Asya Ofshteyn, MD, MPH, Katherine Bingmer, MD, Christopher W Towe, MD, Emily Steinhagen, MD, Sharon L Stein, MD, FACS, FASCRS. University Hospitals Cleveland Medical Center/Case Western Reserve University
Socioeconomic and racial differences have been associated with variations in access to and treatment of cancer within the US. Minimally invasive surgery has been associated with higher income and private insurance in patients with rectal cancer. However, past studies have predominantly focused on laparoscopic approach or excluded key patient populations. We hypothesized that robotic surgery for rectal cancer may be associated with similar disparities.
The National Cancer Database (NCDB) was used to identify patients 18 years of age and older with clinical stage I-III rectal adenocarcinoma who underwent a proctectomy between 2010 and 2014. Patient demographics and hospital factors were analyzed to identify factors associated with choice of robotic approach over other techniques. Factors identified on univariate analyses informed our multivariate analysis.
We identified 33,836 patients who met inclusion criteria; 3,740(11.1%) underwent robotic surgery with 7.8% open conversion rate. On multivariate analysis, factors associated with significantly reduced likelihood of undergoing robotic surgery included female sex (OR 0.89, p=0.001), black race (OR 0.75, p=0.001), increasing age (OR 0.99, p<0.001), lower income (OR 1.09 increase per quartile, p=<0.001) and living less than 25 miles away from the hospital (OR 0.81, p<0.001). Patients at high-volume rectal surgery institutions (OR 1.10, p=0.011) and academic centers (OR 1.60, p<0.001) were more likely to receive robotic surgery (Table 1).
Robotic surgery is performed rarely, and access to it is limited, particularly for patients who are female, black, older, low-income and unable to travel to high-volume teaching institutions. The advantages of robotic surgery may not be available to all patients given disparate access to the robot. More importantly, this inherent bias in access may skew study populations and prevent generalizability of robotic surgery research.
| Variable | OR | 95% CI | p-value |
|---|---|---|---|
| Female | 0.89 | 0.83-0.95 | 0.001 |
| Age | 0.99 | 0.99-0.997 | <0.001 |
| White race | 0.97 | 0.87-1.06 | 0.460 |
| Black race | 0.75 | 0.63-0.88 | 0.001 |
| Income | 1.09 | 1.05-1.13 | <0.001 |
| Hospital <25 miles | 0.83 | 0.75-0.88 | <0.001 |
| High-volume rectal surgery | 1.38 | 1.02-1.20 | 0.011 |
| Academic institution | 1.46 | 1.49-1.72 | <0.001 |
| Clinical stage | 1.05 | 1.00-1.10 | 0.039 |
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 94223
Program Number: S165
Presentation Session: Disparities
Presentation Type: Podium