Impact of socioeconomics on recurrences and survival in non-metastasized colorectal cancer.

BackgroundColorectal cancer prognosis varies substantially with socioeconomic status. We investigated differences in life expectancy between socioeconomic groups and estimated the potential gain in life-years if cancer-related survival differences could be eliminated.MethodsThis population-based study included 470,000 individuals diagnosed with colon and rectal cancers between 1998 and 2013 in England. Using flexible parametric survival models, we obtained a range of life expectancy measures by deprivation status. The number of life-years that could be gained if differences in cancer-related survival between the least and most deprived groups were removed was also estimated.ResultsWe observed up to 10% points differences in 5-year relative survival between the least and most deprived. If these differences had been eliminated for colon and rectal cancers diagnosed in 2013 then almost 8231 and 7295 life-years would have been gained respectively. This results for instance in more than 1-year gain for each colon cancer male patient in the most deprived group on average. Cancer-related differences are more profound earlier on, as conditioning on 1-year survival the main reason for socioeconomic differences were factors other than cancer.ConclusionThis study highlights the importance of policies to eliminate socioeconomic differences in cancer survival as in this way many life-years could be gained.

Racial disparities in colorectal cancer (CRC) persist, despite overall reductions in morbidity and mortality. In addition, incidence is rising among individuals younger than 50 years of age. We compared the survival of young-onset CRC among non-Hispanic black (NHB), non-Hispanic white (NHW), and Hispanic individuals. Using the National Cancer Institute's Surveillance, Epidemiology, and End Results program data, we identified individuals between the ages of 20 and 49 years, diagnosed with CRC between 2000 and 2009. Survival rates and Cox proportional hazards models were used to compare stage-specific 5-year survival among NHBs, NHWs, and Hispanics. We identified 28,145 patients with young-onset CRC (19,497 NHW; 4,384 NHB; 4,264 Hispanic) during the 10-year study period. Overall survival at 5 years after CRC diagnosis was 54.9% among NHB, 68.1% among NHW, and 62.9% among Hispanic individuals (P < .001). NHB individuals had a significantly higher hazard of cancer-specific death compared with NHWs after adjusting for age, sex, race, stage, county-level poverty, and treatment history in cases of colon (hazard ratio [HR], 1.35; 95% CI 1.26 to 1.45) and rectum/rectosigmoid junction (HR, 1.51; 95% CI, 1.37 to 1.68) cancers, whereas there was no significant difference in survival between NHWs and Hispanics. The greatest racial disparities in cancer-specific survival were observed among NHB and NHW patients diagnosed with stage II cancers of the colon (HR, 1.69; 95% CI, 1.33 to 2.14) and stage III cancers of the rectum (HR, 1.98; 95% CI, 1.63 to 2.40). Survival after CRC diagnosis at a young age is significantly worse among NHBs compared with NHWs, even among patients with early-stage disease. Further study is needed to determine whether differences in tumor biology and/or treatment are associated with racial disparities in outcomes, which would have implications for CRC treatment and prevention.

Background: According to the Surveillance, Epidemiology, and End Results Program, the annual percent change in colorectal cancer (CRC) incidence increased by 3.6% from 2013 to 2016 in individuals less than 50 years of age. Data on survival after young onset CRC diagnosis, including differences by sociodemographic characteristics, are lacking. We assessed differences in CRC survival according to sociodemographic factors, including race/ethnicity, sex, health insurance type, and neighborhood socioeconomic status (nSES) in patients under the age of 50 years at CRC diagnosis. Methods: The study included male and female CRC cancer cases under 50 years old, diagnosed from 2000-2015 and followed through 2016 in the California Cancer Registry. Analysis included 21,128 patients and 6,269 CRC deaths. Multivariable Cox proportional hazards regression was used to generate hazard ratios (HR) and 95% confidence intervals (CI) for risk of CRC-specific mortality. Multivariable models were stratified by American Joint Committee on Cancer (AJCC) stage (to account for hazard non-proportionality), and adjusted for age at diagnosis, year of diagnosis, race, sex, tumor size, tumor subsite, tumor grade, marital status, insurance status type, NCI-designated cancer center, nSES, neighborhood percent NH black, urban/rural, and clustering by block group. Results: Compared to non-Hispanic Whites (NHW), risk of dying from CRC was higher in Blacks (HR=1.21; 95% CI, 1.09-1.34) but not in Hispanics (HR=0.98; 95% CI, 0.92-1.05) nor Asian/Pacific Islanders (API) (HR=1.03; 95% CI, 0.96-1.11). CRC mortality was lower in female compared to male patients (HR=0.87; 95% CI, 0.83-0.92). Higher CRC mortality was observed for patients on Medicaid (HR=1.41; 95% CI, 1.31-1.50) and those with no insurance HR=1.32; 95% CI, 1.15-1.52), as compared to privately insured patients. An increase in CRC mortality associated with lower nSES was observed (HR=1.39; 95% CI, 1.25-1.54 for lowest compared to highest statewide quintile; P-trend &amp;lt;0.0001). Conclusion: Results corroborate recent reported disparities in young-onset CRC survival between Blacks and Whites. Our findings further point to higher mortality in patients who are not privately insured and those living in lower SES neighborhoods. Further studies that integrate biological and molecular factors are needed to advance our understanding of CRC mortality in younger patients. Citation Format: Maria Elena Martinez, Scarlett Lin Gomez, Alison J Canchola, James D Murphy, Joshua Demb, Jesse N Nodora, Samir Gupta. Disparities in survival by sociodemographic factors among patients with young-onset colorectal cancer: A population-based study [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr B133.

