Maimonides Evening of Research
Fellow Winner
Pramod Nepal, MBBS, PhD; Elie Sutton, MD; Rebecca Rhee, MD
Division of Colorectal Surgery, Department of Surgery, Maimonides Medical Center, Brooklyn, NY
Patients with Early-Onset Locally advanced Rectal Cancer Receiving Neoadjuvant Therapy: Impact of Socioeconomic Factors on Treatment and Outcomes.
Purpose/Background
The rising incidence of colorectal cancer (CRC) in young adults under 50, known as early-onset CRC, is an emerging epidemic in the U.S. over the past three decades. This shift urges a refocus on managing CRC in this demographic. Socioeconomic inequities impact healthcare access, treatment decisions, and survival outcomes. A better understanding of the impact of the such inequities in younger populations could enhance interventions aimed at addressing the disparity in treatment outcomes.
Methods
We identified patients aged 50 years or less with stage II-III locally advanced rectal cancer, adenocarcinoma in histology, treated with neoadjuvant therapy followed by definitive surgery using the National Cancer Database. Socioeconomic factors, including insurance, median household income, and percentage of no high school degree (HSD) in the zip code of residence, were included. The associations between these factors and time from diagnosis to treatment, radiation therapy, and definitive surgery were analyzed. Further, we compared the survival of the patients using the Kaplan-Meier survival analysis.
Results
A total of 10,286 patients with early onset LARC who underwent neoadjuvant therapy from 2004-2016 followed by definitive surgery were identified. Among them, 60% were male and 40% were female. The patient population was comprised of 76.8 % Non-Hispanic White, 9 % Black, 8.2 % Hispanic, and 6% others. 75.5% patients had private insurance, 11.7% had Medicaid, 3.4% had Medicare, 1.5% had other government insurance, and 6.4% had no insurance.
The median days from diagnosis to start of treatment was 29 days; diagnosis to radiation therapy was 32 days; and diagnosis to definitive surgery was 130 days. Patients in lower median income quartiles had longer wait to start for overall treatment (32 days vs 28 days, p<0.001), radiation therapy (34 vs 31 days, p<0.001), and days to definitive surgery (133 vs 129, p<0.001) compared to higher income quartiles. Similarly, patients from zip codes with a higher percentage of no HSD had longer wait to overall treatment (p<0.001), radiation therapy (p<0.001), systemic therapy (p<0.001), and definitive surgery (p<0.001). Patients with Medicare insurance had longer wait to treatment (p<0.001), radiation therapy (p<0.001), and systemic therapy (p<00.1) compared to other primary payer groups, whereas patients enrolled in Medicaid had a longer wait for definitive surgery (p<0.001). Likewise, Black patients had longer wait for overall treatment, radiation therapy and definitive surgery (p<0.001). Following surgery, the 30-day mortality was 0.1% and 90-day mortality was 0.4%. The overall survival was worst in Black patients (144.5 months, vs highest survival in Hispanic population, 159 months, p<0.001). Likewise, the lowest income group had an overall 145 months survival compared to 165 months of the highest income group, p<0.001. The lowest education group had worse survival rates (145 vs 163.6 months, p<0.001).
Conclusion
Patients from communities with lower median income and level of education, enrolled in Medicaid managed care, and Black patients had longer wait to treatment, which was associated with poorer overall survival. These results warrant further analysis and measures to address this disparity.