Emergency presentation and socioeconomic status in colon cancer

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Abstract

Background

Emergency presentation affects up to every fourth patient with colon cancer, and is associated with worse outcomes. The aim of this study was to investigate any association between socioeconomic status (SES) and mode of presentation in colon cancer.

Materials and methods

Individually attained data on civil status, education and income were linked to quality registries for colon cancer in two large Swedish regions 1997–2006 (n = 12 293) and analyzed by logistic regression, adjusting for age, sex, stage, region and socioeconomic variables.

Results

The frequency of emergency presentation was 23%; 27.8% among patients above the age of 80, and 20.0% among patients aged 70–79 (p < 0.001). There was no difference between men and women (22.6% vs. 23.8%; p = 0.1). Among patients with stage IV colon cancer, 34.6% presented as emergencies.

Odds ratio for an emergency presentation in unmarried patients was 1.24 (96% CI 1.04–1.48), and for unmarried patients above the age of 80, OR was 1.45 (95% CI 0.98–2.13).

Among patients below the age of 70 with compulsory education only, OR was 1.22 (95% CI 0.98–1.48). For patients within the lowest income quartile (Q1), OR was 1.24 (95% CI 1.04–1.49). This was most pronounced in men (OR 1.34; 95% CI 1.40–1.72), in patients below the age of 70 (OR 1.36; 95% CI 1.02–1.82), and above the age of 80 (OR 1.41; 95% CI 1.00–1.98).

Conclusion

Emergency presentation of colon cancer is consistently associated with socioeconomic factors, and this must be considered in efforts aimed at reducing the overall frequency of emergency cases.

Introduction

Colon cancer is the third most common form of malignancy in both men and women worldwide, with an estimated 1.2 million cases annually, as well as the fourth most common cause of cancer-related death.1 About 20–25% of all colon cancer is estimated to present as a surgical emergency.2 Such cases being associated with a considerably higher postoperative mortality of 8.2–22.1%,3, 4, 5, 6, 7 and a 5-year survival rate of around 40%, as opposed to that of elective patients, which is over 60%.8, 9 Risk factors for emergency presentation of colon cancer are not well understood, but the combined effect of it being a relatively common and severe condition, makes it an urgent field to explore.

The association between socioeconomic status (SES) and mode of presentation of colon cancer has, to some extent, been investigated previously. Patients that had lower incomes or lived in deprived areas were more likely to present as emergencies according to a Canadian and a British study.10, 11 Another British study reported the risk of an emergency presentation to be more than twice as high for patients from deprived areas12 but yet another British study has found no variation in the frequency of emergency presentation of colon cancer between deprived and affluent patients.13 A recent study from Sweden focused on emergency presentation and educational level, and a trend but no significant association was found among patients below the age of 75.14 One study from the 1980's in the UK found widowed patients to present as emergencies more often.15

In all, we hypothesized that several aspects of patients' socioeconomic position are of importance for mode of presentation in colon cancer, and set out to explore the association to civil status, education and income, in a population-based setting.

Section snippets

Regional clinical quality registries on colon cancer

All cases of colon cancer reported to the Regional Oncology Centre (ROC) in the Uppsala-Örebro and Stockholm regions during 1997–2006 were included. These two regions were chosen as the Uppsala-Örebro region contains both rural and more densely populated areas, while the Stockholm region represents the population and health care of a larger city. The ROC registries in the two regions cover almost 100% of all colon cancer patients since 1997 and 1996, respectively.16 These quality registries

Statistics

Initially, chi-square tests were performed to compare the proportions of patients with emergency and elective presentations within the various groups defined by each variable. If a significant difference (p < 0.05) was obtained, the variable was included in a multiple logistic regression analysis. However, no information was available on the pattern of referrals due to the emergency condition itself. Any difference associated with the frequency of emergency presentation by type of hospital

Basic characteristics

Overall, 23.2% of all colon cancer patients presented as an emergency (Table 1). About half of the patients had a localized (stage I and II) tumor and just above half of all patients were married when diagnosed with colon cancer. Educational data was missing for every fourth patient, and every other patient was treated at a General District hospital.

Univariate analyses

Patients aged 80 years and above had a higher occurrence of emergency presentation than patients aged 70–79 years (χ2 = 126.7, p < 0.001) (Table 2

Discussion

This study has revealed a consistent association between mode of presentation and socioeconomic status in colon cancer patients. Unmarried and low income patients have been identified as risk groups but also colon cancer patients over the age of 80.

Conflict of interest statement

The authors declare no conflict of interest.

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