University of Southern California Dissertations and Theses

Disparities in colorectal cancer survival among Latinos in California

(USC Thesis Other)

Disparities in colorectal cancer survival among Latinos in California

PDF

Download a page range

Download transcript

Copy asset link

Request this asset

Transcript (if available)

Content D i s pa r i t i e s i n C ol or e c t a l C a nc e r S ur vi va l a m ong L a t i nos i n
C a l i f or ni a
by
R uoxua n W a ng
A T he s i s P r e s e nt e d t o t he
F A C U L T Y O F T H E K E C K S C H O O L O F M E D I C I N E
U N V E R S I T Y O F S O U T H E R N C A L I F O R N I A
I n P a r t i a l F ul f i l l m e nt of t he R e qui r e m e nt s f or t he D e gr e e
M A S T E R O F S C I E N C E
A P P L I E D B I O S T A T I S T I C S A N D E P I D E M I O L O G Y
M a y 2020
T a b l e of C on t e n t s
A c k n ow l e d ge m e n t s ........................................................................................................................ i i
L i s t of T a b l e s ................................................................................................................................. i i i
A b b r e vi a t i on s ................................................................................................................................ i v
A b s t r a c t .......................................................................................................................................... v
1. I n t r od u c t i on ............................................................................................................................ 1
2. M e t h od .................................................................................................................................... 2
2.1 C a s e i d e n t i f i c a t i on ......................................................................................................... 2
2.2 S t u d y va r i a b l e s ............................................................................................................... 3
2.3 S t a t i s t i c a l A n a l ys e s ........................................................................................................ 4
3. R e s u l t s ..................................................................................................................................... 5
3.1 S oc i od e m ogr a p h i c c h a r a c t e r i s t i c s of C R C c a s e s i n C a l i f or n i a ................................. 5
3.2 C l i n i c a l c h a r a c t e r i s t i c s of C R C c a s e s i n C a l i f or n i a .................................................. 14
3.3 D e t e r m i n a n t s of t u m or l oc a t i on a m on g C R C c a s e s .................................................. 18
3.4 D e t e r m i n a n t s of r e c e i p t of t r e a t m e n t a m on g C R C c a s e s ......................................... 23
3.5 D e t e r m i n a n t s of t i m e t o t r e a t m e n t r e c e i p t ................................................................ 31
3.6 S u r vi va l a n a l ys i s .......................................................................................................... 34
4. D i s c u s s i on ............................................................................................................................. 42
R e f e r e n c e s ..................................................................................................................................... 45
i i
A c k n ow l e d ge m e n t s
I w oul d l i ke t o t ha nk m y C om m i t t e e C ha i r , D r . M a r i a na C . S t e r n f or he r pa t i e nt gui da nc e ,
de t a i l e d f e e dba c k a nd e nor m ous s uppor t t hr oughout t he w hol e pr oc e s s of t hi s t he s i s , w hi c h ha ve
be e n i nva l ua bl e f or m e . I w oul d a l s o l i ke t o t ha nk m y ot he r c om m i t t e e m e m be r s , D r . L i hua L i u
a nd D r . M e r e di t h F r a nkl i n, f or t he i r t i m e a nd e f f or t i n a s s i s t i ng m e . I a m a l s o gr a t e f ul t o m y
f a m i l y a nd f r i e nds w ho gi ve gr e a t s uppor t t o m e w he ne ve r I ne e d.
i i i
L i s t of T a b l e s
i v
A b b r e vi a t i on s
C C R C a l i f or ni a C a nc e r R e gi s t r y
C I C onf i de nc e I nt e r va l
C R C C ol or e c t a l c a nc e r
F B F or e i gn bor n
H R H a z a r d r a t i o
I C D - 9 I nt e r na t i ona l C l a s s i f i c a t i on of D i s e a s e s , 9
t h
R e vi s i on
I C D - 10 I nt e r na t i ona l C l a s s i f i c a t i on of D i s e a s e s , 10
t h
R e vi s i on
I C D - O - 3 I nt e r na t i ona l C l a s s i f i c a t i on of D i s e a s e s f or O nc ol ogy, 3
r d
R e vi s i on
I H S I ndi a n H e a l t h S e r vi c e s
L R t e s t L i ke l i hood r a t i o t e s t
N A A C C R N or t h A m e r i c a n A s s oc i a t i on of C e nt r a l C a nc e r R e gi s t r i e s
N C I N a t i ona l C a nc e r I ns t i t ut e
N H I A N A A C C R H i s pa ni c I de nt i f i c a t i on A l gor i t hm
N L B N on- L a t i no bl a c k
N L W N on- L a t i no w hi t e
N O S N ot ot he r w i s e s pe c i f i e d
O R O dds r a t i o
S E E R S ur ve i l l a nc e , E pi de m i ol ogy, a nd E nd R e s ul t s P r ogr a m
S E S S oc i oe c onom i c s t a t us
U S B U .S . bor n
v
A b s t r a c t
P ur pos e
C ol or e c t a l c a nc e r ( C R C ) i s t he f our t h m os t c om m on c a nc e r i n t he U .S . a c c or di ng t o t he
N a t i ona l C a nc e r I ns t i t ut e ( N C I ) a nd i t i s t he s e c ond m os t c om m on c a nc e r a m ong L a t i nos i n
C a l i f or ni a . U s i ng da t a f r om t he C a l i f or ni a C a nc e r R e gi s t r y ( C C R ) , w e i nve s t i ga t e d t he
de t e r m i na nt s of C R C i nc i de nc e a nd s ur vi va l i nc l udi ng de m ogr a phi c a nd c l i ni c a l c ha r a c t e r i s t i c s
of 310,190 C R C c a s e s i nc l udi ng 52,667 L a t i nos l i vi ng i n C a l i f or ni a a nd di a gnos e d dur i ng 1995-
2017 t a ki ng i nt o a c c ount s ubpopul a t i ons de f i ne d by c ount r y of or i gi n.
M e t hods
L a t i nos c a s e s w e r e de f i ne d a c c or di ng t o t he N or t h A m e r i c a n A s s oc i a t i on of C e nt r a l
C a nc e r R e gi s t r i e s ( N A A C C R ) H i s pa ni c I de nt i f i c a t i on A l gor i t hm ( N H I A ) , w hi c h w a s a l s o us e d
t o gr oup c a s e s by c ount r y of or i gi n: M e xi c o ( 12,922, 53.0% ) , C a r i bbe a n ( 1,048, 4.3% ) , C e nt r a l
A m e r i c a ( 2,525, 10.4% ) , S out h A m e r i c a ( 1,365, 5.6% ) , a nd ot he r or unknow n or i gi n ( 6.510,
26.7% ) . W e i nc l ude d 223,191 non- L a t i no w hi t e ( N L W ) a nd 25,332 non- L a t i no bl a c k ( N L B )
C R C c a s e s w e r e i nc l ude d f or c om pa r i s on pur pos e s . C a s e f r e que nc i e s , odds r a t i os ( O R ) f r om
l ogi s t i c r e gr e s s i on, a nd ha z a r d r a t i os ( H R ) f r om s ur vi va l a na l ys e s w e r e us e d t o i de nt i f y a ny
di s pa r i t i e s a m ong L a t i nos , N L B a nd N L W . A “ l og ( f ol l ow - up t i m e ) - l og ( - l og s ur vi va l ) ” pl ot a nd
K a pl a n- M e i e r c ur ve s w e r e us e d t o t e s t pr opor t i ona l ha z a r d a s s um pt i on.
R e s ul t s
D i f f e r e nc e s w e r e obs e r ve d f or a ge a t di a gnos i s , s oc i oe c onom i c s t a t us ( S E S ) , i ns ur a nc e s
s t a t us , m a r i t a l s t a t us , r e l i gi on, t um or l oc a t i on, s t a ge , m e t a s t a s i s , t r e a t m e nt s t a t us , t r e a t m e nt t ype ,
t i m e f r om di a gnos i s t o t r e a t m e nt , a nd t um or s i z e a m ong L a t i nos c om pa r e d t o N L W . T he
de t e r m i na nt s of C R C t um or l oc a t i on w e r e a ge a t di a gnos i s , S E S , m a r i t a l s t a t us ; i n a ddi t i on t o
vi
s oc i ode m ogr a phi c c ha r a c t e r i s t i c s , s t a ge , t um or s i z e , m e t a s t a s i s a nd t um or l oc a t i on w e r e
de t e r m i na nt s of C R C c a s e s w he t he r t o r e c e i ve t r e a t m e nt . S ur vi va l a na l ys e s s how e d t ha t N L B
w a s m or e l i ke l y t o di e f r om C R C c om pa r e d w i t h N L W w hi l e L a t i nos ha d s i m i l a r r i s k of de a t h
f r om C R C a s N L W .
C onc l us i ons
W e obs e r ve d t ha t N L B w e r e m or e l i ke l y t o di e f r om C R C t ha n N L W r e ga r dl e s s of s t a ge
a t di a gnos i s , w he r e a s F B L a t i nos w e r e m or e l i ke l y t o s ur vi ve f r om C R C t ha n N L W i n c ont r a s t t o
U S B L a t i nos w ho w e r e m or e l i ke l y t o di e of C R C t ha n N L W w he n di a gnos e d a t e a r l y s t a ge s , or
e qua l l y l i ke l y t o di e w he n di a gnos e d w i t h l a t e r s t a ge s . C ons i de r a t i on of na t i vi t y a m ong L a t i nos
a l l ow e d us t o unc ove r pos s i bl e di s pa r i t i e s be t w e e n U S B a nd F B L a t i nos . T he s e f i ndi ngs
hi ghl i ght t he i m por t a nt of c ons i de r i ng t he he t e r oge ne i t y i n s ur vi va l a m ong di f f e r e nc e r a c e / e t hni c
gr oups . S i nc e L a t i nos a r e t he l a r ge s t m i nor i t y gr oup i n t he U .S . a nd m or t a l i t y r a t e due t o c a nc e r
i s pr e t t y hi gh a m ong L a t i nos , f i gur i ng out t he r e l a t i ve c ova r i a t e s t o C R C s ur vi va l i s of gr e a t
