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Factors Influencing Selection of Treatment for Colorectal Cancer Patients
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Radiology, Oncology and Radiation Science, Oncology.
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

In Sweden and elsewhere there is evidence of poorer cancer survival for patients of low socioeconomic status (SES), and in some settings differences in treatment by SES have been shown.

The aim of this thesis was to explore factors which influence cancer treatment decisions, such as knowledge reaped from clinical trials, patient-related factors, and physician-related factors. In a register study of colorectal cancer, all stages, patients were stratified for SES-factors. Differences were seen with regards to clinical investigation, surgical and oncological treatment and survival, with the highly educated group being favored. Survival was better for highly educated patients in stages I, II and III but not in stage IV.

In a Scandinavian cohort of newly metastasized colorectal cancer patients, recruitment to clinical trials was studied. Patients entering clinical trials had better performance status and fewer cancer symptoms than those who were treated with chemotherapy outside of a clinical trial. Median survival was 21.3 months for trial-patients and 15.2 months for those treated with chemotherapy outside a  trial. Those not treated with chemotherapy had a median survival of just 2.1 months. Patients in clinical trials are highly selected and conclusions drawn from studies cannot be applied to all patients.

In the same cohort, treatment and survival were stratified for education, smoking and indicators of social structure. Highly educated patients did not have a survival advantage. Patients who lived alone were offered less combination chemotherapy and surgery of metastases than other patients and had 4 months shorter survival than those who lived with a spouse or child. In a fourth study, 20 Swedish gastrointestinal oncologists were interviewed on which factors they considered when deciding on oncological treatment. Oncologists feared chemotherapy complications due to lack of social support, and ordered less combination chemotherapy for patients living alone. Highly educated patients were seen as well-read and demanding, and giving in to these patients’ requests for treatment was regarded as a way of pleasing patients and relatives and of avoiding conflict.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2012. , 45 p.
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 774
Keyword [en]
colorectal cancer, socioeconomic status, clinical trials, education level, family support, living alone, patient-physician interaction
National Category
Cancer and Oncology
Research subject
URN: urn:nbn:se:uu:diva-172533ISBN: 978-91-554-8363-0OAI: diva2:514850
Public defence
2012-06-13, Skoogsalen, Akademiska Sjukhuset Ingång 78, 1 tr, Uppsala, 09:00 (Swedish)
Available from: 2012-05-21 Created: 2012-04-11 Last updated: 2012-08-01Bibliographically approved
List of papers
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2. Clinical trial enrollment, patient characteristics, and survival differences in prospectively registered metastatic colorectal cancer patients
Open this publication in new window or tab >>Clinical trial enrollment, patient characteristics, and survival differences in prospectively registered metastatic colorectal cancer patients
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2009 (English)In: Cancer, ISSN 0008-543X, E-ISSN 1097-0142, Vol. 115, no 20, 4679-87 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Trial accrual patterns were examined to determine whether metastatic colorectal cancer (mCRC) patients enrolled in trials are representative of a general cancer population concerning patient characteristics and survival.

METHODS: A total of 760 mCRC patients referred for their first oncological consideration at 3 hospitals in Scandinavia covering defined populations were registered consecutively during 2003 to 2006. Clinical trial enrollment, patient characteristics, and treatment were recorded prospectively, and the follow-up was complete.

RESULTS: Palliative chemotherapy was initiated in 61% of the patients. Approximately one-third (36%) of patients receiving chemotherapy were included in a trial. The main reason for nonparticipation was failed eligibility criteria (69%). The median survival after chemotherapy was 15.8 months for all patients, and 18 months after combination chemotherapy. Trial patients had better prognostic characteristics and significantly longer survival than nontrial patients: 21.3 months versus 15.2 months when receiving combination chemotherapy. Poor performance status was the main reason for giving best supportive care only, and the median survival was then only 2.1 months. The median survival for all 760 nonresectable mCRC patients was 10.7 months.

CONCLUSIONS: mCRC patients enrolled into clinical trials differ in characteristics from patients receiving chemotherapy outside protocol and have better survival, even when given the same treatment. Although trial patients have a median survival close to 2 years, survival is lower for all patients receiving chemotherapy and much lower for all patients diagnosed with mCRC. Studies that better accept the heterogeneity of the population with mCRC are needed.

National Category
Medical and Health Sciences
urn:nbn:se:uu:diva-113895 (URN)10.1002/cncr.24527 (DOI)000270740900007 ()19562777 (PubMedID)
Available from: 2010-02-04 Created: 2010-02-04 Last updated: 2012-06-19Bibliographically approved
3. Lower treatment intensity and poorer survival in metastatic colorectal cancer patients who live alone
Open this publication in new window or tab >>Lower treatment intensity and poorer survival in metastatic colorectal cancer patients who live alone
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2012 (English)In: British Journal of Cancer, ISSN 0007-0920, E-ISSN 1532-1827, Vol. 107, no 1, 189-194 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Socioeconomic status (SES) and social support influences cancer survival. If SES and social support affects cancer treatment has not been thoroughly explored. METHODS: A cohort consisting of all patients who were initially diagnosed with or who developed metastatic colorectal cancer (mCRC, n = 781) in three Scandinavian university hospitals from October 2003 to August 2006 was set up. Clinical and socioeconomic data were registered prospectively. RESULTS: Patients living alone more often had synchronous metastases at presentation and were less often treated with combination chemotherapy than those cohabitating (HR 0.19, 95% CI 0.04-0.85, P = 0.03). Surgical removal of metastases was less common in patients living alone (HR 0.29, 95% CI 0.10-0.86, P = 0.02) but more common among university-educated patients (HR 2.22, 95% CI 1.10-4.49, P = 0.02). Smoking, being married and having children did not influence treatment or survival. Median survival was 7.7 months in patients living alone and 11.7 months in patients living with someone (P < 0.001). Living alone remained a prognostic factor for survival after correction for age and comorbidity. CONCLUSION: Patients living alone received less combination chemotherapy and less secondary surgery. Living alone is a strong independent risk factor for poor survival in mCRC. 

National Category
Cancer and Oncology
urn:nbn:se:uu:diva-172517 (URN)10.1038/bjc.2012.186 (DOI)000305888400029 ()
Available from: 2012-04-11 Created: 2012-04-11 Last updated: 2012-07-27Bibliographically approved
4. Equal cancer treatment regardless of education level and family support?: A qualitative study of oncologists’ decision-making
Open this publication in new window or tab >>Equal cancer treatment regardless of education level and family support?: A qualitative study of oncologists’ decision-making
2012 (English)In: BMJ Open, ISSN 2044-6055, Vol. 2, no 4, e001248- p.Article in journal (Refereed) Published
Abstract [en]

Objective: Treatment gradients by socioeconomic status have been observed within cancer care in several countries. The objective of this study was to explore whether patients' educational level and social network influence oncologists' clinical decision-making. Design: Semi-structured interviews on factors considered when deciding on treatment for cancer patients. Interviews were transcribed and analysed using inductive qualitative content analysis. Setting: Oncologists in Swedish university-and non-university hospitals were interviewed in their respective places of work. Participants: Twenty Swedish clinical oncologists selected through maximum-variation sampling. Primary and secondary outcome measures: Elements which influence oncologists' decision-making process were explored with focus on educational level and patients' social support systems. Results: Oncologists consciously used less combination chemotherapy for patients living alone, fearing treatment toxicity. Highly educated patients were considered as well-read, demanding and sometimes difficult to reason with. Patients with higher education, those very keen to have treatment and persuasive relatives were considered as challenges for the oncologist. Having large groups of relatives in a room made doctors feel outnumbered. A desire to please patients and relatives was posed as the main reason for giving in to patients' demands, even when this resulted in treatment with limited efficacy. Conclusions: Oncologists tailor treatment for patients living alone to avoid harmful side-effects. Many find patients' demands difficult to handle and this may result in strong socioeconomic groups being over-treated.

National Category
Cancer and Oncology
urn:nbn:se:uu:diva-172518 (URN)10.1136/bmjopen-2012-001248 (DOI)000315049300078 ()
Available from: 2012-04-11 Created: 2012-04-11 Last updated: 2013-03-26Bibliographically approved

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