Impact made by socioeconomic factors in treatment groups undergoing surveillance colonoscopy

From Cancer Guidelines Wiki

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

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

1. following adenoma detection;

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

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


Many studies have found poorer survival following a diagnosis of colorectal cancer (CRCColorectal cancer) among people from low socioeconomic status (SESSocioeconomic status) groups compared with those from high SESSocioeconomic status 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 SESSocioeconomic status.[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 CRCColorectal cancer in Queensland between 1997 and 2007. Analysis showed that patients living in inner regional areas (odds ratio [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 CRCColorectal cancer diagnosis.

Higher SESSocioeconomic status 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 pointA recommendation on a subject that is outside the scope of the search strategy for the systematic review, based on expert opinion and formulated by a consensus process.Question 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 PolypA small growth protruding from a mucous membrane, such as the lining of the bowel. Study[8] was that removal of adenomas with a follow-up of at least 3 years reduced the incidence of CRCColorectal cancer 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 CRCColorectal cancer. 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 CRCColorectal cancer-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 SESSocioeconomic status factors and so assist in developing methods to increase compliance of patients of lower SESSocioeconomic status.

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Surveillance after diagnosis of inflammatory bowel disease

There is a perception that patients with inflammatory bowel disease (IBDInflammatory bowel disease) are of a higher socioeconomic status and have a higher level of education than the general population. However, available research suggests that people with IBDInflammatory bowel disease are not of higher SESSocioeconomic status 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 IBDInflammatory bowel disease 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 IBDInflammatory bowel disease 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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  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
  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 ColorectalReferring to the large bowel, comprising the colon and rectum. 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
  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
  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
  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
  12. Sonnenberg A, Turner KO, Genta RM. Differences in the socio-economic distribution of inflammatory bowel disease and microscopic colitis. ColorectalReferring to the large bowel, comprising the colon and rectum. Dis 2017 Jan;19(1):38-44 Abstract available at

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