0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Article |

Racial Disparities in Rectal Cancer Treatment:  A Population-Based Analysis FREE

Arden M. Morris, MD, MPH; Kevin G. Billingsley, MD; Nancy N. Baxter, MD, PhD; Laura-Mae Baldwin, MD, MPH
[+] Author Affiliations

From the Department of Surgery, Section of Colon and Rectal Surgery, University of Minnesota, Minneapolis (Drs Morris and Baxter); and the Departments of Surgery (Dr Billingsley) and Family Practice (Dr Baldwin), University of Washington, Seattle.


Arch Surg. 2004;139(2):151-155. doi:10.1001/archsurg.139.2.151.
Text Size: A A A
Published online

Hypothesis  We hypothesized that there are significant racial disparities in delivery of care to rectal cancer patients. We examined differential surgical and radiation treatment for these patients and determined whether blacks were less likely than whites to undergo sphincter-sparing procedures, which are associated with a higher quality of life than sphincter-ablating procedures.

Design  Cross-sectional cohort study.

Patients and Setting  The Surveillance Epidemiology and End Results database provided population-based data for rectal cancer patients who were diagnosed between 1988 and 1999, were older than 35 years, and had no prior colorectal or other pelvic cancer.

Main Outcome Measures  Using logistic regression, we compared receipt and type of surgical therapy and radiation therapy, controlling for age, sex, year, geography, stage, and anatomic location.

Results  Among 52 864 patients, 3851 were black and 44 010 were white. Blacks were younger than whites and had more advanced disease (P<.001). Among patients who underwent operation, rates of sphincter-ablating procedure were 37% for whites and 43% for blacks (adjusted odds ratio [AOR], 1.42; 95% confidence interval [CI], 1.23-1.65). Moreover, 53% of whites and 56% of blacks received no radiation therapy for stage II to III disease (AOR, 1.30; 95% CI, 1.15-1.47).

Conclusions  Blacks with rectal cancer were diagnosed at a younger age and more advanced disease stage than whites, implying a need for more aggressive screening. After adjusting for stage and other covariates, surgical and radiation treatment also differed along racial lines. Our data suggest that treatment disparities may contribute to differences in outcome among racial/ethnic groups with rectal cancer, and they highlight the need for improving access to state-of-the-art surgical care for minority patients with rectal cancer.

With a projected incidence of 135 000 cases this year, colorectal cancer is the third most common malignancy diagnosed in the United States and is the second leading cause of cancer mortality.1 Recently, there has been an overall decline in the incidence of and mortality from colorectal cancer. However, black patients have not enjoyed the same decline.2 From 1992 to 1998, the annual decrease in death rate for white males was 2.1% compared with 0.9% for black males; similarly, the annual decrease in death rate for white females was 1.9% compared with 0.6% for black females.3

Two broad hypotheses could explain these outcome discrepancies. Blacks may be physiologically vulnerable and experience a more aggressive disease course. Alternatively, the higher rate of socioeconomic disadvantage among blacks as a group may render their medical care different from that of whites.4 No evidence to date indicates that colorectal cancer itself behaves differently between the races5; studies controlling for stage at diagnosis and those with standardized treatment protocols describe virtually identical outcomes for blacks and whites.6,7 Conversely, lower socioeconomic status in patients with colorectal cancer is significantly associated with worse outcomes.8,9 Taken together, these findings suggest that the possibility of disparities in medical care as a potential influence on outcomes merits further investigation.

Although colon and rectal cancer are combined in most large databases and are histologically identical, their different anatomic features and behavior necessitate different treatment options and standards of care. Rectal cancer is of particular interest because, while complete resection remains the basis of treatment, the type of operation performed and the preservation of normal bowel continuity are closely associated with posttreatment morbidity, quality of care, and quality of life.10,11 For example, an abdominoperineal resection, which is sphincter ablating and therefore includes a permanent colostomy, is unavoidable in some circumstances. However, surgeons operating on higher volumes of patients with rectal cancer have been shown to perform a lower proportion of abdominoperineal resections and to have better overall and disease-free survival rates.1216 These data suggest that practice volume is associated with the use of sphincter-preserving surgery as well as optimal disease control.

