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Low Socioeconomic Status Is Associated with Worse Outcomes After Curative Surgery for Colorectal Cancer: Results from a Large, Multicenter Study

  • I. van den BergEmail author
  • S. Buettner
  • R. R. J. Coebergh van den Braak
  • K. H. J. Ultee
  • H. F. Lingsma
  • J. L. A. van Vugt
  • J. N. M. Ijzermans
Open Access
Original Article
  • 125 Downloads

Abstract

Background

Socioeconomic status (SES) has been associated with early mortality in cancer patients. However, the association between SES and outcome in colorectal cancer patients is largely unknown. The aim of this study was to investigate whether SES is associated with short- and long-term outcome in patients undergoing curative surgery for colorectal cancer.

Methods

Patients who underwent curative surgery in the region of Rotterdam for stage I–III colorectal cancer between January 2007 and July 2014 were included. Gross household income and survival status were obtained from a national registry provided by Statistics Netherlands Centraal Bureau voor de Statistiek. Patients were assigned percentiles according to the national income distribution. Logistic regression and Cox proportional hazard regression were performed to assess the association of SES with 30-day postoperative complications, overall survival and cancer-specific survival, adjusted for known prognosticators.

Results

For 965 of the 975 eligible patients (99%), gross household income could be retrieved. Patients with a lower SES more often had diabetes, more often underwent an open surgical procedure, and had more comorbidities. In addition, patients with a lower SES were less likely to receive (neo) adjuvant treatment. Lower SES was independently associated with an increased risk of postoperative complications (Odds ratio per percent increase 0.99, 95%CI 0.99–0.998, p = 0.004) and lower cancer-specific mortality (Hazard ratio per percent increase 0.99, 95%CI 0.98–0.99, p = 0.009).

Conclusion

This study shows that lower SES is associated with increased risk of postoperative complications, and poor cancer-specific survival in patients undergoing surgery for stage I–III colorectal cancer after correcting for known prognosticators.

Keywords

Colorectal cancer Surgical resection Socioeconomic status Postoperative outcomes Survival 

Introduction

With an incidence of 464,800 patients in 2012, colorectal cancer (CRC) is the second most common cancer in Europe and constitutes a large burden, both in economic and in medical terms.[1, 2] In a recent European article, average costs for treating a single patient with colorectal cancer were estimated at 40,000 Euros [2]. Currently, the TNM classification is the most important determinant for treatment decisions and outcome. Resection still remains the only cure, and the 5-year survival rate for patients with stage I–III varies between 53 and 92% [1]. Still, there are individual differences in clinical outcome within a single tumour stage [3]. Next to these tumour characteristics, several patient factors such as obesity, diabetes mellitus, smoking and nutritional status have been investigated and associated with survival, yet much of the disparity in prognosis remains unexplained [4, 5, 6, 7].

A possible explanation for differences in survival is socioeconomic status (SES). Not only does this influence the ability to pay medical bills and having financial resources to follow through with all hospital check-ups but also other correlating factors such as obesity and diabetes may also have an influence on post-resection CRC survival [8, 9, 10]. In previous studies, SES has been investigated as a possible prognostic factor for survival in cancer patients with contradicting results [11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23]. Some of this variability in outcomes may be explained by accessibility of healthcare [22, 23]. Some studies have been performed in countries where access to and the quality of healthcare is directly linked to income (e.g. USA) [22, 23], whereas others were conducted in countries with equal healthcare access (e.g. Great Britain and Scandinavia) [11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23]. The Dutch healthcare system is known for its equal healthcare access,[24, 25] meaning that differences in outcome associated with SES can be attributed to patient and provider factors and their interaction, rather than disparities in healthcare [26]. In the current study, we aimed to explore the association between SES, as assessed by household income, and outcomes following curative resection for stage I–III colorectal cancer in the Netherlands.

Methods

Study Population

Patients with stage I–III colorectal cancer who underwent curative surgery, enrolled in the MATCH-study between 2007 and 2014, were included in this study. The MATCH study is a prospective multicentre cohort study including patients to obtain fresh frozen CRC tissue samples with matched clinical data from 2007 until December 2017 in six hospitals in the region of Rotterdam [27].

