Colorectal Cancer Disparities Across the Continuum of Cancer Care: A Systematic Review and Meta-Analysis

Of 1,199 publications, 60% focused on Pr evention , Screen ing, or Diagnosis, 20% on Survivorship, 15% on Treatme nt, an d 1% on End-of-Life Care. A tot al of 16 studies, including 1,110,674 patien ts, were a pplied to thr ee sep ara te me ta-analyses r egardi ng utilizatio n of Surgery. Black color ectal cancer pati ents wer e less likely to receive surge ry, twice as lik ely to refuse surge ry, and less likely to r e ceive laparoscopic surgery when compared to Whi te pa tien ts. Concl usions Over th e past 10 years, the majori ty of published res earch r emained focused on t he preven tion, screening, or di agnosis domain. Given th e observed trea tmen t dispari ties and p er sistently el evated disease-specific mortali ty among Black patien ts, futur e efforts t o reduc e colorec t al cancer dispari ties should include int erven tions within Surg ery.

colorect al cancer ; cancer car e continuum; dispari ties ; utiliza tion of sur gery All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted December 2, 2021. ; https://doi.org/10.1101/2021.07.01.21259880doi: medRxiv preprint 3

Despite substa ntial p rogress in car e for patien ts with color ectal cance r over th e p ast several decades, these a dvances have be en unev enly distribut ed. While colo rect al cancer mortali ty rates h ave decreas ed for Black and Whi te pa tien ts a t all stages, the declin es have be en small er for Black pati ents by 15%-28% at every stage. 1 Similarly, the B lack community continues to suffer from worse adverse colorect al cancer ou tcomes such as higher risk-adjusted pos t-oper ative complica t ions and lower over all survival rates. 2 The mor tality differenc e may reflect lower util izati on of recomme nded color ectal cance r trea tmen t among Black pati ents when co mpared to Whit e pati ents . 3 The majority of resea rch and policy work in colorectal canc er dispari ties p erforme d before 2010 was focused on preventio n, scree ning an d diagnosis. 4,5 Over two decades , the re were more than 230 publications and num erous policy and cli nical efforts focused on int ervent ions to i ncrease colo rect al cancer scree ning for Black patie nts. Thes e efforts were associ ate d with an incre as e in colorect al cancer screening ra tes from 32% (2000) to 59% (2016) among Black patients which was s imilar to ra tes among White p atie nts. 6,7 Effective efforts to amelio rat e dispari ties in colorectal canc er ou tcomes have be e n focused on preventi on, scre ening, and diagnosis . Litt le is known about efforts to er adicat e dispariti es across th e remainde r of the colo rect al cancer car e continuum. We conduct ed this systema tic review and meta- analysis to guide futur e rese arch efforts . To that en d, first, we assess ed the volum e of colorectal ca ncer dispariti es publicatio ns att ribut ed t o eac h domain of the cancer ca re con tinuum. Secondly, because Surgery is the prima ry and most commo n trea tmen t for non-metas ta tic colorec ta l cancer, we ex amined dispariti es within the u tiliza tion of Surge ry, as a tre atmen t modality . All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted December 2, 2021. ; https://doi.org/10.1101/2021.07.01.21259880doi: medRxiv preprint 4

Protocol We perfo rmed this systemic revi ew and meta-analysis in accordanc e with th e Pre ferred Repor ting It ems for Systematic Reviews and Met a-Analyses (PRISMA) guidelines . 8 A preliminary version was published on medRxiv. Sinc e its post ing, the study has be en significantly modified. Inform atio n Sourc es and Sear ch Stra te gi es We perfo rmed a systema tic lite ratu re se arch of MEDLINE and Scopus datab ases u sing search terms rel at ed to colo rect al cancer dispa ri ties. Tabl e 1 in the Suppl ement gives th e search str ategy used for MEDLINE. Within the Scopus da tabas e, the following sea rch te rms were appli ed: “colorec tal” AND “disparities”. Ou r search es were limit ed t o studies with full manuscripts, pu blishe d in English, and from Janua ry 1, 2011 to March 29, 2021. Eligibilit y Criteria We included st udies th at r epor ted on col on, rect al, or colo rect al dispari ties within the Unit ed Stat es. W e consider ed studi es along the entir e cancer car e contin uum, as per the Institu te of Me dicine Framework. 