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Abstract
Approximately 38% of patients with advanced colorectal cancer do not receive chemotherapy. To determine whether cumulative social risk (ie, multiple co-occurring sociodemographic risk factors) is associated with lower receipt of chemotherapy among patients with advanced colorectal cancer and whether social support would moderate this association. This cross-sectional, population-based, mailed survey study was conducted from 2012 to 2014. Participants were recruited between 2011 and 2014 from all adults within 1 year after diagnosis of stage III colorectal cancer in the Detroit, Michigan, and State of Georgia Surveillance, Epidemiology, End-Results cancer registries. Patients were eligible if they were aged 18 years or older, had undergone surgery 4 or more months ago, did not have stage IV cancer, and resided in the registry catchment areas. Data analyses were conducted from March 2017 to April 2021. The primary outcome was receipt of chemotherapy. Cumulative social risk represented a sum of 8 risk factors with the potential to drain resources from participants' cancer treatment (marital status, employment, annual income, health insurance, comorbidities, health literacy, adult caregiving, and perceived discrimination). Social support was operationalized as emotional support related to colorectal cancer diagnosis. Surveys were mailed to 1909 eligible patients; 1301 completed the survey (response rate, 68%). A total of 1087 participants with complete data for key variables were included in the sample (503 women [46%]; mean [SD] age, 64 [13] years). Participants with 3 or more risk factors were less likely to receive chemotherapy than participants with 0 risk factors (3 factors, odds ratio [OR], 0.48 [95% CI, 0.26-0.87]; 4 factors, OR, 0.41 [95% CI, 0.21-0.78]; 5 factors, OR, 0.42 [95% CI, 0.20-0.87]; ≥6 factors, OR, 0.22 [95% CI, 0.09-0.55]). Participants with 2 or more support sources had higher odds of undergoing chemotherapy than those without social support (2 sources, OR, 3.05 [95% CI, 1.36-6.85]; 3 sources, OR, 3.24 [95% CI, 1.48-7.08]; 4 sources, OR, 3.69 [95% CI, 1.71-7.97]; 5 sources, OR, 4.40 [95% CI, 1.98-9.75]; ≥6 sources, OR 5.95 [95% CI, 2.58-13.74]). Within each social support level, participants were less likely to receive chemotherapy as cumulative social risk increased. Cumulative social risk was associated with reduced receipt of chemotherapy. These associations were mitigated by social support. Assessing cumulative social risk may identify patients with colorectal cancer who are at higher risk for omitting chemotherapy who can be targeted for support programs to address social disadvantage and increase social support.
Highlights
Adjuvant chemotherapy after surgery among patients with stage III colorectal cancer (CRC) is associated with up to a 30% increase in 5-year survival rates.[1,2,3] Yet, among the 40 000 US individuals with recent diagnoses of stage III CRC,[4] approximately 38% will not receive adjuvant chemotherapy, with no discernable clinical rationale.[5,6,7,8] Patients need resources to accommodate the physical, financial, cognitive, and emotional demands of chemotherapy, and health, demographic, and social factors may deter chemotherapy initiation among patients with CRC
Assessing cumulative social risk may identify patients with colorectal cancer who are at higher risk for omitting chemotherapy who can be targeted for support programs to address social disadvantage and increase social support
The association of cumulative social risk with chemotherapy receipt was moderated by access to social support. Meaning These findings suggest that assessing cumulative social risk may identify patients with advanced colorectal cancer who are at higher risk for omitting chemotherapy
Summary
Adjuvant chemotherapy after surgery among patients with stage III colorectal cancer (CRC) is associated with up to a 30% increase in 5-year survival rates.[1,2,3] Yet, among the 40 000 US individuals with recent diagnoses of stage III CRC,[4] approximately 38% will not receive adjuvant chemotherapy, with no discernable clinical rationale.[5,6,7,8] Patients need resources to accommodate the physical, financial, cognitive, and emotional demands of chemotherapy, and health, demographic, and social factors may deter chemotherapy initiation among patients with CRC. With few exceptions,[9,10] studies have found lower rates of chemotherapy receipt among Black patients compared with White patients with CRC, perhaps because of economic and social disadvantage.[6,11,12,13,14,15,16] Patients with lower income or health literacy levels are less likely to receive chemotherapy.[11,17,18,19,20] The association of perceived discrimination, owing to race or other characteristics, with chemotherapy or other treatment uptake are unknown, but previous studies suggest that there is an association between discrimination and reduced CRC screening.[21,22] To our knowledge, no preexisting research has examined the cumulative associations of multiple, co-occurring social risk factors with chemotherapy receipt for CRC, which may serve as more powerful deterrents than a single barrier alone
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