Assessing burden and outcomes: Colon cancer survival across the U.S. safety-net spectrum.

Abstract

11176 Background: Safety-net hospitals (SNHs) provide essential care for uninsured and underinsured patients but often face systemic constraints that may affect cancer outcomes. Colon cancer, a leading cause of cancer-related death in the United States, requires complex multidisciplinary management. This study assessed the association between hospital safety-net burden and clinical outcomes in colon cancer across a national dataset. We also identified patient-level factors contributing to disparities in care delivery. Methods: Using the National Cancer Database (NCDB), we identified approximately 1.2 million adult patients diagnosed with colon cancer in the United States between 2004 and 2020. Facilities were stratified by safety-net burden into Non–Safety-Net Hospitals (NSNH; < 25% Medicaid/uninsured cases), Safety-Net Hospitals (SNH; 25–75%), and Extreme Safety-Net Hospitals (Extreme-SNH; > 75%). This safety-net spectrum provided a novel framework for capturing both facility- and patient-level disparities that influence colon cancer care and outcomes. Multivariable logistic and Cox regression models were used to evaluate differences in disease stage, treatment timelines, and survival, adjusting for age, comorbidity, and AJCC stage. Kruskal–Wallis and chi-square tests were used for descriptive analyses. Results: SNHs and Extreme-SNHs cared for a greater proportion of patients with advanced-stage disease, lower rates of chemotherapy, immunotherapy, and palliative care utilization, and higher short-term mortality when compared with NSNH. Thirty-day readmission rates after surgery were similar across groups. Survival analyses demonstrated a graded decline in outcomes with increasing safety-net burden: median overall survival was 91.2 months in NSNH, 83.6 months in SNH, and 70.9 months in Extreme-SNH (p < 0.001). One-year survival exceeded 95% across all facilities, but five-year survival declined to 68.9% for NSNH vs 59.4% for Extreme-SNH. Additional disparities in colon cancer outcomes were observed by health literacy level, residential setting (urban, metropolitan, rural), race, age, and sex. Conclusions: Colon cancer patients treated at hospitals with higher safety-net burden experience substantially poorer long-term survival despite comparable short-term outcomes. These findings highlight the need for targeted policy, resource allocation, and quality-improvement efforts to reduce disparities and strengthen oncology care delivery in high-burden safety-net systems. A Plan–Do–Check–Act (PDCA) approach tailored to individual hospital settings and regional contexts may help identify gaps in colon cancer care and guide targeted interventions to improve patient outcomes.