The prognostic value of positive intraoperative peritoneal cytology and lavage cytology, including the differences in their prognostic impact, in colorectal cancer is controversial. We aimed to investigate the prognostic values of positive peritoneal cytology and lavage cytology findings for colorectal cancer and compare their prognostic impact. We retrospectively evaluated 592 clinical stage II-IV colorectal cancer patients who underwent peritoneal cytology (n = 225) or lavage cytology (n = 367) between November 1993 and December 2018. The prognostic factors for cancer-specific survival were identified, and the differences in cancer-specific survival were examined between the patients. The cytology-positive rate was 10.8% (64/592), 17.8% (40/225), and 6.5% (24/367) in the overall, peritoneal cytology, and lavage cytology groups, respectively. Both positive peritoneal cytology (hazard ratio: 2.196) and lavage cytology (hazard ratio: 2.319) were independent prognostic factors. The peritoneal cytology-positive group showed significantly poorer cancer-specific survival than the cytology-negative group (5-year: 3.5% vs. 59.5%; 10-year: 3.5% vs. 46.1%, p < 0.001). Similar results were obtained for lavage cytology (5-year: 14.1% vs. 73.9%; 10-year: 4.7% vs. 63.5%, p < 0.001). The cancer-specific survival was not significantly different between the peritoneal cytology-positive and lavage cytology-positive groups (p = 0.058). Both positive peritoneal and lavage cytology were associated with poorer cancer-specific survival across all colorectal cancer stages. Positive peritoneal and lavage cytology are associated with worse cancer-specific survival in colorectal cancer. The prognostic impact was comparable between positive lavage and peritoneal cytology. Thus, cytology should be a standard assessment modality for colorectal cancer.

The burden of cancer on the diverse U.S. population is not equal. Enduring disparities in survival persist by social determinants of health (SDOH) including race/ethnicity, nativity, individual and contextual socioeconomic status (SES), and marital status. To accurately target cancer control initiatives to patients with the greatest need, it is vital to know where disparities in survival occur. The cancer survival atlas aims to systematically identify disparities in cancer survival in the state of California, applying an intersectional approach to examine disparities jointly by sex and SDOH factors including race/ethnicity, nativity, health insurance, marital status, and neighborhood SES. The atlas will provide the necessary epidemiological underpinning for future initiatives focused on improving outcomes in disadvantaged and under-served populations. Statewide population-based cancer registry data, enhanced with complete nativity and neighborhood characteristics, was used to produce cancer-specific survival at 1-, 3-, 5- and 10-years for all patients diagnosed between the year 2000 and 2013 with one of the five most common cancers in the state (breast, prostate, lung, colorectal and melanoma). Population groups were defined by sex, age, marital status, race/ethnicity (non-Hispanic White, Hispanic, Black, and Asian American &amp; Pacific Islander (AAPI) ethnic groups), nativity, health insurance, and neighborhood SES. Neighborhood SES was assigned to cases based on residential block group, based on principal components analyses derived indices from 2000 Census or 2007-2011 American Community Survey data, and categorized according to statewide quintiles. Age and stage-adjusted survival probabilities were estimated, then multivariable Cox Proportional Hazard models were used to investigate the relative contribution of factors associated with survival and to adjust for confounders. We found considerable socioeconomic and racial/ethnic disparities in survival for all five cancer sites examined, with the largest disparities seen for cancers with a good prognosis (breast, prostate, melanoma), and by health insurance status of all of the SDOH factors. For breast cancer, women residing in neighborhoods with the lowest SES quintile had significantly poorer cancer-specific survival than women in the highest SES quintile (hazard ratio (HR) = 1.53 (95% CI 1.47-1.61), adjusting for stage, health insurance, race/ethnicity). The largest racial/ethnic disparities were also seen in breast cancer. Non-Hispanic Black women had the lowest survival (HR = 1.50 (95% CI 1.44-1.56)), and AAPI women the highest (HR = 0.85 (95% CI 0.81-0.89)) compared to Non-Hispanic White women. Differences in survival by health insurance status were also evident for all five cancers. For melanoma, survival was substantially lower among men with no health insurance (HR = 1.89 (95% CI 1.57-2.26)) and among men with public, military or Medicaid insurance (HR = 1.40 (95% CI 1.29-1.52)) compared to men with private insurance. Disparities in survival by health insurance status were present across all socioeconomic and racial/ethnic groups. Disparities in survival among groups defined by SDOH factors in California are substantial. These results will serve as a resource for the targeting and development of interventions, such as early diagnosis initiatives, to address the needs of specific population groups in California. Citation Format: Elizabeth Ellis, Scarlett L. Gomez. Atlas of disparities in cancer survival in California: An intersectional approach. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr A78.

