Robotic proctectomy for rectal cancer in the US: a skewed population

Background Socioeconomic and racial differences have been associated with disparities in cancer care within the US, including disparate access to minimally invasive surgery for rectal cancer. We hypothesized that robotic approach to rectal cancer may be associated with similar disparities. Methods The National Cancer Database (NCDB) was used to identify patients over 18 years old with clinical stage I-III rectal adenocarcinoma who underwent a proctectomy between 2010 and 2014. Demographic and hospital factors were analyzed for association with robotic approach. Factors identified on bivariate analyses informed multivariate analysis. Results We identified 33,503 patients who met inclusion criteria; 3702 (11.1%) underwent robotic surgery with 7.8% conversion rate. Patients who received robotic surgery were more likely to be male, white, privately insured and with stage III cancer. They were also more likely to live in a metropolitan area, more than 25 miles away from the hospital and with a higher high school graduation rate. The treating hospital was more likely to be academic and high volume. Conclusions Robotic surgery is performed rarely and access to it is limited for patients who are female, black, older, non-privately insured and unable to travel to high-volume teaching institutions. The advantages of robotic surgery may not be available to all patients given disparate access to the robot. This inherent bias in access to robot may skew study populations, preventing generalizability of robotic surgery research. Graphic abstract