Geographic Disparities in Colorectal Cancer Survival

摘要 结直肠癌(CRC)是美国第四大常见癌症和第二大常见癌症 癌症死亡的主要原因。尽管结直肠癌发病率下降，但确诊后的存活率 在过去的几十年里，情况只有轻微的改善。即使环境背景在其中扮演着重要的角色 在健康、疾病和行为中的作用，大多数关于结直肠癌存活率的研究在很大程度上忽略了地理上的 与儿童权利公约有关的地区一级社会经济条件的变化和重要性 筛查、诊断时的结直肠癌分期以及许多其他癌症的存活率。居住在中国的结直肠癌患者 社会经济条件较差的地区比生活在较富裕地区的人存活率更低。 然而，这些地区因素对结直肠癌存活率产生影响的机制 目前仍不清楚。 这项拟议的以人口为基础的前瞻性研究的修订应用有三个具体目标。 目的1)根据以下数据确定全美结直肠癌存活率的地理差异程度 在县(人口普查区)级别的小地理区域使用关联监测、流行病学和 最终结果(SEER)-超过100,000名年龄在66岁或以上的被诊断患有结直肠癌的男性和女性的医疗保险数据。 目的2)确定较高地区的社会经济状况在多大程度上可以解释较低的结直肠癌存活率 在66岁及以上的人中被剥夺权利。目标3)确定潜在的调节途径，通过这些途径 地区社会经济贫困与66岁及以上人群中较低的结直肠癌存活率有关， 即a)患者特征，b)医生和医院特征，c)肿瘤特征，d)类型 接受治疗，以及(E)确诊后监测结直肠癌，以发现复发和转移。 将开发一个多层次空间模型，以满足拟议研究的具体目标。我们会 使用以下现有数据来源：1)1992-2005年来自NCI SEER计划的数据(生存、患者 特征、治疗类型、肿瘤特征)；2)1991-2005年医疗保险数据(患者特征， 治疗类型、诊断后监测)，与SEER数据相联系；3)1991-2005年 服务提供者档案(医院和医生特征)，4)1990-2005年人口普查数据(地区剥夺 措施)，以及5)联邦医疗保险当前受益人调查数据。CRC的高级贝叶斯空间分析 将进行求生，并将使用地理信息系统显示结果。我们的研究 将增进对区域一级社会经济作用的重要机制的理解和确定 对结直肠癌存活率的剥夺。此外，这项研究将有助于提供针对特定目标的机会 利用以下证据在地理区域分配资源和干预措施以改善结直肠癌的存活率： 以此为基础的方法，从而减少与生活在社会经济贫困中的健康差距 区域。

ABSTRACT Colorectal cancer (CRC) is the fourth most common cancer in the United States and the second leading cause of cancer deaths. Despite declines in CRC incidence rates, survival following diagnosis has improved only modestly over the past few decades. Even though environmental contexts play an important role in health, disease, and behavior, most studies about CRC survival have largely ignored the geographic variation and importance of area-level socioeconomic conditions that have been associated with CRC screening, CRC stage at diagnosis, and with the survival of many other cancers. CRC patients who live in areas with worse socioeconomic conditions have decreased survival than those who live under more affluent conditions; however, the mechanisms by which these area-level factors exert their influence on CRC survival remain unclear. This amended application of the proposed population-based, prospective study has three specific aims. Aim 1) Determine the extent of the geographic variation of CRC survival across the United States based on small geographic areas at the sub-county (census-tract) level using the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare data for over 100,000 men and women aged 66 or older diagnosed with CRC. Aim 2) Determine the extent to which lower CRC survival can be explained by higher area socioeconomic deprivation among persons age 66 and older. Aim 3) Identify potential mediating pathways by which higher area socioeconomic deprivation is associated with lower CRC survival among persons age 66 and older, namely a) patient characteristics, b) physician and hospital characteristics, c) tumor characteristics, d) type of treatment received, and e) surveillance for CRC after diagnosis to detect recurrence and metastases. A multilevel spatial model will be developed to address the specific aims of the proposed study. We will use the following existing data sources: 1) 1992-2005 data from NCI's SEER program (survival, patient characteristics, type of treatment, tumor characteristics); 2) 1991-2005 Medicare data (patient characteristics, type of treatment, surveillance after diagnosis) which is linked to the SEER data; 3) 1991-2005 data from the Provider of Services File (hospital and physician characteristics), 4) 1990-2005 census data (area deprivation measures), and 5) Medicare Current Beneficiary Survey data. Advanced Bayesian spatial analyses of CRC survival will be performed and a geographic information system will be used to display the results. Our study will increase understanding of and identify important mechanisms of the role of area-level socioeconomic deprivation on CRC survival. In addition, this study will help provide opportunities for targeting specific geographic areas to allocate resources and interventions locally to improve CRC survival using evidence- based approaches, thereby reducing health disparities associated with living in socioeconomically deprived areas.