Does Patient Rurality Predict Quality Colon Cancer Care?

Abstract

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).

Rural–urban residence and cancer survival in high‐income countries: A systematic review

“…Seventeen studies were conducted in Australia, 16 in the United States, 6 in Europe, 4 in Canada, and 2 in New Zealand . These studies investigated several neoplasms including female breast, male breast, cervix, colorectum, endometrium, esophagus and stomach, liver (intrahepatic cholangiocarcinoma), lung, melanoma, neuroendocrine tumours, non‐Hodgkin lymphoma, ovary, pancreas, prostate, and selected groups of cancers . Most studies used only population‐based cancer registry data, while others used data from a range of sources including hospitals, academic medical centers, or treatment services or registries; others used population‐based cancer registries linked with public and private hospitals and treatment datasets .…”

“…Twenty‐one studies reported overall survival (ie, death from any cause) . The remaining studies presented cancer‐specific or relative survival, which estimate effects on death due to the cancer under study only …”

“…Others defined rural/urban residence based on population size or density, local government area, or distance from treatment centers . Some studies defined location based on the patients’ medical service study area, address, residential postal code, or main income sources for the municipality . One Australian study simply compared metropolitan and other residence, and one study did not provide detailed information on how “rural” and “urban” were defined …”

Geographic disparities in residential proximity to colorectal and cervical cancer care providers

“…Despite improvements in preventive and treatment opportunities for patients with colorectal and cervical cancers, rural patients are less likely to receive state‐of‐the‐art treatment. In fact, previous studies have associated residential rurality with cancer diagnosis at a later stage, inappropriate and/or underuse of treatment, and poorer survival . Across all tumor sites, high disparate mortality rates from colorectal and cervical cancers have raised concerns regarding access to cancer care …”

Rural–urban differences in surgical treatment, regional lymph node examination, and survival in endometrial cancer patients

“…It is important to understand rural–urban differences in the receipt of surgical care for endometrial cancer, especially as rural counties lack spatial access to gynecologic oncologist services, which may put them at greater risk of endometrial cancer mortality [25, 26]. Furthermore, multiple studies have shown that rural patients with other cancer types are less likely to have lymph nodes examined and/or to have adequate lymphadenectomy during their surgical treatment [27–29]. This has not been explored for endometrial cancer patients.…”