Impact of Socioeconomic Status on Presentation and Outcomes in Colorectal Peritoneal Metastases Following Cytoreduction and Chemoperfusion: Persistent Inequalities in Outcomes at a High-Volume Center

Abstract

Background: Cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion (CRS HIPEC) can offer significant survival advantage for select patients with colorectal peritoneal metastases (CRPM). Low socioeconomic status (SES) is implicated in disparities in access to care. We analyze the impact of SES on postoperative outcomes and survival at a high-volume tertiary CRS HIPEC center.

Patients and methods: We conducted a retrospective cohort study examining patients who underwent CRS HIPEC for CRPM from 2000 to 2018. Patients were grouped according to SES. Baseline characteristics, perioperative outcomes, and survival were examined between groups.

Results: A total of 226 patients were analyzed, 107 (47%) low-SES and 119 (53%) high-SES patients. High-SES patients were younger (52 vs. 58 years, p = 0.01) and more likely to be White (95.0% vs. 91.6%, p = 0.06) and privately insured (83% vs. 57%, p < 0.001). They traveled significantly further for treatment and had lower burden of comorbidities and frailty (p = 0.01). Low-SES patients more often presented with synchronous peritoneal metastases (48% vs. 35%, p = 0.05). Following CRS HIPEC, low-SES patients had longer length of stay and higher burden of postoperative complications, 90-day readmission, and 30-day mortality. Median overall survival following CRS HIPEC was worse for low-SES patients (17.8 vs. 32.4 months, p = 0.02). This disparity persisted on multivariate survival analysis (low SES: HR = 1.46, p = 0.03).

Conclusions: Despite improving therapies for CRPM, low-SES patients remain at a significant disadvantage. Even patients who overcome barriers to care experience worse short- and long-term outcomes. Improving access and addressing these disparities is crucial to ensure equitable outcomes and improve patient care.

Fig. 1

Survival analysis by SES: a median overall survival was significantly lower in the low-SES cohort (17.8 versus 32.4 months, p = 0.02), b there was no difference in progression-free survival following cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion (CRS HIPEC) by SES status (9.5 vs. 11.3 months, p = 0.30), c post-recurrence overall survival was significantly lower in the low-SES cohort (9.8 vs. 15.4 months, p = 0.01), and d median overall survival from time of diagnosis of peritoneal metastases was significantly lower in the low-SES cohort (29.5 vs. 48.6 months, p = 0.03)

Fig. 2

Survival analysis by repeat CRS HIPEC: a patients who underwent repeat CRS HIPEC had longer median overall survival compared with those who did not (54.0 vs. 20.0 months, p < 0.001), b for patients who underwent only one CRS HIPEC procedure, median overall survival was 15.8 months in the low-SES cohort versus 22.9 months in the high-SES cohort (p = 0.07), and c for patients who underwent repeat CRS HIPEC, there was no difference in median overall survival (52.7 vs. 55.2 months, p = 0.75)