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Sociodemographic factors associated with stage of diagnosis and treatment uptake among patients with colorectal cancer: A brief report
Journal of Cancer Policy 12 (2017) 79–82
Contents lists available at ScienceDirect
Journal of Cancer Policy journal homepage: www.elsevier.com/locate/jcpo
Sociodemographic factors associated with stage of diagnosis and treatment uptake among patients with colorectal cancer: A brief report Nicole M. Cranley a,∗ , Hannah Crooke b , Thomas J. George Jr. c a
Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA Department of Epidemiology, College of Public Health and Health Professions, College of Medicine, University of Florida, Gainesville, FL, USA c Division of Hematology and Oncology, Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA b
a r t i c l e
i n f o
Article history: Received 1 November 2016 Accepted 8 March 2017 Available online 20 March 2017 Keywords: Cancer Colorectal cancer Decision making Treatment Diagnosis Health disparities
a b s t r a c t Introduction: Previous research has indicated the presence of sociodemographic differences in disease stage at diagnosis and treatment uptake among patients with colorectal cancer (CRC). Patients that identify as black, being female and older age are associated with a decreased uptake of therapeutic options, however these findings are inconsistent in the literature. The purpose of this analysis was to examine the presence of sociodemographic disparities in disease stage and diagnosis and subsequent treatment uptake among patients with CRC. Materials & methods: This secondary data analysis was conducted utilizing a tumor registry database from a academic cancer center with data from patients with diagnosed adenocarcinoma of the colon, rectum or rectosigmoid junction (n = 524) from May 2009 to May 2014. Diagnosed disease stage and treatment uptake differences were assessed among sociodemographic groups. Results: Analyses showed that being female and decreased age were significantly associated with more advanced diagnosed disease stage. There were no significant sociodemographic predictors associated with patients who received treatment versus those who did not. Additionally, there were no significant differences by sociodemographic factors for treatment type. Conclusions: Sociodemographic disparities were present among women and younger patients related to disease stage at diagnosis. Future research is needed to corroborate the presence of and psychosocial mechanisms behind disparities in diagnosis and treatment uptake among patients with CRC. Published by Elsevier Ltd.
1. Introduction Colorectal cancer (CRC) is the third most commonly diagnosed cancer type and third leading cause of cancer death [1]. Within the last decade research has shown that there are racial, age, gender and socioeconomic disparities in cancer diagnosis, treatment and care. In 2015, CRC diagnosis accounted for 10% and 11% of all diagnosed cancer cases among black women and men, respectively. Along with being diagnosed at higher rates (65.1 compared to 52.8, rate ratio = 1.23), black men are also at a significantly higher risk of death compared to white men (rate ratio = 1.53) (all rates are per 100,000) [1,2]. Importantly, the gap in mortality rates for black and whites has not only lingered, but it has increased since the 1970s
∗ Corresponding author. Tel.: +1 919 966 9334x9. E-mail addresses: [email protected] (N.M. Cranley), hcrooke@ufl.edu (H. Crooke), [email protected]fl.edu (T.J. George Jr.). http://dx.doi.org/10.1016/j.jcpo.2017.03.001 2213-5383/Published by Elsevier Ltd.
