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Eaglehouse YL, Darmon S, Gage MM, Shriver CD, Zhu K. Racial comparisons in treatment of rectal adenocarcinoma and survival in the military health system. JNCI Cancer Spectr 2024; 8:pkae074. [PMID: 39208282 DOI: 10.1093/jncics/pkae074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 05/29/2024] [Accepted: 08/22/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Racial disparities in treatment and outcomes of rectal cancer have been attributed to patients' differential access to care. We aimed to study treatment and outcomes of rectal cancer in the equal access Military Health System (MHS) to better understand potential racial disparities. METHODS We accessed the MilCanEpi database to study a cohort of patients aged 18 and older who were diagnosed with rectal adenocarcinoma between 1998 and 2014. Receipt of guideline recommended treatment per tumor stage, cancer recurrence, and all-cause death were compared between non-Hispanic White and Black patients using multivariable regression models with associations expressed as odds (AORs) or hazard ratios (AHRs) and their 95% confidence intervals (CIs). RESULTS The study included 171 Black and 845 White patients with rectal adenocarcinoma. Overall, there were no differences in receipt of guideline concordant treatment (AOR = 0.76, 95% CI = 0.45 to 1.29), recurrence (AHR = 1.34, 95% CI = 0.85 to 2.12), or survival (AHR = 1.08, 95% CI = 0.77 to 1.54) for Black patients compared with White patients. However, Black patients younger than 50 years of age at diagnosis (AOR = 0.34, 95% CI = 0.13 to 0.90) or with stage III or IV tumors (AOR = 0.28, 95% CI = 0.12 to 0.64) were less likely to receive guideline recommended treatment than White patients in stratified analysis. CONCLUSIONS In the equal access MHS, although there were no overall racial disparities in rectal cancer treatment or clinical outcomes between Black and White patients, disparities among those with early-onset or late-stage rectal cancers were noted. This suggests that factors other than access to care may play a role in the observed disparities and warrants further research.
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Affiliation(s)
- Yvonne L Eaglehouse
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | - Sarah Darmon
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | - Michele M Gage
- Department of Surgery, Division of Surgical Oncology, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Craig D Shriver
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Department of Surgery, Division of Surgical Oncology, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Kangmin Zhu
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
- Department of Preventive Medicine & Biostatistics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Luo WY, Varvoglis DN, Agala CB, Comer LH, Shetty P, Wood T, Kapadia MR, Stem JM, Guillem JG. Disparities in Outcomes following Resection of Locally Advanced Rectal Cancer. Curr Oncol 2024; 31:3798-3807. [PMID: 39057152 PMCID: PMC11275254 DOI: 10.3390/curroncol31070280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 06/26/2024] [Accepted: 06/27/2024] [Indexed: 07/28/2024] Open
Abstract
Surgical margins following rectal cancer resection impact oncologic outcomes. We examined the relationship between margin status and race, ethnicity, region of care, and facility type. Patients undergoing resection of a stage II-III locally advanced rectal cancer (LARC) between 2004 and 2018 were identified through the National Cancer Database. Inverse probability of treatment weighting (IPTW) was performed, with margin positivity rate as the outcome of interest, and race/ethnicity and region of care as the predictors of interest. In total, 58,389 patients were included. After IPTW adjustment, non-Hispanic Black (NHB) patients were 12% (p = 0.029) more likely to have margin positivity than non-Hispanic White (NHW) patients. Patients in the northeast were 9% less likely to have margin positivity compared to those in the south. In the west, NHB patients were more likely to have positive margins than NHW patients. Care in academic/research centers was associated with lower likelihood of positive margins compared to community centers. Within academic/research centers, NHB patients were more likely to have positive margins than non-Hispanic Other patients. Our results suggest that disparity in surgical management of LARC in NHB patients exists across regions of the country and facility types. Further research aimed at identifying drivers of this disparity is warranted.
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Affiliation(s)
| | | | | | | | | | | | | | | | - José G. Guillem
- Division of Gastrointestinal Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC 27599-7081, USA (D.N.V.); (C.B.A.); (J.M.S.)
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Shulman RM, Deng M, Handorf EA, Meyer JE, Lynch SM, Arora S. Factors Associated With Racial and Ethnic Disparities in Locally Advanced Rectal Cancer Outcomes. JAMA Netw Open 2024; 7:e240044. [PMID: 38421650 PMCID: PMC10905315 DOI: 10.1001/jamanetworkopen.2024.0044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 12/27/2023] [Indexed: 03/02/2024] Open
Abstract
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.
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Affiliation(s)
- Rebecca M. Shulman
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Mengying Deng
- Biostatistics and Bioinformatics Program, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Elizabeth A. Handorf
- Biostatistics and Bioinformatics Program, Fox Chase Cancer Center, Philadelphia, Pennsylvania
- Cancer Prevention and Control Program, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Joshua E. Meyer
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Shannon M. Lynch
- Cancer Prevention and Control Program, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Sanjeevani Arora
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
- Cancer Prevention and Control Program, Fox Chase Cancer Center, Philadelphia, Pennsylvania
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Lawler T, Parlato L, Warren Andersen S. Racial disparities in colorectal cancer clinicopathological and molecular tumor characteristics: a systematic review. Cancer Causes Control 2024; 35:223-239. [PMID: 37688643 PMCID: PMC11090693 DOI: 10.1007/s10552-023-01783-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 08/21/2023] [Indexed: 09/11/2023]
Abstract
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.
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Affiliation(s)
- Thomas Lawler
- Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI, USA
| | - Lisa Parlato
- School of Medicine and Public Health, Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, USA
| | - Shaneda Warren Andersen
- Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI, USA.
- School of Medicine and Public Health, Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, USA.
- University of Wisconsin-Madison, Suite 1007B, WARF, 610 Walnut Street, Madison, WI, 53726, USA.
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Sawaf T, Gudipudi R, Ofshteyn A, Sarode AL, Bingmer K, Bliggenstorfer J, Stein SL, Steinhagen E. Disparities in Clinical Trial Enrollment and Reporting in Rectal Cancer: A Systematic Review and Demographic Comparison to the National Cancer Database. Am Surg 2024; 90:130-139. [PMID: 37670471 DOI: 10.1177/00031348231191175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Abstract
BACKGROUND Cancer care guidelines based on clinical trial data in homogenous populations may not be applicable to all rectal cancer patients. The aim of this study was to evaluate whether patients enrolled in rectal cancer clinical trials (CTs) are representative of United States (U.S.) rectal cancer patients. METHODS Prospective rectal cancer CTs from 2010 to 2019 in the United States were systematically reviewed. In trials with multiple arms reporting separate demographic variables, each arm was considered a separate CT group in the analysis. Demographic variables considered in the analysis were age, sex, race/ethnicity, facility location throughout the United States, rural vs urban geography, and facility type. Participant demographics from trial and the National Cancer Database (NCDB) participants were compared using chi-squared goodness of fit and one-sample t-test where applicable. RESULTS Of 50 CT groups identified, 42 (82%) studies reported mean or median age. Trial participants were younger compared to NCDB patients (P < .001 all studies). All but three trials had fewer female patients than NCDB (48.2% female, P < .001). Less than half the CT groups reported on race or ethnicity. Eighteen out of 22 trials (82%) had a smaller percentage of Black patients and 4 out of 8 (50%) trials had fewer Hispanic or Spanish origin patients than the NCDB. No CTs reported comorbidities, socioeconomic factors, or education. CT primary sites were largely at academic centers and in urban areas. CONCLUSION The present study supports the need for improved demographic representation and transparency in rectal cancer clinical trials.