9 Commenta ries, l ett ers, a nd publications r epor ting on popula tions ou tside of the Uni ted Stat es were e xcluded . Review ar ticles we re exclud ed from th e primary analysis, b ut thei r refe rence lis ts were used as a sourc e of additio nal rel evant ar ticles. The meta-analysis was designed specific ally to examin e dispari ties in th e utiliz ati on of Surgery as a tre atmen t modality . For th e met a-anal ysis, we included studies rel ating to disp arities in the ut ilizati on of Surgery: recei pt of surgery, r efusal of surgery, and rec eipt of lapa roscopic vers us open surgery. In accordance with the r esults of the syst e matic review, we tail ored o ur met a-anal yses to patie nts of Black race. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted December 2, 2021. ; https://doi.org/10.1101/2021.07.01.21259880doi: medRxiv preprint 5 Study Selec tio n an d Dat a Collec tio n Two authors (S.R. an d S.S.) indep ende ntl y screened study ti tles and a bstrac ts for poten tial inclusion. Full te xt of th e rel evant st udies was extrac ted and reviewed for eligibili t y. Disagreements betwee n the r eviewers wer e resolve d by consensus or by the thi rd aut hor (R.R .K). We manually searched r efer ence lists of review ar ticle s for pertine nt addi tional s tudies . Two authors (S.R. and S.S .) independ ently e xtr acte d data from the i ncluded studies a nd discrepa ncies were r esolved by discussion. Data I tems We captu red t he following: (1) General S tudy Informati on including: ti tle, a utho r(s), year of publication , data sou rce, an d sample size ; (2) Primary Disparity including: race and ethnicity, SES (income level, insurance st atus, loc ation , hospital effects, o r educa tion level), age, gender, comorbiditi es/disabilities , and LGBTQI A+ ; (3) Categorization by th e Cancer Care C ontinuum including: Prevention, Scr eening, or Diagnosis, Trea tment, Su rvivorship, or End-of-Life Care; (4) Treatment Type including: Radia tion, Systemic The rapy, S urgery, or Combined Tr eatm ent; (5) Utili zation of Surge ry Outcome(s) including: receip t of surgery, refusal of surgery, and rec eipt of lapa ros copic versus open surgery. For st udies included in the me ta -analyses, we ex tract ed th e odds ra tios (ORs), correspo nding confidence inte rvals (CIs), the focus and control group sampl e sizes, and the cova riates . Risk of Bias in Indivi du al Studi es Two authors (S.R. an d S.S.) indep ende ntl y assessed the studi es included in t he me ta-analysis for poten tial bias using th e Newcastl e-O tta wa Scale. 10 This scale assesses the po ten t ial of bias in 3 domains: (1) selection of the study groups; (2) comparabili ty of groups; and (3) ascertainme nt of exposu re and outcome. Th e maximum score in th e sele ction domain is 4 stars, in the compar abil ity domain is 2 stars, and in the ou tcome domain is 3 sta rs. St udies with scores of 7 or higher wer e con sidered as having a low risk of bias, scores of 4 to 6 as having a m odera te risk of bias, and scor es less than 4 as having a high risk of bias. Disagreemen ts were r esolved by consensus or by the t hird au thor (R.R .K). All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted December 2, 2021. ; https://doi.org/10.1101/2021.07.01.21259880doi: medRxiv preprint 6 Statisti cal A nalysis We calculat ed combined estimat es for th e five separat e analyses focused on u tiliz ation of Surgery outcomes : recei pt of surgery (colorecta l, colon, an d rect al), refusal of surgery, and rec eipt of laparoscopic versus op en surgery. Firs t, we studied th e associati on be tween r ece ipt of surgery and Black race using ORs and cor respondi ng 95% CIs from the multivariate analyses p resen ted in th e included studies . Given that som e studie s repor ted th eir r esults for color ectal p ro cedures combined while othe rs repo rte d colon and r ectal se parat ely, we conduct