lung cancer surgical treatment: A population‐based cancer registry analysis

BACKGROUND

Lung cancer (LC) continues to be the leading cause of cancer deaths in the United States. Surgical treatment has proven to offer a favorable prognosis and a better 5-year relative survival for patients with early or localized tumors. This novel study investigates the factors associated with the odds of receiving surgical treatment for localized malignant LC in Tennessee.

METHODS

Population-based data of 9679 localized malignant LC patients from the Tennessee Cancer Registry (2005-2015) were utilized to examine the factors associated with receiving surgical treatment for localized malignant LC. Bivariate and multivariate logistic regression analyses, cross-tabulation, and Chi-Square ( χ ² ) tests were conducted to assess these factors.

RESULTS

Patients with localized malignant LC who initiated treatment after 2.7 weeks were 46% less likely to receive surgery (adjusted odds ratio [AOR] = 0.54; 95% confidence interval [CI] = 0.50-0.59; p < 0.0001). Females had a greater likelihood (AOR = 1.14; CI = 1.03-1.24) of receiving surgical treatment compared to men. Blacks had lower odds (AOR = 0.76; CI = 0.65-0.98) of receiving surgical treatment compared to Whites. All marital groups had higher odds of receiving surgical treatment compared to those who were single/never married. Patients living in Appalachian county had lower odds of receiving surgical treatment (AOR = 0.65; CI = 0.59-0.71) compared with those in the non-Appalachian county. Patients with private (AOR = 2.09; CI = 1.55-2.820) or public (AOR = 1.42; CI = 1.06-1.91) insurance coverage were more likely to receive surgical treatment compared to self-pay/uninsured patients. Overall, the likelihood of patients receiving surgical treatment for localized malignant LC decreases with age.

CONCLUSION

Disparities exist in the receipt of surgical treatment among patients with localized malignant LC in Tennessee. Health policies should target reducing these disparities to improve the survival of these patients.

Hospital Rankings and Health Equity

This Viewpoint examines US News &amp;amp; World Report’s approach to evaluating and publicly reporting hospital performance in various aspects of health equity as well as describes several novel equity measures published as part of its “Best Hospitals” rankings program.

Cancer treatment and survivorship statistics, 2022

The number of cancer survivors continues to increase in the United States due to the growth and aging of the population as well as advances in early detection and treatment. To assist the public health community in better serving these individuals, the American Cancer Society and the National Cancer Institute collaborate triennially to estimate cancer prevalence in the United States using incidence and survival data from the Surveillance, Epidemiology, and End Results cancer registries, vital statistics from the Centers for Disease Control and Prevention's National Center for Health Statistics, and population projections from the US Census Bureau. Current treatment patterns based on information in the National Cancer Database are presented for the most prevalent cancer types by race, and cancer-related and treatment-related side-effects are also briefly described. More than 18 million Americans (8.3 million males and 9.7 million females) with a history of cancer were alive on January 1, 2022. The 3 most prevalent cancers are prostate (3,523,230), melanoma of the skin (760,640), and colon and rectum (726,450) among males and breast (4,055,770), uterine corpus (891,560), and thyroid (823,800) among females. More than one-half (53%) of survivors were diagnosed within the past 10 years, and two-thirds (67%) were aged 65 years or older. One of the largest racial disparities in treatment is for rectal cancer, for which 41% of Black patients with stage I disease receive proctectomy or proctocolectomy compared to 66% of White patients. Surgical receipt is also substantially lower among Black patients with non-small cell lung cancer, 49% for stages I-II and 16% for stage III versus 55% and 22% for White patients, respectively. These treatment disparities are exacerbated by the fact that Black patients continue to be less likely to be diagnosed with stage I disease than White patients for most cancers, with some of the largest disparities for female breast (53% vs 68%) and endometrial (59% vs 73%). Although there are a growing number of tools that can assist patients, caregivers, and clinicians in navigating the various phases of cancer survivorship, further evidence-based strategies and equitable access to available resources are needed to mitigate disparities for communities of color and optimize care for people with a history of cancer. CA Cancer J Clin. 2022;72:409-436.

