Influence of Race, Insurance, Rurality, and Socioeconomic Status on Equity of Lung and Colorectal Cancer Care | Annals of Surgical Oncology Skip to main content

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Influence of Race, Insurance, Rurality, and Socioeconomic Status on Equity of Lung and Colorectal Cancer Care

  • Thoracic Oncology
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Abstract

Background

This study evaluated the influence that social determinants of health had on stage at diagnosis and receipt of cancer-directed surgery for patients with lung and colorectal cancer in the North Carolina Central Cancer Registry (2010–2015).

Methods

This study examined non-Hispanic uninsured or privately-insured patients 18 to 64 years of age. Multivariable logistic regression models, including two-way interaction terms, assessed the influence of race, insurance status, rurality, and Social Deprivation Index on stage at diagnosis and receipt of surgery.

Results

6574 lung cancer patients and 5355 colorectal cancer patients were included. Among the lung cancer patients, the uninsured patients had higher odds of having stage IV disease (odds ratio [OR] = 1.46; 95 % confidence interval [CI] = 1.22–1.76) and lower odds of receiving surgery (OR = 0.48; 95 % CI = 0.34–0.69) than the privately-insured patients. Among the colorectal cancer patients, uninsured status was associated with higher odds of stage IV disease (OR = 1.53; 95 % CI = 1.17–2.00) than privately-insured status. A significant insurance status and rurality interaction (p = 0.03) was found in the colorectal model for receipt of surgery. In the privately-insured group, non-Hispanic Black and rural patients had lower odds of receiving colorectal surgery (OR = 0.69; 95 % CI = 0.50–0.94 and OR = 0.68; 95 % CI = 0.52–0.89; respectively) than their non-Hispanic White and urban counterparts.

Conclusions

After controlling for confounding and evaluation of interactions between patient-, community-, and geographic-level factors, uninsured status remained the strongest driver of patients’ presentation with late-stage lung and colorectal cancer. As policy and care delivery transformation targets uninsured and vulnerable populations, explicit recognition, and measurement of intersectionality should be considered.

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Authors and Affiliations

  1. The Geisel School of Medicine at Dartmouth, Hanover, NH, USA

    Mary M. Leech BA, Chad Markey BA & Andrew P. Loehrer MD, MPH

  2. Norris Cotton Cancer Center, Lebanon, NH, USA

    Julie E. Weiss MS

  3. Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA

    Andrew P. Loehrer MD, MPH

  4. The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA

    Andrew P. Loehrer MD, MPH

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  1. Mary M. Leech BA
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Correspondence to Mary M. Leech BA.

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Appendices

Appendix 1

Definition for cancer stagea

Derived AJCC-7 stage GRP

NAACCR item no. 3430

Code

Description

Stage

000

Stage 0

0

010

Stage 0a

0

020

Stage 0is

0

100

Stage 1

1

110

Stage 1NOS

1

120

Stage 1A

1

130

Stage 1A1

1

140

Stage 1A2

1

121

Stage 1A NOS

1

150

Stage 1B

1

160

Stage 1B1

1

170

Stage 1B2

1

151

Stage 1B NOS

1

180

Stage 1C

1

190

Stage 1S

1

300

Stage 2

2

310

Stage 2 NOS

2

320

Stage 2A

2

321

Stage 2A NOS

2

322

Stage 2A1

2

323

Stage 2A NOS

2

330

Stage 2B

2

340

Stage 2C

2

500

Stage 3

3

510

Stage 3 NOS

3

520

Stage 3A

3

530

Stage 3B

3

540

Stage 3C

3

541

Stage 3C1

3

542

Stage 3C2

3

700

Stage 4

4

710

Stage 4 NOS

4

720

Stage 4A

4

730

Stage 4B

4

740

Stage 4C

4

888

Not applicable

9

900

Stage occult

9

999

Stage Unknown

9

  1. aDerived from the American Joint Committee on Cancer (AJCC)-7 Stage Group Crosswalk (https://seer.cancer.gov/data-software/documentation/seerstat/nov2018/TextData.FileDescription.pdf, accessed 7/15/2020)

Appendix 2

Definition for cancer-directed surgery

Code

Surgical procedure of primary site (NAACCR #1290)a

Cancer-directed surgery

00

None; no surgery of primary site; autopsy ONLY

No

10–19

Local tumor destruction, NOS

No

20–80

Site-specific codesb

Yes

90

Surgery, NOS

No

99

Unknown whether surgery was performed; death certificate ONLY

No

  1. aRetrieved 10 July 2020 at https://www.facs.org/~/media/files/quality%20programs/cancer/ncdb/store_manual_2018.ashx, pages 468–470, Appendix B: site-specific surgery codes
  2. bAdditional site-specific codes for lung and colorectal cancer coded as “No” for cancer-directed surgery:

Lung

22 Segmental resection, including lingulectomy

23 Excision, NOS

24 Laser excision

Colorectal

20 Local tumor excision, NOS

27 Excisional biopsy

26 Polypectomy, NOS

28 Polypectomy-endoscopic

29 Polypectomy-surgical excision

Any combination of 20 or 26–29 WITH

21 Photodynamic therapy (PDT)

22 Electrocautery

23 Cryosurgery

24 Laser ablation

25 Laser excision

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Leech, M.M., Weiss, J.E., Markey, C. et al. Influence of Race, Insurance, Rurality, and Socioeconomic Status on Equity of Lung and Colorectal Cancer Care. Ann Surg Oncol 29, 3630–3639 (2022). https://doi.org/10.1245/s10434-021-11160-1

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