Racial disparities in access to minimally invasive proctectomy for rectal cancer-a National Surgical Quality Improvement Program study.

AIM: The aim of this work was to determine racial disparities in access to minimally invasive proctectomy using a national database. METHOD: A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program evaluated for surgical approach (robotic, laparoscopic or open), demographics and comorbidity, and then compared by race. RESULTS: A total of 3511 patients (325 Asian, 2925 White, 261 African American/Black) with cancer who underwent a proctectomy between 2016 and 2020 were included. Both Asians and Whites had significantly higher rates of laparoscopic proctectomy relative to African Americans (38.5%, 33.8% and 28.7%, respectively; p = 0.0001). Asians had the highest rate of robotic proctectomy (38.2%, p = 0.0001). Conversely, Black patients had significantly higher rates of open proctectomy followed by Whites and then Asians (42.1%, 35.4% and 23.4%, respectively; p = 0.0001). In multivariable logistic regression with backward elimination, African Americans were 0.7 times as likely to undergo laparoscopic proctectomy and 1.4 times more likely to undergo open proctectomy than Whites (p = 0.043). Compared with Whites, Asians were 1.8, 1.7 and 1.9 times more likely to undergo minimally invasive, laparoscopic proctectomy and robotic proctectomy, respectively (p = 0.0001, p = 0.001, p = 0.0001). CONCLUSION: Asians had the highest rate of laparoscopic and robotic proctectomy, while Blacks had the highest rate of open proctectomy. African Americans were least likely to undergo laparoscopic proctectomy compared with all races. Race is an independent risk factor for access to minimally invasive proctectomy.

The impact of hospital volume on racial disparities in resected rectal cancer.

BACKGROUND: Although high volume centers (HVC) equate to improved outcomes in rectal cancer, the impact of surgical volume related to race is less defined. METHODS: Patients who underwent surgical resection for stage I-III rectal adenocarcinoma were divided into cohorts based on race and hospital surgical volume. Outcomes were analyzed following 1:1 propensity-score matching using logistic, Poisson, and Cox regression analyses with marginal effects. RESULTS: Fifty-four thousand one hundred and eighty-four (91.5%) non-Black and 5043 (8.5%) Black patients underwent resection of rectal cancer. Following 1:1 matching of non-Black (N = 5026) and Black patients, 5-year overall survival (OS) of Black patients was worse (72% vs. 74.4%, average marginal effects [AME] 0.66, p = 0.04) than non-Black patients. When compared to non-Black patients managed at HVCs, Black patients had worse OS (70.1% vs. 74.7%, AME 1.55, p = 0.03), but this difference was not significant when comparing OS between non-Black and Black patients managed at HVCs (72.3% vs. 74.7%, AME 0.62, p = 0.06). Length of stay was longer among Black and HVC patients across all cohorts. There was no difference across cohorts in 90-day mortality. CONCLUSIONS: Although racial disparities exist in rectal cancer, this disparity appears to be ameliorated when patients are managed at HVCs.

Evaluating disparities in delivery of neoadjuvant guideline-based chemoradiation for rectal cancer: A multicenter, propensity score-weighted cohort study.

BACKGROUND: Despite guideline recommendations, some patients still receive care inappropriate for their clinical stage of disease. Identification of factors that contribute to variation in guideline base care may help eradicate disparities in the treatment of early and locally advanced rectal cancer. METHODS: The American College of Surgeons National Cancer Database from 2010 to 2015 was analyzed with propensity score weighting to identify factors associated with delivery and omission of neoadjuvant guideline-based chemoradiation (GBC) for those with early and locally advanced rectal cancer. RESULTS: Only 74% of patients with rectal cancer received stage-appropriate neoadjuvant chemoradiation; 4544 (88%) of those with early stage disease and 8675 (68%) in locally advanced disease. Chemotherapy and radiotherapy were not planned in 27% and 34% respectively, of those who did not receive GBC. Factors associated with receipt of non-guideline-based neoadjuvant chemoradiation were age >65 years, Medicare insurance, treatment at a community facility, West-South-Central geography, having locally advanced disease, and Charlson-Deyo score >3. Receipt of ideal guideline-based neoadjuvant chemoradiation conferred a survival benefit at 5 years. CONCLUSION: Patient and non-patient factors contribute to disparities in guideline-based delivery of neoadjuvant chemoradiation in the treatment of rectal cancer. Identification of these risk factors are important to help standardize care and improve survival outcomes.