s i gni f i c a nc e
1
1. I n t r od u c t i on
C ol or e c t a l c a nc e r ( C R C ) i s t he f our t h m os t c om m on c a nc e r i n t he U .S . a c c or di ng t o t he
N a t i ona l C a nc e r I ns t i t ut e ( N I H ) a nd t he e s t i m a t e d ne w c a s e s i n 2019 w i l l be 145,600, w hi c h
r e pr e s e nt s 8.3% of a l l ne w c a nc e r c a s e s i n t he U .S . A l t hough 64.4% of pe opl e w i l l s ur vi ve f r om
C R C 5 ye a r s or m or e a f t e r be i ng di a gnos e d, C R C i s s t i l l t he s e c ond l e a di ng c a us e of c a nc e r
de a t h i n t he U .S . [ 1] .
L a t i nos a r e t he l a r ge s t m i nor i t y gr oup i n t he U .S ., a nd U .S . C e ns us B ur e a u r e por t e d t ha t
t he r e w e r e 59.8 m i l l i on L a t i nos i n 2018 w hi c h a c c ount e d f or 18.3% of t he U .S . popul a t i on. T hi s
pr opor t i on i s e xpe c t e d t o gr ow t o 31% by 2060 [ 2] . M os t of t he L a t i nos r e s i de i n t he W e s t a nd
S out h of t he U .S . i n s t a t e s l i ke C a l i f or ni a , T e xa s , a nd F l or i da [ 3] . A m ong a l l s t a t e s , C a l i f or ni a i s
t he f our t h l a r ge s t L a t i no popul a t i on s t a t e w i t h a popul a t i on of 15.5 m i l l i on, w ho r e pr e s e nt 39.3%
of t he s t a t e popul a t i on a nd 25.9% of t he t ot a l U .S . L a t i no popul a t i on. A bout 65.3% of L a t i nos i n
C a l i f or ni a w e r e bor n i n t he U .S . A m ong L a t i nos i n C a l i f or ni a , 82.4% a r e f r om M e xi c o, 9.4% a r e
f r om C e nt r a l A m e r i c a , 2.4% a r e w i t h or i gi n f r om S out h A m e r i c a , 1.5% a r e f r om P ue r t o R i c o,
0.7% a r e f r om C uba , a nd 3.6% a r e of ot he r H i s pa ni c or L a t i no or i gi ns [ 4] .
A l t hough i nc i de nc e r a t e s a nd m or t a l i t y r a t e s of C R C a r e l ow e r i n L a t i nos t ha n t hos e i n
non- L a t i no w hi t e s ( N L W ) , c a nc e r s t i l l a c c ount s f or 21% of de a t hs a m ong L a t i nos [ 5] . A n
e s t i m a t e d 14,400 L a t i nos w e r e e xpe c t e d t o be di a gnos e d w i t h C R C i n 2018, w i t h C R C i nc i de nc e
r a t e s f or L a t i no m a l e s a nd f e m a l e s be i ng 7% a nd 16% l ow e r t ha n t hos e f or N L W m a l e s a nd
f e m a l e s , r e s pe c t i ve l y [ 3] . B a s e d on 2012- 2016 c a s e s , bot h i nc i de nc e r a t e s a nd de a t h r a t e s f or
C R C i n L a t i no m a l e s a r e hi ghe r t ha n t ha t i n L a t i no f e m a l e s . I nc i de nc e r a t e s w e r e 40.0 pe r
100,000 pe r s ons a nd 28.8 pe r 100,000 pe r s ons r e s pe c t i ve l y, w hi l e de a t h r a t e s w e r e 14.4 pe r
100,000 pe r s ons a nd 8.8 pe r 100,000 pe r s ons r e s pe c t i ve l y [ 1] .
2
I n t hi s s t udy, w e de s c r i be ke y s oc i ode m ogr a phi c , c l i ni c a l c ha r a c t e r i s t i c s , a nd s ur vi va l
pa t t e r ns of L a t i nos di a gnos e d w i t h C R C w hi l e l i vi ng i n C a l i f or ni a be t w e e n 1995 a nd 2017 a nd
c om pa r e d t he m t o t hos e obs e r ve d a m ong non- L a t i no B l a c ks ( N L B ) a nd non- L a t i no W hi t e s
( N L W ) . W e c ons i de r di f f e r e nc e s w i t hi n L a t i nos by na t i vi t y ( U S B or F B ) , a nd t a ke i nt o a c c ount
L a t i no s ubpopul a t i ons de f i ne d by c ount r y of or i gi n ( M e xi c a n, P ue r t o R i c a n, C uba n, C e nt r a l
A m e r i c a n, S out h A m e r i c a n a nd L a t i nos f r om ot he r H i s pa ni c or i gi ns ) .
2. M e t h od
2.1 C a s e i de nt i f i c a t i on
W e us e d da t a f r om t he C a l i f or ni a C a nc e r R e gi s t r y ( C C R ) w i t h C R C c a s e s di a gnos e d
a m ong C a l i f or ni a r e s i de nt s w ho w e r e a t l e a s t 18 ye a r s ol d, a nd w e r e di a gnos e d be t w e e n 1995
a nd 2017. P r i m a r y C R C c a s e s w e r e i de nt i f i e d by N a t i ona l C a nc e r I ns t i t ut e ( N C I ) S ur ve i l l a nc e ,
E pi de m i ol ogy, a nd E nd R e s ul t s P r ogr a m ( S E E R ) s i t e c ode s ( 21041- 21052) , a nd i nva s i ve c a nc e r
c a s e s w e r e i nc l ude d i n t hi s s t udy. L a t i no s ubpopul a t i ons w e r e de f i ne d by t he N A A C C R H i s pa ni c
I de nt i f i c a t i on A l gor i t hm ( N H I A ) , w hi c h i s a r e gi s t r y a l gor i t hm t ha t i de nt i f i e s a l l L a t i no pa t i e nt s
a nd c a n be us e d t o de t e r m i ne c ount r y of or i gi n. N H I A i s de r i ve d f r om a c om bi na t i on of
N A A C C R v a r i a b l e s t o c l a s s i f y c a s e s a s L a t i n o s o r n o n - L a t i n o s b a s e d o n S p a n i s h / H i s p a n i c o r i g i n ,
l a s t na m e , m a i de n na m e , bi r t hpl a c e , r a c e , s e x, a nd t he I ndi a n H e a l t h S e r vi c e s ( I H S ) l i nka ge . W e
a s s i gne d na t i vi t y a s U .S . bor n ( U S B ) a nd f or e i gn bor n ( F B ) ba s e d on bi r t hpl a c e i nf or m a t i on. F or
i ndi vi dua l s w i t h m i s s i ng bi r t hpl a c e ( 46.0% ) , w e us e d a n a l gor i t hm pr e vi ous l y r e por t e d [ 6] .
B r i e f l y, i ndi vi dua l s w i t h a ge a t S S N i s s ue of 25 or younge r w e r e c ons i de r e d U S B , w he r e a s t hos e
w i t h a ge a t S S N i s s ue ove r 25 w e r e c ons i de r e d F B . I ndi vi dua l s w ho di d not ha ve i nf or m a t i on on
e i t he r bi r t hpl a c e or S S N i s s ue d a ge w e r e c ons i de r e d a s m i s s i ng va l ue s ( 3.18 % ) . W e c om bi ne d
3
na t i vi t y, r a c e gr oup va r i a bl e , a nd L a t i no s ubpopul a t i ons t o c r e a t e t he f ol l ow i ng m ut ua l l y
e xc l us i ve gr oups : N L W , N L B , U S B L a t i nos , a nd F B L a t i nos . W e a l s o di d s uppl e m e nt a r y
a na l ys e s s ubdi vi di ng F B L a t i nos i n t he f ol l ow i ng m ut ua l l y e xc l us i ve gr oups : F B M e xi c a n, F B
C a r i bbe a n ( i nc l udi ng P ue r t o R i c a n a nd C uba n) , F B C e nt r a l A m e r i c a n, F B S out h A m e r i c a n, a nd
F B not ot he r w i s e s pe c i f i e d ( F B N O S ) t o i nc l ude L a t i nos w hos e bi r t hpl a c e w e r e m i s s i ng. T he
s e pa r a t i on of F B C e nt r a l A m e r i c a n a nd F B S out h A m e r i c a n w a s a c c or di ng t o t he A ppe ndi x D of
C a l i f or ni a C a nc e r R e por t i ng S ys t e m S t a nda r ds : V ol um e I a va i l a bl e a t C C R ’ s w e bs i t e . S ur vi va l
s t a t us ( a l i ve , de c e a s e d due t o C R C , de c e a s e d due t o ot he r c a us e s ) w e r e i de nt i f i e d ba s e d on t he
I nt e r na t i ona l C l a s s i f i c a t i on of D i s e a s e s , 9
t h
R e vi s i on a nd 10
t h
R e vi s i on ( I C D - 9 a nd I C D - 10) .
2.2 S t udy va r i a bl e s
I n a ddi t i on t o na t i vi t y a s de s c r i be d a bove , w e c ons i de r e d t he f ol l ow i ng s oc i o-
de m ogr a phi c va r i a bl e s : a ge a t di a gnos i s ( < 62, 62- 76, > 76, ba s e d on t e r t i l e s of s t udy c a s e s ) , S E S
( l ow , m i ddl e , hi gh) , i ns ur a nc e s t a t us ( not i ns ur e d, m a na ge d c a r e , M e di c a i d, M e di c a r e , ot he r ) ,
m a r i t a l s t a t u s ( s i n g l e , m a r r i e d , s e p a r a t e d / d i v o r c e d / w i d o w e d , u n k n o w n ) , r e l i g i o n ( R o m a n c a t h o l i c ,
N one / a gnos t i c / a t he i s t , C hr i s t i a n not c a t hol i c , J e w i s h, ot he r w e s t e r n, E a s t e r n, unknow n) .
W e a l s o c o n s i d e r e d t h e f o l l o w i n g c l i n i c a l c h a r a c t e r i s t i c s : t u m o r l o c a t i o n ( c o l o n v s r e c t u m ,
I C D - O - 3 c ode s f or c ol on a r e C 180- 189 a nd C 260, a nd I C D - O - 3 c ode s f or r e c t um a r e C 199 a nd
C 209) , c a nc e r s t a ge ba s e d on S t a ge S E E R ( s t a ge I - I V ) , s um m a r y s t a ge a t t he t i m e of di a gnos i s
( l oc a l i z e d, r e gi ona l , di s t a nt ) , t um or s i z e ( < 2 c m , 2- 5 c m , > 5 c m ) , s our c e us e d t o pr e pa r e c a s e s
( he a l t hc a r e f a c i l i t y, a ut ops y, de a t h c e r t i f i c a t e ) , a nd pr e s e nc e of l ym ph node s i nvol ve m e nt ( N 0
a nd N 1) , pr e s e nc e of m e t a s t a s i s ( M 0 a nd M 1) . S pe c i f i c a l l y, N 0 a nd N 1 f or l ym ph node s m e a n
ne ga t i ve a nd pos i t i ve l ym ph node s i nvol ve m e nt , a nd M 0 a nd M 1 i n m e t a s t a s i s r e f e r t o no
m e t a s t a s i s a nd m e t a s t a s i s [ 7] . W e a l s o c ons i de r e d t he f ol l ow i ng t r e a t m e nt va r i a bl e s t o c r e a t e a
4
c om pos i t e ove r a l l t r e a t m e nt s t a t us ( no t r e a t m e nt , ha d t r e a t m e nt , t r e a t m e nt r e c om m e nde d/ not
gi ve n/ r e f us e d) va r i a bl e : s ur ge r y, c he m ot he r a py, r a di a t i on, i m m unot he r a py, hor m one t he r a py,
t r a ns pl a nt a nd ot he r t he r a py. W e a l s o c r e a t e d a t r e a t m e nt t ype va r i a bl e ( none , r a di a t i on, s ur ge r y,
ot he r ) , a nd c ons i de r e d t i m e f r om di a gnos i s t o f i r s t l i ne of t r e a t m e nt ( no t r e a t m e nt , 0- 3 m ont hs , 3-
6 m ont hs , 6- 12 m ont hs , > 12 m ont hs ) .
2.3 S t a t i s t i c a l A na l ys e s
C om pa r i s on of c a s e f r e que nc i e s f or a l l of t he s oc i ode m ogr a phi c a nd c l i ni c a l va r i a bl e s
