Place of Death Among Early-Onset Colorectal Cancer Decedents in the United States, 1999–2020: National Trends and Disparities

Place of Death Among Early-Onset Colorectal Cancer Decedents in the United States, 1999–2020: National Trends and Disparities | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Place of Death Among Early-Onset Colorectal Cancer Decedents in the United States, 1999–2020: National Trends and Disparities Xuewu Zhang, jialu dai, An Jiang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9166828/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Purpose Place of death indicates where end-of-life care ultimately takes place, although it should not be treated as a stand-alone measure of care quality or goal concordance. We used national mortality data to examine long-term patterns in place of death among U.S. decedents with early-onset colorectal cancer (EOCRC) and to assess variation across demographic and regional groups. Methods We analyzed CDC WONDER death certificate data from 1999 to 2020 for decedents younger than 50 years whose underlying cause of death was colorectal cancer (ICD-10 C18-C20). Place of death was grouped as home or hospice facility versus all other locations. Temporal change was assessed with Poisson regression, and subgroup associations were examined with frequency-weighted logistic regression. Because hospice facility became a distinct category after the 2003 revision of the U.S. Standard Certificate of Death, we also conducted a sensitivity analysis restricted to 2003–2020. Results Among 75,428 EOCRC decedents, 40,840 (54.1%) died at home or in hospice facilities. The proportion of deaths in these community settings rose from 48.3% in 1999 to 66.6% in 2020. In adjusted analyses, Black decedents (aOR 0.56, 95% CI 0.54–0.59) and Asian or Pacific Islander decedents (aOR 0.72, 95% CI 0.68–0.76) were less likely than White decedents to die at home or in hospice facilities. Relative to the South, the Northeast was also associated with lower odds (aOR 0.72, 95% CI 0.69–0.76). Findings were materially unchanged in the 2003–2020 sensitivity analysis. Conclusion Over the past two decades, deaths in community settings have become more common among EOCRC decedents, but racial and regional differences remain evident. These patterns are best understood as markers of how end-of-life care is organized and accessed, rather than as direct evidence of care quality. early-onset colorectal cancer place of death hospice palliative care end-of-life care health equity Figures Figure 1 Figure 2 Figure 3 Introduction Colorectal cancer diagnosed before age 50-often referred to as early-onset colorectal cancer (EOCRC)-has emerged as a major public health concern in the United States because both incidence and mortality have risen in younger adults. [ 2 , 3 ] Although EOCRC is now widely recognized as a distinct clinical and epidemiologic challenge, much less is known about how end-of-life care is distributed in this population. For patients with advanced cancer, the final months of life are often marked by substantial symptom burden and repeated contact with the health system. Where death occurs reflects a mix of patient preference, caregiver capacity, symptom severity, local service availability, insurance coverage, and health-system practice patterns. [ 4 – 6 ] Place of death can therefore offer a useful population-level view of how end-of-life care is delivered, even though it does not by itself establish whether care was high quality or aligned with patient goals. [ 4 – 6 ] U.S. studies have shown that cancer deaths increasingly occur at home or in hospice facilities, but they have also documented persistent racial and geographic inequities. [ 7 – 9 ] Whether the same pattern holds for EOCRC is not well established. That question matters because younger patients may face distinct challenges at the end of life, including ongoing employment, childcare responsibilities, financial strain, and a greater likelihood of intensive treatment near death. [ 10 , 23 , 29 , 30 ] Using national death certificate data from CDC WONDER, we examined place-of-death patterns among EOCRC decedents in the United States from 1999 through 2020 and evaluated differences by age, sex, race, and region. We hypothesized that deaths at home or in hospice facilities would become more common over time, but that disparities across population groups would persist. Methods Data source and study population We performed a retrospective, population-based study using the CDC WONDER Underlying Cause of Death database, which compiles U.S. death certificate data. [ 11 , 12 ] We identified EOCRC decedents younger than 50 years whose underlying cause of death was colorectal cancer (ICD-10 C18-C20). Because the analysis relied on publicly available, de-identified mortality data, institutional review board approval and informed consent were not required. The U.S. Standard Certificate of Death began recording hospice facility as a distinct place-of-death category with the 2003 revision. Hospice-specific estimates before and after that revision therefore need to be interpreted with caution. To address this issue, we prespecified a sensitivity analysis limited to 2003–2020. [ 13 , 14 ] Measures and outcome Measures and outcome CDC WONDER reports aggregated counts by decedent characteristics. From these outputs, we extracted age, sex, race, and U.S. Census region. Age is provided in CDC WONDER in detailed categories and was regrouped as < 30, 30–34, 35–39, 40–44, and 45–49 years to capture clinically meaningful bands within EOCRC. Race was classified as White, Black, Asian or Pacific Islander, and American Indian/Alaska Native. Region was categorized as Northeast, Midwest, South, and West. Place of death was categorized as medical facility inpatient, medical facility outpatient or emergency department, decedent's home, hospice facility, nursing home or long-term care, dead on arrival, other, or unknown/not stated. Our primary outcome was death at home or in a hospice facility versus all other locations. We combined home and hospice facility because both represent community-based settings, while recognizing that they are not clinically identical. Home death may depend more heavily on informal caregiving and household resources, whereas hospice facility death may reflect access to dedicated institutional hospice services. Statistical analysis We summarized place-of-death distributions with counts and row percentages overall and within subgroups. Temporal change in the proportion of deaths occurring at home or in hospice facilities was examined overall and within strata defined by age, sex, race, and region. We estimated time trends with log-linked Poisson regression, entering calendar year as a continuous variable and including the logarithm of total deaths as an offset. From these models, we derived annual percent change in the proportion of deaths occurring at home or in hospice facilities. Because this approach assumes a single linear trend over time, the resulting estimates should