Socioeconomic inequalities in the use of radiotherapy for rectal cancer: A nationwide study

doi:10.1016/j.ejca.2010.03.015

European Journal of Cancer

Volume 47, Issue 3, February 2011, Pages 347-353

https://doi.org/10.1016/j.ejca.2010.03.015 Get rights and content

Abstract

Preoperative radiotherapy (PRT) in rectal cancer reduces the risk of local recurrence by at least half but the influence of the socioeconomic status of patients on the use of PRT is little investigated in Europe.

Methods

Individually attained data on civil status, education and income were linked to the Swedish Rectal Cancer Registry 1995–2005 (n = 16,713) and analysed by logistic regression.

Results

Forty-six percentage of the patients received PRT and the crude rate varied with age, gender, civil status, education and income as well as with sublocalisation, stage, type of hospital and health care region. In a multivariate analysis, all civil status groups had PRT to a lesser extent compared with married patients; odds ratio (OR) for unmarried patients was 0.67 (95% confidence interval (CI) 0.59–0.76). Patients with secondary and university education had PRT to the same extent as those with compulsory school (OR 1.04 (0.94–1.15) and 0.92 (0.81–1.06)). The use of PRT was associated with income; OR for patients with income Q1 versus Q4 was 0.76 (0.67–0.86). The inequalities by civil status and income remained unchanged also in groups with a relatively stronger indication for adjuvant radiotherapy, i.e. younger patients and in low rectal cancer.

Conclusion

Unmarried and low-income patients are at increased risk for not receiving PRT in rectal cancer. Comorbidity may explain some differences but increased awareness of the role of non-medical variables for the use of PRT is warranted.

Introduction

Treatment for rectal cancer has changed substantially over the past decades. A refined surgical technique (total mesorectal excision, TME) has been introduced¹ and (neo)adjuvant radiotherapy has become an integrated part of rectal cancer treatment.2, 3 Preoperative radiotherapy (PRT) specifically reduces the risk of local recurrence by at least half and improves disease free-survival.4, 5 In Sweden, PRT has been advocated since many years.³

However, PRT has side-effects, both immediate complications⁶ and a long-term health impact.⁷ The optimal selective use is yet not identified8, 9 and for the time, the factors guiding the use of PRT are age of the patient, clinical stage of the disease and distance of the tumour from the anal verge. Nevertheless, an under-utilisation of radiotherapy in rectal cancer based on race has been reported from the United States.¹⁰ Inequalities in the use of adjuvant radiotherapy in rectal cancer, except for age,¹¹ are little investigated from a European perspective. We hypothesised that the socioeconomic background of patients influences the decision on PRT, also in a population covering health care system, but that the association would be less clear in groups of patients with a relatively stronger indication for PRT, i.e. in younger patients and in low rectal cancer. Female rectal cancer patients have been reported to receive radiotherapy less often than men,12, 13, 14 and we hypothesised that socioeconomic factors contribute to this gender related inequality. We therefore linked individually obtained data on civil status, education and income to a nationwide quality registry for rectal cancer. Our aim was to clarify the use of PRT in rectal cancer in relation to socioeconomic variables in a country with full coverage public health insurance.

Section snippets

The Swedish Rectal Cancer Registry

The Swedish Rectal Cancer Registry (SRCR) was initiated in 1995.¹⁵ All surgical departments deliver diagnostic, clinical, surgical and pathological data on patients with rectal cancer, in addition to the compulsory report to the Swedish Cancer Registry. Six regional oncology centres administer the data initially, check them for completeness and accuracy and then submit the reports to the national centralised SRCR. Annually, approximately 1500 new patients with an invasive adenocarcinoma of the

Baseline characteristics

The majority of patients (57.1%) were men (Table 1). Median age was 72 (range 20–100) years, and one in four patients was 80 years or older. Mid-rectum was the most common sublocalisation (38.8%). Pathological stage was available for just below 90% and 1/6 of the patients had generalised disease at diagnosis. For patients below the age of 75, information on education was available in 94.2% but for patients above the age of 75 years, it was lacking for the majority (84%). Information about

Discussion

In this study, we found very robust results of socioeconomic inequalities in the use of PRT. Unmarried patients and those with the lowest income consistently received PRT less often compared with other groups. A relatively stronger indication for PRT, i.e. younger patients and low rectal cancer, did not change the pattern.

This is the first in-depth analysis on the use of PRT in rectal cancer in relation to socioeconomic background of patients from a country with universal health care. Our

Conflict of interest statement

None declared.

Acknowledgement

The study was supported financially by the Sörmland County Council.