ed thr ee sep ara te a nalyses for each procedur e type : colorec tal, colon , and re ctal. Nex t, we calcula ted pool ed multivari ate ORs and th e associat ed 95% CIs for the a ssociation betwee n refusal of colon surgery and B la ck race. In th e fifth and final analysis, we calculated the association b etwee n receip t of lapar osco pic versus open surgery and Black rac e; multivariat e ORs and correspond ing 95% CIs were obtaine d from the rel evant stu dies. When da ta was unclear o r did not p rovid e the app ropri at e outcome , the s tudy was not included in the analysis for th e outcome . A funnel plot and regr ession asymmetry t est wer e originally planne d to assess for small study bias, but could no t be performed du e th e limited numb er o f studies in each analysis. The Cochran’s tes t was used to assess fo r hete rogen eity of the includ ed studi es in each respective analysis. For t he he ter ogenei t y measure, de rived from two-tail ed tes ts , p values less than 0.10 were de emed to in dicate significanc e. For est plo ts and th e I 2 statis tic resul ts were also assesse d with I 2 > 50% indicating modera te he ter ogeneity. If hete rogen eity was observed (p/i9T/i9T50%), a random-effects model was used to poo l the estima te ac ross studies , per an alysis, with the DerSimonian-Laird met hod. Oth erwise, a fixed-effects model was applied . All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted December 2, 2021. ; https://doi.org/10.1101/2021.07.01.21259880doi: medRxiv preprint 7 All datab ase sea rch resul ts were downlo aded, merg ed, and d eduplicat ed by the s ystematic review managemen t software , Covidence (Veritas Heal th Inn ovation, Melbou rne, Australi a). All analyses were perfo rmed using Sta ta sta tistical so ftware version 16.1 (Sta taCorp , College S tatio n, TX).

A tot al of 2,674 poten tially rel evant publi cations were titl e and abst ract r eviewed (Figure 1). Among them, 1,199 me t the inclusion cri teria for this systematic r eview. Over 60 % of all included publications wer e focused on Preven tion , Screening, o r Diagnosis, followed by Survivorship (20% ), Treatme nt (15%), and End-of-Li fe Care (1%) (Fi gure 2). Within th e studi es repo rting on t rea tme nt dispari ties, 46% were focused on R ace and Ethnicity, followed by SES (28% ), Age (17% ), Gende r (6%), Disabilities/Comorbidities (3%), and LGBTQI+ (0.0%). Within th e tr ea tment ca tegory, the most commonly examined dispar at e popula ti on was Black race. Of 95 articles th at include d surgical dat a, 69 /1,199 (6% ) focused exclusively on surgic al dispariti es and 26/1,199 (2% ) included Surgery as part o f a combined trea tmen t (Table 1). Sixty-seven of the tota l 95 surgery-rela te d articles r epor ted on o the r outcom es such as pain management o r delay in t rea tment and fourte en ei the r did not includ e multivaria te analysis, odds ratios, o r 95% CIs. Ultimat ely, 14 publicat ions (16 studies) were included in th e me ta-analysis as thr ee separa te an alyses: rec eipt of color ectal c ancer surgery, refusal of colon surgery, a nd receip t of laparoscopic versus op en surgery and pa tients of Black rac e. 11-24 Bliton et . al and S amuel et . al were applied t o both r eceip t of colorect al canc er (colon) surgery and Black race and r ec eipt of colorec tal cancer (rectal) surgery and B lack race wit hout pa tien t overlap . All 14 included pub lications were retr ospective , and th e to tal numbe r of patien ts included was 1,110,674 (Table 2 in the Suppl ement). All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted December 2, 2021. ; https://doi.org/10.1101/2021.07.01.21259880doi: medRxiv preprint 8 Risk of Bias Within St udies The quality of studies r anged be tween 6 and 7, indicating pr edominan tly high quality with low risk of bias. For comparabili ty of groups, the variabl es chosen wer e a measur e for patien t comorbidi ties and stage of cancer . All of the s tudies r e porte d a loss-to-follow up due to their re trospec tive natu re and inheren t limita tions within ce rtain n ation al datab ases. (Table 3 in th e Suppleme nt ). Meta-a nal yses