title: Beyond the dollar: Influence of sociodemographic marginalization on surgical resection, adjuvant therapy, and survival in patients with pancreatic cancer.
abstract: BACKGROUND
  The single-payer universal health care system in Ontario, Canada creates a setting with reduced socioeconomic barriers to treatment. Herein, the authors sought to elucidate the influence of sociodemographic marginalization on receipt of pancreatectomy, overall survival (OS), and receipt of adjuvant treatment among patients diagnosed with pancreatic cancer at the population level using an observational cohort study design.
  
  
  METHODS
  Patients diagnosed with pancreatic cancer in Ontario between January 2005 and January 2010 were identified using the provincial cancer registry and linked to administrative databases. Census data obtained from each patient's postal code were used as a proxy for that patient's median income, residential instability, material deprivation, ethnic concentration, and dependency (percentage aged <15 years, aged >65 years, and unemployed). Surgical specimen pathology reports were abstracted for histopathology and margin status. Independent predictors of undergoing pancreatectomy, OS after surgical resection, and receipt of adjuvant treatment were identified by logistic regression and Cox proportional hazards analysis.
  
  
  RESULTS
  Of the 6296 patients diagnosed with pancreatic cancer, 820 (13%) underwent resection of their tumor. Increasing levels of residential instability (odds ratio [OR], 0.86; 95% confidence interval [95% CI], 0.80-0.94) and material deprivation (OR, 0.86; 95% CI, 0.79-0.94) predicted a decreased likelihood of undergoing surgical resection. Patients living in rural areas (OR, 0.68; 95% CI, 0.51-0.91) and those living in urban areas with lower incomes (OR range, 0.49-0.77) were found to have a lower likelihood of undergoing surgical resection compared with patients in the urban areas with the highest income. After surgical resection, an association between sociodemographic marginalization with OS or receipt of adjuvant treatment was not identified.
  
  
  CONCLUSIONS
  Sociodemographic marginalization exerts its influence early in the pancreatic cancer care continuum, and appears to be associated more with which patients undergo surgical resection than the receipt of adjuvant treatment. Cancer 2016;122:3175-82. © 2016 American Cancer Society.
authors.affiliation: Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Kagedan
authors.affiliation: Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Liza
authors.initials: L
authors.lastname: Abraham
authors.affiliation: Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
authors.forename: Nik
authors.initials: N
authors.lastname: Goyert
authors.affiliation: Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
authors.forename: Qing
authors.initials: Q
authors.lastname: Li
authors.affiliation: Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.|Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.|Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
authors.forename: Lawrence F
authors.initials: LF
authors.lastname: Paszat
authors.affiliation: Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.|Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.|Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Alexander
authors.initials: A
authors.lastname: Kiss
authors.affiliation: Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.|Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.|Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
authors.forename: Craig C
authors.initials: CC
authors.lastname: Earle
authors.affiliation: Health Outcomes and PharmacoEconomic (HOPE) Research Centre, Sunnybrook Research Institute, Toronto, Ontario, Canada.
authors.forename: Nicole
authors.initials: N
authors.lastname: Mittmann
authors.affiliation: Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada. natalie.coburn@sunnybrook.ca.|Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. natalie.coburn@sunnybrook.ca.|Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada. natalie.coburn@sunnybrook.ca.|Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada. natalie.coburn@sunnybrook.ca.
authors.forename: Natalie G
authors.initials: NG
authors.lastname: Coburn
mesh_terms: D000230:Adenocarcinoma / Q000188:drug therapy / Q000401:mortality* / Q000601:surgery; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D017024:Chemotherapy, Adjuvant / Q000401:mortality*; D003710:Demography; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D010180:Pancreatectomy / Q000401:mortality*; D010190:Pancreatic Neoplasms / Q000188:drug therapy / Q000401:mortality* / Q000601:surgery; D011379:Prognosis; D012189:Retrospective Studies; D062487:Social Marginalization; D012959:Socioeconomic Factors; D015996:Survival Rate; D055815:Young Adult
keywords: adjuvant chemotherapy; adjuvant radiotherapy; pancreatectomy; pancreatic cancer; population; social marginalization