title: Patterns of Care for Metastatic Colorectal Cancer in Appalachia, and the Clinical, Sociodemographic, and Service Provider Determinants.
abstract: BACKGROUND
  Appalachia has high colorectal cancer (CRC) incidence and mortality, at least in part due to screening disparities. This paper examines patterns and determinants of metastatic colorectal cancer care.
  
  
  METHODS
  CRC patients diagnosed in 2006-2008 from 4 cancer registries (Kentucky, Ohio, Pennsylvania, and North Carolina) were linked to Medicare claims (2005-2009.) The final sample after exclusions included 855 stage IV and 590 stages I-III patients with metachronous or synchronous metastases. We estimate bivariate and multivariate analyses for several surgical and chemotherapeutic strategies of care using clinical, sociodemographic, and contextual determinants.
  
  
  RESULTS
  Among 1,445 CRC patients, 84% had primary tumor resection and 44% received chemotherapy. Of the chemotherapy patients, 44% received newer systemic agents for at least 75% of the cycles. One year survivors with liver or lung metastases were more likely to have their primary tumor resected immediately (86.1% vs 69.5% for liver, and 78.2% vs 64.9% for lung) and have their metastases resected/ablated (15.7% vs 2.6% for liver and 15.0% vs 0.5% for lung). Patients with stages I-III primary tumors (versus IV) were much more likely to be resected, but they were less likely to receive chemotherapy. Patients with comorbidities (congestive heart failure, dementia, or respiratory disease) had lower odds of chemotherapy. Smaller hospital size and surgical volume had higher odds of immediate versus delayed surgery. The newer chemotherapeutic agents were more common with higher surgical volume.
  
  
  CONCLUSIONS
  Metastatic colorectal cancer has clinical, sociodemographic, and service provider determinants.
authors.affiliation: College of Public Health, University of Kentucky, Lexington, Kentucky.
authors.forename: Steven T
authors.initials: ST
authors.lastname: Fleming
authors.affiliation: College of Medicine, Pennsylvania State University, Hershey, Pennsylvania.
authors.forename: Heath B
authors.initials: HB
authors.lastname: Mackley
authors.affiliation: Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia.
authors.forename: Fabian
authors.initials: F
authors.lastname: Camacho
authors.affiliation: Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia.
authors.forename: Nengliang
authors.initials: N
authors.lastname: Yao
authors.affiliation: College of Medicine, Pennsylvania State University, Hershey, Pennsylvania.
authors.forename: Niraj J
authors.initials: NJ
authors.lastname: Gusani
authors.affiliation: College of Public Health, Ohio State University, Columbus, Ohio.
authors.forename: Eric E
authors.initials: EE
authors.lastname: Seiber
authors.affiliation: Department of Sociology, The Pennsylvania State University, University Park, Pennsylvania.
authors.forename: Stephen A
authors.initials: SA
authors.lastname: Matthews
authors.affiliation: Department of Sociology, University at Albany, SUNY, Albany, New York.
authors.forename: Tse-Chuan
authors.initials: TC
authors.lastname: Yang
authors.affiliation: College of Medicine, Pennsylvania State University, Hershey, Pennsylvania.
authors.forename: Wenke
authors.initials: W
authors.lastname: Hwang
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000970:Antineoplastic Agents / Q000627:therapeutic use; D001061:Appalachian Region / Q000453:epidemiology; D003106:Colon / Q000473:pathology / Q000601:surgery; D015179:Colorectal Neoplasms / Q000401:mortality* / Q000473:pathology / Q000628:therapy*; D015897:Comorbidity; D005260:Female; D006742:Hospital Bed Capacity; D006801:Humans; D008113:Liver Neoplasms / Q000556:secondary; D008175:Lung Neoplasms / Q000556:secondary; D008297:Male; D009367:Neoplasm Staging; D012959:Socioeconomic Factors; D061665:Time-to-Treatment
chemical_list: D000970:Antineoplastic Agents
keywords: access to care; colorectal cancer; medical care; metastatic cancer; utilization of health services