Receip t of Surgery and Bl ack Ra ce A tot al of five studies evaluat ed th e recei pt of colorect al cancer surg ery with moderat e hete rogen eity ( I 2 = 94.3%; p = 0.00). In th e random-effects model us ed to ob tain p ooled resu lts, Black patien ts with color ectal cance r were l ess likely to undergo Surge ry (OR 0.75, 95% CI 0.60-0.93) when compared t o Whit e pati ents . The addition al two analyses by cancer type, colon or r ectal , produc ed similar resu lts, but with low between-stu dy hete rogen eity, (colo n: I 2 = 0.0%; p = 0.955) and (recta l: I 2 = 39 .2%; p = 0.193). The analyses by colon or rect al cancer includ ed an additi onal six st udies th at wer e sp ecific to the cance r type: colon (n=3) and rec tal (n=3). Black r ace was associated with a lower likeliho o d of receiving colon cancer surgery (OR 0.78, 95% CI 0.74-0.8 3); and a lower likelihood of r eceiving rec tal cancer surg ery (OR 0.73, 95% CI 0.65-0.81) (Figure 3). Refusal of Colon Sur gery a nd Bl ack Ra ce The 2 studies on refusal of colon surg ery and Black race demons tra ted mod era te hete rogen eity (I 2 = 61.7%; p = 0.106). Applying the ran d om-effects model, our pool ed analysis in dicated t hat Bl ack patien ts ar e more likely to r efuse colon s urgery than W hite p ati ents (OR 2.41, 95 % CI 1.91-3.06) (Fi gure 4). All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted December 2, 2021. ; https://doi.org/10.1101/2021.07.01.21259880doi: medRxiv preprint 9 Receip t of Lapar osco pic vers us Open c olo rectal ca ncer Surger y an d Bla ck Race There was limited b etwe en-study het ero geneity pres ent ed in th e thr ee publica tio ns which assessed th e receip t of lapar oscopic vers us open colorec tal cance r surgery and Bl ack race (I 2 = 0.0%; p = 0.977). In our pool ed analysis, Black pa ti ents were l ess likely to receive l aparosco pic versus open colorect al cancer surge ry when compare d to Whit e pati ents (OR 0.91 , 95% CI 0.88-0.94) (Figure 5).

In 2002, the I nstitu te of Me dicine’s r epor t titl ed “Unequal Tr eatm ent : Confronting Racial and Ethnic Disparities in He alth Car e”, summarized the multi-facto rial ro ots of racial d ispariti es, including patien t, pr ovider, and syst emic factors. 25 Since the publica tion of tha t re por t, th e majority of the published res earch has r emained focuse d on preventi on, scre ening and diagnosis . Our app roach offers resea rchers pe rspective in to what a reas within colorec tal cancer disp ariti es res ea rch may be satura ted versus those which remain un expl ored o r under explo red . We iden tified a dispro port iona te res earc h focus on prevention , screening, o r diag nosis at 64% of all included studi es – four times the volu me of studies focused on tr eatm ent (15 %) and a tenfold difference to pub lications focused o n Sur gery as a trea tmen t (6%). Within the tre a tment st udies, t he majority focused on racial minori ties (46%) and low socioeconomic status (28%) a nd few addressed dispariti es among the LG BTQI+ po pulati o n. Out of th e 1,199 primary ar ticles, no n e of the studi es examine d inte rventio ns designed t o addr ess dispariti es in Surgery. Our findings are consist ent with p revious litera tur e, citing th e limited r esea rch de dicated t o interven tions r egarding color ectal canc er surgery and the r ela tively vast amount o f research on colorect al cancer pr eventi on, scre ening, or diagnosis. 4,5,26,27, 33, 34 Other color ectal cancer reviews have noted a disp ropor tion ately high amoun t of represe nta tion of racial mino riti es and a very limited repr esent ation of t he LGBTQI + communi ty. 30,31 This i s particularly probl ematic given the colo rect al cancer tr eatm ent ba rrie rs and dispar at e outcomes no ted in th e LGBTQI + popula ti on. 32,33,34 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted December 2, 2021. ; https://doi.org/10.1101/2021.07.01.21259880doi: medRxiv preprint 10 Our systema tic review highlights the limi ted numbe r of studies dedic ate d to t rea t ment, particula rly Surgery. The lack of focus on trea tmen t dispari ties may provide an insi ght into th e curre nt stat e of dispariti es within the Unit ed Sta t es. For e xample , curre nt color ectal canc e r rela ted de ath r ates are 47% higher in Black men and 34% higher in Black women compare d to th eir W hite coun terp arts . 