Background The proportion of cancer cases in younger patients is increasing though colorectal cancer (CRC) screening guidelines recommend starting at age 50. The national treatment patterns and outcomes of these patients are largely unknown. Methods This is a population-based retrospective cohort study of the nationally representative Surveillance, Epidemiology, and End Results registry for patients diagnosed with CRC from 1998-2011. Patients were categorized as being younger or older than the recommended screening age. Differences in stage at diagnosis, patterns of therapy, and disease-specific survival were compared between age groups using multinomial regression, multiple regression, cox-proportional hazards regression, and Weibull survival analysis. Results Of 258,024 CRC patients, 37,847 (15%) were younger than 50. Young patients were more likely to present with regional (Relative risk ratio [RRR]: 1.3, p<0.001) or distant (RRR: 1.5, p<0.001) disease. CRC patients with distant metastasis were more likely to receive surgical therapy for their primary tumor in the younger age group (adjusted probability: 72% vs. 63%; p<0.001), and radiation therapy was more likely in younger RC patients (adjusted probability: 53% vs. 48%; p<0.001). Patients younger than screening age had better overall disease-specific survival (Hazard ratio: 0.77; p<0.001), despite a larger proportion presenting with advanced disease. Conclusions Colorectal cancer patients diagnosed before age 50 are more likely to present with advanced stage disease. However, they receive more aggressive therapy and achieve longer disease-specific survival, despite the greater proportion with advanced-stage disease. These findings suggest the need for improved risk assessment and screening decisions for younger adults.
STRUCTURED ABSTRACT PURPOSE Individuals from disadvantaged communities are among millions of uninsured Americans gaining insurance under the Affordable Care Act. The extent to which health insurance can mitigate the effects of the social determinants of health on cancer care is unknown. METHODS We linked the Surveillance, Epidemiology, and End Results (SEER) registries to US-Census data to study patients diagnosed with the 4 leading causes of cancer deaths between 2007–2011. We developed a county-level social determinants score using 5 measures of wealth, education and employment. We stratified patients into quintiles, with the lowest quintile representing the most disadvantaged communities. Logistic regression and Cox proportional hazards models were used to estimate associations and cancer-specific survival. RESULTS A total of 364,507 patients aged 18–64 years were identified (134,105 breast,106,914 prostate, 62,606 lung. and 60,881 colorectal). Overall, patients from the most disadvantaged communities (median household income=$42,885; 22% below poverty level; 17% college completion) were more likely to present with distant disease (Odds ratio [OR]=1.6; p<0.001) and less likely to receive cancer-directed surgery (OR=0.8; p<0.001) than the least disadvantaged communities (median income=$78,249; 9% below poverty; 42% college completion). The differences persisted across quintiles regardless of insurance status. The effect of having insurance on cancer-specific survival was more pronounced in disadvantaged communities (40% vs. 31% relative benefit at 3 years). However, it did not fully mitigate the effect of social determinants on mortality (Hazard Ratio 0.77 vs. 0.68; p<0.001). CONCLUSIONS Cancer patients from disadvantaged communities benefit most from health insurance and there is a reduction in disparities in outcome. However, the gap produced by social determinants of health cannot be bridged by insurance alone.
In the last two decades there have been dramatic changes in the epidemiology of Clostridium difficile infection (CDI), with increases in incidence and severity of disease in many countries worldwide. The incidence of CDI has also increased in surgical patients. Optimization of management of C difficile, has therefore become increasingly urgent. An international multidisciplinary panel of experts prepared evidenced-based World Society of Emergency Surgery (WSES) guidelines for management of CDI in surgical patients.
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