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Affiliation(s)
- Tuleen Sawaf
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Rachana Gudipudi
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Asya Ofshteyn
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Anuja L Sarode
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Katherine Bingmer
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | | | - Sharon L Stein
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Emily Steinhagen
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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Cheng V, Ashbrook M, Youssefzadeh AC, Kohrman N, Matsuo K, Inaba K, Matsushima K. Management for Acute Uncomplicated Appendicitis During Pregnancy: National Trends and Patient Outcomes. Ann Surg 2023; 278:932-936. [PMID: 37132381 DOI: 10.1097/sla.0000000000005893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
OBJECTIVE This study analyzes national trends in the management of uncomplicated appendicitis during pregnancy, comparing outcomes for nonoperative management (NOM) and appendectomy. BACKGROUND In the nonpregnant population, several randomized controlled trials demonstrated noninferiority of NOM compared with appendectomy for acute uncomplicated appendicitis. However, it remains unclear whether these findings are generalizable to pregnant patients. METHODS The National Inpatient Sample was queried for pregnant women diagnosed with acute uncomplicated appendicitis from January 2003 to September 2015. Patients were categorized by treatment: NOM, laparoscopic appendectomy (LA), and open appendectomy. A quasi-experimental analysis with interrupted time series examined the relationship between the year of admission and the likelihood of receiving NOM. Multivariable logistic regression analyses were used to evaluate the association between treatment strategy and patient outcomes. RESULTS A total of 33,120 women satisfied the inclusion criteria. Respectively, 1070 (3.2%), 18,736 (56.6%), and 13,314 (40.2%) underwent NOM, LA, and open appendectomy. The NOM rate significantly increased between 2006 and 2015, with an annual increase of 13.9% (95% CI, 8.5-19.4, P <0.001). Compared with LA, NOM was significantly associated with higher rates of preterm abortion (odds ratio [OR]: 3.057, 95% CI, 2.210-4.229, P <0.001) and preterm labor/delivery (OR: 3.186, 95% CI, 2.326-4.365, P <0.001). Each day of delay to appendectomy was associated with significantly greater rates of preterm abortion (OR: 1.210, 95% CI, 1.123-1.303, P <0.001). CONCLUSIONS Although NOM has been increasing as a treatment for pregnant patients with uncomplicated appendicitis, compared with LA, it is associated with worse clinical outcomes.
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Affiliation(s)
- Vincent Cheng
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Matthew Ashbrook
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Ariane C Youssefzadeh
- Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA
| | - Nathan Kohrman
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Koji Matsuo
- Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA
| | - Kenji Inaba
- Department of Surgery, University of Southern California, Los Angeles, CA
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Del Rosario M, Chang J, Ziogas A, Clair K, Bristow RE, Tanjasiri SP, Zell JA. Differential Effects of Race, Socioeconomic Status, and Insurance on Disease-Specific Survival in Rectal Cancer. Dis Colon Rectum 2023; 66:1263-1272. [PMID: 35849491 PMCID: PMC10548716 DOI: 10.1097/dcr.0000000000002341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND National Comprehensive Cancer Network guideline adherence improves cancer outcomes. In rectal cancer, guideline adherence is distributed differently by race/ethnicity, socioeconomic status, and insurance. OBJECTIVE This study aimed to determine the independent effects of race/ethnicity, socioeconomic status, and insurance status on rectal cancer survival after accounting for differences in guideline adherence. DESIGN This was a retrospective study. SETTINGS The study was conducted using the California Cancer Registry. PATIENTS This study included patients aged 18 to 79 years diagnosed with rectal adenocarcinoma between January 1, 2004, and December 31, 2017, with follow-up through November 30, 2018. Investigators determined whether patients received guideline-adherent care. MAIN OUTCOME MEASURES ORs and 95% CIs were used for logistic regression to analyze patients receiving guideline-adherent care. Disease-specific survival analysis was calculated using Cox regression models. RESULTS A total of 30,118 patients were examined. Factors associated with higher odds of guideline adherence included Asian and Hispanic race/ethnicity, managed care insurance, and high socioeconomic status. Asians (HR, 0.80; 95% CI, 0.72-0.88; p < 0.001) and Hispanics (HR, 0.91; 95% CI, 0.83-0.99; p = 0.0279) had better disease-specific survival in the nonadherent group. Race/ethnicity were not factors associated with disease-specific survival in the guideline adherent group. Medicaid disease-specific survival was worse in both the nonadherent group (HR, 1.56; 95% CI, 1.40-1.73; p < 0.0001) and the guideline-adherent group (HR, 1.18; 95% CI, 1.08-1.30; p = 0.0005). Disease-specific survival of the lowest socioeconomic status was worse in both the nonadherent group (HR, 1.42; 95% CI, 1.27-1.59) and the guideline-adherent group (HR, 1.20; 95% CI, 1.08-1.34). LIMITATIONS Limitations included unmeasured confounders and the retrospective nature of the review. CONCLUSIONS Race, socioeconomic status, and insurance are associated with guideline adherence in rectal cancer. Race/ethnicity was not associated with differences in disease-specific survival in the guideline-adherent group. Medicaid and lowest socioeconomic status had worse disease-specific survival in both the guideline nonadherent group and the guideline-adherent group. See Video Abstract at http://links.lww.com/DCR/B954 . EFECTOS DIFERENCIALES DE LA RAZA, EL NIVEL SOCIOECONMICO COBERTURA SOBRE LA SUPERVIVENCIA ESPECFICA DE LA ENFERMEDAD EN EL CNCER DE RECTO ANTECEDENTES: El cumplimiento de las guías de la National Comprehensive Cancer Network mejora los resultados del cáncer. En el cáncer de recto, el cumplimiento de las guías se distribuye de manera diferente según la raza/origen étnico, nivel socioeconómico y el cobertura médica.OBJETIVO: Determinar los efectos independientes de la raza/origen étnico, el nivel socioeconómico y el estado de cobertura médica en la supervivencia del cáncer de recto después de tener en cuenta las diferencias en el cumplimiento de las guías.DISEÑO: Este fue un estudio retrospectivo.ENTORNO CLINICO: El estudio se realizó utilizando el Registro de Cáncer de California.PACIENTES: Pacientes de 18 a 79 años diagnosticados con adenocarcinoma rectal entre el 1 de enero de 2004 y el 31 de diciembre de 2017 con seguimiento hasta el 30 de noviembre de 2018. Los investigadores determinaron si los pacientes recibieron atención siguiendo las guías.PRINCIPALES MEDIDAS DE RESULTADO: Se utilizaron razones de probabilidad e intervalos de confianza del 95 % para la regresión logística para analizar a los pacientes que recibían atención con adherencia a las guías. El análisis de supervivencia específico de la enfermedad se calculó utilizando modelos de regresión de Cox.RESULTADOS: Se analizaron un total de 30.118 pacientes. Los factores asociados con mayores probabilidades de cumplimiento de las guías incluyeron raza/etnicidad asiática e hispana, seguro de atención administrada y nivel socioeconómico alto. Los asiáticos e hispanos tuvieron una mejor supervivencia específica de la enfermedad en el grupo no adherente HR 0,80 (95 % CI 0,72 - 0,88, p < 0,001) y HR 0,91 (95 % CI 0,83 - 0,99, p = 0,0279). La raza o el origen étnico no fueron factores asociados con la supervivencia específica de la enfermedad en el grupo que cumplió con las guías. La supervivencia específica de la enfermedad de Medicaid fue peor tanto en el grupo no adherente HR 1,56 (IC del 95 % 1,40 - 1,73, p < 0,0001) como en el grupo adherente a las guías HR 1,18 (IC del 95 % 1,08 - 1,30, p = 0,0005). La supervivencia específica de la enfermedad del nivel socioeconómico más bajo fue peor tanto en el grupo no adherente HR 1,42 (IC del 95 %: 1,27 a 1,59) como en el grupo adherente a las guías HR 1,20 (IC del 95 %: 1,08 a 1,34).LIMITACIONES: Las limitaciones incluyeron factores de confusión no medidos y la naturaleza retrospectiva de la revisión.CONCLUSIONES: La raza, el nivel socioeconómico y cobertura médica están asociados con la adherencia a las guías en el cáncer de recto. La raza/etnicidad no se asoció con diferencias en la supervivencia específica de la enfermedad en el grupo que cumplió con las guías. Medicaid y el nivel socioeconómico más bajo tuvieron peor supervivencia específica de la enfermedad tanto en el grupo que no cumplió con las guías como en los grupos que cumplieron. Consulte Video Resumen en http://links.lww.com/DCR/B954 . (Traducción- Dr. Francisco M. Abarca-Rendon).
