Racial disparities in cancer therapy: did the gap narrow between 1992 and 2002?

Cost of ovarian cancer by the phase of care in the United States

BACKGROUND

Ovarian cancer is associated with delayed diagnosis and poor survival; thus, interest is high in identifying predictive and prognostic biomarkers and novel therapeutic agents. Although the costs of ovarian cancer care are likely to increase as newer, more effective, but more expensive treatment regimens become available, information on the current costs of care for ovarian cancer-across the care continuum from diagnosis to the end of life-are lacking.

OBJECTIVE

This study aimed to estimate real-world mean and median costs of ovarian cancer care within the first 5 years after diagnosis by patients' phase of care, age, race/ethnicity, and geographic region.

STUDY DESIGN

We performed a retrospective cohort study of ovarian cancer patients diagnosed between January 1, 2015 and December 31, 2020. We used claims data from Optum's deidentified Clinformatics Data Mart database, which includes inpatient, outpatient, and prescription claims for commercial insurance and Medicare beneficiaries nationwide. Cost of ovarian cancer care were calculated for the start of care (ie, the first 6 months), continuing care (ie, period between the initial and end-of-life care), and end-of-life care (ie, the last 6 months) phases and reported in 2021 U.S. dollar amounts. Ovarian cancer care costs were stratified by age, race/ethnicity, and geographic region. Due to the skewed nature of cost data, the mean cost data were log-transformed for modeling. Ordinary least-squares regression was conducted on the log costs, adjusting for patient categorical age, race/ethnicity, and geographic region.

RESULTS

A total of 7913 patients were included in the analysis. The mean cost per year for ovarian cancer care was >$200,000 during the start of care, between $26,000 and $88,000 during the continuing care phase, and >$129,000 during the end-of-life care phase. There were statistically significant associations between age and costs during each phase of care. Compared to younger patients, older patients incurred higher costs during the continuing care phase and lower costs during the end-of-life care phase. Geographic differences in the costs of ovarian cancer care were also noted regardless of the phase of care. There were no associations between cost and race/ethnicity in our cohort.

CONCLUSION

Ovarian cancer care costs are substantial and vary by the phase of care, age category, and geographic region. As more effective but expensive treatment options for ovarian cancer become available with potential survival benefit, sustainable interventions to reduce the cost of care for ovarian cancer will be needed throughout the cancer care continuum.

Sex and Race/Ethnicity Based Trends in Matriculation to General Surgery Residency and Associated Fellowship Programs

INTRODUCTION

The changing landscape of the surgical workforce and the dynamics of sex and racial/ethnic inequality have been heavily publicized in the surgical community. We sought to report on current sex- and race/ethnicity-based trends in matriculation to general surgery residencies and surgical fellowships.

METHODS

Data were provided by the Association of American Medical Colleges from the Electronic Residency Application Service and were stratified by matriculant-reported sex and race/ethnicity. The Association of American Medical Colleges definition of Underrepresented in Medicine (URiM) was used for the purpose of the analysis. Thus, all matched applicants who self-identified as Asian or White were classified as non-URiM, and any other self-identified race/ethnicity was classified as URiM. Four cohorts (males, females, URiM, and non-URiM) were created for each of the five analyzed disciplines: all general surgery residencies, all surgical fellowships, and specifically complex general surgical oncology (CGSO), pediatric surgery, and colorectal surgery fellowships. Statistical analyses were performed using SAS (version 9.4; SAS Institute, Cary, NC).

RESULTS

From 2008 to 2020, the gap between match rates for male and female matriculants for general surgery residency narrowed from 58% (n = 621) males versus 42% (n = 451) females in 2008, to 51% (n = 708) males versus 49% (n = 670) females in 2020. There was a similar trend toward gender parity in match rates to all surgical fellowships from 2007 to 2018, with males comprising 78% (n = 210) versus 22% (n = 59) females in 2007, compared to 63% (n = 199) males versus 37% (n = 117) females in 2018; albeit a significant disparity remains. Upon further analysis specifically into CGSO, pediatric surgery, and colorectal surgery fellowships, no statistically significant difference between sex-based match rates existed in the most recently analyzed cohort. However, from 2008 to 2020, the proportions of matched URiM and non-URiM applicants in general surgery residency remained unchanged (16% versus 84% respectively). In addition, there were significant discrepancies between match rates for URiM versus non-URiM for CGSO fellowship in the most recently matched cohorts (match rates: 54% URiM versus 78% non-URiM, P = 0.03).

CONCLUSIONS

Overall, sex-based breakdown of applicants matching into general surgery residency and surgical fellowships reveals relative parity between males and females. However, recruitment of URiM applicants remains underwhelming with no significant changes in the racial/ethnic distribution of matched applicants in general surgery residency or surgical fellowships for the last 12 y. A re-examination of the current policies and initiatives geared toward promoting diversity and inclusion in surgery is needed to identify areas of improvement that result in improved representation.

Racial Differences in Stage IV Colorectal Cancer Molecular Profiling and Mutation Rates

INTRODUCTION

Despite advances in colorectal cancer (CRC) treatment, racial disparities persist. The primary aims of the study were to: evaluate differences in molecular testing rates over time by race; and measure the incidence of tumor mutations by race in patients with metastatic CRC.

METHODS

A retrospective cohort study was performed of all adult patients with stage IV CRC (2008-2018) identified within the cancer registry of a large regional health system. Demographic/clinical characteristics were collected through primary data abstraction of the electronic health record. Molecular profiling results were obtained directly from Caris Molecular Intelligence and electronic health record.

RESULTS

Three hundred eighty-three patients were included: 40.5% (n = 155) were Black and 59.5% (n = 228) were White. Significant increases were observed in microsatellite instability (MSI), KRAS, and BRAF testing rates during the study period (P < 0.0001). The odds of testing over time increased more significantly in Black compared to White patients for MSI testing (White: odds ratio [OR] 1.26 [95% confidence interval [CI] 1.12-1.41], Black: OR 1.69 [95% CI 1.41-2.02], P = 0.005) and BRAF testing (White: OR 1.42 [95% CI 1.26-1.62], Black: OR 1.89 [95% CI 1.51-2.36], P = 0.027). An increase in KRAS testing over time was observed for both cohorts and was independent of race (P = 0.58). Mutation rates did not differ by race: KRAS (Black 55.8% versus White 45.6%, P = 0.13) and BRAF (Black 4.8% versus White 10.0%, P = 0.33).

CONCLUSIONS

Within a large regional health system, molecular testing rates in patients with metastatic CRC increased significantly following National Comprehensive Cancer Network guideline changes for both Black and White patients. Black and White patients who underwent molecular testing had similar rates of MSI, KRAS, and BRAF mutations.

Addressing disparities in European cancer outcomes: a qualitative study Protocol of the BEACON project

Introduction

Health disparities represent a crucial factor in cancer survival rates, awareness, quality of life, and mental health of people receiving a cancer diagnosis and their families. Income, education, geographic location, and ethnicity are some of the most important underlying reasons for health disparities in cancer across Europe. Costs of healthcare, access to information, psycho-oncological support options, integration of cancer research and innovative care, and multidisciplinary cancer teams are the main target areas when it comes to addressing disparities in the cancer context. As part of the Beacon Project (BEACON), we developed a protocol for a qualitative study to explore and identify any relevant reasons for cancer inequalities and disparities in Europe.

Methods

Our four stakeholders namely, cancer patients, healthcare providers, researchers, and policymakers will be recruited online, facilitated by collaborative efforts with cancer organizations from various European countries, including but not limited to Italy, Croatia, Estonia, and Slovenia. Qualitative online focus group discussions for each stakeholder will be conducted and transcribed. Subsequently, thematic analysis will be used to identify reasons and aspects that may contribute to the existing disparities in cancer outcomes at various levels of engagement and from different stakeholders' perspectives. Results from focus groups will inform a subsequent Delphi study and a SWOT analysis methodology.

Discussion

Although advances in medical research, cancer screening and treatment options are constantly progressing, disparities in access to and awareness of healthcare in cancer patients are even more noticeable. Thus, mapping the capacity and capability of cancer centres in the European Union, creating decision support tools that will assist the four stakeholders' information needs and improving the quality of European cancer centres will be the main objectives of the BEACON project. The current protocol will outline the methodological and practical procedures to conduct online focus group discussions with different stakeholders.

Racial disparities in the timely receipt of adjuvant radiotherapy for head and neck cancer

PURPOSE

To evaluate the influence of socioeconomic and demographic factors which might predict for excessive delays in the receipt of adjuvant radiotherapy for head and neck cancer.

METHODS AND MATERIALS

The medical records of 430 consecutive patients referred for adjuvant radiation after surgical resection for squamous cell carcinoma of the head and neck were reviewed. The number of days from surgery to initiation of radiation was recorded. To study the variability in which adjuvant radiation was delivered, descriptive statistics were used to determine the percentage of patients who deviated from starting treatment beyond the recommended benchmark of 42 days. The chi-square statistic was used to compare differences in proportion among subsets. A Cox proportional hazards model was constructed to perform a multi-variate analysis to identify factors which independently influenced the likelihood for non-adherence.

RESULTS

The interval between surgery and the start of radiation therapy ranged from 5 to 128 days (mean, 36 days). The mean number of days from surgery to radiation therapy was 31 days, 35 days, 40 days, and 42 days for Caucasians, Asians, Latino, and Black patients (p = 0.01). In all, 359 of 430 patients (83 %) started adjuvant radiation within 42 days. The proportion of patients who initiated radiation therapy within 42 days of surgery was 91 %, 86 %, 71 %, 65 %, and 80 % for Caucasians, Asians, Latinos, Blacks, and Native Hawaiian/Pacific Islanders, respectively (p < 0.001). Patient characteristics associated with higher odds of non-adherence to the timely receipt of adjuvant radiation therapy within then 42-day benchmark from surgery to radiation included race ([OR] = 4.23 95 % CI (1.30-7.97), non-English speaking status ([OR] = 2.38, 95 % CI: 0.61-4.50), and low socioeconomic status ([OR] = 1.21, 95 % CI: 1.01-1.86).

CONCLUSION

Underrepresented minorities are more likely to experience delays in the receipt of adjuvant radiation for head and neck cancer. The potential underlying reasons are discussed.

