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New England Surgical Society

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Intersectionality of Demographics and Surgical Oncology: Influence of Insurance, Race, and Rurality on Lung and Colorectal Cancer Care
Mary M. Leech2, Julie Weiss3, Chad Markey2, Andrew Loehrer1
1Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, United States, 2Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, United States, 3Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, United States

Objective
This study examined the influence of social determinants of health on stage at diagnosis and receipt of cancer-directed surgery (CDS) for lung and colorectal cancer patients.

Design
This retrospective cohort study used multivariable logistic regression models, including two-way interaction terms, to assess the influence of insurance status, race, rurality, and socioeconomic status on stage at diagnosis and receipt of CDS.

Setting
2010-2015 data from the North Carolina Central Cancer Registry.

Patients
Non-Hispanic, uninsured or privately insured patients with lung or colorectal cancer aged 18- 64 were included.

Interventions
N/A

Main Outcome Measure(s)
Odds of Stage IV disease at time of diagnosis and odds of receiving CDS.

Results
Among 6,574 lung cancer patients, uninsured status was associated with increased odds of Stage IV disease (OR=1.46, 95% CI 1.22-1.76) and decreased odds of receiving CDS (OR=0.48, 95% CI 0.34-0.68) compared to private insurance status. Among 5,355 colorectal cancer patients, uninsured status was associated with higher odds of Stage IV disease (OR=1.53, 95% CI 1.17-2.00) compared to private insurance status. A significant insurance status and rurality interaction (p=0.03) was found in the colorectal CDS model. Among those privately insured, non-Hispanic Black and rural patients had decreased odds of receiving colorectal CDS (OR=0.69, 95% CI 0.50-0.94; and OR=0.68, 95% CI 0.52-0.89, respectively), compared to non-Hispanic White and urban patients.

Conclusions
This study highlighted the impact of social determinants, particularly the outsized influence of insurance status, on lung and colorectal cancer stage and treatment. However, disparities by race and rurality persisted even among privately insured patients. More research is needed to understand the interaction between social determinants and the subsequent influence on clinical outcomes for cancer patients.


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