The impact of primary tumor sidedness on survival in early-onset colorectal cancer by stage: A National Veterans Affairs retrospective analysis.

BACKGROUND: The incidence of early-onset colorectal cancer (EOCRC) is rising. Left-sided colorectal cancer (LCC) is associated with better survival compared to right-sided colon cancer (RCC) in metastatic disease. NCCN guidelines recommend the addition of EGFR inhibitors to KRAS/NRAS WT metastatic CRC originating from the left only. Whether laterality impacts survival in locoregional disease and EOCRC is of interest. METHODS: 65,940 CRC cases from the National VA Cancer Cube Registry (2001-2015) were studied. EOCRC (2096 cases) was defined as CRC diagnosed at <50 years. Using ICD codes, RCC was defined from the cecum to the hepatic flexure (C18.0-C18.3), and LCC from the splenic flexure to the rectum (C18.5-18.7; C19 and C20). RESULTS: EOCRC is more likely to originate from the left side (66.65% LCC in EOCRC vs. 58.77% in CRC). Overall, LCC has better 5-year Overall Survival (OS) than RCC in stages I (61.67% vs. 58.01%) and III (46.1% vs. 42.1%) and better 1-year OS in stage IV (57.79% vs. 49.49%). Stage II RCC has better 5-year OS than LCC (53.39% vs. 49.28%). In EOCRC, there is no statistically significant difference between LCC and RCC in stages I-III. Stage IV EOCRC patients with LCC and RCC have a 1-year OS of 73.23% and 59.84%, respectively. CONCLUSION: In EOCRC, LCC is associated with better OS than RCC only stage IV. In the overall population, LCC is associated with better OS in all stages except stage II. The better prognosis of stage II RCC might be due to the high incidence of mismatch repair deficient tumors in this subpopulation.

Survival of colorectal cancer patients in Brunei Darussalam: comparison between 2002-09 and 2010-17.

BACKGROUND: Colorectal cancer (CRC) is a major cause of cancer-related mortality worldwide. It is the second leading cause of cancer death in men and women in Brunei Darussalam in 2017, posing a major burden on society. METHODS: This retrospective cohort study (n = 1035 patients diagnosed with CRC in Brunei Darussalam from 1st January 2002 until 31st December 2017) aims to compare the overall survival rates of CRC patients (2002-2017), to compare survival rates between two study periods (2002-2009 and 2010-2017) and to identify prognostic factors of CRC. Kaplan-Meier estimator and log-rank tests were performed to analyse the overall survival rates of CRC patients. Multiple Cox regression was performed to determine the prognostic factors of CRC with adjusted hazard ratios (Adj. HRs) reported. RESULTS: The 1-, 3- and 5-year survival rates of CRC patients are 78.6, 62.5, and 56.0% respectively from 2002 to 2017. The 1-, 3-, and 5-year survival rates of CRC patients for 2002-2009 are 82.2, 69.6, and 64.7%; 77.0, 59.1, and 51.3% for 2010-2017 respectively. A significant difference in CRC patients' survival rate was observed between the two study periods, age groups, ethnic groups, cancer stages, and sites of cancer (p < 0.05). The Adjusted Hazard Ratios (Adj. HRs) were significantly higher in the 2010-17 period (Adj. HR = 1.78, p < 0.001), older age group ( ≥ 60 years) (Adj. HR = 1.93, p = 0.005), distant cancer (Adj. HR = 4.69, p < 0.010), tumor at transverse colon and splenic flexure of colon (Adj. HR = 2.44, p = 0.009), and lower in the Chinese(Adj. HR = 0.63, p = 0.003). CONCLUSION: This study highlights the lower survival rates of CRC patients in 2010-2017, Malays, older patients, distant cancer, and tumors located at the latter half of the proximal colon (transverse colon), and predominantly LCRC (splenic flexure, descending colon, sigmoid colon, overlapping lesion colon and colon (NOS), as well as the rectosigmoid junction and rectum (NOS)). Age, ethnicity, cancer stage, and tumor location are significant prognostic factors for CRC. These findings underscore the importance of public health policies and programmes to enhance awareness on CRC from screening to developing strategies for early detection and management, to reduce CRC-associated mortality.

Size Criteria Is Not Sufficient in Selecting Patients for Local Excision Versus Radical Excision for Rectal Neuroendocrine Tumors >2 cm: A National Cancer Database Analysis.