a c r os s L a t i nos , N L B , a nd w i t h N L W , a s w e l l a s c om pa r i s ons w i t hi n L a t i nos by na t i vi t y, w a s
done us i ng C hi - s qua r e t e s t s . W e c a l c ul a t e d f r e que nc i e s by r a c e ( N L W , N L B , U S B L a t i nos , a nd
F B L a t i nos ) , a nd us e d p- va l ue s t o t e s t a ny di f f e r e nc e s w i t hi n gr oups . O dds r a t i os ( O R ) f r om
l ogi s t i c r e gr e s s i on m ode l s w e r e us e d t o i de nt i f y de t e r m i na nt s of C R C t um or l oc a t i on, r e c e i pt of
t r e a t m e nt , a nd t i m e f r om di a gnos i s t o t r e a t m e nt . W e c ons i de r e d pot e nt i a l e f f e c t m odi f i e r s f or
r a c e i n e a c h pr e di c t i ve m ul t i va r i a t e m ode l . S t a t i s t i c a l l y s i gni f i c a nt va r i a bl e s a s s oc i a t e d w i t h
C R C c a s e s a t t he p- va l ue < 0.25 l e ve l i n uni va r i a t e a na l ys e s w e r e i nc l ude d i n m ul t i va r i a t e
l ogi s t i c r e gr e s s i on m ode l s . I f one or m or e t ha n one c a t e gor i e s s how e d non- s i gni f i c a nt i n a
va r i a bl e ( W a l d p- va l ue > 0.05) , W a l d t e s t s c oul d be us e d t o de t e r m i ne w he t he r t o ke e p ( p- va l ue
< 0.05) or t o e l i m i na t e ( p- va l ue > 0.05) t ha t . I n a ddi t i on, l i ke l i hood r a t i o t e s t s ( L R t e s t s ) w e r e
us e d t o c he c k i nt e r a c t i on t e r m s f or pr e di c t i ve m ul t i va r i a t e m ode l s , a nd s t a t i s t i c a l l y s i gni f i c a nt
i nt e r a c t i on t e r m s ( L R p- va l ue < 0.05) w e r e c ons i de r e d i n t he f i na l m ode l s . F or c ova r i a t e s
i nc l ude d i n m ul t i va r i a t e m ode l s , t he f i r s t c a t e gor y of e a c h w a s us e d a s a r e f e r e nc e .
W e c onduc t e d C R C - s pe c i f i c s ur vi va l a na l ys e s by f i t t i ng a m ul t i va r i a t e m ode l w i t h our
pr i m a r y va r i a bl e s of i nt e r e s t ( r a c e / e t hni c i t y/ na t i vi t y, gr oupe d a ge a t di a gnos i s , S E S , m a r i t a l
s t a t us , i ns ur a nc e s t a t us , c a nc e r s t a ge ba s e d on S t a ge S E E R , t r e a t m e nt s t a t us , t r e a t m e nt t ype , a nd
5
t i m e f r om di a gnos i s t o t r e a t m e nt ) t ha t s t a t i s t i c a l l y s i gni f i c a nt a s s oc i a t e d w i t h de a t h due t o C R C .
S i nc e a l l t he va r i a bl e s i n t hi s s t udy w e r e c a t e gor i c a l va r i a bl e s , w e t e s t e d t he pr opor t i ona l ha z a r d
a s s um pt i ons gr a phi c a l l y by pl ot t i ng l og f ol l ow - up t i m e a ga i ns t l og s ur vi va l ( “ l og- l og ” pl ot ) a nd
t he s ur vi va l c ur ve de r i ve d f r om t he C ox r e gr e s s i on m ode l ( t ha t i m pos e s a pr opor t i ona l ha z a r d
a s s um pt i on) a ga i ns t t he K a pl a n- M e i e r s ur vi va l c ur ve ( no s uc h a s s um pt i on) . A l l a na l ys e s i n t hi s
s t udy w e r e c om put e d us i ng S T A T A s of t w a r e , ve r s i on 15.1 ( S t a t a C or p L L C , T e xa s ) .
3. R e s u l t s
B e t w e e n 1995 a nd 2017, t he r e w e r e 301,190 C R C c a s e s di a gnos e d i n C a l i f or ni a a m ong
N L W ( 223,191) , N L B ( 25,332) , a nd L a t i nos ( 52,667) . A m ong t hos e i de nt i f i e d a s L a t i nos , 28,298
( 53.7% ) w e r e U S B L a t i nos a nd 24,369 ( 46.3% ) w e r e F B L a t i nos . A m ong a l l F B L a t i no c a s e s ,
12,922 ( 53.0% ) w e r e i de nt i f i e d t o be of M e xi c a n or i gi n, 1,048 ( 4.3% ) w e r e f r om C a r i bbe a n
2,524 ( 10.4% ) w e r e f r om C e nt r a l A m e r i c a , 1,365 ( 5.6% ) w e r e f r om S out h A m e r i c a , a nd 6,510
( 26.7% ) w e r e of ot he r or unknow n c ount r y of or i gi n.
3.1 S oc i ode m ogr a phi c c ha r a c t e r i s t i c s of C R C c a s e s i n C a l i f or ni a
T a bl e 1 s um m a r i z e s t he ke y de m ogr a phi c c ha r a c t e r i s t i c s f or a l l C R C c a s e s of N L W ,
N L B , a nd L a t i nos by na t i vi t y f r om 1995 t o 2017. N L W w a s c ons i de r e d a s t he c om pa r i s on gr oup
i n t hi s s t udy. S t a t i s t i c a l l y s i gni f i c a nt di f f e r e nc e s i n f r e que nc i e s w e r e obs e r ve d f or t he gr oupe d
a ge a t di a gnos i s , S E S , i ns ur a nc e s t a t us , m a r i t a l s t a t us , a nd r e l i gi on w i t h r a c e ( p- va l ue s < 0.001) .
W e obs e r ve d a gr e a t e r pr opor t i on of di a gnos e s be f or e a ge 62 a m ong U S B L a t i nos ( 43.52% ) a nd
F B L a t i nos ( 41.87% ) c om pa r e d t o N L B c a s e s ( 37.09% ) a nd N L W ( 26.00% ) . M or e t ha n ha l f of
N L B ( 56.03% ) , U S B L a t i nos ( 52.27% ) , a nd F B L a t i no ( 62.96% ) pa t i e nt s ha d l ow S E S , w he r e a s
t he m a j or i t y of N L W pa t i e nt s w e r e of hi gh S E S ( 50.54% ) ( p< 0.001) .
6
A c r os s a l l of t he de m ogr a phi c c ha r a c t e r i s t i c s i n T a bl e 1, N L B , U S B L a t i nos , a nd F B
L a t i nos ha d s t a t i s t i c a l l y s i gni f i c a nt di f f e r e nc e s c om pa r e d t o N L W ( p- va l ue s < 0.001) , a nd
s t a t i s t i c a l l y s i gni f i c a nt di f f e r e nc e s w e r e a l s o obs e r ve d be t w e e n U S B L a t i nos a nd F B L a t i nos ( p-
va l ue s < 0.001) .
7
8
9
A m ong F B L a t i nos , c a s e s f r om C a r i bbe a n ( 40.65% ) , S out h A m e r i c a ( 40.88% ) , a nd N O S
( 3 6 . 5 9 % ) h a d h i g h e r p r o p o r t i o n o f d i a g n o s i s a t t h e a g e 6 2 - 7 6 , w h i l e t h o s e f r o m M e x i c o ( 4 8 . 0 0 % )
a nd C e nt r a l A m e r i c a ( 51.47% ) ha d hi ghe r pr opor t i on be i ng di a gnos e d be f or e 62 ye a r s ol d. M os t
of F B L a t i nos w e r e of l ow S E S , e xc e pt t he c a s e s f r om S out h A m e r i c a ( 46.08% i n hi gh S E S )
( p< 0.001) . S t a t i s t i c a l l y s i gni f i c a nt di f f e r e nc e s w e r e obs e r ve d a c r os s c ount r i e s of or i gi n f or F B
L a t i nos . O ve r 60% of F B M e xi c a n, F B C e nt r a l A m e r i c a n a nd F B N O S w e r e i n l ow S E S ,
w he r e a s onl y 46.47% of F B C a r i bbe a n w e r e i n l ow S E S a nd t he m a j or i t y of F B S out h A m e r i c a n
( 46.08% ) w e r e i n hi gh S E S . S t a t i s t i c a l l y s i gni f i c a nt hi ghe r pr opor t i on of C R C c a s e s w i t h
M e di c a r e , M a na ge d c a r e , a nd M e di c a i d w e r e obs e r ve d i n F B C a r i bbe a n ( 49.05% ) , F B S out h
A m e r i c a n ( 40.44% ) , a nd F B C e nt r a l A m e r i c a n ( 21.99% ) , r e s pe c t i ve l y; a nd F B C e nt r a l A m e r i c a n
( 6.70% ) ha d a s i gni f i c a nt hi ghe s t pr opor t i on of not i ns ur e d c a s e s t ha n t he F B L a t i nos f r om t he
ot he r or i gi ns ( p- va l ue < 0.001) . M a r r i e d C R C c a s e s ( 60.22% ) t ook t he l a r ge s t pa r t of F B
M e xi c a n, w hi l e a ppr oxi m a t e one t hi r d of F B C e nt r a l A m e r i c a n w e r e s i ngl e a nd F B C a r i bbe a n
w e r e s e pa r a t e d/ di vor c e d/ w i dow e d.
T he m a j or i t y of F B C a r i bbe a n ( 29.30% ) a nd F B N O S ( 28.56% ) ha d c a nc e r on S t a ge I I ,
w hi l e t ha t f or F B M e xi c a n ( 28.65% ) , F B C e nt r a l A m e r i c a n ( 29.04% ) a nd F B S out h A m e r i c a n
( 30.59% ) w e r e on S t a ge I I I ( T a bl e 2) . M or e F B M e xi c a n ( 86.61% ) , F B C a r i bbe a n ( 86.59% ) a nd
F B N O S ( 90.29% ) ha d ne ga t i ve l ym ph node s t ha n F B C e nt r a l A m e r i c a n ( 84.23% ) a nd F B S out h
A m e r i c a n ( 83.52% ) . O ve r 70% of F B C a r i bbe a n a nd F B S out h A m e r i c a n ha d t um or i n c ol on a nd
m or e F B C a r i bbe a n ( 83.78% ) ha d m e t a s t a s i s t ha n F B M e xi c a n ( 78.51% ) . A s l i ght l y s i gni f i c a nt
hi ghe r pe r c e nt of F B S out h A m e r i c a n ( 93.28% ) w ho ha d t r e a t m e nt w e r e obs e r ve d ( p- va l ue <
0.001) ; a nd a m ong t he t r e a t e d F B S out h A m e r i c a n C R C c a s e s , m or e t ha n ha l f of t he m ha d 2- 5
c m t um or a nd c hos e t o t a ke s ur ge r y. A t l e a s t 80 % of F B L a t i nos de t e r m i ne d t o r e c e i ve t r e a t m e nt
10
w i t hi n 3 m ont hs f r om di a gnos i s , s t a t i s t i c a l l y s i gni f i c a nt di f f e r e nc e s w e r e i ndi c a t e d a m ong t hos e
f r om di f f e r e nt or i gi ns ( p- va l ue < 0.001) .
11
12
13
14
3.2 C l i ni c a l c ha r a c t e r i s t i c s of C R C c a s e s i n C a l i f or ni a
I n T a bl e 3 w e s um m a r i z e c l i ni c a l c ha r a c t e r i s t i c s f or a l l c a s e s . W e obs e r ve d s t a t i s t i c a l l y
s i gni f i c a nt di f f e r e nc e s by r a c e / e t hni c i t y a nd na t i vi t y f or a l l va r i a bl e s c ons i de r e d ( p- va l ue s <
0.001) . O ve r a l l , a bout 90% of C R C c a s e s ha d t r e a t m e nt a nd a t l e a s t 80% of t he m r e c e i ve d
t r e a t m e nt w i t hi n 3 m ont hs a f t e r di a gnos e d. D i f f e r e nc e s w e r e obs e r ve d i n t um or l oc a t i on
di s t r i but i on, w i t h N L B s how i ng a s l i ght l y hi ghe r pr opor t i on of c ol on t ha n N L W ( 75.94% i n N L B
vs . 71.68% i n N L W , p- va l ue < 0.001) w hi l e U S B L a t i nos a nd F B L a t i nos s how i ng a l ow e r
pr opor t i on of c ol on t ha n N L W ( 67.02% i n U S B L a t i nos a nd 65.82% i n F B L a t i nos , r e s pe c t i ve l y,
