S. P. Beierle1, J. McLoughlin1, R. Heidel1, L. Gregory1, M. Casillas1, A. J. Russ1 1University Of Tennessee Graduate School Of Medicine,Surgery,Knoxville, TN, USA
Introduction: Outcomes for colon cancer have improved over the last thirty years due to improved emphasis on screening and better treatment options. However, various regions of the United States remain below the expected outcomes for colon cancer. We hypothesized that rural counties especially in the Appalachian region had worse outcomes for colon cancer and the reasons may be multi-factorial.
Methods: We queried the National Cancer Database (NCDB) for all patients diagnosed with an invasive colon cancer from 2008 – 2013. A total of 712,172 patients were identified in the database. We focused on the South Atlantic and West South Central States which included the states and counties within the defined Appalachian region. We analyzed clinical and pathologic features, socioeconomic factors, distance, and outcomes. Tests for normal distribution, Odds ratio, and Logistic regression were performed.
Results: Of the 712,172 patients identified, we focused on 186,700 patients in the South Atlantic and West South Central states with invasive colon cancer. After accounting for variations in insurance coverage, age, race, income, education, and comorbidities; living beyond 20 miles from the treating hospital increased the likelihood of presenting with metastatic disease (p<0.001). Having no insurance was an independent predictor of presenting with metastatic disease (p<0.001). When evaluating for race , African Americans were 27% more likely to present with metastatic disease at diagnosis than whites [OR 1.27 (p= <.001, 95% CI = 1.234-1.309)]. Additionally the 30 day mortality was higher for African Americans than Caucasians (OR 1.288) and much higher for Charleson Deyo scores of 1 or 2 (OR 6.3 and 7.6). When comparing comorbidities using the Charleson Deyo score, having a known comorbidity corresponded with a decreased likelihood of presenting with metastatic disease at diagnosis (OR 0.837 for 1 comorbidity) and (OR 0.828 for 2 or more comorbidities) (P<.001 for both).
Conclusion: In summary, distance from the treating medical facility as an indicator of rurality confirmed rural communities remain a marker for worse colon cancer outcomes compared to urban communities. Those with no insurance, distance > 20 miles from the treating hospital and African-American race correlated with worse outcomes. Our results suggest that rural communities are undergoing insufficient screening tests for colon cancer given the higher risk of presenting with metastatic disease. Further, the risk of presenting with advanced disease decreased with increasing comorbidities further suggesting a lack of medical access for those in rural communities.