Furthermore, the 1990 National Institutes of Health Consensus Conference recommended radiation therapy as the standard of care for regional control of stage II and III rectal cancer, although it is not recommended for colon cancer.17 Increasingly, neoadjuvant radiation therapy is used as an alternative to postoperative radiation therapy because it allows preoperative downstaging of disease, which facilitates sphincter preservation and offers a favorable toxicity profile.1821

We investigated racial variation in the performance of sphincter-sparing procedures for patients with stage II and III rectal cancer who underwent operation. We also studied race and delivery of any surgical treatment, neoadjuvant radiation therapy, and any radiation therapy to these patients, with implications for quality of care.

SETTING

The National Cancer Institute–funded Surveillance Epidemiology and End Results (SEER) Cancer Incidence Database is an anonymous nationwide population-based database in the public domain. During the era of interest, SEER drew from 11 cancer registries that covered approximately 14% of the US population, with oversampling of racial and ethnic minorities.22 Case ascertainment for SEER began in 1973 in Atlanta, Detroit, Hawaii, New Mexico, San Francisco–Oakland, Seattle-Puget Sound, and Utah, and has been expanded to include Los Angeles and San Jose–Monterey since 1992. The registries collect data, including patient demographics, primary tumor site, morphologic characteristics, stage at diagnosis, first course of treatment, and follow-up for vital status. The ascertainment of radiation therapy use in SEER is considered high for rectal cancer, with 94% concordance with radiation therapy claims in Medicare.23 Similarly, data agreement for resection of colorectal cancer between SEER and Medicare claims has also been excellent, with κ values from 0.78 to 0.84.24 Owing to removal of all patient identifiers and the public availability of the data, this study was approved as exempt from full institutional review board consideration.

SUBJECTS

Data were collected for all patients diagnosed as having rectal cancer and entered into the SEER database between 1988 and 1999. Patients were excluded from analysis if they had a prior diagnosis of colon or rectal cancer, a prior diagnosis of cancer requiring irradiation or surgery in the pelvis (the entire lower urinary tract, female organs, male organs, and anus), or were younger than 35 years at the time of diagnosis.

VARIABLES

We examined race as a primary predictor variable and performed analyses based on black vs white race. Main outcome variables included the proportion of patients undergoing any surgical treatment, the proportion of patients undergoing a sphincter-sparing procedure vs abdominoperineal resection, the delivery of any radiation treatment, and the delivery of neoadjuvant irradiation. Covariates included age, sex, the American Joint Committee on Cancer stage of disease, year of diagnosis, location in the rectum or rectosigmoid, and the SEER site of entry.

STATISTICAL ANALYSIS

We compared racial differences in age at diagnosis and stage of disease using the χ2 test for trend. We examined the treatment provided to patients of different race with stage II and III disease, using χ2 analyses to calculate the unadjusted odds ratio (OR) and multiple logistic regression methods to determine the OR and 95% confidence interval (CI), controlling for main effects of the covariates. Rates and proportions were calculated for categorical data, and means and SEs were calculated for continuous data. Sample size calculations for α = .05 and power = 0.9 revealed that a 3% or greater difference in treatment rate could be determined with minimum samples of 1040 and 12 730. Statistical analyses were performed with STATA version 7 software (Statacorp, College Station, Tex).

Between 1988 and 1999, 56940 patients with rectal cancer were entered into the SEER database. After applying exclusion criteria, 52864 patients remained (Table 1). Blacks (n = 3851) with rectal cancer were younger than whites (n = 44 010) at the time of diagnosis (age, mean ± SD, 64 ± 12 years and 69 ± 12 years, respectively; test for trend, P<.001). The SEER site of entry varied markedly among patients of different race (Table 2), with most blacks entered in Detroit (33%), Los Angeles (23%), Atlanta (15%), and San Francisco–Oakland (15%).

