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Insurance Status, Not Race, is Associated With Use of Minimally Invasive Surgical Approach for Rectal Cancer

Turner, Megan MD; Adam, Mohamed Abdelgadir MD; Sun, Zhifei MD; Kim, Jina MD; Ezekian, Brian MD; Yerokun, Babatunde MD; Mantyh, Christopher MD; Migaly, John MD, FACS, FASCRS

doi: 10.1097/SLA.0000000000001781
Original Articles

Objective: To determine the impact of race and insurance on use of minimally invasive (MIS) compared with open techniques for rectal cancer in the United States.

Background: Race and socioeconomic status have been implicated in disparities of rectal cancer treatment.

Methods: Adults undergoing MIS (laparoscopic or robotic) or open rectal resections for stage I to III rectal adenocarcinoma were included from the National Cancer Database (2010–2012). Multivariate analyses were employed to examine the adjusted association of race and insurance with use of MIS versus open surgery.

Results: Among 23,274 patients, 39% underwent MIS and 61% open surgery. Overall, 86% were white, 8% black, and 3% Asian. Factors associated with use of open versus MIS were black race, Medicare/Medicaid insurance, and lack of insurance. However, after adjustment for patient demographic, clinical, and treatment characteristics, black race was not associated with use of MIS versus open surgery [odds ratio [OR] 0.90, P = 0.07). Compared with privately insured patients, uninsured patients (OR 0.52, P < 0.01) and those with Medicare/Medicaid (OR 0.79, P < 0.01) were less likely to receive minimally invasive resections. Lack of insurance was significantly associated with less use of MIS in black (OR 0.59, P = 0.02) or white patients (OR 0.51, P < 0.01). However, among uninsured patients, black race was not associated with lower use of MIS (OR 0.96, P = 0.59).

Conclusions: Insurance status, not race, is associated with utilization of minimally invasive techniques for oncologic rectal resections. Due to the short-term benefits and cost-effectiveness of minimally invasive techniques, hospitals may need to improve access to these techniques, especially for uninsured patients.

Department of Surgery, Duke University Medical Center, Durham, NC.

Reprints: John Migaly, MD, FACS, FASCRS, Program Director, General Surgery Residency, Associate Professor, Division of Colon and Rectal Surgery, Duke University Medical Center, 7674 HAFS Building, DN, Erwin Road, Durham, NC 27710. E-mail:

The data used in the study are derived from a de-identified National Cancer Database (NCDB) file. The American College of Surgeons and the Commission on Cancer have not verified and are not responsible for the analytic or statistical methodology employed, or the conclusions drawn from these data by the investigator.

The authors obtained no funding for this study.

The authors declare no conflict of interest.

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