Abstract
Background
Deprivation is associated with poorer survival after surgery for colorectal cancer, but determinants of this socioeconomic inequality are poorly understood.
Methods
A total of 4,296 patients undergoing surgery for colorectal cancer in 16 hospitals in the West of Scotland between 2001 and 2004 were identified from a prospectively maintained regional audit database. Postoperative mortality (<30 days) and 5-year relative survival by socioeconomic circumstances, measured by the area-based Scottish Index of Multiple Deprivation 2006, were examined.
Results
There was no difference in age, gender, or tumor characteristics between socioeconomic groups. Compared with the most affluent group, patients from the most deprived group were more likely to present as an emergency (23.5 vs 19.5 %; p = .033), undergo palliative surgery (20.0 vs 14.5 %; p < .001), have higher levels of comorbidity (p = .03), have <12 lymph nodes examined (56.7 vs 53.1 %; p = .016) but were more likely to receive surgery under the care of a specialist surgeon (76.3 vs 72.0 %; p = .001). In multivariate analysis, deprivation was independently associated with increased postoperative mortality [adjusted odds ratio 2.26 (95 % CI, 1.45–3.53; p < .001)], and poorer 5-year relative survival [adjusted relative excess risk (RER) 1.25 (95 % CI, 1.03–1.51; p = .024)] but not after exclusion of postoperative deaths [adjusted RER 1.08 (95 %, CI .87–1.34; p = .472)].
Conclusions
The observed socioeconomic gradient in long-term survival after surgery for colorectal cancer was due to higher early postoperative mortality among more deprived groups.
Similar content being viewed by others
References
Smith JJ, Tilney HS, Heriot AG, Darzi AW, Forbes H, Thompson MR, et al. Social deprivation and outcomes in colorectal cancer. Br J Surg. 2006;93:1123–1131. doi:10.1002/bjs.5357.
Shack LG, Rachet B, Brewster DH, Coleman MP. Socioeconomic inequalities in cancer survival in Scotland 1986–2000. Br J Cancer. 2007;97:999–1004. doi:10.1038/sj.bjc.6603980.
Byres TE, Wolf HJ, Bauer KR, Bolick-Aldrich S, Chen VW, Finch JL, et al. The impact of socioeconomic status on survival after cancer in the United States. Cancer. 2008;3:582–91. doi:10.1002/cncr.23567.
Ward E, Jemal A, Cokkinides V, Singh GK, Cardinez C, Ghafoor A, et al. Cancer disparities by race/ethnicity and socioeconomic status. CA Cancer J Clin. 2004;54:78–93. doi:10.3322/canjclin.54.2.78.
Egeberg R, Halkjoer J, Rottmann N, Hansen L, Holten I. Social inequality and incidence of and survival from cancers of the colon and rectum in a population-based study in Denmark, 1994–2003. Eur J Cancer. 2008;44:1978–1988. doi:10.1016/j.ejca.2008.06.020.
Rachet B, Ellis L, Maringe C, Chu T, Nur U, Quaresma M, et al. Socioeconomic inequalities in cancer survival in England after the NHS cancer plan. Br J Cancer. 2010;103:446–453. doi:10.1038/sj.bjc.6605752.
Singh GK, Miller BA, Hankey BF, Edwards BK. Area socioeconomic variations in US cancer incidence, mortality, stage, treatment and survival, 1975–1999. NCI Cancer Surveillance Monograph Series, Number 4. Bethesda, MD: National Cancer Institute, 2003. Publication No. 03-5417.
Guyot F, Faivre J, Manfredi S, Meny B, Bonithon-Kopp C, Bouvier AM. Time trends in the treatment and survival of recurrences from colorectal cancer. Ann Oncol. 2005;16:756–61. doi:10.1093/annonc/mdi151.
Yu XQ, O’Connell DL, Gibberd RW, Armstrong BK. A population-based study from New South Wales, Australia 1996-2001: area variation in survival from colorectal cancer. Eur J Cancer. 2005;41:2715–21. doi:10.1016/j.ejca.2005.02.018.
Wrigley H, Roderick P, George S, Smith J, Mullee M, Goddard J. Inequalities in survival from colorectal cancer: a comparison of the impact of deprivation, treatment, and host factors on observed and cause specific survival. J Epidemiol Community Health. 2003;57:301–9. doi:10.1136/jech.57.4.301.
Brewster DH, Clark DI, Stockton DL, Munro AJ, Steele RJ. Characteristics of patients dying within 30 days of diagnosis of breast or colorectal cancer in Scotland, 2003–2007. Br J Cancer. 2011;104:60–7. doi:10.1038/sj.bjc.6606036.
MacLeod U, Mitchell ED, Burgess C, MacDonald S, Ramirez AJ. Risk factors for delayed presentation and referral of symptomatic cancer: evidence for common cancers. Br J Cancer. 2009;101:S92–S101. doi:10.1038/sj.bjc.6605398.
Legeune C, Sassi F, Ellis L, Godward S, Mak V, Day M, et al. Socio-economic disparities in access to treatment and their impact on colorectal cancer survival. Int J Epidemiol. 2010;39:710–7. doi:10.1093/ije/dyq048.
Cavalli-Björkman N, Lambe M, Eaker S, Sandin F, Glimelius B. Differences according to educational level in the management and survival of colorectal cancer in Sweden. Eur J Cancer. 2011;47:1398–406. doi:10.1016/j.ejca.2010.12.013.
Moller H, Sandin F, Robinson D, Bray F, Klint S, Linklater KM, et al. Colorectal cancer survival in socioeconomic groups in England: variation is mainly in the short term after diagnosis. Eur J Cancer. 2012;48:46–53. doi:10.1016/j.ejca.2011.05.018.
McArdle CS, Hole DJ. Influence of volume and specialization on survival following surgery for colorectal cancer. Br J Surg. 2004;91:610–7. doi:10.1002/bjs.4456.
Hole DJ, McArdle CS. Impact of socioeconomic deprivation on outcome after surgery for colorectal cancer. Br J Surg. 2002;89:586–90. doi:10.1046/j.1365-2168.2002.02073.x.
Bharathan B, Welfare M, Borowski DW, Mills SJ, Steen IN, Kelly SB, et al. Impact of deprivation on short- and long-term outcomes after colorectal cancer surgery. Br J Surg. 2011;98:854–65. doi:10.1002/bjs.7427.
Harris AR, Bowley DM, Stannard A, Kurrimboccus S, Geh JI, Karandikar S. Socioeconomic deprivation adversely affects survival of patients with rectal cancer. Br J Surg. 2009;96:763–8. doi:10.1002/bjs.6621.
Scottish Government. Scottish Index of Multiple Deprivation. 2010. Available at: http://www.scotland.gov.uk/topics/statistics/SIMD. Accessed 21 Sept 2012.
Statacorp, College Station, TX: Statacorp LP. Stata Statistical Software: Release 11. 2009; 11(IC).
Morris E, Taylor EF, Thomas JD, Quirke P, Finan PJ, Coleman MP, et al. Thirty-day postoperative mortality after colorectal cancer surgery in England. Gut. 2011;60:806–13. doi:10.1136/gut.2010.232181.
Berrino F, Estève J, Coleman MP. Basic issue in estimating and comparing the survival of cancer patients. In Survival of Cancer Patients in Europe. The EUROCARE Study. Lyon: International Agency for Research on Cancer 1995; No 132: 1–14.
Dickman PW, Sloggett A, Michael Hills M, Hakulinen T. Regression models for relative survival. Stat Med. 2004;23:51–64. doi:10.1093/annonc/mdi151.
Acknowledgment
The authors thank all the surgeons who participated, the West of Scotland Colorectal Cancer Managed Clinical Network advisory board who gave permission for MCN audit data to be used in this study, and the London School of Hygiene and Tropical Medicine for providing the Scotland-specific life tables used in the relative survival analyses. The authors declare no conflict of interest.
Author information
Authors and Affiliations
Consortia
Corresponding author
Rights and permissions
About this article
Cite this article
Oliphant, R., Nicholson, G.A., Horgan, P.G. et al. Deprivation and Colorectal Cancer Surgery: Longer-Term Survival Inequalities are Due to Differential Postoperative Mortality Between Socioeconomic Groups. Ann Surg Oncol 20, 2132–2139 (2013). https://doi.org/10.1245/s10434-013-2959-9
Received:
Published:
Issue Date:
DOI: https://doi.org/10.1245/s10434-013-2959-9