[1,2]. According to the American Cancer Society (ACS), in 2007 CRC mortality rates were 44% higher among black compared to whites. Additionally, black were significantly less likely to receive a diagnosis of localized disease, more likely to receive a diagnosis of distant disease and more likely to be diagnosed and die at younger ages [1,3,4]. One study found that black patients had higher mortality rates from CRC after controlling for sex, age, tumor stage and grade [5]. Regarding treatment, blacks and whites are equally likely to have a consultation with a medical oncologist, but blacks are significantly less likely to receive further treatment. Despite a significant improvement in survival from the use of adjuvant therapy in CRC, approximately 33.5% of black patients refused adjuvant chemotherapy compared to 21% of whites. This disparity was largest among blacks between the ages of 66–70 [4]. Disparities in the uptake of adjuvant chemotherapy have been shown among older patients [6], women [7,8], blacks and patients who are unmarried [9]. Additionally, patients with lower incomes and patients who are insured
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Table 1 Sociodemographics, treatment status, and cancer site for the total sample and by disease stage. Total sample (n = 524)
Disease stage 0 (n = 22)
Mean age (SD)†
62.2 (13.3)
1 (n = 114)
2 (n = 103)
3 (n = 135)
4 (n = 127)
63.6 (13.0)
64.3 (12.5)
64.2 (11.8)
59.7 (13.1)
59.8 (13.1)
Sex Male Female
252 (48.1%) 272 (51.9%)
14 (63.6%) 8 (36.6%)
61 (53.5%) 53 (46.5%)
54 (52.4%) 49 (47.6%)
74 (54.8%) 61 (45.2%)
59 (46.5%) 68 (53.5%)
Race* White Black
422 (81.5%) 96 (18.5%)
20 (90.9%) 2 (9.1%)
97 (86.6%) 15 (13.4%)
88 (86.3%) 14 (13.7%)
105 (78.4%) 29 (21.6%)
98 (77.2%) 29 (22.8%)
Marital status* Single Married Divorced/widowed/separated
137 (26.8%) 264 (51.6%) 110 (21.5%)
5 (23.8%) 14 (66.7%) 2 (49.5%)
25 (22.5%) 57 (51.4%) 29 (26.1%)
19 (18.8%) 61 (60.4%) 21 (20.8%)
45 (33.8%) 66 (49.6%) 22 (16.5%)
35 (28.2%) 57 (45.9%) 32 (25.8%)
Insurance status* Uninsured Public insurance Private insurance
48 (9.2%) 310 (59.5%) 163 (31.3%)
2 (9.1%) 14 (63.6%) 6 (27.3%)
8 (7.0%) 68 (59.6%) 38 (33.3%)
10 (9.8%) 63 (61.7%) 29 (28.4%)
16 (11.6%) 77 (57.0%) 42 (31.1%)
9 (7.1%) 74 (58.3%) 44 (34.6%)
3 (13.6%) 19 (86.3%)
6 (5.2%) 108 (94.7%)
6 (5.8%) 97 (94.2%)
2 (1.5%) 133 (98.5%)
23 (18.1%) 104 (81.9%)
13 (59.1%) 6 (27.3%) 3 (13.6%)
61 (53.5%) 45 (39.5%) 8 (7.0%)
58 (56.3%) 36 (34.9%) 9 (8.7%)
78 (57.8%) 44 (32.6%) 13 (9.6%)
92 (72.4%) 24 (18.9%) 11 (8.6%)
0.0049 0.1227
0.1388
0.0841
0.9027
Treatment received* No Yes Cancer site* Colon Rectum Rectosigmoid junction
p-Value
<0.0001
<0.0001 315 (60.1%) 163 (31.1%) 46 (8.9%)
Values shown in bold are significant findings. * Fisher’s exact test used. † Two-sided t-test used.
through Medicaid are less likely to receive adjuvant therapies [9]. Bradley et al. found that patients with Medicaid coverage were less likely to initiate and complete adjuvant therapy, and also less likely to be evaluated by a medical oncologist [10]. However, previous research also found that race was not associated with adjuvant therapy uptake among patients with CRC after controlling for sex, age and insurance status [5]. The purpose of this analysis was to add to the existing body of literature and examine the presence of sociodemographic disparities in disease stage at diagnosis and subsequent treatment uptake among patients with CRC. 2. Methods 2.1. Sample Secondary data analysis was conducted utilizing a tumor registry database at the University of Florida Health Care System. Analysis included all patients, 18 years and older, diagnosed with adenocarcinoma of the colon, rectum or rectosigmoid junction between May 1, 2009 and May 1, 2014. Data used in this analysis is publically available, pre de-identified data therefore IRB approval was not required. 2.2. Measures Patient pathologic staging was categorized as stage 0–4. Treatment uptake was categorized as patients who received treatment versus patients who did not. Treatment type was categorized as surgery only, surgery and adjuvant therapy, no treatment, and other treatment. Demographic variables assessed included, sex, age, race/ethnicity, gender, marital status, and insurance type. Race was dichotomized to white and black due to the low prevalence of other races in the sample population. Insurance type was characterized into three groups: (1) no insurance/self-pay, (2) public