The association between anaesthetic technique and cancer specific survival following surgical resection of non-small cell lung cancer

Non-Hispanic Black (NHB) Americans have a higher incidence of colorectal cancer (CRC) and worse survival than non-Hispanic white (NHW) Americans, but the relative contributions of biological versus access to care remain poorly characterized. This study used two nationwide cohorts in different healthcare contexts to study health system effects on this disparity. We used data from the Surveillance, Epidemiology, and End Results (SEER) registry as well as the United States Veterans Health Administration (VA) to identify adults diagnosed with colorectal cancer between 2010 and 2020 who identified as non-Hispanic Black (NHB) or non-Hispanic white (NHW). Stratified survival analyses were performed using a primary endpoint of overall survival, and sensitivity analyses were performed using cancer-specific survival. We identified 263,893 CRC patients in the SEER registry (36,662 (14%) NHB; 226,271 (86%) NHW) and 24,375 VA patients (4,860 (20%) NHB; 19,515 (80%) NHW). In the SEER registry, NHB patients had worse OS than NHW patients: median OS of 57 months (95% confidence interval (CI) 55-58) versus 72 months (95% CI 71-73) (hazard ratio (HR) 1.14, 95% CI 1.12-1.15, p = 0.001). In contrast, VA NHB median OS was 65 months (95% CI 62-69) versus NHW 69 months (95% CI 97-71) (HR 1.02, 95% CI 0.98-1.07, p = 0.375). There was significant interaction in the SEER registry between race and Medicare age eligibility (p < 0.001); NHB race had more effect in patients <65 years old (HR 1.44, 95% CI 1.39-1.49, p < 0.001) than in those ≥65 (HR 1.13, 95% CI 1.11-1.15, p < 0.001). In the VA, age stratification was not significant (p = 0.21). Racial disparities in CRC survival in the general US population are significantly attenuated in Medicare-aged patients. This pattern is not present in the VA, suggesting that access to care may be an important component of racial disparities in this disease.

BackgroundStudies have indicated that statins influence the risks and mortality rates of several types of solid tumors. However, the association between statin use and survival in patients with colorectal cancer (CRC) remains unclear.MethodsWe searched the PubMed and Embase databases for relevant studies published up to September 2014 that assessed statin use and CRC prognosis. The primary outcomes were overall survival (OS) and cancer-specific survival (CSS). The secondary outcomes were disease-free survival (DFS) and recurrence-free survival (RFS). Hazard ratios (HRs) and 95% confidence intervals (CIs) were extracted and pooled with Mantel–Haenszel random-effect modeling. All statistical tests were two-sided.ResultsFour studies on post-diagnosis statin therapy and five studies on pre-diagnosis statin use were included in our meta-analysis of 70,608 patients. Compared with the non-users, the patients with post-diagnosis statin use gained survival benefits for OS (HR 0.76; 95% CI: 0.68 to 0.85, P<0.001) and CSS (HR 0.70; 95% CI: 0.60 to 0.81, P<0.001). In addition, we observed that pre-diagnosis statin use prolonged the survival of patients with CRC for OS (HR 0.70; 95% CI: 0.54 to 0.91, P=0.007) and CSS (HR 0.80; 95% CI: 0.74 to 0.86, P<0.001). However, we did not observe a survival benefit for DFS (HR 1.13; 95% CI: 0.78 to 1.62, P=0.514) or RFS (HR 0.98; 95% CI: 0.36 to 2.70, P=0.975) in the CRC patients with post-diagnosis statin use.ConclusionsStatin use before or after cancer diagnosis is related to reductions in overall and cancer-specific mortality in colorectal cancer survivors.

