women are diagnosed with colon cancer less often through screening, worsening staging and prognosis
TRANSCRIPT
Women Are Diagnosed With Colon Cancer Less Often Through Screening,
Worsening Staging and Prognosis
Ramzi Amri,1,2 Liliana G Bordeianou,1,2 Patricia Sylla,1,2 David L Berger 1,2
1 Massachusetts General Hospital, Division of General and Gastrointestinal Surgery.2 Harvard Medical School, Department of Surgery.
02/05/159th Annual Academic Surgical Congress, February 4-6 2014
Integrated Oral Presentations I: Clinical Trials/Outcomes 2: Colorectal (22.9)
Introduction
• Colon cancer affects men, women equally
• Screening is independent of gender
• Women historically fare slightly better 1
• Screening changes the affected population
• Reports show underscreening in women2-5
➤Is this true for our center?
➤What are the implications?1 Murphy G, et al. Int J Cancer. 2011;128(7):1668–1675. 2 Meissner HI, et al. . Cancer Epidemiol Biomarkers Prev. 2006;15(2):389–394.3 Shapiro JA, et al. Cancer Epidemiol Biomarkers Prev. 2012;21(6):895–904. 4 Stock C, et al. Gastrointest Endosc. 2010;71(2):366–381.e2. 5 Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep 2008;57(10):253–258.
Methods
• Included: • Surgical colon cancer patients at MGH 2004-2011
• >50, no prior CRC: n=919
• Comparison:• Men vs. women• Non-screened women vs. other patients
• Statistical analysis• Ordinal: χ2, continuous: Mann Whitney U• Multivariate: Cox & binary logistic regression
Results: baseline
Women presented with:
•Higher median age•Lower CRC-associated comorbidity•Better lifestyle
But
•Lower screening rates
Male Female P-value
N (%) 468 (50.9%) 451 (49.1%) - Age (median, IQR) 68 (17) 71 (20) 0.012 Comorbidities Charlson (mean, ±SD) 3.16 (1.6) 3.26 (1.9) 0.56 DM2 22.2% 17.1% 0.05 IBD 3.8% 1.8% 0.058 Lifestyle Current smoking 14.3% 10.2% 0.057 Ever smoking 65.0% 46.4% <0.001 BMI (mean, ±SD) 28.2 (5.8) 27.0 (6.8) 0.004 Presentation Symptomatic 59.2% 64.5% 0.096 Emergency admission 9.4% 10.6% 0.53 Screening diagnosis 32.7% 26.4% 0.036
Endoscopy – Low risk 25.0% 19.7% 0.056 Endoscopy – Hx polyps 5.8% 4.7% 0.47 FOBT* 3.6% 3.3% 0.92
Palliative cases 1.7% 1.8% 0.94 Preop. chemotherapy 3.4% 1.8% 0.12 History of polyps 13.5% 13.1% 0.87
Results
Non-screening Women (n=332)
Others
(n=587)
RR (95% CI) P-value
Surgery Surgery duration (M, mn) 118 (108) 127 (95) - 0.053 Multivisceral resection (%) 20.2% 9.0% 2.26 (1.62-3.17) <0.001
Pathology Nodal metastasis (%N+) 47.6% 34.8% 1.36 (1.16-1.59) <0.001 Distant metastasis (%M1) 12.3% 5.5% 2.27 (1.45-3.53) <0.001 High-grade tumor (%) 26.1% 16.1% 1.62 (1.23-2.13) <0.001 EMVI (%) 34.5% 25.9% 1.34 (1.09-1.63) 0.005
Admission Duration of stay (M, days) 5 (4) 4 (4) - 0.035 Perioperative metastasis 17.8% 11.1% 1.60 (1.15-2.22) 0.004 Mortality (%) 2.4% 1.0% 2.35 (0.83-6.74) 0.11
Results
Univariate Multivariate
Binary outcomes (logistic regression)
OR (95% CI) P-value Covariates OR (95% CI) P-value
Metastatic disease 1.59 (1.17-2.17) 0.003 FU 1.52 (1.12-2.08) 0.008
FU, AJCC 0.95 (0.65-1.39) 0.80
Metastasis in follow-up 1.27 (0.84-1.94) 0.26 FU 1.28 (0.84-1.95) 0.25
FU, AJCC 1.05 (0.68-1.62) 0.83
Death – all causes 1.84 (1.39-2.44) <0.001 Age, CC 1.43 (1.04-1.96) 0.027
Age, CC, AJCC 1.14 (0.82-1.59) 0.43
Death – colon cancer 1.95 (1.38-2.75) <0.001 Age, CC 1.73 (1.19-2.51) 0.004
Age, CC, AJCC 1.30 (0.87-1.96) 0.20 Duration outcomes
(Cox regression) HR (95% CI) P-value Covariates HR (95% CI) P-value
Survival duration 1.66 (1.32-2.08) <0.001 Age, CC 1.44 (0.96-1.53) 0.002
Age, CC, AJCC 1.02 (0.80-1.28) 0.90
Disease-free survival 1.52 (1.17-1.98) 0.002 Met. Presentation 1.10 (0.84-1.44) 0.48
AJCC 1.00 (0.77-1.31) 0.98
FU: Follow-up; CC: Colon cancer-adjusted Charlson comorbidity score; AJCC: Staging OR: odds ratio HR: hazard ratio –calculated for non-screening women vs. other patients
Conclusions
• Women were less likely to be diagnosed through screening means.
• Unscreened women: 73% added risk of mortality• Multivariate models: link with staging• Screening∨Advanced disease∧Mortality∧• Disparities in screening = disparities in
outcomes• Limitation: single-center.• Further research: Why