insurance (i.e. medicare/medicaid/veterans affairs) and (3) private insurance. 2.3. Analysis Differences in age, sex, race, marital status, and cancer location were examined across treatment groups (treatment received versus no treatment received), and across disease stage (0–4) using chi-square tests (Fisher’s Exact used where appropriate). ANOVA and two-sided t-tests were used to compare mean ages across groups. Finally, a multiple linear regression model was used to identify independent factors associated with disease stage at diagnosis, and a logistic regression model was used to identify independent factors associated with treatment type. The data analysis for this paper was generated using SAS software (SAS Institute Inc., Cary, NC, USA). 3. Results 3.1. Patient characteristics Table 1 gives the sociodemographic characteristics of the overall patient sample (n = 524) along with the overall prevalence of each disease stage and treatment uptake. The mean age of patients was 62.2 (SD = 13.3). The majority of patients were white/Caucasian (81.5%) and married (51.6%). Over half had public insurance (59.3%), while 9.2% of patients were uninsured. Most patients had a colon cancer diagnosis (60.1%) with a fairly equal distribution of patients by disease stage 1–4. 3.2. Differences in stage at diagnosis Table 1 also shows the sociodemographic factors associated with disease stage at diagnosis. Overall, average patient age sig-
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81
Table 2 Sociodemographics, cancer stage, and cancer site by treatment group. No treatment received (n = 53)
Treatment received (n = 470)
Mean age (SD)†
69.3 (14.5)
Sex Male Female
26 (49.1%) 27 (50.9%)
245 (52.1%) 225 (47.9%)
Race White Black
39 (76.5%) 12 (23.5%)
383 (82.2%) 83 (17.8%)
Marital status Single Married Divorced/Widowed/Separated
14 (28.6%) 19 (38.9%) 16 (32.6%)
122 (26.5%) 245 (53.2%) 94 (20.4%)
Insurance status Uninsured Public insurance Private insurance
5 (9.6%) 36 (69.2%) 11 (21.2%)
43 (9.2%) 273 (58.3%) 152 (32.5%)
Disease stage* 0 1 2 3 4
3 (7.5%) 6 (15.0%) 6 (15.0%) 2 (5.0%) 23 (57.5%)
19 (4.1%) 108 (23.4%) 97 (21.0%) 133 (28.8%) 104 (22.6%)
Cancer site Colon Rectum Rectosigmoid junction
37 (69.8%) 10 (18.9%) 6 (11.3%)
277 (58.9%) 153 (32.6%) 40 (8.5%)
61.4 (12.8)
p-Value <0.0001 0.6714
0.3168
0.0851
0.2394
<0.0001
0.1208
Values shown in bold are significant findings. * Fisher’s exact test used. † Two-sided t-test used.
nificantly decreased with an increase in disease stage (p = 0.0049). There were no significant differences in sex, race, marital status, or insurance status by diagnosed disease state. Both cancer site (p < 0.0001) and treatment uptake (p < 0.0001) significantly varied by disease state, with stage 4 patients being more likely to have cancer of the colon compared to the rectum or rectosigmoid junction, and with fewer patients opting to receive treatment when their disease state at diagnosis was either 0 or 4. In multiple linear regression testing the association between stage at diagnosis and age, sex, race, marital status, insurance status, cancer site and treatment uptake, only age (ˇ = −0.014, 95% CI −0.023, −0.004) and sex (ˇ = −0.260, 95% CI −0.473, −0.047) were significant predictors of stage of disease at diagnosis, where a decrease in age is associated with more advanced disease status, and being female is associated with more advanced disease status. 3.3. Differences in treatment uptake Table 2 shows the sociodemographic factors associated with treatment uptake. As noted, disease stage at diagnosis is significantly associated with treatment uptake. Additionally, there was a statistically significant difference in mean age, where younger patients were more likely receive treatment (p < 0.0001). In logistic regression, only stage at diagnosis (3 versus 0) was significantly associated with treatment uptake (OR 10.9; 95% CI 1.68, 71.81) after controlling for cancer site, sex insurance marital status, race and age. 4. Discussion Both surveillance data and previous research studies have indicated health disparities in CRC diagnosis and treatment uptake by race, age, gender, insurance type and marital status [1,4,5]. How-