37 According to our findings, Bl ack patien ts have been less likely to u tilize Su rgery fo r the t rea tmen t of colorect al cancer and are twice as likely to refuse Surge ry compared t o Whit e pati ents. Fu rth er, th e laparoscopic app roach t o resec tion has b een used less oft en in Black pati ents (as opposed t o the op en approach) when compar ed to Whi te p ati ents. Thes e surgical tr eatm ent differ ence s have been found to underlie a substan tial por tion of th e mor tality and survival dispari ties in color ecta l cancer outcomes for the Black pa tien t popula tion. 11,14 Receip t of Colore ct al Surgery When conside ring the mod ern publish ed litera tur e, our systema tic review and me ta-analysis further suggests that p ati ent medical fac tors do no t fully explain th e dispar at e del ivery of surgical care to Black pati ents . 14 Additiona lly, in the co ntex t of work by Gill et. , al which repo rte d similar odds of receiving colon cancer surg ery betwe en Black and Whit e pati ents in an e qual acc ess healthca re system, 38 it is plausible tha t access to car e is driving some of the observed differ e nces in the utili zati on of Surgery for colorect al cancer . Refusal of Colon Sur gery The limited lit era tur e on refusal of surge ry also found an increase d likelihood of B lack patien ts refusing recommende d colon surgery wh en compared to Whi te pa tien ts. Refusal of recommended surgery by Black patien ts can be at tribu t ed to socio-cultu ral factors including mis trust of th e US heal th care system, 39,40 the poten tial for a high er likelihood of poo r communication b et ween providers a nd patien ts of varying racial backgrounds, 41 and low health li ter acy among some Black patients . 42,43 Inte resti ngly, physicians commonly overestimat e pati ent l evel of health li te racy, especially among Black All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted December 2, 2021. ; https://doi.org/10.1101/2021.07.01.21259880doi: medRxiv preprint 11 patien ts (54%) compared to Whit e pati e nts (11%). 44 This may be impeding the clarification of common misunderstan dings that d rive pati ents to refuse surgery; misunde rstan dings such as the beli ef that Surgery enabl es cancer t o sprea d or conf usion regarding t he differenc e betw een malignant and metast atic diseas e. 45 Laparosc opi c versus Ope n Colore cta l Can cer Surgery Laparoscopic color ectal r esecti on is associated with be tt er over all outcom es, incl uding: lower frequency of blood tr ansfusions and surg ical site infections an d decre ased ra tes o f readmission and mortali ty. 46,47,48,49 Additionally, th e lapar oscopic approach for colon r esecti on has also been shown to

in an 11.3% r eductio n in postop er ative ileus and a sho rt er lengt h of stay when compared wit h open surgery. 49 Ou r finding that Bl ack patients a re less likely to receive lap arosco pic surgery, when compared t o Whit e pati ents, may cont ri bute t o the obs erved dispa riti es in surgical outcomes and colorect al cancer ou tcomes, in gen eral . 50,51 Patient an d provider fact ors may influen ce the obse rved dispari ties in t he rec eipt of laparoscopic surge ry among Black patien ts. Body mass index (BMI) is the p rimary factor demonst rat ed to be a pr edicto r of open versus lapa rosc opic surgery for colorec tal cancer . 52 It is possible tha t differences in BMI b etwe en th e typical Bl ack and White p atie nt may drive th e obs erved differences in receip t of laparoscopic surge ry. 53 If this is the unde rlying etiology, th en conside rati on for preop era tive optimiza tion to ove rcome this ba rrie r must be pursu ed. Studies, that adjusted for BM I, have sho wn that th e unde rutiliz ation of lap arosco pic colorectal surgery cannot b e enti rely ex plained by differences in pati ent cha ract eristics or a vailability of laparoscopic eq uipment . 