Colon Cancer Treatment: Are There Racial Disparities in an Equal-Access Healthcare System?

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1 ORIGINAL CONTRIBUTION Colon Cncer Tretment: Are There Rcil Disprities in n Equl-Access Helthcre System? Abegil A. Gill, M.P.H 1 Lindsey Enewold, Ph.D. 1 Sheli H. Zhm, Sc.D. 2 Crig D. Shriver, M.D. 3,4,5 Alexnder Stojdinovic, M.D. 5,6 Ktherine A. McGlynn, Ph.D. 7 Kngmin Zhu, M.D. 1,8 1 Division of Militry Epidemiology nd Popultion Sciences, John P. Murth Cncer Center, Wlter Reed-Bethesd, Bethesd, Mrylnd 2 Division of Cncer Epidemiology nd Genetics, Office of the Director, Ntionl Cncer Institute, Ntionl Institutes of Helth, Bethesd, Mrylnd 3 John P. Murth Cncer Center, Wlter Reed-Bethesd, Bethesd, Mrylnd 4 Generl Surgery Service, Wlter Reed-Bethesd, Bethesd, Mrylnd 5 Uniformed Services University of Helth Sciences, Bethesd, Mrylnd 6 Combt Wound Inititive Progrm, Wlter Reed-Bethesd, Bethesd, Mrylnd 7 hormonl nd Reproductive Epidemiology Brnch, Division of Cncer Epidemiology nd Genetics, Ntionl Cncer Institute, Ntionl Institutes of Helth, Bethesd, Mrylnd 8 Deprtment of Preventive Medicine nd Biometrics, Uniformed Services University of Helth Sciences, Bethesd, Mrylnd BACKGROUND: In the generl US popultion, blcks nd whites hve been shown to undergo colon cncer tretment t disproportionte rtes. Accessibility to medicl cre my be the most importnt fctor influencing differences in colon cncer tretment rtes mong whites nd blcks. OBJECTIVE: We ssessed whether rcil disprities in colon cncer surgery nd chemotherpy existed in n equl-ccess helth cre system. In ddition, we sought to exmine whether rcil differences vried ccording to demogrphic nd tumor chrcteristics. Funding/Support: This work ws supported by the John P. Murth Cncer Center, Wlter Reed Ntionl Militry Medicl Center, vi the Uniformed Services University of the Helth Sciences under the uspices of the Henry M. Jckson Foundtion for the Advncement of Militry Medicine nd by the intrmurl reserch progrm of the Ntionl Cncer Institute. The originl dt linkge ws supported by the United Sttes Militry Cncer Institute nd Division of Cncer Epidemiology nd Genetics, Ntionl Cncer Institute. Finncil Disclosure: None reported. Poster presenttion t The Americn Assocition for Cncer Reserch Interntionl Conference on Frontiers in Cncer Prevention Reserch, Anheim, Cliforni, October 16 to 19, Correspondence: Kngmin Zhu, Division of Militry Epidemiology nd Popultion Sciences, John P. Murth Cncer Center, Wlter Reed- Bethesd, Rockville Pike, Suite 1215, Rockville, MD E-mil: kngmin.zhu@usuhs.edu Dis Colon Rectum 2014; 57: DOI: /DCR The ASCRS 2014 Diseses of the Colon & Rectum Volume 57: 9 (2014) DESIGN AND SETTING: Dtbse reserch using the Deprtment of Defense Militry Helth System. PATIENTS: Ptients included 2560 non-hispnic whites (NHW) nd non-hispnic blcks (NHB) with colon cncer dignosed from 1998 to MAIN OUTCOME MEASURES: Logistic regression ws used to ssess the ssocitions between rce nd the receipt of colon cncer surgery or chemotherpy while controlling for vilble potentil confounders, both overll nd strtified by ge t dignosis, sex, nd tumor stge. RESULTS: After multivrite djustment, the odds of receiving colon cncer surgery or chemotherpy for NHBs versus NHWs were similr (OR, 0.75 [95% CI, ]; OR, 0.79 [95% CI, ]). In ddition, no effect modifictions by ge t dignosis, sex, nd tumor stge were observed. LIMITATIONS: Tretment dt might not be complete for beneficiries who lso hd non-deprtment of Defense helth insurnce. CONCLUSIONS: When ccess to medicl cre is equl, rcil disprities in the provision of colon cncer surgery nd chemotherpy were not pprent. Thus, it is possible tht the inequlities in ccess to cre ply mjor role in the rcil disprities seen in colon cncer tretment in the generl popultion. KEY WORDS: Chemotherpy; Colon cncer; Equl ccess; Rce; Surgery; Tretment. 1059