BACKGROUND: Patients with rectal neuroendocrine tumors >2 cm often undergo radical surgery, despite limited data supporting this practice. Five- and 10-year survival rates for these patients have been reported previously as 74.8% and 58.6%. OBJECTIVE: Overall survival was compared between local excision and radical surgery and pN0 and pN1 within the radical surgery subgroup for rectal neuroendocrine tumors >2 cm. Factors independently associated with survival were identified. DESIGN: A retrospective, nationwide, multivariate regression analysis was performed. SETTINGS: Data are from the National Cancer Database (2004-2013). PATIENTS: Patients with rectal neuroendocrine tumors >2 cm, excluding stages T4 and M1, were included. MAIN OUTCOME MEASURES: Outcome measures were overall survival and independent risk factors for overall survival based on multivariate regression analysis. RESULTS: Each group had 178 patients. After local excision, 5- and 10-year overall survival rates were 88% and 72% vs 51% and 42% after radical surgery (p < 0.001). A multivariate Cox proportional hazards model showed similar survival (p = 0.96). Tumor factors independently associated with survival were nodal metastasis (HR = 2.01 (95% CI, 1.01-3.97)), poorly differentiated tumors (HR = 4.82 (95% CI, 1.65-14.01)), and undifferentiated tumors (HR = 9.91 (95% CI, 2.77-35.49)). After radical surgery, patients with and without nodal metastasis had 5-year survival rates of 44% vs 59% (unadjusted p = 0.09; adjusted p = 0.11), with insufficient 10-year survival data. LIMITATIONS: The study is a retrospective analysis and includes only Commission on Cancer-accredited hospitals. Long-term follow-up was limited. Lymphovascular invasion was missing for a majority of patients analyzed. CONCLUSIONS: Local excision for select patients with rectal neuroendocrine tumors >2 cm is a viable alternative to radical surgery. Nodal status and tumor grade independently predict survival and should be factored into surgical intervention selection. In higher-risk patients selected for radical surgery, survival was similar between the pN0 and pN1 groups, possibly indicating a benefit of radical surgery for these patients. See Video Abstract at http://links.lww.com/DCR/B455. EL CRITERIO DE TAMAO NO ES SUFICIENTE PARA SELECCIONAR PACIENTES PARA LA ESCISIN LOCAL VERSUS ESCISIN RADICAL PARA TUMORES NEUROENDOCRINOS RECTALES CM ANLISIS DE UNA BASE DE DATOS NACIONAL DE CANCER: ANTECEDENTES:Los pacientes con tumores neuroendocrinos rectales >2 cm a menudo se someten a cirugía radical, a pesar de los datos limitados que respaldan esta práctica. La supervivencia a cinco y diez años para estos pacientes se había informado anteriormente como 74,8% y 58,6%, respectivamente.OBJETIVO:Se comparó la supervivencia global entre escisión local y cirugía radical, y pN0 y pN1 dentro del subgrupo de cirugía radical para tumores neuroendocrinos rectales >2 cm. Se identificaron factores asociados de forma independiente con la supervivencia.DISEÑO:Se realizó un análisis retrospectivo de regresión multivariante a nivel nacional.AJUSTE:Los datos provienen de la Base de Datos Nacional sobre el cáncer (2004-2013).PACIENTES:Pacientes con tumores neuroendocrinos rectales > 2 cm, excluyendo los estadios T4 y M1.PRINCIPALES MEDIDAS DE RESULTADO:Las medidas de resultado fueron la supervivencia general y los factores de riesgo independientes para la supervivencia general según el análisis de regresión multivariante.RESULTADOS:Cada grupo tuvo 178 pacientes. Después de la escisión local, la supervivencia global a cinco y diez años fue del 88% y 72% frente al 51% y el 42% después de la cirugía radical (p <0,001). Un modelo multivariado de riesgos proporcionales de Cox mostró una supervivencia similar (p = 0,96). Los factores tumorales asociados de forma independiente con la supervivencia fueron metástasis ganglionares (HR = 2,01; IC, 1,01-3,97), tumores pobremente diferenciados (HR = 4,82, IC, 1,65-14,01) y tumores indiferenciados (HR = 9,91, IC, 2,77-35,49). Después de la cirugía radical, los pacientes con y sin metástasis ganglionar tuvieron una supervivencia a cinco años del 44% frente al 59%, respectivamente (p no ajustado = 0,09; p ajustado = 0,11), con datos insuficientes de supervivencia a diez años.LIMITACIONES:El estudio es un análisis retrospectivo e incluye solo hospitales acreditados por la Comisión de Cáncer. El seguimiento a largo plazo fue limitado. La mayoría de los pacientes analizados no tenían invasión linfovascular.CONCLUSIONES:La escisión local para pacientes seleccionados con tumores neuroendocrinos rectales >2 cm es una alternativa viable a la cirugía radical. El estado ganglionar y el grado del tumor predicen de forma independiente la supervivencia y deben tenerse en cuenta en la selección de la intervención quirúrgica. En los pacientes de mayor riesgo seleccionados para cirugía radical, la supervivencia fue similar entre los grupos pN0 vs. pN1, lo que posiblemente indica un beneficio de la cirugía radical para estos pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B455.

