Financial Disclosure. Team. Race-based Socioeconomic and Treatment Disparities in Adolescents and Young Adults with Stage II-III Rectal Cancer

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1 Race-based Socioeconomic and Treatment Disparities in Adolescents and Young Adults with Stage II-III Rectal Cancer Melanie Goldfarb MD, MSc, FACS, FACE John Wayne Cancer Institute at PSJHC, Santa Monica, CA Financial Disclosure No relevant financial disclosures Team David Y Lee MD, Annabelle Teng MD, Rose C Pederson MD, Farees R Tavangari MD, Vikram Attaluri MD, Elisabeth C McLemore MD, Stacey L Stern MS, Anton J Bilchik MD PhD, Melanie Goldfarb MD MSc Department of Surgical Oncology and Biostatistics, The John Wayne Cancer Institute at Providence St John's Health Center, Santa Monica CA, Mount Sinai St Luke s-roosevelt Hospital, New York NY, Kaiser Permanente, Los Angeles CA

2 Learning Objectives Understand how the NCDB PUFs can be leveraged for cancer disparity research Identify disparities in the treatment of young adult (YA) rectal cancer Understand the factors that influence survival for YA rectal cancer patients Potential slide about NCDB Disparities / treatment variables Adolescents and Young Adults (AYA) Ages Distinct population compared to pediatric and adult oncology patients

3 NASS, The Oncologist 2015 Adolescents and Young Adults (AYA) Adolescents and Young Adults (AYA) Cancer is the #1 cause of disease-related death with over 70,000 diagnoses a year Growing consensus that this underserved population requires more resources AYA cancer mortality has not improved in comparison to pediatric and adult cancers wwwcancergov/types/aya/research/ayao-august-2006pdf

4 Racial Differences in Survival from Invasive Cancer (AYA) Colorectal Cancer (CRC) Incidence of CRC in younger patients, especially in the rectum and the distal colon, has been on the rise, whereas in the general population incidence continues to decline Bailey, JAMA Surgery 2015

5 Colorectal Cancer (CRC) CRC is the second leading cause of cancer deaths in the US Mortality is known to be higher in Blacks compared to Whites, a difference which has increased over time Colorectal Cancer Model of Health Disparities: Understanding Incidence and Mortality Differences in Different Populations Polite, JCO

6 Stage II/III Rectal Cancer in Older Adults Improved survival Standardization of neoadjuvant therapy, followed by surgical resection Enhanced efficacy of chemotherapeutic regimens Objective/Aim Identify treatment disparities in Stage II and III rectal CA in the AYA population Identify socioeconomic (SES), racial, and biological factors associated with worse outcomes in Stage II-III rectal CA in the AYA population Hypothesis SES status and racial disparities in treatment play a large role in determining survival (it s not only biology)

7 Methods National Cancer Database (NCDB) Clinical stage II-III rectal cancer patients (AJCC 6 th edition) AYAs - Ages years Compared the outcomes of Non-Hispanic Whites, Blacks, and White-Hispanics n=3295 White (N= 2,372) Demographics Black (N=335) Hispanic (N=333) Others (N=255) Age (mean-years) 339 ± ± ± ± 47 Gender (Male) 1,356 (572%) 194 (579%) 191 (574%) 155 (608%) Co-morbidities 0 1,772 (939%) 241 (903%) 273 (965%) 192 (932%) (58%) 26 (97%) 9 (32%) 13 (63%) 2 6 (03%) 0 (0%) 1 (04%) 1 (05%) Insurance Status Not insured 153 (65%) 41 (122%) 88 (264%) 23 (90%) Private 1,787 (753%)* 169 (504%)* 124 (372%)* 174 (682%)* Medicare 52 (22%) 12 (36%) 7 (21%) 6 (24%) Medicaid 236 (99%) 91 (272%) 82 (246%) 35 (137%) Others/unknown 144 (61%) 22 (66%) 32 (96%) 17 (67%) p-value < 005 denoted in * White (N= 2,372) Black (N=335) Hispanic (N=333) Others (N=255) Median Income <$30, (106%)* 95 (299%)* 76 (235%)* 20 (83%)* $30,000-35, (179%) 59 (186%) 72 (223%) 25 (104%) $36,000-45, (222%) 89 (280%) 96 (297%) 58 (242%) $46, (433%) 75 (236%) 79 (245%) 137 (571%) Population Metro Counties 1,636 (717%) 271 (842%) 297 (897%) 203 (857%) Urban Counties 602 (264%) 50 (155%) 34 (102%) 31 (131%) Rural counties 44 (19%) 1 (03%) 0 (0%) 3 (13%) % no HS degree> 29% 307 (135%)* 110 (346%)* 169 (523%)* 43 (179%)* Treatment Facility type Comprehensive 1,108 (469%) 125 (380%) 137 (416%) 93 (365%) Community Cancer Community Cancer 193 (82%) 23 (70%) 33 (100%) 24 (94%) Academic/Research 1,060 (448%) 181 (550%) 159 (483%) 138 (541%) p-value < 005 denoted in *