54 However, geo graphic and hospit al factors ar e significantly associated wit h receip t of laparoscopic colo rect al surger y, thus poten tially influencing a pa tien t’s options for surgical approach . 55,56 Keller et. al r epor ted t hat t he following factors indicat ed a higher lik elihood of approaching colon canc er lapa roscopicall y: higher volume surgeons (3.5 times), Colorect al versus All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted December 2, 2021. ; https://doi.org/10.1101/2021.07.01.21259880doi: medRxiv preprint 12 Gene ral Surge ons (1.3 times), and urba n versus rural loca tion of hospit al (1.5 time s). Additionally, hospitals in th e No rthe ast and West ern United S tat es were mor e likely to utili ze the lapa roscopic approach versus hospi tals in th e Midwes t. 57 As such, differences in hospi tal and s urgeon selec tion betwee n Black and Whi te pa tien ts may also influence the o bserved dispa rity in th e use of laparoscopic surgery among Black patie nts. Limitati ons This study has several limita tions. Bas ed on the e xisting lit era tur e, all of the s tudi es included in the met a-analysis were r etr ospective . Due to th e limita tions of the da ta sou rces u sed for the prima ry studies, longi tudinal ou tcomes could no t be evaluat ed. We obse rved not able he te rogenei ty for two analyses: rec eipt and refusal of colorec ta l surgery. To address this limi tati on, we used random effects models for thes e analyses. Fo r the receip t of surgery analysis, we also conduct ed separa te an alyses of nonoverlappi ng patie nt groups who r ece ived surgery on the colon or th e rect um. These individual analyses had limited h et erogen eity and t he resul ts among all thr ee analyses p rese nted similar odds ratios . Furth er, s tudies within the r eceipt of surgery analysis, are largely limit ed by the inabili ty to assess whether l ack of surgery was due to pati e nt refusal or whe the r surgery was not pr esent ed as an op tion. The two studies t hat e xamin ed refusal of Surgery had overlap ping patie nt coho rts . Int eres tingly, the more rece nt study demo nstra ted tre nd t owards a grea ter likelih ood for Black pa ti ents to r efuse surge ry than th e ea rlier st udy. Finally, within t he risk of bias assessment for comparabili ty of groups, the prima ry variable of collecting a me asure for com orbiditi es, was absen t in thr ee studi es. T wo of the studies wer e used in the r eceip t of colorect al surgery meta-analysis which may explain th e obs erved high hete rogen eity.

Despite dispari ties t hat exist ac ross the c ontinuum of cancer car e, th e vast majori ty of research in th e past 10 years has rem ained focused on P reventi on, Scre ening, or Diagnosis within racial minoriti es. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted December 2, 2021. ; https://doi.org/10.1101/2021.07.01.21259880doi: medRxiv preprint 13 Relatively few studies have address ed di sparities withi n the tre atmen t domain . A ll of the surgical studies were obse rvational wit hout a ny studies t esting inte rventi ons to r educe surgical di sparities . Futu re studies should includ e an ex pansion of t he exis ting work to unde rstudi ed popula tions such as the LGBTQI+ community. Additi onally, becau se Black patien ts remai n less likely to rec eive colorec tal surgery, twice as likely to r efuse surgery, and less likely to receive l aparosco pic sur gery for colorecta l cancer, futur e efforts to reduc e color ect al cancer dispari ties should includ e int er ventions within Surge ry. Figure Legend Figure 1. Flow Diagram of Study Disposition Figure 2. Propor tion of Studi es Published on Disparities in Colorec tal Cancer Car e Across the Cance r Care Continuum Figure 3. Me ta-analysis of 9 Studies Ass e ssing Receipt of Colorect al, Colon, o r Rec tal Cancer Surg ery and Black Race Figure 4. Me ta-analysis of 2 Studies Ass e ssing Refusal of Colon Cancer Surgery an d Black Race Figure 5. Me ta-analysis of 3 Studies Ass e ssing Receipt of Laparoscopic versus O pe n Colorectal Cance r Surgery and Black Race Data Availability Statement: The data t hat supp ort the findings of