Racial/ethnic disparities in early-onset colorectal cancer: implications for a racial/ethnic-specific screening strategy.

INTRODUCTION: Early-onset colorectal cancer (EO-CRC) is a public health concern. Starting screening at 45 years has been considered, but there is discrepancy in the recommendations. Racial disparities in EO-CRC incidence and survival are reported; however, racial/ethnic differences in EO-CRC features that could inform a racial/ethnic-tailored CRC screening strategy have not been reported. We compared features and survival among Non-Hispanic White (NHW), Non-Hispanic Black (NHB), and Hispanics with EO-CRC. METHODS: CRC patients from SEER 1973-2010 database were identified, and EO-CRC was defined as CRC at <50 years. Clinical/pathological features and survival were compared between NHW, NHB, and Hispanics. Cancer-specific survival (CSS) predictors were assessed in a multivariable Cox proportional hazard model. RESULTS: Of 166,416 patients with CRC, 16,545 (9.9%) had EO-CRC. The EO-CRC frequencies in NHB and Hispanics were higher than NHW (12.7% vs. 16.5% vs. 8.7%, p < 0.001). EO-CRC in NHB presents more frequently in females, with well/moderately differentiated, stage IV, and is less likely to present in locations targetable by sigmoidoscopy than NHW (54.6% vs. 67.7% OR:1.7, 95% p < 0.001). 5-year CSS was lower in NHB (59.4% vs. 72.8%, HR: 1.7; 95% CI: 1.54-1.82) and Hispanics (66.4% vs. 72.8%, HR: 1.3; 95% CI: 1.16-1.39) than NHW. A regression model among patients with EO-CRC showed that being NHB or Hispanic were independent predictors for cancer-specific mortality, after adjusting for gender, grade, stage, and surgery. CONCLUSION: EO-CRC is more likely in NHB and Hispanics. Racial disparities in clinical/pathological features and CSS between NHB and NHW/Hispanics were evidenced. A racial/ethnic specific screening strategy could be considered as an alternative for patients younger than 50 years.

Rural-urban and racial/ethnic trends and disparities in early-onset and average-onset colorectal cancer.

BACKGROUND: Incidence rates (IRs) of early-onset colorectal cancer (EOCRC) are increasing, whereas average-onset colorectal cancer (AOCRC) rates are decreasing. However, rural-urban and racial/ethnic differences in trends by age have not been explored. The objective of this study was to examine joint rural-urban and racial/ethnic trends and disparities in EOCRC and AOCRC IRs. METHODS: Surveillance, Epidemiology, and End Results data on the incidence of EOCRC (age, 20-49 years) and AOCRC (age, ≥50 years) were analyzed. Annual percent changes (APCs) in trends between 2000 and 2016 were calculated jointly by rurality and race/ethnicity. IRs and rate ratios were calculated for 2012-2016 by rurality, race/ethnicity, sex, and subsite. RESULTS: EOCRC IRs increased 35% from 10.44 to 14.09 per 100,000 in rural populations (APC, 2.09; P < .05) and nearly 20% from 9.37 to 11.20 per 100,000 in urban populations (APC, 1.26; P < .05). AOCRC rates decreased among both rural and urban populations, but the magnitude of improvement was greater in urban populations. EOCRC increased among non-Hispanic White (NHW) populations, although rural non-Hispanic Black (NHB) trends were stable. Between 2012 and 2016, EOCRC IRs were higher among all rural populations in comparison with urban populations, including NHW, NHB, and American Indian/Alaska Native populations. By sex, rural NHB women had the highest EOCRC IRs across subgroup comparisons, and this was driven primarily by colon cancer IRs 62% higher than those of their urban peers. CONCLUSIONS: EOCRC IRs increased in rural and urban populations, but the increase was greater in rural populations. NHB and American Indian/Alaska Native populations had particularly notable rural-urban disparities. Future research should examine the etiology of these trends.

