Disparities in access to care among patients with appendiceal or colorectal cancer and peritoneal metastases: A medicare insurance-based study in the United States

Christopher T Aquina; Zachary J Brown; Joal D Beane; Aslam Ejaz; Jordan M Cloyd; Oliver S Eng; John R T Monson; Samantha M Ruff; Gyulnara G Kasumova; Mohamed O Adam; Samilia Obeng-Gyasi; Timothy M Pawlik; Alex C Kim

doi:10.3389/fonc.2022.970237

Disparities in access to care among patients with appendiceal or colorectal cancer and peritoneal metastases: A medicare insurance-based study in the United States

Front Oncol. 2022 Oct 31:12:970237. doi: 10.3389/fonc.2022.970237. eCollection 2022.

Affiliations

¹ Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States.
² Surgical Health Outcomes Consortium (SHOC), Digestive Health and Surgery Institute, AdventHealth Orlando, Orlando, FL, United States.
³ Division of Surgical Oncology, Department of Surgery, University of California Irvine Medical Center, Orange, CA, United States.
⁴ Division of Surgical Oncology, Department of Surgery, University of California San Francisco Medical Center, San Francisco, CA, United States.

Abstract

Background: Prior studies attempting to identify disparities in the care of patients with appendiceal (AC) or colorectal cancer (CRC) with peritoneal metastasis (PM) are limited to single-institution, highly selected patient populations. This observational cohort study sought to identify factors associated with specialty care for Medicare beneficiaries with AC/CRC-PM.

Materials and methods: Patients >65 years old in the United States diagnosed with AC/CRC and isolated PM were identified within the Medicare Standard Analytic File (2013-2017). Mixed-effects analyses assessed patient factors associated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) and outpatient consultation with a peritoneal surface malignancy (PSM) surgeon, and Cox proportional-hazards analysis compared 3-year overall survival (OS) between patients receiving CRS/HIPEC versus systemic therapy alone.

Results: Among 7,653 patients, only 250 (3.3%) underwent CRS/HIPEC. Among those individuals who did not undergo CRS/HIPEC (N=7,403), only 475 (6.4%) had outpatient consultation with a PSM surgeon. Patient factors independently associated with lower odds of CRS/HIPEC and PSM surgery consultation included older age, greater comorbidity burden, higher social vulnerability index, and further distance from a PSM center (p<0.05). CRS/HIPEC was independently associated with better 3-year OS compared with systemic therapy alone (HR=0.29, 95%CI=0.21-0.38).

Conclusion: An exceedingly small proportion of Medicare beneficiaries with AC/CRC-PM undergo CRS/HIPEC or even have an outpatient consultation with a PSM surgeon. Significant disparities in treatment and access to care exist for patients with higher levels of social vulnerability and those that live further away from a PSM center. Future research and interventions should focus on improving access to care for these at-risk patient populations.

Keywords: access to cancer care; appendiceal cancer; colorectal cancer; cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC); healthcare disparities; peritoneal metastases.