Impact of Socioeconomic Status on Presentation and Outcomes in Colorectal Peritoneal Metastases Following Cytoreduction and Chemoperfusion: Persistent Inequalities in Outcomes at a High-Volume Center

Abstract

Background Cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion (CRS HIPEC) can offer significant survival advantage for select patients with colorectal peritoneal metastases (CRPM). Low socioeconomic status (SES) is implicated in disparities in access to care. We analyze the impact of SES on postoperative outcomes and survival at a high-volume tertiary CRS HIPEC center. Patients and Methods We conducted a retrospective cohort study examining patients who underwent CRS HIPEC for CRPM from 2000 to 2018. Patients were grouped according to SES. Baseline characteristics, perioperative outcomes, and survival were examined between groups. Results A total of 226 patients were analyzed, 107 (47%) low-SES and 119 (53%) high-SES patients. High-SES patients were younger (52 vs. 58 years, p = 0.01) and more likely to be White (95.0% vs. 91.6%, p = 0.06) and privately insured (83% vs. 57%, p < 0.001). They traveled significantly further for treatment and had lower burden of comorbidities and frailty (p = 0.01). Low-SES patients more often presented with synchronous peritoneal metastases (48% vs. 35%, p = 0.05). Following CRS HIPEC, low-SES patients had longer length of stay and higher burden of postoperative complications, 90-day readmission, and 30-day mortality. Median overall survival following CRS HIPEC was worse for low-SES patients (17.8 vs. 32.4 months, p = 0.02). This disparity persisted on multivariate survival analysis (low SES: HR = 1.46, p = 0.03). Conclusions Despite improving therapies for CRPM, low-SES patients remain at a significant disadvantage. Even patients who overcome barriers to care experience worse short- and long-term outcomes. Improving access and addressing these disparities is crucial to ensure equitable outcomes and improve patient care.

Racial Disparities in Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: Does Aggressive Surgical Treatment Overcome Cancer Health Inequities?

“…We also found that the occurrence of a major complication postoperatively was associated with overall survival. This agrees with results from a similar study investigating colorectal cancer patients undergoing CRS and HIPEC ( 7 ).…”

“…This finding contrasts the results reported by Rieser et al. who found that for colorectal cancer patients with peritoneal carcinomatosis, patients with lower socioeconomic status had longer lengths of stay, more complications, and higher rates of 90-day readmission and 30-day mortality ( 7 ). The authors argued that patients with lower socioeconomic status experience multiple disadvantages and worse overall survival compared to higher socioeconomic status patients that was not explained by individual cancer biology characteristics.…”

“…Few studies have investigated the disparities present in patients with peritoneal carcinomatosis treated with CRS and HIPEC. The limited number of currently published studies have focused primarily on the impact of socioeconomic status and insurance status on patient outcomes, overlooking possible racial disparities within this patient population ( 7 – 9 ). Racial disparities exist in the diagnosis, treatment, management, and survival of cancer ( 10 – 15 ).…”

Impact of sociodemographic factors on outcomes in patients with peritoneal malignancies following cytoreduction and chemoperfusion

“…There is relatively little published about social disparities and CRS/HIPEC, although one of the largest to date is by Rieser et al 17 who studied the impact of SES on 226 patients who underwent CRS/HIPEC for colorectal peritoneal metastases. They found that high‐SES patients were more likely to be white, privately insured, and had fewer comorbidities.…”

“…[13][14][15][16] While multiple studies have examined the impact of social determinants of health on gastrointestinal malignancies, few studies have examined the effect specifically on patients with peritoneal malignancies undergoing cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC). 17 This patient population is uniquely vulnerable due to the high morbidity and mortality of the required operations, in addition to the complex pre-and postoperative care that is often needed to successfully care for these patients. They often have severe protein malnutrition perioperatively, and can have complex home-care needs including ostomies, drains, nutritional supplements, and wound care.…”