Health care delivery to vulnerable populations is a significant challenge as such systems simultaneously face financial challenges and resource limitations. Complex medical conditions, such as colorectal cancer (CRC), may identify disparities in access or delivery that affect clinical outcomes. Our objective was to examine CRC stage at presentation and mortality in a vulnerable population compared with nationally representative data.
From 1996–2009, consecutive CRC cases from San Francisco General Hospital (SFGH) were identified. Representative CRC cases were identified from the Surveillance, Epidemiology and End Results (SEER) database over the same time period. Demographic data, stage at presentation, survival after diagnosis, and utilization of surgical services were examined in both cohorts and by race/ethnicity. In addition, in patients who had established care at SFGH for at least one year, we examined utilization of CRC screening tests prior to CRC diagnosis.
289 stage 1 to 4 CRC cases were identified at SFGH. Fifty-five percent of the SFGH cohort presented with advanced disease (stage 3 and 4) compared with 44% in the SEER cohort (adjusted odds-ratio (aOR) 1.28, 95% confidence interval (CI) 1.01–1.61, p=0.04). Increased risk of late stage at presentation at SFGH compared with SEER was most evident among blacks (aOR 1.80, 95% CI 1.02–3.17, p=0.04) and Asians (aOR 1.41, 95% CI 0.97–2.05, p=0.07). There was weak evidence for worse survival at SFGH compared with SEER overall (adjusted hazard ratio (aHR) 1.19, 95% CI 0.99–1.45). However, this varied by race (p=0.002), with poorer survival at SFGH among whites (HR 2.13, 95% CI 1.51–3.02) and possibly blacks (HR 1.38, 95% CI 0.95–2.01), but some evidence for better survival among Asians (HR 0.77, 95% CI 0.53–1.12). Among CRC patients at SFGH, Asians and Hispanics had significantly better survival than whites and blacks. Of the 56% patients receiving care at SFGH for at least 1 year, only 22% had received any form of CRC screening.
In this study comparing history of screening, stage at presentation, and mortality among CRC cases at SFGH with the SEER cancer registry, we found that SFGH cases were more likely to present with late CRC, in particular blacks and Asians, and mostly had shorter survival, especially whites and blacks. The screening rates among SFGH patients in care for at least 1 year at diagnosis were low, and may have contributed to late stage at presentation. These findings provide an opportunity to examine access and utilization by race/ethnicity in a vulnerable population and to identify areas where quality of CRC care can be improved.