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Affiliation(s)
- Michael Del Rosario
- Division of Hematology/Oncology, Department of Medicine, University of California, Irvine, Irvine, California
| | - Jenny Chang
- Department of Medicine, University of California, Irvine, Irvine, California
| | - Argyrios Ziogas
- Department of Medicine, University of California, Irvine, Irvine, California
| | - Kiran Clair
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, Irvine, Irvine, California
| | - Robert E. Bristow
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, Irvine, Irvine, California
| | - Sora P. Tanjasiri
- Department of Medicine, University of California, Irvine, Irvine, California
- Chao Family Comprehensive Cancer Center, University of California, Irvine, Irvine, California
| | - Jason A. Zell
- Division of Hematology/Oncology, Department of Medicine, University of California, Irvine, Irvine, California
- Department of Medicine, University of California, Irvine, Irvine, California
- Chao Family Comprehensive Cancer Center, University of California, Irvine, Irvine, California
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Lee KC, Zhao B, Pianka K, Liu S, Eisenstein S, Ramamoorthy S, Lopez NE. Current trends in nonoperative management for rectal adenocarcinoma: An unequal playing field? J Surg Oncol 2022; 126:1504-1511. [PMID: 36056914 DOI: 10.1002/jso.27082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 07/28/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES Increasing evidence suggests patient-oriented benefits of nonoperative management (NOM) for rectal cancer. However, vigilant surveillance requires excellent access to care. We sought to examine patient, socioeconomic, and facility-level factors associated with NOM over time. METHODS Using the National Cancer Database (2006-2017), we examined patients with Stage II-III rectal adenocarcinoma, who received neoadjuvant chemoradiation and received NOM versus surgery. Factors associated with NOM were assessed using multivariable logistic regression with backward stepwise selection. RESULTS There were 59,196 surgical and 8520 NOM patients identified. NOM use increased from 12.9% to 15.9% between 2006 and 2017. Patients who were Black (adjusted odds ratio [aOR]: 1.36, 95% confidence interval [CI]: 1.26-1.47), treated at community cancer centers (aOR: 1.22, 95% CI: 1.12-1.30), without insurance (aOR: 1.87, 95% CI: 1.68-2.09), and with less education (aOR: 1.53, 95% CI: 1.42-1.65) exhibited higher odds of NOM. Patients treated at high-volume centers (aOR: 0.79, 95% CI: 0.74-0.84) and those who traveled >25.6 miles for care (aOR: 0.59, 95% CI: 0.55-0.64) had lower odds of NOM. CONCLUSIONS Vulnerable groups who traditionally have difficulty accessing comprehensive cancer care were more likely to receive NOM, suggesting that healthcare disparities may be driving utilization. More research is needed to understand NOM decision-making in rectal cancer treatment.
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Affiliation(s)
- Katherine C Lee
- Department of Surgery, University of California, San Diego, La Jolla, California, USA
| | - Beiqun Zhao
- Department of Surgery, University of California, San Diego, La Jolla, California, USA
| | - Kurt Pianka
- Department of Surgery, University of California, San Diego, La Jolla, California, USA
| | - Shanglei Liu
- Department of Surgery, University of California, San Diego, La Jolla, California, USA
| | - Samuel Eisenstein
- Department of Surgery, University of California, San Diego, La Jolla, California, USA
| | - Sonia Ramamoorthy
- Department of Surgery, University of California, San Diego, La Jolla, California, USA
| | - Nicole E Lopez
- Department of Surgery, University of California, San Diego, La Jolla, California, USA
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Naffouje SA, Ali MA, Kamarajah SK, White B, Salti GI, Dahdaleh F. Assessment of Textbook Oncologic Outcomes Following Proctectomy for Rectal Cancer. J Gastrointest Surg 2022; 26:1286-1297. [PMID: 35441331 DOI: 10.1007/s11605-021-05213-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 11/20/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Outcomes of rectal adenocarcinoma vary considerably. Composite "textbook oncologic outcome" (TOO) is a single metric that estimates optimal clinical performance for cancer surgery. METHODS Patients with stage II/III rectal adenocarcinoma who underwent single-agent neoadjuvant chemoradiation and proctectomy within 5-12 weeks were identified in the National Cancer Database (NCDB). TOO was defined as achievement of negative distal and circumferential resection margin (CRM), retrieval of ≥ 12 nodes, no 90-day mortality, and length of stay (LOS) < 75th percentile of corresponding year's range. Multivariable logistic regression was used to identify predictors of TOO. RESULTS Among 318,225 patients, 8869 met selection criteria. Median age was 62 years (IQR 54-71), and 5550 (62.6%) were males. Low anterior resection was the most common procedure (LAR, 6,037 (68.1%) and 3084 (34.8%) were treated at a high-volume center (≥ 20 rectal resections/year). TOO was achieved in 3967 patients (44.7%). Several components of TOO were achieved commonly, including negative CRM (87.4%), no 90-day mortality (98.0%), no readmission (93.0%), and no prolonged hospitalization (78.8%). Logistic regression identified increasing age, non-private insurance, low-volume centers, open approach, Black race, Charlson score ≥ 3, and abdominoperineal resection (APR) as predictors of failure to achieve TOO. Over time, TOOs were attained more commonly which correlated with increased minimally invasive surgery (MIS) adoption. TOO achievement was associated with improved survival. CONCLUSIONS Rectal adenocarcinoma patients achieve TOO uncommonly. Treatment at high-volume centers and MIS approach were among modifiable factors associated with TOO in this study.
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Affiliation(s)
- Samer A Naffouje
- Department of Surgical Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Muhammed A Ali
- Department of Surgery, Queen Elizabeth Hospital Birmingham, University Hospital Birmingham NHS Trust, Birmingham, UK
| | - Sivesh K Kamarajah
- Department of Surgery, Queen Elizabeth Hospital Birmingham, University Hospital Birmingham NHS Trust, Birmingham, UK
| | - Bradley White
- Department of General Surgery, University of Illinois Hospital and Health Sciences System, Chicago, IL, USA
| | - George I Salti
- Department of General Surgery, University of Illinois Hospital and Health Sciences System, Chicago, IL, USA.,Department of Surgical Oncology, Edward-Elmhurst Health, 120 Spalding Drive, Ste 205, Naperville, IL, 60540, USA
| | - Fadi Dahdaleh
- Department of Surgical Oncology, Edward-Elmhurst Health, 120 Spalding Drive, Ste 205, Naperville, IL, 60540, USA.
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Toboni MD, Cohen A, Gentry ZL, Ostby SA, Wang Z, Bae S, Leath C. Sociodemographic characteristics and cervical cancer survival in different regions of the United States: a National Cancer Database study. Int J Gynecol Cancer 2022; 32:724-731. [DOI: 10.1136/ijgc-2021-003227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
ObjectiveTo determine how sociodemographic factors impact cervical cancer survival in different geographic locations in the USA.MethodsA retrospective cohort of patients with cervical cancer from January 1, 2004 to December 31, 2015 in the National Cancer Database (NCDB) was identified. Tumor characteristics as well as race, income, insurance type, and treating facility types were compared among nine geographic regions. χ2 tests and Cox regression were used to compare differences between regions; p values <0.05 were considered significant.ResultsA total of 48 787 patients were included. Survival was inferior in seven of nine regions for underinsured patients. In six regions survival was inferior for Medicaid and Medicare patients, respectively: Middle Atlantic: hazard ratio (HR) 1.25 and 1.22; South Atlantic: HR 1.41 and HR 1.22; East North Central: HR 1.36 and HR 1.25; East South Central: HR 1.37 and HR 1.25; West North Central: HR 1.67 and HR 1.42; West South Central: HR 1.44 and HR 1.46. In the Pacific region survival was inferior for Medicare patients (HR 1.35) but not inferior for Medicaid patients. Being uninsured was associated with worse survival in the South Atlantic (HR 1.23), East North Central (HR 1.23), East South Central (HR 1.56), and West South Central (HR 1.31) regions. Annual income level under $38 000 was associated with worse survival in the Middle Atlantic (HR 1.24), South Atlantic (HR 1.35), and East North Central (HR 1.49) regions. Lastly, when compared with academic research institutions, comprehensive community cancer centers had significantly worse survival in four of the nine regions.ConclusionsCervical cancer mortality is higher for women with a low income, underinsured (Medicaid or Medicare) or uninsured status, and decreased access to academic institutions in most US regions. An increase in cervical cancer mortality was associated with underinsured or uninsured populations in regions mainly located in the South and Midwest.
