Background Over fifty million people reside in rural America. However, the impact of patient rurality on colon cancer care has been incompletely characterized, despite its known impact on screening. Objective Our study sought to examine the impact of patient rurality on quality and comprehensive colon cancer care. Design Using the 1996–2008 California Cancer Registry, we constructed a retrospective cohort of 123,129 patients with stage 0–IV colon cancer. Rural residence was established based on the patient’s medical service study area designated by the registry. Patients All patients diagnosed between 1996–2008 with tumors located in the colon were eligible for inclusion in this study. Main Outcome Measures Baseline characteristics were compared by rurality status. Multivariate regression models then were used to examine the impact of rurality on stage in the entire cohort, adequate lymphadenectomy in stage I–III disease and receipt of chemotherapy for stage III disease. Proportional hazards regression was used to examine the impact of rurality on cancer specific survival. Results Of all patients diagnosed with colon cancer, 18,735 (15%) resided in rural areas. Our multivariate models demonstrate that rurality was associated with later stage of diagnosis, inadequate lymphadenectomy in stage I–III disease and lower likelihood of receiving chemotherapy for stage III disease. In addition, rurality was associated with worse cancer specific survival. Limitations We could not account for socioeconomic status directly, though we used insurance status as one surrogate. Furthermore, we did not have access to treatment location or distance traveled. We also could not account for provider or hospital case volume, patient comorbidities nor complications. Conclusions A significant portion of patients treated for colon cancer live in rural areas. Yet, rural residence is associated with modest differences in stage, adherence to quality measures and survival. Future endeavors should help improve care to this vulnerable population (see SDC1: video abstract).

Background Stakeholders derive many benefits from cancer clinical trials, including guidance for future oncologic treatment decisions. However, whether enrollment in cancer trials also improves patient survival independently of trial outcomes remains under-investigated. We hypothesized that cancer trial enrollment is not associated with patient survival outcomes. Methods Using the 2002–2008 California Cancer Registry, we identified 555,469 patients with stage I–IV solid organ tumors. Baseline characteristics were compared by trial participation status. Logistic regression determined predictors of trial enrollment. Multivariate Cox proportional hazards regression examined the impact of trial participation on overall and cancer specific mortality with adjustment for covariates. Results Only 0.33% of our cohort was enrolled in clinical trials. Trial participants were likely to be younger than 65 (OR 2.13; 95% CI 1.90–2.38), Hispanic rather than non-Hispanic white (OR 0.78; 95% CI 0.67–0.90) and have breast cancer (OR 3.14; 95% CI 2.62–3.77). Multivariate survival analyses demonstrated that enrollment in cancer trials predicted a lower hazard of death. However, when stratified by disease site, this survival benefit was only observed in lung, colon and breast cancers (Table). Sensitivity and interaction analyses confirmed these relationships. Conclusions In this first population-based study examining trial effect in solid organ cancers, enrollment into cancer trials predicted lower overall and cancer specific mortality among common cancer sites. While these findings may demonstrate a survival benefit due to trial enrollment, they likely also reflect the favorable attributes of trial enrollees. Once corroborated, stakeholders must consider broader cancer trial designs representative of the cancer burden treated in the real world.

The outcomes after colectomy for cancer are comparable in right-sided and left-sided resections, except for in the case of superficial SSI, which is less common in right-sided resections. Further research on SSI after colectomy should incorporate right vs left side as a potential preoperative risk factor.

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