Racial Disparities in Incidence of Young-Onset Colorectal Cancer and Patient Survival.

BACKGROUND & AIMS: Increasing rates of young-onset colorectal cancer (CRC) have attracted substantial research and media attention, but we know little about racial disparities among younger adults with CRC. We examined racial disparities in young-onset CRC by comparing CRC incidence and relative survival among younger (<50-year-old) adults in 2 time periods. METHODS: Using data from the Surveillance, Epidemiology, and End Results program of cancer registries, we estimated CRC incidence rates (per 100,000 persons 20-49 years old) from 1992 through 2014 for different periods (1992-1996 vs 2010-2014) and races (white vs black). Relative survival was calculated as the ratio of observed survival to expected survival in a comparable cancer-free population. RESULTS: From 1992-1996 to 2010-2014, CRC incidence increased from 7.5 to 11.0 per 100,000 in white individuals and from 11.7 to 12.7 per 100,000 in black individuals. The increase in rectal cancer was larger in whites (from 2.7 to 4.5 per 100,000) than in blacks (from 3.4 to 4.0 per 100,000); in the 2010-2014 period, blacks and whites had similar rates of rectal cancer. Compared with whites, blacks had smaller increases in relative survival with proximal colon cancer but larger increases in survival with rectal cancer (from 55.3% to 70.8%). CONCLUSION: In an analysis of the Surveillance, Epidemiology, and End Results database, we found racial disparities in incidence of young-onset CRC and patient survival for cancer of the colon but minimal difference for rectal cancer. Well-documented and recent increases in young-onset CRC have largely been due to increases in rectal cancer, especially in whites.

Decreased Use of Sphincter-Preserving Procedures Among African Americans with Rectal Cancer.

BACKGROUND: Improved multimodality rectal cancer treatment has increased the use of sphincter-preserving surgery. This study sought to determine whether African American (AA) patients with rectal cancer receive sphincter-preserving surgery at the same rate as non-AA patients. METHODS: The study used the Nationwide Inpatient Sample for years 1998-2012 to compare AA and non-AA patients with rectal cancer undergoing low anterior resection or abdominoperineal resection. The logistic regression model was used to adjust for age, gender, admission type, Elixhauser comorbidity index, and hospital factors such as size, location (urban vs.rural), teaching status, and procedure volume. RESULTS: The search identified 22,697 patients, 1600 of whom were identified as AA. After adjustment for age and gender, the analysis showed that AA patients were less likely to undergo sphincter-preserving surgery than non-AA patients [odds ratio (OR) 0.70; 95% confidence interval (CI) 0.63-0.78; p < 0.0001). After further adjustment for the Elixhauser comorbidity index, admission type, hospital-specific factors, and insurance status, the analysis showed that AA patients still were less likely to undergo sphincter-preserving surgery (OR 0.78; 95% CI 0.70-0.87; p < 0.0001). Although the proportion of non-AA patients undergoing sphincter-preserving surgery increased during the study period (p = 0.0003), this trend was not significant for the AA patients (p = 0.13). CONCLUSION: In this data analysis, the AA patients with rectal cancer had lower rates of sphincter-preserving surgery than the non-AA patients, even after adjustment for patient- and hospital-specific factors. Further work is required to elucidate why. Eliminating racial disparities in rectal cancer treatment should continue to be a priority for the surgical community.

Rectal cancer survival in the United States by race and stage, 2001 to 2009: Findings from the CONCORD-2 study.

BACKGROUND: In the first CONCORD study, 5-year survival for patients with diagnosed with rectal cancer between 1990 and 1994 was <60%, with large racial disparities noted in the majority of participating states. We have updated these findings to 2009 by examining population-based survival by stage of disease at the time of diagnosis, race, and calendar period. METHODS: Data from the CONCORD-2 study were used to compare survival among individuals aged 15 to 99 years who were diagnosed in 37 states encompassing up to 80% of the US population. We estimated net survival up to 5 years after diagnosis correcting for background mortality with state-specific and race-specific life table. Survival estimates were age-standardized with the International Cancer Survival Standard weights. We present survival estimates by race (all, black, and white) for 2001 through 2003 and 2004 through 2009 to account for changes in collecting the data for Surveillance, Epidemiology, and End Results Summary Stage 2000. RESULTS: There was a small increase in 1-year, 3-year, and 5-year net survival between 2001-2003 (84.6%, 70.7%, and 63.2%, respectively), and 2004-2009 (85.1%, 71.5%, and 64.1%, respectively). Black individuals were found to have lower 1-year, 3-year, and 5-year survival than white individuals in both periods; the absolute difference in survival between black and white individuals declined only for 5-year survival. Black patients had lower 5-year survival than whites at each stage at the time of diagnosis in both time periods. CONCLUSIONS: There was little improvement noted in net survival for patients with rectal cancer, with persistent disparities noted between black and white individuals. Additional investigation is needed to identify and implement effective interventions to ensure the consistent and equitable use of high-quality screening, diagnosis, and treatment to improve survival for patients with rectal cancer. Cancer 2017;123:5037-58. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

