Socioeconomic inequalities of 3-year survival in formal employees with colorectal cancer between 2012 and 2019 in Colombia

Abstract

Background Colorectal cancer is a high-burden disease that requires comprehensive multidisciplinary management. In Colombia, despite a healthcare system covering 97% of the population, socioeconomic disparities persist. Lower income levels are associated with decreased survival, potentially due to delays in diagnosis or treatment and a higher probability of advanced staging at diagnosis, These inequities persist even among relatively advantaged populations, such as formal employee who are assumed to have fewer barriers to accessing healthcare services compared to informal workers. Objective This study aimed to assess the association monthly minimum wages (MMW) as a measure of socioeconomic status in three-year survival among formal employees diagnosed with colorectal cancer in Colombia from 2012 to 2019. Methods A retrospective cohort study was conducted using administrative databases that included healthcare and mortality records. Formal employees newly diagnosed with colorectal cancer were identified through diagnostic and oncological procedure codes and were followed for three years from the date of diagnosis or until death. The exposure variable was the legal monthly minimum wage (MMW) at the time of diagnosis, used as a proxy for socioeconomic status, while the outcome variable was three-year survival. Patients were stratified into quartiles based on their MMW. The three-year mortality proportion was calculated for each quartile. To assess survival differences, Cox proportional hazards regression models were applied to estimate adjusted hazard ratios (HRs). Socioeconomic gradients in survival were quantified using the Relative Index of Inequality (RII) and the Slope Index of Inequality (SII). Results The cohort included 1,913 formal employees (mean age: 49.9 years), with 660 deaths (34.5%) recorded over the follow-up period. Patients in the lowest MMW quartile experienced the highest three-year mortality (39.5%) compared to those in the highest quartile (30.7%). After adjusting for confounders, individuals in the highest quartile had a 25% lower risk of death than those in the lowest quartile (aHR: 0.74; 95% CI: 0.59–0.92). The RII indicated a 50% higher risk of death in the lowest income group (RII: 1.50; 95% CI: 1.13–1.99), while the SII revealed an absolute difference of 0.16 deaths per 1,000 individuals (p=0.01). Conclusion Significant income-based disparities in colorectal cancer survival were observed among formal employees in Colombia despite the theoretically equitable healthcare system. These findings underscore the persistent influence of socioeconomic factors on health outcomes, even within populations assumed to have better access to care.