2 1060 Gill et l: Rce nd Colon Cncer Tretment Colorectl cncer (CRC) is the third leding cuse of cncer incidence nd mortlity mong men nd women in the United Sttes. 1 The Americn Cncer Society estimted tht 143,460 new cses nd 51,690 deths would result from CRC in 2012; the mjority (72%) of these incidence cses were expected to occur in the colon. 1 Although CRC mortlity rtes hve declined over time for both sexes mong blcks nd whites, rcil disprities hve widened nd re not fully understood. 2,3 Tumor stge t dignosis is strong predictor of CRC mortlity; given tht blcks tend to be dignosed with lter-stge CRC, 4 rcil vrition in tumor stge t dignosis likely ccounts for much of the rcil disprity in CRC mortlity. However, within the sme tumor stge, the decline in CRC mortlity rte over time hs been lower mong blcks thn whites. 3 Thus, rcil vritions in other fctors, such s cncer tretment 5,6 nd follow-up cre, 7 re likely importnt s well. In the generl US popultion, blcks nd whites hve been shown to undergo colon cncer tretment t disproportionte rtes given the sme tumor stge 6,8 or fter djusting for tumor stge. 5,9 Although the gp between whites nd blcks in the receipt of colon cncer surgery nd chemotherpy hs lessened over the yers, rcil differences re still pprent. 10,11 Compred with whites, blcks tend to be less likely to receive surgery 9,12,13 nd chemotherpy. 8,9,13 Rcil disprities in tretment my be relted to ptient nd physicin chrcteristics, s well s fctors relted to the helth cre system. 14,15 Although physicin recommendtions on tretment, 16,17 ptient knowledge nd beliefs on cncer, 18,19 ptient-doctor interction, 20,21 nd shred decision mking with fmily nd friends 22,23 my be relted to the receipt of cncer tretment, ccessibility to medicl cre (ie, cost nd loction of cre 24,25 nd insurnce type) 24 my be the most importnt fctor, becuse it is directly relted to the vilbility nd implementtion of tretment. In the United Sttes, blcks tend to be less likely thn whites to hve helth insurnce nd more likely to be insured through government progrms, thus hving lower ccess to medicl cre. 24,26 28 Therefore, blck ptients my be less likely to receive sufficient nd timely tretment thn white ptients. In n equl-ccess helth cre system, different rcil/ ethnic groups hve the sme level of ccess to medicl cre. Thus, ny rcil differences in the system my result from fctors relted to the ctul use of cre rther thn the ccess. Among studies performed in n equl-ccess system, white nd blck ptients with CRC were found to undergo surgery, chemotherpy, nd rdition therpy t equl rtes. 29,30 In ddition to the studies in equl-ccess systems, reserch in qulity-seeking fcilities, such s the Ntionl Cncer Institute designted cncer centers nd Americn College of Surgeons Ntionl Surgicl Qulity Improvement Progrm hospitls, showed similr cncer outcomes between rcil/ethnic groups. 