p- va l ue s < 0.001) . M or e N L B ( 25.61% ) ha d c a nc e r on s t a ge I V t ha n N L W ( 19.70% ) a nd m os t
of N L W w e r e on s t a ge I I ( 28.55% ) , how e ve r , t he m a j or i t y of L a t i nos w e r e on s t a ge I I I ( 27.25%
i n U S B L a t i nos a nd 27.86% i n F B L a t i nos ) . W e obs e r ve d t ha t N L W ( 82.42% ) s how e d a s l i ght l y
s i gni f i c a nt hi ghe r pr opor t i on of m e t a s t a s i s t ha n N L B ( 78.83% ) , U S B L a t i nos ( 81.53% ) a nd F B
L a t i nos ( 80.30% ) . U S B L a t i nos s how e d a hi ghe r pr opor t i on of r e c e i vi ng t r e a t m e nt c om pa r e d
w i t h F B L a t i nos ( 91.99% i n U S B L a t i nos vs . 90.07% i n F B L a t i nos , p- va l ue < 0.001) . N L B
( 33.26% ) , U S B L a t i nos ( 33.56% ) , a nd F B L a t i nos ( 36.84% ) s how e d hi ghe r pr opor t i on of l a r ge
t um or s ( > 5 c m ) t ha n N L W ( 31.38% ) , p- va l ue s < 0.001) .
H ow e ve r , w he n c om pa r i ng U S B a nd F B L a t i nos t o N L W , no s t a t i s t i c a l l y s i gni f i c a nt
di f f e r e nc e s w e r e obs e r ve d i n l ym ph node s ( p- va l ue = 0.440, p- va l ue = 0.213, r e s pe c t i ve l y) .
T he r e w e r e not a ny s t a t i s t i c a l l y s i gni f i c a nt di s pa r i t i e s be t w e e n U S B L a t i nos a nd F B L a t i nos i n
l ym ph node s ( p- va l ue = 0.686) a nd s our c e us e d t o pr e pa r e c a s e s ( p- va l ue = 0.663) , e i t he r .
15
16
17
18
3.3 D e t e r m i na nt s of t um or l oc a t i on a m ong C R C c a s e s
W e c ons i de r e d ke y s oc i ode m ogr a phi c a nd c l i ni c a l va r i a bl e s t o i de nt i f y de t e r m i na nt s of
t um or l oc a t i on us i ng m ul t i va r i a bl e m ode l s ( T a bl e 4) . S t a t i s t i c a l l y s i gni f i c a nt a s s oc i a t i ons w e r e
obs e r ve d be t w e e n t um or l oc a t i on a nd t he f ol l ow i ng de t e r m i na nt s : r a c e / e t hni c i t y/ na t i vi t y, a ge a t
di a gnos i s , S E S , i ns ur a nc e s t a t us , m a r i t a l s t a t us , a nd r e l i gi on ( p- va l ue s < 0.0001) . C om pa r e d t o
N L W , N L B w e r e 20% l e s s l i ke l y t o ha ve t um or i n r e c t um ( O R = 0.80, 95% C I = 0.78- 0.83) ,
w hi l e U S B L a t i nos w e r e 25% ( O R = 1.25, 95% C I = 1.21- 1.28) a nd F B L a t i nos w e r e 31% ( O R
= 1.31, 95% C I = 1.28- 1.35) m or e l i ke l y t o ha ve t um or i n r e c t um . C R C c a s e s di a gnos e d a f t e r 62
ye a r s ol d w i t h m i ddl e or hi gh S E S w e r e l e s s l i ke l y t o ha ve t um or i n r e c t um t ha n c ol on c om pa r e d
t o c a s e s di a gnos e d a t t he a ge younge r t ha n 62 w i t h l ow S E S . I n a ddi t i on, C R C c a s e s w i t h
M e di c a i d w e r e 1.18 t i m e s a s l i ke l y t o ha ve r e c t um c a nc e r t ha n c ol on c a nc e r c om pa r e d t o pe opl e
w ho w e r e not i ns ur e d ( O R = 1.180, 95% C I = 1.10- 1.27) , w hi l e c a s e s w i t h ot he r i ns ur a nc e s t a t us
w e r e m or e l i ke l y t o ha ve c ol on c a nc e r t ha n r e c t um c a nc e r . M a r r i e d ( O R = 0.91, 95% C I = 0.89-
0.94) or s e pa r a t e d/ di vor c e d/ w i dow e d C R C c a s e s ( O R = 0.72, 95% C I = 0.70- 0.73) w e r e a bout 9-
28% l e s s l i ke l y t o ha ve t um or i n r e c t um c om pa r e d t o s i ngl e c a s e s ; how e ve r , t hos e w i t h unknow n
m a r i t a l s t a t us w e r e 1.11 t i m e s a s l i ke l y t o ha ve r e c t a l t um or a s s i ngl e pa t i e nt s ( 95% C I = 1.07-
1.16) .
W e obs e r ve d t ha t t he a s s oc i a t i on be t w e e n r a c e / e t hni c i t y a nd t um or l oc a t i on w a s m odi f i e d
by a ge a t di a gnos i s ( L R p- va l ue < 0.0001, T a bl e 5) . S pe c i f i c a l l y, w e obs e r ve d t ha t a m ong t hos e
di a gnos e d a t a ge 62 or younge r , U S B L a t i nos di d not di f f e r f r om N L W i n t he r i s k of ha vi ng
r e c t a l t um or s ; how e ve r , f or c a s e s di a gnos e d a bove 62 ye a r s ol d, U S B L a t i nos ha d a s l i ght
i nc r e a s e ( 13% - 22% ) i n t he r i s k of r e c t a l t um or s . F or N L B a nd F B L a t i nos , r i s k of r e c t a l t um or s
19
di f f e r s s l i ght l y by a ge , but w a s s i gni f i c a nt l y l ow e r t ha n N L W a m ong N L B a nd s i gni f i c a nt l y
hi ghe r t ha n N L W f or F B L a t i nos t hr oughout a ge gr oups .
20
21
22
23
3.4 D e t e r m i na nt s of r e c e i pt of t r e a t m e nt a m ong C R C c a s e s
T he r e w e r e s t a t i s t i c a l l y s i gni f i c a nt a s s oc i a t i on be t w e e n r e c e i pt of t r e a t m e nt a nd ke y
s oc i ode m ogr a phi c a nd c l i ni c a l va r i a bl e s , a s s um m a r i z e d i n T a bl e 6 ( p- va l ue s < 0.0001) .
S pe c i f i c a l l y, c om pa r e d t o N L W , N L B w e r e 0.74 t i m e s ( 95% C I = 0.71- 0.77) a nd F B L a t i nos
w e r e 0.91 t i m e s ( 95% C I = 0.87- 0.95) a s l i ke l y t o r e c e i ve t r e a t m e nt , w he r e a s U S B L a t i nos w e r e
15% ( O R = 1.15, 95% C I = 1.10- 1.20) m or e l i ke l y t o r e c e i ve t r e a t m e nt . W e c ons i de r e d pos s i bl e
c onf ounde r s of t he a s s oc i a t i ons of t r e a t m e nt r e c e i pt a nd r a c e / e t hni c i t y a nd our m ul t i va r i a bl e
m ode l ( T a bl e 6) s how e d t ha t ove r a l l pa t i e nt s ha d hi ghe r r i s k of r e c e i vi ng t r e a t m e nt i f t he y w e r e
younge r t ha n 62, w i t h i nc r e a s i ng S E S , w e r e m a r r i e d, ha d i ns ur a nc e , w i t h i nc r e a s i ng non-
m e t a s t a t i c s t a ge , a nd pr e s e nc e of pos i t i ve l ym ph node s . I ns t e a d, pa t i e nt s w i t h m e t a s t a s e s or
r e c t a l t um or l oc a t i on w e r e l e s s l i ke l y t o r e c e i ve t r e a t m e nt .
24
25
26
27
A m o n g C R C c a s e s w h o d i d n o t r e c e i v e t r e a t m e n t , U S B L a t i n o s ( 3 5 . 8 4 % , p - v a l u e < 0 . 0 0 1 )
a nd F B L a t i nos ( 35.41% , p- va l ue < 0.001) ha d s t a t i s t i c a l l y s i gni f i c a nt hi ghe r pr opor t i ons of
r e c t a l t um or t ha n N L W ( 29.03% ) , w hi l e C R C t um or l oc a t i on f or N L B ha d a s i gni f i c a nt hi ghe r
pr opor t i on i n c ol on ( 73.60% i n N L B vs . 70.97% i n N L W , p- va l ue = 0.004) c om pa r e d t o N L W .
N L B ( 73.62% ) a nd F B L a t i nos ( 72.74% ) ha d m or e c a s e s on s t a ge I V t ha n N L W ( 79.53% )
c ons i de r i ng non- t r e a t m e nt c a s e s ( p- va l ue = 0.005 f or N L B vs . N L W ; p- va l ue = 0.010 f or F B
L a t i nos vs . N L W ) , w hi l e no s i gni f i c a nt di f f e r e nc e s w e r e s how n be t w e e n U S B L a t i nos a nd N L W
( p- va l ue = 0.959) . T he r e w e r e not a ny s t a t i s t i c a l l y s i gni f i c a nt di f f e r e nc e s f or N L B ( p- va l ue =
0.246) , U S B L a t i nos ( p- va l ue = 0.210) , F B L a t i nos ( p- va l ue = 0.211) w i t h N L W i n l ym ph node s .
A s f or t um or s i z e , s i gni f i c a nt di f f e r e nc e s w e r e obs e r ve d f or U S B L a t i nos a nd F B L a t i nos
c om pa r e d t o N L W ( p- va l ue < 0.001 f or U S B L a t i nos vs . N L W ; p- va l ue = 0.001 f or F B L a t i nos
vs . N L W ) , w hi c h i s t ha t l e s s U S B L a t i nos ( 44.29% ) a nd F B L a t i nos ( 44.84% ) ha d 2- 5 c m t um or s
t ha n N L W ( 50.60% ) ( T a bl e 7) .
N o s t a t i s t i c a l l y s i gni f i c a nt di f f e r e nc e s w e r e obs e r ve d be t w e e n U S B L a t i nos a nd F B
L a t i nos i n t um or l oc a t i on ( p- va l ue = 0.763) , c a nc e r s t a ge ( p- va l ue = 0.117) , l ym ph node s ( p-
va l ue = 0.060) , m e t a s t a s i s ( p- va l ue = 0.445) , a nd t um or s i z e ( p- va l ue = 0.508) ( T a bl e 7) .
28
29
30
31
3.5 D e t e r m i na nt s of t i m e t o t r e a t m e nt r e c e i pt
W e e xa m i ne d de t e r m i na nt s of r e c e i pt of f i r s t l i ne of t r e a t m e nt w i t hi n 3 m ont hs a f t e r C R C
di a gnos i s , a nd obs e r ve d t ha t N L B ( O R = 1.53, 95% C I = 1.43- 1.62) , U S B L a t i nos ( O R = 1.43,
95% C I = 1.35- 1.51) a nd F B L a t i nos ( O R = 1.97, 95% C I = 1.86- 2.08) w e r e m or e l i ke l y t o
r e c e i ve f i r s t l i ne of t r e a t m e nt a f t e r 3 m ont hs s i nc e di a gnos i s c om pa r e d t o N L W . C a s e s di a gnos e d
a f t e r 62 ye a r s ol d or w i t h m i ddl e a nd hi gh S E S w e r e m or e l i ke l y t o r e c e i ve t r e a t m e nt w i t hi n 3
m ont hs c om pa r e d t o t hos e di a gnos e d be f or e 62 ye a r s of a ge or w i t h l ow S E S ( T a bl e 8) .
C om pa r e d t o s i ngl e c a s e s , C R C c a s e s w i t h ot he r m a r i t a l s t a t us w e r e l e s s l i ke l y t o ha ve t r e a t m e nt
ove r 3 m ont hs a f t e r di a gnos e d.
T he a s s oc i a t i on be t w e e n r a c e / e t hni c i t y a nd t i m e t o r e c e i pt of t r e a t m e nt w a s m odi f i e d by
i ns ur a nc e ( L R p- va l ue < 0.0001) . S pe c i f i c a l l y, w e obs e r ve d t ha t a m ong t hos e w ho w e r e not
i ns ur e d, no s i gni f i c a nt di f f e r e nc e s a m ong N L B , U S B L a t i nos , F B L a t i nos c om pa r e d w i t h N L W
i n r e c e i pt of f i r s t l i ne of t r e a t m e nt w i t hi n 3 m ont hs or a f t e r 3 m ont hs s i nc e C R C di a gnos i s ( p-