The rationale of the MATCH study was to identify subtypes of colorectal cancer, related prognostic markers and outcome of treatment [28]. The study was approved by the Erasmus MC IRB (MEC-2007-088) and all patients provided written informed consent.

Study Parameters

Socioeconomic status was defined as gross household income (GHI), the most commonly used and accepted surrogate marker for SES [26, 29, 30, 31]. GHI from the year prior to surgery was used for analyses, as the income in the year of surgery was possibly lower due to disease-related absence from work. Annual earnings were obtained from Statistics Netherlands, a governmental organisation enabling studies on social issues on the basis of reliable statistical information (Centraal Bureau voor de Statistiek; CBS), including all types of income of people sharing a household or place of residence combined (i.e. salary, state pension, social compensation, and investment revenues). Patients were assigned percentiles and quartiles (Q1–Q4) according to the national income distribution (i.e. patients of a household with an annual salary corresponding to 0–25% of the GHI of the Dutch population were stratified to the first income quartile). Baseline characteristics and variables were retrieved from the prospective database of the MATCH study.

Dutch Healthcare System

The current Dutch healthcare system was introduced on January 1, 2006. All Dutch citizens are legally required to have healthcare insurance offered by several private insurers. Basic insurance premiums have a legal maximum and allowances are available for the lower incomes. Basic insurances cover all medical costs concerning regular cancer care including all in hospital care, costs for medicines, cancer rehabilitation, emergency transfer to hospitals, dietary help and psychosocial assistance. Out-of-pocket expenses such as transportation represented 14.7 percent of healthcare spending in 2014 [32].

Outcome Measures

The primary endpoints were overall survival (OS) and cancer-specific survival (CSS) after surgery for colorectal cancer, calculated from the day of surgery to the day of death (from disease) or loss to follow-up, whichever came first. Date and cause of death were obtained from the national registry of Statistics Netherlands. Secondary outcome measures were 30-day postoperative complications. Severity of complications was scored according to the Clavien-Dindo classification, and major 30-day postoperative complications were defined as Clavien-Dindo score ≥ 3a [33].

Statistical Methods

Descriptive statistics and multivariable analyses were performed using SPSS version 24.0 (SPSS, Inc., Chicago, IL, USA). Differences in baseline characteristics between the SES quartiles were tested with Pearson’s chi-square analysis or Mann-Whitney U-test as appropriate. Logistic regression analysis was used to calculate the odds ratio (OR) with 95% confidence intervals (95% CI) to evaluate the influence of SES, patient and tumour characteristics and operation techniques on 30-day postoperative complications. The outcomes OS and CSS were analysed with Cox proportional hazards regression. Unadjusted differences in the survival between income quartiles were assessed using the log-rank test. The predictors included in regression models were selected based on clinical relevance based on previous literature. Two-sided p values < 0.05 were considered statistically significant.

Results

A total of 975 patients met the inclusion criteria. For 10 patients, gross household income (GHI) could not be retrieved, leaving a final sample size of 965 (99%) patients. Patients with low SES were more often female and older (both p < 0.001) (Table 1). Diabetes mellitus and higher American Society of Anesthesiologists (ASA) classification were more common among patients with low SES (both p = 0.001). The Charlson comorbidity index was significantly higher for patients in the lowest quartile (p < 0.001). The median length of stay (LOS) was higher for patients in the lowest quartile (p < 0.001). Treatment strategies also differed between the quartiles; patients with low SES more often underwent open surgery (p = 0.003) and less often received neoadjuvant and adjuvant treatment (p = 0.037 and p = 0.001, respectively).
Table 1

Baseline characteristics

 

Q1

%

Q2

%

Q3

%

Q4

%

p value

 

(n = 244)

 

(n = 348)

 

(n = 187)

 

(n = 186)

  

Demographics

  Sex female

146

(59.8)

153

(44)

75

(40.1)

63

(33.9)

< 0.001

  Age (median, IQR)

76

(69–81)

72

(66–78)

66

(60–72)

59

(55–65)

< 0.001

  BMI (median, IQR)

25.9

(23.3–29.4)

25.9

(23.5–28.5)

25.8

(23.0–28.3)

25.4

(23.4–28.7)

0.795

  CEA preoperative (median, IQR)

3.3

(2.0–8.0)

3.5

(2.0–8.0)

3.3

(1.85–6.9)

2.9

(1.9–5.75)