31,32 Ptients who visit these fcilities my hve good ccess to cre despite their rce, nd the similr outcomes might result from similr tretment between whites nd blcks. The US Deprtment of Defense (DoD) Militry Helth System (MHS) provides equl medicl cre to ll of its beneficiries, regrdless of rcil bckground; therefore, the MHS offers n excellent environment to ssess whether rcil differences in cncer tretment exist given equl ccess to cre. A recent study by Hofmnn et l 29 found no differences in colon cncer tretment between whites nd blcks who were treted t DoD fcilities. However, severl issues tht my hve ffected the results should be investigted further. First, tretment dt, which were scertined from the cncer registry only, my hve been incomplete, becuse tretment tht occurs multiple months fter dignosis might be underdetermined; the use of medicl clims dt in conjunction with registry dt my provide more complete informtion. Second, Hispnic ethnicity, which my confound the white-blck comprison, ws not considered. Third, comorbidities, which cn ffect the use of tretment nd re known to vry by rce, 33,34 were not considered. Furthermore, the potentil confounding effects of demogrphic fctors, tumor chrcteristics, nd comorbidities were not considered simultneously. The objective of the current study ws to use dt from both the cncer registry nd the medicl clims system of the MHS to exmine colon cncer tretment mong non- Hispnic white (NHW) nd non-hispnic blck (NHB) beneficiries. We imed to ssess whether rcil disprities in colon cncer surgery nd chemotherpy exist in n equl-ccess helth cre system; we simultneously controlled for ll of the vilble potentil confounders, including ethnicity nd comorbidities, nd ssessed whether the reltionship between rce/ethnicity nd tretment vried by ge t dignosis, sex, or tumor stge. MATERIALS AND METHODS Dt Source This project used consolidted dt from 2 sources, the DoD Centrl Cncer Registry (CCR) nd the MHS Dt Repository (MDR). Both dt sources contin informtion from DoD beneficiries, including ctive duty members, retirees, Ntionl Gurd nd Reserve members, nd their dependents. The CCR includes ll of the cncer cses tht re dignosed nd/or treted t militry tretment fcilities, nd informtion is bstrcted from ptient records nd entered into the CCR dtbse by certified cncer registrrs. The CCR contins dt on demogrphics (ge, sex, rce/ethnicity, nd mritl sttus), tumor chrcteristics (stge, grde, nd histology), screening, tretment (eg, surgery, chemotherpy, nd rdition), nd

3 Diseses of the Colon & Rectum Volume 57: 9 (2014) 1061 dignosis. The MDR contins dministrtive nd medicl cre clims dt (ie, informtion on clinicl dignoses, dignostic procedures, prescription medictions, nd tretment) for inptient nd outptient services tht re provided directly t militry tretment fcilities or pid for by the DoD t civilin fcilities. The project on which this nlysis ws bsed ws reviewed nd pproved by the institutionl review bords of the Wlter Reed Ntionl Militry Medicl Center, Tricre Mngement Activity, nd the Ntionl Institutes of Helth Office of Humn Subjects Reserch. Study Popultion Ptients with colon denocrcinom were eligible for this study. The initil study popultion included 3311 ptients (1960 men nd 1351 women) who were dignosed with histologiclly confirmed colon cncer between 1998 nd 2007 in both the CCR nd MDR. Tumors tht were solely reported vi deth certificte or utopsy were not included. Ptients who were neither NHW nor NHB (n = 644), did not hve n denocrcinom histology (n = 97), or hd in situ tumors (n = 10) were excluded from the study. Study Vribles Demogrphic vribles were obtined from the CCR unless the vlues were missing, then supplementl dt from the MDR were included. Vlues missing in both the CCR nd MDR were clssified s unknown. Rce ws ctegorized into 2 mutully exclusive groups on the bsis of the definitions used in the 2000 US Census nd ws clssified s NHW nd NHB. Mritl sttus t dignosis ws clssified s never mrried, mrried, other (seprted, divorced, or widowed), nd unknown. Beneficiries were clssified s either ctive duty or nonctive duty (ie, retiree nd dependent) t the time of dignosis. Affilited service brnch ws ctegorized s Army, Air Force, Mrines, Nvy, other (ie, Cost Gurd or Public Helth Service), nd unknown. Tumor chrcteristic dt were obtined from the CCR. Tumor stge t dignosis ws defined ccording to the Americn Joint Committee on Cncer stging recommendtions nd ws ctegorized s stge I, stge II, stge III, nd stge IV. 35 Tumor grde ws clssified into 4 ctegories, by level of differentition, including well differentited, modertely differentited, poorly differentited, nd unknown. 35 Colon cncer sites included cecum (C180), scending colon (C182), heptic flexure (C183), trnsverse colon (C184), splenic flexure (C185), descending colon (C186), sigmoid colon (C187), nd unknown/ colon, not otherwise specified (C188-C189). Tretments compred were determined ccording to the Ntionl Institutes of Helth clinicl guideline tht does not indicte rdition tretment for ptients with colon cncer; 36 thus, receipt of rdition ws not ssessed in this study. The receipt of colon cncer surgery nd chemotherpy ws determined by combining the CCR nd MDR dt nd ws considered yes if either dtbse recorded their occurrence within 12 months postdignosis. Yes/no concordnce between the CCR nd MDR ws 88% for surgery nd 82% for chemotherpy. Comorbidities were considered present if dignosis bsed on the Interntionl Clssifiction of Diseses, ninth revision, codes ws recorded in inptient nd/or outptient MDR dt during the yer before colon cncer dignosis; to reduce the possibility of flse dignoses, comorbidity hd to be recorded in the dt t lest 3 times. The level of comorbidity for ech individul ws clculted on the bsis of the Chrlson comorbidity index, 37 excluding colon cncer dignosis, nd ws ctegorized s hving weighted comorbidity of 0, 1, or 2. Sttisticl Anlysis χ 2 tests of significnce were used to compre demogrphic, tumor, nd helth chrcteristics, s well s colon cncer tretment, between the 2 rcil groups. Logistic regression ws used to control for potentil confounders in ssessing the ssocitions between rce nd the receipt of colon cncer surgery or chemotherpy. Vribles tht re ssocited with both rce/ethnicity nd tretment or could possibly confound results were djusted for in regression nlyses. These vribles included ge t dignosis, sex, mritl sttus, ctive duty sttus, service brnch, tumor stge, tumor grde, colon cncer site, presence of comorbidities, nd recurrence. Regression nlyses were conducted both overll nd strtified by ge t dignosis (<50 yers, yers, or 65 yers), sex, nd tumor stge. The ges of 50 nd 65 yers were chosen s cutoff points, becuse 50 yers is the ge recommended for colon cncer screening 38 nd 65 yers is the ge eligible for Medicre coverge. 39 Individuls with Medicre my visit medicl fcilities tht re not covered by the MHS, nd the dt completeness my vry by rce/ethnicity. ORs nd 95% CIs were clculted. All of the sttisticl nlyses were performed using SAS softwre, version 9.3 for Windows (SAS Institute, Inc, Cry, NC). All of the significnce tests were 2 sided nd performed t n α of RESULTS A totl of 2560 ptients were included in the study (2047 NHWs nd 513 NHBs). Rcil differences in demogrphics nd tumor chrcteristics were observed (Tbles 1 nd 2). Compred with NHWs, t the time of dignosis, NHBs were more likely to be younger, never mrried, on ctive duty, nd ffilited with the Army (p 0.02; Tble 1). In ddition, NHBs were more likely thn NHWs to be dignosed with lter-stge colon cncer nd cncers locted in the cecum or descending colon nd less likely to hve

