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Why many stage 3 colorectal cancer patients skip chemo

As risk factors such as no health insurance and low income accumulate, colorectal cancer patients are less likely to finish chemotherapy.

Chemotherapy after stage 3 colorectal cancer surgery is effective and its side effects are usually limited, yet about a third of patients do not receive the treatment.

To better understand why -- and to inform practices that encourage patients to undergo chemo -- Arden Morris, MD, a professor of surgery, and her colleagues surveyed patients. They found that the more social risk factors a patient faced, the more likely they were to skip chemotherapy. Those factors included not having health insurance, being low income, not having a spouse or someone else to care for them, and an experience of discrimination.

However, even when patients had a number of risk factors, the likelihood they would complete chemotherapy improved if they had a strong social support network -- from a spouse or partner, faith community, friends, or coworkers.

"If you have people offering to help with chores, giving you rides, encouraging you to get to your appointments, you're much more likely to undergo treatment," Morris said.

The research was published June 9 in JAMA Network Open.

Increase in survival

Chemotherapy after surgery for stage 3 colorectal cancer is associated with a 30% increase in five-year survival rates, according to the study. The treatment is generally less debilitating than treatments for other forms of cancer, Morris said, adding that many patients can work while receiving chemotherapy.

"It's pretty rare for colon cancer chemo to be horrible," Morris said. Still, 38% of Americans with stage 3 colorectal cancer do not receive it.

For the study, Morris and her colleagues evaluated survey responses from 1,087 patients who had undergone surgery in Michigan and Georgia. Besides asking whether they completed chemotherapy, the researchers inquired about eight risk factors that could adversely affect the patients' willingness or ability to complete chemotherapy: no spouse or partner, unemployment, low income, no health insurance, low health literacy, perceived discrimination, caring for another adult, and additional health problems.

They also asked about the patients' social support. They found that among patients who reported little social support, 60% of those who listed no risk factors completed chemotherapy, while 40% of those with six or more risk factors did. Among patients who reported having a high level of social support, 90% of those with no risk factors completed the treatments, while 75% of those with six or more risk factors did.

Patients fail to complete treatment for a host of reasons, Morris said. Though the side effects of colorectal cancer chemotherapy are comparatively mild, infusion sessions take a few hours a day, five days a week, for three to six months.

Although infusion centers try to work around patients' schedules, Morris said, "Some people lose their jobs during chemotherapy treatment." If they lose their jobs, she noted, they often lose their insurance.

The burden of chemo

Other patients might feel overwhelmed by other responsibilities, such as caring for an aging parent, she said. Sometimes they are struggling with health problems besides the cancer, so patients and their physicians may perceive chemotherapy as too much of a burden.

Another problem may be unclear communication, Morris said. Surgeons will sometimes tell patients after surgery, "I got it all." Patients often interpret that to mean, "Your cancer is gone," and they don't understand why chemotherapy is necessary. But what the surgeons mean is that they were able to remove cancerous tissues they could see, though microscopic cancer remains.

Morris said there are steps clinicians can take to encourage more patients to undergo chemotherapy. They can, for example, ask patients to think about assembling a team of supporters to help them get through the treatment.

Physicians can also ask about any fears or treatment barriers patients might face and do what they can to address those barriers; in addition, they can ensure that patients understand the importance of continuing treatment.

"Instead of just talking to the patient, we need to get better at listening -- asking questions and ascertaining what patients understand and value," Morris said.

"Surgeons and oncologists also need to work together and present a united voice for patients. Fortunately, this is increasingly common in cancer clinics. If patients hear the same recommendations from all their doctors, they'll have more trust in us."


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