ever, these disparities are inconsistently found throughout the literature [11]. Thus, the purpose of this analysis was add to the existing body of literature by examining sociodemographic factors associated with differences in disease stage at diagnosis and subsequent treatment uptake among patients with CRC at a large academic medical center. Findings from this analysis indicated no statistically significant differences in diagnosed disease stage by patient sex, race, marital status and insurance status. However, being female and decreasing age was significantly associated with diagnosed disease stage indicating that for this population both age and gender are independent predictors of diagnosed disease stage. This corroborates previous findings that women and younger patients are more likely to be diagnosed with more advanced disease stage [12]. Findings related to gender may be attributed to many women’s primary role as caregivers. Women may be more concerned about the health of their partners than their own health and thus be delayed in seeking treatment [12]. Younger patients in our sample were diagnosed with more advanced disease. This may be due to a lack of routine screening (unless they are high-risk surveillance) and a subsequent failure to identify the cancer until the patient is experiencing symptoms. Additionally, CRC preferentially affects younger patients with cancer family or genetic syndromes or inflammatory bowel disease. Contrastingly, older individuals are more likely to engage in preventative measures or screening interventions [12]. There were no significant differences among patient demographic characteristics for treatment uptake with the exception of diagnosed pathologic staging. This finding contradicts previous research that has indicated treatment disparities, particularly among African American populations [3,4]. As previously mentioned, our findings may be attributed to the low prevalence of African Americans in our sample. An additional limitation is associated with incomplete medical information regarding treatments
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received for those patients diagnosed, but not treated in this healthcare system. However, the lack of sociodemographic disparities in treatment uptake in this sample is noteworthy given the overall relatively diverse provider and practice size, suggesting appropriately provided care. The primary limitation of this analysis was the small sample size, particularly following stratification by disease stage. This was a single-center study, which limits the potential for generalizability. However, the distribution of gender, cancer site diagnosis (i.e., colon, rectum, rectosigmoid junction) and race are representative of both hospital and national trends among this population. Additionally, the data in this analysis is limited to treatment uptake only and does not reflect the rates of treatment completion. In conclusion, our results partially corroborate previous findings related to gender and younger age serving as a significant predictor of more advanced disease stage at diagnosis. However, there were no disparities related to treatment uptake noted in this analysis. Future research is needed to corroborate the presence of and psychosocial mechanisms behind disparities in diagnosis and treatment uptake among patients with CRC. Conflict of interest statement None. Author contributions Nicole M. Cranley: Dr. Cranley was the architect behind this study, developed study aims, coded and analyzed data. She also was responsible for the majority of writing and final edits. Hannah Crooke: Dr. Crooke assisted with project development, data coding, analysis and presentation. She also assisted with writing and editing. Thomas J. George, Jr.: Dr. George assisted with obtaining the data, conceptualization and the writing and editing of the manuscript. Acknowledgments Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. During the writing of this manuscript, Dr. Crooke was a pre-doctoral trainee supported through the University of Florida Substance Abuse Training Center in Public Health (T32DA035167). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Competing interests: None declared. Ethical approval: Not applicable. Data used in this analysis is publically available, pre de-identified data therefore IRB approval was not required. References [1] National Cancer Institute, SEER Cancer Statistics Factsheets: Colon and Rectum Cancer, 2013, http://seer.cancer.gov/statfacts/html/colorect.html (retreived on: 20 June 2016). [2] American Cancer Society, Cancer Facts and Figures for African Americans 2013–2014, American Cancer Society, Atlanta, GA, 2013. [3] J. Berry, L. Caplan, S. Davis, et al., A black-white comparison of the quality of stage-specific colon cancer treatment, Cancer 116 (2010) 713–722. [4] J. Berry, K. Bumpers, V. Ogunlade, et al., Examining racial disparities in colorectal cancer care, J. Psychosoc. Oncol. 