Table Graphic Jump LocationTable 1. Demographics and Cancer Stage of 1988-1999 SEER Rectal Cancer Cases by Race
Table Graphic Jump LocationTable 2. Geographic Distribution of 1988-1999 SEER Rectal Cancer Cases by Race

Although nearly all patients underwent some surgical treatment, the type of operation differed along racial lines (Table 3). Among patients with stage II and III disease, 4% of whites and 6% of blacks had no operation (adjusted OR [AOR], 1.30; 95% CI, 1.12-1.95). Among patients who underwent surgical treatment, 37% of whites and 43% of blacks underwent abdominoperineal resection (a sphincter-ablating procedure) (AOR, 1.42; 95% CI, 1.23-1.65).

Table Graphic Jump LocationTable 3. Comparison of Surgical Treatment by Race Among Patients With Stage II and III Rectal Cancer *

Table 4 presents a comparison of adjuvant treatment by race among patients with stage II and III disease. Fifty-three percent of whites and 56% of blacks received no radiation therapy (AOR, 1.30; 95% CI, 1.15-1.47). Rates of neoadjuvant radiation therapy delivered were 7% for both groups.

Table Graphic Jump LocationTable 4. Comparison of Adjuvant Radiation Therapy by Race Among Patients With Stage II and III Rectal Cancer

Racially disparate incidence and outcomes among cancer patients have become well-established phenomena cited by a number of databases and studies.25 A later stage at diagnosis, potentially resulting from a lower rate of screening, has been identified as one etiologic factor.26 We found that disease was detected in blacks at a significantly younger age and more advanced stage compared with whites, reaffirming previous findings that more targeted or more effective screening could improve outcomes among these patients.26,27

To examine the effect of race on disparate outcomes in more detail, we investigated the delivery of care to blacks vs whites, using a national population-based database. We chose to examine the experience of patients with rectal cancer specifically because the standard of care has been changing during the past 12 years. Surgical therapy has gradually shifted to a dominance of sphincter-sparing operations (resulting in bowel continuity) over sphincter-ablating procedures (resulting in permanent ileostomy).11 The shift toward sphincter-sparing procedures most likely results from several studies that have indicated similar or improved outcomes11,28 and a perceived improvement in quality of life.10,2931 In a review of 17 studies that compared physical, psychological, social, and sexual function, Sprangers et al10 noted that patients who have undergone sphincter-sparing procedures and those with permanent colostomies frequently experienced diarrhea and some impairment of social and sexual functioning. However, patients with ostomies consistently reported increased psychological distress, restrictions in social functioning, and impairment in sexual function compared with those without ostomies.

After controlling for stage of disease at diagnosis, we identified the type of operation performed as the most notably divergent outcome between blacks and whites. Among patients undergoing either a sphincter-sparing operation or an abdominoperineal resection, the adjusted odds of having a permanent colostomy were 42% greater for blacks than whites. Although our data do not allow us to establish a precise mechanism for this discrepancy, controlling for age, sex, stage of disease, geographic region, year of diagnosis, and even approximate tumor site ("rectum" vs "rectosigmoid") only increased the odds of a more invasive sphincter-ablating procedure among blacks. To our knowledge, racial variation in treatment pertaining to quality of life issues among patients with rectal cancer has not been addressed previously,32 although one may presume that the desire for intestinal continuity traverses racial barriers.

While most patients of both races underwent some surgical procedure for rectal cancer, after adjusting for stage, surgical therapy was less likely to be provided to blacks than whites. Two similar reports from national databases indicate that, among the less severely ill, black inpatients with colorectal cancer are treated less aggressively than whites.33,34 These published data suggest that the less aggressive surgical care cannot be explained wholly by clinical data. Furthermore, studies of standardized adjuvant treatment protocols describe similar or identical treatment efficacy for blacks and whites.6,7 Thus, among patients with colorectal cancer, differences in provision of surgical and adjuvant care do not appear to be based wholly on biological predicates, such as comorbid disease.