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Alese OB, Zhou W, Jiang R, Zakka K, Huang Z, Okoli C, Shaib WL, Akce M, Diab M, Wu C, El-Rayes BF. Predictive and Prognostic Effects of Primary Tumor Size on Colorectal Cancer Survival. Front Oncol 2021; 11:728076. [PMID: 34956863 PMCID: PMC8695445 DOI: 10.3389/fonc.2021.728076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 10/27/2021] [Indexed: 01/09/2023] Open
Abstract
Background Pathologic staging is crucial in colorectal cancer (CRC). Unlike the majority of solid tumors, the current staging model does not use tumor size as a criterion. We evaluated the predictive and prognostic impact of primary tumor size on all stages of CRC. Methods Using the National Cancer Database (NCDB), we conducted an analysis of CRC patients diagnosed between 2010 and 2015 who underwent resection of their primary cancer. Univariate and multivariate analyses were used to identify predictive and prognostic factors, Kaplan-Meier analysis and Cox proportional hazards models for association between tumor size and survival. Results About 61,000 patients met the inclusion criteria. Median age was 63 years and majority of the tumors were colon primary (82.7%). AJCC stage distribution was: I - 20.1%; II - 32.1%; III - 34.7% and IV - 13.1%. The prognostic impact of tumor size was strongly associated with survival in stage III disease. Compared to patients with tumors <2cm; those with 2-5cm (HR 1.33; 1.19-1.49; p<0.001), 5-10cm (HR 1.51 (1.34-1.70; p<0.001) and >10cm (HR 1.95 (1.65-2.31; p<0.001) had worse survival independent of other variables. Stage II treated without adjuvant chemotherapy had comparable survival outcomes (HR 1.09; 0.97-1.523; p=0.148) with stage III patients who did, while Stage II patients who received adjuvant chemotherapy did much better than both groups (HR 0.76; 0.67-0.86; p<0.001). Stage III patients who did not receive adjuvant chemotherapy had the worst outcomes among the non-metastatic disease subgroups (HR 2.66; 2.48-2.86; p<0.001). Larger tumors were associated with advanced stage, MSI high, non-rectal primary and positive resection margins. Conclusions Further studies are needed to clarify the role of tumor size in prognostic staging models, and how to incorporate it into therapy decisions.
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Affiliation(s)
- Olatunji B Alese
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Wei Zhou
- Winship Data and Technology Applications Shared Resource, Emory University, Atlanta, GA, United States
| | - Renjian Jiang
- Winship Data and Technology Applications Shared Resource, Emory University, Atlanta, GA, United States
| | - Katerina Zakka
- Department of Medicine, Wellstar Atlanta Medical Center, Atlanta, GA, United States
| | - Zhonglu Huang
- Winship Data and Technology Applications Shared Resource, Emory University, Atlanta, GA, United States
| | - Chimuanya Okoli
- Department of Medicine, Advocate Illinois Masonic Medical Center, Chicago, IL, United States
| | - Walid L Shaib
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Mehmet Akce
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Maria Diab
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Christina Wu
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Bassel F El-Rayes
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, United States
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Beltrami A, Hilliard A, Green AL. Demographic and socioeconomic disparities in pediatric cancer in the United States: Current knowledge, deepening understanding, and expanding intervention. Cancer Epidemiol 2021; 76:102082. [PMID: 34923289 DOI: 10.1016/j.canep.2021.102082] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 12/06/2021] [Accepted: 12/08/2021] [Indexed: 01/19/2023]
Abstract
While survival of pediatric cancer has improved greatly over the past 40 years, demographic and socioeconomic disparities have meant that some groups have not benefitted as much from these advances. We conducted a rapid review to summarize literature on demographic and socioeconomic disparities in outcomes of childhood cancer, starting in 2000. We find that unequal outcomes have been noted for many of these groups across hematologic malignancies, central nervous system tumors, and other solid tumors, although occasional studies have noted absence of disparities for particular at-risk groups and diseases, and gaps in understanding of disparities for some cancer subtypes and groups still exist. These include disparities in duration of overall survival, risk of death, more extensive disease at presentation, and differences/delays in treatment. Black race, Hispanic ethnicity, lack of private insurance, and adolescent/young adult age are most often associated with these poorer outcomes. We then delve into documented and theorized causes of these disparities, including impaired access to care and clinical trials, differences in cancer biology, treatment non-adherence, language barriers, and implicit racial bias. Here, it is clear that socioeconomic factors account for a large proportion of disparities seen, although not all, and that the causes of disparities are complex and interconnected and still need to be better understood. Finally, in an effort to shift emphasis to addressing disparities, we review interventions against disparities that have been studied in childhood cancer patients and other populations, including improving clinical trial representation, communication, health literacy, and family navigation. We suggest ways forward in disparity mitigation toward a goal of achieving equitable cancer outcomes for all children.
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Affiliation(s)
- Alina Beltrami
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States; Department of Biological Sciences, University of Denver, Denver, CO, United States
| | - Alexandra Hilliard
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States; Department of Biological Sciences, University of Denver, Denver, CO, United States
| | - Adam L Green
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States; Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, CO, United States.
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Hao S, Parikh AA, Snyder RA. Racial Disparities in the Management of Locoregional Colorectal Cancer. Surg Oncol Clin N Am 2021; 31:65-79. [PMID: 34776065 DOI: 10.1016/j.soc.2021.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Racial disparities pervade nearly all aspects of management of locoregional colorectal cancer, including time to treatment, receipt of resection, adequacy of resection, postoperative complications, and receipt of neoadjuvant and adjuvant multimodality therapies. Disparate gaps in treatment translate into enduring effects on survivorship, recurrence, and mortality. Efforts to reduce these gaps in care must be undertaken on a multilevel basis and focus on modifiable factors that underlie racial disparity.
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Affiliation(s)
- Scarlett Hao
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Boulevard, Surgical Oncology Suite, 4S-24, Greenville, NC 27834, USA
| | - Alexander A Parikh
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Boulevard, Surgical Oncology Suite, 4S-24, Greenville, NC 27834, USA
| | - Rebecca A Snyder
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Boulevard, Surgical Oncology Suite, 4S-24, Greenville, NC 27834, USA.
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Shaib WL, Zakka K, Penley M, Jiang R, Akce M, Wu C, Maithel SK, Sarmiento JM, Kooby D, Behera M, Alese OB, El-Rayes BF. Role of Resection of the Primary in Metastatic Well-Differentiated Neuroendocrine Tumors. Pancreas 2021; 50:1382-1391. [PMID: 35041337 PMCID: PMC10848811 DOI: 10.1097/mpa.0000000000001936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Resection of the primary (RP) in metastatic neuroendocrine tumor (NET) is controversial. The aim was to evaluate survival outcomes for RP in metastatic NET patients. METHODS Data were obtained from US hospitals at the National Cancer Database between 2004 and 2014. χ2, analysis of variance tests, univariate, and multivariate cox proportional hazards models were evaluated. Kaplan-Meier curves and log-rank tests conducted to compare the survival difference of patient characteristics. RESULTS A total of 2361 patients were identified. The mean age was 62.1 years (standard deviation, 13 years), male-to-female ratio 1:1; 33% were small intestine, 26.3% pancreas, and 24.4% lung; 69.6% were well-differentiated; and 42.5% underwent RP. The 5-year overall survival (OS) was significantly improved for patients who underwent RP in small intestine (5-year OS, 63.9% vs 44.2%), lung (5-year OS, 65.4% vs 20.2%), and pancreas tumors (5-year OS, 75.6% vs 30.6%). On multivariate analysis, RP (hazard ratio, 0.46; 95% confidence interval, 0.29-0.73; P < 0.001), female, year of diagnosis 2010-2014, margin, Charlson-Deyo score less than 2, and age less than 51 years, were associated with better OS. CONCLUSIONS Resection of the primary in metastatic well-differentiated NET is associated with improved OS compared with no RP.
