Geographic remoteness, area-level socioeconomic disadvantage and inequalities in colorectal cancer survival in Queensland: a multilevel analysis

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Abstract

Background

To explore the impact of geographical remoteness and area-level socioeconomic disadvantage on colorectal cancer (CRC) survival.

Methods

Multilevel logistic regression and Markov chain Monte Carlo simulations were used to analyze geographical variations in five-year all-cause and CRC-specific survival across 478 regions in Queensland Australia for 22,727 CRC cases aged 20–84 years diagnosed from 1997–2007.

Results

Area-level disadvantage and geographic remoteness were independently associated with CRC survival. After full multivariate adjustment (both levels), patients from remote (odds Ratio [OR]: 1.24, 95%CrI: 1.07-1.42) and more disadvantaged quintiles (OR = 1.12, 1.15, 1.20, 1.23 for Quintiles 4, 3, 2 and 1 respectively) had lower CRC-specific survival than major cities and least disadvantaged areas. Similar associations were found for all-cause survival. Area disadvantage accounted for a substantial amount of the all-cause variation between areas.

Conclusions

We have demonstrated that the area-level inequalities in survival of colorectal cancer patients cannot be explained by the measured individual-level characteristics of the patients or their cancer and remain after adjusting for cancer stage. Further research is urgently needed to clarify the factors that underlie the survival differences, including the importance of geographical differences in clinical management of CRC.

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Most cited references 29

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Impact of comorbidity on chemotherapy use and outcomes in solid tumors: a systematic review.

Monika Krzyzanowska, Belinda W Y Cheung, Benjamin E. Atkinson … (2011)

The treatment of cancer in patients with comorbidities can be challenging as these individuals are underrepresented in clinical trials. We conducted a systematic review to determine the impact of comorbidity on chemotherapy use, delivery, tolerability, and survival among patients with solid tumors to summarize current data and provide recommendations for future research. METHODS All English-language articles from 1990 to 2009 that explored the association between comorbidity and chemotherapy were identified from MEDLINE and EMBASE. Abstracts were reviewed for eligibility, and data on study design and results were extracted. Thirty-four articles met the inclusion criteria. Study populations and design were heterogeneous, and the quality of reporting was generally poor. Most studies were retrospective (76%), were based on a cancer registry linked with administrative data (47%), and assessed the overall effect of comorbidity using an index score (76%). Sixteen studies (47%) investigated chemotherapy use, and 29 (85%) addressed survival. The majority reported decreased chemotherapy use (75%) and inferior survival (69%) for patients with comorbidities compared to those without. In 11 of 14 studies, inferior survival was independent of treatment. Of the few studies that addressed chemotherapy tolerability, seven of 10 reported an increased rate of severe toxicity, and three of five reported increased treatment delays for patients with comorbidity. CONCLUSION Chemotherapy use and outcomes among cancer patients with comorbidities are generally inferior, but the existing evidence is limited and of insufficient quality to determine the relationship between decreased use and inferior survival. Further studies that are prospective and site and stage specific are warranted.

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Socioeconomic status and changing inequalities in colorectal cancer? A review of the associations with risk, treatment and outcome.

Mieke J Aarts, Valery E.P.P. Lemmens, Marieke Louwman … (2010)

Upcoming mass screening for colorectal cancer (CRC) makes a review of recent literature on the association with socioeconomic status (SES) relevant, because of marked and contradictory associations with risk, treatment and outcome. The Pubmed database using the MeSH terms 'Neoplasms' or 'Colorectal Neoplasms' and 'Socioeconomic Factors' for articles added between 1995 and 1st October 2009 led to 62 articles. Low SES groups exhibited a higher incidence compared with high SES groups in the US and Canada (range risk ratio (RR) 1.0-1.5), but mostly lower in Europe (RR 0.3-0.9). Treatment, survival and mortality all showed less favourable results for people with a lower socioeconomic status: Patients with a low SES received less often (neo)adjuvant therapy (RR ranging from 0.4 to 0.99), had worse survival rates (hazard ratio (HR) 1.3-1.8) and exhibited generally the highest mortality rates up to 1.6 for colon cancer in Europe and up to 3.1 for rectal cancer. A quite consistent trend was observed favouring individuals with a high SES compared to those with a low SES that still remains in terms of treatment, survival and thus also mortality. We did not find evidence that the low/high SES gradients for treatment chosen and outcome are decreasing. To meet increasing inequalities in mortality from CRC in Europe for people with a low SES and to make mass screening successful, a high participation rate needs to be realised of low SES people in the soon starting screening program. Copyright © 2010 Elsevier Ltd. All rights reserved.

