Geographic Disparities in Colorectal Cancer Survival

摘要 结直肠癌（CRC）是美国第四大常见癌症， 癌症死亡的主要原因。尽管CRC发病率下降，但确诊后的生存率 在过去的几十年里只略有改善。尽管环境背景在 在健康、疾病和行为中的作用，大多数关于CRC生存的研究在很大程度上忽略了地理分布， 与CRC相关的地区级社会经济条件的变化和重要性 筛查、诊断时的CRC分期以及许多其他癌症的生存率。居住在以下地区的CRC患者 社会经济条件差的地区比生活在富裕地区的人的生存率要低。 条件;然而，这些地区因素对CRC生存率产生影响的机制 仍然不清楚。 这项拟议的基于人群的前瞻性研究的修订申请有三个具体目标。 目的1）根据以下因素确定美国各地CRC生存率的地理差异程度： 在县以下（人口普查区）一级使用关联的监测、流行病学和 最终结果（SEER）-超过100，000名66岁或以上被诊断患有CRC的男性和女性的医疗保险数据。 目的2）确定CRC生存率较低在多大程度上可以由较高的地区社会经济状况解释。 66岁及66岁以上的人被剥夺权利。目的3）确定潜在的介导途径，通过这些途径， 地区社会经济贫困与66岁及以上人群的CRC存活率较低相关， 即a）患者特征，B）医师和医院特征，c）肿瘤特征，d）肿瘤类型， 接受治疗，和e）诊断后监测CRC以检测复发和转移。 将建立一个多层次的空间模型，以解决拟议研究的具体目标。我们将 使用以下现有的数据来源：1）1992-2005年来自NCI SEER项目的数据（生存率，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数据相关联; 3）1991-2005年数据来自 服务提供者档案（医院和医生特点），4）1990-2005年人口普查数据（地区贫困 5）医疗保险当前受益人调查数据。CRC的高级贝叶斯空间分析 将进行生存测试，并使用地理信息系统显示结果。我们的研究 将增加对地区一级社会经济作用的理解，并确定其重要机制 剥夺儿童权利委员会的生存权。此外，这项研究将有助于提供机会， 地理区域分配资源和当地干预措施，以提高CRC生存率，使用证据- 健康差距，从而减少与生活在社会经济贫困人口中的 地区

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.