Massachusetts Chapter of the American College of Surgeons

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The Persistence of Poverty and its Impact on Cancer Diagnosis, Treatment and Survival
Marianna V. Papageorge, MD1, Alison P. Woods, MD1,2, Susanna W.L. de Geus, MD, PhD1, Sing Chau Ng, MS1, David McAneny, MD 1, Jennifer F. Tseng, MD, MPH1, Kelly M. Kenzik, PhD1,3, Teviah E. Sachs, MD, MPH1
1Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA; 2Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; 3Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, AL

Disparities in cancer outcomes exist in counties with high levels of poverty (>19.5% of residents), but little is known about how the duration of poverty (defined by the USDA as past, current or persistent, since 1980) impacts care. This study examines the association of persistent poverty on the diagnosis, surgical resection and survival of patients with non-small cell lung (NSCLC), breast and colorectal cancer.

Patients with NSCLC (n=163352), breast (n=236956) and colorectal (n=122215) cancer were identified from SEER (2012-2016). County-level poverty proportions were obtained from the American Community Survey (1980-2015). Outcomes included advanced stage at diagnosis (stage III-IV), resection of localized disease (stage I-II) and cancer-specific survival. Hierarchical generalized linear models and accelerated failure time models with Weibull distribution were used, adjusted for patient-level covariates and region.

Patients living in persistent poverty were more likely to present with advanced stage disease (NSCLC OR 1.17, 95%CI 1.11-1.23; breast OR 1.14, 95%CI 1.07-1.22; colorectal OR 1.02, 95%CI 0.97-1.08), less likely to undergo surgical resection (NSCLC OR 0.77, 95%CI 0.70-0.84; breast OR 0.86, 95%CI 0.76-0.97; colorectal OR 0.80, 95%CI 0.68-0.95) and had increased cancer-specific mortality (NSCLC HR 1.13, 95%CI 1.10-1.17; breast HR 1.23, 95%CI 1.10-1.38; colorectal HR 1.12, 95%CI 1.05-1.19) as compared to those without poverty. These differences persisted compared to counties classified as current and past poverty.

Patients in counties experiencing persistent poverty have worse cancer-specific outcomes than patients in other counties, including those experiencing current or past poverty. This work supports investment in these communities to ensure equitable outcomes.

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