Comorbidity, age, race and stage at diagnosis in colorectal cancer: a retrospective, parallel analysis of two health systems.

Abstract

BACKGROUND: Stage at diagnosis plays a significant role in colorectal cancer (CRC) survival. Understanding which factors contribute to a more advanced stage at diagnosis is vital to improving overall survival. Comorbidity, race, and age are known to impact receipt of cancer therapy and survival, but the relationship of these factors to stage at diagnosis of CRC is less clear. The objective of this study is to investigate how comorbidity, race and age influence stage of CRC diagnosis. METHODS: Two distinct healthcare populations in the United States (US) were retrospectively studied. Using the Cancer Care Outcomes Research and Surveillance Consortium database, we identified CRC patients treated at 15 Veterans Administration (VA) hospitals from 2003-2007. We assessed metastatic CRC patients treated from 2003-2006 at 10 non-VA, fee-for-service (FFS) practices. Stage at diagnosis was dichotomized (non-metastatic, metastatic). Race was dichotomized (white, non-white). Charlson comorbidity index and age at diagnosis were calculated. Associations between stage, comorbidity, race, and age were determined by logistic regression. RESULTS: 342 VA and 340 FFS patients were included. Populations differed by the proportion of patients with metastatic CRC at diagnosis (VA 27% and FFS 77%) reflecting differences in eligibility criteria for inclusion. VA patients were mean (standard deviation; SD) age 67 (11), Charlson index 2.0 (1.0), and were 63% white. FFS patients were mean age 61 (13), Charlson index 1.6 (1.0), and were 73% white. In the VA cohort, higher comorbidity was associated with earlier stage at diagnosis after adjusting for age and race (odds ratio (OR) 0.76, 95% confidence interval (CI) 0.58-1.00; p = 0.045); no such significant relationship was identified in the FFS cohort (OR 1.09, 95% CI 0.82-1.44; p = 0.57). In both cohorts, no association was found between stage at diagnosis and either age or race. CONCLUSION: Higher comorbidity may lead to earlier stage of CRC diagnosis. Multiple factors, perhaps including increased interactions with the healthcare system due to comorbidity, might contribute to this finding. Such increased interactions are seen among patients within a healthcare system like the VA system in the US versus sporadic interactions which may be seen with FFS healthcare.

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Citation

Published Version (Please cite this version)

10.1186/1471-2407-8-345

Publication Info

Zafar, S Yousuf, Amy P Abernethy, David H Abbott, Steven C Grambow, Jennifer E Marcello, James E Herndon, Krista L Rowe, Jane T Kolimaga, et al. (2008). Comorbidity, age, race and stage at diagnosis in colorectal cancer: a retrospective, parallel analysis of two health systems. BMC Cancer, 8. p. 345. 10.1186/1471-2407-8-345 Retrieved from https://hdl.handle.net/10161/16116.

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Scholars@Duke

Zafar

Syed Yousuf Zafar

Adjunct Professor in the Department of Medicine

Dr. Zafar is a gastrointestinal medical oncologist and Associate Professor of Medicine, Public Policy, and Population Health Science at the Duke Cancer Institute and Duke-Margolis Center for Health Policy. He serves as Director of Healthcare Innovation at the Duke Cancer Institute. Dr. Zafar also serves as Clinical Associate Director of Duke Forge (Health Data Science Center). Dr. Zafar is considered an international expert in identifying and intervening upon the financial burden of cancer care. His research explores ways to improve cancer care delivery with a primary focus on improving the value of cancer treatment from both patient-focused and policy perspectives.

Dr. Zafar speaks internationally on his research and cancer care delivery. He has over 100 publications in top peer-reviewed journals including the New England Journal of Medicine, the Journal of Clinical Oncology, and JAMA Oncology. His research has been funded by the National Institutes of Health and the American Cancer Society, among others. His work has been covered by national media outlets including New York Times, Forbes, Wall Street Journal, NPR, and Washington Post. He is a Fellow of the American Society of Clinical Oncology.

Grambow

Steven C. Grambow

Associate Professor of Biostatistics & Bioinformatics

I am an academic statistician with a focus on educational leadership and administration, teaching, mentoring, and collaborative clinical research. I serve as the director of multiple education programs, both formal degree programs and certificate-based training programs. I also provide administrative oversight of multiple graduate degree programs and educational initiatives focusing on clinical and translational science workforce development at the student, staff, and faculty levels.

I have many years of experience with in-person and online teaching across a variety of teaching venues (formal degree programs, domestic and international certificate-based training programs, faculty development seminars, residency/fellowship training programs) and health sciences audiences (medical students, residents, fellows, faculty, and other health professionals), including more than 21 years as a statistics course director in the Duke Clinical Research Training Program.

As a collaborative scientist I have experience with a broad range of clinical research areas and clinical research designs, including observational studies, epidemiology investigations, and randomized clinical trials, including those utilizing web, mobile, and telemedicine-based health behavior interventions. I have collaborated on projects spanning a broad range of clinical research areas, including amyotrophic lateral sclerosis (ALS), post-traumatic stress disorder (PTSD), Prader-Willi syndrome (PWS), prostate cancer, quality of colorectal cancer care, osteoarthritis, lifestyle modification through weight loss, CVD risk reduction through hypertension control, smoking cessation, and substance abuse recovery.

Herndon

James Emmett Herndon

Professor of Biostatistics & Bioinformatics

Current research interests have application to the design and analysis of cancer clinical trials. Specifically, interests include the use of time-dependent covariables within survival models, the design of phase II cancer clinical trials which minimize some of the logistical problems associated with their conduct, and the analysis of longitudinal studies with informative censoring (in particular, quality of life studies of patients with advanced cancer).

Zullig

Leah L Zullig

Professor in Population Health Sciences

Leah L. Zullig, PhD, MPH is a health services researcher and an implementation scientist. She is a Professor in the Duke Department of Population Health Sciences and an investigator with the Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) at the Durham Veterans Affairs Health Care System. Dr. Zullig leads INTERACT, the Implementation Science Research Collaborative, and is co-leader of Duke Cancer Institute's cancer prevention and control program.

Dr. Zullig’s overarching research interests address three domains: improving cancer care delivery and quality; promoting cancer survivorship and chronic disease management; and improving medication adherence. Throughout these three area of foci Dr. Zullig uses an implementation science lens with the goal of providing equitable care for all by implementing evidence-based practices in a variety of health care environments. She has authored over 200 peer-reviewed publications. 

Dr. Zullig completed her BS in Health Promotion, her MPH in Public Health Administration, and her PhD in Health Policy.

Areas of expertise: Implementation Science, Health Measurement, Health Policy, Health Behavior, Telehealth, and Health Services Research


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