va l ue > 0.05) ; how e ve r , f or c a s e s w i t h m a na ge d c a r e a nd M e di c a r e , N L B , U S B L a t i nos a nd F B
L a t i nos w e r e m or e l i ke l y t o ha d t r e a t m e nt w i t hi n 3 m ont hs c om pa r e d t o N L W ( T a bl e 9) . F or
c a s e s w i t h M e di c a i d a nd unknow n i ns ur a nc e s t a t us , onl y F B L a t i nos s how e d s i gni f i c a nt hi ghe r
pos s i bi l i t y t o r e c e i ve t r e a t m e nt w i t hi n 3 m ont hs c om pa r e d t o N L W .
32
33
34
3.6 S ur vi va l a na l ys i s
R e s ul t s f r om uni va r i a t e a na l ys e s ( T a bl e 10) s how e d t ha t a m ong C R C c a s e s , t hos e ove r 62
ye a r s ol d w e r e m or e l i ke l y t o di e due t o C R C ove r f ol l ow - up, a nd N L B pa t i e nt s w e r e ~ 20% t o
di e of C R C t ha n N L W ( H R = 1.21; 95% C I = 1.18- 1.24, W a l d p- va l ue < 0.001) . C R C c a s e s of
m i ddl e S E S w e r e 8% l e s s l i ke l y t o di e of C R C c om pa r e d t o l ow S E S pa t i e nt s ( H R = 0.92, 95%
C I = 0.90- 0.94, W a l d p- va l ue < 0.001) a nd t hos e of hi gh S E S 17% l e s s l i ke l y ( H R = 0.83, 95%
C I = 0.81- 0.84, W a l d p- va l ue < 0.001) ( L R p- va l ue < 0.0001) . C om pa r e d t o C R C c a s e s w ho
w e r e not i ns ur e d, c a s e s i ns ur e d w i t h m a na ge d c a r e ( H R = 0.65, 95% C I = 0.62- 0.69, W a l d p-
va l ue < 0.001) , M e di c a r e ( H R = 0.85, 95% C I = 0.80- 0.89, W a l d p- va l ue < 0.001) , a nd ot he r
i ns ur a nc e t ype s ( H R = 0.75, 95% C I = 0.71- 0.80, W a l d p- va l ue < 0.001) w e r e l e s s l i ke l y t o di e
due t o C R C , w he r e a s t hos e w i t h M e di c a i d ( H R = 1.09, 95% C I = 1.02- 1.15, W a l d p- va l ue =
0.005) a nd unknow n i ns ur a nc e s t a t us ( H R = 1.10, 95% C I = 1.04- 1.16, W a l d p- va l ue = 0.002)
w e r e m or e l i ke l y t o di e f r om C R C . M a r r i e d pa t i e nt s w e r e l e s s l i ke l y t o di e of C R C c om pa r e d t o
s i ngl e c a s e s w a s ( H R = 0.78; 95% C I = 0.76- 0.79, W a l d p- va l ue < 0.001) .
A ddi t i ona l de t e r m i na nt s of r i s k of C R C de a t h i nc l ude d s t a ge , w i t h i nc r e a s e d r i s k w i t h
i nc r e a s e d s t a ge , ( s t a ge I I H R = 2.00; 95% C I = 1.95- 2.07, W a l d p- va l ue < 0.001; s t a ge I I I H R =
3.94; 95% C I = 3.83- 4.06, W a l d p- va l ue < 0.001; s t a ge I V H R = 19.62; 95% C I = 19.09- 20.16,
W a l d p - v a l u e < 0 . 0 0 1 ) , r e c e i p t o f t r e a t m e n t v e r s u s n o t r e a t m e n t ( H R = 0 . 2 2 ; 9 5 % C I = 0 . 2 2 - 0 . 2 3 ,
W a l d p- va l ue < 0.001) , a nd r e c e i pt of t r e a t m e nt w i t hi n 3 m ont hs ( H R = 1.85; 95% C I = 1.80-
1.91) .
T o c om pr e he ns i ve l y e xa m i ne t he r ol e of r a c e / e t hni c i t y on C R C s ur vi va l w e c ons i de r e d
t he r ol e of s t a ge a s a pos s i bl e e f f e c t m odi f i e r , a nd c ons i de r e d t he a bove - m e nt i one d va r i a bl e s a s
pos s i bl e c onf ounde r s . T he va r i a bl e s i n t he s ur vi va l m ode l s w e r e a l l c a t e gor i c a l , s o a “ l og
35
( f ol l ow - up t i m e ) - l og ( - l og s ur vi va l ) ” pl ot , t he obs e r ve d K a pl a n- M e i e r c ur ve s , a nd t he pr e di c t e d
s ur vi va l c ur ve s f r om C ox r e gr e s s i on w e r e us e d t o t e s t t he pr opor t i ona l ha z a r d a s s um pt i on. G i ve n
t ha t t he l i ne s f or s t a ge w e r e r oughl y pa r a l l e l i n “ l og ( f ol l ow - up t i m e ) - l og ( - l og s ur vi va l ) ” pl ot
( F i gur e 1a ) a nd t he obs e r ve d K a pl a n- M e i e r c ur ve s a nd t he e s t i m a t e d c ur ve s f r om C ox r e gr e s s i on
w e r e r oughl y ove r l a ppi ng ( F i gur e 1b) , w e c onc l ude d t ha t t he pr opor t i ona l ha z a r d a s s um pt i on
hol ds f or t he s ur vi va l m ode l s t r a t i f i e d by s t a ge .
a b
F i g u r e 1 . G r a p h s f o r p r o p o r t i o n a l h a z a r d a s s u m p t i o n t e s t
I n m ul t i va r i a bl e a na l ys e s , w e obs e r ve d t ha t c om pa r e d t o N L W , U S B L a t i nos w e r e 1.06
( 95% C I = 1.01- 1.12, W a l d p- va l ue = 0.026) t i m e s m or e l i ke l y t o di e f r om C R C w he n di a gnos e d
w i t h s t a ge I or I I , w he r e a s U S B L a t i nos di a gnos e d w i t h s t a ge I I I or I V ha d no s t a t i s t i c a l l y
s i gni f i c a nt di f f e r e nc e c om pa r e d t o N L W ( W a l d p- va l ue = 0.414) . I n c ont r a s t , F B L a t i nos w e r e
l e s s l i ke l y t o di e of C R C c om pa r e d t o N L W , r e ga r dl e s s of s t a ge ( H R = 0.92, 95% C I = 0.87- 0.98
f or s t a ge I or I I ; H R = 0.85, 95% C I = 0.82- 0.88 i n s t a ge I I I or I V ) ; a nd N L B w e r e m or e l i ke l y t o
di e of C R C c om pa r e d t o N L W r e ga r dl e s s of s t a ge , a l t hough t he y ha d a gr e a t e r r i s k w he n
di a gnos e d w i t h s t a ge I or I I . R e c e i pt of t r e a t m e nt s i gni f i c a nt l y de c r e a s e d t he r i s k of dyi ng onl y
a m ong pa t i e nt s di a gnos e d w i t h s t a ge s I I I or I V , a m ong t hos e di a gnos e d w i t h s t a ge I or I I t he r i s k
36
of dyi ng w a s not s t a t i s t i c a l l y s i gni f i c a nt di f f e r e nt by t r e a t m e nt s t a t us ( T a bl e 11) . C om pa r e d t o
C R C c a s e s w ho ha d no t r e a t m e nt , s ur ge r y, c he m ot he r a py, t r a ns pl a nt t he r a py a nd hor m one
t he r a py w e r e m or e e f f e c t i ve f or pe opl e on s t a ge I or I I w hi l e c om bi na t i on t he r a py, a nd
i m m unot he r a py w e r e m or e e f f e c t i ve f or pe opl e on s t a ge I I I or I V ; a nd C R C c a s e s r e ga r dl e s s of
s t a ge w e r e l e s s l i ke l y t o di e f r om C R C i f t he y r e c e i ve d t r e a t m e nt no m a t t e r how s oon s i nc e t he y
w e r e di a gnos e d c om pa r e d t o t hos e w ho di d not ha ve t r e a t m e nt ( T a bl e 11) .
37
38
39
40
41
42
4. D i s c u s s i on
I n t hi s s t udy, w e r e por t di s pa r i t i e s r e ga r di ng s oc i ode m ogr a phi c , c l i ni c a l c ha r a c t e r i s t i c s
a nd s ur vi va l w he n c ons i de r i ng di f f e r e nt r a c i a l / e t hni c gr oups a nd w he n c ons i de r i ng na t i vi t y
w i t hi n L a t i nos . S pe c i f i c a l l y, w e obs e r ve d t ha t N L B w e r e m or e l i ke l y t o di e f r om C R C t ha n
N L W r e ga r dl e s s of s t a ge a t di a gnos i s , w he r e a s F B L a t i nos w e r e m or e l i ke l y t o s ur vi ve f r om
C R C t ha n N L W i n c ont r a s t t o U S B L a t i nos w ho w e r e m or e l i ke l y t o di e of C R C t ha n N L W
w h e n d i a g n o s e d a t e a r l y s t a g e s , o r e q u a l l y l i k e l y t o d i e w h e n d i a g n o s e d w i t h l a t e r s t a g e s . O v e r a l l ,
c a s e s w i t h ot he r i ns ur a nc e ot he r t ha n M e di c a i d w e r e m or e l i ke l y t o s ur vi ve f r om C R C t ha n
uni ns ur e d c a s e s ; how e ve r , c a s e s i ns ur e d w i t h M e di c a i d w e r e l e s s l i ke l y t o s ur vi ve t ha n uni ns ur e d
c a s e s . I n a ddi t i on, L a t i nos ha d m or e r e c t a l c a nc e r t ha n N L W , a nd ove r a l l , c a s e s w i t h r e c t a l
c a nc e r w e r e l e s s l i ke l y t o s ur vi ve f r om C R C t ha n t hos e w i t h c ol on c a nc e r .
I n a gr e e m e nt w i t h our f i ndi ngs , s om e pr e vi ous s t udi e s s how e d t ha t N L W ha d hi ghe r
s ur vi va l r a t e t ha n ot he r r a c i a l / e t hni c gr oups , a nd t he r i s k of de a t h f or L a t i nos w a s s i m i l a r t o t ha t
f or N L W [ 8, 9, 10] , a nd di s pa r i t i e s i n C R C m or t a l i t y w e r e f ound i n s t udi e s c onduc t e d us i ng
S E E R da t a s how i ng t ha t L a t i nos ha d up t o 20% hi ghe r m or t a l i t y t ha n N L W [ 11] . I m por t a nt l y,
w he n di s a ggr e ga t i ng L a t i nos by na t i vi t y a nd ge nde r , di s pa r i t i e s a r e e ve n w i de r , w i t h U S B L a t i no
m e n ha vi ng up t o 30% hi ghe r m or t a l i t y t ha n N L W . M or e ove r , di s pa r i t i e s ha ve be e n a l s o
r e por t e d w i t hi n L a t i no s ubpopul a t i ons , w i t h P ue r t o R i c a n a nd C uba n ha vi ng hi ghe r m or t a l i t y
t ha n M e xi c a ns [ 12] . U S B L a t i nos w e r e f ound t o ha ve l ow e r s ur vi va l t ha n F B L a t i nos i n t he
s t udi e s by T a o e t al . [ 13] .
H ow e ve r , unl i ke our s t udy, ot he r s t udi e s di d not c ons i de r na t i vi t y, w hi c h m a y c l oud
pos s i bl e di f f e r e nc e s be t w e e n U S B a nd F B L a t i nos . A s t udy w hi c h ha d s i x r a c i a l / e t hni c gr oups
( N L W , N L B , L a t i nos , A m e r i c a n I ndi a n/ A l a s ka N a t i ve , F i l i pi no, a nd ot he r A s i a n/ P a c i f i c
43
I s l a nde r s ) i nc l ude d w i t hout c ons i de r i ng na t i vi t y by C a l l a ha n e t al . a l s o r e por t e d t ha t pa t i e nt s
w i t h s t a ge I V ha d a 14 t i m e s hi ghe r r i s k of de a t h t ha n t hos e w i t h s t a ge I [ 14] . L a t i nos w i t hout
m e nt i oni ng na t i vi t y on s t a ge I a nd I I w i t h M e di c a i d w e r e r e por t e d t o ha ve l ow e r s ur vi va l t ha n
uni ns ur e d pa t i e nt s a nd pa t i e nt s w i t h ot he r i ns ur a nc e , a nd s i m i l a r l y t o our f i ndi ng f or U S B