27 (2009) 59–83. [5] X.L. Du, S. Fang, S.W. Vernon, et al., Racial disparities and socioeconomic status in association with survival in a large population-based cohort of elderly patients with colon cancer, Cancer 110 (2007) 660–669. [6] D. Renouf, H. Kennecke, S. Gill, Trends in chemotherapy utilization for colorectal cancer, Clin. Colorectal Cancer 7 (2008) 386–389. [7] M.L. McGory, D.S. Zingmond, E. Sekeris, et al., A patient’s race/ethnicity does not explain the underuse of appropriate adjuvant therapy in colorectal cancer, Dis. Colon Rectum 49 (2006) 319–329. [8] J.M. Jessup, A. Stewart, F.L. Greene, et al., Adjuvant chemotherapy for stage III colon cancer: implications of race/ethnicity, age, and differentiation, JAMA 294 (2005) 2703–2711. [9] D.A. Etzioni, A.B. El-Khoueiry, R.W. Beart, Rates and predictors of chemotherapy use for stage III colon cancer: a systematic review, Cancer 113 (2008) 3279–3289. [10] C.J. Bradley, C.W. Given, B. Dahman, et al., Adjuvant chemotherapy after resection in elderly medicare and medicaid patients with colon cancer, Arch. Intern. Med. 168 (2008) 521–529. [11] G. Lyratzopoulos, D.C. Greenberg, G.P. Rubin, et al., Advanced stage diagnosis of cancer: who is at greater risk? Expert Rev. Anticancer Ther. 12 (2012) 993–996. [12] J.W. Snyder, K.L. Foley, Disparities in colorectal cancer stage of diagnosis among medicaid-insured residents of North Carolina, N. C. Med. J. 71 (2010) 206–212.
Contents lists available at ScienceDirect
Journal of Cancer Policy journal homepage: www.elsevier.com/locate/jcpo
Sociodemographic factors associated with stage of diagnosis and treatment uptake among patients with colorectal cancer: A brief report Nicole M. Cranley a,∗ , Hannah Crooke b , Thomas J. George Jr. c a
Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA Department of Epidemiology, College of Public Health and Health Professions, College of Medicine, University of Florida, Gainesville, FL, USA c Division of Hematology and Oncology, Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA b
a r t i c l e
i n f o
Article history: Received 1 November 2016 Accepted 8 March 2017 Available online 20 March 2017 Keywords: Cancer Colorectal cancer Decision making Treatment Diagnosis Health disparities
a b s t r a c t Introduction: Previous research has indicated the presence of sociodemographic differences in disease stage at diagnosis and treatment uptake among patients with colorectal cancer (CRC). Patients that identify as black, being female and older age are associated with a decreased uptake of therapeutic options, however these findings are inconsistent in the literature. The purpose of this analysis was to examine the presence of sociodemographic disparities in disease stage and diagnosis and subsequent treatment uptake among patients with CRC. Materials & methods: This secondary data analysis was conducted utilizing a tumor registry database from a academic cancer center with data from patients with diagnosed adenocarcinoma of the colon, rectum or rectosigmoid junction (n = 524) from May 2009 to May 2014. Diagnosed disease stage and treatment uptake differences were assessed among sociodemographic groups. Results: Analyses showed that being female and decreased age were significantly associated with more advanced diagnosed disease stage. There were no significant sociodemographic predictors associated with patients who received treatment versus those who did not. Additionally, there were no significant differences by sociodemographic factors for treatment type. Conclusions: Sociodemographic disparities were present among women and younger patients related to disease stage at diagnosis. Future research is needed to corroborate the presence of and psychosocial mechanisms behind disparities in diagnosis and treatment uptake among patients with CRC. Published by Elsevier Ltd.
1. Introduction Colorectal cancer (CRC) is the third most commonly diagnosed cancer type and third leading cause of cancer death [1]. Within the last decade research has shown that there are racial, age, gender and socioeconomic disparities in cancer diagnosis, treatment and care. In 2015, CRC diagnosis accounted for 10% and 11% of all diagnosed cancer cases among black women and men, respectively. Along with being diagnosed at higher rates (65.1 compared to 52.8, rate ratio = 1.23), black men are also at a significantly higher risk of death compared to white men (rate ratio = 1.53) (all rates are per 100,000) [1,2]. Importantly, the gap in mortality rates for black and whites has not only lingered, but it has increased since the 1970s
∗ Corresponding author. Tel.: +1 919 966 9334x9. E-mail addresses: [email protected] (N.M. Cranley), hcrooke@ufl.edu (H. Crooke), [email protected]fl.edu (T.J. George Jr.). http://dx.doi.org/10.1016/j.jcpo.2017.03.001 2213-5383/Published by Elsevier Ltd.