4 1062 Gill et l: Rce nd Colon Cncer Tretment TABLE 1. Rcil comprisons of demogrphic chrcteristics mong Deprtment of Defense colon cncer cses, white (N = 2047) blck (N = 513) Chrcteristic n (%) n (%) p Age t dignosis, y <0.01 < (14) 122 (24) (10) 65 (13) (13) 65 (13) (18) 94 (18) (11) 67 (13) (11) 47 (9) (10) 31 (6) (13) 22 (4) Sex 0.92 Men 1254 (61) 313 (61) Women 793 (39) 200 (39) Mritl sttus t dignosis 0.02 Never mrried 56 (3) 27 (5) Mrried 1563 (76) 378 (74) Other 342 (17) 91 (18) Unknown 86 (4) 17 (3) Active duty sttus t <0.01 dignosis No 1895 (93) 447 (87) Yes 152 (7) 66 (13) Service brnch b <0.01 Army 667 (33) 256 (50) Air force 690 (34) 130 (25) Mrines 85 (4) 19 (4) Nvy 470 (23) 81 (16) Other 22 (1) 4 (1) Unknown 113 (6) 23 (4) N = Dt show 2-sided p vlue. b Dt include the service brnch of ctive duty member or sponsor. cncer in the sigmoid colon (p < 0.01; Tble 2). Tumor grde, level of comorbidity, nd recurrence did not differ significntly by rce. Univrite nlysis reveled rcil differences in colon cncer tretment overll nd/or when strtified by demogrphic chrcteristics (Tble 3). No differences in surgery were seen mong NHWs nd NHBs overll; however, rcil differences were seen t ge t dignosis, with younger NHBs undergoing surgery less frequently thn NHWs (p = 0.04). Rcil differences in chemotherpy were observed overll nd by sex in univrite nlyses. Overll, NHBs were more likely thn NHWs to receive chemotherpy (p < 0.01). However, this difference ws seen only mong men (p < 0.01). After controlling for demogrphic, tumor, nd helth chrcteristics, the odds of receiving surgery or chemotherpy were similr between NHWs nd NHBs (Tble 4). In ddition, rcil differences in the receipt of chemotherpy did not vry by ge t dignosis, sex, or tumor stge. Strtified nlyses were not conducted for surgery, becuse lmost ll of the NHBs underwent surgery for certin strt. TABLE 2. Rcil comprisons of tumor nd helth chrcteristics mong Deprtment of Defense colon cncer cses, DISCUSSION white (N = 2047) blck (N = 513) Chrcteristic n (%) n (%) p Tumor stge <0.01 I 504 (25) 92 (18) II 500 (24) 111 (22) III 552 (27) 152 (30) IV 309 (15) 109 (21) Unknown 182 (9) 49 (10) Tumor grde 0.32 Well differentited 321 (16) 67 (13) Modertely 1295 (63) 342 (67) differentited Poorly differentited 293 (14) 66 (13) Unknown 138 (7) 38 (7) Colon cncer site <0.01 Cecum 437 (21) 117 (23) Ascending colon 407 (20) 96 (19) Heptic flexure 101 (5) 25 (5) Trnsverse colon 166 (8) 47 (9) Splenic flexure 68 (3) 34 (7) Descending colon 130 (6) 52 (10) Sigmoid colon 687 (34) 128 (25) Unknown/colon, NOS 51 (2) 14 (3) Comorbidities b (59) 328 (64) (13) 62 (12) (27) 123 (24) Recurrence 0.09 No 1797 (88) 436 (85) Yes 250 (12) 77 (15) N = 2560; NOS = not otherwise specified. Dt show 2-sided p vlue. b Comorbidities vi the Chrlson comorbidity index. Colon cncer ws not included in clcultion. In this study, we exmined rcil disprities in colon cncer surgery nd chemotherpy mong DoD beneficiries of ll stges of disese who hve equl ccess to cre. Univrite nlysis reveled tht, overll, there were no rcil differences in surgery but tht NHBs were more likely to receive chemotherpy thn NHWs. In ddition, younger NHWs were more likely to undergo surgery compred with NHBs, wheres NHB men were more likely to receive chemotherpy thn their NHW counterprts. However, fter multivrite djustment, the odds of receiving colon cncer surgery or chemotherpy were similr between the 2 rcil groups. Our findings suggest no rcil/ethnic differences in the receipt of therpy in MHS beneficiries. These results re consistent with previous nlysis within the MHS 29 ; however, the current study used not only cncer registry but lso medicl clims dt to provide more complete tretment informtion nd considered potentil effects of dditionl fctors tht could influence the receipt of tretment

