Rural residents at higher risk for colon cancer surgery; post-op outcomes differ by race
All residents of rural areas were more likely to undergo surgery for nonmetastatic colon cancer vs. metropolitan residents, yet only rural Black patients experienced higher odds of postoperative complications and mortality, researchers noted.
“In this study of fee-for-service Medicare beneficiaries with incident nonmetastatic colon cancer, we found that the rurality of a patient’s residence was associated with surgical management and postoperative outcomes in unexpected ways: patients residing in small town and rural areas were more likely to undergo surgery than those from metropolitan areas but were also more likely to undergo emergent surgery and less likely to have [minimally invasive surgery (MIS)],” Niveditta Ramkumar, PhD, MPH, and colleagues from the Geisel School of Medicine at Dartmouth, wrote in JAMA Network Open.
The researchers added that “important differences in postoperative outcomes by rurality became apparent after stratifying by race and ethnicity, noting that rurality was associated with higher postoperative mortality for Black patients but not for other racial and ethnicity groups. Our findings highlight the intersectional nature of underlying disparities in colon cancer management.”
Study design
To study the connection between race and ethnicity, socioeconomic status and rurality and treatment and outcomes of nonmetastatic colon cancer, investigators used ICD-10 codes to identify patients 57,710 Medicare beneficiaries who were diagnosed between April 1, 2016, and Sept. 30, 2018. Patients were monitored until Dec. 31, 2018.
Researchers also used Rural-Urban Commuting Area codes to categorize patients’ residence as metropolitan, micropolitan, or small town or rural. Colectomy, emergent surgery, MIS, 90-day postoperative surgical complications and 90-day postoperative mortality served as primary outcomes. Researchers used Kaplan-Meier failure curves, log-rank tests and multivariable Cox proportional hazards regression to determine the link between rurality and time to surgery from diagnosis and performed multivariable logistic regression to assess the association between rurality and surgical outcomes among patients who had procedures within 90 days of diagnosis.
The mean age of patients was 76.6 years and 53.4% were women. Nearly 90% of patients were white, 6.4% were Black, 3.7% were Hispanic and 3.8% were American Indian or Alaska Native, Asian or Pacific Islander, or of an unknown race or ethnicity. Most patients lived in metropolitan areas (74%), followed by small town or rural areas (13.1%) and micropolitan areas (12.9%).
Race and rural living
Patients in micropolitan and small or rural areas were more likely to undergo cancer-directed surgery (69.2%) compared with metropolitan patients (63.9%). While investigators identified Black race as independently associated with a lower hazard of surgical resection (HR = 0.92; 95% CI, 0.88-0.95), they found race and measures of socioeconomic status did not affect the association of surgery with rurality.
Although patients in small town or rural areas had significantly higher odds of emergent surgery compared with those in metropolitan areas (adjusted OR = 1.32; 95% CI, 1.2-1.44)), they were significantly less likely to have MIS (aOR = 0.75; 95% CI, 0.7-0.8). Researchers reported similar results for patients in micropolitan areas.
In addition, the association between rurality and postoperative mortality differed by race, with patients from historically underrepresented groups having higher odds of both postoperative mortality and surgical complications.
While white patients in small town or rural areas had lower odds of postoperative mortality compared with white patients in metropolitan areas (aOR = 0.81; 95% CI, 0.71-0.92), Black patients in small town or rural areas had almost twice the odds of postoperative mortality as Black patients in metropolitan areas (aOR = 1.86; 95% CI, 1.16-2.97).
“Although poorer surgical outcomes have been reported for patients residing in rural areas and Black patients, to our knowledge, our study is among the first to explore the intersection of these [two] factors,” the researchers wrote.
“We noted several differences in the characteristics of white vs. Black rural-residing patients undergoing operations: Black patients were more likely to live in an area of higher deprivation and were more likely to have Medicare-Medicaid dual eligibility, indicating socioeconomic deprivation or disability,” they added. “Although we adjusted for these factors, it appears that the experience of health care in rural settings is different for Black and white beneficiaries, suggesting the role of interpersonal and structural barriers (eg, discrimination, mistrust, structural racism) that contribute to this racial disparity.”
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