be interpreted as average annual change across the study period rather than as joinpoint-based average annual percent change. CDC WONDER suppresses some small cell counts in stratified outputs. In tables, these cells appear as "Suppressed." For regression analyses based on aggregated counts, suppressed cells were treated as missing rather than imputed. Accordingly, subgroup-specific totals may not sum exactly to the overall total. We assessed associations between decedent characteristics and death at home or in a hospice facility using frequency-weighted logistic regression, reporting unadjusted and adjusted odds ratios (ORs/aORs) with 95% confidence intervals. Each observation in the regression dataset represented an aggregated count defined by calendar year, age group, sex, race, region, and binary place-of-death category. Multivariable models adjusted for age group, sex, race, and region. Analyses were conducted in Stata/SE 18.0 (StataCorp, College Station, TX), and two-sided P values < 0.05 were considered statistically significant. [ 16 , 17 ] Results Study population and place of death distribution Among 75,428 EOCRC decedents younger than 50 years, 40,840 (54.1%) died at home or in a hospice facility; 33,994 (45.1%) died at home and 6,846 (9.1%) in hospice facilities. The share of deaths occurring in these settings was similar in women and men, but it varied across racial groups and regions. Home/hospice death was most common among White decedents (57.5%) and least common among Black decedents (43.1%). By region, the proportion ranged from 48.6% in the Northeast to 56.8% in the West (Table 1 ). Table 1 Place of death among EOCRC decedents aged < 50 years, United States, 1999–2020, overall and by subgroup. Characteristic Total deaths Home or hospice facility, n (%) Other locations, n (%) Overall 75,428 40,840 (54.1%) 34,588 (45.9%) < 30 years 2,534 1,357 (53.6%) 1,177 (46.4%) 30–34 years 4,494 2,477 (55.1%) 2,017 (44.9%) 35–39 years 9,821 5,261 (53.6%) 4,560 (46.4%) 40–44 years 19,468 10,575 (54.3%) 8,893 (45.7%) 45–49 years 37,967 20,916 (55.1%) 17,051 (44.9%) Female 33,489 18,099 (54.0%) 15,390 (46.0%) Male 41,819 22,741 (54.4%) 19,078 (45.6%) American Indian or Alaska Native 437 255 (58.4%) 182 (41.6%) Asian or Pacific Islander 3,018 1,585 (52.5%) 1,433 (47.5%) Black or African American 14,387 6,205 (43.1%) 8,182 (56.9%) White 56,884 32,683 (57.5%) 24,201 (42.5%) South 31,444 17,130 (54.5%) 14,314 (45.5%) Northeast 12,651 6,154 (48.6%) 6,497 (51.4%) Midwest 15,773 8,808 (55.8%) 6,965 (44.2%) West 15,358 8,728 (56.8%) 6,630 (43.2%) Note: "Other locations" includes inpatient medical facility, outpatient or emergency department, nursing home/long-term care, dead on arrival, other/unknown, and not stated. Because CDC WONDER suppresses some small stratified cell counts, subgroup totals may not sum exactly to the overall total. Table 2 Temporal trends (annual percent change) in home/hospice death among EOCRC decedents aged < 50 years, United States, 1999–2020. Variable Group Annual percent change 95% CI P Overall Overall 1.81 1.65–1.97 < 0.01 Age Group 45–49 years 1.79 1.57–2.01 < 0.01 40–44 years 1.85 1.54–2.16 < 0.01 35–39 years 1.84 1.41–2.26 < 0.01 30–34 years 2.27 1.64–2.91 < 0.01 < 30 years 1.47 0.62–2.32 < 0.01 Sex Male 1.69 1.48–1.90 < 0.01 Female 1.96 1.72–2.19 < 0.01 Race White 1.56 1.39–1.73 < 0.01 American Indian or Alaska Native 2.09 -0.03-4.25 0.05 Asian or Pacific Islander 2.54 1.72–3.37 < 0.01 Black or African American 2.86 2.46–3.27 < 0.01 Region South 2.33 2.08–2.57 < 0.01 Northeast 1.38 0.98–1.78 < 0.01 Midwest 1.53 1.19–1.86 < 0.01 West 1.31 0.97–1.64 < 0.01 Temporal trends in home/hospice deaths The proportion of EOCRC deaths occurring at home or in a hospice facility increased from 48.3% in 1999 to 66.6% in 2020 (Fig. 1 A), corresponding to an annual percent change of 1.81% (95% CI 1.65–1.97; P < 0.01). When the analysis was restricted to 2003–2020, the increase remained evident, suggesting that the overall trend was not driven solely by the addition of hospice facility as a distinct reporting category. Over that restricted period, the combined home/hospice outcome increased by 2.18% per year (95% CI 2.03–2.33), home death alone increased modestly (0.46% per year, 95% CI 0.29–0.62), and hospice facility death increased more sharply (9.98% per year, 95% CI 9.33–10.63). Upward trends were seen across demographic and regional strata (Fig. 1 B-E). To reduce instability related to small cell counts and suppression, race-specific patterns were additionally summarized in Fig. 3 using annual percent change estimates rather than yearly point estimates alone. Although the magnitude of change differed across groups, the overall direction was consistent: deaths in community settings became more common over time. Factors associated with home/hospice death After adjustment for age group, sex, race, and region (reference categories: age 45–49 years, male sex, White race, and South region), younger age was associated with slightly lower odds of dying at home or in a hospice facility (Table 3 ). Decedents younger than 30 years had an adjusted odds ratio of 0.94 (95% CI 0.88-1.00; P = 0.05), while those aged 30–34 years had an aOR of 0.94 (95% CI 0.89–0.99; P = 0.02). Odds were similar for ages 35–39 and 40–44 years relative to ages 45–49 years. Table 3 Associations (OR/aOR) with home/hospice death among EOCRC decedents aged < 50 years, United States, 1999–2020. Variable Group OR 95% CI P aOR 95% CI P Overall Overall - - - - - - Age Group 45–49 years Ref. - - Ref. - - 40–44 years 0.97 0.94–1.01 0.15 0.97 0.94–1.01 0.14 35–39 years 0.95 0.91–0.99 0.03 0.94 0.90–0.99 0.01 30–34 years 0.95 0.89–1.01 0.09 0.93 0.88–0.99 0.03 < 30 years 0.92 0.84–0.99 0.04 0.89 0.82–0.97 0.01 Sex Male Ref. - - Ref. - - Female 0.99 0.96–1.02 0.58 1.00 0.97–1.03 0.77 Race White Ref. - - Ref. - - American Indian or Alaska Native 1.17 0.95–1.44 0.14 1.07 0.87–1.31 0.52 Asian or Pacific Islander 0.73 0.68–0.79 < 0.01 0.72 0.66–0.77 < 0.01 Black or African American 0.57 0.55–0.59 < 0.01 0.56 0.54–0.59 < 0.01 Region South Ref. - - Ref. - - Northeast 0.78 0.75–0.82 < 0.01 0.74 0.71–0.77 < 0.01 Midwest 1.06 1.02–1.11 0.00 0.99 0.95–1.03 0.52 West 1.12 1.07–1.16 < 0.01 1.03 0.99–1.07 0.15 Compared with White decedents, the likelihood of home/hospice death was lower among Black decedents (aOR 0.56, 95% CI 0.54–0.59; P < 0.01) and Asian or Pacific Islander decedents (aOR 0.72, 95% CI 0.68–0.76; P < 0.01), whereas estimates for American Indian/Alaska Native decedents were imprecise and not statistically significant. Regional differences were also evident: compared with the South, the Northeast had lower odds of home/hospice death (aOR 0.72, 95% CI 0.69–0.76; P < 0.01), while the Midwest and West did not differ materially after adjustment. Discussion In this national analysis of U.S. death certificate data from 1999 to 2020, we found that an increasing share of EOCRC deaths occurred at home or in hospice facilities. The rise was seen across demographic and regional subgroups, but