Underuse of Surgical Resection in Patients with Nonmetastatic Colorectal Cancer: Location, Location, Location
*Nestor F Esnaola1, *Mulugeta Gebregziabher1, *Chris Finney2, *Marvella Ford1
1Medical University of South Carolina, Charleston, SC;2South Carolina Office of Research and Statistics, Charleston, SC
OBJECTIVE(S): Studies have reported potential underuse of surgical resection in black patients with nonmetastatic colorectal cancer. Our objective was to determine the independent, adverse effects of race and tumor location on surgical resection, controlling for comorbidity and socioeconomic/insurance status.
METHODS: All cases of nonmetastatic colon/rectal cancer reported to our state’s Central Cancer Registry from 1996-2002 were identified and linked to Inpatient/Outpatient Surgery Files and the 2000 Census. Comorbidity (Deyo-Charlson Index) was calculated using ICD-9-CM codes and educational level/income were estimated (zip code level) using Census data. Characteristics between whites and blacks were compared using chi-square tests. Odds ratios (OR) of resection were calculated using logistic regression analysis.
RESULTS: We identified 5,590/1,932 white and 1,906/466 black patients with colon/rectal cancer. Blacks were more likely to be younger, not married, rural, less educated, poor, and uninsured/covered by Medicaid compared to whites (all P<.001). Underuse of surgery was far greater among blacks with rectal cancer (82.0% v. 89.3% in whites, P<0.001) compared to blacks with colon cancer (92.9% v. 94.5% in whites, P<0.001). After controlling for tumor location and comorbidity/socioeconomic/insurance status, the adjusted OR (95% CI) for resection for blacks with colon cancer and poor blacks with rectal cancer were 0.67 (0.51-0.88) and 0.20 (0.07-0.57), respectively.
CONCLUSIONS: Black race is a particularly powerful predictor of underuse of surgery in poor patients with rectal cancer. It is incumbent on the gastroenterology/surgical community to determine whether misperceptions about rectal surgery or barriers to successfully navigating multidisciplinary, rectal cancer care may account for these disparities.