Machine learning models for predicting survival in patients with ampullary adenocarcinoma

Objective

The aim of this study was to predict the long-term survival probability of patients with ampullary adenocarcinoma (AAC), which would provide a theoretical basis for the long-term care of these patients.

Methods

Data on patients with AAC during 2004–2015 were obtained from the Surveillance, Epidemiology, and End Results database, which were split at a 7:3 ratio into two independent cohorts: training and testing cohorts. Differences in survival between the two groups were tested using the Kaplan–Meier estimator and log-rank test methods. We constructed six survival analysis methods: the American Joint Committee on Cancer TNM stage, Cox Proportional Hazards regression, CoxTime, DeepSurv, XGBoost Survival Embeddings, and Random Survival Forest. The performances of these models were evaluated using the C-index, receiver operating characteristic (ROC), and calibration curves.

Results

This study included 2,935 patients with AAC. Univariate Cox regression analyses of the training cohort indicated that race, marital status at diagnosis, scope of regional lymph node surgery, tumor grade, summary stage, American Joint Committee on Cancer stage, TNM stage T, and TNM stage N were important factors affecting survival (P ​< ​0.05). The results of the C-index indicated that DeepSurv performed the best among the six models, with the highest C-index of 0.731. The areas under the ROC curves of the DeepSurv model at the 1-year, 3-year, 5-year, and 10-year time points were 0.823, 0.786, 0.803, and 0.813, respectively. The calibration curve indicated that DeepSurv performed well, with good calibration.

Conclusions

Machine learning models such as DeepSurv have a stronger performance in the survival analysis of patients with AAC.

Colorectal Cancer Screening in a Changing World

Early detection of colorectal neoplasia significantly reduces mortality from colorectal cancer (CRC), and numerous screening options exist. Guidelines for CRC screening from US and international professional societies provide menus of options based on strength of evidence. Despite availability of screening and its proven impact, 40% of guideline-eligible patients are not screened as recommended in the United States. Adherence to or uptake of CRC screening is especially poor among underserved populations, including those with low income and African American and Hispanic populations. Consideration of screening options must not only take into account test performance, but issues of resources and individual versus population benefits.

Anatomic location of colorectal cancer presents a new paradigm for its prognosis in African American patients

Among all racial groups in the U.S., African Americans (AA) have the highest incidence of and mortality from colorectal cancer (CRC). Although socioeconomic factors, as the major contributors to racial disparity of CRC, have been widely investigated, there is a dearth of information germane to understanding its biological basis. To better elucidate the clinicopathologic features we extracted demographic, clinical, pathologic and molecular features of 500 consecutive cases of CRC diagnosed at our institution which has an AA-predominant patient population (75% of all patients). We compared data from our AA patients with those of white patients both from our institution and from SEER and the published literature for meaningful comparison. AA patients were more likely to be at an advanced disease stage (25.9% vs. 20.8%, p = 0.041), have low grade tumors (89.2% vs. 77.5%, p<0.001) in cecum (18.7% vs. 16.2%, p<0.001) and <60-years-old than white patients (31.8% vs. 26.3%, p = 0.015). The frequency of KRAS mutation was higher in AA patients than in white patients (56.8% vs. 20.7%, p<0.001). Amongst subtypes of KRAS tested in CRC, codon 12 mutation is more common in AA than white patients (85.2% vs. 68.9%, p = 0.020). Compared with other racial groups, we found AA patients to have worse disease-free survival (HR = 3.682, p = 0.035). Also, AA patients with CRC in distal (sigmoid and rectum) or proximal (cecum) colon have worse overall survival than those with CRC in middle colon (HR = 2.926, p = 0.014), a finding not observed in white patients. In both racial groups, advanced stage, perforation, and hypertension were independent prognostic factors for overall survival (p<0.05). Similarly, low body-mass index at presentation, mucinous adenocarcinoma, lymphovascular invasion, perineural invasion and KRAS mutations were independent factors significantly associated with poor disease-free survival. Collectively, our data provide new insights into the roles of clinicopathologic features, especially anatomic distribution, in predicting outcomes of CRC in AA population.

