The associations of food environment with gastrointestinal cancer outcomes in the United States.

ABSTRACT

BACKGROUND: Social conditions and dietary behaviors have been implicated in the rising burden of gastrointestinal cancers (GIC). The "food environment" reflects influences on a community level relative to food availability, nutritional assistance, and social determinants of health. Using the US Department of Agriculture-Food Environment Atlas (FEA), we sought to characterize the association of food environment on GIC presenting stage and long-term survival. METHODS: Patients diagnosed with GIC between 2013 and 2017 were identified using the SEER database. FEA-scores were based on 282 county-level food security variables, store-restaurant availability, SNAP/WIC enrollment, pricing/taxes, and producer vicinity adjusted-for factors of socioeconomic status, race-ethnicity, transportation access, and comorbidities. Relative FEA rankings across US counties were averaged into a composite score and assigned to patients by county-of-residence. The association of FEA, cancer stage, and survival were analyzed using multiple logistic regression and cox-proportional hazard models relative to White/non-White race/ethnicity. RESULTS: Among 287,148 patients, the most common GIC-sites were colon (n = 97,942, 34%), pancreas (n = 49,785, 17.3%), liver (n = 31,098, 11.0%) and esophagus (n = 16,271, 5.7%). A worse food environment was independently associated with increased odds of late-stage diagnosis (esophageal odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.05; hepatic OR 1.06, 95% CI 1.03-1.08; pancreatic OR 1.04, 95% CI 1.01-1.06) among all patients; in contrast, food environment was associated with colorectal cancer stage among non-White patients only (OR 1.04, 95% CI 1.03-1.06). Worse food environment was associated with worse 3-year survival (colon OR 1.03, 95% CI 1.01-1.04; hepatic OR 1.12, 95% CI 1.08-1.17; gastric OR 1.07, 95% CI 1.01-1.13). Similar associations were noted relative to overall survival among the entire cohort (biliary tract hazard ratio [HR] 1.03, 95% CI 1.01-1.05; esophageal HR 1.02, 95% CI 1.01-1.04; hepatic HR 1.07, 95% CI 1.06-1.09; pancreatic HR 1.04, 95% CI 1.02-1.05; rectum HR 1.03, 95% CI 1.01-1.04; gastric HR 1.05, 95% CI 1.03-1.07), as well as among non-White patients (biliary HR 1.04, 95% CI 1.01-1.07; colon HR 1.03, 95% CI 1.01-1.05; esophageal HR 1.05, 95% CI 1.02-1.08; hepatic HR 1.08, 95% CI 1.06-1.10) (all p < 0.003). CONCLUSIONS: Food environment was independently associated with late-stage tumor presentation and worse 3-year and overall survival among GIC patients. Interventions to address inequities across communities relative to food environments are needed to alleviate disparities in cancer care.