Utilization of pelvic floor therapy after a colorectal cancer diagnosis in a universal-access health system

Background: About 70-90% of patients with colorectal cancer experience declined bowel function after treatment. Pelvic floor therapy (PFT) can improve bowel function and quality of life, yet access to PFT remains limited and factors associated with its use are understudied. Conducting this research within the U.S. Military Health System, a universal healthcare system, allows a clearer assessment of demographic, clinical, and system-level factors associated with receiving PFT while minimizing the effects of affordability and access on the results. Methods: We conducted a nested case-control study of adults (≥18 years) with stage I-III colorectal cancer who had surgery within 6 months of diagnosis (2001-2014) in the MilCanEpi database. PFT recipients (cases) and non-recipients (controls) were matched by diagnosis month/year with a 1:1 ratio. Patients with non-TRICARE insurance (except Medicare which is part of coverage for all patients aged ≥65 years with TRICRE for Life) were excluded. Stepwise multivariable logistic regression was used to calculate adjusted odds ratios (aORs) with 95% confidence intervals (CIs) and identify factors associated with PFT use. To assess potential effect modification by sex, results from the overall adjusted model were compared with a men-only analysis. Results: PFT recipients (n=679) were older (median [min-max]: 60 [21-94] vs 55 [23-88]) and more likely to be male (64% vs 58%), unmarried (24% vs 19%), have ≥1 comorbidity (43% vs 32%), and receive care at a military treatment facility (MTF; 37% vs 29%) than non-recipients (n=679). In the fully adjusted model, the use of PFT was more likely among patients with increased age (aOR=1.03, 95% CI: 1.01, 1.04), males (aOR=1.34, 95% CI: 1.02, 1.77), ≥3 comorbidities (aOR=2.13, 95% CI: 1.34, 3.38), active-duty status (aOR=1.67, 95% CI: 1.09, 2.55), and among those receiving care at a MTF compared to the private-sector (aOR=1.91, 95% CI: 1.39, 2.61). Among men, older age (aOR=1.04, 95% CI: 1.02, 1.06), total (vs partial) colectomy and/or proctectomy (aOR=4.97, 95% CI: 1.52, 16.27) and receiving care at a MTF compared to the private-sector (aOR=3.08, 95% CI: 1.60, 5.91) were associated with higher PFT use. Conclusion: Within the MHS, fully adjusted analyses showed that PFT utilization after colorectal cancer surgery was higher among older patients, males, those with ≥3 comorbidities, active-duty service members, and patients receiving care at a MTF compared to the private-sector, highlighting the influence of demographic, clinical, and healthcare system factors on PFT use. In men, total (vs partial) surgery was the only factor additionally associated with higher PFT use. These findings suggest that targeted strategies may be needed to increase PFT utilization among groups of patients with a lower likelihood of use in the MHS, such as among younger patients and females.