Psychosocial determinants of colorectal Cancer screening uptake among African-American men: understanding the role of masculine role norms, medical mistrust, and normative support

OBJECTIVES

Despite having the highest colorectal cancer (CRC) incidence and mortality across all major racial/ethnic groups, African-American men consistently have poor CRC screening rates. Gendered and racialized beliefs and norms have been associated with African-American men's lower medical assistance-seeking rates, but how these notions influence African-American men's CRC screening practices merits further investigation. The purpose of this study was to examine the influence of psychosocial determinants of men's health on CRC screening uptake among African-American men in three states.

DESIGN

Participants were recruited via CuttingCRC.com and through culturally-tailored flyers, newspaper ads, and snowball sampling, among other methods. From April 2019-August 2019, 11 focus groups were conducted with English-speaking Black/African-American men who (a) were between ages 45-75, (b) were born in the United States, (c) had a working telephone, and (d) lived in Minnesota, Ohio, or Utah. Multiple-cycle coding, Hatch's 9-step approach, and constant comparative data analysis was employed for de-identified transcript data.

RESULTS

Eighty-four African-American men met inclusion criteria and participated. Their mean age was 59.34 ± 7.43. In regards to CRC screening status, Ohio had the most previously screened participants (85%), followed by Minnesota (84%) and Utah (76%). Two major CRC screening barriers (masculine role norms and medical mistrust) - both encompassed 3-5 subthemes, and one major facilitator (normative support from family members or social networks) emerged.

CONCLUSIONS

Despite CRC screening's life-saving potential, African-American men have had the lowest 5-year relative survival for more than 40 years. When developing interventions and health promotion programs aiming to eliminate the racial disparity in CRC outcomes, addressing both masculine role norms and medical mistrust barriers to CRC screening completion among African-American men is warranted.

The Impact of Palliative Care and Nursing Intervention on the Psychology and Quality of Life of Elderly Patients with Colorectal Cancer

Colorectal cancer patients face physical, psychological, and social difficulties. Psychosocial therapies appear to be successful in improving cancer patients' psychological and social results. Preoperative and postoperative psychological therapies for colorectal surgery patients have not been extensively studied. During their treatment, up to 35% of cancer patients experience clinically severe psychological discomfort. As a consequence, a greater knowledge of health-related quality of life and its causes can assist oncology nurses in developing effective treatments to improve the health-related quality of life. The palliative care model and the nursing intervention model are used in this study to assess the effectiveness of an individually customized nursing intervention for lowering chemotherapy-related symptom distress in adult patients with colorectal cancer. Initially, the dataset is collected and split into the control group and the experimental group. The patient conditions are evaluated using the novel accelerated gradient boosting regression tree (AGBRT) estimation model. For improving the evaluation process, we have proposed the enriched gravitational search optimization algorithm (EGSOA). The system's success is evaluated in terms of the patients' psychological well-being and quality of life.

American Cancer Society's report on the status of cancer disparities in the United States, 2021

In this report, the authors provide comprehensive and up-to-date US data on disparities in cancer occurrence, major risk factors, and access to and utilization of preventive measures and screening by sociodemographic characteristics. They also review programs and resources that have reduced cancer disparities and provide policy recommendations to further mitigate these inequalities. The overall cancer death rate is 19% higher among Black males than among White males. Black females also have a 12% higher overall cancer death rate than their White counterparts despite having an 8% lower incidence rate. There are also substantial variations in death rates for specific cancer types and in stage at diagnosis, survival, exposure to risk factors, and receipt of preventive measures and screening by race/ethnicity, socioeconomic status, and geographic location. For example, kidney cancer death rates by sex among American Indian/Alaska Native people are ≥64% higher than the corresponding rates in each of the other racial/ethnic groups, and the 5-year relative survival for all cancers combined is 14% lower among residents of poorer counties than among residents of more affluent counties. Broad and equitable implementation of evidence-based interventions, such as increasing health insurance coverage through Medicaid expansion or other initiatives, could substantially reduce cancer disparities. However, progress will require not only equitable local, state, and federal policies but also broad interdisciplinary engagement to elevate and address fundamental social inequities and longstanding systemic racism.

