Association of Distance to Treatment Facility, U.S. Region, and Insurance Status With Diagnosis of Advanced Colon Cancer

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In a National Cancer Database analysis reported in JAMA Network Open, Brand et al found that patients with colon cancer who lived farther from their treatment facility and those with no insurance or Medicaid alone were more likely to present with advanced-stage disease.

As stated by the investigators, “In the U.S., more than 100,000 new colon cancer diagnoses and 35,000 colon cancer deaths are estimated to occur each year. Less than 40% of patients with new diagnoses will have early-stage disease, which has a 5-year overall survival as high as 90%. There is a need to identify interventions to promote the early diagnosis of colon cancer.”

Study Details

The study included data from patients with a primary diagnosis of colon cancer between 2020 and 2017. Patients with rectal cancer or multiple cancer diagnoses were excluded from the analysis. A secondary analysis to identify factors associated with diagnosis at advanced pathologic stage excluded patients who did not receive surgical intervention, those who received neoadjuvant therapy, and those who received surgical intervention on multiple sites during their index operation.  

Key Findings

Among 208,085 patients with clinical-stage colon cancer, 49% were diagnosed at stage I/II and 51% at stage III/IV. On multivariate analysis, compared with patients who lived less than 20.2 km from their medical facility, those living at distances of 20.2 to 80.0 km (odds ratio [OR] = 1.11, 95% confidence interval [CI] = 1.09–1.14), 81.0 to 400.0 km (OR = 1.39, 95% CI = 1.34–1.44), and > 400.0 km (OR = 1.78, 95% CI = 1.62–1.94) had a significantly increased likelihood of presenting at clinical stage III/IV disease.

Among 238,309 patients who underwent surgical resection, multivariate analysis showed that having no insurance (OR = 1.33, 95% CI = 1.27–1.39) and having only Medicaid (OR = 1.22, 95% CI = 1.18–1.27) were associated with advanced pathologic stage.

When the analysis was repeated with an interaction term between distance traveled to medical facility and region of the United States, distance of 81 to 400 km from a treating center was associated with increased risk of advanced pathologic stage in the West North Central (OR = 1.19, 95% CI = 1.07–1.34), Mountain (OR = 1.23, 95% CI = 1.05–1.43), New England (OR = 1.26, 95% CI = 1.00–1.58), East South Central (OR = 1.16, 95% CI = 1.02–1.31),  East North Central (OR = 1.31, 95% CI = 1.16–1.48), and West South Central (OR = 1.14, 95% CI = 1.01–1.29) regions compared with the reference South Atlantic region; no significant difference in risk was observed for the Pacific region or Middle Atlantic region vs the South Atlantic region.

The investigators stated, “In our study, distance from the treating facility was associated with advanced-stage colon cancer. This finding was not uniform, and patients living in the Mountain, Central, and Northeast regions had higher odds of advanced-stage disease if living 81 to 400 km from their treating facility compared with patients living in the Southeast. We also identified insurance status as a risk factor for diagnosis of advanced-stage colon cancer. These findings support previous studies that have identified marginal insurance as an important risk factor for both poor overall survival and advanced-stage disease at presentation.”

Ankit Sarin, MD, MHA, of the Department of Surgery, University of California, San Francisco, is the corresponding author for the JAMA Network Open article.

Disclosure: For full disclosures of the study authors, visit

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