5 Diseses of the Colon & Rectum Volume 57: 9 (2014) 1063 TABLE 3. Rcil comprison of colon cncer tretment mong Deprtment of Defense colon cncer cses, white (N = 2047) blck (N = 513) Prmeter Tretment Yes (%) Yes (%) All study subjects Surgery 1995 (97) 496 (97) 0.33 Chemotherpy 940 (46) 273 (53) <0.01 Tumor stge I Surgery 503 (100) 92 (100) 0.67 Chemotherpy 12 (2) 5 (5) 0.11 II Surgery 498 (100) 111 (100) 0.50 Chemotherpy 184 (37) 47 (42) 0.28 III Surgery 551 (100) 151 (99) 0.33 Chemotherpy 447 (81) 124 (82) 0.87 IV Surgery 300 (97) 105 (96) 0.70 Chemotherpy 231 (75) 81 (74) 0.93 Age t dignosis, y <50 Surgery 284 (99) 117 (96) 0.04 Chemotherpy 209 (73) 92 (75) Surgery 822 (99) 219 (98) 0.42 Chemotherpy 448 (54) 124 (55) Surgery 889 (96) 160 (96) 0.91 Chemotherpy 283 (31) 57 (34) 0.36 Sex Men Surgery 1216 (97) 303 (97) 0.88 Chemotherpy 552 (44) 163 (52) <0.01 Women Surgery 779 (98) 193 (97) 0.13 Chemotherpy 388 (49) 110 (55) 0.12 N = Dt show 2-sided p vlue. p (eg, Hispnic ethnicity nd the presence of comorbidities). In previous study within the Veterns Affirs helth cre system, 30 which is nother equl-ccess system, there were lso no differences in the receipt of colon cncer tretment between white nd blck ptients. Findings of these studies in n equl-ccess system contrst those of previous studies in the generl popultion tht hve found tht blcks re less likely to receive surgery nd chemotherpy compred with whites. 8,9,12,13 Accessibility to medicl cre my ply role in the receipt of disproportionte tretment mong whites nd blcks in these studies. For exmple, in popultion-bsed study tht exmined the effects of rce on use of surgery, lck of helth insurnce nd use of Medicid resulted in decresed receipt of surgicl resection mong blcks. 9 In the MHS, ll of the beneficiries receive helth cre without chrge or for miniml fee regrdless of rcil/ethnic bckground, nd, thus, ccess to cre is equl mong vrious rcil/ethnic groups. These findings in n equl-ccess system suggest tht rcil vritions in colon cncer tretment observed in the generl popultion likely result minly from different levels of ccess to helth cre, which my ffect tretment received. Beyond ccess to cre, physicin tretment recommendtions, 16,17 ptient-provider communiction, 20,21 ptientphysicin rce concordnce, 40 shred decision mking with fmily nd friends, 22,23,34,35 nd ptient knowledge, ttitude, nd beliefs on cncer 18,19 my lso be relted to the rcil differences in colon cncer tretment observed in the generl popultion. However, similr tretment use mong MHS beneficiries in this study suggests tht these fctors my not be substntilly different between rcil TABLE 4. Multivrite regression nlyses ssessing rce nd the odds of tretment mong ll of the study subjects nd by tumor stge, ge, nd sex Prmeter OR 95% CI Surgery, ll subjects Chemotherpy, ll subjects Tumor stge I II III IV Age t dignosis, y < Sex Men Women N = ORs nd 95% CIs of rce (non-hispnic blck versus non-hispnic white) nd tretment fter djusting for rce, yer of dignosis, ge t dignosis (continuous), sex, mritl sttus t dignosis, ctive duty sttus t dignosis, service brnch of ctive duty member/sponsor, colon cncer site, tumor stge, tumor grde, surgery, chemotherpy, recurrence, nd comorbidities. Respective tretments nd strtified vribles were not included in strtified nlysis.

