National disparities in use of minimally invasive surgery for rectal cancer in older adults

Abstract

BACKGROUND: Minimally invasive surgery (MIS) is safe and improves outcomes in older persons with rectal cancer but may be underutilized. As older persons are the largest surgical population, investigation of the current use and factors impacting MIS use is warranted. Our goal is to investigate the trends and disparities that affect utilization of MIS in older persons with rectal cancer. METHODS: The National Cancer Database was reviewed for persons 65 years and older who underwent curative resection for rectal adenocarcinoma from 2010 to 2017. Cases were stratified by surgical approach (open or MIS [laparoscopic or robotic]). Univariate analysis compared patient and provider demographics across approaches. Multivariate analysis investigated variables associated with MIS use. Main outcome measures were trends and factors associated with MIS use in older persons. RESULTS: Of 31,910 patients analyzed, 51.9% (n = 16,555) were open and 48.1% (n = 15,355) MIS. The MIS cohort was 66.7% (n = 10,236) laparoscopic and 33.3% (n = 5119) robotic. MIS increased from 29% in 2010 (n = 1197; 25%laparoscopic, 4% robotic) to 65% in 2017 (n = 2382; 35% laparoscopic, 30% robotic), likely from annual increases in robotics (OR 1.24/year, p < 0.0001). In the unadjusted analysis, there were significant differences in MIS use by age, race, comorbidity, socioeconomic status, and facility type. In multivariate analysis, patients with advancing age (OR 0.93, p < 0.001), major comorbidity (OR 0.75, p < 0.001), total proctectomy (OR0.78, p < 0.001), and advanced pathologic stage (OR 0.51, p < 0.001) were less likely to undergo MIS. CONCLUSION: Nationwide, less than half of rectal cancer cases in older persons were performed with MIS, despite steady robotic growth. Patient and facility factors impacted MIS use. Further work on regionalizing rectal cancer care and ensuring equitable MIS access and training could improve utilization.

Disparities in access to robotic technology and perioperative outcomes among patients treated with radical prostatectomy

“…Furthermore, non‐Hispanic Black patients are less likely to undergo surveillance or to receive treatment in the forms of radiation or surgery for prostate cancer and have worse outcomes compared to other patients—even after treatment in equitable environments 41 . Though previous research by Kim and colleagues using data from 2006 to 2008 found non‐Hispanic Black patients had decreased odds of undergoing RARP, when evaluating patients who underwent radical prostatectomy in 2010–2017 we found no statistically significant difference in odds of undergoing RARP versus ORP compared to non‐Hispanic White patients in multivariable analysis 42,43 . Even though non‐Hispanic Black patients are less likely to undergo any type of treatment, including surgical treatment, for those who access surgical treatment they are no less likely to receive minimally invasive techniques.…”

“…41 Though previous research by Kim and colleagues using data from 2006 to 2008 found non-Hispanic Black patients had decreased odds of undergoing RARP, when evaluating patients who underwent radical prostatectomy in 2010-2017 we found no statistically significant difference in odds of undergoing RARP versus ORP compared to non-Hispanic White patients in multivariable analysis. 42,43 Even though non-Hispanic Black patients are less likely to undergo any type of treatment, including surgical treatment, for those who access surgical treatment they are no less likely to receive minimally invasive techniques. These findings may reflect the overall trend of increased uptake and availability of minimally invasive surgical technology in hospitals in metropolitan areas where the majority of non-Hispanic Black patients receive their care.…”

A scoping review of racial, ethnic, socioeconomic, and geographic disparities in the outcomes of older adults with cancer

“…20,48 Area-level measures were primarily related to poverty status 19,37,42,47 or included in indices as composites with other variables (e.g., area deprivation index 34 or area-level poverty 19,42 ). Most studies examined disparities based on socioeconomic differences that were influenced by individual factors (n = 24), 19,20,27,30,34,37,42,45,47,48,50,[53][54][55][56]60,61,[63][64][65]67,70,71,74,75 built environment (n = 14), 19,30,37,42,47,48,53,54,56,61,63,64,71,75 and healthcare systems (n = 15). 20,…”

“…Most studies examined disparities based on socioeconomic differences that were influenced by individual factors (n = 24), 19,20,27,30,34,37,42,45,47,48,50,[53][54][55][56]60,61,[63][64][65]67,70,71,74,75 built environment (n = 14), 19,30,37,42,47,48,53,54,56,61,63,64,71,75 and healthcare systems (n = 15). 20,27,29,37,40,42,45,48,[54][55][56]60,…”

“…After screening, 130 articles initially and 59 articles subsequently met the inclusion criteria for this review (Table 1). Most articles were retrospective analyses (n = 52), [17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32]34,[36][37][38][39][41][42][43][45][46][47][48][49][50]52,[55][56][57][58][59][60][61][62][63][64][66][67][68][69][70][71][73][74][75]…”