Comorbidity, age, race and stage at diagnosis in colorectal cancer: a retrospective, parallel analysis of two health systems.
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2008-11-25
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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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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
Syed Yousuf Zafar
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.
Steven C. Grambow
Transforming research education through innovation, mentorship, and collaboration.
Steven C. Grambow, PhD is Associate Professor and Associate Chair of Education in the Department of Biostatistics and Bioinformatics at Duke University School of Medicine. He serves as Director of the Clinical Research Training Program (CRTP), Duke’s flagship degree-granting program for clinical and translational research education, and as Co-Director of the Workforce Development Pillar of the Duke Clinical and Translational Science Institute (CTSI). Dr. Grambow provides strategic oversight for multiple educational and workforce development initiatives that span the full continuum of learners, from students to faculty.
With over two decades of experience in graduate and professional education, Dr. Grambow has taught statistical methods and research design to more than 1,000 physician-scientists, clinical fellows, and faculty at Duke and the NIH. He has led the CRTP’s core statistics course for over 21 years and has directed or co-directed national and international certificate programs across multiple institutions. His expertise spans classroom, hybrid, and online environments, and he has served as a leader in designing programs that respond to evolving workforce and research needs.
A central focus of Dr. Grambow’s work is building pathways into clinical and translational research careers. He has cultivated longstanding partnerships with academic and community institutions, including North Carolina Central University and Durham Technical Community College, to create educational models that prepare learners for impactful roles in research. His efforts emphasize strong mentorship, practical experience, and tailored program design to meet learners where they are and help them advance.
Dr. Grambow is also at the forefront of educational innovation, leading initiatives that explore the integration of artificial intelligence into biostatistical training and academic workflows. His current work includes faculty development in AI literacy, emerging pedagogical models that support active learning and reflective practice, and new frameworks for clinical research education that emphasize adaptability and cross-disciplinary collaboration.
As a collaborative statistical scientist, Dr. Grambow has contributed to a wide range of clinical research studies, including observational studies, randomized trials, and epidemiologic investigations. His research collaborations have addressed public health and clinical challenges such as amyotrophic lateral sclerosis (ALS), post-traumatic stress disorder (PTSD), Prader-Willi syndrome (PWS), prostate cancer, cardiovascular risk reduction, and substance use recovery.
Dr. Grambow’s leadership has been recognized through institutional and national awards, including teaching honors from the American Statistical Association and Duke University. He brings a unique combination of academic rigor, educational strategy, and programmatic leadership to his roles, helping to shape the future of clinical research training through thoughtful innovation and sustained collaboration.
James Emmett Herndon
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).
Leah L Zullig
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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