6 1064 Gill et l: Rce nd Colon Cncer Tretment nd ethnic groups. As result, it is possible tht ptient nd physicin fctors my not ply crucil role when ccess to medicl cre is equl nd tretment is vilble. Thus, it is likely tht rcil disprities in colon cncer tretment cn be reduced through equl ccess to cre. Although this study hd strengths in using more complete tretment dt nd considering the potentil effects by ethnicity nd comorbidities, there were lso some limittions. DoD beneficiries with supplementl helth insurnce my obtin helth cre services tht re not pid for by the DoD; thus, our tretment dt my not hve been complete. However, during sensitivity nlysis, when dt were confined to DoD beneficiries with TRICARE Prime, helth cre progrm provided by the DoD in which beneficiries receive free cre or py miniml fees for services in helth mintennce orgniztion like setting nd re thus less likely to receive helth cre services not pid by the DoD, no differences in the receipt of colon cncer tretment were observed between NHWs nd NHBs regrdless of ge t dignosis, sex, nd tumor stge (dt not shown). Therefore, it ppers tht incomplete tretment informtion might not hve substntilly ffected our results. Accurte timing nd durtion of chemotherpy nd surgery could lso not be clculted in this study becuse only the strting nd ending month nd yer (rther thn dy) of tretment were vilble bsed on the pproved institutionl review bord protocol. Therefore, our results should be tempered with potentil cution becuse similr tretment frequencies between the different rcil groups my, but do not necessrily, men tht the different rcil groups received tretment in comprble mnner in terms of tretment timing nd durtion. Furthermore, our study did not ddress whether blck nd white ptients differed in terms of the intervl between dignosis nd tretment nd the frequency nd durtion of chemotherpy. As result, further reserch is wrrnted. CONCLUSION In helth cre system in which NHWs nd NHBs hve the sme level of ccess to medicl cre, rcil disprities in the receipt of colon cncer surgery nd chemotherpy were not pprent. Our study suggests the possibility tht unequl ccess to cre plys mjor role in the rcil disprities seen in colon cncer tretment in the generl popultion. ACKNOWLEDGMENTS The uthors thnk the following individuls nd institutes for their contributions to or support for the originl dt linkge project: Guy J. Grnett, Dvid E. Rdune, nd Dr. Aliz Fink of ICF Mcro; Wendy Funk, Julie Anne Mutersbugh, Lind Cottrell, nd Lur Hopkins of Kennel nd Assocites, Inc.; Kim Frzier, Dr. Elder Grnger, nd Dr. Thoms V. Willims of TMA; Annette Anderson, Dr. Ptrice Robinson, nd Dr. Chris Owner of the Armed Forces Institute of Pthology; Dr. Joseph F. Frumeni, Jr., Dr. Robert N. Hoover, Dr. Susn S. Deves, nd Glori Gridley of the Ntionl Cncer Institute; nd Dr. John Potter, Rul Prr, Ann Smith, Fion Renlds, Willim Mhr, Hongyu Wu, Dr. Lrry Mxwell, Miguel Buddle, nd Virgini Vn Horn of the United Sttes Militry Cncer Institute. The uthors lso thnk Dr. Jon Wrren for her comments on this rticle nd help with progrmming for the Chrlson comorbidity index. REFERENCES 1. Americn Cncer Society. Colorectl Cncer Fcts & Figures Atlnt, GA: Americn Cncer Society; DeLncey JO, Thun MJ, Jeml A, Wrd EM. Recent trends in blck-white disprities in cncer mortlity. Cncer Epidemiol Biomrkers Prev. 2008;17: Robbins AS, Siegel RL, Jeml A. 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7 Diseses of the Colon & Rectum Volume 57: 9 (2014) Morris AM, Rhods KF, Stin SC, Birkmeyer JD. Understnding rcil disprities in cncer tretment nd outcomes. J Am Coll Surg. 2010;211: Lthn CS, Neville BA, Erle CC. The effect of rce on invsive stging nd surgery in non-smll-cell lung cncer. J Clin Oncol. 