title: National disparities in minimally invasive surgery for rectal cancer.
abstract: BACKGROUND
  Social and racial disparities have been identified as factors contributing to differences in access to care and oncologic outcomes in patients with colorectal cancer. The aim of this study was to investigate national disparities in minimally invasive surgery (MIS), both laparoscopic and robotic, across different racial, socioeconomic and geographic populations of patients with rectal cancer.
  
  
  METHODS
  We utilized the American College of Surgeons National Cancer Database to identify patients with rectal cancer from 2004 to 2011 who had undergone definitive surgical procedures through either an open, laparoscopic or robotic approach. Inclusion criteria included only one malignancy and no adjuvant therapy. Multivariate analysis was performed to investigate differences in age, gender, race, income, education, insurance coverage, geographic setting and hospital type in relation to the surgical approach.
  
  
  RESULTS
  A total of 8633 patients were identified. The initial surgical approach included 46.5% open (4016), 50.9% laparoscopic (4393) and 2.6% robotic (224). In evaluating type of insurance coverage, patients with private insurance were most likely to undergo laparoscopic surgery [OR (odds ratio) 1.637, 95% CI 1.178-2.275], although there was a less statistically significant association with robotic surgery (OR 2.167, 95% CI 0.663-7.087). Patients who had incomes greater than $46,000 and received treatment at an academic center were more likely to undergo MIS (either laparoscopic or robotic). Race, education and geographic setting were not statistically significant characteristics for surgical approach in patients with rectal cancer.
  
  
  CONCLUSIONS
  Minimally invasive approaches for rectal cancer comprise approximately 53% of surgical procedures in patients not treated with adjuvant therapy. Robotics is associated with patients who have higher incomes and private insurance and undergo surgery in academic centers.
authors.affiliation: Department of Surgical Oncology, Roswell Park Cancer Institute, Carlton House A-206, Elm and Carlton Streets, Buffalo, NY, 14216, USA. emmanuel.gabriel@roswellpark.org.
authors.forename: Emmanuel
authors.identifier: http://orcid.org/0000-0001-8570-4784
authors.initials: E
authors.lastname: Gabriel
authors.affiliation: Department of Surgical Oncology, Roswell Park Cancer Institute, Carlton House A-206, Elm and Carlton Streets, Buffalo, NY, 14216, USA.
authors.forename: Pragatheeshwar
authors.initials: P
authors.lastname: Thirunavukarasu
authors.affiliation: Department of Surgical Oncology, Roswell Park Cancer Institute, Carlton House A-206, Elm and Carlton Streets, Buffalo, NY, 14216, USA.
authors.forename: Eisar
authors.initials: E
authors.lastname: Al-Sukhni
authors.affiliation: Department of Biostatistics, Roswell Park Cancer Institute, Buffalo, NY, USA.
authors.forename: Kristopher
authors.initials: K
authors.lastname: Attwood
authors.affiliation: Department of Surgical Oncology, Roswell Park Cancer Institute, Carlton House A-206, Elm and Carlton Streets, Buffalo, NY, 14216, USA.
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Nurkin
mesh_terms: D000230:Adenocarcinoma / Q000601:surgery*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016208:Databases, Factual; D005006:Ethnicity; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D054625:Healthcare Disparities / Q000191:economics / Q000208:ethnology / Q000706:statistics & numerical data*; D006801:Humans; D010535:Laparoscopy / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D018358:Neuroendocrine Tumors / Q000601:surgery*; D012004:Rectal Neoplasms / Q000601:surgery*; D065287:Robotic Surgical Procedures / Q000706:statistics & numerical data*; D012959:Socioeconomic Factors; D014481:United States
keywords: Disparities; Rectal cancer; Robotic surgery