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The accuracy of cancer mortality statistics based on death certificates in the United States.

Melonie Heron, Megan L. Finch, Amanda Stewart … (2011)

One measure of the accuracy of cancer mortality statistics is the concordance between cancer defined as the underlying cause of death from death certificates and cancer diagnoses recorded in central, population-based cancer registries. Previous studies of such concordance are outdated. To characterize the accuracy of cancer mortality statistics from the concordance between cancer cause of death and primary cancer site at diagnosis. Central cancer registry records from California, Colorado, and Idaho in the U.S. were linked with state vital statistics data and evaluated by demographic and tumor information across 79 site categories. A retrospective arm (confirmation rate per 100 deaths) compared death certificate data from 2002 to 2004 with cancer registry diagnoses from 1993 to 2004, while a prospective arm (detection rate per 100 deaths) compared cancer registry diagnoses from 1993 to 1995 with death certificate data from 1993 to 2004 by International Statistical Classification of Diseases and Related Health Problems (ICD) version used to code deaths. With n=265,863 deaths where cancer was recorded as the underlying cause based on the death certificate, the overall confirmation rate for ICD-10 was 82.8% (95% confidence interval [CI], 82.6-83.0%), the overall detection rate for ICD-10 was 81.0% (95% CI, 80.4-81.6%), and the overall detection rate for ICD-9 was 85.0% (95% CI, 84.8-85.2%). These rates varied across primary sites, where some rates were <50%, some were 95% or greater, and notable differences between confirmation and detection rates were observed. Important unique information on the quality of cancer mortality data obtained from death certificates is provided. In addition, information is provided for future studies of the concordance of primary cancer site between population-based cancer registry data and data from death certificates, particularly underlying causes of death coded in ICD-10. Copyright © 2010 Elsevier Ltd. All rights reserved.

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Author and article information

Contributors

Peter D Baade

Paramita Dasgupta

Joanne F Aitken

Gavin Turrell

Journal

Journal ID (nlm-ta): BMC Cancer

Journal ID (iso-abbrev): BMC Cancer

Title: BMC Cancer

Publisher: BioMed Central

ISSN (Electronic): 1471-2407

Publication date Collection: 2013

Publication date (Electronic): 24 October 2013

Volume: 13

Page: 493

Affiliations

[1 ]Cancer Council Queensland, Brisbane, Australia

[2 ]School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia

[3 ]Griffith Health Institute, Griffith University, Gold Coast, Australia

[4 ]School of Population Health, University of Queensland, Brisbane, Australia

[5 ]Senior Research Fellow, Cancer Council Queensland, PO Box 201, Spring Hill, QLD 4001, Australia

Article

Publisher ID: 1471-2407-13-493

DOI: 10.1186/1471-2407-13-493

PMC ID: 3871027

PubMed ID: 24152961

SO-VID: 1bb4b0bc-bd5e-4c18-beba-19bcab25101b

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Geographic remoteness, area-level socioeconomic disadvantage and inequalities in colorectal cancer survival in Queensland: a multilevel analysis

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Karger: Oncology

Most cited references 29

Impact of comorbidity on chemotherapy use and outcomes in solid tumors: a systematic review.

Socioeconomic status and changing inequalities in colorectal cancer? A review of the associations with risk, treatment and outcome.

The accuracy of cancer mortality statistics based on death certificates in the United States.

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