L a t i nos , t hos e w i t h s t a ge I V C R C ha d s i m i l a r s ur vi va l r a t e a s N L W [ 15] . L e e t al . r e por t e d t ha t
N L B a nd L a t i nos w e r e m or e l i ke l y t o ha ve c ol on c a nc e r c om pa r e d w i t h N L W , w i t h L a t i nos
ha vi ng a s l i ght l y hi ghe r s ur vi va l r a t e t ha n N L W w i t h c ol on c a nc e r [ 16] .
I n a ddi t i on, s i ngl e - c e nt e r s t udi e s a c r os s t he U S ha ve r e por t e d t ha t i n s pi t e of r e c e i vi ng
s i m i l a r t r e a t m e nt s , L a t i nos ha ve w or s e s ur vi va l t ha n N L W [ 17, 18, 19] . T hus , t he obs e r ve d
di f f e r e nc e s a r e unl i ke l y t o be e xpl a i ne d by s oc i o- de m ogr a phi c s , a c c e s s t o c a r e , a nd qua l i t y of
c a r e , a nd s ugge s t t ha t bi ol ogi c a l de t e r m i na nt s m i ght pl a y a r e l e va nt r ol e .
S t r e ngt hs of our s t udy i nc l ude t he us e of da t a f r om t he C C R , w hi c h i s a l a r ge da t a s e t t ha t
c ont a i ns ove r 0.3 m i l l i on c a s e s , l e ndi ng s t r e ngt h t o our f i ndi ngs . A f ur t he r s t r e ngt h i s
c ons i de r a t i on of na t i vi t y a m ong L a t i nos w hi c h a l l ow e d us t o unc ove r pos s i bl e di s pa r i t i e s
be t w e e n U S B a nd F B L a t i nos . T he m a i n w e a kne s s of our s t udy i s t he m i s s i ng va l ue s of c a nc e r
s t a ge ba s e d on S t a ge S E E R f or a ppr oxi m a t e 15% of c a s e s w hi c h r e duc e d our da t a s e t f or s ur vi va l
a na l ys e s , a s w e l l a s m i s s i ng i nf or m a t i on on c ount r y of or i gi n on 4.94% of L a t i nos , w hi c h
pr e c l ude d us f r om pur s ui ng f ur t he r a na l ys e s ba s e d on t hi s va r i a bl e a nd goi ng pa s t F B L a t i no
s t a t us .
I n s um m a r y, our s t udy r e por t s di s pa r i t i e s i n c ol or e c t a l c a nc e r s ur vi va l a s w e l l a s
s oc i ode m ogr a phi c a nd c l i ni c a l c ha r a c t e r i s t i c s a m ong L a t i nos a nd N L B c om pa r e d w i t h N L W i n
C a l i f or ni a . T he s e f i ndi ngs hi ghl i ght t he i m por t a nt of c ons i de r i ng t he he t e r oge ne i t y i n s ur vi va l
a m ong di f f e r e nc e r a c e / e t hni c gr oups . S i nc e L a t i nos a r e t he l a r ge s t m i nor i t y gr oup i n t he U .S . a nd
44
m or t a l i t y r a t e due t o c a nc e r i s pr e t t y hi gh a m ong L a t i nos , f i gur i ng out t he r e l a t i ve c ova r i a t e s t o
C R C s ur vi va l i s of gr e a t s i gni f i c a nc e .
45
R e f e r e n c e s
[ 1] S E E R C a nc e r S t a t F a c t s : C ol or e c t a l C a nc e r . N a t i ona l C a nc e r I ns t i t ut e . ( 2019, O c t obe r
19) . R e t r i e ve d f r om ht t ps : / / s e e r .c a nc e r .gov/ s t a t f a c t s / ht m l / c ol or e c t .ht m l
[ 2] B e l c he r , M . ( 2016) . S uppor t i ng O ur L a t i no C om m uni t y. P r of e s s i ona l S a f e t y, 61( 1) , 8.
ht t p: / / s e a r c h.pr oque s t .c om / doc vi e w / 1766811388/
[ 3] A m e r i c a n C a nc e r S oc i e t y ( 2018) C a nc e r f a c t s a nd f i gur e s f or H i s pa ni c s / L a t i nos 2018- 2020.
A m e r i c a n C a nc e r S oc i e t y, A t l a nt a , G A ( N a t i ona l C a nc e r I ns t i t ut e , 2020)
[ 4] T he U ni t e d S t a t e s C e ns us B ur e a u ( 2018)
[ 5] R e ye s - O r t i z , C ., E s c hba c h, K ., Z ha ng, D ., & G oodw i n, J . ( 2008) . N e i ghbor hood c om pos i t i on
a nd c a nc e r a m ong H i s pa ni c s : t um or s t a ge a nd s i z e a t t i m e of di a gnos i s . C a nc e r E pi de m i ol ogy,
B i om a r ke r s & P r e ve nt i on: A P ubl i c a t i on of t he A m e r i c a n A s s oc i a t i on f or C a nc e r R e s e a r c h,
C os pons or e d by t he A m e r i c a n S oc i e t y of P r e ve nt i ve O nc ol ogy, 17( 11) , 2931–2936.
ht t ps : / / doi .or g/ 10.1158/ 1055- 9965.E P I - 07- 0430
[ 6] T a o, L ., L a da ba um , U ., G om e z , S ., & C he ng, I . ( 2014) . C ol or e c t a l c a nc e r m or t a l i t y a m ong
H i s pa ni c s i n C a l i f or ni a : D i f f e r e nc e s by ne i ghbor hood s oc i oe c onom i c s t a t us a nd na t i vi t y. C a nc e r ,
120( 22) , 3510–3518. ht t ps : / / doi .or g/ 10.1002/ c nc r .28837
[ 7] D oe khi e , F ., M e s ke r , W ., K uppe n, P ., V a n L e e uw e n, G ., M or r e a u, H ., D e B oc k, G ., …
T ol l e na a r , R . ( 2010) . D e t a i l e d e xa m i na t i on of l ym ph node s i m pr ove s pr ognos t i c a t i on i n
c ol or e c t a l c a nc e r . I nt e r na t i ona l J our na l of C a nc e r , 126( 11) , 2644–2652.
ht t ps : / / doi .or g/ 10.1002/ i j c .24817
[ 8] W a n, N ., Z ha n, F ., L u, Y ., & T i e f e nba c he r , J . ( 2012) . A c c e s s t o he a l t hc a r e a nd di s pa r i t i e s i n
c ol or e c t a l c a nc e r s ur vi va l i n T e xa s . H e a l t h a nd P l a c e , 18( 2) , 321–329.
ht t ps : / / doi .or g/ 10.1016/ j .he a l t hpl a c e .2011.10.007
46
[ 9] S i m ps on, D ., M a r t í ne z , M ., G upt a , S ., H a t t a nga di - G l ut h, J ., M e l l , L ., H e e s t a nd, G ., …
M ur phy, J . ( 2013) . R a c i a l D i s pa r i t y i n C ons ul t a t i on, T r e a t m e nt , a nd t he I m pa c t on S ur vi va l i n
M e t a s t a t i c C ol or e c t a l C a nc e r . J our na l of T he N a t i ona l C a nc e r I ns t i t ut e , 105( 23) , 1814–1820.
ht t ps : / / doi .or g/ 10.1093/ j nc i / dj t 318
[ 10] D oube ni , C ., F i e l d, T ., B ui s t , D ., K or ne r , E ., B i ge l ow , C ., L a m e r a t o, L ., … W a gne r , E .
( 2007) . R a c i a l di f f e r e nc e s i n t um or s t a ge a nd s ur vi va l f or c ol or e c t a l c a nc e r i n a n i ns ur e d
popul a t i on. C a nc e r , 109( 3) , 612–620. ht t ps : / / doi .or g/ 10.1002/ c nc r .22437
[ 11] C hi e n, C ., M or i m ot o, L ., T om , J ., & L i , C . ( 2005) . D i f f e r e nc e s i n c ol or e c t a l c a r c i nom a
s t a ge a nd s ur vi va l by r a c e a nd e t hni c i t y. C a nc e r , 104( 3) , 629–639.
ht t ps : / / doi .or g/ 10.1002/ c nc r .21204
[ 12] P i nhe i r o, P ., C a l l a ha n, K ., G om e z , S ., M a r c os - G r a ge r a , R ., C obb, T ., R oc a - B a r c e l o, A ., &
R a m i r e z , A . ( 2017) . H i gh c a nc e r m or t a l i t y f or U S - bor n L a t i nos : e vi de nc e f r om C a l i f or ni a a nd
T e xa s .( R e por t ) . B M C C a nc e r , 17( 1) , 478. ht t ps : / / doi .or g/ 10.1186/ s 12885- 017- 3469- 0
[ 13] T a o, L ., L a da ba um , U ., G om e z , S ., & C he ng, I . ( 2014) . C ol or e c t a l c a nc e r m or t a l i t y a m ong
H i s pa ni c s i n C a l i f or ni a : D i f f e r e nc e s by ne i ghbor hood s oc i oe c onom i c s t a t us a nd na t i vi t y. C a nc e r ,
120( 22) , 3510–3518. ht t ps : / / doi .or g/ 10.1002/ c nc r .28837
[ 14] C a l l a ha n, K ., P onc e , C ., C r os s , C ., S y, F ., P i nhe i r o, P ., & Z e e b, H . ( 2019) . L ow c ol or e c t a l
c a nc e r s ur vi va l i n t he M ount a i n W e s t s t a t e of N e va da : A popul a t i on- ba s e d a na l ys i s . P L oS O N E ,
14( 8) , e 0221337. ht t ps : / / doi .or g/ 10.1371/ j our na l .pone .0221337
[ 15] P ul t e , D ., J a ns e n, L ., & B r e nne r , H . ( 2017) . S oc i a l di s pa r i t i e s i n s ur vi va l a f t e r di a gnos i s
w i t h c ol or e c t a l c a nc e r : C ont r i but i on of r a c e a nd i ns ur a nc e s t a t us . C a nc e r E pi de m i ol ogy, 48, 41–
47. ht t ps : / / doi .or g/ 10.1016/ j .c a ne p.2017.03.004
47
[ 16] L e , H ., Z i oga s , A ., L i pki n, S ., & Z e l l , J . ( 2008) . E f f e c t s of s oc i oe c onom i c s t a t us a nd
t r e a t m e nt di s pa r i t i e s i n c ol or e c t a l c a nc e r s ur vi va l . C a nc e r E pi de m i ol ogy, B i om a r ke r s &
P r e ve nt i on: a P ubl i c a t i on of t he A m e r i c a n A s s oc i a t i on f or C a nc e r R e s e a r c h, C os pons or e d by t he
A m e r i c a n S oc i e t y of P r e ve nt i ve O nc ol ogy, 17( 8) , 1950–1962. ht t ps : / / doi .or g/ 10.1158/ 1055-
9965.E P I - 07- 2774
[ 17] S t e f a ni di s , H ., P ol l oc k, E ., M i r a nda , L ., W ong, R ., S ha r ke y, S ., R ous s e a u, S ., …
K a hl e nbe r g, S . ( 2006) . C ol or e c t a l C a nc e r i n H i s pa ni c s : A P opul a t i on a t R i s k f or E a r l i e r O ns e t ,
A dva nc e d D i s e a s e , a nd D e c r e a s e d S ur vi va l . A m e r i c a n J our na l of C l i ni c a l O nc ol ogy, 29( 2) , 123–
126. ht t ps : / / doi .or g/ 10.1097/ 01.c oc .0000199918.31226.f 8
[ 18] A r s ha d, H ., T e t a ngc o, E ., S ha h, N ., K a bi r , C ., R a dda w i , H ., & A r s ha d, H . ( 2016) . R a c i a l
D i s pa r i t i e s i n C ol or e c t a l C a r c i nom a I nc i de nc e , S e ve r i t y a nd S ur vi va l T i m e s O ve r 10 Y e a r s : A
R e t r os pe c t i ve S i ngl e C e nt e r S t udy. J our na l of C l i ni c a l M e di c i ne R e s e a r c h, 8( 11) , 777–786.
ht t ps : / / doi .or g/ 10.14740/ j oc m r 2696w
[ 19] S ha bi hkha ni , M ., Y u, S ., Y a ng, D ., L i n, S ., H a m i l t on, A ., L e nz , H ., & B a r z i , A . ( 2016) .
M e t a s t a t i c C ol or e c t a l C a nc e r i n H i s pa ni c s : T r e a t m e nt O ut c om e s i n a T r e a t e d P opul a t i on.
C l i ni c a l C ol or e c t a l C a nc e r , 15( 4) , e 221 –e 227. ht t ps : / / doi .or g/ 10.1016/ j .c l c c .2016.03.001

