Rural-urban disparities in mortality and geriatric assessment among older adults with cancer: The cancer & aging resilience evaluation (CARE) registry

Mackenzie E Fowler; Kelly M Kenzik; Mustafa Al-Obaidi; Christian Harmon; Smith Giri; Sankalp Arora; Coryn Stephenson; Moh''d Khushman; Darryl Outlaw; Smita Bhatia; Grant R Williams

doi:10.1016/j.jgo.2023.101505

Rural-urban disparities in mortality and geriatric assessment among older adults with cancer: The cancer & aging resilience evaluation (CARE) registry

J Geriatr Oncol. 2023 May;14(4):101505. doi: 10.1016/j.jgo.2023.101505. Epub 2023 Apr 21.

Authors

Affiliations

¹ Department of Medicine, University of Alabama at Birmingham, 1720 2(nd) Avenue South, BDB 860, Birmingham, AL 35294, USA. Electronic address: mefowler@uab.edu.
² 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. Electronic address: kellykenzik@uabmc.edu.
³ Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, 1600 7(th) Avenue South, Lowder Building Suite 500, Birmingham, AL 35233, USA. Electronic address: Mustafa.AlObaidi@Pennmedicine.upenn.edu.
⁴ Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, 1600 7(th) Avenue South, Lowder Building Suite 500, Birmingham, AL 35233, USA. Electronic address: christianharmon@uabmc.edu.
⁵ 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. Electronic address: smithgiri@uabmc.edu.
⁶ Department of Medicine, University of Alabama at Birmingham, 1720 2(nd) Avenue South, BDB 860, Birmingham, AL 35294, USA. Electronic address: sarora@uabmc.edu.
⁷ University of Missouri, 230 Jesse Hall, Columbia, MO 65211, USA.
⁸ Department of Medicine, University of Alabama at Birmingham, 1720 2(nd) Avenue South, BDB 860, Birmingham, AL 35294, USA. Electronic address: mkhushman@uabmc.edu.
⁹ Department of Medicine, University of Alabama at Birmingham, 1720 2(nd) Avenue South, BDB 860, Birmingham, AL 35294, USA. Electronic address: darryloutlaw@uabmc.edu.
¹⁰ Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, 1600 7(th) Avenue South, Lowder Building Suite 500, Birmingham, AL 35233, USA; Department of Pediatrics, University of Alabama at Birmingham, 1600 7th Avenue South, Lowder Building, Birmingham, AL 35233-1771, USA. Electronic address: smitabhatia@uabmc.edu.
¹¹ 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. Electronic address: grwilliams@uabmc.edu.

Abstract

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_Overall = 1.83, 95% CI = 1.27, 2.57; HR_Frail = 2.05, 95% CI = 1.23, 3.41; HR_{Not Frail} = 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.

Keywords: Geriatric assessment; Geriatric oncology; Health status disparities; Neoplasms; Rural health.

Publication types

Research Support, Non-U.S. Gov't
Research Support, U.S. Gov't, P.H.S.
Research Support, N.I.H., Extramural

MeSH terms

Aged
Aging
Frailty* / diagnosis
Frailty* / epidemiology
Geriatric Assessment
Humans
Neoplasms*
Registries
Rural Population

Abstract

Publication types

MeSH terms

Grants and funding