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Affiliation(s)
- Walid L. Shaib
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Katerina Zakka
- Department of Internal Medicine, Wellstar Atlanta Medical Center, Atlanta, GA
| | - McKenna Penley
- Winship Research Informatics, Emory University, Atlanta, GA
| | - Renjian Jiang
- Winship Research Informatics, Emory University, Atlanta, GA
| | - Mehmet Akce
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Christina Wu
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Shishir K. Maithel
- Department of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | | | - David Kooby
- Department of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Madhusmita Behera
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
- Winship Research Informatics, Emory University, Atlanta, GA
| | - Olatunji B. Alese
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Bassel F. El-Rayes
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
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Salem ME, Puccini A, Trufan SJ, Sha W, Kadakia KC, Hartley ML, Musselwhite LW, Symanowski JT, Hwang JJ, Raghavan D. Impact of Sociodemographic Disparities and Insurance Status on Survival of Patients with Early-Onset Colorectal Cancer. Oncologist 2021; 26:e1730-e1741. [PMID: 34288237 PMCID: PMC8488791 DOI: 10.1002/onco.13908] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 07/13/2021] [Indexed: 12/12/2022] Open
Abstract
Background Low socioeconomic status (SES) has been linked to worse survival in patients with colorectal cancer (CRC); however, the impact of SES on early‐onset CRC remains undescribed. Materials and Methods Retrospective analysis of data from the National Cancer Database (NCDB) between 2004 and 2016 was conducted. We combined income and education to form a composite measure of SES. Logistic regression and χ2 testing were used to examine early‐onset CRC according to SES group. Survival rates and Cox proportional hazards models compared stage‐specific overall survival (OS) between the SES groups. Results In total, 30,903 patients with early‐onset CRC were identified, of whom 78.7% were White; 14.5% were Black. Low SES compared with high SES patients were more likely to be Black (26.3% vs. 6.1%) or Hispanic (25.3% vs. 10.5%), have T4 tumors (21.3% vs. 17.8%) and/or N2 disease (13% vs. 11.1%), and present with stage IV disease (32.8% vs. 27.7%) at diagnosis (p < .0001, all comparisons). OS gradually improved with increasing SES at all disease stages (p < .001). In stage IV, the 5‐year survival rate was 13.9% vs. 21.7% for patients with low compared with high SES. In multivariable analysis, SES (low vs. high group; adjusted hazard ratio [HRadj], 1.35; 95% confidence interval [CI], 1.26–1.46) was found to have a significant effect on survival (p < .0001) when all of the confounding variables were adjusted. Insurance (not private vs. private; HRadj, 1.38; 95% CI, 1.31–1.44) mediates 31% of the SES effect on survival. Conclusion Patients with early‐onset CRC with low SES had the worst outcomes. Our data suggest that SES should be considered when implementing programs to improve the early detection and treatment of patients with early‐onset CRC. Implications for Practice Low socioeconomic status (SES) has been linked to worse survival in patients with colorectal cancer (CRC); however, the impact of SES on early‐onset CRC remains undescribed. In this retrospective study of 30,903 patients with early‐onset CRC in the National Cancer Database, a steady increase in the yearly rate of stage IV diagnosis at presentation was observed. The risk of death increased as socioeconomic status decreased. Race and insurance status were independent predictors for survival. Implementation of programs to improve access to care and early diagnostic strategies among younger adults, especially those with low SES, is warranted. The incidence of and mortality from early‐onset colorectal cancer (CRC) is on the rise. This article details the relationship between socioeconomic status and clinical outcomes of young adults with early‐onset CRC.
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Affiliation(s)
- Mohamed E Salem
- Departments of Solid Tumor Oncology, Levine Cancer Institute, Charlotte, North Carolina, USA
| | - Alberto Puccini
- Ospedale Policlinico San Martino IRCCS, University of Genova, Genoa, Italy
| | - Sally J Trufan
- Cancer Biostatistics, Levine Cancer Institute, Charlotte, North Carolina, USA
| | - Wei Sha
- Cancer Biostatistics, Levine Cancer Institute, Charlotte, North Carolina, USA
| | - Kunal C Kadakia
- Departments of Solid Tumor Oncology, Levine Cancer Institute, Charlotte, North Carolina, USA
| | - Marion L Hartley
- The Ruesch Center for the Cure of Gastrointestinal Cancers at Georgetown Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - Laura W Musselwhite
- Departments of Solid Tumor Oncology, Levine Cancer Institute, Charlotte, North Carolina, USA
| | - James T Symanowski
- Cancer Biostatistics, Levine Cancer Institute, Charlotte, North Carolina, USA
| | - Jimmy J Hwang
- Departments of Solid Tumor Oncology, Levine Cancer Institute, Charlotte, North Carolina, USA
| | - Derek Raghavan
- Departments of Solid Tumor Oncology, Levine Cancer Institute, Charlotte, North Carolina, USA
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Racial Disparities in Treatment for Rectal Cancer at Minority-Serving Hospitals. J Gastrointest Surg 2021; 25:1847-1856. [PMID: 32725520 DOI: 10.1007/s11605-020-04744-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 07/14/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Racial disparities exist in patients with rectal cancer with respect to both treatment and survival. Minority-serving hospitals (MSHs) provide healthcare to a disproportionately large percent of minority patients in the USA. We examined the effects of rectal cancer treatment at MSH to understand drivers of these disparities. METHODS The NCDB was queried (2004-2015), and patients diagnosed with stage II or III rectal adenocarcinoma were identified. Racial case mix distribution was calculated at the institutional level, and MSHs were defined as those within the top decile of Black and Hispanic patients. Logistic regression was used to identify predictors of receipt of standard of care treatment. Survival was assessed using the Kaplan-Meier method, and Cox proportional hazards models were used to evaluate adjusted risk of death. Analyses were clustered by facility. RESULTS A total of 68,842 patients met the inclusion criteria. Of these patients, 63,242 (91.9%) were treated at non-MSH, and 5600 (8.1%) were treated at MSH. In multivariable analysis, treatment at MSH (OR 0.70 95%CI 0.61-0.80 p < 0.001) and Black race (OR 0.75 95%CI 0.70-0.81 p < 0.001) were associated with significantly lower odds of receiving standard of care. In adjusted analysis, Black patients had a significantly higher risk of mortality (HR 1.20 95%CI 1.14-1.26 p < 0.001). CONCLUSIONS Treatment at MSH institutions and Black race were associated with significantly decreased odds of receipt of recommended standard therapy for locally advanced rectal adenocarcinoma. Survival was worse for Black patients compared to White patients despite adjustment for receipt of standard of care.
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Shaib WL, Zakka K, Huang W, Chen Z, Alese OB, Wu C, Akce M, El-Rayes BF. Survival Outcomes of Acinar Cell Pancreatic Cancer: A National Cancer Database Analysis. Pancreas 2021; 50:529-536. [PMID: 33939665 DOI: 10.1097/mpa.0000000000001788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Acinar cell pancreatic carcinomas (ACPCs) are rare neoplasms accounting for 1% to 2% of pancreatic tumors in adults. The objective of this study is to evaluate the benefit of chemotherapy in the adjuvant setting in resected ACPC and in the palliative setting for metastatic ACPC. METHODS Data were obtained from all US hospitals that contributed to the National Cancer Database between 2004 and 2014. Cases were identified using the histology code 8550. RESULTS A total of 593 patients with ACPC were identified. The mean age was 64.4 years (range, 18-90 years), with a male preponderance (72.8%, n = 432). Localized stage disease comprised 52.3% (n = 310) of patients. Among localized ACPC patients, 88.0% (n = 191) underwent surgery and 50.6% (n = 91) received adjuvant chemotherapy. The 5-year overall survival in those who received adjuvant treatment was slightly higher than those who did not receive adjuvant treatment (46.7% vs 44.8%, P = 0.3271). Among advanced-stage ACPC patients, 67.6% received chemotherapy, which translated into improved 5-year overall survival compared with no chemotherapy (8.1% vs 0%, P < 0.0001). CONCLUSIONS Chemotherapy in the palliative setting for advanced-stage ACPC patients was associated with improved survival. Adjuvant therapy did not translate into significant survival benefit.
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Affiliation(s)
- Walid L Shaib
- From the Department of Hematology and Oncology, Winship Cancer Institute
| | - Katerina Zakka
- From the Department of Hematology and Oncology, Winship Cancer Institute
| | - Weixing Huang
- Winship Research Informatics, Biostatistics, Emory University, Atlanta, GA
| | - Zhengjia Chen
- Winship Research Informatics, Biostatistics, Emory University, Atlanta, GA
| | - Olatunji B Alese
- From the Department of Hematology and Oncology, Winship Cancer Institute
| | - Christina Wu
- From the Department of Hematology and Oncology, Winship Cancer Institute
| | - Mehmet Akce
- From the Department of Hematology and Oncology, Winship Cancer Institute
| | - Bassel F El-Rayes
- From the Department of Hematology and Oncology, Winship Cancer Institute
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Ghaffarpasand E, Welten VM, Fields AC, Lu PW, Shabat G, Zerhouni Y, Farooq AO, Melnitchouk N. Racial and Socioeconomic Disparities After Surgical Resection for Rectal Cancer. J Surg Res 2020; 256:449-457. [DOI: 10.1016/j.jss.2020.07.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/02/2020] [Accepted: 07/11/2020] [Indexed: 01/17/2023]
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Alese OB, Zakka K, Huo X, Jiang R, Shaib WL, Akce M, Behera M, Sullivan P, Wu C, El-Rayes BF. Perioperative therapy in metastatic colorectal cancer: Pattern of use and survival outcomes. J Surg Oncol 2020; 123:596-605. [PMID: 33125756 DOI: 10.1002/jso.26278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 10/09/2020] [Accepted: 10/12/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Multimodality therapy of metastatic colorectal cancer (mCRC) is currently considered the standard of care. The aim of this study was to evaluate the impact of perioperative therapy on surgical resection in mCRC. METHODS The National Cancer Database was analyzed for affected patients between 2004 and 2013. Univariate and multivariate analyses were done to identify factors associated with patient outcomes. Kaplan-Meier analysis and Cox proportional hazards models were used for the association between patient characteristics and survival. RESULTS About 61,940 patients with mCRC were identified. Mean age = 63.4 years (SD ± 14). About 69% had a colon primary and 32% had only one metastatic site. Only 49% of those who underwent surgery for both primary and metastatic sites received postoperative chemotherapy (p < .001). Negative prognostic factors included no chemotherapy received (hazard ratio [HR], 2.32; 2.27-2.37; p < .001), more than three metastatic sites (HR, 2.28; 2.09-2.48; p < .001), year of diagnosis between 2004 and 2008 (HR, 1.71; 1.15-1.20; p < .001) and colon tumor location with right worse than left-sided (HR, 1.21; 1.19-1.24; p < .001). Five-year overall survival for resection of the primary and metastatic site (28.2%) was higher than for no surgical treatment (4.7%). CONCLUSION Perioperative therapy was associated with improved survival, following resection of metastatic sites or primary tumor.
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Affiliation(s)
- Olatunji B Alese
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Katerina Zakka
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Xingyue Huo
- Winship Research Informatics, Emory University, Atlanta, Georgia, USA
| | - Renjian Jiang
- Winship Research Informatics, Emory University, Atlanta, Georgia, USA
| | - Walid L Shaib
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Mehmet Akce
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Madhusmita Behera
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA.,Winship Research Informatics, Emory University, Atlanta, Georgia, USA
| | - Patrick Sullivan
- Division of General and GI Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Christina Wu
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Bassel F El-Rayes
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
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Shaib WL, Zakka KM, Jiang R, Yan M, Alese OB, Akce M, Wu C, Behera M, El-Rayes BF. Survival outcome of adjuvant chemotherapy in deficient mismatch repair stage III colon cancer. Cancer 2020; 126:4136-4147. [PMID: 32697360 DOI: 10.1002/cncr.33049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/11/2020] [Accepted: 05/31/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND The prognostic impact of DNA mismatch repair (MMR) status remains controversial in patients with stage III colon cancer who are treated with adjuvant chemotherapy (AC). The aim of this study was to evaluate the survival outcome of AC in deficient mismatch repair (dMMR)/microsatellite instable (MSI) stage III CC. METHODS Patients with pathological stage III CC between 2010 and 2013 were identified from the National Cancer Database using International Classification of Diseases for Oncology (3rd Edition) morphology and topography codes 8140, 8480, and C18.0-18.8. Patients with pathologic stage T3N2, T4N1, or T4N were considered high risk; patients with stage T3N1 were considered low risk. Univariate and multivariable analyses were conducted, and Kaplan-Meier analysis and Cox proportional hazards models were used to identify the association between AC and overall survival (OS). RESULTS A total of 9226 patients with pathological stage III CC were identified, of which 2384 (25.8%) were MSI-high (MSI-H) and met the inclusion criteria of the final analysis. MSI-low (MSI-L) patients (n = 6842) were excluded. There was a preponderance of women (55.0% [n = 1311]), and 76.6% (n = 1825) of patients were non-Hispanic white. The median age was 65 years (range, 19-90 years). The primary sites were the cecum (29.7% [n = 707]), ascending colon (26.0% [n = 620]), sigmoid colon (17.2% [n = 410]), and transverse colon (10.8% [n = 257]). The most common tumor grade was moderately differentiated (n = 50.4% [1202]), followed by poorly differentiated (34.1% [n = 813]) and well differentiated (5.1% [n = 121]). High-risk pathologic stage III CC (T4N1, TxN2) constituted 51.0% (n = 1215) of the study population. High-risk stage III was associated with worse OS compared with low-risk stage III on univariate (P < .001) analysis and displayed a similar trend on multivariable analysis, without a statistically significant difference. Multiagent AC was associated with improved OS compared with no treatment on univariate (P < .001) and multivariable (P < .001) analysis. When stratified by risk status, multiagent AC was associated with improved OS compared with no treatment for high-risk (P < .001) and low-risk (P < .001) stage III disease. CONCLUSION Adjuvant chemotherapy is associated with better OS in stage III dMMR/MSI-H CC. An enhanced benefit was shown for high-risk stage III disease.
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Affiliation(s)
- Walid L Shaib
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Katerina M Zakka
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Renjian Jiang
- Winship Research Informatics, Emory University, Atlanta, Georgia
| | - Ming Yan
- Winship Research Informatics, Emory University, Atlanta, Georgia
| | - Olatunji B Alese
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Mehmet Akce
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Christina Wu
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Madhusmita Behera
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia.,Winship Research Informatics, Emory University, Atlanta, Georgia
| | - Bassel F El-Rayes
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
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21
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Song KS, Park SC, Sohn DK, Oh JH, Kim MJ, Park JW, Ryoo SB, Jeong SY, Park KJ, Oh HK, Kim DW, Kang SB. Oncologic Risk of Rectal Preservation Against Medical Advice After Chemoradiotherapy for Rectal Cancer: A Multicenter Comparative Cross-Sectional Study with Rectal Preservation as Supported by Surgeon. World J Surg 2020; 43:3216-3223. [PMID: 31410512 DOI: 10.1007/s00268-019-05128-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Rectal preservation against medical advice after neoadjuvant chemoradiotherapy for rectal cancer may increase oncologic uncertainty. This study aimed to compare the oncologic outcomes of patients undergoing rectal preservation as intended by the surgeon, and the outcomes of patients refusing rectal resection against medical advice. METHODS The study population consisted of patients in whom the rectum was preserved after neoadjuvant chemoradiotherapy for clinical stage I-III mid or low rectal cancer between May 2003 and August 2017 (n = 2883); these patients were divided into those in whom rectal preservation was intended by their surgeon (intended rectal preservation, group A, n = 41) and those in whom the rectum was not resected against medical advice (unintended rectal preservation, group B, n = 101), defined as non-operative management or local excision. RESULTS The tumor distance, age, and performance status of patients were not significantly different between the groups, while the clinical T stage before chemoradiotherapy was lower in group A than in group B (P < 0.001). During the median follow-up period of 34 months (interquartile range 18.0-72.0 months), the 3-year overall survival in group B (59.7%) was worse than that in group A (90.1%; P < 0.001), and 80.2% of group B patients had residual or unknown disease status. CONCLUSIONS This study showed that unintended rectal preservation increases oncologic risk after neoadjuvant chemoradiotherapy for rectal cancer regardless of short-term follow-up. Therefore, these findings could be shared with rectal cancer patients who choose to ignore medical advice after chemoradiotherapy to preserve their rectum.
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Affiliation(s)
- Kwang-Seop Song
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Sung Chan Park
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Dae Kyung Sohn
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Jae Hwan Oh
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Min Jung Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ji Won Park
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seung-Bum Ryoo
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seung-Yong Jeong
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyu Joo Park
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Heung-Kwon Oh
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Duck-Woo Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sung-Bum Kang
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.
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22
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Fields AC, Lu PW, Yoo J, Irani J, Goldberg JE, Bleday R, Melnitchouk N. Treatment of stage I-III rectal cancer: Who is refusing surgery? J Surg Oncol 2020; 121:990-1000. [PMID: 32090341 DOI: 10.1002/jso.25873] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 02/10/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Surgical resection is a cornerstone in the management of patients with rectal cancer. Patients may refuse surgical treatment for several reasons although the rate of refusal is currently unknown. METHODS The National Cancer Database was utilized to identify patients with stage I-III rectal cancer. Patients who refused surgical resection were compared to patients who underwent curative resection. RESULTS A total of 509 (2.6%) patients with stage I and 2082 (3.5%) patients with stage II/III rectal cancer refused surgery. In multivariable analysis for stage I disease, older age, Black race, and Medicaid/no insurance were independent predictors of surgery refusal. Patients were less likely to refuse surgery if they had a higher income or lived further distances from the treatment facility. In multivariable analysis for stage II/III disease, older age, Black race, insurance other than private, and rural county were independent predictors of surgery refusal. Patients were less likely to refuse surgery if they had higher Charlson comorbidity scores, lived further distances from the treatment facility, or underwent chemoradiation. There was a significant decrease in survival for patients refusing surgery compared to patients undergoing recommended surgery. CONCLUSIONS A small proportion of patients refuse surgery for rectal cancer, and this treatment decision significantly affects survival.
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Affiliation(s)
- Adam C Fields
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Pamela W Lu
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - James Yoo
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Jennifer Irani
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Joel E Goldberg
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Ronald Bleday
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Nelya Melnitchouk
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Surgery, Harvard Medical School, Boston, Massachusetts
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23
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Akce M, Zakka K, Penley M, Jiang R, Alese OB, Shaib WL, Wu C, Behera M, El-Rayes BF. Clinicopathological features and survival outcomes of rare histologic variants of gallbladder cancer. J Surg Oncol 2020; 121:294-302. [PMID: 31782161 DOI: 10.1002/jso.25781] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 11/15/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Adenocarcinoma (AC) is the most common histological type in gallbladder carcinoma (GBC). Squamous cell carcinoma (SCC), adenosquamous carcinoma (ASC), and papillary carcinoma (PC) are rare histologic variants of GBC. METHODS Patients with AC, SCC, ASC, and PC of the gallbladder between 2004 and 2013 were identified from the National Cancer Database. Univariate and multivariate analyses were performed, and Kaplan-Meier curves were used to compare overall survival (OS) based on histological subtype. RESULTS A total of 5956 patients ≥18 years of age were included in the final analysis. Most patients (n = 5398; 90.6%) had AC compared with variant histologies. PC (n = 227; 3.8%) was the most common variant, followed by ASC (n = 216; 3.6%) and SCC (n = 115; 1.9%); 70.3% were female and 78.9% Caucasian. The median age was 70 (range, 25-90) years. Surgical resection was performed in 77.7% of AC, 53.0% of SCC, 88.9% of ASC, and 96.9% of PC (P < .001). Systemic therapy after surgery was administered in 25.1% of AC, 18.3% of SCC, 35.7% of ASC, and 19.4% of PC (P = .001). In multivariate analysis, multiagent chemotherapy was associated with improved OS in all histologies except for SCC and PC (p < .001), and adjuvant systemic therapy was associated with improved OS in ASC and AC (P < .001). CONCLUSION Survival differs between the gallbladder variants. Except for SCC, GBC variants underwent surgical resection more often than AC. Adjuvant systemic therapy was associated with improved OS in ASC and AC.
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Affiliation(s)
- Mehmet Akce
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Katerina Zakka
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - McKenna Penley
- Winship Research Informatics, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Renjian Jiang
- Winship Research Informatics, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Olatunji B Alese
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Walid L Shaib
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Christina Wu
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Madhusmita Behera
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia.,Winship Research Informatics, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Bassel F El-Rayes
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
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24
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Ofshteyn A, Bingmer K, Dorth J, Dietz D, Steinhagen E, Stein SL. Disparities in neoadjuvant radiation dosing for treatment of rectal cancer. Am J Surg 2020; 220:987-992. [PMID: 31959352 DOI: 10.1016/j.amjsurg.2020.01.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 01/09/2020] [Accepted: 01/10/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Certain patients are less likely to undergo appropriate cancer treatment, worsening their overall cancer survival. The purpose of this investigation was to identify factors associated with inadequate neoadjuvant radiation for rectal cancer. METHODS The National Cancer Database was queried for patients with locally advanced rectal cancer who received neoadjuvant radiation 2006-2014. Adequate radiation was considered to be 4,500-5,040 cGy. Demographic, hospital and clinical variables were analyzed for association with inadequate radiation. RESULTS The study cohort was 34,391 patients; 1,842(5.4%) received inadequate radiation. On multivariate analysis, female gender, older age, other race, government-provided insurance, lower clinical stage and rural location correlated with inadequate radiation. CONCLUSIONS Women were 50% less likely than men to receive correct neoadjuvant radiation dosing. Other factors including age, race, insurance, clinical stage, geographic location and neoadjuvant chemotherapy were significantly associated with radiation dosing. These factors should be evaluated to determine if they can be modified to improve outcomes.
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Affiliation(s)
- Asya Ofshteyn
- Department of Surgery, University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Katherine Bingmer
- Department of Surgery, University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jennifer Dorth
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - David Dietz
- Department of Surgery, University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Emily Steinhagen
- Department of Surgery, University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Sharon L Stein
- Department of Surgery, University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
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25
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Alese OB, Jiang R, Zakka KM, Wu C, Shaib W, Akce M, Behera M, El-Rayes BF. Analysis of racial disparities in the treatment and outcomes of colorectal cancer in young adults. Cancer Epidemiol 2019; 63:101618. [PMID: 31600666 DOI: 10.1016/j.canep.2019.101618] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 09/24/2019] [Accepted: 09/29/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND The incidence of colorectal cancer (CRC) in young adults is increasing. Minority populations with CRC are known to have worse survival outcomes. The aim of this study is to evaluate adults under age 50 years with CRC by race and ethnicity. METHODS Data were obtained from all US hospitals that contributed to the National Cancer Database (NCDB) between 2004 and 2013. Univariate and multivariable testing was done to identify factors associated with patient outcome. Kaplan-Meier analysis and Cox proportional hazards models were used for association between patient characteristics and survival. RESULTS A total of 83,449 patients between 18 and 50 years of age were identified. Median age was 45 years (SD ± 6), with male preponderance (53.9%). 72% were non-Hispanic Whites (NHW), Blacks (AA) were 15.1% and Hispanics (who did not identify as Blacks) were 8.3% of the study population. Distribution across stages IIV was 15.6%, 22.4%, 33.9% and 27% consecutively. 41.8% of NHW and 28.4% of AA had rectal cancers (p < 0.001). Despite equally receiving standard of care (SOC) as per national guidelines, AA had significantly lower 5-year survival rates (58.8%) compared to Hispanics (64.8%) and NHW (66.9%; HR 1.42; 1.38-1.46; p < 0.001). Furthermore, NHW (HR 0.85; 0.81-0.88; p < 0.001) and Hispanics (HR 0.75; 0.70-0.79; p < 0.001) were more likely to benefit from chemotherapy compared to AA. SOC utilization was associated with improved survival across all racial groups, especially in AA (HR 0.64; 0.60-0.69; p < 0.001). CONCLUSION Despite comparable rates of SOC utilization, AA young adults had worse survival outcomes compared to other races. More colon (compared to rectal) cancers in AA may have contributed to their worse outcomes.
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Affiliation(s)
- Olatunji B Alese
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
| | - Renjian Jiang
- Winship Research Informatics, Emory University, Atlanta, GA, USA
| | - Katerina M Zakka
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Christina Wu
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Walid Shaib
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Mehmet Akce
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Madhusmita Behera
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA; Winship Research Informatics, Emory University, Atlanta, GA, USA
| | - Bassel F El-Rayes
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
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26
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Banham D, Roder D, Eckert M, Howard NJ, Canuto K, Brown A. Cancer treatment and the risk of cancer death among Aboriginal and non-Aboriginal South Australians: analysis of a matched cohort study. BMC Health Serv Res 2019; 19:771. [PMID: 31665005 PMCID: PMC6820943 DOI: 10.1186/s12913-019-4534-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 09/13/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Aboriginal and Torres Strait Islander Australians have poorer cancer outcomes than other Australians. Comparatively little is known of the type and amount of cancer treatment provided to Aboriginal and Torres Strait Islander people and the consequences for cancer survival. This study quantifies the influence of surgical, systemic and radiotherapy treatment on risk of cancer death among matched cohorts of cancer cases and, the comparative exposure of cohorts to these treatments. METHODS Cancers registered among Aboriginal South Australians in 1990-2010 (N = 777) were matched with randomly selected non-Indigenous cases by sex, birth and diagnostic year, and primary site, then linked to administrative cancer treatment for the period from 2 months before to 13 months after diagnosis. Competing risk regression summarised associations of Indigenous status, geographic remoteness, comorbidities, cancer stage and treatment exposure with risk of cancer death. RESULTS Fewer Aboriginal cases had localised disease at diagnosis (37.2% versus 50.2%) and they were less likely to: experience hospitalisation with cancer diagnosis, unadjusted odds ratio (UOR) = 0.76; 95%CI = 0.59-0.98; have surgery UOR = 0.65; 95%CI = 0.53-0.80; systemic therapies UOR = 0.64; 95%CI = 0.52-0.78; or radiotherapy, UOR = 0.76; 95%CI = 0.63-0.94. Localised disease carried lower risk of cancer death compared to advanced cases receiving surgery or systemic therapies, SHR = 0.34; 95%CI = 0.25-0.47 and SHR = 0.35; 95%CI = 0.25-0.48. Advanced disease and no treatment carried higher risk of cancer death, SHR = 1.82; 95%CI = 1.26-2.63. CONCLUSION The effects of treatment did not differ between Aboriginal and non-Indigenous cohorts. However, comparatively less exposure to surgical and systemic treatments among Aboriginal cancer cases further complicated the disadvantages associated with geographic remoteness, advanced stage of disease and co-morbid conditions at diagnosis and add to disparities in cancer death. System level responses to improving access, utilisation and quality of effective treatments are needed to improve survival after cancer diagnosis.
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Affiliation(s)
- David Banham
- Wardliparingga Aboriginal Research Unit, South Australian Health and Medical Research Institute, Adelaide, Australia.
| | - David Roder
- School of Health Sciences, Cancer Research Institute, University of South Australia, Adelaide, Australia
| | - Marion Eckert
- Rosemary Bryant AO Research Centre, School of Nursing and Midwifery, University of South Australia North Terrace, Adelaide, Australia
| | - Natasha J Howard
- School of Health Sciences, Cancer Research Institute, University of South Australia, Adelaide, Australia
| | - Karla Canuto
- Wardliparingga Aboriginal Research Unit, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Alex Brown
- Wardliparingga Aboriginal Research Unit, South Australian Health and Medical Research Institute, Adelaide, Australia
- Aboriginal Health Research Group, Cancer Research Institute, University of South Australia, Adelaide, Australia
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27
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Robotic proctectomy for rectal cancer in the US: a skewed population. Surg Endosc 2019; 34:2651-2656. [PMID: 31372887 DOI: 10.1007/s00464-019-07041-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 07/24/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Socioeconomic and racial differences have been associated with disparities in cancer care within the US, including disparate access to minimally invasive surgery for rectal cancer. We hypothesized that robotic approach to rectal cancer may be associated with similar disparities. METHODS The National Cancer Database (NCDB) was used to identify patients over 18 years old with clinical stage I-III rectal adenocarcinoma who underwent a proctectomy between 2010 and 2014. Demographic and hospital factors were analyzed for association with robotic approach. Factors identified on bivariate analyses informed multivariate analysis. RESULTS We identified 33,503 patients who met inclusion criteria; 3702 (11.1%) underwent robotic surgery with 7.8% conversion rate. Patients who received robotic surgery were more likely to be male, white, privately insured and with stage III cancer. They were also more likely to live in a metropolitan area, more than 25 miles away from the hospital and with a higher high school graduation rate. The treating hospital was more likely to be academic and high volume. CONCLUSIONS Robotic surgery is performed rarely and access to it is limited for patients who are female, black, older, non-privately insured and unable to travel to high-volume teaching institutions. The advantages of robotic surgery may not be available to all patients given disparate access to the robot. This inherent bias in access to robot may skew study populations, preventing generalizability of robotic surgery research.
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28
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Zakka K, Jiang R, Alese OB, Shaib WL, Wu C, Wedd JP, Sellers MT, Behera M, El-Rayes BF, Akce M. Clinical outcomes of rare hepatocellular carcinoma variants compared to pure hepatocellular carcinoma. J Hepatocell Carcinoma 2019; 6:119-129. [PMID: 31413960 PMCID: PMC6660638 DOI: 10.2147/jhc.s215235] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 06/26/2019] [Indexed: 12/12/2022] Open
Abstract
Background HCC variants are rare primary hepatic tumors. The aim of this study is to compare clinical characteristics and outcomes of HCC variants with pure HCC. Methods Patients diagnosed between 2004 and 2013 with ICD-O-3 8180/3 and 8170/3-8175/3 were identified from the National Cancer Database. Univariate and multivariate survival analyses were conducted to analyze the association between histology and overall survival (OS). Results 80,280 patients were identified; pure HCC 78,461 (97.7%), fibrolamellar (FLHCC) 310 (0.4%), scirrhous 161 (0.2%), spindle cell 72 (0.1%), clear cell 487 (0.6%), pleomorphic 23 (0.0%), and combined HCC and cholangiocarcinoma (mixed HCC) 766 (1.0%). 76.7% were male and 72% Caucasian. Liver transplant was performed in 10.1% of pure HCC, 14.5% of mixed HCC, 16.2% of scirrhous, 6.9% of spindle cell, 8.8% of clear cell, 8.7% of pleomorphic, and 3.2% of FLHCC (p<0.001). Pure HCC (10.6%) underwent surgical resection without transplant less often than variants except for scirrhous (9.9%) (p<0.001). More than a third of patients in each histological type received chemotherapy. FLHCC had the best 5-year OS (38.7%), spindle cell and pleomorphic had the worst (9.6% and 13.0%). In multivariate analysis stratified by histology variants, chemotherapy was associated with improved OS in all histologies except for scirrhous and pleomorphic HCC. Conclusion HCC variants underwent surgical resection more often than pure HCC. FLHCC had the best 5-year OS. Liver transplant was commonly performed in HCC variants.
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Affiliation(s)
- Katerina Zakka
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Renjian Jiang
- Department of Research Informatics, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Olatunji B Alese
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Walid L Shaib
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Christina Wu
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Joel P Wedd
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Marty T Sellers
- Division of General and GI Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Madhusmita Behera
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA.,Department of Research Informatics, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Bassel F El-Rayes
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Mehmet Akce
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
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29
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Colton MD, Goulding D, Beltrami A, Cost C, Franklin A, Cockburn MG, Green AL. A U.S. population-based study of insurance disparities in cancer survival among adolescents and young adults. Cancer Med 2019; 8:4867-4874. [PMID: 31240865 PMCID: PMC6712520 DOI: 10.1002/cam4.2230] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 04/04/2019] [Accepted: 04/21/2019] [Indexed: 12/19/2022] Open
Abstract
Background Adolescents and young adults (AYA), patients age 15‐39, may experience worse outcomes than pediatric and adult patients. The aim of this paper was to document survival disparities associated with insurance status across the AYA age continuum in the United States. Methods We utilized the Surveillance, Epidemiologic, and End Results database to identify 66 556 AYA patients between 2007 and 2014 with 10 International Classification of Childhood Cancer diagnoses and calculated the Cox proportional hazard ratios of death for those with public or no insurance status compared to private insurance. The odds ratios of having a late stage of diagnosis by insurance status were also calculated. Results Insurance status was a statistically significant predictor of death for lymphoid leukemia (age 15‐19, 30‐34, and 35‐39), acute myeloid leukemia (age 15‐19 and 25‐29), Hodgkin lymphoma (all ages), non‐Hodgkin lymphoma (age 20‐24, 25‐29, 30‐34, and 35‐39), astrocytomas (age 30‐34), other gliomas (age 25‐29, 30‐34, and 35‐39), hepatic carcinomas (age 25‐29), fibrosarcomas, peripheral nerve and other fibrous tumors (age 30‐34), malignant gonadal germ cell tumors (age 20‐24, 25‐29, 30‐34, and 35‐39), and other and unspecified carcinomas (age 20‐24, 25‐29, 30‐34, and 35‐39), independent of stage at diagnosis. This hazard increased with age for most cancer types. Insurance status strongly predicted the odds of a metastatic cancer diagnosis for lymphoma, fibrosarcomas (age 15‐19), germ cell tumors, and other carcinomas. Conclusions AYA in the US experience disparities in cancer survival based on insurance status, independent of late stage of presentation. Patients age 26‐39 may be especially vulnerable to health outcomes associated with poor socioeconomic status, treatment disparities, and poor access to care.
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Affiliation(s)
- Meryl D Colton
- University of Colorado School of Medicine, Aurora, Colorado
| | | | | | - Carrye Cost
- University of Colorado School of Medicine, Aurora, Colorado.,Children's Hospital Colorado, Aurora, Colorado
| | - Anna Franklin
- University of Colorado School of Medicine, Aurora, Colorado.,Children's Hospital Colorado, Aurora, Colorado
| | - Myles G Cockburn
- University of Colorado School of Medicine, Aurora, Colorado.,Colorado School of Public Health, Aurora, Colorado
| | - Adam L Green
- University of Colorado School of Medicine, Aurora, Colorado.,Children's Hospital Colorado, Aurora, Colorado
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