Abstract
162 Background: Studies using cancer registry data have shown that cancer patients living in socioeconomically disadvantaged areas have worse cancer outcomes. Socioeconomic deprivation (SD) has not been systematically examined in clinical trial patients, who are uniformly staged according to trial eligibility criteria and have access to protocol-directed care. Methods: We examined survival for patients enrolled in phase III clinical trials for all major cancers conducted by SWOG from 1985-2012. SD was measured using trial participant’s residence zip codes linked to the Area Deprivation Index (ADI) , a comprehensive index composed of 17 indicators reflecting a diverse set of socioeconomic variables, scored from 0-100, split into quintiles. Five-year overall survival (OS), progression-free survival (PFS), and cancer-specific survival (CSS) were examined using Cox regression, adjusting for age (in 5 year intervals), sex, race (black v. non-black), and, for a subset of patients, insurance status (Medicaid/no insurance v. other). Analyses were stratified by cancer histology and stage. Results: In total, n = 41,182 patients from 55 trials comprising 24 cancer histology and stage-specific strata were examined. Compared to trial participants in the most affluent areas (ADI 0%-20%), trial participants from areas with the highest SD (ADI 80%-100%) had worse OS (HR = 1.26, 95% CI, 1.18-1.35, p < .001), PFS (HR = 1.19, 95% CI, 1.12-1.27, p < .001) and CSS (HR = 1.25, 95% CI, 1.17-1.35, p < .001). Results were similar after also adjusting for insurance status. For each outcome, there was a continuous increase in risk of an event as the ADI quintile increased. Conclusions: In cancer patients with access to protocol-directed care in clinical trials, area-level SD was associated with worse survival, even after adjusting for patient-level race and insurance. Future research should examine whether the etiology of this residual disparity is related to reduced access to supportive care or post-protocol therapy, and/or to differences in health status not reflected by protocol staging criteria. Policies to mitigate socioeconomic differences in cancer outcomes should emphasize access to cancer care services beyond initial therapy.
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