Purpose: Population-based studies indicated that prognosis of pancreatic adenocarcinoma (PAC) is worse in black patients compared to other races. Nonetheless, survival probabilities can change over time based on number of years (yr.) already survived by patients; a concept called conditional survival. This study explored the dynamic changes in risk according to patient characteristics, particularly race, on survival of PAC patients using cancer-specific survival (CSS) estimates. Methods: The Surveillance, Epidemiology, and End Results (SEER) database was queried for data on adult patients with non-metastatic PAC, diagnosed between 1988 and 2010. Patient characteristics, such as age, race, tumor grade, and stage were collected at the time of diagnosis. CSS probabilities, as well as Cox proportional hazard ratios (HRs), were computed at the time of diagnosis (Actuarial CSS and baseline HR), and after already surviving 1 to 6 yr. after diagnosis (Conditional CSS and HR). Harrell’s concordance index (C-index) was used to measure the cross-validation accuracy of the Cox models. Results: Our search retrieved data on 20,491 patients, with a mean age at diagnosis of 67.2 yr. Most of the patients were White (81.6%), followed by Black (12%) and Asians/Pacific Islander (6.4%). The stage was T1-2N0M0 in 15.9%, T3-4N0M0 in 41.8%, and T1-4N1M0 in 42.3% of patients. The 3-yr actuarial CSS calculated from time of diagnosis was significantly different across racial groups, at 11%, 10%, and 13% for Whites, Blacks, and Asians, respectively (P &amp;lt; 0.01). Conversely, for patients who already survived 1 yr. after diagnosis, the probability of surviving an additional 2 yr. was similar across races, at 26.2%, 27.1%, and 29.9%, for Whites, Blacks, and Asians, respectively (P = 0.218). As patients survived for longer periods of time following diagnosis, conditional CSS estimates increased similarly across different races; for White, Black, and Asian patients who already survived 3 yr. after diagnosis, the probability of surviving an additional 2 yr. was 62.6%, 60.5%, and 62.1%, respectively (P = 0.532). In multivariate cox models, the prognostic effect of race lost significance if patients already survived ≥1 yr. after diagnosis (Baseline HR = 1.114, 95%CI [1.045- 1.187], mean C-index = 67%; conditional HR at 1 yr = 1.015, 95%CI [0.919- 1.12], mean C-index = 60%). The prognostic effect of tumor grade, site, and age lost significance if patients already survived ≥2, ≥4, and ≥6 yr. after diagnosis, respectively. Tumor stage maintained its prognostic significance over time (conditional HR at 6 yr = 1.522, 95%CI [1.049- 2.208], mean C-index = 59%). Conclusion: Racial disparities in survival outcomes exist at the time of diagnosis for PAC patients. However, the survival impact of these disparities does not seem to persist over time. Other variables, such as age, tumor grade, stage, and treatment received should be taken into account when predicting future prognosis of PAC patients who have already survived ≥ 1 yr. after diagnosis. Citation Format: Anas M Saad, Maha AT Elsebaie, Mohamed Amgad, Muneer J Al-Husseini, Kyrillus S Shohdy, Omar Abdel-Rahman. Racial disparities in pancreatic adenocarcinoma survival. Do they exist for patients who already survived their first year? [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr B110.