0.160

Comorbid conditions

  Charlson comorbidity index (median, IQR)

1

(0.0–2.0)

1

(0–2.0)

0

(0–1.0)

0

(0–0.1)

< 0.001

  Diabetes mellitus

62

(25.5)

72

(20.7)

28

(15)

20

(10.8)

0.001

  COPD

27

(11.1)

29

(8.3)

14

(7.5)

12

(6.5)

0.344

ASA

• I–II

189

(78.1)

274

(79)

159

(86.4)

168

(90.8)

0.001

• III+

53

(21.9)

73

(21)

25

(13.6)

17

(9.2)

 

• Missing

2

 

1

 

3

 

1

  

Surgical technique

• Open

121

(49.8)

154

(44.3)

66

(35.9)

77

(41.6)

0.003

• Laparoscopic

102

(42)

168

(48.3)

105

(57.1)

80

(43.2)

 

• Conversion

20

(8.2)

26

(7.5)

13

(7.1)

28

(15.1)

 

• Missing

1

 

0

 

3

 

1

  

Stoma

69

(38.3)

106

(30.5)

61

(33)

55

(29.7)

0.768

• Missing

0

 

1

 

2

 

1

  

Length of stay (LOS)

9

(6–14)

7.5

(6–13)

7

(5–10)

7

(5–12)

< 0.001

Blood loss (L)

0.159

(0.05–0.40)

1

(0.03–0.40)

0.11

(0.04–0.25)

0.1

(0.02–0.35)

0.065

Operation duration (hours)

2.53

(1.83–3.28)

2.47

(1.83–3.25)

2.5

(2.0–3.2)

2.67

(1.87–3.52)

0.356

Neoadjuvant therapy

57

(23.4)

84

(24.2)

63

(33.7)

57

(30.6)

0.037

Adjuvant chemotherapy

28

(11.6)

60

(17.3)

40

(21.4)

50

(26.9)

0.001

• Missing

3

 

2

 

0

 

0

  

Tumour characteristics

         

Tumour stage

         

• I

82

(33.6)

107

(30.7)

52

(27.8)

64

(34.4)

0.278

• II

82

(33.6)

139

(39.9)

69

(36.9)

56

(30.1)

 

• III

80

(32.8)

102

(29.3)

66

(35.3)

66

(35.5)

 

Tumour grade differentiation

• Good

59

(25.5)

89

(26.6)

54

(29.7)

48

(26.4)

0.534

• Moderate

144

(62.3)

214

(64.1)

105

(57.7)

120

(65.9)

 

• Poor

28

(12.1)

31

(9.3)

23

(12.6)

14

(7.7)

 

• Missing

13

 

14

 

5

 

4

  

Angioinvasion

• No

65

(28.8)

94

(28.8)

60

33.9)

57

(32.8)

0.749

• Yes

25

(11.1)

29

(8.9)

15

8.5)

13

(7.5)

 

• Not reported

136

(60.2)

203

(62.3)

102

57.6)

104

(59.8)

 

• Missing

18

 

22

 

10

 

12

  

Location of tumour rectum

64

(26.2)

99

(28.4)

66

(35.3)

67

(36)

0.059

SES and Postoperative Complications

A total of 443 patients (45.9%) suffered at least one postoperative complication. The overall complication rate gradually decreased from 53.3% in Q1 to 36.0% in Q4 (p < 0.001). Major complications (i.e. Clavien-Dindo score ≥ 3) occurred in 170 patients (17.6%), for which a similar gradual decrease was observed (21.3% in Q1 to 12.4% in Q4; p < 0.001). No significant differences in readmission and reoperation rates were observed between the quartiles (Fig. 1).
Figure 1

Postoperative complications per quartile

In univariable logistic regression, GHI was associated with overall postoperative complications (OR 0.99, 95%CI 0.99 – 0.99, p < 0.001), as was older age (OR 1.02, 95%CI 1.01–1.04, p < 0.001), rectal cancer (OR 1.56, 95%CI 1.19–2.05, p = 0.001), and open surgery (OR 0.56, 95% CI 0.44–0.73, p < 0.001). The association between GHI and overall postoperative complications remained significant in the multivariable model (OR 0.99, 95%CI 0.99–0.998, p = 0.004) (Table 2). For major postoperative complications, no independent association was found in multivariable analysis (OR 0.99, 95% CI 0.99–1.00, p = 0.103) (Table 3).
Table 2

