Effects of Social and Contextual Factors Including Marital Status and Children on the Use of Palliative Chemotherapy in Metastatic Colorectal Cancer Shahid Ahmed, MD, PhD, FRCPC, FACP,* Tayyba Baig, PhD,* Nayyer Iqbal, MD, FRCP,* Duc Le, MD, MSc, FRCPC,* Haji Chalchal, MD,* Adnan Zaidi, MD, FRCPC,* and Punam Pahwa, PhD† Background: There is evidence that social and contextual factors such as living alone are associated with outcomes in cancer patients. How- ever, little is known about their influence on the use of palliative che- motherapy in metastatic colorectal cancer (mCRC). In this study, we examined social and contextual factors, including marital status, having children, and distance to a cancer center, for their association with the use of chemotherapy in patients with mCRC. Methods: A cohort of patients with mCRC diagnosed from 2006 to 2010 in Saskatchewan was evaluated. Logistic regression analyses were performed to assess the relationship between the variables and use of chemotherapy. Results: Of 569 patients, 326 (57%) received chemotherapy significant differences were noted between the chemotherapy versus no chemo- therapy groups with respect to age (62 vs. 76 y), poor performance status (18% vs. 58%), comorbid illness (24% vs. 63%), low albumin (61% vs. 89%), anemia (61% vs. 87%), elevated alkaline phosphatase (53% vs. 84%), elevated creatinine (6% vs. 11%), hyponatremia (20% vs. 14%), primary tumor resection (61% vs. 47%), metastasectomy (21% vs. 9%), mean distance to cancer center (98.7 ± 113.6 vs. 127.8 ± 124.6 km), married/partnered (67% vs. 33%), and having chil- dren (64% vs. 36%). On multivariate logistic regression analysis, low performance status (odds ratio [OR], 5.1; 95% confidence interval [CI]: 3.1-8.1), not having children (OR, 3.3; 95% CI: 1.78-6.2), hypona- tremia (OR, 2.9; 95% CI: 1.6-5.1), elevated alkaline phosphatase (OR, 2.9; 95% CI: 1.8-4.8), and low albumin (OR, 2.2; 95% CI: 1.2-3.8) were correlated with low rates of chemotherapy use. Conclusions: Our results showed that the use of chemotherapy in patients with mCRC significantly varies between those with and with- out children. Key Words: metastatic colorectal cancer, children, marital status, travel distance, chemotherapy (Am J Clin Oncol 2019;42:363–366) U se of chemotherapy and biological agents in patients with metastatic colorectal cancer (mCRC) has resulted in sig- nificant improvement in their rates of disease control and overall survival. 1,2 We previously examined a cohort of patients with mCRC diagnosed from 1992 to 2005 and noted that despite improvement in the outcomes, a substantial number of real-world patients did not receive chemotherapy. 3 Several patient-related and tumor-related factors correlate with the use of chemotherapy, such as baseline performance status, comor- bid illness, and age. Nevertheless, we did not assess the correlation between nonmedical factors, for instance, travel distance and family support and the use of chemotherapy. There is evidence that social and contextual factors such as living alone and distance to a cancer center are associated with out- comes in cancer patients. 4,5 Travel burden is an important contextual factor that can affect access to cancer care and treatment. 5–7 In one study, Lin and colleagues reported that in patients with node-positive colon cancer, travel distance to a cancer center was correlated with the use of adjuvant chemotherapy. They found that the rate of adjuvant chemotherapy was significantly lower in patients with an increased travel burden. 5 In addition, some studies have found that social support, such as marital status, also correlates with the use of cancer therapy and outcomes in cancer patients. 4,8,9 For example, Aizer and colleagues assessed out- comes of patients with various solid and hematological malig- nancies using the Surveillance, Epidemiology and End Results administrative database and found that use of definitive treat- ment for cancer was 53% higher among married patients compared with unmarried patients. 4 Likewise, by evaluating the California Registry database, Ayanian et al 8 showed that unmarried patients with stage III colon cancer and stage II or III rectal cancer were significantly less likely to receive chemo- therapy as compared with other patients. Moreover, Randen et al 9 also reported similar results and found an association between being married and receiving palliative chemotherapy using univariate analysis. In contrast to travel distance and marital status, little is known about whether having children can influence the use of palliative chemotherapy in patients with mCRC. In this study, we examined social and contextual factors, including marital status, having children, and distance to a cancer center, for their association with the use of chemo- therapy in patients with mCRC. METHODS The study was approved by the University of Saskatch- ewan Biomedical Ethics Board. Using the Saskatchewan Tumor Registry, which is one of the oldest registries that prospectively collects data on all cancer patients in the province, eligible patients with synchronous mCRC, who were diagnosed from 2006 to 2010 in Saskatchewan, were identified. Patients with From the *Saskatchewan Cancer Agency, Division of Oncology; and †Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, SK Canada. Part of the data was presented in the Annual Gastrointestinal Cancer Symposium on January 20, 2018 in Chicago, IL. The authors declare no conflicts of interest. Reprints: Shahid Ahmed, MD, PhD, FRCPC, FACP, Saskatoon Cancer Center, 20 Campus Drive, University of Saskatchewan, Saskatoon, SK Canada, S7N4H4. E-mail: shahid.ahmed@saskcancer.ca. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0277-3732/19/4204-0363 DOI: 10.1097/COC.0000000000000530 ORIGINAL ARTICLE American Journal of Clinical Oncology  Volume 42, Number 4, April 2019 www.amjclinicaloncology.com | 363 Copyright r 2019 Wolters Kluwer Health, Inc. All rights reserved.