Nationwide cohort study of the impact of education, income and social isolation on survival after acute colorectal cancer surgery

Abstract

Background: Acute colorectal cancer surgery has been associated with a high postoperative mortality. The primary aim of this study was to examine the association between socioeconomic position and the likelihood of undergoing acute versus elective colorectal cancer surgery. A secondary aim was to determine 1-year survival among patients treated with acute surgery.Methods: All patients who had undergone a surgical procedure according to the Danish Colorectal Cancer Group (DCCG.dk) database, or who were registered with stent or diverting stoma in the National Patient Register from 2007 to 2015, were reviewed. Socioeconomic position was determined by highest attained educational level, income, urbanicity and cohabitation status, obtained from administrative registries. Co-variables included age, sex, year of surgery, Charlson Co-morbidity Index score, smoking status, alcohol consumption, BMI, stage and tumour localization. Logistic regression analysis was performed to determine the likelihood of acute colorectal cancer surgery, and Kaplan-Meier and Cox proportional hazards regression methods were used for analysis of 1-year overall survival.Results: In total, 35 661 patients were included; 5310 (14⋅9 per cent) had acute surgery. Short and medium education in patients younger than 65 years (odds ratio (OR) 1⋅58, 95 per cent c.i. 1⋅32 to 1⋅91, and OR 1⋅34, 1⋅15 to 1⋅55 respectively), low income (OR 1⋅12, 1⋅01 to 1⋅24) and living alone (OR 1⋅35, 1⋅26 to 1⋅46) were associated with acute surgery. Overall, 40⋅7 per cent of patients died within 1 year of surgery. Short education (hazard ratio (HR) 1⋅18, 95 per cent c.i. 1⋅03 to 1⋅36), low income (HR 1⋅16, 1⋅01 to 1⋅34) and living alone (HR 1⋅25, 1⋅13 to 1⋅38) were associated with reduced 1-year survival after acute surgery.Conclusion: Low socioeconomic position was associated with an increased likelihood of undergoing acute colorectal cancer surgery, and with reduced 1-year overall survival after acute surgery.

The cancer survival index—A prognostic score integrating psychosocial and biological factors in patients diagnosed with cancer or haematologic malignancies

“…39 Recent publications demonstrate (1) a correlation between lower education and high body mass index in the highly developed and industrialised countries, (2) the impact of high body mass index on all-cause mortality and (3) that poverty and low education are associated with higher mortality. [6][7][8][9]11,40 The present data indicate that each of these factors does not act alone but results in a vicious circle aggravating the social impact and burden of cancer and explain how psychosocial factors might complement the predictive value of biological factors identifying patients with a high unmet medical need.…”

“…The following factors were included in the analysis: (1) Biological indicators: sex, age, cancer site, presence of distant metastases (M1 vs. M0) and haemoglobin levels (<11 vs. >11 g/dl) 2–5 . (2) Social indicators: household income, education level, status of employment, marital status, living environment (urban / rural) and children (yes / no) 6–9,11 . (3) Psychological indicators: previous psychiatric disorders, general psychological distress, and symptoms of anxiety and depression 15–19,22 …”

“…In addition to established tumour sitespecific scores or the TNM (tumour-node-metastasis) staging system, factors impacting OS of cancer patients include sex, age, cancer site or anaemia. [2][3][4][5] Indicators of socioeconomic status, including household income, education level, and social support, [6][7][8][9][10][11][12][13] as well as psychological factors, such as general psychological distress, anxiety, and depression, [14][15][16][17][18][19][20][21][22] have been recognised as important to OS in cancer patients, but are usually not considered in risk assessment, clinical trial design and patient management. Existing prognostic scores for cancer survival mostly focus on biological aspects, but do not include psychosocial or socioeconomic factors.…”

“…[2][3][4][5] (2) Social indicators: household income, education level, status of employment, marital status, living environment (urban / rural) and children (yes / no). [6][7][8][9]11 (3) Psychological indicators: previous psychiatric disorders, general psychological distress, and symptoms of anxiety and depression. 15-19,22…”

“…Indicators of socioeconomic status, including household income, education level, and social support, 6–13 as well as psychological factors, such as general psychological distress, anxiety, and depression, 14–22 have been recognised as important to OS in cancer patients, but are usually not considered in risk assessment, clinical trial design and patient management. Existing prognostic scores for cancer survival mostly focus on biological aspects, but do not include psychosocial or socioeconomic factors 23,24 .…”