Abstract (if available)

Abstract Purpose: Colorectal cancer (CRC) is the fourth most common cancer in the U.S. according to the National Cancer Institute (NCI) and it is the second most common cancer among Latinos in California. Using data from the California Cancer Registry (CCR), we investigated the determinants of CRC incidence and survival including demographic and clinical characteristics of 310,190 CRC cases including 52,667 Latinos living in California and diagnosed during 1995-2017 taking into account subpopulations defined by country of origin. ❧ Methods: Latinos cases were defined according to the North American Association of Central Cancer Registries (NAACCR) Hispanic Identification Algorithm (NHIA), which was also used to group cases by country of origin: Mexico (12,922, 53.0%), Caribbean (1,048, 4.3%), Central America (2,525, 10.4%), South America (1,365, 5.6%), and other or unknown origin (6.510, 26.7%). We included 223,191 non-Latino white (NLW) and 25,332 non-Latino black (NLB) CRC cases were included for comparison purposes. Case frequencies, odds ratios (OR) from logistic regression, and hazard ratios (HR) from survival analyses were used to identify any disparities among Latinos, NLB and NLW. A “log (follow-up time)-log (-log survival)” plot and Kaplan-Meier curves were used to test proportional hazard assumption. ❧ Results: Differences were observed for age at diagnosis, socioeconomic status (SES), insurances status, marital status, religion, tumor location, stage, metastasis, treatment status, treatment type, time from diagnosis to treatment, and tumor size among Latinos compared to NLW. The determinants of CRC tumor location were age at diagnosis, SES, marital status

