QS214 - Social Vulnerability Index, Red Flag Symptoms and Timely Assessment in Squamous Cell Carcinoma of the Anus

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Purpose/Background: Squamous cell carcinoma of the anus (SCCA) is a rare cancer and chemoradiation is the standard treatment for locoregional disease. Unfortunately, the incidence of advanced stage disease and mortality has been increasing. While patients with localized disease have an expected 5-year overall survival rate of 78%, survival drops to 19% in patients with distant metastasis. In colon cancer, “red flag” symptoms have been identified and may be useful for earlier detection. Recognizing red flag symptoms may therefore also prove helpful in SCCA. We hypothesized that social factors may contribute to delay in assessment. Therefore, the aim of this study was to determine the effect of sociodemographic factors and red flag symptoms on the timely assessment/official diagnosis by a colorectal surgeon.

Methods/Interventions: A retrospective cohort study of patients diagnosed with SCCA at two geographically distinct tertiary referral centers from 2018-2023 was performed. Patients with a history of inflammatory bowel disease, known history of anal dysplasia or HIV were excluded. The date of the red flag symptoms spurring referral was recorded (RFD), as was the date of final pathologic diagnosis. Demographics, clinical presentations and colonoscopy dates were obtained using the electronic medical record for the year prior to diagnosis. Social Vulnerability Index (SVI) scores by county were obtained from the CDC public data file (score closer to 1 indicating higher vulnerability). Patients were then identified as having an assessment delay if the time between RFD and pathologic diagnosis was > 6 weeks. Univariate analyses were performed using Wilcoxon rank sum test or Chi-square tests as appropriate. Modified Poisson regression was performed to identify the impact of SVI and red flag symptoms on assessment/diagnostic delay.

Results/Outcomes: A total of 264 patients were identified, 48 (18.2%) of whom experienced a delay in assessment/official diagnosis with a mean time of 90 days (SD144). Seventy (26.5%) patients were referred to a specialty other than colorectal surgery first (ie, dermatology, plastic surgery, gynecology). The median age was 62yrs(IQR 53,69); 181(68.6%)were female, 242(91.7%) white, and 252(95.5%) were insured. The median SVI was 0.54(IQR0.32,0.83). The most common symptom in those with a delay was bleeding (11,30.6%) while in those without a delay, the most common was a bleeding mass (38, 23.3%; p=0.25). On regression analysis, uninsured patients were twice as likely to experience a delay(IRR2.006, p=0.009). Increasing age was also associated with a delay (IRR1.03, p=0.05). There were no differences in delay by SVI or other sociodemographic factors.

Conclusion/Discussion: The time between recognition/referral to colorectal surgery and official pathologic diagnosis for patients with SCCA was 3 months, and a quarter of patients were referred to specialists other than colorectal surgery. Lack of Insurance was associated with delay, however, other sociodemographic factors, including SVI, were not. This suggests that delays occurring after patients present to a healthcare professional are not necessarily the result of measurable health accessibility factors. Future research to understand referral patterns and improve recognition may help to reduce unnecessary delays.