Impact made by socioeconomic factors in treatment groups undergoing surveillance colonoscopy

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Does lower SES have to result in poorer outcome for curative resection for colonic cancer?

This question focuses on those modifiable socioeconomic status (SES)-related factors which impact on surveillance in the three groups being considered:

1. following adenoma detection;

2. post-curative resection for colorectal cancer (CRC); and

3. in the setting of dysplasia surveillance in inflammatory bowel disease (IBD).

Background

Many studies have found poorer survival following a diagnosis of colorectal cancer (CRC) among people from low socioeconomic status (SES) groups compared with those from high SES groups, but with some exceptions.[1][2] Differences between health systems may account for these contradictory findings. Influences of comorbidities rather than other factors, such as treatment or patient characteristics, may also contribute to the effect of SES.[3] Further research remains to be done, but it seems that if practitioners assist their patients to access best care and promote management of comorbidities, they could promote equality of outcomes.

Overview of evidence (non-systematic literature review)

No systematic reviews were undertaken for this topic. Practice points are based on selected evidence and guidelines (see Guideline development process).

A cohort study of white and African American males with advanced lung and colon cancer, who had not had previous chemotherapy, had their socioeconomic and biological data collected prospectively in 12 medical centres in the US Veterans Administration System (1981–1986).[4] The essential finding of the study was that lung and colon cancer outcomes "may be similar among black and white patients who have equal access to comparable medical care in spite of socioeconomic differences". This study highlights the importance of access to good clinical care in improving outcomes.[5][4] This is highly relevant to Australia.

The relationships between geographic remoteness, area disadvantage and risk of advanced colorectal cancer was looked at among people aged 20–79 years diagnosed with CRC in Queensland between 1997 and 2007. Analysis showed that patients living in inner regional areas (odds ratioA comparison of the odds (probability) of something happening in one group with the odds of it happening in another. [OR]=1.09, 1.01–1.19) and outer regional areas (OR=1.11, 1.01–1.22) areas were significantly more likely to be diagnosed with advanced cancer than those in major cities (P=0.045), after adjusting for individual-level variables. The authors noted that “[g]iven the relationship between stage and survival outcomes, it is imperative that the reasons for these rurality inequities in advanced disease be identified and addressed".[6] The reasons clearly relate to surveillance pre- and post-initial CRC diagnosis.

Higher SES and being married were associated with greater participation in surveillance in a large US study.[7] Patients over age 80 years and those with rectal cancer were less likely to undergo surveillance.


Practice pointQuestion mark transparent.png

After curative resection for colorectal cancer, survival outcomes in disadvantaged patients may be improved by clinicians and health systems by addressing the barriers and access to optimal clinical care.

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Surveillance after colonic polypectomy

In the post-adenoma setting, risk reduction is related to participation in surveillance and lifestyle modifications.

A finding of the National Polyp Study[8] was that removal of adenomas with a follow-up of at least 3 years reduced the incidence of CRC recurrence. Eighty per cent compliance was achieved, but the general population compliance was not known. This study suggests that risk reduction requires effective participation in surveillance while previously mentioned studies provide strong evidence that lifestyle modification is important for the prevention of colorectal polyps, especially advanced and multiple adenomas, established precursors of colorectal cancer.

A systematic review and meta-analysis to quantify the evidence for an association between weight gain and colorectal adenoma occurrence found an increased risk of colorectal adenoma throughout the whole range of weight gain. Even a small amount of adult weight gain was related to higher odds of colorectal adenoma occurrence. The findings suggest a benefit of weight control in reducing the development of metachronous colorectal adenomas and preventing CRC. The study findings emphasise the importance of patient awareness and the clinician’s ability to communicate information to patients.[9] Studies have also reported that weight loss after bariatric surgery or physical activity helped reduce the risk of CRC-related mortality[10] The key question in the context of surveillance is the time to benefit for those identified as at increased risk.[11] Further studies of general population compliance need to address SES factors and so assist in developing methods to increase compliance of patients of lower SES.


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Surveillance after diagnosis of inflammatory bowel disease

There is a perception that patients with inflammatory bowel disease (IBD) are of a higher socioeconomic status and have a higher level of education than the general population. However, available research suggests that people with IBD are not of higher SES and at some time in the course of their illness, they are more likely to be out of work than the general population.[12] Recommendations to increase participation in surveillance are likely to apply equally to people with IBD as to other groups.

Issues requiring more clinical research study

Carefully planned studies are required to specifically address surveillance colonoscopy and colorectal cancer and possibly IBD in Aboriginal and Torres Strait Islander people.

Resources will be required to assist in implementation of guideline recommendations in Aboriginal and Torres Strait Islander communities.

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References

  1. Carstairs V. Multiple deprivation and health state. Community Med 1981 Jan 1;3(1):4-13.
  2. Townsend P, Simpson D, Tibbs N. Inequalities in health in the city of Bristol: a preliminary review of statistical evidence. Int J Health Ser 1985;15(4):637-663.
  3. Frederiksen BL, Osler M, Harling H, Ladelund S, Jørgensen T. Do patient characteristics, disease, or treatment explain social inequality in survival from colorectal cancer? Soc Sci Med 2009 Oct;69(7):1107-15 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19695753.
  4. 4.04.1 Akerley WL, Moritz TE, Ryan LS, Henderson WG, Zacharski LR. Racial comparison of outcomes of male Department of Veteran Affairs patients with lung cancer and colon cancer. Arch Intern Med 1993;153(14):1681-1688.
  5. Australian Cancer Network Colorectal Cancer Guidelines Revision Committee. Clinical practice guidelines for the prevention, early detection and management of colorectal cancer. The Cancer Council Australia and Australian Cancer Network 2005.
  6. Baade PD, Dasgupta P, Aitken J, Turrell G. Geographic remoteness and risk of advanced colorectal cancer at diagnosis in Queensland: a multilevel study. Br J Cancer 2011 Sep 27;105(7):1039-41 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21897391.
  7. Rulyak SJ, Mandelson MT, Brentnall TA, Rutter CM, Wagner EH. Clinical and sociodemographic factors associated with colon surveillance among patients with a history of colorectal cancer. Gastrointest Endosc 2004;59(2):239-247.
  8. Winawer SJ. The achievements, impacts and future of the National Polyp Study. Gastrointestinal Endoscopy 2006 Jan 1;64(6):975-978.
  9. Schlesinger S, Aleksandrova K, Abar L, Vieria AR, Vingeliene S, Polemiti E, et al. Adult weight gain and colorectal adenomas-a systematic review and meta-analysis. Ann Oncol 2017 Jun 1;28(6):1217-1229 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/28327995.
  10. Giovannucci E, Colditz GA, Stampfer MJ, Willett WC. Physical activity, obesity, and risk of colorectal adenoma in women (United States). Cancer Causes Control 1996 Mar;7(2):253-63 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/8740738.
  11. Fu Z, Shrubsole MJ, Smalley WE, Wu H, Chen Z, Shyr Y, et al. Lifestyle factors and their combined impact on the risk of colorectal polyps. Am J Epidemiol 2012 Nov 1;176(9):766-76 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23079606.
  12. Sonnenberg A, Turner KO, Genta RM. Differences in the socio-economic distribution of inflammatory bowel disease and microscopic colitis. Colorectal Dis 2017 Jan;19(1):38-44 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/27166978.

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Appendices

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