We also specifically investigated rectal cancer treatment because radiation therapy11,35 has been increasingly accepted as the standard of care for stage II and III rectal cancer since the 1990 National Institutes of Health consensus conference on adjuvant therapy for colon and rectal cancer.17 Neoadjuvant radiation therapy provides the added benefit of tumor shrinkage, potentially allowing a sphincter-sparing procedure to be performed on patients with more distal tumors.11,36 Among stage II and III patients, we found that any radiation therapy was less likely to be delivered to blacks than whites. We were surprised to find that less than 50% of patients overall underwent radiation treatment. Using a linked SEER-Medicare database, Schrag and colleagues37 documented slightly higher rates of radiation treatment among patients older than 65 years, but these were insured patients assessed between 1992 and 1996, and those with local excision or rectosigmoid disease were excluded. Our decision to include patients diagnosed as having rectosigmoid cancer was based on the highly variable anatomic transition of rectum to sigmoid colon38 and would tend to bias our results toward the null hypothesis.

A recent publication examining the treatment of rectal and rectosigmoid cancer patients in California between 1994 and 1996 noted that only 44% of patients with stage II disease and 60% of patients with stage III disease received some adjuvant therapy.39 However, these patients experienced wide variation in treatment regimens that could not be wholly explained by clinical data. Our finding that an even smaller proportion of patients received the recommended treatment on the national level likely reflects regional differences in the diffusion of standardized care.

Neoadjuvant radiation therapy, which can facilitate sphincter preservation and may be a marker for increased expertise in rectal cancer care,11,20 was delivered more equitably but to only 7% of patients overall. As neoadjuvant radiation therapy is more widely performed in the future, monitoring its delivery may provide further insights into whether race-based variations in care are narrowing.

This study has several limitations. Using the SEER database limited our ability to assess the effect of potentially important confounders, including some tumor-related features, patient comorbidities and preferences, provider and hospital system characteristics, and socioeconomic variables. Future investigations using linked databases will allow us to account for many of these potential confounders. Additionally, we did not have detailed information regarding technical issues, such as precise location of the tumor in the rectum, which may influence the type of procedure performed. However, while previous studies suggest that blacks have a higher incidence of proximal colon cancer,40 there is no evidence to suggest that blacks have a higher incidence of distal rectal cancer than whites. Furthermore, we found a relatively increased proportion of women among black patients with rectal cancer, and the female pelvis renders a sphincter-sparing operation more technically feasible.

Despite these limitations, we found evidence of consistent racial disparities in the receipt of established treatment regimens for rectal cancer. The differences extended most markedly to the disparate rates of sphincter-ablating operations, which mandate permanent colostomy, and may have a profound effect on self-image and quality of life. We also identified discrepancies in the application of recommended surgical and radiation therapy, which have been consistently shown to enhance survival.17,28 Further studies are warranted to investigate the relationships among race, treatment, and, ultimately, survival, controlling for patient- and provider-related variables. These findings further underscore the need for surgeons, oncologists, and health care policy makers to intensify their efforts to deliver state-of-the-art combined modality rectal cancer therapy to all patients.

Corresponding author: Arden M. Morris, MD, MPH, Division of Colorectal Surgery, Taubman Center 2920, University of Michigan, Ann Arbor, MI 48109-0331 (e-mail: ammsurg@umich.edu). No reprints are available.

Accepted for publication July 11, 2003.

This study was supported in part by the Robert Wood Johnson Foundation, Princeton, NJ.

The opinions, views, and conclusions are those of the authors and not necessarily those of the Robert Wood Johnson Foundation.

Not Available, Surveillance Epidemiology and End Results Cancer Incidence Database.  Silver Spring, Md Information Management Services Inc1998;
Greenlee  RTMurray  TBolden  SWingo  PA Cancer statistics, 2000. CA Cancer J Clin. 2000;507- 33
PubMed Link to Article
Howe  HWingo  PAThul  M  et al.  Annual report to the nation on the status of cancer (1973 through 1998), featuring cancers with increasing trends. J Natl Cancer Inst. 2001;93824- 842
PubMed Link to Article
Boring  CCSquires  TSHealth Jr  CW Cancer statistics for African Americans. CA Cancer J Clin. 1992;427- 17[published correction appears in CA Cancer J Clin. 1992;42:125].
PubMed Link to Article
Bach  PBSchrag  DBrawley  OWGalaznik  AYakren  SBegg  CB Survival of blacks and whites after a cancer diagnosis. JAMA. 2002;2872106- 2113
PubMed Link to Article
Dignam  JJColangelo  LTian  W  et al.  Outcomes among African-Americans and Caucasians in colon cancer adjuvant therapy trials: findings from the National Surgical Adjuvant Breast and Bowel Project. J Natl Cancer Inst. 1999;911933- 1940
PubMed Link to Article
Dominitz  JASamsa  GPLandsman  PProvenzale  D Race, treatment, and survival among colorectal carcinoma patients in an equal-access medical system. Cancer. 1998;822312- 2320
PubMed Link to Article
Kaufman  JSCooper  RSMcGee  DL Socioeconomic status and health in blacks and whites: the problem of residual confounding and the resiliency of race. Epidemiology. 1997;8621- 628
PubMed
Pollock  AMVickers  N Deprivation and emergency admissions for cancers of colorectum, lung, and breast in south east England: ecological study. BMJ. 1998;317245- 252
PubMed Link to Article
Sprangers  MATaal  BGAaronson  NKte Velde  A Quality of life in colorectal cancer: stoma vs nonstoma patients. Dis Colon Rectum. 1995;38361- 369
PubMed Link to Article
Ng  AKRecht  ABusse  PM Sphincter preservation therapy for distal rectal carcinoma: a review. Cancer. 1997;79671- 683
PubMed Link to Article
Simons  AJKer  RGroshen  S  et al.  Variations in treatment of rectal cancer: the influence of hospital type and caseload. Dis Colon Rectum. 1997;40641- 646
PubMed Link to Article
Read  TEMyerson  RJFleshman  JW  et al.  Surgeon specialty is associated with outcome in rectal cancer treatment. Dis Colon Rectum. 2002;45904- 914
PubMed Link to Article
Martling  ACedermark  BJohansson  HRutqvist  LEHolm  T The surgeon as a prognostic factor after the introduction of total mesorectal excision in the treatment of rectal cancer. Br J Surg. 2002;891008- 1013
PubMed Link to Article
Porter  GASoskolne  CLYakimets  WWNewman  SC Surgeon-related factors and outcome in rectal cancer [see comments]. Ann Surg. 1998;227157- 167
PubMed Link to Article
Paszat  LFBrundage  MDGroome  PASchulze  KMackillop  WJ A population-based study of rectal cancer: permanent colostomy as an outcome. Int J Radiat Oncol Biol Phys. 1999;451185- 1191
PubMed Link to Article
NIH consensus conference, Adjuvant therapy for patients with colon and rectal cancer. JAMA. 1990;2641444- 1450
PubMed Link to Article
Minsky  BDCohen  AMKemeny  N  et al.  Combined modality therapy of rectal cancer: decreased acute toxicity with the preoperative approach. J Clin Oncol. 1992;101218- 1224
PubMed
Wagman  RMinsky  BDCohen  AMGuillem  JGPaty  PP Sphincter preservation in rectal cancer with preoperative radiation therapy and coloanal anastomosis: long term follow-up. Int J Radiat Oncol Biol Phys. 1998;4251- 57
PubMed Link to Article
Camma  CGiunta  MFiorica  FPagliaro  LCraxi  ACottone  M Preoperative radiotherapy for resectable rectal cancer: a meta-analysis. JAMA. 2000;2841008- 1015
PubMed Link to Article
Not Available, Adjuvant radiotherapy for rectal cancer: a systematic overview of 8,507patients from 22 randomised trials. Lancet. 2001;3581291- 1304
PubMed Link to Article
Not Available, Surveillance, Epidemiology, and End Results. About SEER. National Cancer Institute, Bethesda, Md. Available at: http://seer.cancer.gov. Accessed June 12, 2002.
Virnig  BAWarren  JLCooper  GSKlabunde  CNSchussler  NFreeman  J Studying radiation therapy using SEER-Medicare-linked data. Med Care. 2002;40(suppl 8)IV-49-54
Cooper  GSVirnig  BKlabunde  CNSchussler  NFreeman  JWarren  JL Use of SEER-Medicare data for measuring cancer surgery. Med Care. 2002;40(suppl 8)43- 48
Link to Article
Wingo  PARies  LARosenberg  HMMiller  DSEdwards  BK Cancer incidence and mortality, 1973-1995: a report card for the US. Cancer. 1998;821197- 1207
PubMed Link to Article
Mayberry  RMMili  FOfili  E Racial and ethnic differences in access to medical care. Med Care Res Rev. 2000;57(suppl 1)108- 145
PubMed Link to Article
Oluwole  SFAli  AOAdu  A  et al.  Impact of a cancer screening program on breast cancer stage at diagnosis in a medically underserved urban community. J Am Coll Surg. 2003;196180- 188
PubMed Link to Article
Beart  RWSteele Jr  GDMenck  HRChmiel  JSOcwieja  KEWinchester  DP Management and survival of patients with adenocarcinoma of the colon and rectum: a national survey of the Commission on Cancer. J Am Coll Surg. 1995;181225- 236
PubMed
Nugent  KPDaniels  PStewart  BPatankar  RJohnson  CD Quality of life in stoma patients. Dis Colon Rectum. 1999;421569- 1574
PubMed Link to Article
Renner  KRosen  HRNovi  GHolbling  NSchiessel  R Quality of life after surgery for rectal cancer: do we still need a permanent colostomy? Dis Colon Rectum. 1999;421160- 1167
PubMed Link to Article
Ramsey  SDAndersen  MREtzioni  R  et al.  Quality of life in survivors of colorectal carcinoma. Cancer. 2000;881294- 1303
PubMed Link to Article
Camilleri-Brennan  JSteele  RJ Quality of life after treatment for rectal cancer. Br J Surg. 1998;851036- 1043
PubMed Link to Article
Cooper  GSYuan  ZLandefeld  CSRimm  AA Surgery for colorectal cancer: race-related differences in rates and survival among Medicare beneficiaries. Am J Public Health. 1996;86582- 586
PubMed Link to Article
Ball  JKElixhauser  A Treatment differences between blacks and whites with colorectal cancer. Med Care. 1996;34970- 984
PubMed Link to Article
Coia  LWizenberg  MHanlon  A  et al.  Evaluation and treatment of patients receiving radiation for cancer of the rectum or sigmoid colon in the United States: results of the 1988-1989 Patterns of Care Study process survey. J Clin Oncol. 1994;12954- 959
PubMed
Not Available, Improved survival with preoperative radiotherapy in resectable rectal cancer: Swedish Rectal Cancer Trial. N Engl J Med. 1997;336980- 987
PubMed Link to Article
Schrag  DGelfand  SEBach  PBGuillem  JMinsky  BDBegg  CB Who gets adjuvant treatment for stage II and III rectal cancer? insight from Surveillance, Epidemiology, and End Results—Medicare. J Clin Oncol. 2001;193712- 3718
PubMed
Nelson  HPetrelli  NCarlin  A  et al.  Guidelines 2000 for colon and rectal cancer surgery. J Natl Cancer Inst. 2001;93583- 596
PubMed Link to Article
Schroen  ATCress  RD Use of surgical procedures and adjuvant therapy in rectal cancer treatment: a population-based study. Ann Surg. 2001;234641- 651
PubMed Link to Article
Cheng  XChen  VWSteele  B  et al.  Subsite-specific incidence rate and stage of disease in colorectal cancer by race, gender, and age group in the United States, 1992-1997. Cancer. 2001;922547- 2554
PubMed Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1. Demographics and Cancer Stage of 1988-1999 SEER Rectal Cancer Cases by Race
Table Graphic Jump LocationTable 2. Geographic Distribution of 1988-1999 SEER Rectal Cancer Cases by Race
Table Graphic Jump LocationTable 3. Comparison of Surgical Treatment by Race Among Patients With Stage II and III Rectal Cancer *
Table Graphic Jump LocationTable 4. Comparison of Adjuvant Radiation Therapy by Race Among Patients With Stage II and III Rectal Cancer

References

Not Available, Surveillance Epidemiology and End Results Cancer Incidence Database.  Silver Spring, Md Information Management Services Inc1998;
Greenlee  RTMurray  TBolden  SWingo  PA Cancer statistics, 2000. CA Cancer J Clin. 2000;507- 33
PubMed Link to Article
Howe  HWingo  PAThul  M  et al.  Annual report to the nation on the status of cancer (1973 through 1998), featuring cancers with increasing trends. J Natl Cancer Inst. 2001;93824- 842
PubMed Link to Article
Boring  CCSquires  TSHealth Jr  CW Cancer statistics for African Americans. CA Cancer J Clin. 1992;427- 17[published correction appears in CA Cancer J Clin. 1992;42:125].
PubMed Link to Article
Bach  PBSchrag  DBrawley  OWGalaznik  AYakren  SBegg  CB Survival of blacks and whites after a cancer diagnosis. JAMA. 2002;2872106- 2113
PubMed Link to Article
Dignam  JJColangelo  LTian  W  et al.  Outcomes among African-Americans and Caucasians in colon cancer adjuvant therapy trials: findings from the National Surgical Adjuvant Breast and Bowel Project. J Natl Cancer Inst. 1999;911933- 1940
PubMed Link to Article
Dominitz  JASamsa  GPLandsman  PProvenzale  D Race, treatment, and survival among colorectal carcinoma patients in an equal-access medical system. Cancer. 1998;822312- 2320
PubMed Link to Article
Kaufman  JSCooper  RSMcGee  DL Socioeconomic status and health in blacks and whites: the problem of residual confounding and the resiliency of race. Epidemiology. 1997;8621- 628
PubMed
Pollock  AMVickers  N Deprivation and emergency admissions for cancers of colorectum, lung, and breast in south east England: ecological study. BMJ. 1998;317245- 252
PubMed Link to Article
Sprangers  MATaal  BGAaronson  NKte Velde  A Quality of life in colorectal cancer: stoma vs nonstoma patients. Dis Colon Rectum. 1995;38361- 369
PubMed Link to Article
Ng  AKRecht  ABusse  PM Sphincter preservation therapy for distal rectal carcinoma: a review. Cancer. 1997;79671- 683
PubMed Link to Article
Simons  AJKer  RGroshen  S  et al.  Variations in treatment of rectal cancer: the influence of hospital type and caseload. Dis Colon Rectum. 1997;40641- 646
PubMed Link to Article
Read  TEMyerson  RJFleshman  JW  et al.  Surgeon specialty is associated with outcome in rectal cancer treatment. Dis Colon Rectum. 2002;45904- 914
PubMed Link to Article
Martling  ACedermark  BJohansson  HRutqvist  LEHolm  T The surgeon as a prognostic factor after the introduction of total mesorectal excision in the treatment of rectal cancer. Br J Surg. 2002;891008- 1013
PubMed Link to Article
Porter  GASoskolne  CLYakimets  WWNewman  SC Surgeon-related factors and outcome in rectal cancer [see comments]. Ann Surg. 1998;227157- 167
PubMed Link to Article
Paszat  LFBrundage  MDGroome  PASchulze  KMackillop  WJ A population-based study of rectal cancer: permanent colostomy as an outcome. Int J Radiat Oncol Biol Phys. 1999;451185- 1191
PubMed Link to Article
NIH consensus conference, Adjuvant therapy for patients with colon and rectal cancer. JAMA. 1990;2641444- 1450
PubMed Link to Article
Minsky  BDCohen  AMKemeny  N  et al.  Combined modality therapy of rectal cancer: decreased acute toxicity with the preoperative approach. J Clin Oncol. 1992;101218- 1224
PubMed
Wagman  RMinsky  BDCohen  AMGuillem  JGPaty  PP Sphincter preservation in rectal cancer with preoperative radiation therapy and coloanal anastomosis: long term follow-up. Int J Radiat Oncol Biol Phys. 1998;4251- 57
PubMed Link to Article
Camma  CGiunta  MFiorica  FPagliaro  LCraxi  ACottone  M Preoperative radiotherapy for resectable rectal cancer: a meta-analysis. JAMA. 2000;2841008- 1015
PubMed Link to Article
