Abstract
BACKGROUND: In the United States (US), incidence of early age of onset colorectal cancer (EOCRC, diagnosed <50 years of age) has been increasing. Using a Bayesian analytic approach, we evaluated the association between county-level ecological factors and survival among individuals with EOCRC and identified hotspot and coldspot counties with unexplained low and high survival, respectively. METHODS: Principal component (PC) analysis was used to reduce dimensionality of 36 county-level social, behavioral, and preventive factors from the Centers for Disease Control and Prevention data. Survival information was derived from the Surveillance, Epidemiology, and End Results Program data from January 1, 2000 to December 31, 2019. The association between the identified PCs and survival was evaluated using multivariable spatial generalized linear mixed models. Counties with residual low and high survival (i.e., unexplained by the PCs) were classified as hotspots and coldspots, respectively. RESULTS: Four PCs were used to explain the spatial variability in 5-year survival among 75,215 individuals with EOCRC: PC1) poverty, chronic disease, health risk behaviors (β = -0.03, 95% credible interval (CrI): -0.04, -0.03); PC2) younger age, chronic disease-free, minority status (β = -0.01, 95% CrI: -0.02, 0.00); PC3) urban environment, preventive services (β = 0.02, 95% CrI: 0.00, 0.03); and PC4) older age (-0.04, 95% CrI: -0.06, -0.02). Among individuals with distant malignancies, the residual spatial variability remained high for two US counties: 1) Salt Lake County, UT residents experiencing 26.5% (95% CrI: 1.5%, 47.8%) lower odds of survival [hotspot], and 2) Riverside County, CA residents experiencing 37% (95% CrI: 7.97%, 78.8%) higher odds survival [coldspot] after adjustment for county-level factors. CONCLUSIONS: County-level ecological factors are strongly associated with survival among individuals with EOCRC. Yet there is some evidence of survival disparities among individuals with distant malignancies that remain unexplained by the included factors.