[1,2]. According to the American Cancer Society (ACS), in 2007 CRC mortality rates were 44% higher among black compared to whites. Additionally, black were significantly less likely to receive a diagnosis of localized disease, more likely to receive a diagnosis of distant disease and more likely to be diagnosed and die at younger ages [1,3,4]. One study found that black patients had higher mortality rates from CRC after controlling for sex, age, tumor stage and grade [5]. Regarding treatment, blacks and whites are equally likely to have a consultation with a medical oncologist, but blacks are significantly less likely to receive further treatment. Despite a significant improvement in survival from the use of adjuvant therapy in CRC, approximately 33.5% of black patients refused adjuvant chemotherapy compared to 21% of whites. This disparity was largest among blacks between the ages of 66–70 [4]. Disparities in the uptake of adjuvant chemotherapy have been shown among older patients [6], women [7,8], blacks and patients who are unmarried [9]. Additionally, patients with lower incomes and patients who are insured
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Table 1 Sociodemographics, treatment status, and cancer site for the total sample and by disease stage. Total sample (n = 524)
Disease stage 0 (n = 22)
Mean age (SD)†
62.2 (13.3)
1 (n = 114)
2 (n = 103)
3 (n = 135)
4 (n = 127)
63.6 (13.0)
64.3 (12.5)
64.2 (11.8)
59.7 (13.1)
59.8 (13.1)
Sex Male Female
252 (48.1%) 272 (51.9%)
14 (63.6%) 8 (36.6%)
61 (53.5%) 53 (46.5%)
54 (52.4%) 49 (47.6%)
74 (54.8%) 61 (45.2%)
59 (46.5%) 68 (53.5%)
Race* White Black
422 (81.5%) 96 (18.5%)
20 (90.9%) 2 (9.1%)
97 (86.6%) 15 (13.4%)
88 (86.3%) 14 (13.7%)
105 (78.4%) 29 (21.6%)
98 (77.2%) 29 (22.8%)
Marital status* Single Married Divorced/widowed/separated
137 (26.8%) 264 (51.6%) 110 (21.5%)
5 (23.8%) 14 (66.7%) 2 (49.5%)
25 (22.5%) 57 (51.4%) 29 (26.1%)
19 (18.8%) 61 (60.4%) 21 (20.8%)
45 (33.8%) 66 (49.6%) 22 (16.5%)
35 (28.2%) 57 (45.9%) 32 (25.8%)
Insurance status* Uninsured Public insurance Private insurance
48 (9.2%) 310 (59.5%) 163 (31.3%)
2 (9.1%) 14 (63.6%) 6 (27.3%)
8 (7.0%) 68 (59.6%) 38 (33.3%)
10 (9.8%) 63 (61.7%) 29 (28.4%)
16 (11.6%) 77 (57.0%) 42 (31.1%)
9 (7.1%) 74 (58.3%) 44 (34.6%)
3 (13.6%) 19 (86.3%)
6 (5.2%) 108 (94.7%)
6 (5.8%) 97 (94.2%)
2 (1.5%) 133 (98.5%)
23 (18.1%) 104 (81.9%)
13 (59.1%) 6 (27.3%) 3 (13.6%)
61 (53.5%) 45 (39.5%) 8 (7.0%)
58 (56.3%) 36 (34.9%) 9 (8.7%)
78 (57.8%) 44 (32.6%) 13 (9.6%)
92 (72.4%) 24 (18.9%) 11 (8.6%)
0.0049 0.1227
0.1388
0.0841
0.9027
Treatment received* No Yes Cancer site* Colon Rectum Rectosigmoid junction
p-Value
<0.0001
<0.0001 315 (60.1%) 163 (31.1%) 46 (8.9%)
Values shown in bold are significant findings. * Fisher’s exact test used. † Two-sided t-test used.
