Disparities in access to care among patients with appendiceal or colorectal cancer and peritoneal metastases: A medicare insurance-based study in the United States

Abstract

BackgroundPrior studies attempting to identify disparities in the care of patients with appendiceal (AC) or colorectal cancer (CRC) with peritoneal metastasis (PM) are limited to single-institution, highly selected patient populations. This observational cohort study sought to identify factors associated with specialty care for Medicare beneficiaries with AC/CRC-PM.Materials and methodsPatients >65 years old in the United States diagnosed with AC/CRC and isolated PM were identified within the Medicare Standard Analytic File (2013-2017). Mixed-effects analyses assessed patient factors associated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) and outpatient consultation with a peritoneal surface malignancy (PSM) surgeon, and Cox proportional-hazards analysis compared 3-year overall survival (OS) between patients receiving CRS/HIPEC versus systemic therapy alone.ResultsAmong 7,653 patients, only 250 (3.3%) underwent CRS/HIPEC. Among those individuals who did not undergo CRS/HIPEC (N=7,403), only 475 (6.4%) had outpatient consultation with a PSM surgeon. Patient factors independently associated with lower odds of CRS/HIPEC and PSM surgery consultation included older age, greater comorbidity burden, higher social vulnerability index, and further distance from a PSM center (p<0.05). CRS/HIPEC was independently associated with better 3-year OS compared with systemic therapy alone (HR=0.29, 95%CI=0.21-0.38).ConclusionAn exceedingly small proportion of Medicare beneficiaries with AC/CRC-PM undergo CRS/HIPEC or even have an outpatient consultation with a PSM surgeon. Significant disparities in treatment and access to care exist for patients with higher levels of social vulnerability and those that live further away from a PSM center. Future research and interventions should focus on improving access to care for these at-risk patient populations.

Race and Ethnicity Impacts Overall Survival of Patients with Appendiceal Cancer Who Undergo Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy

“…Perhaps this variable alone reflects socioeconomic differences and disparities that contribute to access to care. For example, in a recent Medicare-based cohort study of individuals in the United States 65 years and older with colorectal peritoneal metastases, the authors demonstrated that living further away from an HIPEC center and higher measured social vulnerability were independently associated with lower odds of accessing CRS/HIPEC [29]. This, along with our data, advocates for increased CRS/HIPEC access and the treatment of appendiceal cancer for diverse patient populations.…”

Towards Equal Access to Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy and Survival in Patients with Isolated Colorectal Peritoneal Metastases: A Nationwide Population-Based Study

“… 5 However, previous studies showed significant disparities in access to CRS-HIPEC based on hospital of diagnosis. 6 , 7 …”

“…While a substantial body of literature emphasizes the reduction of inequalities in access to care, it primarily focuses on disparities driven by factors such as socioeconomic status (SES), race and ethnicity (e.g., 10 – 12 ). Despite numerous studies illustrating inter-hospital variation in access to care (e.g., 6 , 7 ), limited attention has been given to the effects of (national) efforts aimed at reducing such disparities. Hence, the current study assessed whether the variation in utilization of CRS-HIPEC, and, as a consequence, survival, of patients with isolated synchronous PMCRC reduced since national efforts were initiated.…”