8 Tumor Characteristics White (N= 2,372) Black (N=335) Hispanic (N=333) Others (N=255) Clinical Staging II 933 (393%) 140 (418%) 127 (381%) 83 (325%) III 1,439 (607%) 195 (582%) 206 (619%) 172 (675%) Tumor Size 468 ± 409* 568 ± 671* 552 ± 667* 460 ± 240* (mean- mm) Mean # of nodes Harvested 137 ± ± ± ± 136 % with positive nodes 813 (462%) 109 (470%) 124 (551%) 92 (495%) Mean # of + nodes 22 ± ± ± ± 32 Tumor differentiation Well 156 (66%) 14 (42%) 22 (67%) 15 (59%) Moderate 1,433 (604%) 189 (564%) 178 (534%) 147 (576%) Poor 441 (186%) 67 (200%) 74 (222%) 62 (243%) Unknown 342 (144%) 64 (191%) 59 (177%) 31 (122%) No surgery performed (%) p < Recommended but no surgery performed (%) p < Recommended but contraindicated due to risks (%) Recommended but not performed, reasons unknown (%) Recommended but refused (%) p-value < 005 denoted in *

9 Days to surgery Blacks 1249 Hispanics 1182 p < 0001 Whites 1142 No chemotherapy / radiation therapy (%) 271 % without radiation therapy p < 0001 % without chemotherapy p-value < 005 denoted in * Days to radiation / chemotherapy Blacks 454 p < Hispanics p < 0001 Whites p < 0001 Days to chemotherapy Days to radiation p-value < 005 denoted in *

10 Recommended but no radiation given (%) 323 p < Recommended but contraindicated due to risks (%) Recommended but not performed, reasons unknown (%) Recommended but refused (%) p-value < 005 denoted in * Recommended but no chemotherapy given (%) Recommended but contraindicated due to risks (%) Recommended but not performed, reasons unknown (%) Recommended but refused (%) p-value < 005 denoted in * Received neoadjuvant chemoradiation (%) 750 p <

11 Survival Distribution Survival Distribution Factors Associated with Decreased Receipt of Neoadjuvant Chemoradiation Prognostic Factors Adjusted OR (95%CI) p Value Race White Black 066 ( ) 0014 Hispanic 063 ( ) 0012 Other 067 ( ) 0017 Gender Female Male 130 ( ) 0011 Insurance Status Private insurance No insurance 050 ( ) <0001 Medicaid/Medicare/Government 080 ( ) 0088 Urban Status Greater than 250,000 2, , ( ) 0017 Less than 2, ( ) 0087 Facility Type Community Cancer Program 149 ( ) 0024 Comprehensive Community Cancer Program Academic/Research Program 193 ( ) <0001 Other 057 ( ) 0692 Overall Survival All Patients year OS White: 749% Hispanic: 659% Black: 598% Other: 729% 050 P < Months OS: Patients s/p Neoadjuvant Chemoradiation year OS White: 815% Hispanic: 787% Black: 733% Other: 794% P= Months

12 Factors Associated with Poor Survival Prognostic Factors Adjusted HR (95%CI) p Value Gender Male Female 067 ( ) 0009 Nodal disease Negative Referent Positive 263 ( ) <0001 Surgery Yes No 714 ( ) <0001 Neoadjuvant chemoradiation Yes No 192 ( ) 0040 Grade Well differentiated Moderately differentiated 156 ( ) 0258 Poorly differentiated/anaplastic 296 ( ) 0007 Other 167 ( ) 0239 Insurance Private No insurance 171 ( ) 0022 Government 186 (133, 259) <0001 Limitations NCDB lacks: disease-specific mortality, indices of recurrence, treatment response, MSI, data of prior cancers, pediatric or adult-trained treating team, specific chemotherapy regimen, or number of chemotherapy cycles completed NCDB captures approximately 50% of cancer cases in patients of Hispanic origin; thus, it is possible that this skews the data from which we drew conclusions from that specific demographic Conclusions Racial and SES disparities exist in the multidisciplinary treatment of rectal cancer for AYAs There may be a cultural component Differences in treatment account for much of the survival differences between races, but biology still plays some role

13 Future Directions Interventions that can address and mitigate these differences may lead to improvements in OS for some patients Sub-group Analysis of All Surgical Patients: Decreased OS