Response to Letter: Comment on "Insurance Status, Not Race Is Associated With Use of Minimally Invasive Surgical Approach for Rectal Cancer".

Reply: We would like to thank Dr Nurkin and colleagues for their interest in our recently published article ‘‘Insurance Status, Not Race is Associated With Use of Minimally Invasive Surgical Approach for Rectal Cancer.’’ We agree with their conclusions regarding the importance of understanding disparities in accessing minimally invasive surgical techniques for rectal cancer, as studies have demonstrated the short-term superiority of minimally invasive rectal surgery compared with the open approach. In their letter, the authors highlighted their previous article which focused on identifying factors associated with utilization of minimally invasive rectal resection for cancer, inclusive of insurance status. In contrast, our article specifically explored the overlapping association between race and insurance status in use of minimally invasive rectal surgery for cancer. Understanding this relationship is important, given the historic effect of race on cancer treatment in the United States and its overlapping association with insurance coverage. The current shift in the healthcare payer system warrants improved understanding on the effect of insurance status, because it generally relates to minimally invasive surgery, with our publication specifically addressing rectal cancer. The authors raised a question about whether there is a difference in disparate access to robotic compared with laparoscopic techniques for rectal cancer resection. Our study hypothesis did not focus on examining the differences between laparoscopic and robotic surgery. Although this question is important, recent manuscripts including patients from the American College of Surgeons National Cancer Data Base suggest the equivalency of short-term outcomes between laparoscopic and robotic approaches, but concerns remain for increased operative times and potential increased costs with the robotic technique for colorectal resections. Nevertheless, as suggested by the authors, it is fair to assume that the majority of patients included in our study had laparoscopic surgery, given that it is the most common form of minimally invasive rectal technique practiced in the country. In the studies by Gabriel et al and Sun et al, 2.6% and 8.7%, respectively, underwent robotic rectal surgery. These percentages highlight that whereas the popularity of robotic surgery is increasing, the adoption of robotic rectal surgery remains in its infancy. Therefore, factors associated with use of robotic rectal surgery may not be consistent across institutions, as many surgeons are at the beginning of the learning curve and may use different criteria to offer the procedure, limiting the generalizability. More recent and consistent data may be needed to accurately inform the readership regarding national practice patterns of the association between robotic rectal surgery, race, and insurance. Our study demonstrates that insurance status is an important determinant in utilization of minimally invasive approaches for rectal cancer resection in the United States. Patient race, on the contrary, is not associated with open or minimally invasive approach. These findings have important implications with regard to providing equitable oncologic care for patients with rectal cancer and the role of race in the delivery of surgical treatment in the United States. These findings may suggest that improvements have been made in mitigating some of the racial disparities in the surgical management of rectal cancer. Hospitals may need to expand utilization of minimally invasive rectal surgery, especially to patients with disadvantageous insurance coverage, because minimally invasive rectal techniques have been proven to be cost-effective and associated with improved short-term outcomes. This becomes more important with the changing dynamic of our healthcare system and the shift toward value-based reimbursement. As surgeons, we have a duty towards our patients to advocate for equitable access to care, especially in our rapidly changing healthcare environment.