title: Underuse of surgical resection in black patients with nonmetastatic colorectal cancer: location, location, location.
abstract: OBJECTIVE
  Studies have reported potential underuse of surgical resection in black patients with nonmetastatic colorectal cancer. Our objective was to determine the independent, adverse effect of race on surgical resection, controlling for tumor location, comorbidity, and socioeconomic/insurance status.
  
  
  METHODS
  All cases of nonmetastatic colon/rectal cancer reported to our state's Central Cancer Registry from 1996 to 2002 were identified and linked to Inpatient/Outpatient Surgery Files and the 2000 Census. Comorbidity (Deyo-Charlson Index) was calculated using ICD-9-CM codes and educational level/income were estimated at the zip code level. Characteristics between whites and blacks were compared using [chi]2 tests. Odds ratios (OR) of resection were calculated using logistic regression analysis.
  
  
  RESULTS
  We identified 5590/1932 white and 1906/466 black patients with colon/rectal cancer. Blacks were more likely to be younger, not married, rural, less educated, live in poverty, and uninsured/covered by Medicaid compared with whites (all P < 0.001). Underuse of surgery was far greater among blacks with rectal cancer (82.0% vs. 89.3% in whites, P< 0.001) compared with blacks with colon cancer (92.9% vs. 94.5% in whites, P < 0.001). After controlling for comorbidity/socioeconomic/insurance status and tumor location, the adjusted OR (95% CI) for resection for blacks with colon cancer and blacks with rectal cancer living in poverty were 0.67 (0.51–0.88) and 0.20 (0.07–0.57), respectively.
  
  
  CONCLUSIONS
  Black race is a powerful, independent predictor of underuse of surgery in rectal cancer patients living in poverty. It is incumbent on the gastroenterology/surgical community to determine whether misperceptions about rectal surgery or barriers to successfully navigating multidisciplinary, rectal cancer care may account for these disparities.
authors.affiliation: Department of Surgery, Medical University of South Carolina, Charleston, SC 29425, USA. esnaolan@musc.edu
authors.forename: Nestor F
authors.initials: NF
authors.lastname: Esnaola
authors.forename: Mulugeta
authors.initials: M
authors.lastname: Gebregziabher
authors.forename: Chris
authors.initials: C
authors.lastname: Finney
authors.forename: Marvella E
authors.initials: ME
authors.lastname: Ford
mesh_terms: D001741:Black or African American / Q000706:statistics & numerical data*; D000368:Aged; D016009:Chi-Square Distribution; D015179:Colorectal Neoplasms / Q000208:ethnology* / Q000601:surgery*; D003107:Colorectal Surgery / Q000706:statistics & numerical data*; D015897:Comorbidity; D004522:Educational Status; D005260:Female; D006801:Humans; D007182:Income / Q000706:statistics & numerical data; D016015:Logistic Models; D008297:Male; D017057:Medically Uninsured / Q000706:statistics & numerical data; D008875:Middle Aged; D011204:Poverty Areas; D012042:Registries; D012307:Risk Factors; D012959:Socioeconomic Factors; D013022:South Carolina; D014481:United States; D044465:White People / Q000706:statistics & numerical data