this study are openly availa ble in PubMed (https://pubmed.ncbi .nlm.nih .gov/ ) at Referenc e number 11; DO I Link: 10.1016/j.amjsurg.2020.06.020 Referenc e number 12; DO I Link: 10.1245/s10434-017-6306 -4 Referenc e number 13; DO I Link: 10.1016/j.suronc.2018.11.010 Referenc e number 14; DO I Link: 10.1158/1055-9965.EPI-20-095 0 Referenc e number 15; DO I Link: 10.1002/cncr.26034 Referenc e number 16; DO I Link: 10.1007/s00464-017-5782 -8 Referenc e number 17; DO I Link: 10.1002/jso.25917 Referenc e number 18; DO I Link: 10.1016/s0027-9684 (15)30112 -7 Referenc e number 19; DO I Link: 10.1002/cam4.3316 Referenc e number 20; DO I Link: 10.1097/DCR.0000000000000874 Referenc e number 21; DO I Link: 10.1097/MCG.0000000000000951 Referenc e number 22; DO I Link: 10.2105/AJPH.2014.302079 Referenc e number 23; DO I Link: 10.1097/SLA.0000000000001781 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted December 2, 2021. ; https://doi.org/10.1101/2021.07.01.21259880doi: medRxiv preprint 14 Referenc e number 24; DO I Link: 10.1002/cncr.32529

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Dis Colon Rectum . 2015 Oct;58(10):950-6. doi: 10.1097/DCR.0000000000000448. PMID: 26347967. 54. Reames BN , Shee tz KH, Wai ts SA, Dimick JB, Reg enbogen SE. Geogr aphic variati on in use of laparoscopic colec tomy for colon cancer . J Clin Oncol. 2014 Nov 10;32(32):3667-7 2. doi: 10.1200/JCO.2014.57.1588 . Epub 2014 O ct 6. PMID: 25287826; PMCID: PMC4220 045. 55. Keller, D.S. , Parikh, N. & Sen agore , A. J. Pr edicting oppor tuni ties to inc reas e utiliza t ion of laparoscopy for colon cance r. Surg En dos c 31, 1855–1862 (2017). https://doi. org/10.1007/s00464-016-518 5-2 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted December 2, 2021. ; https://doi.org/10.1101/2021.07.01.21259880doi: medRxiv preprint Figure I. Flow Diagram of Study Disposition All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted December 2, 2021. ; https://doi.org/10.1101/2021.07.01.21259880doi: medRxiv preprint Figure 2. Proportion of Studies Published on Disparities in Colorectal Cancer Care Across the Cancer Care Continuum Prevention, Diagnosis and Screening (64%) Treatment (15%) Survivorship (20%) End of Life Care (1%) All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted December 2, 2021. ; https://doi.org/10.1101/2021.07.01.21259880doi: medRxiv preprint Figure 3. Meta-analysis of 9 Studies Assessing Receipt of Colorectal, Colon, or Rectal Cancer Surgery and Black Race All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted December 2, 2021. ; https://doi.org/10.1101/2021.07.01.21259880doi: medRxiv preprint Figure 4. Meta-analysis of 2 Studies Assessing Refusal of Colon Cancer Surgery and Black Race All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted December 2, 2021. ; https://doi.org/10.1101/2021.07.01.21259880doi: medRxiv preprint Figure 5. Meta-analysis of 3 Studies Assessing Receipt of Laparoscopic versus Open Colorectal Cancer Surgery and Black Race All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted December 2, 2021. ; https://doi.org/10.1101/2021.07.01.21259880doi: medRxiv preprint Table I. Distribution of Treatment Disparities Studies within Colorectal Cancer by Treatment Type and Study Population Distribution of Treatment Disparities Studies within Colorectal Cancer by Treatment Type Treatment Type Surgery Combined Radiation Systemic Therapy w/ Surgery w/o Surgery Publications, n (%) 69 (6% ) 26 (2% ) 37 (3% ) 13 (1% ) 33 (3% ) Distribution of Treatment Disparities Studies within Colorectal Cancer by Study Population Disparate Population Race and Ethnicity SES Age Gender Disabilities/Comorbidities LGBTQI+ Publications, n (%) 82 (46% ) 50 (28% ) 30 (17% ) 10 (6% ) 6 (3% ) 0 (0% ) Not e. Percen tages for t he type of t rea tm ent ar e calculat ed out of the to tal numb er of dispariti es studi es; Percentag es for the stu dy populati on are calculated ou t of the t otal numb er of pu blications on t rea tmen t dispariti es All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprintthis version posted December 2, 2021. ; https://doi.org/10.1101/2021.07.01.21259880doi: medRxiv preprint