Univariable and multivariable analyses on overall postoperative complications

 

Odds ratio

Univariable

  

Multivariable

 

95% confidence interval

p value

Odds ratio

95% confidence interval

p value

Gender–male = reference

0.84

0.65–1.08

0.174

0.79

0.60–1.00

0.086

Age (years)

1.02

1.01–1.04

< 0.001

1.02

1.00–1.03

0.044

Charlson comorbidity

1.09

1.00–1.19

0.051

1.03

0.94–1.00

0.497

Rectal carcinoma

1.56

1.19–2.05

0.001

1.81

1.00–2.00

< 0.001

Surgical technique

Open = reference

0.56

0.44–0.73

< 0.001

0.56

0.42–0.73

< 0.001

Gross household income

0.99

0.99–0.99

< 0.001

0.99

0.99–0.998

0.004

Table 3

Univariable and multivariable analyses on major postoperative complications (Clavien Dindo ≥ 3 )

  

Univariable

  

Multivariable

 
 

Odds ratio

95% confidence interval

p value

Odds ratio

95% confidence interval

p value

Gender–male = reference

0.83

0.60–1.16

0.283

0.85

0.6–1.20

0.354

Age (years)

1.02

1.01–1.04

0.009

1.01

1.00–1.03

0.142

Charlson comorbidity

1.13

1.02–1.25

0.017

1.08

0.97–1.20

0.187

Rectal carcinoma

1.54

1.09–2.17

0.014

1.72

1.19–2.47

0.004

Surgical technique–open procedure = reference

0.47

0.34–0.66

< 0.001

0.47

0.33–0.67

< 0.001

Gross household income

0.99

0.99–0.998

0.009

0.99

0.99–1.00

0.103

SES and Overall Survival

OS increased gradually with increasing socioeconomic status (Fig. 2). The median OS was only reached in Q1 (88.9 months, 95% CI 79.1–98.7), whereas the median OS was not reached in any of the other quartiles. Patients in Q1 had a worse OS compared with patients in Q2 (p = 0.016) and patients in Q2 had a worse survival compared with patients in Q3 (p = 0.01). Patients in Q3 and Q4 had a similar survival (p = 0.918).
Figure 2

Overall 5 year survival per socioeconomic income quartile

In univariable analysis, GHI was associated with OS (HR 0.98, 95% CI 0.98–0.99, p < 0.001). Furthermore, age (HR 1.04, 95% CI 1.02–1.06, p < 0.001), CCI (HR 1.24, 95% CI 1.17–1.32, p < 0.001), tumour stage (HR 1.90, 95%CI 1.42–2.55, p < 0.001) and tumour grade (HR 1.89, 95%CI 1.29–2.76, p = 0.001) were associated with OS. In the multivariable analysis, GHI was not independently associated with OS (HR 0.99, 95%CI 0.99-1.00, p = 0.158), in contrast to age (HR 1.07, 95%CI 1.05–1.08, p < 0.001), CCI (HR 1.17, 95%CI 1.10–1.25, p < 0.001) tumour stage (HR 2.34, 95%CI 1.72–3.19, p < 0.001) and tumour grade (HR 1.53, 95% CI 1.04–2.26, p = 0.030) (Table 4).
Table 4

Univariable and multivariable Cox regression analyses on overall survival

 

Univariable

Multivariable

 

Hazard ratio

95% confidence interval

p value

Hazard ratio

95% confidence interval

p value

Age

1.04

1.02–1.06

< 0.001

1.07

1.05–1.08

< 0.001

Charlson comorbidity index

1.24

1.17–1.32

< 0.001

1.17

1.10–1.25

< 0.001

Tumour stage I (Ref)

-

-

-

-

-

-

Tumour stage II

1.26

0.93–1.71

0.138

1.20

0.88–1.65

0.253

Tumour stage III

1.90

1.42–2.55

< 0.001

2.34

1.72–3.19

< 0.001

Tumour grade good (Ref)

-

-

-

-

-

-

Tumour grade moderate

0.87

0.65–1.16

0.340

0.81

0.60–1.09

0.167

Tumour grade poor

1.89

1.29–2.76

0.001

1.53

1.04–2.26

0.030

Gross household income

0.98

0.98–0.99

< 0.001

0.99

0.99–1.00

0.158

SES and Cancer-Specific Survival

The median CSS was not reached for any of the quartiles. Patients in Q1 had a worse CSS compared with patients in Q2 (p = 0.035). No difference in survival was found between Q2 and Q3, nor for Q3 and Q4 (p = 0.080 and p = 0.637, respectively) (Fig. 3).
Figure 3

Cancer specific survival per socioeconomic income quartile

In the univariable model for CSS, GHI showed a significant association (HR 0.98, 95%CI 0.98–0.99, p < 0.001) as well as age (HR 1.04, 95%CI 1.02–1.06, p < 0.001), CCI (HR 1.14, 95%CI 1.04–1.25, p = 0.006), tumour stage (HR 3.58, 95% CI 2.31–5.56, p < 0.001) and tumour grade (HR 2.62, 95% CI 1.52–4.52, p = 0.001). The association between GHI and CSS remained statistically significant in the multivariable model (HR 0.99, 95%CI 0.98–0.99, p = 0.009). Other factors that were independently associated with CSS were age (HR 1.03, 95%CI 1.01–1.05, p = 0.001) and tumour stage (HR 3.95, 95%CI 2.49–6.28, p < 0.001) (Table 5).
Table 5

Univariable and multivariable Cox regression analysis on cancer specific survival

 

Univariable

Multivariable

 

Hazard ratio

95% confidence interval

p value

Hazard ratio

95% confidence interval

p value

Age

1.04

1.02–1.06

< 0.001

1.03

1.01–1.05

0.001

Charlson comorbidity index

1.14

1.04–1.25

0.006

1.07

0.96–1.18

0.214

Tumour stage I (Ref)

-

-

-

-

-

-

Tumour stage II

1.33

0.81–2.19

0.262

1.28

0.76–2.16

0.353

Tumour stage III

3.58

2.31–5.56

< 0.001

3.95

2.49–6.28

< 0.001

Tumour grade good (Ref)

-

-

-

-

-

-

Tumour grade moderate

1.19

0.77–1.84

0.430

1.09

0.71–1.69

0.694

Tumour grade pore

2.62

1.52–4.52

0.001

1.84

1.06–3.19

0.031

Gross household income

0.98

0.98–0.99

< 0.001

0.99

0.98–0.997

0.009

Discussion

The results of this study show that lower SES is significantly associated with worse outcome in patients with stage I–III colorectal cancer undergoing curative surgery. We observed an increased rate of postoperative complications, after correcting for captured confounding factors. Although SES was not independently associated with OS, we observed a significant association between SES and CSS after correction for other known captured prognosticators (HR: 0.99 per percentile). This corresponds to a hazard ratio of 0.80 per quartile incremental SES increase. The current results should be viewed in the context of the Dutch equal access healthcare system. Therefore, the association between income and postoperative survival that was demonstrated in the present study cannot be attributed to inequality in healthcare resources. This is, to our knowledge, the first study to explore the influence of SES in a prospective cohort of consecutive colorectal cancer patients and stresses the importance of SES as a prognostic factor in these patients.

As in previous studies, our results indicate that SES is also associated with short-term outcome [17, 34]. This may partially be explained by confounding factors associated with both lower SES and higher postoperative morbidity. At baseline, diabetes mellitus was more prevalent in patients in the lower quartiles. This factor, as well as several others, such as liver disease, is incorporated in the ASA classification. These were significantly higher in the lower SES quartiles as well. Patients in the lower SES quartiles more often underwent open surgery, despite tumour characteristics being similar with regards to location, stage and pathologic prognostic factors. Moreover, patients were significantly older in the lower SES quartiles, and therefore a larger part of these patients may have been retired the year prior to surgery and have less income.

These differences in treatment, without apparent clinical explanation, mirror those described in previous studies.[34, 35, 36] Even after correction for known confounding risk factors including comorbidities, SES was a significant predictor for postoperative morbidity. These results suggest that the correlation between SES and postoperative outcomes is determinant upon factors that are currently not adequately considered or understood.