Linked assets

University of Southern California Dissertations and Theses

Conceptually similar

PDF

Prostate cancer disparities among Californian Latinos by country of origin: clinical characteristics, incidence, treatment received and survival

PDF

Predictive factors of breast cancer survival: a population-based study

PDF

Air pollution and breast cancer survival in California teachers: using address histories and individual-level data

PDF

Disparities in gallbladder, intra-hepatic bile duct, and other biliary cancers among multi-ethnic populations: a California Cancer Registry study

PDF

An analysis of disease-free survival and overall survival in inflammatory breast cancer

PDF

Fish consumption and risk of colorectal cancer

PDF

Red and processed meat consumption and colorectal cancer risk: meta-analysis of case-control studies

PDF

A novel risk-based treatment strategy evaluated in pediatric head and neck non-rhabdomyosarcoma soft tissue sarcomas (NRSTS) patients: a survival analysis from the Children's Oncology Group study...

PDF

Comparison of Cox regression and machine learning methods for survival analysis of prostate cancer

PDF

The impact of the COVID-19 pandemic on cancer care delivery

PDF

The effect of renal function on toxicity of E7389 (eribulin) among patients with bladder cancer

PDF

Investigating racial and ethnic disparities in patient experiences with care and health services use following colorectal cancer diagnosis among older adults with comorbid chronic conditions

PDF

Instability of heart rate and rating of perceived exertion during high-intensity interval training in breast cancer patients undergoing anthracycline chemotherapy

PDF

A comparison of three different sources of data in assessing the adolescent and young adults cancer survivors

PDF

Diet quality and pancreatic cancer incidence in the multiethnic cohort

PDF

Effect of biomass fuel exposure on infant respiratory health outcomes in Bangladesh

PDF

Carcinogen metabolism genes, meat intake, and colorectal cancer risk

PDF

Racial/ethnic differences in colorectal cancer patient experiences, health care utilization and their association with mortality: findings from the SEER-CAHPS data

PDF

Association between informed decision-making and mental health-related quality of life in long term prostate cancer survivors

PDF

Survival of children and adolescents with low-risk non-rhabdomyosarcoma soft tissue sarcomas (NRSTS) treated with surgery only: an analysis of 234 patients from the Children’s Oncology Group stud...

Asset Metadata

Creator Wang, Ruoxuan (author)

Core Title Disparities in colorectal cancer survival among Latinos in California

School Keck School of Medicine

Degree Master of Science

Degree Program Applied Biostatistics and Epidemiology

Publication Date 02/17/2020

Defense Date 01/26/2020

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag colorectal cancer,disparities,Latinos,OAI-PMH Harvest,Survival

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Stern, Mariana (committee chair), Franklin, Meredith (committee member), Liu, Lihua (committee member)

Creator Email ruoxuan@usc.edu,wangrx94@163.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-269181

Unique identifier UC11673410

Identifier etd-WangRuoxua-8181.pdf (filename),usctheses-c89-269181 (legacy record id)

Legacy Identifier etd-WangRuoxua-8181.pdf

Dmrecord 269181

Document Type Thesis

Rights Wang, Ruoxuan

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA