Underuse of surgical resection in black patients with nonmetastatic colorectal cancer: Location, location, location

OBJECTIVES: Studies have reported potential underuse of surgical resection in black patients with nonmetastatic colorectal cancer. Our objective was to determine the independent, adverse effect of race on surgical resection, controlling for tumor location, comorbidity, and socioeconomic/insurance status. METHODS: All cases of nonmetastatic colon/rectal cancer reported to our state's Central Cancer Registry from 1996 to 2002 were identified and linked to Inpatient/Outpatient Surgery Files and the 2000 Census. Comorbidity (Deyo-Charlson Index) was calculated using ICD-9-CM codes and educational level/income were estimated at the zip code level. Characteristics between whites and blacks were compared using χ tests. Odds ratios (OR) of resection were calculated using logistic regression analysis. RESULTS: We identified 5590/1932 white and 1906/466 black patients with colon/rectal cancer. Blacks were more likely to be younger, not married, rural, less educated, live in poverty, and uninsured/covered by Medicaid compared with whites (all P < 0.001). Underuse of surgery was far greater among blacks with rectal cancer (82.0% vs. 89.3% in whites, P< 0.001) compared with blacks with colon cancer (92.9% vs. 94.5% in whites, P < 0.001). After controlling for comorbidity/socioeconomic/insurance status and tumor location, the adjusted OR (95% CI) for resection for blacks with colon cancer and blacks with rectal cancer living in poverty were 0.67 (0.51-0.88) and 0.20 (0.07-0.57), respectively. CONCLUSIONS: Black race is a powerful, independent predictor of underuse of surgery in rectal cancer patients living in poverty. It is incumbent on the gastroenterology/surgical community to determine whether misperceptions about rectal surgery or barriers to successfully navigating multidisciplinary, rectal cancer care may account for these disparities.