Colorectal cancer screening at US community health centers: Examination of sociodemographic disparities and association with patient-provider communication.

BACKGROUND: Colorectal cancer (CRC) screening rates are low among underserved populations. High-quality patient-physician communication potentially influences patients' willingness to undergo CRC screening. Community health centers (HCs) provide comprehensive primary health care to underserved populations. This study's objectives were to ascertain national CRC screening rates and to explore the relations between sociodemographic characteristics and patient-provider communication on the receipt of CRC screening among HC patients. METHODS: Using 2014 Health Center Patient Survey data, bivariate and multivariate analyses examined the association of sociodemographic variables (sex, race/ethnicity, age, geography, preferred language, household income, insurance, and employment status) and patient-provider communication with the receipt of CRC screening. RESULTS: Patients between the ages of 65 and 75 years (adjusted odds ratio [aOR], 2.49; 95% confidence interval [CI], 1.33-4.64) and patients not in the labor force (aOR, 2.32; 95% CI, 1.37-3.94) had higher odds of receiving CRC screening, whereas patients who were uninsured (aOR, 0.33; 95% CI, 0.18-0.61) and patients who were non-English-speaking (aOR, 0.42; 95% CI, 0.18-0.99) had lower odds. Patient-provider communication was not associated with the receipt of CRC screening. CONCLUSIONS: The CRC screening rate for HC patients was 57.9%, whereas the rate was 65.1% according to the 2012 Behavioral Risk Factor Surveillance System and 58.2% according to the 2013 National Health Interview Survey. The high ratings of patient-provider communication, regardless of the screening status, suggest strides toward a patient-centered medical home practice transformation that will assist in a positive patient experience. Addressing the lack of insurance, making culturally and linguistically appropriate patient education materials available, and training clinicians and care teams in cultural competency are critical for increasing future CRC screening rates. Cancer 2017;123:4185-4192. © 2017 American Cancer Society.

Surviving rectal cancer: examination of racial disparities surrounding access to care.

BACKGROUND: The aim of this study was to evaluate whether survival differences are attributable to disproportionate access to stage-specific rectal cancer treatment recommended by the National Comprehensive Care Network. METHODS: A retrospective analysis of the National Cancer Data Base between 1998 and 2006 was performed. A series of Kaplan-Meier survival analyses were used to compare 5-y survival among race cohorts. Propensity score matching was used to compare Caucasian and African American patients who received the same treatment by accounting for covariates. RESULTS: 5-y overall survival in African Americans was 50.7% versus 56.2% in Caucasians (P < 0.001). In patients with stage I-III disease, 5-y survival was 58.7% in African Americans versus 63.1% in Caucasians (P < 0.001). Analysis of patients receiving surgery for stage I-III disease, revealed a 61.1% 5-y survival in African Americans versus 65.8% in Caucasians (P < 0.001). Propensity score matching did not eliminate the racial disparity. The median survival for Caucasian patients was 109.6 mo as compared to 85.8 mo for African Americans (P < 0.001). CONCLUSIONS: These data show that access to standard care appears to decrease but not eliminate the survival differences between African Americans and Caucasians with rectal cancer.

High-Quality Diets Associate With Reduced Risk of Colorectal Cancer: Analyses of Diet Quality Indexes in the Multiethnic Cohort.

BACKGROUND & AIMS: Healthy eating patterns assessed by diet quality indexes (DQIs) have been related to lower risk of colorectal cancer-mostly among whites. We investigated the associations between 4 DQI scores (the Healthy Eating Index 2010 [HEI-2010], the Alternative Healthy Eating Index 2010 [AHEI-2010], the alternate Mediterranean diet score [aMED], and the Dietary Approaches to Stop Hypertension score) and colorectal cancer risk in the Multiethnic Cohort. METHODS: We analyzed data from 190,949 African American, Native Hawaiian, Japanese American, Latino, and white individuals, 45 to 75 years old, who entered the Multiethnic Cohort study from 1993 through 1996. During an average 16 years of follow-up, 4770 invasive colorectal cancer cases were identified. RESULTS: Scores from all 4 DQIs associated inversely with colorectal cancer risk; higher scores associated with decreasing colorectal cancer risk (all P's for trend ≤ .003). Associations were not significant for AHEI-2010 and aMED scores in women after adjustment for covariates: for the highest vs lowest quintiles, the hazard ratio for the HEI-2010 score in men was 0.69 (95% confidence interval [CI], 0.59-0.80) and in women was 0.82 (95% CI, 0.70-0.96); for the AHEI-2010 score the hazard ratio in men was 0.75 (95% CI, 0.65-0.85) and in women was 0.90 (95% CI, 0.78-1.04); for the aMED score the hazard ratio in men was 0.84 (95% CI, 0.73-0.97) and in women was 0.96 (95% CI, 0.82-1.13); for the Dietary Approaches to Stop Hypertension score the hazard ratio in men was 0.75 (95% CI, 0.66-0.86) and in women was 0.86 (95% CI, 0.75-1.00). Associations were limited to the left colon and rectum for all indexes. The inverse associations were less strong in African American individuals than in the other 4 racial/ethnic groups. CONCLUSIONS: Based on an analysis of data from the Multiethnic Cohort Study, high-quality diets are associated with a lower risk of colorectal cancer in most racial/ethnic subgroups.

Racial and Socioeconomic Treatment Disparities in Adolescents and Young Adults with Stage II-III Rectal Cancer.

INTRODUCTION: Stage II-III rectal cancer requires multidisciplinary cancer care, and adolescents and young adults (AYA, ages 15-39 years) often do not receive optimal cancer therapy. METHODS: Overall, 3295 AYAs with clinical stage II-III rectal cancer were identified in the National Cancer Database. Factors associated with the receipt of adjuvant and surgical therapies, as well as overall survival (OS), were examined. RESULTS: The majority of patients were non-Hispanic White (72.0 %), male (57.5 %), and without comorbidities (93.8 %). A greater proportion of Black and Hispanic patients did not receive radiation (24.5 and 27.1 %, respectively, vs. 16.5 % for non-Hispanic White patients), surgery (22.4 % and 21.6 vs. 12.3 %), or chemotherapy (21.5 % and 24.1 vs. 14.7 %) compared with non-Hispanic White patients (all p < 0.05). After controlling for competing factors, Black (odds ratio [OR] 0.7, 95 % confidence interval [CI] 0.5-0.9) and Hispanic patients (OR 0.6, 95 % CI 0.4-0.9) were less likely to receive neoadjuvant chemoradiation compared with non-Hispanic White patients. Females, the uninsured, and those treated at a community cancer center were also less likely to receive neoadjuvant therapy. Having government insurance (OR 0.22, 95 % CI 010-0.49) was a predictor for not receiving surgery. Although 5-year OS was lower (p < 0.05) in Black (59.8 %) and Hispanic patients (65.9 %) compared with non-Hispanic White patients (74.9 %), on multivariate analysis race did not impact mortality. Not having surgery (hazard ratio [HR] 7.1, 95 % CI 2.8-18.2) had the greatest influence on mortality, followed by poorly differentiated histology (HR 3.0, 95 % CI 1.3-6.5), nodal positivity (HR 2.6, 95 % CI 1.9-3.6), no chemotherapy (HR 1.9, 95 % CI 1.03-3.6), no insurance (HR 1.7, 95 % CI 1.1-2.7), and male sex (HR 1.5, 95 % CI 1.1-2.0). CONCLUSION: There are racial and socioeconomic disparities in the treatment of stage II-III rectal cancer in AYAs, many of which impact OS. Interventions that can address and mitigate these differences may lead to improvements in OS for some patients.

Insurance Status, Not Race, is Associated With Use of Minimally Invasive Surgical Approach for Rectal Cancer.

OBJECTIVE: To determine the impact of race and insurance on use of minimally invasive (MIS) compared with open techniques for rectal cancer in the United States. BACKGROUND: Race and socioeconomic status have been implicated in disparities of rectal cancer treatment. METHODS: Adults undergoing MIS (laparoscopic or robotic) or open rectal resections for stage I to III rectal adenocarcinoma were included from the National Cancer Database (2010-2012). Multivariate analyses were employed to examine the adjusted association of race and insurance with use of MIS versus open surgery. RESULTS: Among 23,274 patients, 39% underwent MIS and 61% open surgery. Overall, 86% were white, 8% black, and 3% Asian. Factors associated with use of open versus MIS were black race, Medicare/Medicaid insurance, and lack of insurance. However, after adjustment for patient demographic, clinical, and treatment characteristics, black race was not associated with use of MIS versus open surgery [odds ratio [OR] 0.90, P = 0.07). Compared with privately insured patients, uninsured patients (OR 0.52, P < 0.01) and those with Medicare/Medicaid (OR 0.79, P < 0.01) were less likely to receive minimally invasive resections. Lack of insurance was significantly associated with less use of MIS in black (OR 0.59, P = 0.02) or white patients (OR 0.51, P < 0.01). However, among uninsured patients, black race was not associated with lower use of MIS (OR 0.96, P = 0.59). CONCLUSIONS: Insurance status, not race, is associated with utilization of minimally invasive techniques for oncologic rectal resections. Due to the short-term benefits and cost-effectiveness of minimally invasive techniques, hospitals may need to improve access to these techniques, especially for uninsured patients.

QuickStats: Age-Adjusted Death Rates* for Top Five Causes of Cancer Death,(†) by Race/Hispanic Ethnicity - United States, 2014.

In 2014, the top five causes of cancer deaths for the total population were lung, colorectal, female breast, pancreatic, and prostate cancer. The non-Hispanic black population had the highest age-adjusted death rates for each of these five cancers, followed by non-Hispanic white and Hispanic groups. The age-adjusted death rate for lung cancer, the leading cause of cancer death in all groups, was 42.1 per 100,000 standard population for the total population, 45.4 for non-Hispanic white, 45.7 for non-Hispanic black, and 18.3 for Hispanic populations.

Characterizing Short-Term Outcomes Following Surgery for Rectal Cancer: the Role of Race and Insurance Status.

BACKGROUND: There is a paucity of data demonstrating the effect race and insurance status have on postoperative outcomes for patients with rectal cancer. We evaluated factors impacting short-term outcomes following rectal cancer surgery. DESIGN: Patients who underwent surgery for rectal cancer using the University Health System Consortium database from 2011 to 2012 were studied. Univariate and multivariable analyses were used to identify patient related risk factors for 30-day outcomes after proctectomy: complication rate, 30-day readmission, ICU stay, and length of hospital stay (LOS). RESULTS: A total of 9272 proctectomies were identified in this cohort. After adjustment for potential confounders, black patients were more likely to have 30-day readmissions (OR 1.51, 95 % CI 1.26-1.81), ICU stays (OR 1.25, 95 % CI 1.03-1.51), and longer LOS (+1.67 days, 95 % CI 1.21-2.13) when compared to whites. Compared to those with private insurance, patients with public or military insurance or who were self-pay had a higher likelihood of having postoperative complications. CONCLUSIONS: In patients who undergo elective proctectomy for rectal cancer, non-white and non-privately insured status are associated with significantly worse short-term outcomes. Further studies are needed to determine the implications with respect to receipt of adjuvant therapy and survival.

Dietary Inflammatory Index and Risk of Colorectal Cancer: A Case-Control Study in Korea.

The role of diet-associated inflammation in colorectal cancer is of interest. Accordingly, we aimed to examine whether the dietary inflammatory index (DII) was associated with the risk of colorectal cancer in a case-control study conducted in Korea. The DII was based on dietary intake, which was determined by a 106-item semi-quantitative food frequency questionnaire completed by 923 colorectal cancer cases and 1846 controls. Logistic regression was used to estimate odd ratios (ORs) and 95% confidence intervals (CIs). Subgroup analyses were conducted by the anatomical site of the cancer, sex, and other risk factors. Higher DII scores were associated with an increased incidence of colorectal cancer (OR (95% CI) = 2.16 (1.71, 2.73) for highest vs. lowest tertile). The magnitude differed by anatomical site and sex. This association was slightly weaker in subjects with proximal colon cancer (1.68 (1.08, 2.61)) and was stronger in women (2.50 (1.64, 3.82)). Additionally, stronger associations were observed in subjects who were older than 50 years (p for interaction = 0.004) and engaged in physical activity (p for interaction < 0.001). Results from this study suggest that diet-associated inflammation may increase the risk of colorectal cancer, and this effect may differ by certain factors, such as anatomical site, age, sex, and lifestyle.