Rural colon cancer patients fare worse than urban patients

Colon cancer patients who live in rural areas are more likely to receive late-stage diagnoses and to die from their colon cancer, and less likely to receive an early diagnosis, chemotherapy, or thorough surgical treatment compared with patients living in urban areas.

This retrospective study analyzed data on more than 123,000 colon cancer patients between 1996 and 2008 from the California Cancer Registry, which is one of the nation's most demographically diverse registries. Approximately 15% of the patients resided in rural areas, as defined by the registry. The researchers, who are surgeons at the University of Minnesota, Minneapolis, and the Minneapolis Veterans Affairs Medical Center, considered each patient's stage of diagnosis, whether cancerous lymph nodes were thoroughly removed, and whether stage III patients received chemotherapy. The risk of death from colon cancer was compared between the rural and urban patients.

“Often we will see patients from rural areas outside of Minneapolis. They've traveled hours to get to the university and they sometimes travel hours to get to their operations, radiation, and chemotherapy,” explained Christopher J. Chow, MD, a categorical general surgery resident at the University of Minnesota. “We wanted to know if that factor was a barrier to receiving care. Early reports looking at this question tend to focus on cancer screening. Research shows that rural patients don't get screened for cancer as often as urban patients do, and this difference affects their outcomes. But no one had really looked at the full spectrum of diagnosis and treatment. We wanted to look at what happens with rural patients at various stages of the process.”

The rural residents had 4% higher odds of receiving a stage III or IV diagnosis than urban patients, after controlling for the influence of other factors that include race, sex, age, marital status, insurance status, and year of diagnosis. The odds of receiving an adequate lymphadenectomy were 18% lower for rural patients with stage I-III colon cancer, meaning that a substandard number of lymph nodes were removed during the operation. Regarding inadequate lymph node removal, Chow explained that, “It's a surrogate marker for how the different groups involved in the patients' care performed—the pathology technician, the pathologist, and the surgeon.”

The odds of receiving chemotherapy for stage III disease are 17% lower for rural patients than for urban patients. The rural group had a 5% higher hazard of cancer-specific death compared with the urban group, after adjusting for patient, tumor, and treatment factors.

“These findings do not mean that if you're a rural patient and you've been diagnosed with colon cancer [that] you should move,” Chow cautioned. “What they mean is that, we as surgeons who treat both rural and urban patients, need to start targeting rural patients to ensure that they receive care that is as high quality as urban patients.”

This research was presented at the 2012 Annual Clinical Congress of the American College of Surgeons.
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