through Medicaid are less likely to receive adjuvant therapies [9]. Bradley et al. found that patients with Medicaid coverage were less likely to initiate and complete adjuvant therapy, and also less likely to be evaluated by a medical oncologist [10]. However, previous research also found that race was not associated with adjuvant therapy uptake among patients with CRC after controlling for sex, age and insurance status [5]. The purpose of this analysis was to add to the existing body of literature and examine the presence of sociodemographic disparities in disease stage at diagnosis and subsequent treatment uptake among patients with CRC. 2. Methods 2.1. Sample Secondary data analysis was conducted utilizing a tumor registry database at the University of Florida Health Care System. Analysis included all patients, 18 years and older, diagnosed with adenocarcinoma of the colon, rectum or rectosigmoid junction between May 1, 2009 and May 1, 2014. Data used in this analysis is publically available, pre de-identified data therefore IRB approval was not required. 2.2. Measures Patient pathologic staging was categorized as stage 0–4. Treatment uptake was categorized as patients who received treatment versus patients who did not. Treatment type was categorized as surgery only, surgery and adjuvant therapy, no treatment, and other treatment. Demographic variables assessed included, sex, age, race/ethnicity, gender, marital status, and insurance type. Race was dichotomized to white and black due to the low prevalence of other races in the sample population. Insurance type was characterized into three groups: (1) no insurance/self-pay, (2) public
insurance (i.e. medicare/medicaid/veterans affairs) and (3) private insurance. 2.3. Analysis Differences in age, sex, race, marital status, and cancer location were examined across treatment groups (treatment received versus no treatment received), and across disease stage (0–4) using chi-square tests (Fisher’s Exact used where appropriate). ANOVA and two-sided t-tests were used to compare mean ages across groups. Finally, a multiple linear regression model was used to identify independent factors associated with disease stage at diagnosis, and a logistic regression model was used to identify independent factors associated with treatment type. The data analysis for this paper was generated using SAS software (SAS Institute Inc., Cary, NC, USA). 3. Results 3.1. Patient characteristics Table 1 gives the sociodemographic characteristics of the overall patient sample (n = 524) along with the overall prevalence of each disease stage and treatment uptake. The mean age of patients was 62.2 (SD = 13.3). The majority of patients were white/Caucasian (81.5%) and married (51.6%). Over half had public insurance (59.3%), while 9.2% of patients were uninsured. Most patients had a colon cancer diagnosis (60.1%) with a fairly equal distribution of patients by disease stage 1–4. 3.2. Differences in stage at diagnosis Table 1 also shows the sociodemographic factors associated with disease stage at diagnosis. Overall, average patient age sig-
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Table 2 Sociodemographics, cancer stage, and cancer site by treatment group. No treatment received (n = 53)
Treatment received (n = 470)
Mean age (SD)†
69.3 (14.5)
Sex Male Female
26 (49.1%) 27 (50.9%)
245 (52.1%) 225 (47.9%)
Race White Black
39 (76.5%) 12 (23.5%)
383 (82.2%) 83 (17.8%)
Marital status Single Married Divorced/Widowed/Separated
14 (28.6%) 19 (38.9%) 16 (32.6%)
122 (26.5%) 245 (53.2%) 94 (20.4%)
Insurance status Uninsured Public insurance Private insurance
5 (9.6%) 36 (69.2%) 11 (21.2%)
43 (9.2%) 273 (58.3%) 152 (32.5%)
Disease stage* 0 1 2 3 4
3 (7.5%) 6 (15.0%) 6 (15.0%) 2 (5.0%) 23 (57.5%)
19 (4.1%) 108 (23.4%) 97 (21.0%) 133 (28.8%) 104 (22.6%)
Cancer site Colon Rectum Rectosigmoid junction
37 (69.8%) 10 (18.9%) 6 (11.3%)
277 (58.9%) 153 (32.6%) 40 (8.5%)
61.4 (12.8)
p-Value <0.0001 0.6714
0.3168
0.0851
0.2394
<0.0001
0.1208
Values shown in bold are significant findings. * Fisher’s exact test used. † Two-sided t-test used.
nificantly decreased with an increase in disease stage (p = 0.0049). There were no significant differences in sex, race, marital status, or insurance status by diagnosed disease state. Both cancer site (p < 0.0001) and treatment uptake (p < 0.0001) significantly varied by disease state, with stage 4 patients being more likely to have cancer of the colon compared to the rectum or rectosigmoid junction, and with fewer patients opting to receive treatment when their disease state at diagnosis was either 0 or 4. In multiple linear regression testing the association between stage at diagnosis and age, sex, race, marital status, insurance status, cancer site and treatment uptake, only age (ˇ = −0.014, 95% CI −0.023, −0.004) and sex (ˇ = −0.260, 95% CI −0.473, −0.047) were significant predictors of stage of disease at diagnosis, where a decrease in age is associated with more advanced disease status, and being female is associated with more advanced disease status. 3.3. Differences in treatment uptake Table 2 shows the sociodemographic factors associated with treatment uptake. As noted, disease stage at diagnosis is significantly associated with treatment uptake. Additionally, there was a statistically significant difference in mean age, where younger patients were more likely receive treatment (p < 0.0001). In logistic regression, only stage at diagnosis (3 versus 0) was significantly associated with treatment uptake (OR 10.9; 95% CI 1.68, 71.81) after controlling for cancer site, sex insurance marital status, race and age. 4. Discussion Both surveillance data and previous research studies have indicated health disparities in CRC diagnosis and treatment uptake by race, age, gender, insurance type and marital status [1,4,5]. How-
ever, these disparities are inconsistently found throughout the literature [11]. Thus, the purpose of this analysis was add to the existing body of literature by examining sociodemographic factors associated with differences in disease stage at diagnosis and subsequent treatment uptake among patients with CRC at a large academic medical center. Findings from this analysis indicated no statistically significant differences in diagnosed disease stage by patient sex, race, marital status and insurance status. However, being female and decreasing age was significantly associated with diagnosed disease stage indicating that for this population both age and gender are independent predictors of diagnosed disease stage. This corroborates previous findings that women and younger patients are more likely to be diagnosed with more advanced disease stage [12]. Findings related to gender may be attributed to many women’s primary role as caregivers. Women may be more concerned about the health of their partners than their own health and thus be delayed in seeking treatment [12]. Younger patients in our sample were diagnosed with more advanced disease. This may be due to a lack of routine screening (unless they are high-risk surveillance) and a subsequent failure to identify the cancer until the patient is experiencing symptoms. Additionally, CRC preferentially affects younger patients with cancer family or genetic syndromes or inflammatory bowel disease. Contrastingly, older individuals are more likely to engage in preventative measures or screening interventions [12]. There were no significant differences among patient demographic characteristics for treatment uptake with the exception of diagnosed pathologic staging. This finding contradicts previous research that has indicated treatment disparities, particularly among African American populations [3,4]. As previously mentioned, our findings may be attributed to the low prevalence of African Americans in our sample. An additional limitation is associated with incomplete medical information regarding treatments
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received for those patients diagnosed, but not treated in this healthcare system. However, the lack of sociodemographic disparities in treatment uptake in this sample is noteworthy given the overall relatively diverse provider and practice size, suggesting appropriately provided care. The primary limitation of this analysis was the small sample size, particularly following stratification by disease stage. This was a single-center study, which limits the potential for generalizability. However, the distribution of gender, cancer site diagnosis (i.e., colon, rectum, rectosigmoid junction) and race are representative of both hospital and national trends among this population. Additionally, the data in this analysis is limited to treatment uptake only and does not reflect the rates of treatment completion. In conclusion, our results partially corroborate previous findings related to gender and younger age serving as a significant predictor of more advanced disease stage at diagnosis. However, there were no disparities related to treatment uptake noted in this analysis. Future research is needed to corroborate the presence of and psychosocial mechanisms behind disparities in diagnosis and treatment uptake among patients with CRC. Conflict of interest statement None. Author contributions Nicole M. Cranley: Dr. Cranley was the architect behind this study, developed study aims, coded and analyzed data. She also was responsible for the majority of writing and final edits. Hannah Crooke: Dr. Crooke assisted with project development, data coding, analysis and presentation. She also assisted with writing and editing. Thomas J. George, Jr.: Dr. George assisted with obtaining the data, conceptualization and the writing and editing of the manuscript. Acknowledgments Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. During the writing of this manuscript, Dr. Crooke was a pre-doctoral trainee supported through the University of Florida Substance Abuse Training Center in Public Health (T32DA035167). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
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