Socioeconomic and Racial Disparities in the Use of Robotic-Assisted Proctectomy in Rectal Cancer

Background: Rectal cancer surgery is technically demanding, especially in males. Robotic assistance may help overcome these challenges. This study aimed to identify factors associated with robotic-assisted proctectomy in rectal cancer. Methods: Retrospective case-control analysis of patients with clinical stage I-III rectal adenocarcinoma who underwent proctectomy from the National Cancer Database (2010-2019) was conducted. Univariable and multivariable binary logistic regression analyses were conducted to determine predictive factors of robotic-assisted proctectomy in rectal cancer. Results: 67 145 patients (60.9% male; mean age: 61.15 +/- 12.49 years) were included. 44.7% had stage III disease and 66.2% received neoadjuvant radiation. The surgical approach was laparotomy (n = 29 725), laparoscopy (n = 21 657), and robotic-assisted proctectomy (n = 15 763). Independent predictors for the use of robotic-assisted proctectomy were age <50 years (OR: 1.06; P = .032), male sex (OR: 1.07, P < .001), Asian race (OR: 1.25; P < .001), private insurance (OR: 1.25; P < .001), rectal cancer treatment between 2015 and 2019 (OR: 3.52; P < .001), stage III disease (OR: 1.06; P = .048), neoadjuvant radiation (OR: 1.26; P < .001), and pull-through coloanal anastomosis (OR: 1.15; P < .001). Robotic-assisted surgery was less often used in Black (OR: .857, P < .001) and American Indian patients (OR: .62, P = .002) and those with a Charlson score = 3 (OR: .818, P = .002), living in rural areas (OR: .865, P = .033), who were uninsured (OR: .611, P < .001), and undergoing pelvic exenteration (OR: .461, P < .001). Conclusions: Demographic and insurance disparities of robotic-assisted proctectomy are Black and American Indian patients and those with higher Charlson comorbidity index scores and uninsured patients were less likely to undergo robotic-assisted proctectomy. While patients with advanced disease and/or received neoadjuvant radiation were more likely to undergo robotic-assisted proctectomy, robotic-assisted surgery was less often performed in pelvic exenteration.