Not Available, Adjuvant radiotherapy for rectal cancer: a systematic overview of 8,507patients from 22 randomised trials. Lancet. 2001;3581291- 1304
PubMed Link to Article
Not Available, Surveillance, Epidemiology, and End Results. About SEER. National Cancer Institute, Bethesda, Md. Available at: http://seer.cancer.gov. Accessed June 12, 2002.
Virnig  BAWarren  JLCooper  GSKlabunde  CNSchussler  NFreeman  J Studying radiation therapy using SEER-Medicare-linked data. Med Care. 2002;40(suppl 8)IV-49-54
Cooper  GSVirnig  BKlabunde  CNSchussler  NFreeman  JWarren  JL Use of SEER-Medicare data for measuring cancer surgery. Med Care. 2002;40(suppl 8)43- 48
Link to Article
Wingo  PARies  LARosenberg  HMMiller  DSEdwards  BK Cancer incidence and mortality, 1973-1995: a report card for the US. Cancer. 1998;821197- 1207
PubMed Link to Article
Mayberry  RMMili  FOfili  E Racial and ethnic differences in access to medical care. Med Care Res Rev. 2000;57(suppl 1)108- 145
PubMed Link to Article
Oluwole  SFAli  AOAdu  A  et al.  Impact of a cancer screening program on breast cancer stage at diagnosis in a medically underserved urban community. J Am Coll Surg. 2003;196180- 188
PubMed Link to Article
Beart  RWSteele Jr  GDMenck  HRChmiel  JSOcwieja  KEWinchester  DP Management and survival of patients with adenocarcinoma of the colon and rectum: a national survey of the Commission on Cancer. J Am Coll Surg. 1995;181225- 236
PubMed
Nugent  KPDaniels  PStewart  BPatankar  RJohnson  CD Quality of life in stoma patients. Dis Colon Rectum. 1999;421569- 1574
PubMed Link to Article
Renner  KRosen  HRNovi  GHolbling  NSchiessel  R Quality of life after surgery for rectal cancer: do we still need a permanent colostomy? Dis Colon Rectum. 1999;421160- 1167
PubMed Link to Article
Ramsey  SDAndersen  MREtzioni  R  et al.  Quality of life in survivors of colorectal carcinoma. Cancer. 2000;881294- 1303
PubMed Link to Article
Camilleri-Brennan  JSteele  RJ Quality of life after treatment for rectal cancer. Br J Surg. 1998;851036- 1043
PubMed Link to Article
Cooper  GSYuan  ZLandefeld  CSRimm  AA Surgery for colorectal cancer: race-related differences in rates and survival among Medicare beneficiaries. Am J Public Health. 1996;86582- 586
PubMed Link to Article
Ball  JKElixhauser  A Treatment differences between blacks and whites with colorectal cancer. Med Care. 1996;34970- 984
PubMed Link to Article
Coia  LWizenberg  MHanlon  A  et al.  Evaluation and treatment of patients receiving radiation for cancer of the rectum or sigmoid colon in the United States: results of the 1988-1989 Patterns of Care Study process survey. J Clin Oncol. 1994;12954- 959
PubMed
Not Available, Improved survival with preoperative radiotherapy in resectable rectal cancer: Swedish Rectal Cancer Trial. N Engl J Med. 1997;336980- 987
PubMed Link to Article
Schrag  DGelfand  SEBach  PBGuillem  JMinsky  BDBegg  CB Who gets adjuvant treatment for stage II and III rectal cancer? insight from Surveillance, Epidemiology, and End Results—Medicare. J Clin Oncol. 2001;193712- 3718
PubMed
Nelson  HPetrelli  NCarlin  A  et al.  Guidelines 2000 for colon and rectal cancer surgery. J Natl Cancer Inst. 2001;93583- 596
PubMed Link to Article
Schroen  ATCress  RD Use of surgical procedures and adjuvant therapy in rectal cancer treatment: a population-based study. Ann Surg. 2001;234641- 651
PubMed Link to Article
Cheng  XChen  VWSteele  B  et al.  Subsite-specific incidence rate and stage of disease in colorectal cancer by race, gender, and age group in the United States, 1992-1997. Cancer. 2001;922547- 2554
PubMed Link to Article

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 70

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles