Socio-economic disparities in access to treatment and their impact on colorectal cancer survival

Inserm, U866, Dijon, France.
International Journal of Epidemiology (Impact Factor: 9.18). 04/2010; 39(3):710-7. DOI: 10.1093/ije/dyq048
Source: PubMed


Significant socio-economic disparities have been reported in survival from colorectal cancer in a number of countries, which remain largely unexplained. We assessed whether possible differences in access to treatment among socio-economic groups may contribute to those disparities, using a population-based approach.
We retrospectively studied 71 917 records of colorectal cancer patients, diagnosed between 1997 and 2000, linked to area-level socio-economic information (Townsend index), from three cancer registries in UK. Access to treatment was measured as a function of delay in receipt of treatment. We assessed socio-economic differences in access through logistic regression models. Based on relative survival < or =3 years after diagnosis, we estimated excess hazard ratios (EHRs) of death for different socio-economic groups.
Compared with more affluent patients, deprived patients had poorer survival [EHR = 1.20; 95% confidence interval (CI) 1.16-1.25], were less likely to receive any treatment within 6 months [odds ratio (OR) = 0.87, 95% CI 0.82-0.92] and, if treated, were more likely to receive late treatment. No disparities in survival were detected among patients receiving treatment within 1 month from diagnosis. Disparities existed among patients receiving later or no treatment (EHR = 1.30; 95% CI 1.22-1.39), and persisted after adjustment for age and stage at diagnosis (EHR = 1.15; 95% CI 1.08-1.24).
Tumour stage helped explain socio-economic disparities in colorectal cancer survival. Disparities were also greatly attenuated among patients receiving early treatment. Aspects other than those captured by our measure of access, such as quality of care and patient preferences in relation to treatment, might contribute to a fuller explanation.

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    • "Studies from other western countries have provided only limited and inconsistent findings (Coughlin et al., 2006; Clegg et al., 2009; Donnelly and Gavin, 2011). However, numerous studies have suggested that disadvantaged individuals and/or those living far from a reference cancer centre or in remote areas could have poorer access to CRC screening and to specialized healthcare, or could be more prone to an advanced stage at diagnosis leading to a worse prognosis (Dejardin et al., 2005; Blais et al., 2006; Parikh-Patel et al., 2006; Dejardin et al., 2008; Von Wagner et al., 2009; Jambon et al., 2010; Lejeune et al., 2010; Baade et al., 2011; Hines et al., 2014). "
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    ABSTRACT: The aim of this study was to assess the impact of area deprivation and primary care facilities on colorectal adenoma detection and on colorectal cancer (CRC) incidence in a French well-defined population before mass screening implementation. The study population included all patients aged 20 years or more living in Côte d'Or (France) with either colorectal adenoma or invasive CRC first diagnosed between 1995 and 2002 and who were identified from the Burgundy Digestive Cancer Registry and the Côte d'Or Polyp Registry. Area deprivation was assessed using the European deprivation index on the basis of the smallest French area available (Ilots Regroupés pour l'Information Statistique). Healthcare access was assessed using medical density of general practitioners (GPs) and road distance to the nearest GP and gastroenterologist. Bayesian regression analyses were used to estimate influential covariates on adenoma detection and CRC incidence rates. The results were expressed as relative risks (RRs) with their 95% credibility interval. In total, 5399 patients were diagnosed with at least one colorectal adenoma and 2125 with invasive incident CRC during the study period. Remoteness from GP [RR=0.71 (0.61-0.83)] and area deprivation [RR=0.98 (0.96-1.00)] independently reduced the probability of adenoma detection. CRC incidence was only slightly affected by GP medical density [RR=1.05 (1.01-1.08)] without any area deprivation effect [RR=0.99 (0.96-1.02)]. Distance to gastroenterologist had no impact on the rates of adenoma detection or CRC incidence. This study highlighted the prominent role of access to GPs in the detection of both colorectal adenomas and overall cancers. Deprivation had an impact only on adenoma detection.
    European journal of cancer prevention: the official journal of the European Cancer Prevention Organisation (ECP) 06/2015; DOI:10.1097/CEJ.0000000000000175 · 3.03 Impact Factor
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    • "This could be indicative of more severe symptoms at presentation and could be attributed to discrepancies in access to hospital care [42]. Socio-economic differences in survival have also been linked to discrepancies in access to treatment, with those in the most deprived groups more likely to receive late treatment [44], and less likely to receive preferred procedures such as anterior resection for rectal cancer, as compared to the least deprived groups [42]. Geographical and ethnic differences in survival could be reflective of variations in access to hospital care and deprivation [42, 45], but more evidence is needed to substantiate such hypotheses. "
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    ABSTRACT: Background Colorectal cancer survival in the UK is lower than in other developed countries, but the association of time interval between diagnosis and treatment on excess mortality remains unclear. Methods Using data from cancer registries in England, we identified 46,511 patients with localised colorectal cancer between 1996–2009, who were 15 years and older, and who underwent a major surgical resection within 62 days of diagnosis. We used relative survival and excess risk modeling to investigate the association of time between diagnosis and major resection (exposure) with survival (outcome). Results Compared to patients who had major resection within 25–38 days of diagnosis, patients with a shorter time interval between diagnosis and resection and those waiting longer for resection had higher excess mortality (Excess Hazards Ratio, EHR <25 vs 25–38 days: 1.50; 95% Confidence Interval, CI: 1.37 to 1.66; EHR 39–62 vs 25–38 days : 1.16; 95% CI: 1.04 to 1.29). Excess mortality was associated with age (EHR 75+ vs. 15–44 year olds: 2.62; 95% CI: 2.00 to 3.42) and deprivation (EHR most vs. least deprived: 1.27; 95% CI: 1.12 to 1.45), but time between diagnosis and resection did not explain these differences. Conclusion Within 62 days of diagnosis, a U-shaped association of time between diagnosis and major resection with excess mortality for localised colorectal cancer was evident. This indicates a complicated treatment pathway, particularly for patients who had resection earlier than 25 days, and requires further investigation.
    BMC Cancer 08/2014; 14(1):642. DOI:10.1186/1471-2407-14-642 · 3.36 Impact Factor
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    • "While Australia does have universal free hospital cover, previous research has shown that colorectal cancer patients who seek medical care in private hospitals have experienced better outcomes [10]. It is also possible that these area-level effects may at least partially reflect geographical differences in the distribution of other important patient characteristics that are known to influence prognosis, such as overweight, physical inactivity, smoking, dietary patterns, comorbidities and general health status as well as treatment [4-6,9,42]. For example people living in socioeconomically disadvantaged or rural areas are more likely to engage in high risk behaviors such as smoking and decreased physical activity [47]. "
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    ABSTRACT: To explore the impact of geographical remoteness and area-level socioeconomic disadvantage on colorectal cancer (CRC) survival. Multilevel logistic regression and Markov chain Monte Carlo simulations were used to analyze geographical variations in five-year all-cause and CRC-specific survival across 478 regions in Queensland Australia for 22,727 CRC cases aged 20--84 years diagnosed from 1997--2007. Area-level disadvantage and geographic remoteness were independently associated with CRC survival. After full multivariate adjustment (both levels), patients from remote (odds Ratio [OR]: 1.24, 95%CrI: 1.07-1.42) and more disadvantaged quintiles (OR = 1.12, 1.15, 1.20, 1.23 for Quintiles 4, 3, 2 and 1 respectively) had lower CRC-specific survival than major cities and least disadvantaged areas. Similar associations were found for all-cause survival. Area disadvantage accounted for a substantial amount of the all-cause variation between areas. We have demonstrated that the area-level inequalities in survival of colorectal cancer patients cannot be explained by the measured individual-level characteristics of the patients or their cancer and remain after adjusting for cancer stage. Further research is urgently needed to clarify the factors that underlie the survival differences, including the importance of geographical differences in clinical management of CRC.
    BMC Cancer 10/2013; 13(1):493. DOI:10.1186/1471-2407-13-493 · 3.36 Impact Factor
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