The Impact of Income and Social Mobility on Colorectal Cancer Outcomes and Treatment: A Cross-sectional Study

OBJECTIVE

To determine the impact of income mobility on racial disparities in colorectal cancer.

BACKGROUND

There are well-documented disparities in colorectal cancer treatment and outcomes between Black and White patients. Socioeconomic status, insurance, and other patient-level factors have been shown important, but little has been done to show the discriminatory factors that lead to these outcomes.

METHODS

Data were obtained from the Surveillance Epidemiology and End-Results database for Black and White patients with colorectal cancer between 2005 and 2015. County level measures of Black (BIM) and White income mobility (WIM) were obtained from the Opportunity Atlas as a measure of intergenerational poverty and social mobility. Regression models were created to assess the relative risk of advanced stage at diagnosis (Stage IV), surgery for localized disease (Stage I/II), and cancer-specific mortality.

RESULTS

There was no significant association of BIM or WIM on advanced stage at diagnosis in Black or White patients. An increase of $10,000 of BIM was associated with a 9% decrease in hazards of death for both Black (hazard ratio 0.91, 95% confidence interval 0.86,0.95) and White (0.91, 95%CI 0.90,0.93) patients, while the same increase in WIM was associated with no significant difference in hazards among Black patients (hazard ratio 0.99, 95% confidence interval 0.97,1.02). There were no predicted racial differences in hazards of death at high levels of BIM.

CONCLUSIONS

Increased Black income mobility significantly improves survival for both Black and White patients. Interventions aimed at increasing economic and social mobility could significantly decrease mortality in both Black and White patients while alleviating disparities in outcomes.

Healthcare Disparities and Colorectal Cancer

Health care disparities are defined as health differences between groups that are avoidable, unnecessary, and unjust. Racial disparities in colorectal cancer mortality, particularly for Black patients, are well-described. Disparities in preventative measures, early detection, effective treatment, and posttreatment services contribute to these differences. Underlying these issues are patient, provider, health care system, and policy-level factors that lead to these disparities. Multilevel interventions designed to address each level of care can provide an effective means to mitigate these disparities.

Black patients with multiple myeloma have better survival than white patients when treated equally: a matched cohort study

We assessed differences in survival between non-Hispanic black (NHB) and non-Hispanic white (NHW) patients with multiple myeloma (MM), and the sequential effects of patient characteristics, and diagnosis and treatment-related factors on the survival disparity using data from 3319 NHB and 20,831 NHW MM patients in the SEER-Medicare (1999-2017) database. Four sets of 3319 NHWs were matched sequentially to the same set of 3319 NHBs, based on demographics (age, sex, year of diagnosis, marital status, and SEER site), socioeconomic status (SES, demographics plus SES), presentation factors (SES variables plus comorbidity), and treatment factors (presentation variables plus antimyeloma therapies). We found NHBs were less likely to receive treatment than NHWs even among patients matched for demographics, SES, and comorbidities. The absolute difference in 5-year survival between NHBs and NHWs was not significant in the demographics match (0.6%; P = 0.30) and remained non-significant after matching for SES (1.4%, P = 0.17). When matching for presentation, NHBs had significantly longer 5-year survival than NHWs (absolute difference = 3.8%, P = 0.003). Additional matching on treatment-related factors further enlarged the racial difference in 5-year survival to 4.6% (P < 0.001). Our findings reinforce the importance of equitable access to effective treatment modalities to further improve the survival of NHB patients with MM.

The association of health insurance and race with treatment and survival in patients with metastatic colorectal cancer

Background

Black patients and underinsured patients with colorectal cancer (CRC) present with more advanced disease and experience worse outcomes. The study aim was to evaluate the interaction of health insurance status and race with treatment and survival in metastatic CRC.

Materials and methods

Patients diagnosed with metastatic CRC within NCDB from 2006–2016 were included. Primary outcomes included receipt of chemotherapy and 3-year all-cause mortality. Multivariable logistic regression and Cox-regression (MVR) including a two-way interaction term of race and insurance were performed to evaluate the differential association of race and insurance with receipt of chemotherapy and mortality, respectively.

Results

128,031 patients were identified; 70.6% White, 14.4% Black, 5.7% Hispanic, and 9.3% Other race. Chemotherapy use was higher among White compared to Black patients. 3-year mortality rate was higher for Blacks and lower for Hispanics, in comparison with White patients. By MVR, Black patients were less likely to receive chemotherapy. When stratified by insurance status, Black patients with private and Medicare insurance were less likely to receive chemotherapy than White patients. All-cause mortality was higher in Black patients and lower in Hispanic patients, and these differences persisted after controlling for insurance and receipt of chemotherapy.

Conclusion

Black patients and uninsured or under-insured patients with metastatic CRC are less likely to receive chemotherapy and have increased mortality. The effect of health insurance among Blacks and Whites differs, however, and improving insurance alone does not appear to fully mitigate racial disparities in treatment and outcomes.

Racial Disparities in Surgery for Malignant Bowel Obstruction

BACKGROUND

Operative management of patients with malignant bowel obstruction (MBO) may provide effective palliation, but is associated with substantial risks. This study aimed to analyze racial and ethnic differences in surgical outcomes for patients with MBO.

METHODS

This retrospective study, using National Surgical Quality Improvement Program (NSQIP) registry data from 2010 to 2019, compared differences in outcomes by race and ethnicity for 2762 patients undergoing surgery for MBO. Multivariable logistic regression controlled for relevant covariates.

RESULTS

Black patients (n = 407) had higher rates of preoperative comorbidity and were more likely than White patients (n = 2081) to have major complications (28.5% vs 21.8%; p = 0.0031), overall complications (47.4% vs 40.4%; p = 0.0087), a longer median hospital stay (12 days; interquartile range [IQR, 8-19 days] vs 10 days [IQR, 7-17 days]; p = 0.0007), and unplanned readmission (17.1% vs 12.9%; p = 0.0266). Black patients had a similar mortality rate to that of White patients and were less frequently discharged to home (67.6% vs 73.0%; p = 0.0315). Differences in morbidity between Black patients and White patients persisted after controlling for potentially confounding variables. Hispanic patients had lower mortality than White patients (6.3% vs 13.1%; p = 0.0130) and a longer hospital stay (12 days [IQR, 8-18 days] vs 10 days [IQR, 7-17 days]; p = 0.0313). Outcomes did not differ between Asian patients and White patients.

CONCLUSIONS

This study demonstrated significant disparities for Black patients undergoing surgery for MBO. Understanding and addressing what drives these differences, including systemic inequalities such as access to care and racial biases, is essential to the achievement of more equitable, higher-quality patient care.

Calling Attention to the Role of Race-Driven Societal Determinants of Health on Aggressive Tumor Biology: A Focus on Black Americans

Blacks have the highest incidence and mortality from most cancers. The reasons for these disparities remain unclear. Blacks are exposed to adverse social determinants because of historic and contemporary racist polices; however, how these determinants affect the disparities that Blacks experience is understudied. As a result of discriminatory community policies, like redlining, Blacks have higher exposure to air pollution and neighborhood deprivation. Studies investigating how these factors affect tumor biology are emerging. We highlight the literature that connects racism-related community exposure to the tumor biology in breast, lung, prostate, and colorectal cancer. Further investigations that clarify the link between adverse social determinants that result from systemic racism and aggressive tumor biology are required if health equity is to be achieved. Without recognition that racism is a public health risk with carcinogenic impact, health care delivery and cancer care will never achieve excellence. In response, health systems ought to establish corrective actions to improve Black population health and bring medical justice to marginalized racialized groups.

Programmed Death Ligand-1 Expression Is Associated With Poorer Survival in Anal Squamous Cell Carcinoma

Context.—

Upregulation of programmed death ligand-1 (PD-L1), an immunoregulatory protein, is associated with an adverse outcome in several malignancies. Very few studies have evaluated PD-L1 expression in invasive anal squamous cell carcinoma (ASCC).

Objective.—

To assess PD-L1 expression in patients with ASCC and correlate it with clinicopathologic factors and clinical outcomes.

Design.—

Fifty-one cases of ASCC were immunostained for PD-L1. PD-L1 expression by combined positive score and tumor proportion score was correlated with age, gender, HIV status, HIV viral load, CD4 count, stage, and outcomes. Kaplan-Meier curves for overall survival were plotted and compared using the log-rank test. Cox regression analysis was performed to identify significant prognostic factors (2-tailed P &lt; .05 was considered statistically significant).

Results.—

PD-L1 was positive in 24 of 51 cases (47%) by combined positive score and in 18 of 51 (35%) by tumor proportion score. The median cancer-specific survival and 5-year overall survival were significantly lower in PD-L1+ patients. Age, gender, HIV status, HIV viral load, stage, and cancer progression were not significantly different between the two groups. CD4 count of more than 200/μL was significantly higher in PD-L1+ patients. PD-L1+ status remained statistically significant for worse overall survival on multivariate analysis.

Conclusions.—

PD-L1+ status is an independent adverse prognostic factor for overall survival in ASCC. This study highlights the potential of PD-L1 targeted therapy in better management of ASCC.

Naïve Bayesian network-based contribution analysis of tumor biology and healthcare factors to racial disparity in breast cancer stage-at-diagnosis

BACKGROUND

Variation in breast cancer stage at initial diagnosis (including racial disparities) is driven both by tumor biology and healthcare factors.

METHODS

We studied women age 67-74 with initial diagnosis of breast cancer from 2006 through 2014 in the SEER-Medicare database. We extracted variables related to tumor biology (histologic grade and hormone receptor status) and healthcare factors (screening mammography [SM] utilization and time delay from mammography to diagnostic biopsy). We used naïve Bayesian networks (NBNs) to illustrate the relationships among patient-specific factors and stage-at-diagnosis for African American (AA) and white patients separately. After identifying and controlling confounders, we conducted counterfactual inference through the NBN, resulting in an unbiased evaluation of the causal effects of individual factors on the expected utility of stage-at-diagnosis. An NBN-based decomposition mechanism was developed to evaluate the contributions of each patient-specific factor to an actual racial disparity in stage-at-diagnosis. 2000 bootstrap samples from our training patients were used to compute the 95% confidence intervals (CIs) of these contributions.

RESULTS

Using a causal-effect contribution analysis, the relative contributions of each patient-specific factor to the actual racial disparity in stage-at-diagnosis were as follows: tumor grade, 45.1% (95% CI: 44.5%, 45.8%); hormone receptor status, 5.0% (4.5%, 5.4%); mammography utilization, 23.1% (22.4%, 24.0%); and biopsy delay 26.8% (26.1%, 27.3%).

CONCLUSION

The modifiable mechanisms of mammography utilization and biopsy delay drive about 49.9% of racial difference in stage-at-diagnosis, potentially guiding more targeted interventions to eliminate cancer outcome disparities.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s13755-021-00165-5.

Evaluation and Prediction Analysis of 3- and 5-Year Survival Rates of Patients with Cecal Adenocarcinoma Based on Period Analysis

Background

Cecal adenocarcinoma has a high degree of malignancy and poor prognosis, thereby bringing serious disease burden to patients. The long-term survival rate of patients with cecal adenocarcinoma deserves us to explore more deeply. In addition, appropriate methods that evaluate the survival outcome of cecal adenocarcinoma are few.

Methods

This study used the data provided by the Surveillance, Epidemiology, and End Results (SEER) database to evaluate and predict the survival rates of patients with cecal adenocarcinoma from 2002 to 2016 and from 2017 to 2021, respectively. The cohort of population taken are all older than 20 years old, which is from National Cancer Institute. The period analysis was used to check the data in the SEER database. Reliable results could be obtained using period analysis, which provided important information for prevention and treatment strategies.

Results

From 2002 to 2016, the relative survival rate of patients with cecal adenocarcinoma increased yearly. Compared with those in previous 15 years, the relative survival rate between 2017 and 2021 still increased but to a low extent. The relative survival rates of patients with cecal adenocarcinoma were remarkably different in terms of age, sex, race, differentiation grade, stages, and socioeconomic status. Even if there is a significant improvement, the survival rate of patients with distant-stage cancer is at a very low level.

Conclusion

Understanding the survival rate of patients with cecal adenocarcinoma in the past 15 years is helpful in predicting the future trend and providing basic data and scientific basis to evaluate the harm of cecal adenocarcinoma to patients’ health, prepare cancer prevention plans, and evaluate the effect of cancer prevention and treatment by exploring the differences in survival rate corresponding to different ages, sexes, races, differentiation grades, stages, and socioeconomic status.

Racial disparities negatively impact outcomes in early-onset colorectal cancer independent of socioeconomic status

BACKGROUND

The incidence of colorectal cancer (CRC) in patients under age 50 is rising for unclear reasons. We examined the effects of socioeconomic factors on outcomes for patients with early-onset CRC compared to late-onset CRC.

METHODS

Patients with CRC from 2004 to 2015 in the National Cancer Database were included and categorized by age (under or over 50 years). Differences in demographic and socioeconomic factors, disease characteristics, and survival outcomes between early-onset versus late-onset CRC patients were assessed by Chi-squared test and Cox models.

RESULTS

The study population included 1,061,204 patients, 108,058 (10.2%) of whom were under age 50. The proportion of patients diagnosed under age 50 increased over time: 9.4% in 2004-2006, 10.1% in 2007-2009, 10.5% in 2010-2012, and 10.7% in 2013-2015 (p < 0.0001). Early-onset CRC patients were more likely to be Black (15.1% vs. 11.3%) or Hispanic (8.6% vs. 4.6%) and to present with stage 4 disease (24.9% vs. 17.0%), p < 0.0001 for all. Black patients had the worst median OS (58.3 months) compared to White (67.0 months), Hispanic (91.6 months), or Asian (104.9 months) patients, p < 0.0001. Within the subgroup of early-onset CRC patients with private insurance, Black patients had worse OS compared to White patients, even in communities with higher income and education status.

CONCLUSIONS

Early-onset CRC continues to increase. Patients with early-onset CRC are more likely to be Black or Hispanic and to present with stage 4 cancer. Early-onset Black patients showed worse OS compared to White patients in all income subgroups, even with private insurance.

The growing trend for no primary surgery in colorectal cancer

AIM

In colorectal cancer (CRC), surgery of the primary site is commonly curative. Our aim was to determine estimates of 'no surgery' for primary CRC while identifying common reasons for no surgery.

METHOD

We identified all patients with a diagnosis of colorectal adenocarcinoma from the National Cancer Database between January 2004 and December 2016. Then, we identified patients who did not undergo surgery on the primary tumour and their demographic, tumour and institutional characteristics. Kaplan-Meier and logistic regression analyses were used to evaluate specific factors associated with overall survival as related to no surgery and recommendations against operative management.

RESULTS

A total of 1,208,878 patients with CRC were identified, 14.5% of whom had no surgery of the primary cancer. No surgery was more common in rectal cancer than in colon cancer. Despite a steady incidence of CRC diagnoses, the likelihood of no surgery grew by 170% over the study period. Metastatic disease was noted in 53.7% of the no surgery cohort. Nine per cent of the no surgery patient cohort received a recommendation against surgery despite the absence of metastatic disease, 7.5% refused surgery and only 2% underwent palliative surgery. On multivariable analysis, patients who were not recommended to have surgery were more likely to be older, uninsured, comorbid and receive care at a single hospital. The no surgery patients had significantly lower overall survival.

CONCLUSION

A substantial proportion of patients with CRC do not have surgery. Interventions aimed at expanding access and promoting second opinions at other cancer hospitals might reduce the growing rate of no surgery in CRC.