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The choice of treatment for rectal cancer often differs in older and younger patients, with the rate of radiotherapy use lower among older adults. In our daily practice, when evaluating a frail older patient with rectal cancer, we usually choose to give less treatment. This may be due to concern that the patient will not be able to tolerate radiotherapy. The Geriatric 8 score (G8GS) is a guide to evaluating treatment tolerability as it relates to frailty in older adults with cancer. The aim of this study was to evaluate treatment outcomes and tolerability in older patients with rectal cancer treated with radiotherapy (RT) accompanied by G8GS.
Patients aged 65 and older with stage I-III rectal adenocarcinoma who were treated with RT and had a G8 evaluation were included in this multicenter retrospective study. Prognostic factors related to G8GS were calculated using Chi-square and logistic regression tests and survival rates were calculated by the Kaplan–Meier test using the SPSS v24.0 software. All p-values ≤0.05 were considered statistically significant.
A total of 699 patients from 16 national institutions were evaluated. The median age was 72 years (range 65–96), and the median follow-up was 43 (range 1-190) months. Four hundred and fifty patients (64%) were categorized as frail with G8GS ≤14 points. Frail patients had higher ages (p = 0.001) and more comorbidities (p = 0.001). Ability to receive concomitant and/or adjuvant chemotherapy rates were significantly higher in fit patients (p = 0.002 and p = 0.001, respectively). No significant difference was observed in terms of grade 3-4 early and late toxicity for both groups. Cancer-related death was higher (p = 0.003), and 5- and 8-year survival rates were significantly lower (p = 0.001), in the frail group. Age and being frail were significantly associated with survival.
Radiotherapy is a tolerable and effective treatment option for older adults with rectal cancer even with low G8GS. Being in the frail group according to G8GS and having multiple comorbidities was negatively associated with survival. Addressing the medical needs of frail patients through a comprehensive geriatric assessment prior to radiotherapy may improve G8GS, allowing for standard treatment and increased survival rates.
Despite multi-disciplinary team discussions the socioeconomic disparities persist in the oncological treatment of non-metastasized colorectal cancer
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The introduction of national guidelines should eliminate previously observed associations between socioeconomic status (SES) and colorectal cancer treatment. The aim of the study was to investigate whether inequalities remain.
CRCBaSe, a register-linkage originating from the Swedish Colorectal Cancer Registry, was used to identify information on patient and tumour characteristics, for 83,460 patients with stage I-III disease diagnosed 2008–2021. SES was measured as disposable income (quartiles) and the highest level of education. Outcomes of interest were emergency surgery, multidisciplinary team (MDT) conference discussion, and oncological treatment. Differences in treatment between SES groups were explored using multivariable logistic regression adjusted for year of diagnosis, age at diagnosis, sex, civil status, comorbidities, tumour location and stage.
Patients in the highest income quartile had a lower risk of emergency surgery (OR 0.73 95%CI 0.68–0.80), a higher chance of being discussed at the preoperative (OR 1.39 95%CI 1.28–1.51) and postoperative MDT (OR 1.41 95%CI 1.30–1.53), receiving neoadjuvant (OR 1.15 95%CI 1.06–1.25) and adjuvant treatment (OR 2.04 95%CI 1.88–2.20). Higher education level increased the odds of MDT discussion but was not associated with oncological treatment. The proportion of patients discussed at the MDT increased, with almost all patients discussed since 2016. Despite this, treatment differences remained when patients diagnosed since 2016 were analysed separately.
There were significant differences in how patients with different SES were treated for colorectal cancer. Further action is required to investigate the drivers of these differences as well as their impact on mortality and, ultimately, eliminate the inequalities.
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As regards colorectal cancer (CRC) in France, social inequalities in health (SIH) exist. Underprivileged patients are characterized by reduced incidence of CRC and, conversely, by excess mortality. The explanatory mechanisms of the SIHs influencing survival are complex, multidimensional and variable according to healthcare system. Among the most deprived compared to the least deprived patients, SIHs are reflected by lower participation in screening campaigns, and CRC diagnosis is more frequently given at a later stage in an emergency context. During treatment, disadvantaged patients are more at risk of having to undergo open surgery and of enduring severe postoperative complications and belated chemotherapy (when recommended). Study of SIHs poses unusual challenges, as it is necessary not only to pinpoint social deprivation, but also to locate the different treatment facilities existing in a given territorial expanse. In the absence of individualized socioeconomic information, research in France on the social determinants of health is based on duly constituted cancer registries, in which an ecological index of social deprivation, the European Deprivation Index (EDI), provides an aggregate measure of the socioeconomic environment of a given individual in a given geographical setting at a given point in time. All in all, studies on SIHs are justified as means of identification and comprehension of the mechanisms underlying social deprivation, the objective being to more precisely orient programs and practices aimed at combating SIH.
Radiotherapy utilisation rates for patients with cancer as a function of age: A systematic review
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Citation Excerpt :
The RTU rate for patients with rectal cancer decreased with increasing age for all studies (Fig. 2d). The largest study of rectal cancer patients was by Olsson et al. [16] This population-based cohort study analysed 16,713 patients registered in the Swedish Rectal Cancer Registry from 1995 to 2005. The RTU rate decreased from 63.8% (≤ 65 years) to 49.6% (66–79 years)to 14.6% for the oldest age group (80+ years) [16].