Effect of a same day appointment initiative on racial disparities in access for radiation oncology

PURPOSE

We present our single-institution experience with the development of a same day access scheduling initiative for an outpatient radiation oncology unit, focusing on its potential influence on ameliorating racial disparities.

METHODS AND MATERIALS

From March 2021 to August 2022, a pilot initiative was conducted such that all new patients referred to a tertiary care-based radiation oncology department were offered the ability to be seen as a same day consultation. The timespan of this analysis was categorized into 2 distinct successive periods over 36 months-a 18-month pre-initiative period (September 2019 to February 2021) and another subsequent one (March 2021 to August 2022). Descriptive statistics were used to study the impact of this initiative on access-related benchmarks.

RESULTS

A total of 2897 patients were referred. Among the 2107 patients scheduled, three hundred and sixteen (15 %) opted for same day appointments. Black, Latino, and Asian patients were significantly more likely to use the same day access initiative versus Caucasian patients (p = 0.01). The same day access initiative increased the proportion of patients seen within 5 days from referral from 8 % to 34 % for Blacks, 12-57 % for Latinos, and 18-67 % for Asians, compared to 39-55 % for Caucasians (p < 0.001). The no-show rate was reduced from 20 % to 7 % and 14-5 %, for Black and Latino patients, respectively (p < 0.001).

CONCLUSIONS

The implementation of a same day access initiative narrowed disparities with respect to access-related benchmarks.

Disparities in Receipt of National Comprehensive Cancer Network Guideline-Adherent Care and Outcomes among Women with Triple-Negative Breast Cancer by Race/Ethnicity, Socioeconomic Status, and Insurance Type

BACKGROUND

The National Comprehensive Cancer Network guidelines were designed to improve patient outcomes. Here, we examine factors that may contribute to outcomes and guideline adherence in patients with triple-negative breast cancer.

METHODS

This was a retrospective cohort study of women with triple-negative breast cancer using the California Cancer Registry. Adherent treatment was defined as the receipt of a combination of surgery, lymph node assessment, adjuvant radiation, and/or chemotherapy. A multivariable logistic regression was used to determine the effects of independent variables on adherence to the NCCN guidelines. Disease-specific survival was calculated using Cox regression analysis.

RESULTS

A total of 16,858 women were analyzed. Black and Hispanic patients were less likely to receive guideline-adherent care (OR 0.82, 95%CI 0.73-0.92 and OR 0.87, 95%CI 0.79-0.95, respectively) compared to White patients. Hazard ratios adjusted for adherent care showed that Black patients had increased disease-specific mortality (HR 1.28, 95%CI 1.16-1.42, p < 0.0001) compared to White patients.

CONCLUSIONS

A significant majority of breast cancer patients in California continue to receive non-guideline-adherent care. Non-Hispanic Black patients and patients from lower SES quintile groups were less likely to receive guideline-adherent care. Patients with non-adherent care had worse disease-specific survival compared to recipients of NCCN guideline-adherent care.

Patterns of Evidence-Based Care for the Diagnosis, Staging, and First-line Treatment of Breast Cancer by Race-Ethnicity: A SEER-Medicare Study

BACKGROUND

Racial and ethnic disparities in guideline-recommended breast cancer treatment are well documented, however studies including diagnostic and staging procedures necessary to determine treatment indications are lacking. The purpose of this study was to characterize patterns in delivery of evidence-based services for the diagnosis, clinical workup, and first-line treatment of breast cancer by race-ethnicity.

METHODS

SEER-Medicare data were used to identify women diagnosed with invasive breast cancer between 2000 and 2017 at age 66 or older (n = 2,15,605). Evidence-based services included diagnostic procedures (diagnostic mammography and breast biopsy), clinical workup (stage and grade determination, lymph node biopsy, and HR and HER2 status determination), and treatment initiation (surgery, radiation, chemotherapy, hormone therapy, and HER2-targeted therapy). Poisson regression was used to estimate rate ratios (RR) and 95% confidence intervals (CI) for each service.

RESULTS

Black and American Indian/Alaska Native (AIAN) women had significantly lower rates of evidence-based care across the continuum from diagnostics through first-line treatment compared to non-Hispanic White (NHW) women. AIAN women had the lowest rates of HER2-targeted therapy and hormone therapy initiation. While Black women also had lower initiation of HER2-targeted therapy than NHW, differences in hormone therapy were not observed.

CONCLUSIONS

Our findings suggest patterns along the continuum of care from diagnostic procedures to treatment initiation may differ across race-ethnicity groups.

IMPACT

Efforts to improve delivery of guideline-concordant treatment and mitigate racial-ethnic disparities in healthcare and survival should include procedures performed as part of the diagnosis, clinical workup, and staging processes.

Trends in Racial and Gender Diversity Among Complex General Surgical Oncology Fellowship Trainees

BACKGROUND

This study examines trends in racial and gender diversity of trainees within Complex General Surgical Oncology Fellowships, and compares the racial and gender proportions of trainees across different fields to assess potential barriers to increasing diversity within surgical oncology training programs.

METHODS

Accredited Council for Graduate Medical Education (ACGME) data were queried to identify surgical trainees between 2013 and 2021. Trainees were identified based on self-reported race and gender and were stratified based on residency type and fellowship program type if applicable. Chi-square tests were used to assess differences between groups and trends.

RESULTS

A significantly lower proportion of individuals who are underrepresented in medicine (URMs) trained in surgical oncology fellowships (8.9%) compared with both the overall trainee pool (12.8%) and general surgery residency programs (13.1%) [p < 0.05]. There was no significant increase in URM representation in surgical oncology fellowships across the study period. Furthermore, there was a significantly lower proportion of females training in surgical oncology fellowships (38.6%) compared with the overall trainee pool (45.6%) [p < 0.05]. Despite a significant increase in female representation in general surgery residency and other surgical fellowships, there was no significant increase in female representation in surgical oncology fellowships across the study period.

CONCLUSIONS

This study identifies disparities in gender and racial minority representation within ACGME-accredited Complex General Surgical Oncology Fellowship training programs. While steps have been taken to expand diversity, more needs to be done to combat the systemic barriers that both racial minorities and women face during their training.

Persistent Disparities in Access to Elective Colorectal Cancer Surgery After Medicaid Expansion Under the Affordable Care Act: A Multistate Evaluation

BACKGROUND

Despite their higher incidence of colorectal cancer, ethnoracial minority and low-income patients have reduced access to elective colorectal cancer surgery. Although the Affordable Care Act's Medicaid expansion increased screening of colonoscopies, its effect on disparities in elective colorectal cancer surgery remains unknown.

OBJECTIVE

This study assessed the effects of Medicaid expansion on elective colorectal cancer surgery rates overall and by race-ethnicity and income.

DESIGN

Using the 2012 to 2015 State Inpatient Databases, a retrospective cohort study was conducted.

SETTINGS

State Inpatient Databases from 3 expansion states (Maryland, New Jersey, and Kentucky) and 2 nonexpansion states (Florida and North Carolina) were used.

PATIENTS

This study examined 22,304 adult patients aged 18 to 64 years who underwent colorectal cancer surgery.

MAIN OUTCOME MEASURES

Using interrupted time series analysis, the effect of Medicaid expansion on the odds of elective colorectal cancer surgery was assessed.

RESULTS

Elective vs nonelective surgery rates remained unchanged overall (70.2% vs 70.7%, p = 0.63) and in ethnoracial minorities in expansion states (whites from 72.8% to 73.8% pre to post, p = 0.40 and non-white from 64.0% to 63.1% pre to post, p = 0.67). There was an instantaneous increase in odds of elective surgery in expansion vs nonexpansion states at policy implementation (adjusted OR 1.37; 95% CI, 1.05-1.79; p = 0.02), but it subsequently decreased (combined adjusted OR 0.95; 95% CI, 0.92-0.99; p = 0.03). Elective surgery rates were also unchanged among ethnoracial minorities (instantaneous changes in expansion states, combined effect 1.06; pre-trend 1.01 vs post-trend 0.98) and low-income persons in expansion states (pre-trend 1.03 vs post-trend 0.97) (for all, p > 0.1).

LIMITATIONS

The study was limited to 5 states. Although patients may have increased access to cancer screening services and surgery after expansion, the State Inpatient Databases only provide information on patients who underwent surgery.

CONCLUSIONS

Despite gains in screening, Medicaid expansion was not associated with reductions in known ethnoracial or income-based disparities in elective colorectal cancer surgery rates. Expanding access to colorectal cancer surgery for underserved populations likely requires attention to provider and health system factors contributing to persistent disparities. See Video Abstract at http://links.lww.com/DCR/C217 .

DISPARIDADES PERSISTENTES EN EL ACCESO A LA CIRUGA ELECTIVA DEL CNCER COLORRECTAL DESPUS DE LA EXPANSIN DE MEDICAID EN VIRTUD DE LA LEY DEL CUIDADO DE SALUD A BAJO PRECIO UNA EVALUACIN MULTIESTATAL

ANTECEDENTES: A pesar de su mayor incidencia de cáncer colorrectal, los pacientes de minorías etnoraciales y de bajos ingresos tienen un acceso reducido a la cirugía electiva de cáncer colorrectal. Aunque la expansión de Medicaid de la Ley del Cuidado de Salud a Bajo Precio aumentó las colonoscopias de detección, aún se desconoce su efecto sobre las disparidades en la cirugía electiva de cáncer colorrectal.OBJETIVO: Este estudio evaluó los efectos de la expansión de Medicaid en las tasas de cirugía electiva de cáncer colorrectal en general y por raza, etnia e ingresos.DISEÑO: Utilizando las bases de datos estatales de pacientes hospitalizados de 2012-2015, se realizó un estudio de cohorte retrospectivo.CONFIGURACIÓN: Se utilizaron bases de datos estatales de pacientes hospitalizados de tres estados en expansión (Maryland, Nueva Jersey, Kentucky) y dos estados sin expansión (Florida, Carolina del Norte).PACIENTES: Este estudio examinó a 22,304 pacientes adultos de 18 a 64 años que se sometieron a cirugía de cáncer colorrectal.RESULTADO PRINCIPAL: Mediante el análisis de series de tiempo interrumpido, se evaluó el efecto de la expansión de Medicaid en las probabilidades de cirugía electiva de cáncer colorrectal.RESULTADOS: Las tasas de cirugía electiva frente a no electiva permanecieron sin cambios en general (70,2% frente a 70,7%, p = 0,63) y en las minorías etnoraciales en los estados de expansión (blancos del 72,8% al 73,8 % antes y después, p = 0,40 y no blancos del 64,0% al 63,1% pre a post, p = 0,67). Hubo un aumento instantáneo en las probabilidades de cirugía electiva en los estados de expansión frente a los de no expansión en la implementación de la política (OR ajustado 1,37, IC del 95%, 1,05-1,79, p = 0,02), pero disminuyó posteriormente (OR ajustado combinado 0,95, 95% IC, 0,92-0,99, p = 0,03). Las tasas de cirugía electiva también se mantuvieron sin cambios entre las minorías etnoraciales (cambios instantáneos en los estados de expansión, efecto combinado 1,06; antes de la tendencia 1,01 frente a la postendencia 0,98) y las personas de bajos ingresos en los estados de expansión (antes de la tendencia 1,03 frente a la postendencia 0,97; para todos, p > 0,1).LIMITACIONES: El estudio se limitó a cinco estados. Si bien los pacientes pueden tener un mayor acceso a los servicios de detección de cáncer y la expansión posterior a la cirugía, la base de datos de pacientes hospitalizados del estado solo brinda información sobre los pacientes que se sometieron a cirugía.CONCLUSIONES: A pesar de los avances en la detección, la expansión de Medicaid no se asoció con reducciones en las disparidades etnoraciales o basadas en los ingresos conocidas en las tasas de cirugía electiva de cáncer colorrectal. Ampliar el acceso a la cirugía del cáncer colorrectal para las poblaciones desatendidas probablemente requiera atención a los factores del proveedor y del sistema de salud que contribuyen a las disparidades persistentes. Consulte el Video Resumen en http://links.lww.com/DCR/C217 . (Traducción-Dr. Yesenia.Rojas-Khalil ).

Assessing the Complex General Surgical Oncology Pipeline: Trends in Race and Ethnicity Among US Medical Students, General Surgery Residents, and Complex General Surgical Oncology Trainees

BACKGROUND

Cancer incidence is expected to increase in coming decades, disproportionately so among minoritized communities. Racially and ethnically concordant care is essential to addressing disparities in cancer outcomes within at-risk groups. Here, we assess trends in racial and ethnic representation of medical students (MS), general surgery (GS) residents, and complex general surgical oncology (CGSO) fellows.

METHODS

This is a retrospective review of data from the American Association of Medical Colleges and the Accreditation Council of Medical Education (ACGME) from 2015 to 2020. Self-reported race and ethnicity was obtained for MS, GS, and CGSO trainees. Race and ethnicity proportions were compared with respective representation in the 2020 US Census. Mann-Kendall, Wilcoxon rank sum, and linear regression were used to assess trends, as appropriate.

RESULTS

A total of 316,448 MS applicants, 128,729 MS matriculants, 27,574 GS applicants, 46,927 active GS residents, 710 CGSO applicants, and 659 active CGSO fellows were included. With every progressive stage in training, there was a smaller proportion of URM active trainees than applicants. Further, URM, Hispanic/Latino, and Black/African American trainees were significantly underrepresented compared with 2020 Census data. While the proportion of White CGSO fellows increased over time (54.5-69.2%, p = 0.009), the proportion of Black/African American and Hispanic/Latino (URM) CGSO fellows did not significantly change over the study period, though URM representation was lower in 2020 as compared with 2015.

DISCUSSION

From 2015 to 2020, minority representation decreased at every advancing stage in surgical oncology training. Efforts to address barriers for URM applicants to CGSO fellowships are needed.

Differences in racial/ethnic disparities in patient care experiences between prostate cancer survivors and males without cancer: A SEER-CAHPS study

INTRODUCTION

Our purpose was to evaluate whether racial/ethnic disparities in patient care experiences (PCEs) differ between males with prostate cancer ("PCa group") and males without cancer ("non-cancer group").

MATERIALS AND METHODS

This retrospective study used 2007-2015 National Cancer Institute's Surveillance, Epidemiology and End Results registry data linked to Consumer Assessment of Healthcare Providers and Systems surveys. PCa and non-cancer groups were propensity score matched 1:5 on demographic and clinical characteristics. Differences in racial/ethnic disparities (DRD) (non-Hispanic Black [NHB], Hispanic, non-Hispanic Asian [NHA], and Other Races compared to non-Hispanic White [NHW]) in PCEs (getting needed care, getting care quickly, doctor communication, customer service, and getting needed prescription drugs) were compared between matched PCa and non-cancer groups. Per prior literature, DRD in PCE scores were categorized as small (<3), medium (≥3 but <5) or large (≥5).

RESULTS

There were 7312 males in the PCa group and 36,559 matched males in the non-cancer group. Within each group, all racial/ethnic minority categories reported worse scores compared to NHW individuals (p < 0.05) for ≥3 PCE composite measures. Compared to PCa group, a larger NHA-NHW difference was observed in non-cancer group for getting needed care (-4.65 in PCa vs. -7.77 in non-cancer; DRD = 3.11, p = 0.029) and doctor communication (-2.46 in PCa vs. -4.85 in non-cancer; DRD = 2.38, p = 0.023).

DISCUSSION

In both PCa and non-cancer groups, racial/ethnic minorities reported worse experiences compared to NHW individuals for several PCE measures. However, the difference in getting needed care and doctor communication between NHA and NHW individuals were more pronounced in non-cancer group than PCa group.

Disparities in Receipt of Adjuvant Therapy After Upfront Surgical Resection for Pancreatic Ductal Adenocarcinoma

BACKGROUND

A multimodal approach of surgery and chemotherapy, with or without radiation, is the mainstay of therapy with curative-intent for resectable pancreatic ductal adenocarcinoma (PDAC). This study compared utilization trends and outcomes of upfront surgery with and without adjuvant therapy.

METHODS

The National Cancer Database was queried for patients with a diagnosis of stage 1 or 2 PDAC who underwent upfront resection. Multivariable regression was applied to identify factors associated with initiation of adjuvant therapy.

RESULTS

Of the 39,128 patients in the study, 67% initiated adjuvant therapy after resection, whereas 33% received upfront surgery alone. Receipt of adjuvant multimodal therapy increased from 59% in 2006 to 69% in 2017 (P < 0.0001). Non-white race was associated with lower odds of receiving adjuvant therapy after adjustment for income status, education attainment, and other variables (Hispanic/Spanish [odds ratio {OR}, 0.77; 95% confidence interval {CI}, 0.69-0.86] and non-Hispanic black [OR 0.84; 95% CI 0.78-0.91 vs non-Hispanic white; P < 0.001). The variables that contributed to receipt of adjuvant therapy were place of residence in high versus low education attainment area (OR 1.30; 95% CI 1.18-1.44; P < 0.0001) and lower odds for initiation of adjuvant therapy with increasing distance from the treating facility (> 50 miles [OR 0.51; 95% CI 0.47-0.54] vs <12.5 miles; P < 0.0001). The median unadjusted overall survival (OS) time was 18.2 months (95% CI 17.7-18.8 months) for upfront surgery alone and 25.3 months (95% CI 24.9-25.8 months) for surgery with adjuvant therapy.

CONCLUSIONS

The patients who underwent upfront surgical resection for PDAC showed wide socioeconomic disparities in the use of adjuvant therapy independent of insurance status, facility type, or travel distance.

Racial disparities in clinical presentation, surgical procedures, and hospital outcomes among patients with hepatocellular carcinoma in the United States

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related deaths in the United States (US), with substantial disparities observed in cancer incidence and survival among racial groups. This study provides analyses on race and ethnicity disparities for patients with HCC.

METHODS

This is a cross-sectional analysis of data from the National Inpatient Sample (NIS) between 2011 and 2016, utilizing the STROBE guidelines. Multivariate logistic regression analyses were used to examine the risk-adjusted associations between race and pre-treatment clinical presentation, surgical procedure allocation, and post-treatment hospital outcomes. All clinical parameters were identified using ICD-9-CM and ICD-10-CM diagnosis and procedure codes.

RESULTS

83,876 weighted HCC hospitalizations were reported during the study period. Patient demographics were divided according to NIS racial/ethnic categorization, which includes Caucasian (57.3%), African American (16.9%), Hispanic (15.7%), Asian or Pacific Islanders (9.3%), and Native American (0.8%). Association between greater odds of hospitalization and Elixhauser Comorbidity Index > 4 was significantly higher among Native Americans (aOR=1.79; 95% CI: 1.23-2.73), African Americans (aOR=1.24; 95% CI: 1.12-1.38), and Hispanics (aOR=1.11; 95% CI, 1.01-1.24). Risk-adjusted association between race and receipt of surgical procedures demonstrated that the odds of having surgery was significantly lower for African Americans (aOR=0.64; 95% CI: 0.55-0.73) and Hispanics (aOR=0.70; 95% CI: 0.59-0.82), while significantly higher for Asians/Pacific Islanders (aOR=1.36; 95% CI: 1.28-1.63). Post-operative complications were significantly lower for African Americans (aOR=0.68; 95% CI: 0.55-0.86) while the odds of in-hospital mortality were significantly higher for African Americans (aOR=1.28; 95% CI: 1.11-1.49) and Asians/Pacific Islanders (aOR=1.26; 95% CI: 1.13-1.62).

CONCLUSIONS

After controlling for potential confounders, there were significant racial disparities in pre-treatment presentations, surgical procedure allocations, and post-treatment outcomes among patients with HCC. Further studies are needed to determine the underlying factors for these disparities to develop targeted interventions to reduce these disparities of care.

Racial disparities in breast cancer treatment patterns and treatment related adverse events

The main objective of this work was to perform a comprehensive analysis and provide a race-stratified epidemiological report accounting for differences in treatment patterns and treatment related adverse events in Non-Hispanic women with breast cancer (BC). The cohort included women ≥ 18 years diagnosed with in-situ, early-stage, and late-stage BC (2005-2022). Treatment patterns included: surgery, breast radiation, chemotherapy, endocrine therapy, or biologic therapy. Treatment related adverse events were: chemotherapy complications, cardiovascular toxicities, immune-related adverse events, psychological affectations, or cognitive decline/dementia. The influence of race on the outcomes was measured via Cox proportional-hazards models. We included 17,454 patients (82% non-Hispanic Whites [NHW]). Most of the patients had a Charlson Comorbidity Score between 1 and 2 (68%), and TNM stage I (44.5%). Surgery was performed in 51.5% of the cases, while 30.6% received radiotherapy, 26.4% received chemotherapy, 3.1% received immunotherapy, and 41.2% received endocrine therapy. Non-Hispanic Blacks (NHB) had a lower probability of undergoing breast cancer surgery (aHR = 0.92, 95% CI 0.87-0.97) and of being prescribed endocrine therapy (aHR = 0.83, 95% CI 0.79-0.89), but a higher probability of receiving adjuvant radiotherapy (aHR = 1.40, 95% CI 1.29-1.52). Moreover, NHBs had lower risk of being diagnosed with psychological issues (aHR = 0.71, 95% CI 0.63-0.80) but a higher risk for cognitive decline/dementia (aHR = 1.30, 95% CI 1.08-1.56). In conclusion, NHB women diagnosed with BC were less likely than NHW to undergo curative intent surgery or receive endocrine therapy, and had a higher risk of cognitive decline/dementia after cancer treatment. Public policy measures are urgently needed which equalize access to quality healthcare for all patients and that promote a learning healthcare system which can improve cancer outcomes.

Racial Differences in Germline Genetic Testing for Prostate Cancer: A Systematic Review

PURPOSE

Testing for pathogenic variants can aid in oncologic risk stratification and identification of targeted therapies. Despite known disparities in access to prostate cancer (PCa) care, little has been written about access to germline genetic testing (GGT) for Black men and other historically marginalized populations. This systematic review sought to delineate racial/ethnic disparities in GGT for PCa.

METHODS

This systematic review identified articles published from January 1996 through May 2021 in PubMed, Web of Science, and Embase. We included studies that reported rates of GGT in men with PCa in the United States by race/ethnicity as reflective of routine clinical care or research. A narrative synthesis was performed.

RESULTS

Of 4,309 unique records, 91 studies examining 50 unique study populations met inclusion criteria. Of these, four populations included men who received GGT through routine clinical care, accounting for 4,415 men (72.6% White and 7.2% Black). The other 46 populations included men who received GGT as part of a research study, accounting for 30,824 men (64.3% White and 21.6% Black). Of these 46 research populations, 19 used targeted methods to increase recruitment from a specific demographic.

CONCLUSION

Most studies that report GGT rates by race/ethnicity are in research settings. Many of these studies used targeted recruitment methods and subsequently have a greater proportion of Black men than clinical and US population-based studies. Other historically marginalized populations are not well represented. There remains a knowledge gap regarding the extent of racial disparities in the use of GGT, particularly in the clinical setting.

American Indian/Alaska Native and black colon cancer patients have poorer cause-specific survival based on disease stage and anatomic site of diagnosis

OBJECTIVES

Studies of race-specific colon cancer (CC) survival differences between right- vs. left-sided CC typically focus on Black and White persons and often consider all CC stages as one group. To more completely examine potential racial and ethnic disparities in side- and stage-specific survival, we evaluated 5-year CC cause-specific survival probabilities for five racial/ethnic groups by anatomic site (right or left colon) and stage (local, regional, distant).

METHODS

We obtained cause-specific survival probability estimates from National Cancer Institute's population-based Surveillance, Epidemiology, and End Results (SEER) for CC patients grouped by five racial/ethnic groups (Non-Hispanic American Indian/Alaska Native [AIAN], Non-Hispanic Asian/Pacific Islander [API], Hispanic, Non-Hispanic Black [NHB], and Non-Hispanic White [NHW]), anatomic site, stage, and other patient and SEER registry characteristics. We used meta-regression approaches to identify factors that explained differences in cause-specific survival.

RESULTS

Diagnoses of distant-stage CC were more common among NHB and AIAN persons (>22 %) than among NHW and API persons (< 20 %). Large disparities in anatomic site-specific survival were not apparent. Those with right-sided distant-stage CC had a one-year cause-specific survival probability that was 16.4 % points lower (99 % CI: 12.2-20.6) than those with left-sided distant-stage CC; this difference decreased over follow-up. Cause-specific survival probabilities were highest for API, and lowest for NHB, persons, though these differences varied substantially by stage at diagnosis. AIAN persons with localized-stage CC, and NHB persons with regional- and distant-stage CC, had significantly lower survival probabilities across follow-up.

CONCLUSIONS

There are differences in CC presentation according to anatomic site and disease stage among patients of distinct racial and ethnic backgrounds. This, coupled with the reality that there are persistent survival disparities, with NHB and AIAN persons experiencing worse prognosis, suggests that there are social or structural determinants of these disparities. Further research is needed to confirm whether these CC cause-specific survival disparities are due to differences in risk factors, screening patterns, cancer treatment, or surveillance, in order to overcome the existing differences in outcome.

Disparities in germline testing among racial minorities with prostate cancer

Germline testing is becoming increasingly relevant in prostate cancer (PCa) screening, prognosis, and management. A subset of patients with PCa harbor pathogenic/likely pathogenic variants (P/LPVs) in genes mediating DNA-repair processes, and these P/LPVs have implications for cancer screening, treatment, and cascade testing. As a result, it is recommended that all men with high-risk localized and metastatic PCa undergo routine germline testing. As more PCa patients undergo germline testing, it is important that clinicians and genetics experts recognize current disparities in germline testing rates among racial/ethnic minorities in the United States. The reasons for these disparities are multiple and require similarly manifold consideration to close the germline testing gap and reduce inequities in PCa screening, management, and treatment.

Predicting Race And Ethnicity To Ensure Equitable Algorithms For Health Care Decision Making

Algorithms are currently used to assist in a wide array of health care decisions. Despite the general utility of these health care algorithms, there is growing recognition that they may lead to unintended racially discriminatory practices, raising concerns about the potential for algorithmic bias. An intuitive precaution against such bias is to remove race and ethnicity information as an input to health care algorithms, mimicking the idea of "race-blind" decisions. However, we argue that this approach is misguided. Knowledge, not ignorance, of race and ethnicity is necessary to combat algorithmic bias. When race and ethnicity are observed, many methodological approaches can be used to enforce equitable algorithmic performance. When race and ethnicity information is unavailable, which is often the case, imputing them can expand opportunities to not only identify and assess algorithmic bias but also combat it in both clinical and nonclinical settings. A valid imputation method, such as Bayesian Improved Surname Geocoding, can be applied to standard data collected by public and private payers and provider entities. We describe two applications in which imputation of race and ethnicity can help mitigate potential algorithmic biases: equitable disease screening algorithms using machine learning and equitable pay-for-performance incentives.

Racial and ethnic differences in patient ratings of colorectal and non-small-cell lung cancer care: A SEER-CAHPS study

PURPOSE

Although significant racial and ethnic disparities exist in colorectal and lung cancer treatment and survival, racial differences in patient-reported experience of care are not well understood. The purpose of this study was to examine differences in patient-reported ratings of colorectal and non-small-cell lung cancer care by race/ethnicity.

METHODS

Medicare beneficiaries with AJCC stage I-IV colorectal and non-small-cell lung cancer (2003-2013) who completed a Medicare Consumer Assessment of Healthcare Providers (CAHPS) survey within 5 years of cancer diagnosis were identified in the linked SEER-CAHPS dataset. Scores were compared by race/ethnicity, defined as White, Black, or any other race/ethnicity.

RESULTS

Of the 2,621 identified patients, 161 (6.1%) were Black, 2,279 (87.0%) White, and 181 (6.9%) any other race/ethnicity. Compared to White patients, Black patients were younger, had lower educational level, and had higher census tract poverty indicator (p < 0.001). Black patients rated their ability to get care quickly significantly lower than White patients (63.5 (SE 3.38) vs. 71.4 (SE 2.12), p < 0.01), as did patients of any other race/ethnicity (LS mean 66.2 (SE 2.89), p = 0.02). Patients of any other race/ethnicity reported their ability to get needed care significantly lower than White patients (LS mean 81.9 (SE 2.46) vs. 86.7 (SE 1.75), p = 0.02); however, there was no difference in ability to get needed care between Black and White patients.

CONCLUSION

Patient ratings for getting care quickly were lower in non-White patients, indicating racial disparities in perceived timeliness of care.

Influence of Race, Insurance, Rurality, and Socioeconomic Status on Equity of Lung and Colorectal Cancer Care

BACKGROUND

This study evaluated the influence that social determinants of health had on stage at diagnosis and receipt of cancer-directed surgery for patients with lung and colorectal cancer in the North Carolina Central Cancer Registry (2010-2015).

METHODS

This study examined non-Hispanic uninsured or privately-insured patients 18 to 64 years of age. Multivariable logistic regression models, including two-way interaction terms, assessed the influence of race, insurance status, rurality, and Social Deprivation Index on stage at diagnosis and receipt of surgery.

RESULTS

6574 lung cancer patients and 5355 colorectal cancer patients were included. Among the lung cancer patients, the uninsured patients had higher odds of having stage IV disease (odds ratio [OR] = 1.46; 95 % confidence interval [CI] = 1.22-1.76) and lower odds of receiving surgery (OR = 0.48; 95 % CI = 0.34-0.69) than the privately-insured patients. Among the colorectal cancer patients, uninsured status was associated with higher odds of stage IV disease (OR = 1.53; 95 % CI = 1.17-2.00) than privately-insured status. A significant insurance status and rurality interaction (p = 0.03) was found in the colorectal model for receipt of surgery. In the privately-insured group, non-Hispanic Black and rural patients had lower odds of receiving colorectal surgery (OR = 0.69; 95 % CI = 0.50-0.94 and OR = 0.68; 95 % CI = 0.52-0.89; respectively) than their non-Hispanic White and urban counterparts.

CONCLUSIONS

After controlling for confounding and evaluation of interactions between patient-, community-, and geographic-level factors, uninsured status remained the strongest driver of patients' presentation with late-stage lung and colorectal cancer. As policy and care delivery transformation targets uninsured and vulnerable populations, explicit recognition, and measurement of intersectionality should be considered.

Race-specific prostate cancer outcomes in a cohort of low and favorable-intermediate risk patients who underwent external beam radiation therapy from 1990 to 2017

BACKGROUND

Previous research exploring the role of race on prostate cancer (PCa) outcomes has demonstrated greater rates of disease progression and poorer overall survival for African American (AA) compared to Caucasian American (CA) men. The current study examines self-reported race as a predictor of long-term PCa outcomes in patients with low and favorable-intermediate risk disease treated with external beam radiation therapy (EBRT).

METHODS

This retrospective cohort study examined patients who were consented to enrollment in the Center for Prostate Disease Research Multicenter National Database between January 01, 1990 and December 31, 2017. Men self-reporting as AA or CA who underwent EBRT for newly diagnosed National Comprehensive Cancer Network-defined low or favorable-intermediate risk PCa were included. Dependent study outcomes included: biochemical recurrence-free survival, (ii) distant metastasis-free survival, and (iii) overall survival. Each outcome was modeled as a time-to-event endpoint using race-stratified Kaplan-Meier estimation curves and multivariable Cox proportional hazards analysis.

RESULTS

Of 840 men included in this study, 268 (32%) were AA and 572 (68%) were CA. The frequency of biochemical recurrence, distant metastasis, and deaths from any cause was 151 (18.7%), 29 (3.5%), and 333 (39.6%), respectively. AA men had a significantly younger median age at time of EBRT and slightly higher biopsy Gleason scores. Multivariable Cox proportional hazards analyses demonstrated no racial differences in any of the study endpoints.

CONCLUSIONS

These findings reveal no racial disparity in PCa outcomes for AA compared to CA men, in a long-standing, longitudinal cohort of patients with comparable access to cancer care.

Does a Cancer Diagnosis in Mid-to-Later Life Modify Racial Disparities in Memory Aging?

BACKGROUND

It is unknown whether an incident cancer diagnosis differentially impacts acute and long-term memory aging between older White and Black Americans.

METHODS

Incident cancer diagnoses and memory (immediate and delayed recall, combined with proxy-reported memory) were assessed at biennial study interviews in the US Health and Retirement Study (N=14,235, 1998-2016). We used multivariable segmented linear mixed-effects models to evaluate the rate of change in standardized memory score (SD/decade) in the years before, acutely at the time of, and in the years following an incident cancer diagnosis, compared to cancer-free adults, by race.

RESULTS

Black participants experienced faster memory decline than White participants (cancer-free group: -1.211 vs. -1.077; P<0.0001). An incident cancer diagnosis was associated with an acute memory drop in White, but not Black participants (-0.065 vs. 0.024; P<0.0001). However, White cancer survivors experienced slower memory decline than cancer-free White adults before and after diagnosis, but this memory advantage was not observed among Black cancer survivors.

CONCLUSIONS

Racial disparities in memory aging are not modified by an incident cancer diagnosis. The acute cancer-related memory decline and long-term memory advantage experienced by White, but not Black, cancer survivors relative to cancer-free older adults, requires further investigation.

Social Justice and Equity: Why Older Adults With Cancer Belong-A Life Course Perspective

The population of older adults with cancer in the United States is rapidly increasing, which will have a substantial impact on the oncology and public health workforces across the cancer continuum, from prevention to end of life. Unfortunately, inequities in existing social structures that cause increased psychosocial stressors have led to disparities in the incidence of cancer and the morbidity and mortality of cancer for individuals from marginalized backgrounds. It is imperative that older adults, especially those from historically marginalized backgrounds, be adequately represented in all stages of cancer research to address health inequities. Continued efforts and progress toward achieving social justice and health equity require a deeper commitment to and better understanding of the impact of social determinants of health within the cancer domain. Undoubtedly, a more holistic and integrated view that extends beyond the biologic and genetic factors of health must be adopted for health entities to recognize the critical role of environmental, behavioral, and social determinants in cancer health disparities. Against this backdrop, this paper uses a life course approach to present a multifactorial framework for understanding and addressing cancer disparities in an effort to advance social justice and health equity for racially and ethnically diverse older adults.

Colorectal Cancer Survival Trends in the United States From 1992 to 2018 Differ Among Persons From Five Racial and Ethnic Groups According to Stage at Diagnosis: A SEER-Based Study

INTRODUCTION

Survival following colorectal cancer (CRC) has improved in the US since 1975, but there is limited information on stage-specific survival trends among racial and ethnic subgroups.

OBJECTIVES

The purpose of this study was to estimate and compare trends in 1- and 5-year CRC cause-specific survival in the United States by both stage and race/ethnicity.

METHODS

We performed a retrospective cohort study of individuals diagnosed with CRC using the 1992-2018 Surveillance, Epidemiology and End Results (SEER) database. We estimated and compared time trends in 1- and 5-year survival for CRC stage by race/ethnicity.

RESULTS

Data from 399 220 individuals diagnosed with CRC were available. There were significant differences in stage-specific 1-year survival trends by race and ethnicity. Differences were most notable for distant stage CRC: survival probabilities increased most consistently for non-Hispanic American Indian/Alaska Native (AIAN) and Black (NHB) persons, but their trend lines were lower than those of Hispanic, and non-Hispanic Asian/Pacific Islander (API) and White (NHW) persons, whose initially greater gains appear to be slowing. Although the data do not support significant racial/ethnic differences in 5-year CRC survival trends by stage, AIAN and NHB persons have the lowest average survival probabilities for multiple CRC stages, and no racial/ethnic group has 5-year survival probabilities above 20% for distant-stage CRC.

CONCLUSION

Although there has been an overall improvement in adjusted CRC-specific survival probabilities since 1992, AIAN and NHB persons continue to experience worse prognosis than those of other races/ethnicities. This highlights the importance of reinvigorating efforts to understand the causes of mortality in CRC, including those which may differ according to an individual's race or ethnicity.

Socioeconomic Determinants of the Use of Molecular Testing in Stage IV Colorectal Cancer

OBJECTIVES

Treatment with epidermal growth factor receptor monoclonal antibodies extends life for patients with advanced colorectal cancers (CRCs) whose tumors exhibit wild-type KRAS, but KRAS testing may be underused. We studied the role of socioeconomic factors in the application of KRAS testing.

MATERIALS AND METHODS

We identified subjects with stage IV colorectal adenocarcinoma diagnosed 2010-2015 in the Surveillance, Epidemiology, and End Results (SEER) database. We used multivariable logistic regression models to evaluate associations between clinical/demographic factors and the rate of KRAS testing. We used multivariable-adjusted Cox proportional hazards models to assess survival.

RESULTS

We identified 37,676 patients with stage IV CRC, 31.1% of whom were tested for KRAS mutations, of those who had documented KRAS testing, 44% were KRAS mutant. Patients were more likely to be tested if they were younger (odds ratio [OR]=5.10 for age 20 to 29 vs. 80+, 95% confidence interval [CI]: 3.99-6.54, P<0.01), diagnosed more recently (OR=1.92 for 2015 vs. 2010, 95% CI: 1.77-2.08, P<0.01), or lived in an area of high median household income (OR=1.24 for median household income of >$69,311 vs. <$49,265, 95% CI: 1.14-1.35, P<0.01). Patients were less likely to be tested if they had Medicaid (OR=0.83, 95% CI: 0.77-0.88, P<0.01) or were unmarried (OR=0.78, 95% CI: 0.75-0.82, P<0.0001). The risk of death was decreased in patients who received KRAS testing (hazard ratio=0.77, 95% CI: 0.75-0.80, P<0.01).

CONCLUSIONS

We found a low rate of KRAS testing in CRC patients with those living in low-income areas less likely to be tested, even after controlling for Medicaid insurance. Our study suggests that socioeconomic disparities persist despite Medicaid insurance.

Disparities in Creating a Diverse Surgical Oncology Physician Workforce: Just a Leaky Pipeline?

Demographic shifts in the Unites States population highlight the growing need for a diverse physician workforce to care for communities of color and to eliminate existing disparities in cancer care and outcomes for these potentially vulnerable patients. The current surgical oncology workforce lacks adequate racial and ethnic representation, and the pool of medical students and surgical trainees who are underrepresented in medicine (URM) is scant. This review critically evaluates data, summarizes challenges in the recruitment and retention of URM surgeons to surgical oncology, and provides strategies to address these workforce deficits.

Racial differences in survival and response to therapy in patients with metastatic colorectal cancer: A secondary analysis of CALGB/SWOG 80405 (Alliance A151931)

BACKGROUND

The objective of this study was to evaluate the association between self-identified race and overall survival (OS), progression-free survival (PFS), and response to therapy among patients enrolled in the randomized Cancer and Leukemia Group B (CALGB)/SWOG 80405 trial.

METHODS

Patients with advanced or metastatic colorectal cancer who were enrolled in the CALGB/SWOG 80405 trial were identified by race. On the basis of covariates (treatment arm, KRAS status, sex, age, and body mass index), each Black patient was exact matched with a White patient. The association between race and OS and PFS was examined using a marginal Cox proportional hazard model for matched pairs. The interaction between KRAS status and race was tested in the model. The association between race and response to therapy and adverse events were examined using a marginal logistic regression model.

RESULTS

In total, 392 patients were matched and included in the final data set. No difference in OS (hazard ratio [HR], 0.92; 95% confidence interval [CI], 0.73-1.16), PFS (HR, 0.97; 95% CI, 0.78-1.20), or response to therapy (odds ratio [OR], 1.00; 95% CI, 0.65-1.52) was observed between Black and White patients. Patients with KRAS mutant status (HR, 1.31; 95% CI, 1.02-1.67), a performance statusscore of 1 (reference, a performance status of 0; HR, 1.49; 95% CI, 1.18-1.88), or ≥3 metastatic sites (reference, 1 metastatic site; HR, 1.67; 95% CI, 1.22-2.28) experienced worse OS. Black patients experienced lower rates and risk of grade ≥3 fatigue (6.6% vs 13.3%; OR, 0.46; 95% CI, 0.24-0.91) but were equally likely to be treated with a dose reduction (OR, 1.09; 95% CI, 0.72-1.65).

CONCLUSIONS

No difference in OS, PFS, or response to therapy was observed between Black patients and White patients in an equal treatment setting of the CALGB/SWOG 80405 randomized controlled trial.

LAY SUMMARY

Despite improvements in screening and treatment, studies have demonstrated worse outcomes in Black patients with colorectal cancer. The purpose of this study was to determine whether there was a difference in cancer-specific outcomes among Black and White patients receiving equivalent treatment on the CALGB/SWOG 80405 randomized clinical trial. In this study, there was no difference in overall survival, progression-free survival, or response to therapy between Black and White patients treated on a clinical trial. These findings suggest that access to care and differences in treatment may be responsible for racial disparities in colorectal cancer.

Insurance Status and Travel Distance to Single Treatment Facility Predictive of Mastectomy

BACKGROUND

We evaluated the impact of insurance status and travel distance on the receipt of total mastectomy without reconstruction (TM) compared to breast conserving surgery with radiation (BCT) for early-stage breast cancer (BC) patients who received care at a single facility. We hypothesized that, lack of insurance and increased travel distance would be predictive of TM over BCT and disparities would vary by different races and/or ethnicities.

METHODS

Using the National Cancer Database from 2010-2017, we examined surgical patients with stage I or II BC, who received care at one facility. Chi-square tests examined subgroup differences by BCT or TM. Multivariable logistic regressions evaluated patient, facility, and pathologic factors associated with the receipt of TM over BCT for the entire cohort and by races and/or ethnicities.

RESULTS

Of the 284,202 patients, 70.1% received BCT while 29.9% received TM. After adjustment travel distance > 60 miles to a treatment facility, and non-insured patients were more likely to receive TM over BCT, when compared to travel distance < 20 miles and private insurance (all P < 0.05). Compared to other races and/or ethnicities, African Americans traveling > 60 miles were 65.4% more likely to receive TM over BCT compared to those traveling < 20 miles (P < .0001). Across all races and/or ethnicities after adjustment, lack of insurance was predictive for receipt of TM over BCT (P < 0.05).

CONCLUSIONS

Despite treatment at one facility, increased travel distance and insurance status are independently predictive of the receipt of TM over BCT in patients with early-stage BC. While travel distance is particularly impactful for African Americans, the impact of not having insurance on surgical treatments is universal across all races and/or ethnicities.

Interaction between race and prostate cancer treatment benefit in the Veterans Health Administration

BACKGROUND

Studies have demonstrated that Black men may undergo definitive prostate cancer (CaP) treatment less often than men of other races, but it is unclear whether they are avoiding overtreatment of low-risk disease or experiencing a reduction in appropriate care. The authors' aim was to assess the role of race as it relates to treatment benefit in access to CaP treatment in a single-payer population.

METHODS

The authors used the Veterans Health Administration (VHA) Corporate Data Warehouse to perform a retrospective cohort study of veterans diagnosed with low- or intermediate-risk CaP between 2011 and 2017.

RESULTS

The authors identified 35,427 men with incident low- or intermediate-risk CaP. When they controlled for covariates, Black men had 1.05 times the odds of receiving treatment in comparison with non-Black men (P < .001), and high-treatment-benefit men had 1.4 times the odds of receiving treatment in comparison with those in the low-treatment-benefit group (P < .001). The interaction of race and treatment benefit was significant, with Black men in the high-treatment-benefit category less likely to receive treatment than non-Black men in the same treatment category (odds ratio, 0.89; P < .001).

CONCLUSIONS

Although race does appear to influence the receipt of definitive treatment in the VHA, this relationship varies in the context of the patient's treatment benefit, with Black men receiving less definitive treatment in high-benefit situations. The influence of patient race at high treatment benefit levels invites further investigation into the driving forces behind this persistent disparity in this consequential group.

Immune Checkpoint Inhibitor Uptake in Real-World Patients With Malignant Pleural Mesothelioma

INTRODUCTION

Since the July 2017 National Comprehensive Cancer Network (NCCN) malignant pleural mesothelioma (MPM) guideline revision recommended second-line immune checkpoint inhibitors (ICIs), studies have suggested a greater response to ICI among patients with nonepithelioid MPM. Nevertheless, little is known regarding adoption of ICI in routine practice and if uptake differs by histologic subtype. Our objectives were to evaluate the real-world uptake of second-line ICI among patients with MPM and to reveal its association with histologic subtype.

METHODS

This was a multicenter, retrospective cohort study of real-world patients with MPM receiving at least two lines of systemic therapy between 2011 and 2019. We found the uptake of second-line ICI over time and evaluated the association between histologic subtype and ICI use, adjusting for relevant patient demographic and clinical factors.

RESULTS

Among the 426 patients with MPM in our cohort, 310 had epithelioid and 116 nonepithelioid histologic subtype. The median age was 73 years (interquartile range: 67-78). Overall, 144 patients (33.8%) received second-line ICI and 282 (66.2%) traditional chemotherapy. ICI uptake began in early 2015 before the NCCN guideline revision and increased rapidly to 2019. After the 2017 NCCN guideline revision, patients with nonepithelioid MPM histologic subtypes had more than 3 times the odds of receiving second-line ICI (OR = 3.26; 95% confidence interval: 1.41-7.54).

CONCLUSIONS

Among real-world patients with MPM, second-line ICI uptake began over two years before the 2017 NCCN guideline recommendations and was associated with nonepithelioid histologic subtype after contemporary studies suggested increased clinical benefit in this population, reflecting prompt integration of scientific discovery into clinical practice.

Racial Disparities in Recurrence and Overall Survival in Patients With Locoregional Colorectal Cancer

BACKGROUND

The purpose of this study was to determine the association between race and long-term cancer outcomes (recurrence and overall survival) within a population of US patients with locoregional colorectal cancer (CRC).

METHODS

A cohort study of primary patient data merged with the National Cancer Database as part of a Commission on Cancer Special Study was performed. The study population was a random sample of patients undergoing surgery for stage I to III CRC between years 2006 and 2007 with 5 years of follow-up. Propensity-weighted multivariable Cox regression was performed with pooled results to yield statistical inferences. Prespecified sensitivity analysis was performed only for patients who received guideline concordant care (GCC) of primary CRC. All statistical tests were 2-sided.

RESULTS

The study population included 8176 patients, 9.9% (n = 811) Black and 90.1% (n = 7365) White. Black patients were more likely to be uninsured or underinsured, have lower household income, and lower educational status (all P < .001). Rates of GCC were higher among Black vs White patients with colon cancer (76.9% vs 72.6%, P = .02), and Black and White patients with rectal cancer were treated with radiation at similar rates (69.1% vs 66.6%, P = .64). Black race was independently associated with increased risk of recurrence (hazard ratio [HR] = 1.48, 95% confidence interval [CI] = 1.26 to 1.73) and mortality (HR = 1.37, 95% CI = 1.18 to 1.59). In sensitivity analysis of only patients who received GCC, observed effects for recurrence (HR = 1.51, 95% CI = 1.27 to 1.79) and overall survival (HR = 1.40, 95% CI = 1.18 to 1.66) persisted.

CONCLUSIONS

Despite higher rates of GCC for CRC, Black patients experience a higher risk of recurrence and mortality compared with White patients.

Racially Disparate Expression of mTOR/ERK-1/2 Allied Proteins in Cancer

Recent studies revealed that ethnic differences in mechanistic target of rapamycin (mTOR) and extracellular signal-regulated kinase (ERK-1/2) signaling pathways might be associated with the development and progression of different human malignancies. The African American (AA) population has an increased rate of cancer incidence and mortality compared to the Caucasian American (CA) population. Although the socioeconomic differences across different ethnic groups contribute to the disparity in developing different cancers, recent scientific evidence indicates the association of molecular and genetic variations in racial disparities of different human malignancies. The mTOR and ERK-1/2 signaling pathways are one of the well-known oncogenic signaling mechanisms that regulate diverse molecular and phenotypic aspects of normal as well as cancer cells in response to different external or internal stimuli. To date, very few studies have been carried out to explore the significance of racial disparity with abnormal mTOR and ERK-1/2 kinase signaling pathways, which may contribute to the development of aggressive human cancers. In this review, we discuss the differential regulation of mTOR and ERK-1/2 kinase signaling pathways across different ethnic groups, especially between AA and CA populations. Notably, we observed that key signaling proteins associated with mTOR and ERK-1/2 pathway including transforming growth factor-beta (TGF-β), Akt, and VEGFR showed racially disparate expression in cancer patients. Overall, this review article encompasses the significance of racially disparate signaling molecules related to mTOR/ERK1/2 and their potential in developing tailor-made anti-cancer therapies.

Risk Factors for Emergency Room and Hospital Care Among Patients With Solid Tumors on Immune Checkpoint Inhibitor Therapy

OBJECTIVES

Immune checkpoint inhibitors (ICIs) are being increasingly used across cancer types. Emergency room (ER) and inpatient (IP) care, common in patients with cancer, remain poorly defined in this specific population, and risk factors for such care are unknown.

METHODS

We retrospectively reviewed charts for patients with solid tumors who received >1 ICI dose at 1 of 2 sites from January 1, 2011 to April 28, 2017. Demographics, medical history, cancer diagnosis/therapy/toxicity details, and outcomes were recorded. Descriptive data detailing ER/IP care at the 2 associated hospitals during ICI therapy (from first dose to 3 mo after last dose) were collected. The Fisher exact test and multivariate regression analysis was used to study differences between patients with versus without ER/IP care during ICI treatment.

RESULTS

Among 345 patients studied, 50% had at least 1 ER visit during ICI treatment and 43% had at least 1 IP admission. Six percent of ER/IP visits eventually required intensive care. A total of 12% of ER/IP visits were associated with suspected or confirmed immune-related adverse events. Predictors of ER care were African-American race (odds ratio [OR]: 3.83, P=0.001), Hispanic ethnicity (OR: 3.12, P=0.007), and coronary artery disease (OR: 2.43, P=0.006). Predictors of IP care were African-American race (OR: 2.38, P=0.024), Hispanic ethnicity (OR: 2.29, P=0.045), chronic kidney disease (OR: 3.89, P=0.006), angiotensin converting enzyme inhibitor/angiotensin receptor blocker medication use (OR: 0.44, P=0.009), and liver metastasis (OR: 2.32, P=0.003).

CONCLUSIONS

Understanding demographic and clinical risk factors for ER/IP care among patients on ICIs can help highlight disparities, prospectively identify high-risk patients, and inform preventive programs aimed at reducing such care.

Association of Patient Experience With Guideline-Concordant Colon Cancer Treatment in the Elderly

PURPOSE

The association between patient-reported experience of care and care quality is not well described. The purpose of this study was to assess the relationship between the patient-reported experience and receipt of guideline-concordant colon cancer (CC) treatment.

METHODS

Medicare beneficiaries with resected stage I-III CC (2003-2013) were identified in the linked SEER Consumer Assessment of Healthcare Providers and Systems data set. Patient-reported scores were compared by receipt of guideline concordant care (GCC) (resection of ≥ 12 lymph nodes [stage I-III] and adjuvant chemotherapy [stage III]). Linear mixed-effects regression was performed to compare adjusted mean patient experience scores by GCC.

RESULTS

Of the 1,010 identified patients, 58.4% of stage I (n = 192/329) and 73.4% of stage II (n = 298/406) patients underwent resection of ≥ 12 LN. Among stage III patients, 76.0% (n = 209/275) underwent resection of ≥ 12 lymph node and 52.4% (n = 144/275) received adjuvant chemotherapy. By multivariable analysis, patient-reported scores of healthcare quality, physicians, physician communication, getting needed care, and getting care quickly were similar among patients who received GCC compared with those who did not. However, mean scores of overall healthcare quality (91.3 v 82.4, P = .0004) and getting needed care (92.8 v 86.8, P = .047) were higher among stage III patients who received GCC compared with those who did not.

CONCLUSION

Patient-reported scores of healthcare quality and ability to get needed care are associated with GCC among elderly patients with stage III CC. Further investigation is needed to determine whether patient-reported experience correlates with other clinical measures of quality of CC care.

Social Determinants of Racial Disparities in Breast Cancer Mortality Among Black and White Women

INTRODUCTION

Mortality from breast cancer among Black women is 60% greater than that of White women in South Carolina (SC). The aim of this study was to assess racial differences in mortality among Black and White breast cancer patients based on variations in social determinants and access to state-based early detection programs.

METHODS

We obtained a retrospective record for breast cancer patients diagnosed between 2002 and 2010 from the SC Central Cancer Registry. Mortality was the main outcome while race-stratified Cox proportional hazard models were performed to assess disparities in mortality. We assessed effect modification, and we used an automated backward elimination process to obtain the best fitting models.

RESULTS

There were 3286 patients of which the majority were White women (2186, 66.52%). Compared with married White women, the adjusted hazard ratio (aHR) for mortality was greatest among Black unmarried women (aHR 2.31, CI 1.83, 2.91). Compared with White women who lived in the Low Country region mortality was greatest among Black women who lived in the Midland (aHR 2.17 CI 1.47, 3.21) and Upstate (aHR 2.96 CI 1.96, 2.49). Mortality was higher among Black women that were not receiving services in the Best Chance Network (BCN) program (aHR 1.70, CI 1.40, 2.04) compared with White women.

CONCLUSIONS

To reduce the racial disparity gap in survival in SC, Black breast cancer patients who live in the Upstate, are unmarried, and those that are not enrolled in the BCN program may benefit from more intense navigation efforts directed at early detection and linkage to breast cancer treatments.

Racial and geographic disparities in stage-specific incidence and mortality in the colorectal cancer hotspot region of eastern North Carolina, 2008-2016

BACKGROUND

Despite improvements in colorectal cancer (CRC) outcomes, geographic disparities persist. Spatial mapping identified distinct "hotspots" of increased CRC mortality, including 11 rural counties in eastern North Carolina (ENC). The primary aims of this study were to measure CRC incidence and mortality by stage and determine if racial disparities exist within ENC.

METHODS

Data from 2008 to 2016 from the NC Central Cancer Registry were analyzed by stage, race, and region. Age-adjusted incidence and death rates (95% CI) were expressed per 100,000 persons within hotspot counties, all ENC counties, and Non-ENC counties.

RESULTS

CRC incidence [43.7 (95% CI 39.2-48.8) vs. 38.4 (95% CI 37.6-39.2)] and mortality rates [16.1 (95% CI 16.6-19.7) vs. 13.9 (95% CI 13.7-14.2)] were higher in the hotspot than non-ENC, respectively. Overall, localized, and regional CRC incidence rates were highest among African Americans (AA) residing in the hotspot compared to Whites or Non-ENC residents. Incidence rates of distant disease were higher among AA but did not differ by region. CRC mortality rates were highest among AA in the hotspot (AA 22.0 vs. Whites 15.8) compared to Non-ENC (AA 19.3 vs. Whites 13.0), although significant stage-stratified mortality differences were not observed.

CONCLUSIONS

Patients residing in the hotspot counties have higher age-adjusted incidence of overall, localized, regional, and distant CRC and mortality rates than patients in non-hotspot counties. Incidence and mortality rates remain highest among AA residing in the hotspot.

IMPACT

Increased CRC incidence and mortality rates were observed among all patients in the hotspot and were highest among AA, suggestive of ongoing racial and geographic disparities.

Racial Differences in the Influence of Health Care System Factors on Informal Support for Cancer Care Among Black and White Breast and Lung Cancer Survivors

This retrospective, secondary qualitative analysis investigates whether health system factors influence social support among Black and white breast and lung cancer survivors and racial differences in support. These data come from race- and cancer-stratified focus groups (n = 6) and interviews (n = 2) to inform a randomized controlled trial utilizing antiracism and community-based participatory research approaches. Findings indicate social support was helpful for overcoming treatment-related challenges, including symptom management and patient-provider communication; racial differences in support needs and provision were noted. Resources within individual support networks reflect broader sociostructural factors. Reliance on family/friends to fill gaps in cancer care may exacerbate racial disparities.

Improving Access to Cancer Care in the HIV Population: Qualitative Research to Identify Barriers to Care

Purpose: People living with HIV are less likely to receive cancer treatment and have worse cancer-specific survival, yet underlying drivers of this disparity have minimally been explored. We investigated cancer care barriers from the perspective of patients living with HIV and cancer (PLWHC) to inform future interventions, reduce disparities, and improve outcomes.

Methods: We conducted in-depth semistructured interviews with 27 PLWHC. The interview guide explored perceptions of the cancer care experience, treatment decision making, and barriers to cancer treatment. Interview data were analyzed using the constant comparative method of qualitative analysis.

Results: Study participants were predominantly men (n=22, 81%) with a median age of 56 years and median annual income of $24,000. Among those who experienced challenges with cancer treatment adherence, barriers included debilitating side effects of cancer treatment, stigma surrounding HIV, issues with coping and mental health, the financial burden of cancer care, and challenges with care accessibility. Despite these challenges, participants indicated that their past experiences of coping with HIV had prepared them to accept and address their cancer diagnosis. Resiliency and social support were key facilitators for cancer treatment adherence.

Conclusion: This qualitative study of PLWHC in the United States found that a cancer diagnosis created a substantial added stress to an already challenging situation. Health- and stigma-related stressors impacted patients' ability to fully complete cancer treatment as prescribed. There is a need for improved provider communication and mental health support for PLWHC to ensure equitable access to and completion of cancer treatment.

Effects of taurocholic acid metabolism by gut bacteria: A controlled feeding trial in adult African American subjects at elevated risk for colorectal cancer

Colorectal cancer (CRC) is the third leading cause of cancer and second leading cause of cancer death in the United States. Recent evidence has linked a high fat and animal protein diet and microbial metabolism of host bile acids as environmental risk factors for CRC development. We hypothesize that the primary bile salt taurocholic acid (TCA) is a key, diet-controlled metabolite whose use by bacteria yields a carcinogen and tumor-promoter, respectively. The work is motivated by our published data indicating hydrogen sulfide (H₂S) and secondary bile acid production by colonic bacteria, serve as environmental insults contributing to CRC risk. The central aim of this study is to test whether a diet high in animal protein and saturated fat increases abundance of bacteria that generate H₂S and pro-inflammatory secondary bile acids in African Americans (AAs) at high risk for CRC. Our prospective, randomized, crossover feeding trial will examine two microbial mechanisms by which an animal-based diet may support the growth of TCA metabolizing bacteria. Each subject will receive two diets in a crossover design- an animal-based diet, rich in taurine and saturated fat, and a plant-based diet, low in taurine and saturated fat. A mediation model will be used to determine the extent to which diet (independent variable) and mucosal markers of CRC risk and DNA damage (dependent variables) are explained by colonic bacteria and their functions (mediator variables). This research will generate novel information targeted to develop effective dietary interventions that may reduce the unequal CRC burden in AAs.

Modifiable health behaviors among low-income, uninsured men with prostate cancer

BACKGROUND

As life expectancy of men with prostate cancer (CaP)improves, the risks of chronic diseases and comorbid conditions become more relevant. Improving modifiable health behaviors now serves as a focus of guidelines to reduce all-cause morbidity and mortality from chronic disease among CaP survivors. Few studies have reported on these health behaviors in low-income, uninsured men with CaP METHODS: In addition to baseline demographic data, we collected four health behaviors in low-income men with CaP via telephone survey: physical activity, dietary intake of fruits and vegetables, weight management, and alcohol consumption. These behaviors were assessed for adherence to the American Cancer Society Prostate Cancer Survivorship Care Guidelines for health promotion.

RESULTS

Of 236 participants, most self-identified as racial/ethnic minority (61% Hispanic, 16% Black). Most men demonstrated low (21%) or moderate (66%) adherence to guidelines, almost all of whom had poor adherence with recommendations for physical activity and fruit and vegetable intake. Multivariate analysis showed that non-white men were more likely to demonstrate low or moderate adherence.

CONCLUSIONS

Most men in this cohort of low-income, uninsured CaP survivors did not engage the healthy behaviors promulgated by the American Cancer Society. Future interventions in this population should focus on encouraging and facilitating healthier lifestyle choices in physical activity, diet, and weight management.

The impact of the Patient Protection and Affordable Care Act on insurance coverage and cancer-directed treatment in HIV-infected patients with cancer in the United States

BACKGROUND

To the authors' knowledge, little is known regarding the impact of the Patient Protection and Affordable Care Act (ACA) on people living with HIV and cancer (PLWHC), who have lower cancer treatment rates and worse cancer outcomes. To investigate this research gap, the authors examined the effects of the ACA on insurance coverage and receipt of cancer treatment among PLWHC in the United States.

METHODS

HIV-infected individuals aged 18 to 64 years old with cancer diagnosed between 2011 and 2015 were identified in the National Cancer Data Base. Health insurance coverage and cancer treatment receipt were compared before and after implementation of the ACA in non-Medicaid expansion and Medicaid expansion states using difference-in-differences analysis.

RESULTS

Of the 4794 PLWHC analyzed, approximately 49% resided in nonexpansion states and were more often uninsured (16.7% vs 4.2%), nonwhite (65.2% vs 60.2%), and of low income (36.3% vs 26.9%) compared with those in Medicaid expansion states. After 2014, the percentage of uninsured individuals decreased in expansion states (from 4.9% to 3%; P = .01) and nonexpansion states (from 17.6% to 14.6%; P = .06), possibly due to increased Medicaid coverage in expansion states (from 36.9% to 39.2%) and increased private insurance coverage in nonexpansion states (from 29.5% to 34.7%). There was no significant difference in cancer treatment receipt noted between Medicaid expansion and nonexpansion states. However, the percentage of PLWHC treated at academic facilities increased significantly only in expansion states (from 40.2% to 46.7% [P < .0001]; difference-in-differences analysis: 7.2 percentage points [P = .02]).

CONCLUSIONS

The implementation of the ACA was associated with improved insurance coverage among PLWHC. Lack of insurance still is common in non-Medicaid expansion states. Patients with minority or low socioeconomic status more often resided in nonexpansion states, thereby highlighting the need for further insurance expansion.

Ethnic disparities in cancer incidence and survival among the oldest old in the United States

Objective: To examine potential ethnic disparities in cancer incidence and survival rates among the oldest old using data from the SEER Program.Design: Cases diagnosed with one of the leading four cancer sites (lung and bronchus, colon and rectum, female breast, prostate) and four cancer sites (stomach, liver and intrahepatic bile duct, gallbladder, and cervical) that disproportionally affect Hispanics were reported to one of 18 SEER registries. Differences in cancer incidence were examined for cases aged ≥85 years diagnosed during the most recent 5-year time period (2009-2013) and, to examine changes over time, from 1992 to 2013. Five-year relative cancer survival probability was examined for Hispanics and non-Hispanics aged ≥85 years diagnosed 2006-2012.Results: From 2009 to 2013, non-Hispanics aged ≥85 years had higher incidence rates compared to Hispanics for colon and rectum, lung and bronchus, female breast, and prostate cancers. Five-year survival probability for cancers of all stages combined was higher for non-Hispanics than Hispanics in this age group. However, Hispanics had higher survival probability of colon and rectum and lung and bronchus cancers diagnosed at regional (colon and rectum: 67.2% vs. 60.5%; lung and bronchus: 15.9% vs. 12.7%) and distant (colon and rectum: 5.4% vs. 3.8%; lung and bronchus: 2.8% vs. 2.2%) stages than non-Hispanics, respectively.Conclusion: Ethnic differences in cancer incidence and survival probability exist for the ≥85 population. Continued efforts are needed to understand and reduce ethnic disparities in cancer prevention and treatment for this population.

Cost and Utilization of Lung Cancer End-of-Life Care Among Racial-Ethnic Minority Groups in the United States

BACKGROUND

The end-of-life period is a crucial time in lung cancer care. To have a better understanding of the racial-ethnic disparities in health care expenditures, access, and quality, we evaluated these disparities specifically in the end-of-life period for patients with lung cancer in the U.S.

MATERIALS AND METHODS

We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to analyze characteristics of lung cancer care among those diagnosed between the years 2000 and 2011. Linear and logistic regression models were constructed to measure racial-ethnic disparities in end-of-life care cost and utilization among non-Hispanic (NH) Asian, NH black, Hispanic, and NH white patients while controlling for other risk factors such as age, sex, and SEER geographic region.

RESULTS

Total costs and hospital utilization were, on average, greater among racial-ethnic minorities compared with NH white patients in the last month of life. Among patients with NSCLC, the relative total costs were 1.27 (95% confidence interval [CI], 1.21-1.33) for NH black patients, 1.36 (95% CI, 1.25-1.49) for NH Asian patients, and 1.21 (95% CI, 1.07-1.38) for Hispanic patients. Additionally, the odds of being admitted to a hospital for NH black, NH Asian, and Hispanic patients were 1.22 (95% CI, 1.15-1.30), 1.47 (95% CI, 1.32-1.63), and 1.18 (95% CI, 1.01-1.38) times that of NH white patients, respectively. Similar results were found for patients with SCLC.

CONCLUSION

Minority patients with lung cancer have significantly higher end-of-life medical expenditures than NH white patients, which may be explained by a greater intensity of care in the end-of-life period.

IMPLICATIONS FOR PRACTICE

This study investigated racial-ethnic disparities in the cost and utilization of medical care among lung cancer patients during the end-of-life period. Compared with non-Hispanic white patients, racial-ethnic minority patients were more likely to receive intensive care in their final month of life and had statistically significantly higher end-of-life care costs. The findings of this study may lead to a better understanding of the racial-ethnic disparities in end-of-life care, which can better inform future end-of-life interventions and help health care providers develop less intensive and more equitable care, such as culturally competent advanced care planning programs, for all patients.

The Effect of Socioeconomic Status on Treatment and Mortality in Non-Small Cell Lung Cancer Patients

BACKGROUND

Treatment decisions for patients with non-small cell lung cancer (NSCLC) are based on patient and tumor characteristics, including socioeconomic status (SES) factors. The objective was to assess the contribution of SES factors to treatment and outcomes among patients with stage I NSCLC.

METHODS

The National Cancer Database was queried for operable patients with stage I NSCLC. Patients were divided into three treatment groups: primary resection (ie, surgery only); nonstandard treatments consisting of chemotherapy with or without radiation; and no therapy. The SES of patients who made up the treatment groups was assessed, and the 5-year survival of all groups was analyzed.

RESULTS

The cohort included 69,168 patients with stage I NSCLC. Each of these patients had between zero and five SES risk factors. The factors associated with no surgery were low income, nonwhite race, low high school graduation rate, Medicaid or no insurance, rural residence, and distance less than 12.5 miles from treatment facility. Patients with several SES risk factors have linearly increasing odds of undergoing nonstandard treatments and quadratically increasing odds of having no therapy (for patients with five factors, to odds ratio 4.7; 95% confidence interval, 3.44 to 6.30). Surgery alone was associated with significantly longer 5-year survival (71.8%) compared with nonstandard treatments (22.7%) and no therapy (21.8%; P < .001).

CONCLUSIONS

Socioeconomic status factors increase the risk of undergoing guideline discordant therapy for stage I NSCLC. As the number of SES factors increases, the odds of no therapy rises quadratically whereas the odds of nonstandard treatments rises constantly. The surgery only group had significantly longer survival than the nonstandard treatment and no therapy groups.

Racial/ethnic, age and sex disparities in leukemia survival among adults in the United States during 1973-2014 period

There has been marked improvement in leukemia survival, particularly among children in recent time. However, the long-term trends in survival among adult leukemia patients and the associated sex and racial survival disparities are not well understood. We, therefore, evaluated the secular trends in survival improvement of leukemia patients from 1973 through 2014, using Surveillance Epidemiology and End-Result Survey Program (SEER) data. ICD-O-3 morphology codes were used to group leukemia into four types: acute lymphoblastic leukemia (ALL), acute myeloid leukemia (AML), chronic lymphocytic leukemia (CLL), chronic myeloid leukemia (CML). Survival analysis for each leukemia type stratified by race/ethnicity, age, sex was performed to generate relative survival probability estimates for the baseline time period of 1973 through 1979. Hazard ratios (HR) and respective 95% confidence intervals (CIs) for survival within subsequent 10-year time periods by race, age and sex were calculated using Cox proportional hazard models. Of the 83,255 leukemia patients for the current analysis, the 5-year survival of patients with ALL, AML, CLL, and CML during 1973-1979 were 42.0%, 6.5%, 66.5%, and 20.9%, respectively. Compared to the baseline, there were substantial improvements of leukemia-specific survival in 2010-2014 among African-American (81.0%) and Asian (80.0%) patients with CML and among 20-49 year of age with CLL (96.0%). African-American patients, those with AML and those older than 75 years of age had the lowest survival improvements. Asians experienced some of the largest survival improvements during the study period. Others, including African-American and the elderly, have not benefited as much from advances in leukemia treatment.

Inequities in breast cancer treatment in sub-Saharan Africa: findings from a prospective multi-country observational study

BACKGROUND

Improving breast cancer survival in sub-Saharan Africa (SSA) is urgently needed, requiring early diagnosis and improved access to treatment. However, data on the types of and barriers to receiving breast cancer therapy in this region are limited and have not been compared between different SSA countries and treatment settings.

METHODS

In different health care settings across Uganda, Nigeria and Namibian sites of the prospective African Breast Cancer - Disparities in Outcomes cohort study, we assessed the percentage of newly diagnosed breast cancer patients who received treatment (systemic, surgery and/or radiotherapy) for cancer and their socio-demographic and clinical determinants. Treatment data were systematically extracted from medical records, as well as self-reported by women during 6-month follow-up interviews, and were used to generate a binary indicator of treatment received within 12 months of diagnosis (yes/no), which was analysed via logistic regression.

RESULTS

Of 1325 women, cancer treatment had not been initiated treatment within 1 year of diagnosis for 227 (17%) women and 185 (14%) of women with stage I-III disease. Untreated percentages were highest in two Nigerian regional hospitals where 38% of 314 women were not treated (32% among stage I-III). At a national referral hospital in Uganda, 18% of 430 women were not treated (15% among stage I-III). In contrast, at a cancer care centre in Windhoek, Namibia, where treatment is provided free to the patient, all non-black (100%) and almost all (98.7%) black women had initiated treatment. Percentages of untreated women were higher in women from lower socio-economic groups, women who believed in traditional medicine and, in Uganda, in HIV+ women. Self-reported treatment barriers confirmed treatment costs and treatment refusal as contributors to not receiving treatment.

CONCLUSIONS

Financial support to ensure treatment access and education of treatment benefits are needed to improve treatment access for breast cancer patients across sub-Saharan Africa, especially at regional treatment centres, for lower socio-economic groups, and for the HIV-positive woman with breast cancer.