Department of Medicine, University of Alabama at Birmingham, 1720 2(nd) Avenue South, BDB 860, Birmingham, AL 35294, USA.
Department of Medicine, University of Alabama at Birmingham, 1720 2(nd) Avenue South, BDB 860, Birmingham, AL 35294, USA; Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, 1600 7(th) Avenue South, Lowder Building Suite 500, Birmingham, AL 35233, USA.
J Geriatr Oncol. 2023 May;14(4):101505. doi: 10.1016/j.jgo.2023.101505. Epub 2023 Apr 21.
INTRODUCTION: Rural-urban disparities persist in cancer mortality, despite improvement in cancer screening and treatment. Although older adults represent the majority of cancer cases and are over-represented in rural areas, few studies have explored rural-urban disparities in mortality and age-related impairments among older adults with cancer. MATERIALS AND METHODS: We included 962 newly-diagnosed older adults (≥60 years) with cancer who underwent geriatric assessment (GA) at their first pre-chemotherapy visit to an academic medical center in the Southeastern United States. We used Rural-Urban Commuting Area (RUCA) codes to classify residence at time of diagnosis into urban and rural areas. We used one-year survival and pre-treatment frailty as outcomes. We used Cox proportional hazards regression to evaluate the association between residence and one-year mortality, and logistic regression to evaluate the association between residence and pre-treatment frailty. All tests were two-sided. RESULTS: Median age at GA was 68.0 (interquartile rage [IQR]: 64.0, 74.0) years; most had colorectal cancer (24.3%) with advanced stage (III/IV 73.2%) disease. Overall, 11.4% resided in rural and 88.6% in urban areas. Rural areas had a higher proportion of White and less educated participants. After adjustment for age, sex, race, education, employment status, and cancer type/stage, rural residence was associated with higher hazard of one-year mortality (hazard ratio [HR] = 1.78, 95% confidence interval [CI] = 1.23, 2.57) compared to urban residence. Frailty was an effect modifier of this association (HR = 1.83, 95% CI = 1.27, 2.57; HR = 2.05, 95% CI = 1.23, 3.41; HR = 1.55, 95% CI = 0.90, 2.68). DISCUSSION: Among older adults with newly diagnosed cancer, rural residence was associated with reduced one-year survival, particularly among frail older adults. The rural-urban disparities observed in the current study may be due to frailty in conjunction with disparities in social determinants of health across rural and urban areas. Future studies should focus on understanding and intervening on underlying causes of these disparities.
介绍：尽管癌症筛查和治疗有所改善，但城乡之间的癌症死亡率仍存在差异。尽管老年人是癌症病例的大多数，并且在农村地区的比例过高，但很少有研究探讨老年人癌症死亡率和与年龄相关的障碍方面的城乡差异。
材料和方法：我们纳入了 962 名在东南美国一所学术医疗中心首次化疗前就诊时接受老年评估（GA）的新诊断的老年（≥60 岁）癌症患者。我们使用农村-城市通勤区（RUCA）代码将诊断时的居住地点分类为城市和农村地区。我们使用一年生存率和治疗前虚弱作为结局。我们使用 Cox 比例风险回归来评估居住地与一年死亡率之间的关联，使用逻辑回归来评估居住地与治疗前虚弱之间的关联。所有检验均为双侧。
结果：GA 时的中位年龄为 68.0（四分位数范围[IQR]：64.0，74.0）岁；大多数患者患有结直肠癌（24.3%），且处于晚期（III/IV 期 73.2%）。总体而言，11.4%的人居住在农村地区，88.6%的人居住在城市地区。农村地区的白人和受教育程度较低的参与者比例较高。在调整年龄、性别、种族、教育程度、就业状况和癌症类型/分期后，与城市居住地相比，农村居住地与一年死亡率的风险增加相关（危险比[HR]为 1.78，95%置信区间[CI]为 1.23，2.57）。虚弱是这种关联的效应修饰剂（HR 为 1.83，95%CI 为 1.27，2.57；HR 为 2.05，95%CI 为 1.23，3.41；HR 为 1.55，95%CI 为 0.90，2.68）。
讨论：在新诊断患有癌症的老年人中，农村居住地与一年生存率降低相关，尤其是在虚弱的老年人中。本研究中观察到的城乡差异可能是由于农村和城市地区社会决定因素健康的脆弱性所致。未来的研究应侧重于了解和干预这些差异的根本原因。
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