There is an increasing incidence of cancer in older people, but limited data on radiotherapy uptake, and in particular, radiotherapy utilisation (RTU) rates. The RTU rate for older adults with cancer may be lower than recommended due to lower tolerance for radiotherapy as well as additional comorbidities, reduced life expectancy and travel for treatment. Radiotherapy use must be aligned with best available, age-specific evidence to ensure older adults with cancer receive optimal benefit without harms.
A systematic review was conducted to synthesise the published data on the actual RTU rate for patients with cancer as a function of age.
MEDLINE and EMBASE were systematically searched to identify relevant population-based and hospital-based cohort studies on radiotherapy utilisation for all age groups, published in English, from 1 January 1990 to 1 July 2020. We focused on the following common cancers in older adults for which radiotherapy is recommended: breast, prostate, lung, rectal cancer, glioblastoma multiforme (GBM), and cervical cancer. Age-specific radiotherapy utilisation data were extracted and analysed as a narrative synthesis.
From 2606 studies screened, 75 cohort and population-based studies were identified with age-specific radiotherapy utilisation data. The total number of patients in the 75 studies was 4,792,138. The RTU rate decreased with increasing age for all tumour sites analysed, except for patients receiving curative radiotherapy as definitive treatment for prostate or cervical cancer. This reduction with increasing age was demonstrated in both palliative and curative settings.
There is a global reduction in radiotherapy utilisation with increasing age for most tumour sites. The reduction in delivery of radiotherapy warrants further examination and evidence-based guidelines specific to this population.
Disparities in neoadjuvant radiation dosing for treatment of rectal cancer
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Citation Excerpt :
An NCDB study of young adults and adolescents with locally advanced rectal cancer also demonstrated black and Hispanic patients were less likely to receive neoadjuvant chemoradiation, along with uninsured patients and those treated at community cancer centers.7 Other socioeconomic factors previously linked with inadequate rectal cancer care include income, insurance type, and education level.16–18 Similar to these findings, our study demonstrated that inadequate radiation was associated with demographic and socioeconomic variables including age, race, insurance and living area population density.
Certain patients are less likely to undergo appropriate cancer treatment, worsening their overall cancer survival. The purpose of this investigation was to identify factors associated with inadequate neoadjuvant radiation for rectal cancer.
The National Cancer Database was queried for patients with locally advanced rectal cancer who received neoadjuvant radiation 2006–2014. Adequate radiation was considered to be 4,500-5,040 cGy. Demographic, hospital and clinical variables were analyzed for association with inadequate radiation.
The study cohort was 34,391 patients; 1,842(5.4%) received inadequate radiation. On multivariate analysis, female gender, older age, other race, government-provided insurance, lower clinical stage and rural location correlated with inadequate radiation.
Women were 50% less likely than men to receive correct neoadjuvant radiation dosing. Other factors including age, race, insurance, clinical stage, geographic location and neoadjuvant chemotherapy were significantly associated with radiation dosing. These factors should be evaluated to determine if they can be modified to improve outcomes.
Colorectal cancer care in elderly patients: Unsolved issues
2016, Digestive and Liver Disease
Citation Excerpt :
The functional results are impacted by neo-adjuvant treatment. Radiotherapy is rarely used in elderly patients [11,46]. Some concerns have been raised about the benefit of neo-adjuvant radiotherapy in elderly patients [47].
Colorectal cancers are common in elderly patients. However, cancer screening is poorly used after 75. Elderly patients form a heterogeneous population with specific characteristics. Standards of care cannot therefore be transposed from young to elderly patients. Tumour resection is frequently performed but adjuvant chemotherapy is rarely prescribed as there are no clearly established standards of care. In a metastatic setting, recent phase III studies have demonstrated that doublet front-line chemotherapy provided no survival benefit. Moreover, several studies have established the benefit of bevacizumab in association with chemotherapy. There is a lack of evidence for the efficacy of anti-epidermal growth factor antibodies in elderly patients. Geriatric assessments could help to select the adequate treatment strategy for individual patients. Geriatric oncology is now the challenge we have to face, and more specific trials are needed.

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Socioeconomic inequalities in the use of radiotherapy for rectal cancer: A nationwide study

Abstract

Methods

Results

Conclusion

Introduction

Section snippets

The Swedish Rectal Cancer Registry

Baseline characteristics

Discussion

Conflict of interest statement

Acknowledgement

Lancet

Eur J Surg Oncol

Eur J Surg Oncol

Eur J Cancer

Eur J Cancer

Patient Educ Couns

Patient Educ Couns

The mesorectum in rectal cancer surgery – the clue to pelvic recurrence?

Brit J Surg

A systematic overview of radiation therapy effects in rectal cancer

Acta Oncol

Pre-operative radiotherapy and curative surgery for the management of localized rectal carcinoma

Cochrane Database Syst Rev

Acute side effects and complications after short-term preoperative radiotherapy combined with total mesorectal excision in primary rectal cancer: report of a multicenter randomized trial

J Clin Oncol

Late adverse effects of radiation therapy for rectal cancer – a systematic overview

Acta Oncol

Advances in radiotherapy in operable rectal cancer

Dig Surg