A retrospective cohort study of patients with stomach and liver cancers: the impact of comorbidity and ethnicity on cancer care and outcomes.
BACKGROUND
Comorbidity has an adverse impact on cancer survival partly through its negative impact on receipt of curative treatment. Comorbidity is unevenly distributed within populations, with some ethnic and socioeconomic groups having considerably higher burden. The aim of this study was to investigate the inter-relationships between comorbidity, ethnicity, receipt of treatment, and cancer survival among patients with stomach and liver cancer in New Zealand.


METHODS
Using the New Zealand Cancer Registry, Māori patients diagnosed with stomach and liver cancers were identified (n = 269), and compared with a randomly selected group of non-Māori patients (n = 255). Clinical and outcome data were collected from medical records, and the administrative hospitalisation and mortality databases. Logistic and Cox regression modelling with multivariable adjustment were used to examine the impacts of ethnicity and comorbidity on receipt of treatment, and the impact of these variables on all-cause and cancer specific survival.


RESULTS
More than 70% of patients had died by two years post-diagnosis. As comorbidity burden increased among those with Stage I-III disease, the likelihood that the patient would receive curative surgery decreased (e.g. C3 Index score 6 vs 0, adjusted OR: 0.32, 95% CI 0.13-0.78) and risk of mortality increased (e.g. C3 Index score 6 vs 0, adjusted all-cause HR: 1.44, 95% CI 0.93-2.23). Receipt of curative surgery reduced this excess mortality, in some cases substantially; but the extent to which this occurred varied by level of comorbidity. Māori patients had somewhat higher levels of comorbidity (34% in highest comorbidity category compared with 23% for non-Māori) and poorer survival that was not explained by age, sex, site, stage, comorbidity or receipt of curative surgery (adjusted cancer-specific HR: 1.36, 95% CI 0.97-1.90; adjusted all-cause HR: 1.33, 95% CI 0.97-1.82). Access to healthcare factors accounted for 25-36% of this survival difference.


CONCLUSIONS
Patients with comorbidity were substantially less likely to receive curative surgery and more likely to die than those without comorbidity. Receipt of curative surgery markedly reduced their excess mortality. Despite no discernible difference in likelihood of curative treatment receipt, Māori remained more likely to die than non-Māori even after adjusting for confounding and mediating variables.
Department of Public Health, University of Otago Wellington, PO Box 7343, Wellington 6242, New Zealand. diana.sarfati@otago.ac.nz.
Diana
D
Sarfati
Jason
J
Gurney
James
J
Stanley
Jonathan
J
Koea
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000787:Angina Pectoris / Q000208:ethnology; D001145:Arrhythmias, Cardiac / Q000208:ethnology; D006528:Carcinoma, Hepatocellular / Q000208:ethnology* / Q000401:mortality* / Q000601:surgery; D015897:Comorbidity; D003920:Diabetes Mellitus / Q000208:ethnology; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006801:Humans; D006973:Hypertension / Q000208:ethnology; D008113:Liver Neoplasms / Q000208:ethnology* / Q000401:mortality* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D009520:New Zealand; D012189:Retrospective Studies; D013274:Stomach Neoplasms / Q000208:ethnology* / Q000401:mortality* / Q000601:surgery; D015996:Survival Rate