important disparities remained. Black decedents and Asian or Pacific Islander decedents were less likely than White decedents to die in these community settings, and decedents in the Northeast were less likely than those in the South to do so. Several factors may help explain the growing proportion of community-based deaths. Over the past two decades, hospice capacity has expanded, palliative care has become more integrated into oncology practice, and many patients and families have increasingly expressed a preference for care outside the hospital when feasible. [ 6 , 18 – 20 , 31 – 33 ] Our sensitivity analysis strengthens this interpretation: even after restricting the analysis to years in which hospice facility was explicitly coded, community-based deaths continued to increase, with a modest rise in home death and a steeper increase in hospice facility death. Taken together, these findings suggest that the overall trend is unlikely to be an artifact of coding change alone. We also found persistent racial differences in community-based death after adjustment for age, sex, and region. Lower odds among Black decedents and Asian or Pacific Islander decedents likely reflect multiple structural and interpersonal influences rather than any single mechanism. Prior work has pointed to differences in hospice access, insurance coverage, referral patterns, communication, trust, cultural preferences, and caregiving resources. [ 8 , 9 , 24 , 25 ] Our data cannot distinguish among these explanations, but they are consistent with broader evidence that access to end-of-life services remains uneven across racial and ethnic groups. Regional differences followed a similar pattern. Compared with the South, the Northeast had lower adjusted odds of death at home or in a hospice facility. This variation may relate to differences in hospice supply, state policy environments, local practice styles, urban-rural composition, or hospital use near the end of life. [ 19 , 20 , 26 – 28 ] At the same time, the present study was not designed to identify the specific drivers of regional variation, so these explanations should be viewed as plausible contextual factors rather than causal inferences. Age-related differences were modest, but the youngest decedents were somewhat less likely to die at home or in hospice facilities. In EOCRC, this pattern is clinically plausible. Younger patients may be more likely to receive intensive treatment near the end of life, and their families may still be managing work obligations, childcare, or substantial financial strain. [ 23 , 29 , 30 ] Those circumstances can make sustained home-based care difficult, even when it is desired. From a public health standpoint, place-of-death patterns can help identify where access to community-based end-of-life care may be uneven and where supportive services may need to be strengthened. Still, these data should not be overinterpreted. Dying at home or in a hospice facility is not inherently preferable in every circumstance, and death certificate data do not indicate whether the observed location matched patient wishes or reflected the quality of care received. [ 4 , 5 ] Limitations This study has several limitations. CDC WONDER provides aggregated death certificate data, which prevented adjustment for important clinical factors such as cancer stage, treatment history, symptom burden, comorbidity, insurance coverage, marital status, household support, and individual hospice enrollment. Place of death on a death certificate may also be recorded with some error, and the available categories are necessarily coarse. Small-cell suppression and occasional missingness can affect subgroup estimates. We treated suppressed cells as missing in regression analyses and noted suppression in the tables, but some imprecision likely remains, especially for smaller racial groups. In addition, because the data are aggregated, residual confounding cannot be excluded. Hospice facility was not recorded as a distinct place-of-death category until the 2003 revision of the death certificate, which complicates interpretation of hospice-specific estimates across the full study period. We therefore added a sensitivity analysis restricted to 2003–2020. Finally, our trend models assumed a single linear change over time and may not capture shorter-term inflection points. Conclusions Between 1999 and 2020, a much larger proportion of EOCRC deaths in the United States occurred in community settings, specifically at home or in hospice facilities. Racial and regional differences, however, remained substantial. These findings support continued attention to equitable access to hospice and palliative care for younger patients with colorectal cancer while underscoring that place of death is an indirect marker of care delivery, not a stand-alone measure of care quality. Declarations Ethics statement This study used publicly available, de-identified data and was exempt from institutional review board review; informed consent was not required. Data availability The underlying data are publicly available through the CDC WONDER Underlying Cause of Death database. Aggregate outputs used for analysis can be reproduced using the query parameters described in the Appendix. Author contributions Xuewu Zhang extracted and curated the CDC WONDER outputs, performed the statistical analyses, generated the figures and tables, and drafted the manuscript. Jialu Dai contributed to the literature review and interpretation of the findings and provided substantive edits to improve the clarity and relevance of the Discussion. An Jiang conceived and supervised the study, guided the analytic approach, and critically revised the manuscript for important intellectual content. All authors reviewed and approved the final version and agree to be accountable for the work. Funding This research received no specific grant from any funding agency, commercial or not-for-profit sectors. Competing interests The authors declare no competing interests. Acknowledgments None. References Sonal S, Jain B, Bajaj SS, Dee EC, Boudreau C, Cusack JC, et al. Trends and Determinants of Location of Death Due to Colorectal Cancer in the United States: A Nationwide Study. Ann Surg Oncol. 2024;31(3):1447–54. Sinicrope FA. Increasing Incidence of Early-Onset Colorectal Cancer. N Engl J Med. 2022;386(16):1547–58. Li J, Guo H, Yu J, Gai Z. Research Progress in Early-onset Colorectal Cancer. J Clin Nurs Res. 2024;8(6):201–5. Ernecoff NC, Wessell KL, Bennett AV, Hanson LC. Measuring Goal-Concordant Care in Palliative Care Research. J Pain Symptom Manage. 2021;62(3):e305–14. Hoare S, Antunes B, Kelly MP, Barclay S. End-of-life care quality measures: beyond place of death. BMJ Supportive Palliat Care. 2024;14(e1):e613–21. Pinto S, Lopes S, de Sousa AB, Delalibera M, Gomes B. 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J Clin Oncol. 2024;42(19):2336–57. 10.1200/JCO.24.00542 . Additional Declarations No competing interests reported. Supplementary Files Appendix.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 10 May, 2026 Reviewers agreed at journal 27 Apr, 2026 Reviewers agreed at journal 26 Apr, 2026 Reviewers invited by journal 26 Apr, 2026 Editor assigned by journal 24 Apr, 2026 Submission checks completed at journal 16 Apr, 2026 First submitted to journal 19 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9166828","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":633232228,"identity":"4b0507cb-6f19-424f-8596-f718cd44e5ce","order_by":0,"name":"Xuewu Zhang","email":"","orcid":"","institution":"The Second Affiliated Hospital of Xi'an Jiaotong University","correspondingAuthor":false,"prefix":"","firstName":"Xuewu","middleName":"","lastName":"Zhang","suffix":""},{"id":633232229,"identity":"1970fbe7-d68e-4b37-89e0-31203e61f9cd","order_by":1,"name":"jialu dai","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"jialu","middleName":"","lastName":"dai","suffix":""},{"id":633232230,"identity":"89d0fb2d-09b4-4ad7-ae90-d3e4cd46664e","order_by":2,"name":"An Jiang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3UlEQVRIiWNgGAWjYBACxmYILcfAcABEMxOvxZiB4TCRWmAgsQGimggtzO3Mzx5+qbmTvuHg+WMSDBXWiQ3sZw8QcBibubHMsWe5MxsOs0kwnElPbODJSyCghcFMWoLtcG4/A1ALY9vhxAYJHgMCWti/SUv8O5zOBtbyjygtPGaSH9sOJ/CDtTQQp6VMmrHvsCHQL8YWCcfSjdt4cvBrMew/vk3yx7fD8gY3Dj688aHGWraf/QwBLQ3AgOYBsSQOMDAkAGk2vOqBQB7kuB8gFn8DIbWjYBSMglEwUgEA1atDUtRuA0AAAAAASUVORK5CYII=","orcid":"","institution":"The Second Affiliated Hospital of Xi'an Jiaotong University","correspondingAuthor":true,"prefix":"","firstName":"An","middleName":"","lastName":"Jiang","suffix":""}],"badges":[],"createdAt":"2026-03-19 08:23:38","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9166828/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9166828/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108804221,"identity":"f2e86563-9e59-4b96-b170-aab5ac489594","added_by":"auto","created_at":"2026-05-08 15:18:09","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":820605,"visible":true,"origin":"","legend":"\u003cp\u003eProportion of EOCRC deaths occurring at home/hospice over time overall and by subgroup (age, sex, race, and census region), United States, 1999–2020. (Race trends summarized using 5-year periods to mitigate instability from small cell counts.)\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9166828/v1/7f003fb04c069de2b2be55ac.png"},{"id":108804153,"identity":"0c5a6164-9d8c-45e3-9a0a-eeff7e7c3380","added_by":"auto","created_at":"2026-05-08 15:16:44","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":199807,"visible":true,"origin":"","legend":"\u003cp\u003eAdjusted odds ratios (aORs) with 95% confidence intervals for death at home/hospice versus other locations among EOCRC decedents (\u0026lt;50 years), United States, 1999–2020. Multivariable frequency-weighted logistic regression adjusted for age group, sex, race, and census region (reference: 45–49 years, male, White, South); dashed line indicates aOR=1.0. EOCRC: ICD-10 C18–C20 (including C19).\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-9166828/v1/09478d3ae13affeab13889ca.png"},{"id":108531310,"identity":"bc996bcc-c1a1-4d0c-a181-3c207bec2a1e","added_by":"auto","created_at":"2026-05-05 16:00:35","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":203124,"visible":true,"origin":"","legend":"\u003cp\u003eAnnual percent change in death at home or hospice facility between 1999 and 2020 in EOCRC decedents by race (A), sex (B), age group (C), and region (D).\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-9166828/v1/bf944ffb2c86697e7bb2e488.png"},{"id":108809010,"identity":"62d75d5b-71cc-4ae6-afb8-f57fe483953b","added_by":"auto","created_at":"2026-05-08 15:48:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1314259,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9166828/v1/55677db3-11ad-439c-93a0-0c41605c329a.pdf"},{"id":108531307,"identity":"539cd27d-2168-4206-94b9-c44318075826","added_by":"auto","created_at":"2026-05-05 16:00:34","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":13952,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-9166828/v1/dda9b0d882e07463bdd8e961.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Place of Death Among Early-Onset Colorectal Cancer Decedents in the United States, 1999–2020: National Trends and Disparities","fulltext":[{"header":"Introduction","content":"\u003cp\u003eColorectal cancer diagnosed before age 50-often referred to as early-onset colorectal cancer (EOCRC)-has emerged as a major public health concern in the United States because both incidence and mortality have risen in younger adults. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] Although EOCRC is now widely recognized as a distinct clinical and epidemiologic challenge, much less is known about how end-of-life care is distributed in this population.\u003c/p\u003e \u003cp\u003eFor patients with advanced cancer, the final months of life are often marked by substantial symptom burden and repeated contact with the health system. Where death occurs reflects a mix of patient preference, caregiver capacity, symptom severity, local service availability, insurance coverage, and health-system practice patterns. [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] Place of death can therefore offer a useful population-level view of how end-of-life care is delivered, even though it does not by itself establish whether care was high quality or aligned with patient goals. [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eU.S. studies have shown that cancer deaths increasingly occur at home or in hospice facilities, but they have also documented persistent racial and geographic inequities. [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] Whether the same pattern holds for EOCRC is not well established. That question matters because younger patients may face distinct challenges at the end of life, including ongoing employment, childcare responsibilities, financial strain, and a greater likelihood of intensive treatment near death. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eUsing national death certificate data from CDC WONDER, we examined place-of-death patterns among EOCRC decedents in the United States from 1999 through 2020 and evaluated differences by age, sex, race, and region. We hypothesized that deaths at home or in hospice facilities would become more common over time, but that disparities across population groups would persist.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData source and study population\u003c/h2\u003e \u003cp\u003eWe performed a retrospective, population-based study using the CDC WONDER Underlying Cause of Death database, which compiles U.S. death certificate data. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] We identified EOCRC decedents younger than 50 years whose underlying cause of death was colorectal cancer (ICD-10 C18-C20). Because the analysis relied on publicly available, de-identified mortality data, institutional review board approval and informed consent were not required.\u003c/p\u003e \u003cp\u003eThe U.S. Standard Certificate of Death began recording hospice facility as a distinct place-of-death category with the 2003 revision. Hospice-specific estimates before and after that revision therefore need to be interpreted with caution. To address this issue, we prespecified a sensitivity analysis limited to 2003\u0026ndash;2020. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMeasures and outcome\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003eMeasures and outcome\u003c/div\u003e \u003cp\u003eCDC WONDER reports aggregated counts by decedent characteristics. From these outputs, we extracted age, sex, race, and U.S. Census region. Age is provided in CDC WONDER in detailed categories and was regrouped as \u0026lt;\u0026thinsp;30, 30\u0026ndash;34, 35\u0026ndash;39, 40\u0026ndash;44, and 45\u0026ndash;49 years to capture clinically meaningful bands within EOCRC. Race was classified as White, Black, Asian or Pacific Islander, and American Indian/Alaska Native. Region was categorized as Northeast, Midwest, South, and West.\u003c/p\u003e \u003cp\u003ePlace of death was categorized as medical facility inpatient, medical facility outpatient or emergency department, decedent's home, hospice facility, nursing home or long-term care, dead on arrival, other, or unknown/not stated. Our primary outcome was death at home or in a hospice facility versus all other locations. We combined home and hospice facility because both represent community-based settings, while recognizing that they are not clinically identical. Home death may depend more heavily on informal caregiving and household resources, whereas hospice facility death may reflect access to dedicated institutional hospice services.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eWe summarized place-of-death distributions with counts and row percentages overall and within subgroups. Temporal change in the proportion of deaths occurring at home or in hospice facilities was examined overall and within strata defined by age, sex, race, and region.\u003c/p\u003e \u003cp\u003eWe estimated time trends with log-linked Poisson regression, entering calendar year as a continuous variable and including the logarithm of total deaths as an offset. From these models, we derived annual percent change in the proportion of deaths occurring at home or in hospice facilities. Because this approach assumes a single linear trend over time, the resulting estimates should be interpreted as average annual change across the study period rather than as joinpoint-based average annual percent change.\u003c/p\u003e \u003cp\u003eCDC WONDER suppresses some small cell counts in stratified outputs. In tables, these cells appear as \"Suppressed.\" For regression analyses based on aggregated counts, suppressed cells were treated as missing rather than imputed. Accordingly, subgroup-specific totals may not sum exactly to the overall total.\u003c/p\u003e \u003cp\u003eWe assessed associations between decedent characteristics and death at home or in a hospice facility using frequency-weighted logistic regression, reporting unadjusted and adjusted odds ratios (ORs/aORs) with 95% confidence intervals. Each observation in the regression dataset represented an aggregated count defined by calendar year, age group, sex, race, region, and binary place-of-death category. Multivariable models adjusted for age group, sex, race, and region. Analyses were conducted in Stata/SE 18.0 (StataCorp, College Station, TX), and two-sided P values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered statistically significant. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStudy population and place of death distribution\u003c/h2\u003e \u003cp\u003eAmong 75,428 EOCRC decedents younger than 50 years, 40,840 (54.1%) died at home or in a hospice facility; 33,994 (45.1%) died at home and 6,846 (9.1%) in hospice facilities. The share of deaths occurring in these settings was similar in women and men, but it varied across racial groups and regions. Home/hospice death was most common among White decedents (57.5%) and least common among Black decedents (43.1%). By region, the proportion ranged from 48.6% in the Northeast to 56.8% in the West (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePlace of death among EOCRC decedents aged\u0026thinsp;\u0026lt;\u0026thinsp;50 years, United States, 1999\u0026ndash;2020, overall and by subgroup.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal deaths\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHome or hospice facility, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOther locations, n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e75,428\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40,840 (54.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e34,588 (45.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;30 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2,534\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1,357 (53.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1,177 (46.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026ndash;34 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4,494\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2,477 (55.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2,017 (44.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e35\u0026ndash;39 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9,821\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5,261 (53.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4,560 (46.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e40\u0026ndash;44 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19,468\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10,575 (54.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8,893 (45.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e45\u0026ndash;49 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37,967\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20,916 (55.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17,051 (44.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33,489\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18,099 (54.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15,390 (46.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41,819\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22,741 (54.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19,078 (45.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmerican Indian or Alaska Native\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e437\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e255 (58.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e182 (41.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsian or Pacific Islander\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3,018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1,585 (52.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1,433 (47.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack or African American\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14,387\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6,205 (43.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8,182 (56.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56,884\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32,683 (57.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24,201 (42.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSouth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31,444\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17,130 (54.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14,314 (45.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNortheast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12,651\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6,154 (48.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6,497 (51.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMidwest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15,773\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8,808 (55.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6,965 (44.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15,358\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8,728 (56.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6,630 (43.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNote: \"Other locations\" includes inpatient medical facility, outpatient or emergency department, nursing home/long-term care, dead on arrival, other/unknown, and not stated. Because CDC WONDER suppresses some small stratified cell counts, subgroup totals may not sum exactly to the overall total.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTemporal trends (annual percent change) in home/hospice death among EOCRC decedents aged\u0026thinsp;\u0026lt;\u0026thinsp;50 years, United States, 1999\u0026ndash;2020.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAnnual percent change\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.65\u0026ndash;1.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45\u0026ndash;49 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.57\u0026ndash;2.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u0026ndash;44 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.54\u0026ndash;2.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u0026ndash;39 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.41\u0026ndash;2.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u0026ndash;34 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.64\u0026ndash;2.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;30 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.62\u0026ndash;2.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.48\u0026ndash;1.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.72\u0026ndash;2.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.39\u0026ndash;1.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAmerican Indian or Alaska Native\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.03-4.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAsian or Pacific Islander\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.72\u0026ndash;3.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBlack or African American\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.46\u0026ndash;3.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSouth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.08\u0026ndash;2.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNortheast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.98\u0026ndash;1.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMidwest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.19\u0026ndash;1.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.97\u0026ndash;1.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eTemporal trends in home/hospice deaths\u003c/h2\u003e \u003cp\u003eThe proportion of EOCRC deaths occurring at home or in a hospice facility increased from 48.3% in 1999 to 66.6% in 2020 (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA), corresponding to an annual percent change of 1.81% (95% CI 1.65\u0026ndash;1.97; P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). When the analysis was restricted to 2003\u0026ndash;2020, the increase remained evident, suggesting that the overall trend was not driven solely by the addition of hospice facility as a distinct reporting category. Over that restricted period, the combined home/hospice outcome increased by 2.18% per year (95% CI 2.03\u0026ndash;2.33), home death alone increased modestly (0.46% per year, 95% CI 0.29\u0026ndash;0.62), and hospice facility death increased more sharply (9.98% per year, 95% CI 9.33\u0026ndash;10.63).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eUpward trends were seen across demographic and regional strata (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB-E). To reduce instability related to small cell counts and suppression, race-specific patterns were additionally summarized in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e using annual percent change estimates rather than yearly point estimates alone. Although the magnitude of change differed across groups, the overall direction was consistent: deaths in community settings became more common over time.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eFactors associated with home/hospice death\u003c/h3\u003e\n\u003cp\u003eAfter adjustment for age group, sex, race, and region (reference categories: age 45\u0026ndash;49 years, male sex, White race, and South region), younger age was associated with slightly lower odds of dying at home or in a hospice facility (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Decedents younger than 30 years had an adjusted odds ratio of 0.94 (95% CI 0.88-1.00; P\u0026thinsp;=\u0026thinsp;0.05), while those aged 30\u0026ndash;34 years had an aOR of 0.94 (95% CI 0.89\u0026ndash;0.99; P\u0026thinsp;=\u0026thinsp;0.02). Odds were similar for ages 35\u0026ndash;39 and 40\u0026ndash;44 years relative to ages 45\u0026ndash;49 years.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociations (OR/aOR) with home/hospice death among EOCRC decedents aged\u0026thinsp;\u0026lt;\u0026thinsp;50 years, United States, 1999\u0026ndash;2020.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eaOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45\u0026ndash;49 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u0026ndash;44 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.94\u0026ndash;1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.94\u0026ndash;1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u0026ndash;39 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.91\u0026ndash;0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.90\u0026ndash;0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u0026ndash;34 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.89\u0026ndash;1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.88\u0026ndash;0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;30 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.84\u0026ndash;0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.82\u0026ndash;0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.96\u0026ndash;1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.97\u0026ndash;1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAmerican Indian or Alaska Native\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.95\u0026ndash;1.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.87\u0026ndash;1.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAsian or Pacific Islander\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.68\u0026ndash;0.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.66\u0026ndash;0.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBlack or African American\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.55\u0026ndash;0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.54\u0026ndash;0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSouth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNortheast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.75\u0026ndash;0.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.71\u0026ndash;0.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMidwest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.02\u0026ndash;1.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.95\u0026ndash;1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.07\u0026ndash;1.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.99\u0026ndash;1.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eCompared with White decedents, the likelihood of home/hospice death was lower among Black decedents (aOR 0.56, 95% CI 0.54\u0026ndash;0.59; P\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and Asian or Pacific Islander decedents (aOR 0.72, 95% CI 0.68\u0026ndash;0.76; P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), whereas estimates for American Indian/Alaska Native decedents were imprecise and not statistically significant. Regional differences were also evident: compared with the South, the Northeast had lower odds of home/hospice death (aOR 0.72, 95% CI 0.69\u0026ndash;0.76; P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), while the Midwest and West did not differ materially after adjustment.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this national analysis of U.S. death certificate data from 1999 to 2020, we found that an increasing share of EOCRC deaths occurred at home or in hospice facilities. The rise was seen across demographic and regional subgroups, but important disparities remained. Black decedents and Asian or Pacific Islander decedents were less likely than White decedents to die in these community settings, and decedents in the Northeast were less likely than those in the South to do so.\u003c/p\u003e \u003cp\u003eSeveral factors may help explain the growing proportion of community-based deaths. Over the past two decades, hospice capacity has expanded, palliative care has become more integrated into oncology practice, and many patients and families have increasingly expressed a preference for care outside the hospital when feasible. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] Our sensitivity analysis strengthens this interpretation: even after restricting the analysis to years in which hospice facility was explicitly coded, community-based deaths continued to increase, with a modest rise in home death and a steeper increase in hospice facility death. Taken together, these findings suggest that the overall trend is unlikely to be an artifact of coding change alone.\u003c/p\u003e \u003cp\u003eWe also found persistent racial differences in community-based death after adjustment for age, sex, and region. Lower odds among Black decedents and Asian or Pacific Islander decedents likely reflect multiple structural and interpersonal influences rather than any single mechanism. Prior work has pointed to differences in hospice access, insurance coverage, referral patterns, communication, trust, cultural preferences, and caregiving resources. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] Our data cannot distinguish among these explanations, but they are consistent with broader evidence that access to end-of-life services remains uneven across racial and ethnic groups.\u003c/p\u003e \u003cp\u003eRegional differences followed a similar pattern. Compared with the South, the Northeast had lower adjusted odds of death at home or in a hospice facility. This variation may relate to differences in hospice supply, state policy environments, local practice styles, urban-rural composition, or hospital use near the end of life. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] At the same time, the present study was not designed to identify the specific drivers of regional variation, so these explanations should be viewed as plausible contextual factors rather than causal inferences.\u003c/p\u003e \u003cp\u003eAge-related differences were modest, but the youngest decedents were somewhat less likely to die at home or in hospice facilities. In EOCRC, this pattern is clinically plausible. Younger patients may be more likely to receive intensive treatment near the end of life, and their families may still be managing work obligations, childcare, or substantial financial strain. [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] Those circumstances can make sustained home-based care difficult, even when it is desired.\u003c/p\u003e \u003cp\u003eFrom a public health standpoint, place-of-death patterns can help identify where access to community-based end-of-life care may be uneven and where supportive services may need to be strengthened. Still, these data should not be overinterpreted. Dying at home or in a hospice facility is not inherently preferable in every circumstance, and death certificate data do not indicate whether the observed location matched patient wishes or reflected the quality of care received. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has several limitations. CDC WONDER provides aggregated death certificate data, which prevented adjustment for important clinical factors such as cancer stage, treatment history, symptom burden, comorbidity, insurance coverage, marital status, household support, and individual hospice enrollment. Place of death on a death certificate may also be recorded with some error, and the available categories are necessarily coarse.\u003c/p\u003e \u003cp\u003eSmall-cell suppression and occasional missingness can affect subgroup estimates. We treated suppressed cells as missing in regression analyses and noted suppression in the tables, but some imprecision likely remains, especially for smaller racial groups. In addition, because the data are aggregated, residual confounding cannot be excluded.\u003c/p\u003e \u003cp\u003eHospice facility was not recorded as a distinct place-of-death category until the 2003 revision of the death certificate, which complicates interpretation of hospice-specific estimates across the full study period. We therefore added a sensitivity analysis restricted to 2003\u0026ndash;2020. Finally, our trend models assumed a single linear change over time and may not capture shorter-term inflection points.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eBetween 1999 and 2020, a much larger proportion of EOCRC deaths in the United States occurred in community settings, specifically at home or in hospice facilities. Racial and regional differences, however, remained substantial. These findings support continued attention to equitable access to hospice and palliative care for younger patients with colorectal cancer while underscoring that place of death is an indirect marker of care delivery, not a stand-alone measure of care quality.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics statement\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study used publicly available, de-identified data and was exempt from institutional review board review; informed consent was not required.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData availability\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe underlying data are publicly available through the CDC WONDER Underlying Cause of Death database. Aggregate outputs used for analysis can be reproduced using the query parameters described in the Appendix.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthor contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eXuewu Zhang extracted and curated the CDC WONDER outputs, performed the statistical analyses, generated the figures and tables, and drafted the manuscript. Jialu Dai contributed to the literature review and interpretation of the findings and provided substantive edits to improve the clarity and relevance of the Discussion. An Jiang conceived and supervised the study, guided the analytic approach, and critically revised the manuscript for important intellectual content. All authors reviewed and approved the final version and agree to be accountable for the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency, commercial or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgments\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSonal S, Jain B, Bajaj SS, Dee EC, Boudreau C, Cusack JC, et al. Trends and Determinants of Location of Death Due to Colorectal Cancer in the United States: A Nationwide Study. 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J Clin Oncol. 2024;42(19):2336\u0026ndash;57. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1200/JCO.24.00542\u003c/span\u003e\u003cspan address=\"10.1200/JCO.24.00542\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-gastrointestinal-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijgc","sideBox":"Learn more about [Journal of Gastrointestinal Cancer](https://www.springer.com/journal/12029)","snPcode":"12029","submissionUrl":"https://submission.nature.com/new-submission/12029/3","title":"Journal of Gastrointestinal Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"early-onset colorectal cancer, place of death, hospice, palliative care, end-of-life care, health equity","lastPublishedDoi":"10.21203/rs.3.rs-9166828/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9166828/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003ePlace of death indicates where end-of-life care ultimately takes place, although it should not be treated as a stand-alone measure of care quality or goal concordance. We used national mortality data to examine long-term patterns in place of death among U.S. decedents with early-onset colorectal cancer (EOCRC) and to assess variation across demographic and regional groups.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe analyzed CDC WONDER death certificate data from 1999 to 2020 for decedents younger than 50 years whose underlying cause of death was colorectal cancer (ICD-10 C18-C20). Place of death was grouped as home or hospice facility versus all other locations. Temporal change was assessed with Poisson regression, and subgroup associations were examined with frequency-weighted logistic regression. Because hospice facility became a distinct category after the 2003 revision of the U.S. Standard Certificate of Death, we also conducted a sensitivity analysis restricted to 2003\u0026ndash;2020.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong 75,428 EOCRC decedents, 40,840 (54.1%) died at home or in hospice facilities. The proportion of deaths in these community settings rose from 48.3% in 1999 to 66.6% in 2020. In adjusted analyses, Black decedents (aOR 0.56, 95% CI 0.54\u0026ndash;0.59) and Asian or Pacific Islander decedents (aOR 0.72, 95% CI 0.68\u0026ndash;0.76) were less likely than White decedents to die at home or in hospice facilities. Relative to the South, the Northeast was also associated with lower odds (aOR 0.72, 95% CI 0.69\u0026ndash;0.76). Findings were materially unchanged in the 2003\u0026ndash;2020 sensitivity analysis.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eOver the past two decades, deaths in community settings have become more common among EOCRC decedents, but racial and regional differences remain evident. These patterns are best understood as markers of how end-of-life care is organized and accessed, rather than as direct evidence of care quality.\u003c/p\u003e","manuscriptTitle":"Place of Death Among Early-Onset Colorectal Cancer Decedents in the United States, 1999–2020: National Trends and Disparities","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-05 16:00:29","doi":"10.21203/rs.3.rs-9166828/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-10T22:46:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"176370101347067193942273514792249042313","date":"2026-04-27T14:31:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"240645346751716266690015268385037418750","date":"2026-04-27T01:32:48+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-27T00:56:36+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-24T13:38:33+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-16T07:13:47+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Gastrointestinal Cancer","date":"2026-03-19T08:16:05+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-gastrointestinal-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijgc","sideBox":"Learn more about [Journal of Gastrointestinal Cancer](https://www.springer.com/journal/12029)","snPcode":"12029","submissionUrl":"https://submission.nature.com/new-submission/12029/3","title":"Journal of Gastrointestinal Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"d14fe7a1-22cb-4eba-b75a-d798ef7529be","owner":[],"postedDate":"May 5th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-10T22:46:21+00:00","index":29,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-05T16:00:29+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-05 16:00:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9166828","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9166828","identity":"rs-9166828","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}