2006;24: VnEenwyk J, Cmpo JS, Ossinder EM. Socioeconomic nd demogrphic disprities in tretment for crcinoms of the colon nd rectum. Cncer. 2002;95: Busch S. Elderly Africn Americn women s knowledge nd belief bout colorectl cncer. ABNF J. 2003;14: Green PM, Kelly BA. Colorectl cncer knowledge, perceptions, nd behviors in Africn Americns. Cncer Nurs. 2004;27:206 15; quiz Ashton CM, Hidet P, Pterniti DA, et l. Rcil nd ethnic disprities in the use of helth services: bis, preferences, or poor communiction? J Gen Intern Med. 2003;18: Johnson RL, Roter D, Powe NR, Cooper LA. Ptient rce/ethnicity nd qulity of ptient-physicin communiction during medicl visits. Am J Public Helth. 2004;94: Mtsuym RK, Grnge C, Lyckholm LJ, Utsey SO, Smith TJ. Culturl perceptions in cncer cre mong Africn-Americn nd Cucsin ptients. J Ntl Med Assoc. 2007;99: Wgner SE, Drke BF, Elder K, Hébert JR. Socil nd clinicl predictors of prostte cncer tretment decisions mong men in South Crolin. Cncer Cuses Control. 2011;22: Wrd E, Hlpern M, Schrg N, et l. Assocition of insurnce with cncer cre utiliztion nd outcomes. CA Cncer J Clin. 2008;58: Bicker K, Chndr A, Skinner JS, Wennberg JE. Who you re nd where you live: how rce nd geogrphy ffect the tretment of medicre beneficiries. Helth Aff (Millwood). 2004;Suppl Vrition:VAR33 VAR Kirby JB, Kned T. Unhelthy nd uninsured: exploring rcil differences in helth nd helth insurnce coverge using life tble pproch. Demogrphy. 2010;47: DeNvs-Wlt C, Proctor BD, Smith JC. Income, Poverty, nd Helth Insurnce Coverge in the United Sttes: Current Popultion Reports. Wshington, DC: US Government Printing Office; 2011: Fedew SA, Lerro C, Chse D, Wrd EM. Insurnce sttus nd rcil differences in uterine cncer survivl: study of ptients in the Ntionl Cncer Dtbse. Gynecol Oncol. 2011;122: Hofmnn LJ, Lee S, Wddell B, Dvis KG. Effect of rce on colon cncer tretment nd outcomes in the Deprtment of Defense helthcre system. Dis Colon Rectum. 2010;53: Dominitz JA, Sms GP, Lndsmn P, Provenzle D. Rce, tretment, nd survivl mong colorectl crcinom ptients in n equl-ccess medicl system. Cncer. 1998;82: Oneg T, Duell EJ, Shi X, Demidenko E, Goodmn DC. Rce versus plce of service in mortlity mong medicre beneficiries with cncer. Cncer. 2010;116: Prsons HM, Hbermnn EB, Stin SC, Vickers SM, Al-Refie WB. Wht hppens to rcil nd ethnic minorities fter cncer surgery t Americn College of Surgeons Ntionl Surgicl Qulity Improvement Progrm hospitls? J Am Coll Surg. 2012;214: Berglund A, Grmo H, Tishelmn C, Holmberg L, Stttin P, Lmbe M. Comorbidity, tretment nd mortlity: popultion bsed cohort study of prostte cncer in PCBSe Sweden. J Urol. 2011;185: Field TS, Bosco JL, Prout MN, et l. Age, comorbidity, nd brest cncer severity: impct on receipt of definitive locl therpy nd rte of recurrence mong older women with erly-stge brest cncer. J Am Coll Surg. 2011;213: Greene FL, Pge DL, Fleming ID, et l. AJCC Cncer Stging Mnul, 6th ed. New York, NY: Springer-Verlg; Adjuvnt Therpy for Ptients with Colon nd Rectum Cncer. NIH Consens Sttement Online 1990 Apr [cited 2012 My 19];8: Chrlson ME, Pompei P, Ales KL, McKenzie CR. A new method of clssifying prognostic comorbidity in longitudinl studies: development nd vlidtion. J Chronic Dis. 1987;40: Levin B, Liebermn DA, McFrlnd B, et l.; Americn Cncer Society Colorectl Cncer Advisory Group; US Multi-Society Tsk Force; Americn College of Rdiology Colon Cncer Committee. Screening nd surveillnce for the erly detection of colorectl cncer nd denomtous polyps, 2008: joint guideline from the Americn Cncer Society, the US Multi-Society Tsk Force on Colorectl Cncer, nd the Americn College of Rdiology. CA Cncer J Clin. 2008;58: Socil Security Administrtion. Medicre. pubs/en pdf. Accessed Februry 14, LVeist TA, Nuru-Jeter A, Jones KE. The ssocition of doctorptient rce concordnce with helth services utiliztion. J Public Helth Policy. 2003;24: