Latino patients' desire to participate in informed decisions regarding colorectal cancer screening

Colorectal cancer (CRC) has become a public health concern due to the underutilization of the various screening methods. There is a need to understand a patient's decision making process in regards to their health and obtaining the appropriate screening. Previous research has defined patient autonomy in two dimensions: The patient's involvement in the decision making process and their desire to be informed (Ende, Kazis, Ash, & Moskowitz, 1989). Past research shows that patients have a high desire to be informed, but a low desire to be involved in the medical decision process. Deber, Kraetschmer, and Irvine (1996) developed a measure which consisted of two subscales that measures patients' involvement: Patient's desire to be involved in the problem solving (PS) and decision making (DM) process. Little research has examined the desire for involvement and decision making of Latino populations. The present study sought to investigate the psychometric properties of the Deber et al. (1996) measure. In general, Latino patients in the present sample had low desire for autonomy in health decisions or to be involved in the decision making processes of their health related issues. ^

A meta-analysis: Obesity and colorectal cancer screening

Of cancer death, colorectal cancer death ranks second in the United States. Obesity is an important risk factor for colorectal cancer (1). Early detection of colorectal cancer when it is localized can effectively reduce mortality of colorectal cancer and increase survival time of patients if they are treated. Also, previous studies showed that obese women were more likely to delay breast cancer screening and cervical cancer screening than normal weight women (2-5). However, results from prior studies demonstrating the relationship between obesity and colorectal cancer screening are not consistent. This research was done to conduct a meta-analysis of previous cross-sectional studies selected from the Medline database and to evaluate the association between obesity and colorectal cancer screening. While the odds ratio was not statistically different from one, the results from this meta-analysis under the random effects model showed that obese people are slightly less likely to have colorectal cancer screening compared to normal weight individuals (OR,0.93;95% CI 0.75-1.15). This meta-analysis was particularly sensitive to one individual study (6) and the effect of obesity on colorectal cancer screening was statistically significant (OR, 0.87; 95% CI, 0.81-0.92) after removing Heo's study. Further systematic studies focused on whether the effect of obesity on colorectal cancer screening is limited to women only are suggested. ^

Uncertainty analysis of cost effectiveness in a tailored intervention to promote screening for colorectal cancer

Background. Screening for colorectal cancer (CRC) is considered cost effective but screening compliance in the US remains low. There have been very few studies on economic analyses of screening promotion strategies for colorectal cancer. The main aim of the current study is to conduct a cost effectiveness analysis (CEA) and examine the uncertainty involved in the results of the CEA of a tailored intervention to promote screening for CRC among patients of a multispeciality clinic in Houston, TX. ^ Methods. The two intervention arms received a PC based tailored program and web based educational information to promote CRC screening. The incremental cost of implementing a tailored PC based program was compared to the website based education and the status quo of no intervention for each unit of effect after 12 months of delivering the intervention. Uncertainty analysis in the point estimates of cost and effect was conducted using nonparametric bootstrapping. ^ Results. The cost of implementing a web based educational intervention was $36.00 per person and the cost of the tailored PC based interactive intervention was $43.00 per person. The additional cost per person screened for the web-based strategy was $2374 and the effect of the tailored intervention was negative. ^

A systematic review of community-based colorectal cancer screening randomized controlled trials with multi-ethnic groups

Background. The CDC estimates that 40% of adults 50 years of age or older do not receive time-appropriate colorectal cancer screening. Sixty percent of colorectal cancer deaths could be prevented by regular screening of adults 50 years of age and older. Yet, in 2000 only 42.5% of adults age 50 or older in the U.S. had received recommended screening. Disparities by health care, nativity status, socioeconomic status, and race/ethnicity are evident. Disparities in minority, underserved populations prevent us from attaining Goal 2 of Healthy People 2010 to “eliminate health disparities.” This review focuses on community-based screening research among underserved populations that includes multiple ethnic groups for appropriate disparities analysis. There is a gap in the colorectal cancer screening literature describing the effectiveness of community-based randomized controlled trials. ^ Objective. To critically review the literature describing community-based colorectal cancer screening strategies that are randomized controlled trials, and that include multiple racial/ethnic groups. ^ Methods. The review includes a preliminary disparities analysis to assess whether interventions were appropriately targeted in communities to those groups experiencing the greatest health disparities. Review articles are from an original search using Ovid Medline and a cross-matching search in Pubmed, both from January 2001 to June 2009. The Ovid Medline literature review is divided into eight exclusionary stages, seven electronic, and the last stage consisting of final manual review. ^ Results. The final studies (n=15) are categorized into four categories: Patient mailings (n=3), Telephone outreach (n=3), Electronic/multimedia (n=4), and Counseling/community education (n=5). Of 15 studies, 11 (73%) demonstrated that screening rates increased for the intervention group compared to controls, including all studies (100%) from the Patient mailings and Telephone outreach groups, 4 of 5 (80%) Counseling/community education studies, and 1 of 4 (25%) Electronic/multimedia interventions. ^ Conclusions. Patient choice and tailoring education and/or messages to individuals have proven to be two important factors in improving colorectal cancer screening adherence rates. Technological strategies have not been overly successful with underserved populations in community-based trials. Based on limited findings to date, future community-based colorectal cancer screening trials should include diverse populations who are experiencing incidence, survival, mortality and screening disparities. ^

Comparing barriers and predictors for colorectal cancer screening between African Americans and Whites

Colorectal cancer (CRC) has been one of the leading causes of cancer death in the United States. Although incidence and mortality rates of colorectal cancer in the United States have decreased in recent years, the disparity in CRC incidence and mortality between African Americans and Whites remain. Disparity in CRC screening rates is believed to be one of the causes that contribute to the disparity in CRC incidence and mortality between these two races. Finding the differences in CRC screening barriers and predictors between these two groups can help us to design more effective intervention programs to improve CRC screening rates for African Americans. However, most of the previous studies have investigated different types of CRC screening barriers for African Americans and/or Whites, but no studies have compared the same CRC screening barriers between African Americans and Whites. The purpose of this study is to describe and compare the same CRC screening barriers between these two races. Using chi-square analysis, significant differences between African Americans and Whites were found for marital status, income and education. Compared to Whites, African Americans were less aware of CRC screening procedures and lacked CRC knowledge. Significant differences were found between African Americans and Whites in the awareness of sigmoidoscopy, colonoscopy and barium enema. After adjusting for sex, education, marital status, and household income, six out of thirteen CRC screening barriers and two out of nine CRC screening predictors remained to be statistically significantly different between African Americans and Whites. The results of this study indicated that different CRC screening barriers and predictors had different impact on African Americans, and African Americans had more CRC barriers to overcome than Whites.^

Racial/ethnic disparities in colorectal cancer screening and survival in a large nationwide population-based cohort

Background. Colorectal cancer (CRC) is the third most commonly diagnosed cancer (excluding skin cancer) in both men and women in the United States, with an estimated 148,810 new cases and 49,960 deaths in 2008 (1). Racial/ethnic disparities have been reported across the CRC care continuum. Studies have documented racial/ethnic disparities in CRC screening (2-9), but only a few studies have looked at these differences in CRC screening over time (9-11). No studies have compared these trends in a population with CRC and without cancer. Additionally, although there is evidence suggesting that hospital factors (e.g. teaching hospital status and NCI designation) are associated with CRC survival (12-16), no studies have sought to explain the racial/ethnic differences in survival by looking at differences in socio-demographics, tumor characteristics, screening, co-morbidities, treatment, as well as hospital characteristics. ^ Objectives and Methods. The overall goals of this dissertation were to describe the patterns and trends of racial/ethnic disparities in CRC screening (i.e. fecal occult blood test (FOBT), sigmoidoscopy (SIG) and colonoscopy (COL)) and to determine if racial/ethnic disparities in CRC survival are explained by differences in socio-demographic, tumor characteristics, screening, co-morbidities, treatment, and hospital factors. These goals were accomplished in a two-paper format.^ In Paper 1, "Racial/Ethnic Disparities and Trends in Colorectal Cancer Screening in Medicare Beneficiaries with Colorectal Cancer and without Cancer in SEER Areas, 1992-2002", the study population consisted of 50,186 Medicare beneficiaries diagnosed with CRC from 1992 to 2002 and 62,917 Medicare beneficiaries without cancer during the same time period. Both cohorts were aged 67 to 89 years and resided in 16 Surveillance, Epidemiology and End Results (SEER) regions of the United States. Screening procedures between 6 months and 3 years prior to the date of diagnosis for CRC patients and prior to the index date for persons without cancer were identified in Medicare claims. The crude and age-gender-adjusted percentages and odds ratios of receiving FOBT, SIG, or COL were calculated. Multivariable logistic regression was used to assess race/ethnicity on the odds of receiving CRC screening over time.^ Paper 2, "Racial/Ethnic Disparities in Colorectal Cancer Survival: To what extent are racial/ethnic disparities in survival explained by racial differences in socio-demographics, screening, co-morbidities, treatment, tumor or hospital characteristics", included a cohort of 50,186 Medicare beneficiaries diagnosed with CRC from 1992 to 2002 and residing in 16 SEER regions of the United States which were identified in the SEER-Medicare linked database. Survival was estimated using the Kaplan-Meier method. Cox proportional hazard modeling was used to estimate hazard ratios (HR) of mortality and 95% confidence intervals (95% CI).^ Results. The screening analysis demonstrated racial/ethnic disparities in screening over time among the cohort without cancer. From 1992 to 1995, Blacks and Hispanics were less likely than Whites to receive FOBT (OR=0.75, 95% CI: 0.65-0.87; OR=0.50, 95% CI: 0.34-0.72, respectively) but their odds of screening increased from 2000 to 2002 (OR=0.79, 95% CI: 0.72-0.85; OR=0.67, 95% CI: 0.54-0.75, respectively). Blacks and Hispanics were less likely than Whites to receive SIG from 1992 to 1995 (OR=0.75, 95% CI: 0.57-0.98; OR=0.29, 95% CI: 0.12-0.71, respectively), but their odds of screening increased from 2000 to 2002 (OR=0.79, 95% CI: 0.68-0.93; OR=0.50, 95% CI: 0.35-0.72, respectively).^ The survival analysis showed that Blacks had worse CRC-specific survival than Whites (HR: 1.33, 95% CI: 1.23-1.44), but this was reduced for stages I-III disease after full adjustment for socio-demographic, tumor characteristics, screening, co-morbidities, treatment and hospital characteristics (aHR=1.24, 95% CI: 1.14-1.35). Socioeconomic status, tumor characteristics, treatment and co-morbidities contributed to the reduction in hazard ratios between Blacks and Whites with stage I-III disease. Asians had better survival than Whites before (HR: 0.73, 95% CI: 0.64-0.82) and after (aHR: 0.80, 95% CI: 0.70-0.92) adjusting for all predictors for stage I-III disease. For stage IV, both Asians and Hispanics had better survival than Whites, and after full adjustment, survival improved (aHR=0.73, 95% CI: 0.63-0.84; aHR=0.74, 95% CI: 0.61-0.92, respectively).^ Conclusion. Screening disparities remain between Blacks and Whites, and Hispanics and Whites, but have decreased in recent years. Future studies should explore other factors that may contribute to screening disparities, such as physician recommendations and language/cultural barriers in this and younger populations.^ There were substantial racial/ethnic differences in CRC survival among older Whites, Blacks, Asians and Hispanics. Co-morbidities, SES, tumor characteristics, treatment and other predictor variables contributed to, but did not fully explain the CRC survival differences between Blacks and Whites. Future research should examine the role of quality of care, particularly the benefit of treatment and post-treatment surveillance, in racial disparities in survival.^

Gender differences in colorectal cancer screening and incidence in large nationwide, population-based cohorts

Background. A few studies have reported gender differences along the colorectal cancer (CRC) continuum but none has done so longitudinally to compare a cancer and a non-cancer populations.^ Objectives and Methods. To examine gender differences in colorectal cancer screening (CRCS); to examine trends in gender differences in CRC screening among two groups of patients (Medicare beneficiaries with and without cancer); to examine gender differences in CRC incidence; and to examine for any differences over time. In Paper 1, the study population consisted of men and women, ages 67–89 years, with CRC (73,666) or without any cancer (39,006), residing in 12 U.S. Surveillance Epidemiology and End-Results (SEER) regions. Crude and age-adjusted percentages and odds ratios of receiving fecal occult blood test (FOBT), sigmoidoscopy (SIG), or colonoscopy (COL) were calculated. Multivariable logistic regression was used to assess gender on the odds of receiving CRC screening over time.^ In Paper 2, age-adjusted incidence rates and proportions over time were reported across race, CRC subsite, CRC stage and SEER region for 373,956 patients, ages 40+ years, residing in 9 SEER regions and diagnosed with malignant CRC. ^ Results. Overall, women had higher CRC screening rates than men and screening rates in general were higher in the SEER sample of persons with CRC diagnosis. Significant temporal divergence in FOBT screening was observed between men and women in both cohorts. Although the largest temporal increases in screening rates were found for COL, especially among the cohort with CRC, little change in the gender gap was observed over time. Receipt of FOBT was significantly associated with female gender especially in the period of full Medicare coverage. Receipt of COL was also significantly associated with male gender, especially in the period of limited Medicare coverage.^ Overall, approximately equal numbers of men (187,973) and women (185,983) were diagnosed with malignant CRC. Men had significantly higher age-adjusted CRC incidence rates than women across all categories of age, race, subsite, stage and SEER region even though rates declined in all categories over time. Significant moderate increases in rate difference occurred among 40-59 year olds; significant reductions occurred among patients age 70+, within subsite rectum, unstaged and distant stage CRC, and eastern and western SEER regions. ^ Conclusions. Persistent gender differences in CRC incidence across time may have implications for gender-based interventions that take age into consideration. A shift toward proximal cancer was observed over time for both genders, but the high proportion of men who develop rectal cancer suggests that a greater proportion of men may need to be targeted with newer screening methods such as fecal DNA or COL. Although previous reports have documented higher CRC screening among men, higher incidence of CRC observed among men suggests that higher risk categories of men are probably not being reached. FOBT utilization rates among women have increased over time and the gender gap has widened between 1998 and 2005. COL utilization is associated with male gender but the differences over time are small.^

Increasing awareness of colorectal cancer screening through targeted exam room based video messages

Colorectal cancer (CRC) is the third largest cause of cancer death in the United States. While the disease burden is high, there are proven methods to screen for CRC and detect it at a stage that is amenable to cure. Patients with low health literacy have difficulty navigating the health care system and are at increased risk to not receive preventive care services such as colorectal cancer screening (CRCS). To address this need, an exam-room based video was developed to be played for patients in the privacy of the exam room, while they are waiting to be seen by their medical provider. In roughly 2 minutes, the video informs the patient about CRC and CRCS and how they can successfully complete CRCS. One of the key barriers to completing CRCS is the need to increase patients' knowledge and improve attitudes surrounding CRCS. This study examines the impact of the video on patients' knowledge and attitudes about CRC and CRCS in a medically underserved patient population in Houston, Texas. ^ Sixty-one patients presenting for routine medical care were enrolled in the study. Depending on their randomization, the patients either received routine information about CRC and CRCS or they watched the video. We found that the patients who did watch the video did have improvements in their knowledge and improved attitudes about CRC and CRCS. Future studies will be needed to examine whether the video improves the patients' completion of CRCS.^

The role and impact of transitional care utilization in colorectal cancer

BACKGROUND Although one out of every five gastrointestinal cancer patients needs transitional care (home-based skilled care or placement in skilled nursing or rehabilitation facilities) following treatment, few studies have examined outcomes in this population compared to patients who return home without assistance. This study has two primary goals: 1. To evaluate long-term cancer-specific outcomes in colorectal cancer patients utilizing transitional care compared to those that return home without assistance following therapy 2. To compare results using standard regression techniques and propensity scores. ^ METHODS Patients undergoing curative surgery for colorectal adenocarcinoma will be identified using data from a tertiary care Veterans Administration hospital. Survival and recurrence will then be determined from VA records and the Social Security Death Index. ^ The association between transitional care utilization and overall and disease-free survival will be evaluated using Cox proportional hazards regression to adjust for confounding factors. Predictors of transitional care utilization will be assessed using multiple logistic regression to generate a propensity score which will also be used to assess differences in survival based on transitional care use. ^ POTENTIAL SIGNIFICANCE If transitional care utilization is associated with worse survival and recurrence following therapy then it will be important to subsequently assess the mechanism in order to target interventions to improve outcomes. If there is no difference in cancer-specific outcomes, then this project can potentially highlight benefits of supportive therapy following colorectal cancer resection.^

Colorectal cancer: An insight on dietary factors

Aim. To assess the relationships between dietary factors and colorectal cancer risk. ^ Methods. We looked at all the systematic reviews published in last ten years on the topic. ^ Results. For fruits-vegetables some studies1 were significant for heterogeneity and others2 were not. In study by Aune at al3 only fruits were significant, although all the studies had protective RR between 0.90 to 0.94. For folate only case-control group of studies, the study by Sanjoaquin et al4 was significant with p heterogeneity being 0.01 and all of them had protective effect with RR between 0.75 to 0.95, for dietary as well as total folate. For fiber study by Park et al5 p was insignificant at 0.14 an RR was 0.84. Vitamin B6 study by Larsson et al6 had significant p with RR 0.90. For dietary fat both Alexander7 and Liu8 concluded that there is insufficient evidence that dietary fat is an independent causative risk factor. Only one study by Norat et al9 out of three was able to achieve significant p heterogeneity for meat. All the studies reported RR between 1.14 to 1.35, clearly implicating meat as culprit for increasing the risk of colorectal cancer. ^ Conclusions. We would recommend the use of fruits and vegetables to be protective against colorectal cancer. Also meat consumption increases the risk of colorectal cancer.^ *Please refer to dissertation for references/footnotes.^

"I understood what she meant when she said '21st century medicine'": A qualitative analysis of patient responses for plans for colorectal cancer screening following a recommendation from their physician

Although physician recommendation has been significantly associated with colorectal cancer screening (CRCS), it still does not motivate all patients to get CRCS. Although improved physician recommendation for CRCS has been shown to increase patient CRCS screening, questions remain about what elements of that discussion may lead to screening. The objective of this study is to describe patients' perceptions and interpretations about their physician's recommendation for CRCS during their annual wellness exam. A subset of patients (n=51) participating in a supplement study of a behavioral intervention trial designed to increase CRCS completed a follow-up, open-ended interview two to four weeks after their annual wellness visit. Using qualitative methods, transcripts of these interviews were analyzed. Findings suggest that most patients would follow their physician's recommendation for CRCS despite not engaging in much discussion. Patients may refrain from CRCS discussion because of a commitment to CRCS, awareness of screening guidelines, and trust in physician's honesty and beneficence. Yet many patients left their wellness exams with questions, refraining because of future plans to consult with their physicians, perceived time constraints or a lack of a patient-physician relationship. If patients are leaving their wellness exams with unanswered questions, interventions should prepare physicians for patient reticence, teaching physicians how to assure patients that CRCS is a primary care activity where all questions and concerns, including cost and scheduling, may be resolved.^

Genetic variants associated with metastatic prostate cancer

Introduction. Distant metastasis remains the leading cause of death among prostate cancer patients. Several genetic susceptibility loci associated with Prostate cancer have been identified by the Genome Wide Association Studies (GWAS). To date, few studies have explored the ability of these SNPs to identify metastatic prostate cancer. Based on the identification of genetic variants as predictors of aggressive disease, a case comparison study of prostate cancer patients was designed to explore the association of 96 GWAS single nucleotide polymorphisms (SNPs) with metastatic disease. ^ Method. 1242 histologically confirmed prostate cancer patients, with and without metastatic disease, were enrolled into the study. Data were collected from personal interviews, hospital database and abstraction of medical records. Ninety six SNPs identified from GWAS studies based on their associations with prostate cancer risk were genotyped in the study population. Univariate and multivariate logistic regression analyses were used to explore the relationships of the variants with metastatic prostate cancer in Whites and African American men. ^ Results. Four SNPs showed independent associations with metastatic prostate cancer (rs721048 in EHBP1 (2p15), rs3025039 in VEGF (6p12), rs11228565 in Intergenic(11q13.2) and rs2735839 in KLK3(19q13.33)) in the White population. For SNP rs2735839 in KLK3, genotype GA was 1.71 times as likely to be associated with metastatic prostate cancer diagnosis as genotype AA after adjusting for other significant SNPs and covariates (95% CI, 1.12-2.60; p=0.012). In men of African descent, three SNPs: rs1512268 in NKX3-1(8p21.2), rs12155172 in intergenic (7p15.3) & rs10486567 in JAZF1 (7p15.2) were positively associated with metastatic disease in the multivariate analysis. The strongest SNP was rs1512268 heterozygous genotype AG in NKX3-1(8p21.2) which was associated with 3.97-fold increased risk of metastatic prostate cancer diagnosis (95% CI, 1.69-9.34; p =0.002). ^ Conclusion. Genetic variants associated with metastatic prostate cancer were different in Whites and African American men. Given the high mortality rate recorded in men diagnosed with metastatic prostate tumor, further studies are needed to validate associations and establish their clinical application.^

Cost-effectiveness analysis of stereotactic body radiotherapy and radiofrequency ablation for medically inoperable liver metastases from colorectal cancer

This report describes the development of a Markov model for comparing percutaneous radiofrequency ablation (RFA) and stereotactic body radiation therapy (SBRT) in terms of their cost-utility in treating isolated liver metastases from colorectal cancer. The model is based on data from multiple retrospective and prospective studies, available data on different utility states associated with treatment and complications, as well as publicly available Medicare costs. The purpose of this report is to establish a well-justified model for clinical management decisions. In comparison with SBRT, RFA is the most cost-effective treatment for this patient population. From the societal perspective, SBRT may be an acceptable alternative with an ICER of $28,673/QALY. ^

Colorectal cancer screening: Participation and determinants in West Texas

Early detection by screening is the key to colorectal cancer control. However, colorectal cancer screening and its determinants in rural areas have not been adequately studied. This goal of this study was to investigate the screening participation and determinants of colonoscopy, sigmoidoscopy, and/or fecal occult blood test (FOBT) in subjects of Project Frontier from the rural counties of Cochran, Bailey and Parmer, Texas. Subjects ( n=820 with 435 Hispanics, 355 Non-Hispanic Whites, 26 African Americans, and 4 unknown ethnicity; 255 males, 565 females, aged from 40 to 92 years) were from Project FRONTIER. Stepwise logistic regression analysis was performed. Explanatory variables included ethnicity (Hispanic, Non-Hispanic white and African American), gender, health insurance, smoking status, household income, education (years), physical activity, overweight, other health screenings, personal physicians, family history (first-degree relatives) of cancers, and preferred language (English vs. Spanish) for interview/testing. The screening percentage for ever having had a colonoscopy/sigmoidoscopy (51.8%) in this cohort aged 50 years or older is well below the percentage of the nation (65.2%) and Texas (64.6%) while the percentage for FOBT (29.2%) is higher than in the nation (17.2%) and Texas (14.9%). However, Hispanics had significantly lower participation than non-Hispanic whites for colonoscopy/sigmoidoscopy (37.0% vs. 66.0%) and FOBT (16.5% vs. 41.7%), respectively. Stepwise logistic regression showed that predictors for colonoscopy, sigmoidoscopy or FOBT included Hispanic race (p = 0.0045), age (p < 0.0001), other screening procedure (p < 0.0001), insurance status (p < 0.0001) and physician status (p = 0.0053). Screening percentage for colonoscopy/sigmoidoscopy in this rural cohort is well below the national and Texas level mainly due to the lower participation of Hispanics vs. Non-Hispanic whites. Health insurance, having had a personal physician, having had screenings for other cancers, race, and older age are among the main predictors.^

Assessing the patterns of colorectal cancer treatment, adherence to treatment guidelines and survival in Texas

Colorectal cancer (CRC) is the third leading cancer in both incidence and mortality in Texas. This study investigated the adherence of CRC treatment to standard treatment guidelines and the association between standard treatment and CRC survival in Texas. The author used Texas Cancer Registry (TCR) and Medicare linked data to study the CRC treatment patterns and factors associated with standard treatment in patients who were more than 65 years old and were diagnosed in 2001 through 2007. We also determined whether adherence to standard treatment affect patients' survival. Multiple logistic regression and Cox regression analysis were used to analyze our data. Both regression models are adjusted for demographic characteristics and tumor characteristics. We found that for the 3977 regional colon cancer patients 80 years old or younger, 60.2% of them received chemotherapy, in adherence to the recommended treatment guidelines. People with younger age, female gender, higher education and lower comorbidity score are more likely adherent to this surgery guideline. Patients' adherence to chemotherapy in this cohort have better survival compared to those who are not (HR: 0.76, 95% CI: 0.68-0.84). For the 12709 colon cancer patients treated with surgery, 49.3% have more than 12 lymph nodes removed, in adherence to the treatment guidelines. People with younger age, female gender, higher education, regional stage, lager tumor size and lower comorbidity score are more likely to adherent to this surgery guideline. Patients with more than 12 lymph nodes removed in this cohort have better survival (HR: 0.86, 95% CI: 0.82-0.91). For the 1211 regional rectal cancer patients 80 years old or younger, 63.2% of them were adherent to radiation treatment. People with smaller tumor size and lower comorbidity score are more likely to adherent to this radiation guideline. There is no significant survival difference between radiation adherent patients and non-adherent patients (HR: 1.03, 95% CI: 0.82-1.29). For the 1122 regional rectal cancer patients 80 years old or younger who were treated with surgery, 76.0% of them received postoperative chemotherapy, in adherence to the treatment guidelines. People with younger age and smaller comorbidity score are related with higher adherence rate. Patients adherent with adjuvant chemotherapy in this cohort have better survival than those were not adherent (HR: 0.60, 95% CI: 0.45-0.79).^