In general, long-term results presented in our study are in line with previous studies, showing impaired survival in patients with low SES [20, 22, 23, 37]. Several previous studies have offered explanations for this survival discrepancy in a setting of equal healthcare access [38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51]. These possible explanations include psychological factors, medication compliance and diet, exercise, air pollution, and even epigenetic factors [38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51]. Interestingly, in our study, the correlation between SES and CSS was more outspoken than the correlation of SES with OS (i.e. all-cause mortality), making some of these explanations less plausible. In addition, this suggests that the survival discrepancy between SES quartiles was not solely attributable to the unequal distribution of age and comorbidities between the groups, as these factors have a less obvious effect on cancer-related outcome. Fowler et al. showed that tumour stage and treatment contributed for a great part towards the difference in 3-month mortality between the most and least deprived patient groups [52]. Known and relevant tumour characteristics, as earlier described, did not significantly differ across SES quartiles. In contrast however, treatment strategies were different between groups. In addition to a different surgical approach between the quartiles, fewer patients of lower SES quartiles received neoadjuvant and adjuvant chemotherapy. The inequality of treatment with neoadjuvant therapy can partially be explained by differences in proportion of patients with rectal cancer between the SES quartiles. Neoadjuvant chemotherapy is only registered in patients with rectal cancer whereas adjuvant chemotherapy is only offered to patients with colon cancer. However, as in our study, previous studies show that lower-middle SES and low-SES patients were less likely to receive chemotherapy in general [53]. Furthermore, since SES remained significantly associated with CSS after correction for baseline variables, it is possible that some of the driving factors of treatment differences cause additional differences in strategy not captured in our cohort. Besides differences in the administration of chemotherapy, compliance with treatment may also play a role. Prospective studies will be required to elucidate the exact causal mechanism of this remaining correlation.

GHI was chosen as a surrogate marker for SES in this study, as it is a proven accurate reflection of SES-related health disparities [26, 29, 30, 31]. It was not adjusted to household size, as previous studies showed this adjustment did not improve predictability of the associated health disparities [30]. Other reported determinants of SES include the highest attained level of education, current occupation, parent’s education and occupation, and household conditions [34, 36, 54, 55, 56]. Unfortunately, no previous studies have compared the accuracy of these markers in a cohort of (colorectal) cancer patients, which limits their comparability [11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23]. Since GHI is a valid and readily available metric for all Dutch citizens registered by an independent organization (Dutch Statistics; CBS), we believe this marker adequately captures SES for our purposes. Use of this marker in different populations or different countries would add to the comparability of the plethora of SES studies currently being conducted.

Some inherent shortcomings of this study should be noted. First, with regards to patient factors, we were unable to determine several lifestyle factors of potential importance, due to the inherent limitations in our database. These include smoking, diet, and compliance with medication [44, 45, 57]. Even though these factors reportedly do not explain all differences, we believe correcting for them would have enhanced our results [30, 58, 59]. An additional drawback in our study was our inability to comment on exact healthcare consumption for CRC and comorbidities, limiting our ability of testing the premise of equal healthcare accessibility. Variation in SES between the hospitals can have some effect on the outcome; however, guideline adherence was equal across the hospitals plus complications and survival outcomes did not differ between the hospitals.

Finally, ethnicity could be a confounding factor with SES, and the unfavourable surgical outcome of GHI in this study might also partially be explained by differences in ethnicity. However, ethnicity is not reported in the Netherlands, which limits this study because no analyses can be performed on the actual relevance of this risk factor [37].

In conclusion, our results show that low SES is associated with worse outcome in patients undergoing curative surgery for stage I–III colorectal cancer. Future studies are required to elucidate the association between SES and survival in cancer patients, which suggest that SES encompasses risk factors and behaviours currently not adequately considered. Such studies would require additional power and potential explaining factors and would ideally be able to distinguish between the effects of patient and treatment related measures.

Notes

Author’s Contributions

1. Substantial contributions to the conception or design of the work or the acquisition, analysis, or interpretation of data for the work

2. Drafting the work or revising it critically for important intellectual content

3. Final approval of the version to be published

4. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no competing interests.

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© The Author(s) 2019

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Authors and Affiliations

  1. 1.Department of SurgeryErasmus MC - University Medical CenterRotterdamThe Netherlands
  2. 2.Department of Public HealthErasmus MC - University Medical CenterRotterdamThe Netherlands

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