Society of University Surgeons| Volume 154, ISSUE 3, P444-452, September 2013

Age, poverty, acculturation, and gastric cancer


      Gastric cancer is an aggressive disease, and overall changes in incidence rates have been noted. There are conflicting data on whether young patients have worse outcomes than older patients; the roles of tumor biology and access to care are critical to answering this question. Our objectives were to explore how gastric cancer rates, receipt of care, and outcomes are affected by age, poverty, and acculturation.


      A total of 42,187 patients were identified from the 1980–2009 Surveillance, Epidemiology, and End Results registry. We compared trends in incidence rates between patients <40, 40–64, and ≥65 years using ordinary least-squares regression. Separate multivariate regression models were used to evaluate the impact of age, poverty, and acculturation on receipt of cancer-directed therapy and hazard of mortality.


      Patients <40 years had stable incidence rates over the 3-decade period compared with decreases for patients 40–64 and ≥65 years. They are also more likely to present with aggressive, advanced disease (P < .0001 for both). On unadjusted and adjusted analyses, patients <40 years were more likely to receive cancer-directed therapies and have better survival than those ≥65 years. Residing in high poverty areas was associated with not receiving appropriate cancer-directed therapy; the adjusted hazard ratio of mortality for surgically resected patients was, however, not affected by poverty. Residing in high immigration areas was associated with a low hazard ratio (HR, 0.74; 95% confidence interval [CI], 0.7–0.79) of mortality. Foreign-born patients also had a low hazard ratio (HR, 0.87; 95% CI, 0.83–0.91) of mortality.


      Although trends in incidence rates for patients <40 years remain unchanged and their disease is aggressive and advanced at presentation, they do not experience disparities in gastric cancer-directed therapies and survival after resection. For patients residing in impoverished areas or high immigration communities, operative resection and adjustment for appropriate aftercare is associated with comparable or better survival when compared with those living in low poverty or low immigration areas. Disparities remain in receipt of appropriate cancer-directed therapies, and future efforts should focus on decreasing structural variations in care and unconscious biases regarding patients from these vulnerable communities.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. Stomach cancer [cited 2013 Jan 1]. Available from:

      2. SEER stat fact sheets: stomach [cited 2013 Jan 1]. Available from: at

        • Bleyer A.
        • Ulrich C.
        • Martin S.
        Young adults, cancer, health insurance, socioeconomic status, and the Patient Protection and Affordable Care Act.
        Cancer. 2012; 118: 6018-6021
        • Anderson W.F.
        • Camargo M.C.
        • Fraumeni Jr., J.F.
        • Correa P.
        • Rosenberg P.S.
        • Rabkin C.S.
        Age-specific trends in incidence of noncardia gastric cancer in US adults.
        JAMA. 2010; 303: 1723-1728
        • Lau M.
        • Le A.
        • El-Serag H.B.
        Noncardia gastric adenocarcinoma remains an important and deadly cancer in the United States: secular trends in incidence and survival.
        Am J Gastroenterol. 2006; 101: 2485-2492
        • Wachtel M.S.
        • Zhang Y.
        • Chiriva-Internati M.
        • Frezza E.E.
        Different regression equations relate age to the incidence of Lauren types 1 and 2 stomach cancer in the SEER database: these equations are unaffected by sex or race.
        BMC Cancer. 2006; 6: 65
        • Smith B.R.
        • Stabile B.E.
        Extreme aggressiveness and lethality of gastric adenocarcinoma in the very young.
        Arch Surg. 2009; 144: 506-510
        • Theuer C.P.
        • de Virgilio C.
        • Keese G.
        • et al.
        Gastric adenocarcinoma in patients 40 years of age or younger.
        Am J Surg. 1996; 172: 473-476
        • Al-Refaie W.B.
        • Hu C.Y.
        • Pisters P.W.
        • Chang G.J.
        Gastric adenocarcinoma in young patients: a population-based appraisal.
        Ann Surg Oncol. 2011; 18: 2800-2807
        • Smith E.C.
        • Ziogas A.
        • Anton-Culver H.
        Association between insurance and socioeconomic status and risk of advanced stage Hodgkin lymphoma in adolescents and young adults.
        Cancer. 2012; 118: 6179-6187
        • Guggenheim D.E.
        • Shah M.A.
        Gastric cancer epidemiology and risk factors.
        J Surg Oncol. 2013; 107: 230-236
        • McWhorter W.P.
        • Schatzkin A.G.
        • Horm J.W.
        • Brown C.C.
        Contribution of socioeconomic status to black/white differences in cancer incidence.
        Cancer. 1989; 63: 982-987
        • Bradley C.J.
        • Given C.W.
        • Roberts C.
        Race, socioeconomic status, and breast cancer treatment and survival.
        J Natl Cancer Inst. 2002; 94: 490-496
        • Gornick M.E.
        • Eggers P.W.
        • Riley G.F.
        Associations of race, education, and patterns of preventive service use with stage of cancer at time of diagnosis.
        Health Serv Res. 2004; 39: 1403-1427
        • Woods L.M.
        • Rachet B.
        • Coleman M.P.
        Origins of socio-economic inequalities in cancer survival: a review.
        Ann Oncol. 2006; 17: 5-19
        • Kent E.E.
        • Sender L.S.
        • Largent J.A.
        • Anton-Culver H.
        Leukemia survival in children, adolescents, and young adults: influence of socioeconomic status and other demographic factors.
        Cancer Causes Control. 2009; 20: 1409-1420
        • Miller B.A.
        • Hankey B.F.
        • Thomas T.L.
        Impact of sociodemographic factors, hormone receptor status, and tumor grade on ethnic differences in tumor stage and size for breast cancer in US women.
        Am J Epidemiol. 2002; 155: 534-545
        • McGhan L.J.
        • Etzioni D.A.
        • Gray R.J.
        • Pockaj B.A.
        • Coan K.E.
        • Wasif N.
        Underuse of curative surgery for early stage upper gastrointestinal cancers in the United States.
        J Surg Res. 2012; 177: 55-62
        • Al-Refaie W.B.
        • Gay G.
        • Virnig B.A.
        • et al.
        Variations in gastric cancer care.
        Cancer. 2010; 116: 465-475
        • Hsieh M.-C.
        • Velasco C.
        • Wu X.-C.
        • Pareti L.A.
        • Andrews P.A.
        • Chen V.W.
        Influence of socioeconomic status and hospital type on disparities of lymph node evaluation in colon cancer patients.
        Cancer. 2012; 118: 1675-1683
        • Coburn N.G.
        • Swallow C.J.
        • Kiss A.
        • Law C.
        Significant regional variation in adequacy of lymph node assessment and survival in gastric cancer.
        Cancer. 2006; 107: 2143-2151
        • Link B.G.
        • Phelan J.C.
        Understanding sociodemographic differences in health—the role of fundamental social causes.
        Am J Public Health. 1996; 86: 471-473
        • Macdonald J.S.
        • Smalley S.R.
        • Benedetti J.
        • et al.
        Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction.
        N Engl J Med. 2001; 345: 725-730
        • Wu X.-C.
        • Lund M.J.
        • Kimmick G.G.
        • et al.
        Influence of race, insurance, socioeconomic status, and hospital type on receipt of guideline-concordant adjuvant systemic therapy for locoregional breast cancers.
        J Clin Oncol. 2012; 30: 142-150
        • Singh G.K.
        • Siahpush M.
        Ethnic-immigrant differentials in health behaviors, morbidity, and cause-specific mortality in the United States: an analysis of two national data bases.
        Human Biol. 2002; 74: 83-109