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Original Investigation | Association of VA Surgeons

Associations of Socioeconomic Variables With Resection, Stage, and Survival in Patients With Early-Stage Pancreatic Cancer

Mia Shapiro, MD1,2; Qi Chen, MD, PhD3,4; Qin Huang, MD, PhD1,5; Valia A. Boosalis, MD4,6; Charles H. Yoon, MD, PhD1,7; Mandeep S. Saund, MD1,8,9; Edward E. Whang, MD1,2,7; Jason S. Gold, MD1,2,7
[+] Author Affiliations
1Harvard Medical School, Boston, Massachusetts
2Surgery Service, VA Boston Healthcare System, Boston, Massachusetts
3Research Service, VA Boston Healthcare System, Boston, Massachusetts
4Boston University School of Medicine, Boston, Massachusetts
5Pathology Service, VA Boston Healthcare System, Boston, Massachusetts
6Medicine Service, VA Boston Healthcare System, Boston, Massachusetts
7Brigham and Women’s Hospital, Boston, Massachusetts
8Harvard Vanguard Medical Associates, Boston, Massachusetts
9Beth Israel Deaconess Medical Center, Boston, Massachusetts
JAMA Surg. 2016;151(4):338-345. doi:10.1001/jamasurg.2015.4239.
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Importance  Socioeconomic variables including sex, race, ethnicity, marital status, and insurance status are associated with survival in pancreatic cancer. It remains unknown exactly how these variables influence survival, including whether they affect stage at presentation or receipt of treatment or are independently associated with outcomes.

Objectives  To investigate the relationship between socioeconomic factors and odds of resection in early-stage, resectable pancreatic adenocarcinoma and to determine whether these same factors were independently associated with survival in patients who underwent resection.

Design, Setting, and Participants  This was a retrospective cohort study of patients diagnosed as having T1 through T3 M0 pancreatic adenocarcinoma between January 1, 2004, and December 31, 2011, identified from the Surveillance, Epidemiology, and End Results database.

Main Outcomes and Measures  Socioeconomic and geographic variables associated with utilization of resection and disease-specific survival.

Results  A total of 17 530 patients with localized, nonmetastatic pancreatic cancer were identified. The resection rate among these patients was 45.4% and did not change over time. Utilization of resection was independently associated with white vs African American race (odds ratio [OR] = 0.76; 95% CI, 0.65-0.88; P < .001), non-Hispanic ethnicity (for Hispanic, OR = 0.72; 95% CI, 0.60-0.85; P < .001), married status (OR = 1.42; 95% CI, 1.30-1.57; P < .001), insurance coverage (OR = 1.63; 95% CI, 1.22-2.18; P = .001), and the Northeast region (vs Southeast, OR = 1.67; 95% CI, 1.44-1.94; P < .001). Stage at presentation correlated with sex, race, ethnicity, marital status, and geographic region (ethnicity, P = .003; all others, P < .001); however, the factors associated with increased resection correlated with more advanced stage. Patients who underwent resection had significantly improved disease-specific survival compared with those who did not undergo resection (median, 21 vs 6 months; hazard ratio [HR] for disease-specific death = 0.32; 95% CI, 0.31-0.33; P < .001). Disease-specific survival among the patients who underwent surgical resection was independently associated with geographic region, with patients in the Pacific West (HR for death = 0.706; 95% CI, 0.628-0.793), Northeast (HR for death = 0.766; 95% CI, 0.667-0.879), and Midwest (HR for death = 0.765; 95% CI, 0.640-0.913) having improved survival in comparison with those in the Southeast (all P < .001).

Conclusions and Relevance  Disparities in the utilization of surgical resection for patients with early-stage, resectable pancreatic cancer are associated with socioeconomic variables including race, ethnicity, marital status, insurance status, and geographic location. Of these factors, only geographic location is independently associated with survival in patients undergoing resection.

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Figure 1.
Rate of Surgical Resection for Patients With T1 Through T3 Pancreatic Adenocarcinomas Diagnosed Between 2004 and 2011

Error bars indicate 95% confidence intervals as determined by the adjusted Wald method.

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Figure 2.
Association of Tumor Resection With Disease-Specific Survival for Patients With T1 Through T3 Pancreatic Adenocarcinoma
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