BackgroundInequalities in survival from colorectal cancer (CRC) across socioeconomic groups and by area of residence have been described in various health care settings. Few population-wide datasets which include clinical and treatment information are available in Australia to investigate disparities. This study examines socio-demographic differences in survival for CRC patients in South Australia (SA), using a population-wide database derived via linkage of administrative and surveillance datasets. MethodsThe study population comprised all cases of CRC diagnosed in 2003-2008 among SA residents aged 50-79 yrs in the SA Central Cancer Registry. Measures of socioeconomic status (area level), geographical remoteness, clinical characteristics, comorbid conditions, treatments and outcomes were derived through record linkage of central cancer registry, hospital-based clinical registries, hospital separations, and radiotherapy services data sources. Socio-demographic disparities in CRC survival were examined using competing risk regression analysis.ResultsFour thousand six hundred and forty one eligible cases were followed for an average of 4.7 yrs, during which time 1525 died from CRC and 416 died from other causes. Results of competing risk regression indicated higher risk of CRC death with higher grade (HR high v low =2.25, 95 % CI 1.32-3.84), later stage (HR C v A = 7.74, 95 % CI 5.75-10.4), severe comorbidity (HR severe v none =1.21, 95 % CI 1.02-1.44) and receiving radiotherapy (HR = 1.41, 95 % CI 1.18-1.68). Patients from the most socioeconomically advantaged areas had significantly better outcomes than those from the least advantaged areas (HR =0.75, 95 % 0.62-0.91). Patients residing in remote locations had significantly worse outcomes than metropolitan residents, though this was only evident for stages A-C (HR = 1.35, 95 % CI 1.01-1.80). These disparities were not explained by differences in stage at diagnosis between socioeconomic groups or area of residence. Nor were they explained by differences in patient factors, other tumour characteristics, comorbidity, or treatment modalities.ConclusionsSocio-economic and regional disparities in survival following CRC are evident in SA, despite having a universal health care system. Of particular concern is the poorer survival for patients from remote areas with potentially curable CRC. Reasons for these disparities require further exploration to identify factors that can be addressed to improve outcomes.

A systematic review and meta-analysis assessing the impact of body mass index on long-term survival outcomes after surgery for colorectal cancer

Gender differences in the prognosis of colorectal cancer (CRC) remain controversial. The aim of this study was to complete a comprehensive analysis of gender differences in CRC survival derived from population registries in Taiwan. We analyzed survival data for patients diagnosed with CRC between 1998 and 2005 derived from the Taiwan Cancer Registry database. During this time period, 65,113 patients were registered, and 62,060 patients were eligible. Gender differences in overall survival and cancer-specific survival were analyzed by use of the Kaplan-Meier method. We then modeled the risk in different genders by use of a multivariate proportional hazard (Cox) model adjusting for possible confounders of survival. The 5-year period overall and cancer-specific survivals were significantly higher in women than in men [51.84% (95% confidence interval (CI), 51.22-52.46) vs. 47.68% (95% CI, 47.14-48.22), log-rank p < 0.001; and 56.44% (95% CI, 55.82-57.07) vs. 53.47 % (95 % CI, 52.92-54.01), log-rank p < 0.001, respectively]. Subgroup analysis revealed higher overall and cancer-specific survivals in women between 50 and 80 years age and those with adenocarcinomas (p < 0.001). By use of Cox modeling, we noted a decreased hazard ratio (HR) for death from CRC in women compared with men (HR, 0.820-0.971), especially in the 50-80-year age group. All estimated HRs, after adjusting for age, tumor histology, and tumor site, had significant trends of a decreasing risk of death from CRC in women. Our findings suggest that overall and cancer-specific survival advantage was most evident in women between 50 and 80 years of age.

Several observational studies have shown that metformin can modify the risk and survival of colorectal cancer (CRC) in patients with diabetes mellitus, although the magnitude of this relationship has not been determined. We conducted an updated systematic review and meta-analysis to analyze the association between metformin and CRC mortality and searched relevant databases up to July 2016. The primary outcome was overall survival (OS). Secondary outcomes were cancer-specific survival (CS) and disease-free survival (DFS). Summary hazard ratios (HRs) were calculated using a random-effects model. Seventeen studies enrolling 269,417 participants were eligible for inclusion. Comparing with non-metformin users in diabetic CRC patients, the summary HRs for OS in metformin users were 0.69 (95% CI, 0.61-0.77). Subgroup analyses stratified by the study characteristics and sensitivity analysis by the trim-and-fill method (adjusted HR 0.77, 95% CI, 0.67-0.87) confirmed the robustness of the results. However, significant OS benefit was noted in patients with stage II and III disease. Five studies reported the CRC prognosis for CS and three for DFS; metformin intake was significantly associated with patient CS (HR 0.75, 95% CI, 0.59-0.94), but not DFS (HR 0.38, 95% CI, 0.13-1.17). Our findings suggest that metformin intake is associated with improved survival outcomes in terms of OS and CS in CRC patients with diabetes, particular for OS in stage II and stage III patients. Further studies should be conducted to determine CRC survival between metformin use and patient specific clinical and molecular profiles.

Gender Specific Differences in Disease-Free, Cancer Specific and Overall Survival after Radical Cystectomy for Bladder Cancer: A Systematic Review and Meta-Analysis

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